|
1
|
Gray C, Collings M, Benito J, Velasco R, Lyttle MD, Roland D, Schuh S, Shihabuddin B, Kwok M, Mahajan P, Johnson M, Zorc J, Khanna K, Yock-Corrales A, Fernandes RM, Santhanam I, Cheema B, Ong GYK, Jaiganesh T, Powell C, Dalziel S, Babl FE, Couper J, Craig S. Analysis of the asthma scores recommended in guidelines for children presenting to the emergency department: a Pediatric Emergency Research Networks study. Arch Dis Child 2025; 110:422-428. [PMID: 40155002 DOI: 10.1136/archdischild-2024-327635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2024] [Accepted: 03/17/2025] [Indexed: 04/01/2025]
Abstract
RATIONALE While there are numerous published paediatric asthma scores, it is unknown how commonly scores are recommended in asthma guidelines across different geographical regions globally, and what their validation status is. OBJECTIVES (1) To describe which clinical guidelines recommend asthma scores across different geographical regions. (2) To describe the initial and subsequent validation of the commonly recommended asthma scores. METHODS Observational study of asthma scores recommended in guidelines for the management of acute paediatric asthma from institutions across the Pediatric Emergency Medicine Network; global paediatric emergency medicine research network comprising all eight local and regional paediatric emergency medicine research networks. MAIN RESULTS 158 guidelines were identified. Overall, 83/158 (53%) guidelines recommend a bedside clinical score for assessment of asthma severity. While a single country-specific clinical score was recommended in all guidelines from Spain and Canada, 27/28 (96%) of the USA guidelines recommend a wide variety of scores, and scores are rarely recommended in guidelines from other research networks (PERUKI, Paediatric Emergency Research in the UK and Ireland and PREDICT, Paediatric Research in Emergency Departments International Collaborative in Australia and New Zealand) and other countries (Costa Rica, South Africa, Nigeria, Singapore, India).The Pediatric Respiratory Assessment Measure (PRAM) and the pulmonary score (PS) were the most frequently used scoring instruments. While the PRAM has undergone the most extensive validation, including construct validity, validation studies for the PS are limited. Inter-rater reliability, as well as the criterion, responsiveness and discriminative validity aspects represent the most common limitations in many of the scores. CONCLUSIONS There are marked geographical differences in both the recommendation for and the type of clinical asthma score in clinical practice guidelines. While many asthma scores are recommended, most have insufficient validation.
Collapse
Affiliation(s)
- Charmaine Gray
- Adelaide Medical School, The University of Adelaide Faculty of Health and Medical Sciences, Adelaide, South Australia, Australia
- Emergency Department, Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - Madeline Collings
- Department of Paediatrics, Monash University, Clayton, Victoria, Australia
| | - Javier Benito
- Pediatric Emergency Department, Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces, Bilbao, Spain
- University of the Basque Country, UPV/EHU, Bilbao, Spain
| | - Roberto Velasco
- Pediatric Emergency Unit, Hospital Universitari Parc Tauli, Institut d'Investigacio i Innovacio 13PT, Sabadell, Spain
- University College Cork, Cork, Ireland
| | - Mark D Lyttle
- Emergency Department, Bristol Royal Hospital for Children, Bristol, UK
- Research in Emergency Care, Avon Collaborative Hub (REACH), University of the West of England, Bristol, UK
| | - Damian Roland
- SAPPHIRE Group, Population Health Sciences, Leicester University, Leicester, UK
- Paediatric Emergency Medicine Leicester Academic (PEMLA) Group, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Suzanne Schuh
- Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
- SickKids Research Institute, Toronto, Ontario, Canada
| | - Bashar Shihabuddin
- Division of Emergency Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Maria Kwok
- Department of Emergency Medicine, Columbia University Irving Medical Center, New York, New York, USA
- NewYork-Presbyterian Morgan Stanley Children's Hospital, New York, New York, USA
| | - Prashant Mahajan
- Department of Emergency Medicine and Pediatrics, University of Michigan School of Medicine, Ann Arbor, Michigan, USA
| | - Mike Johnson
- Department of Pediatrics, University of Utah Health, Salt Lake City, Utah, USA
| | - Joseph Zorc
- Division of Emergency Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Kajal Khanna
- Department of Emergency Medicine, School of Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Adriana Yock-Corrales
- Emergency Department, Hospital Nacional de Ninos "Dr Carlos Saenz Herrera", CCSS, San Jose, Costa Rica
| | | | - Indumathy Santhanam
- Pediatrc Emergency Medicine, Institute of Child Health and Hospital for Children, Chennai, Tamil Nadu, India
| | - Baljit Cheema
- Department of Paediatrics and Child Health, University of Cape Town Faculty of Health Sciences, Western Cape, South Africa
| | | | | | - Colin Powell
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - Stuart Dalziel
- Department of Surgery and Paediatrics, The University of Auckland Faculty of Medical and Health Sciences, Auckland, New Zealand
- Starship Children's Health, Auckland, New Zealand
| | - Franz E Babl
- Departments of Paediatrics and Critical Care, University of Melbourne, Melbourne, Victoria, Australia
- Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Jennifer Couper
- Women's and Children's Hospital Adelaide, North Adelaide, South Australia, Australia
- Robinson Research Institute, The University of Adelaide Faculty of Health and Medical Sciences, Adelaide, South Australia, Australia
| | - Simon Craig
- Monash Medical Centre Clayton, Clayton, Victoria, Australia
- Monash University Faculty of Medicine Nursing and Health Sciences, Melbourne, Victoria, Australia
| |
Collapse
|
|
2
|
Andoh AA, Truelove A, Helwig S, Nash MC, Ulrich L, Shell R, Leonard JC. Performance of the Asthma Clinical Score in the Evaluation of Acute Asthma in the Emergency Department. Pediatr Pulmonol 2025; 60:e71084. [PMID: 40226890 PMCID: PMC11995675 DOI: 10.1002/ppul.71084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2024] [Revised: 03/17/2025] [Accepted: 03/26/2025] [Indexed: 04/15/2025]
Abstract
OBJECTIVE The primary objective of this study was to examine the performance of the Asthma Clinical Score (ACS) relative to the Pediatric Respiratory Assessment Measure (PRAM). Our secondary objectives were to determine interrater reliability, discriminative validity, responsiveness, and predictive validity of the ACS and PRAM. METHODS This was a single-site prospective observational study of children ages 2 to < 18 years presenting to the emergency department (ED) for asthma exacerbations. Clinicians completed paired assessments using ACS and PRAM at three time points of each patients ED stay. Construct validity correlating the performance of the ACS to PRAM, and interrater reliability were analyzed using Spearmen's rank correlation coefficients and Cohen's kappa coefficient, respectively. Cohen's d was calculated to compare the scores of patients who received certain treatments to patients who did not. Reliable change index (RCI) was used to determine the responsiveness of each score. Predictive validity for hospitalization was analyzed using Area Under the Receiver Operating Characteristic curve (AUROCc) and Akaike Information Criterion (AIC). RESULTS 399 children were enrolled with 338 paired clinician observations. The ACS and PRAM scores were strongly correlated at all time points (n = 1383,ρ $\rho $ = 0.874). Both the ACS and PRAM showed moderate interrater reliability at all time points (n = 338, κw = 0.77 and κw = 0.69, respectively). Patients receiving albuterol nebulization or adjunctive medications had higher average ACS and PRAM scores. ACS showed a better ability to detect responsiveness than the PRAM (31% vs 15% respectively). The pretreatment ACS showed comparable predictive validity to the PRAM. CONCLUSION The ACS was highly correlated with PRAM and is a reliable score in this cohort. The ACS showed good discriminative validity, predictive validity and responsiveness. This study supports the ACS as a useful tool in ED assessment of asthma exacerbation severity in children.
Collapse
Affiliation(s)
- Adjoa A. Andoh
- Division of Emergency Medicine, Department of PediatricsNationwide Children's HospitalColumbusOhioUSA
- The Ohio State University College of MedicineColumbusOhioUSA
| | - Annie Truelove
- Division of Emergency Medicine, Department of PediatricsNationwide Children's HospitalColumbusOhioUSA
- The Abigail Wexner Research Institute at Nationwide Children's HospitalColumbusOhioUSA
| | - Sara Helwig
- Division of Emergency Medicine, Department of PediatricsNationwide Children's HospitalColumbusOhioUSA
- The Abigail Wexner Research Institute at Nationwide Children's HospitalColumbusOhioUSA
| | - Matthew C. Nash
- Division of Emergency Medicine, Department of PediatricsNationwide Children's HospitalColumbusOhioUSA
- The Abigail Wexner Research Institute at Nationwide Children's HospitalColumbusOhioUSA
| | - Lisa Ulrich
- The Ohio State University College of MedicineColumbusOhioUSA
- Division of Pulmonary, Sleep Medicine and Cystic Fibrosis, Department of PediatricsNationwide Children's HospitalColumbusOhioUSA
| | - Richard Shell
- The Ohio State University College of MedicineColumbusOhioUSA
- Division of Pulmonary, Sleep Medicine and Cystic Fibrosis, Department of PediatricsNationwide Children's HospitalColumbusOhioUSA
| | - Julie C. Leonard
- Division of Emergency Medicine, Department of PediatricsNationwide Children's HospitalColumbusOhioUSA
- The Ohio State University College of MedicineColumbusOhioUSA
- The Abigail Wexner Research Institute at Nationwide Children's HospitalColumbusOhioUSA
| |
Collapse
|
|
3
|
McNamara PS, Clayton D, Burchett C, Compton V, Peak M, Clark J, Jones AP. Humidified and standard oxygen therapy in acute severe asthma in children (HUMOX): A pilot randomised controlled trial. PLoS One 2022; 17:e0263044. [PMID: 35113903 PMCID: PMC8812987 DOI: 10.1371/journal.pone.0263044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 12/23/2021] [Indexed: 11/19/2022] Open
Abstract
Background
Oxygen (O2) is a mainstay of treatment in acute severe asthma but how it is administered varies widely. The objectives were to examine whether a trial comparing humidified O2 to standard O2 in children is feasible, and specifically to obtain data on recruitment, tolerability and outcome measure stability.
Methods
Heated humidified, cold humidified and standard O2 treatments were compared for children (2–16 years) with acute severe asthma in a multi-centre, open, parallel, pilot randomised controlled trial (RCT). Multiple outcomes were assessed.
Results
Of 258 children screened, 66 were randomised (heated humidified O2 n = 25; cold humidified O2 n = 21; standard O2 n = 20). Median (IQR) length of stay (hours) in hospital was 37.9 (29.1), 52 (35.4) and 49.1 (29.7) for standard, heated humidified and cold humidified respectively and time (hours) on O2 was 15.9 (9.4), 13.6 (14.9) and 13.1 (14.9) for the three groups respectively. The mean (standard deviation) time (hours) taken to step down nebulised to inhaled treatment was 5.6 (14.3), 35.1 (28.2) and 32.7 (20.1). Asthma Severity Score decreased in all three groups similarly, although missing data prevented complete analysis. Humidified O2 was least well tolerated with eight participants discontinuing their randomised treatment early. An important barrier to recruitment was research nurse availability.
Conclusion
Although, the results of this pilot study should not be extrapolated beyond the study sample and inferential conclusions should not be drawn from the results, this is the first RCT to compare humidified and standard O2 therapy in acute severe asthmatics of any age. These findings and accompanying screening data show that a large RCT of O2 therapy is feasible. However, challenges associated with randomisation and data collection should be addressed in any future trial design.
Collapse
Affiliation(s)
- Paul S. McNamara
- Department of Child Health (University of Liverpool), Institute in the Park, Alder Hey Children’s NHS Foundation Trust, Liverpool, United Kingdom
- * E-mail:
| | - Dannii Clayton
- Liverpool Clinical Trials Centre, University of Liverpool, a member of the Liverpool Health Partners, Liverpool, United Kingdom
| | - Caroline Burchett
- Paediatric Department, The Longhouse, Countess of Chester Hospital NHS Foundation Trust, Chester, United Kingdom
| | - Vanessa Compton
- Physiotherapy Department, Alder Hey Children’s NHS Foundation Trust, Liverpool, United Kingdom
| | - Matthew Peak
- Clinical Research Division, Institute in the Park, Alder Hey Children’s NHS Foundation Trust, Liverpool, United Kingdom
| | - Janet Clark
- Clinical Research Division, Institute in the Park, Alder Hey Children’s NHS Foundation Trust, Liverpool, United Kingdom
| | - Ashley P. Jones
- Liverpool Clinical Trials Centre, University of Liverpool, a member of the Liverpool Health Partners, Liverpool, United Kingdom
| |
Collapse
|
|
4
|
Attanasi M, Sferrazza Papa S, Porreca A, Sferrazza Papa GF, Di Filippo P, Piloni F, Dodi G, Sansone F, Di Pillo S, Chiarelli F. Use of lung ultrasound in school-aged children with wheezing. Front Pediatr 2022; 10:926252. [PMID: 36699291 PMCID: PMC9869023 DOI: 10.3389/fped.2022.926252] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 12/08/2022] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND There is limited information available on fast and safe bedside tools that could help clinicians establish whether the pathological process underlying cases of wheezing is due to asthmatic exacerbation, asthmatic bronchitis, or pneumonia. The study's aim was to characterize Lung Ultrasound (LUS) in school-aged children with wheezing and evaluate its use for their follow-up treatment. MATERIALS AND METHODS We carried out a cross-sectional study involving 68 consecutive outpatients (mean age 9.9 years) with wheezing and suggestive signs of an acute respiratory infection. An expert sonographer, blinded to all subject characteristics, clinical course, and the study pediatrician's diagnosis, performed an LUS after spirometry and before BDT. The severity of acute respiratory symptoms was determined using the Pediatric Respiratory Assessment Measure (PRAM) score. RESULTS The LUS was positive in 38.2% (26/68) of patients [12 (46.1%) with multiple B-lines, 24 (92.3%) with consolidation, and 22 (84.6%) with pleural abnormalities]. In patients with pneumonia, asthmatic bronchitis, and asthma, the percentages of those patients with a positive LUS were 100%, 57.7%, and 0%, respectively. Of note, patients with a positive LUS were associated with an increased need for hospital admission (30.8% vs. 2.4%, p = 0.001), administration of oxygen therapy (14.6% vs. 0%, p = 0.009), oral corticosteroids (84.6% vs. 19.0%, p < 0.001), and antibiotics (88.5% vs. 11.9%, p < 0.001); and a higher median value of PRAM score (4.0 (2.0-7.0) vs. 2.0 (1.0-5.0); p < 0.001). CONCLUSIONS Our findings would suggest the use of LUS as a safe and cheap tool used by clinicians to define the diagnosis of school-aged children with wheezing of unknown causes.
Collapse
Affiliation(s)
- Marina Attanasi
- Department of Pediatrics, Pediatric Allergy and Pulmonology Unit, University of Chieti-Pescara, Chieti, Italy
| | - Simone Sferrazza Papa
- Department of Pediatrics, Pediatric Allergy and Pulmonology Unit, University of Chieti-Pescara, Chieti, Italy
| | - Annamaria Porreca
- Department of Economic Studies, University of Chieti-Pescara, Chieti, Italy
| | - Giuseppe F Sferrazza Papa
- Department of Health Sciences, Università degli Studi di Milano, Milan, Italy.,Department of Neurorehabilitation Sciences, Casa di Cura del Policlinico, Milan, Italy
| | - Paola Di Filippo
- Department of Pediatrics, Pediatric Allergy and Pulmonology Unit, University of Chieti-Pescara, Chieti, Italy
| | - Francesca Piloni
- Department of Pediatrics, Pediatric Allergy and Pulmonology Unit, University of Chieti-Pescara, Chieti, Italy
| | - Giulia Dodi
- Department of Pediatrics, Pediatric Allergy and Pulmonology Unit, University of Chieti-Pescara, Chieti, Italy
| | - Francesco Sansone
- Department of Pediatrics, Pediatric Allergy and Pulmonology Unit, University of Chieti-Pescara, Chieti, Italy
| | - Sabrina Di Pillo
- Department of Pediatrics, Pediatric Allergy and Pulmonology Unit, University of Chieti-Pescara, Chieti, Italy
| | - Francesco Chiarelli
- Department of Pediatrics, Pediatric Allergy and Pulmonology Unit, University of Chieti-Pescara, Chieti, Italy
| |
Collapse
|
|
5
|
Leung JS. Paediatrics: how to manage acute asthma exacerbations. Drugs Context 2021; 10:dic-2020-12-7. [PMID: 34113386 PMCID: PMC8166724 DOI: 10.7573/dic.2020-12-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 04/13/2021] [Indexed: 12/11/2022] Open
Abstract
Background Asthma is the most common chronic disease of childhood and a major source of childhood health burden worldwide. These burdens are particularly marked when children experience characteristic ‘symptom flare-ups’ or acute asthma exacerbations (AAEs). AAE are associated with significant health and economic impacts, including acute Emergency Department visits, occasional hospitalizations, and rarely, death. To treat children with AAE, several medications have been studied and used. Methods We conducted a narrative review of the literature with the primary objective of understanding the evidence of their efficacy. We present this efficacy evidence in the context of a general stepwise management pathway for paediatric AAEs. This framework is developed from the combined recommendations of eight established (inter)national paediatric guidelines. Discussion Management of paediatric AAE centres around four major care goals: (1) immediate and objective assessment of AAE severity; (2) prompt and effective medical interventions to decrease respiratory distress and improve oxygenation; (3) appropriate disposition of patient; and (4) safe discharge plans. Several medications are currently recommended with varying efficacies, including heliox, systemic corticosteroids, first-line bronchodilators (salbutamol/albuterol), adjunctive bronchodilators (ipratropium bromide, magnesium sulfate) and second-line bronchodilators (aminophylline, i.v. salbutamol, i.v. terbutaline, epinephrine, ketamine). Care of children with AAE is further enhanced using clinical severity scoring, pathway-driven care and after-event discharge planning. Conclusions AAEs in children are primarily managed by medications supported by a growing body of literature. Continued efforts to study the efficacy of second-line bronchodilators, integrate AAE management with long-term asthma control and provide fair/equitable care are required.
Collapse
Affiliation(s)
- James S Leung
- McMaster University, Faculty of Health Sciences, Department of Pediatrics, McMaster Children's Hospital, Hamilton, ON, Canada
| |
Collapse
|
|
6
|
Abecassis L, Gaffin JM, Forbes PW, Schenkel SR, McBride S, DeGrazia M. Validation of the Hospital Asthma Severity Score (HASS) in children ages 2-18 years old. J Asthma 2020; 59:315-324. [PMID: 33198536 DOI: 10.1080/02770903.2020.1852414] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION The Hospital Asthma Severity Score (HASS) was developed to communicate inpatient asthma severity between providers. The purpose of this prospective study was to validate the HASS against the Pediatric Respiratory Assessment Measure (PRAM) and spirometry for assessment of inpatient asthma exacerbation severity in patients 2-18 years old, at a single point-in-time. METHODS This study was registered with clinicaltrials.gov (NCT02782065). Children admitted to a tertiary care, free-standing children's hospital were assessed for asthma severity using the HASS, PRAM, and pulmonary function by spirometry. Inter-rater agreement of HASS and PRAM scores was assessed between two blinded clinician raters. Spirometry results were obtained by a certified pulmonary laboratory technician and correlated with HASS and PRAM scores. RESULTS The sample included 58 subjects. Allowing for a one-point difference in continuous HASS and PRAM scores, inter-rater agreement was 79% for the HASS and 60% for the PRAM. When the scores were categorized as mild, moderate, and severe, inter-rater agreement was 62% for the HASS and 93% for the PRAM (p < .0001). Additionally, intra-rater agreement between HASS and PRAM severity categories was 71% for Rater 1 and 64% for Rater 2. A weak correlation was noted between both the HASS and FEV1 (r = -0.31; p = 0.11), and PRAM and FEV1 (r = -0.30; p = 0.11) for the 29 subjects with acceptable spirometry results. CONCLUSIONS The HASS and PRAM have acceptable inter-rater and intra-rater agreement. These results support validation of the HASS for managing hospitalized patients during asthma exacerbations.
Collapse
Affiliation(s)
- Leah Abecassis
- Cardiovascular and Critical Care Services, Boston Children's Hospital, Boston, MA, USA
| | - Jonathan M Gaffin
- Division of Pulmonary Medicine, Boston Children's Hospital, Boston, MA, USA.,Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Peter W Forbes
- Clinical Research Center, Boston Children's Hospital, Boston, MA, USA
| | - Sara R Schenkel
- Division of Pediatric Global Health, Massachusetts General Hospital, Boston, MA, USA
| | - Sarah McBride
- Division of General Pediatrics, Boston Children's Hospital, Boston, MA, USA
| | - Michele DeGrazia
- Cardiovascular and Critical Care Services, Boston Children's Hospital, Boston, MA, USA.,Department of Medicine, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
|
7
|
Lee MO, Sivasankar S, Pokrajac N, Smith C, Lumba‐Brown A. Emergency department treatment of asthma in children: A review. J Am Coll Emerg Physicians Open 2020; 1:1552-1561. [PMID: 33392563 PMCID: PMC7771822 DOI: 10.1002/emp2.12224] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 07/27/2020] [Accepted: 07/28/2020] [Indexed: 12/11/2022] Open
Abstract
Asthma is the most common chronic illness in children, with >700,000 emergency department (ED) visits each year. Asthma is a respiratory disease characterized by a combination of airway inflammation, bronchoconstriction, bronchial hyperresponsiveness, and variable outflow obstruction, with clinical presentations ranging from mild to life-threatening. Standardized ED treatment can improve patient outcomes, including fewer hospital admissions. Informed by the most recent guidelines, this review focuses on the optimal approach to diagnosis and treatment of children with acute asthma exacerbations who present to the ED.
Collapse
Affiliation(s)
- Moon O. Lee
- Department of Emergency MedicineStanford University School of MedicineStanfordCaliforniaUSA
| | - Shyam Sivasankar
- Department of Emergency MedicineStanford University School of MedicineStanfordCaliforniaUSA
| | - Nicholas Pokrajac
- Department of Emergency MedicineStanford University School of MedicineStanfordCaliforniaUSA
| | - Cherrelle Smith
- Department of Emergency MedicineStanford University School of MedicineStanfordCaliforniaUSA
| | - Angela Lumba‐Brown
- Department of Emergency MedicineStanford University School of MedicineStanfordCaliforniaUSA
| |
Collapse
|
|
8
|
Arnold DH, Van Driest SL, Reiss TF, King JC, Akers WS. Pilot Study of Peak Plasma Concentration After High-Dose Oral Montelukast in Children With Acute Asthma Exacerbations. J Clin Pharmacol 2020; 61:360-367. [PMID: 32960980 DOI: 10.1002/jcph.1738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 08/22/2020] [Indexed: 11/06/2022]
Abstract
Acute asthma exacerbations are primarily due to airway inflammation and remain one of the most frequent reasons for childhood hospitalizations. Although systemic corticosteroids remain the mainstay of therapy because of their anti-inflammatory properties, not all inflammatory pathways are responsive to systemic corticosteroids, necessitating hospital admission for further management. Cysteinyl leukotrienes (LTs) are proinflammatory mediators that play an important role in systemic corticosteroids non-responsiveness. Montelukast is a potent LT-receptor antagonist, and an intravenous preparation caused rapid, sustained improvement of acute asthma exacerbations in adults. We hypothesized that a 30-mg dose of oral montelukast achieves peak plasma concentrations (Cmax ), comparable to the intravenous preparation (1700 ng/mL) and would be well tolerated in 15 children aged 5 to 12 years with acute asthma exacerbations. After administration of montelukast chewable tablets, blood samples were collected at 0, 15, 30, 45, 60, 120, 180, and 240 minutes. Plasma was separated and frozen at -80°C until analysis for montelukast concentration using liquid chromatography- tandem mass spectrometry. Median time to Cmax (tmax ) was 3.0 hours. Six participants (40%) achieved Cmax of 1700 ng/mL or higher. However, there was high interindividual variability in peak plasma concentration (median Cmax of 1378 ng/mL; range, 16-4895 ng/mL). No participant had side effects or adverse events. Plasma concentrations from this pilot study support the design of a weight-based dose-finding study aimed at selecting an optimal dose for future clinical trials to assess the efficacy of high-dose oral montelukast in children with moderate to severe asthma exacerbations.
Collapse
Affiliation(s)
- Donald H Arnold
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA.,Center for Asthma Research, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Sara L Van Driest
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA.,Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | | | - Jennifer C King
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Wendell S Akers
- Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee, USA.,Department of Pharmaceutical Sciences, Lipscomb University College of Pharmacy, Nashville, Tennessee, USA
| |
Collapse
|
|
9
|
Lambert KA, Prendergast LA, Dharmage SC, Tang M, O'Sullivan M, Tran T, Druce J, Bardin P, Abramson MJ, Erbas B. The role of human rhinovirus (HRV) species on asthma exacerbation severity in children and adolescents. J Asthma 2017; 55:596-602. [PMID: 29020463 DOI: 10.1080/02770903.2017.1362425] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE It is recognized that human rhinovirus (HRV) infection is an important factor in asthma exacerbations requiring hospitalization in children. However, previous studies have disagreed on the differential impact of various HRV species. We sought to assess the impact of HRV species on the severity of asthma exacerbations in children and adolescents. We also examined whether the effect of HRV species on severity was modified by age and gender. METHODS Virus strain was determined for 113 children with HRV detectable at the time of admission for asthma exacerbation. Patient characteristics were collected on admission and exacerbation severity was scored using several validated scales. RESULTS HRV species by itself was not associated with moderate/severe vs. mild exacerbations. Boys with HRV-C infections were more likely (OR: 3.7, 95% CI: 1.2-13.4) to have a moderate/severe exacerbation than girls with HRV-C (p = 0.04 for interaction term). Higher odds were observed in younger boys (3 years old: OR: 9.1, 95% CI: 1.8-47.1 vs 5 years old: OR: 3.3, 95% CI: 0.9-11.8 vs 7 years old: OR: 1.2, 95% CI: 0.2-6.6). In contrast, children with HRV-C infection and sensitized to pollen during the pollen season were less likely to have moderate/severe exacerbations (p = 0.01 for the interaction term). CONCLUSION Acute asthma exacerbations are more likely to be moderate/severe in boys under 5 years of age who had HRV-C infection on admission. The opposite was found in children with sensitization to pollen during pollen season.
Collapse
Affiliation(s)
- Katrina A Lambert
- a School of Psychology and Public Health , La Trobe University , Victoria , Melbourne , Australia
| | - Luke A Prendergast
- b Department of Mathematics and Statistics , La Trobe University , Victoria , Melbourne , Australia
| | - Shyamali C Dharmage
- c Allergy and Lung Health Unit, Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health , The University of Melbourne , Victoria , Melbourne , Australia
| | - Mimi Tang
- d Department of Paediatrics , The University of Melbourne , Victoria , Melbourne , Australia.,e Murdoch Children's Research Institute , The Royal Children's Hospital , Victoria , Melbourne , Australia
| | - Molly O'Sullivan
- e Murdoch Children's Research Institute , The Royal Children's Hospital , Victoria , Melbourne , Australia
| | - Thomas Tran
- f Victorian Infectious Diseases Reference Laboratory, The Doherty Institute , Victoria , Melbourne , Australia
| | - Julian Druce
- f Victorian Infectious Diseases Reference Laboratory, The Doherty Institute , Victoria , Melbourne , Australia
| | - Philip Bardin
- g Faculty of Medicine, Nursing and Health Sciences , Monash University and Hospital , Victoria , Melbourne , Australia
| | - Michael J Abramson
- h School of Public Health and Preventive Medicine , Monash University , Victoria , Melbourne , Australia
| | - Bircan Erbas
- a School of Psychology and Public Health , La Trobe University , Victoria , Melbourne , Australia
| |
Collapse
|
|
10
|
Johnson MD, Nkoy FL, Sheng X, Greene T, Stone BL, Garvin J. Direct concurrent comparison of multiple pediatric acute asthma scoring instruments. J Asthma 2017; 54:741-753. [PMID: 27831833 PMCID: PMC5425314 DOI: 10.1080/02770903.2016.1258081] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Accepted: 11/02/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Appropriate delivery of Emergency Department (ED) treatment to children with acute asthma requires clinician assessment of acute asthma severity. Various clinical scoring instruments exist to standardize assessment of acute asthma severity in the ED, but their selection remains arbitrary due to few published direct comparisons of their properties. Our objective was to test the feasibility of directly comparing properties of multiple scoring instruments in a pediatric ED. METHODS Using a novel approach supported by a composite data collection form, clinicians categorized elements of five scoring instruments before and after initial treatment for 48 patients 2-18 years of age with acute asthma seen at the ED of a tertiary care pediatric hospital ED from August to December 2014. Scoring instruments were compared for inter-rater reliability between clinician types and their ability to predict hospitalization. RESULTS Inter-rater reliability between clinician types was not different between instruments at any point and was lower (weighted kappa range 0.21-0.55) than values reported elsewhere. Predictive ability of most instruments for hospitalization was higher after treatment than before treatment (p < 0.05) and may vary between instruments after treatment (p = 0.054). CONCLUSIONS We demonstrate the feasibility of comparing multiple clinical scoring instruments simultaneously in ED clinical practice. Scoring instruments had higher predictive ability for hospitalization after treatment than before treatment and may differ in their predictive ability after initial treatment. Definitive conclusions about the best instrument or meaningful comparison between instruments will require a study with a larger sample size.
Collapse
Affiliation(s)
- Michael D. Johnson
- Department of Pediatrics, University of Utah School of Medicine, 100
N Mario Capecchi Drive, Salt Lake City, UT 84113, USA
| | - Flory L. Nkoy
- Department of Pediatrics, University of Utah School of Medicine, 100
N Mario Capecchi Drive, Salt Lake City, UT 84113, USA
- Department of Biomedical Informatics, University of Utah School of
Medicine, Suite 140, 421 Wakara Way, Salt Lake City, UT 84108, USA
| | - Xiaoming Sheng
- Department of Pediatrics, University of Utah School of Medicine, 100
N Mario Capecchi Drive, Salt Lake City, UT 84113, USA
| | - Tom Greene
- Department of Population Health Sciences, University of Utah School
of Medicine, 295 Chipeta Way, Salt Lake City, UT 84108, USA
| | - Bryan L. Stone
- Department of Pediatrics, University of Utah School of Medicine, 100
N Mario Capecchi Drive, Salt Lake City, UT 84113, USA
| | - Jennifer Garvin
- Department of Biomedical Informatics, University of Utah School of
Medicine, Suite 140, 421 Wakara Way, Salt Lake City, UT 84108, USA
| |
Collapse
|
|
11
|
Maue DK, Krupp N, Rowan CM. Pediatric asthma severity score is associated with critical care interventions. World J Clin Pediatr 2017; 6:34-39. [PMID: 28224093 PMCID: PMC5296627 DOI: 10.5409/wjcp.v6.i1.34] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Revised: 10/09/2016] [Accepted: 11/02/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To determine if a standardized asthma severity scoring system (PASS) was associated with the time spent on continuous albuterol and length of stay in the pediatric intensive care unit (PICU).
METHODS This is a single center, retrospective chart review study at a major children’s hospital in an urban location. To qualify for this study, participants must have been admitted to the PICU with a diagnosis of status asthmaticus. There were a total of 188 participants between the ages of two and nineteen, excluding patients receiving antibiotics for pneumonia. PASS was calculated upon PICU admission. Subjects were put into one of three categories based on PASS: ≤ 7 (mild), 8-11 (moderate), and ≥ 12 (severe). The groups were compared based on different variables, including length of continuous albuterol and PICU stay.
RESULTS The age distribution across all groups was similar. The median length of continuous albuterol was longest in the severe group with a duration of 21.5 h (11.5-27.5), compared to 15 (7.75-23.75) and 10 (5-15) in the moderate and mild groups, respectively (P = 0.001). The length of stay was longest in the severe group, with a stay of 35.6 h (22-49) compared to 26.5 (17-30) and 17.6 (12-29) in the moderate and mild groups, respectively (P = 0.001).
CONCLUSION A higher PASS is associated with a longer time on continuous albuterol, an increased likelihood to require noninvasive ventilation, and a longer stay in the ICU. This may help safely distribute asthmatics to lower and higher levels of care in the future.
Collapse
|
|
12
|
Arnold DH. Acute asthma exacerbations, viral respiratory infections, and corticosteroid treatment. THE LANCET RESPIRATORY MEDICINE 2016; 4:930-932. [PMID: 27451346 DOI: 10.1016/s2213-2600(16)30202-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Accepted: 07/07/2016] [Indexed: 12/12/2022]
Affiliation(s)
- Donald Hayes Arnold
- Department of Pediatrics, Division of Emergency Medicine, Center for Asthma Research, Vanderbilt University School of Medicine, Nashville, TN, USA.
| |
Collapse
|
|
13
|
Arnold DH, Sills MR, Walsh CG. The asthma prediction rule to decrease hospitalizations for children with asthma. Curr Opin Allergy Clin Immunol 2016; 16:201-9. [PMID: 26918532 PMCID: PMC5380119 DOI: 10.1097/aci.0000000000000259] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
PURPOSE OF REVIEW The aim of the present review was to discuss the challenges around clinical decision-making for hospitalization of children with acute asthma exacerbations and the development, internal validation, and future potential of the asthma prediction rule (APR) to provide meaningful clinical decision-support that might decrease unnecessary hospitalizations. RECENT FINDINGS The APR was developed and internally validated using predictor variables available before treatment in the emergency department, and performed well to predict 'need-for-hospitalization.' Oxygen saturation on room air and expiratory phase prolongation were most strongly associated with need-for-hospitalization. SUMMARY Research on prediction rules in pediatric asthma is rare. We developed and internally validated the APR using clinically intuitive predictor variables that are available at the bedside. Before incorporation into electronic decision-support the APR must undergo external validation and an impact analysis to determine if use of this tool will change clinician behavior and improve patient outcomes.
Collapse
Affiliation(s)
- Donald H Arnold
- aDivision of Emergency Medicine, Department of Pediatrics and Center for Asthma Research, Vanderbilt University School of Medicine, Nashville, Tennessee bSection of Emergency Medicine, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado cDepartment of Biomedical Informatics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | | | | |
Collapse
|
|
14
|
Arnold DH, Wang L, Hartert TV. Pulse Oximeter Plethysmograph Estimate of Pulsus Paradoxus as a Measure of Acute Asthma Exacerbation Severity and Response to Treatment. Acad Emerg Med 2016; 23:315-22. [PMID: 26727986 DOI: 10.1111/acem.12886] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Revised: 10/09/2015] [Accepted: 10/10/2015] [Indexed: 10/22/2022]
Abstract
OBJECTIVES Pulsus paradoxus is one of the few objective bedside measures of acute asthma exacerbation severity but is difficult to measure in tachypneic and tachycardic patients and in noisy clinical environments. Our primary objective was to examine whether pulse oximeter plethysmograph estimate of pulsus paradoxus (PEP) is associated with physiologic and symptom measures of acute exacerbation severity (airway resistance by impulse oscillometry [%IOS] and the Acute Asthma Intensity Research Score [AAIRS]). Secondary objectives were to validate the previous association of PEP with percent predicted forced expiratory volume in 1 second (%FEV1 ) and to examine associations of change of PEP with change of these outcomes after 2 hours of treatment. METHODS This was a secondary analysis of data from a prospective observational study of patients aged 5-17 years with acute asthma exacerbations. The predictor variable, PEP, was measured using a dedicated pulse oximeter and waveform analysis program. Outcome measures included the AAIRS, %IOS, and %FEV1 at baseline and after 2 hours of treatment. We examined associations of PEP with %IOS and the AAIRS at baseline using multiple linear regression models adjusted for age, sex, and race. As secondary analyses we similarly examined the association of PEP with %FEV1 at baseline and change of PEP with change of %IOS, the AAIRS, and %FEV1 after 2 hours of treatment using multiple linear regression models adjusted for the baseline value of the outcome measure and the AAIRS. RESULTS Among 684 participants (61% males; 61% African American) there were associations of baseline PEP with %IOS, the AAIRS, and %FEV1 (p < 0.001). Change of PEP after 2 hours of treatment was associated with change of %FEV1 (p < 0.001) and change of the AAIRS (p = 0.01) but not with change of %IOS (p = 0.60). CONCLUSIONS PEP demonstrates criterion validity in predicting baseline %IOS, the AAIRS, and %FEV1 , and responsiveness to change of the AAIRS and %FEV1 . Data contained in the oximeter plethysmograph waveform might be utilized as a continuous, objective measure of acute asthma exacerbation severity and real-time response to treatment.
Collapse
Affiliation(s)
- Donald H. Arnold
- Department of Pediatrics; Division of Emergency Medicine; Vanderbilt University School of Medicine; Nashville TN
- Center for Asthma Research; Vanderbilt University School of Medicine; Nashville TN
| | - Li Wang
- Department of Biostatistics; Vanderbilt University School of Medicine; Nashville TN
| | - Tina V. Hartert
- Department of Medicine; Division of Allergy, Pulmonary & Critical Care Medicine; Vanderbilt University School of Medicine; Nashville TN
- Center for Asthma Research; Vanderbilt University School of Medicine; Nashville TN
| |
Collapse
|
|
15
|
Aung YN, Majaesic C, Senthilselvan A, Mandhane PJ. Physician specialty influences important aspects of pediatric asthma management. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2014; 2:306-12.e5. [PMID: 24811022 DOI: 10.1016/j.jaip.2013.12.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 07/26/2013] [Revised: 11/25/2013] [Accepted: 12/16/2013] [Indexed: 10/25/2022]
Abstract
BACKGROUND Physician training influences patient care. OBJECTIVE To compare asthma management and change in the percentage predicted FEV1 among pediatric physician specialties. METHODS A retrospective cohort of children 6 years of age or older, seen in a multidisciplinary asthma clinic between 2009 and 2010, and followed to 2012, was completed to examine differences in asthma outcomes by specialty (2 pediatricians, 3 pediatric allergists, 5 pediatric respirologists). Univariate analyses compared investigation, including allergy testing (skin prick or RAST), comorbid conditions, and prescription by specialty. Multivariate regression, which controlled for random effect of the individual physician, examined specialty differences for prescribed inhaled corticosteroids (ICS) and changes in percentage predicted FEV1. RESULTS More than 56% of the patients (309/548) were seen by pediatric respirologists, 26% by pediatric allergists, and 18% by pediatricians. Physician specialty influences investigation requested, comorbid diagnoses, treatment, and improvement in FEV1. Pediatric allergists' patients had more allergy tests, were more likely to be diagnosed with allergic rhinitis and, consequently, were more likely to be prescribed nasal steroids than pediatricians and pediatric respirologists. Pediatricians were less likely to prescribe ICS (odds ratio 0.39 [95% CI, 0.15-0.96]; P < .05) than pediatric allergists, with the greatest difference in ICS prescription among children with a percentage predicted FEV1 ≥ 80%. Improvement in FEV1 among children who received care with pediatric allergists was higher than those seen by pediatricians (13%; P < .001) and pediatric respirologists (8%; P = .005). CONCLUSIONS Patient management domains with the greatest room for discretion (investigations, comorbid diagnoses, and treatment with ICS among children with normal lung function) are most heavily influenced by physician specialty. These results have implications for asthma management at the patient level and in future practice guidelines.
Collapse
Affiliation(s)
- Yin Nwe Aung
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada; School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | - Carina Majaesic
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | | | - Piushkumar J Mandhane
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada; School of Public Health, University of Alberta, Edmonton, Alberta, Canada.
| |
Collapse
|