Improving Management of Severe Asthma: BiPAP and Beyond

Acute severe asthma exacerbations present unique challenges in the pediatric emergency department. While most children presenting to the emergency department respond to standard asthma therapy including inhaled β₂-agonists, ipratropium, and systemic corticosteroids, some children remain refractory to these treatments and require adjunct therapies. Here we provide a review of the most recent National Asthma Education and Prevention Program guidelines, Global Initiative for Asthma guidelines, as well as recent evidence guiding the management of severe asthma exacerbations in the pediatric emergency department.     

Effect of a clinical pathway on the hospitalisation rates of children with asthma: a prospective study.

AIM: To determine the effect of implementing a clinical pathway, using evidence-based clinical practice guidelines, for the emergency care of children and adolescents with asthma. METHODS: A prospective, before-after, controlled trial was conducted, which included patients aged 1-18 years who had acute exacerbations of asthma treated in a tertiary care paediatric emergency department. Data were collected for identical 2-month seasonal periods before and after implementation of the clinical pathway to determine hospitalisation rate and other outcomes. For 2 weeks after emergency visits, the rate at which patients returned to emergency care for worsening asthma was evaluated. A multidisciplinary panel, using national guidelines and a systematic review, developed the pathway. RESULTS: 267 patients were studied. The rate of hospitalisation was significantly lower in the post-implementation group (10/74; 13.5%) than in the pre-implementation control group (53/193; 27.5%; p = 0.02; number needed to treat 7.1). All reduction in hospitalisation occurred in children with moderate to severe asthma exacerbation. After implementation of the clinical pathway, the rate of administration of oral corticosteroids to patients with moderate or severe exacerbations increased from 71% to 92% (p = 0.01), and significantly more patients received beta2-agonists in the first hour (p = 0.02). No significant change in relapse to acute care occurred within 2 weeks (p = 0.19). CONCLUSIONS: An evidence-based clinical pathway for children and adolescents with moderate to severe exacerbations of acute asthma markedly decreases their rate of hospitalisation without increased return to emergency care.     

Can asthma education improve the treatment of acute asthma exacerbation in young children?

Acute exacerbation of asthma requires timely and appropriate treatment. Young children are completely reliant on others in this respect. This paper aims to evaluate the effectiveness of staff asthma education programs in ensuring correct treatment for young children experiencing asthma exacerbations in formal care. A systematic review was undertaken of studies focusing on staff asthma education in relation to pharmacological treatment of acute asthma exacerbation. Three randomised controlled trials and seven uncontrolled pre‐ and post‐test intervention studies were included for review. Asthma education was found to increase staff knowledge and confidence in managing asthma. There was a distinct lack of staff performance testing and studies undertaken in the pre‐school setting. Staff asthma education appears effective in increasing asthma knowledge; however, utility of this measure is limited with respect to staff performance in treating acute asthma exacerbation. Further studies evaluating asthma education through performance are needed.     

Focused assessment of patients with asthma in the emergency department

Asthma remains a common cause for presentation to the emergency department. Multiple clinical asthma scores (CAS) have been developed to assess the severity of an asthma exacerbation. The objective of this retrospective study was to determine if adoption of a CAS and asthma guidelines identifies patients with more severe asthma and to identify factors that predict the need for hospital admission. The results identified the admission rates in the pre- and post-CAS groups to be similar. Within the post-CAS group, patients requiring admission received more aggressive therapy and were frequently hypoxic on initial presentation. In conclusion, CAS aids in identifying severe asthma exacerbations. Lack of response to aggressive therapy or hypoxia on initial presentation should prompt the emergency department physician to arrange for admission.     

Use of magnesium sulfate in the treatment of children with acute asthma

Asthma is the most common chronic disease of childhood. An acute asthma exacerbation is one of the common medical reasons for which a child requires care in an emergency department (ED). Despite the development of asthma management guidelines and many new medications available to treat asthma, there is still a population Mio does not respond to conventional therapy. The author provides a critical review of the literature on the use of magnesium in the treatment of asthma and provides some recommendations for the use of magnesium in selected cases.     

Effectiveness of magnesium sulfate as initial treatment of acute severe asthma in children, conducted in a tertiary-level university hospital: A randomized, controlled trial

Introduction. Magnesium sulfate is a calcium antagonist that inhibits bronchial smooth muscle contraction promoting bronchodilation. It is used for the management of acute severe asthma in children; however most of the studies have been performed in adults. Objective. To evaluate the effectiveness of intravenous magnesium sulfate for the treatment of pediatric patients with acute severe asthma exacerbations. Population and Methods. A clinical, randomized, controlled trial was conducted between March 2006 and March 2011 at Hospital Universitario Austral. Children with acute severe asthma admitted to the emergency department were randomized into two groups. Group A (control group): standard protocol for the initial treatment of acute asthma exacerbation. Group B: treatment protocol with magnesium sulphate for acute severe asthma exacerbation. The primary outcome was the requirement of invasive or non invasive mechanical ventilation support. Results. One hundred and forty three patients randomized into 2 groups were analyzed. The treatment group included 76 patients receiving magnesium sulfate within the first hour of the initiation of rescue treatment at the hospital, and the control group included 67 patients not treated with magnesium sulphate. Among the patients in the control group, 33% (n= 22) required mechanical ventilation support, compared to only 5% (n= 4) of the patients in the treatment group (p = 0.001). Conclusions. Intravenous infusion of magnesium sulfate during the first hour of hospitalization in patients with acute severe asthma significantly reduced the percentage of children who required mechanical ventilation support.     

High-flow nasal cannula in children with asthma exacerbation: A review of current evidence

Asthma is the commonest obstructive airway disease and the leading cause of morbidity in children. In the pediatric population, acute exacerbations of asthma are a frequent cause of presentations and hospital admissions. An acute asthma exacerbation is potentially life-threatening; it is predominantly treated using conventional oxygen therapy with bronchodilators and systemic corticosteroids. The treatment of those who do not respond to conventional therapy is escalated to noninvasive positive pressure ventilation (NIPPV) before invasive ventilation. Although NIPPV has demonstrated benefits and safety, it still has limitations such as treatment intolerance caused mainly by discomfort and complications. High-flow oxygen therapy administered through a nasal cannula (HFNC) provides respiratory support with adequate airway humidity and has demonstrated safety and benefits in clinical practice. In the present review, we discuss HFNC and variations in HFNC use, focusing on its feasibility and current evidence of using it on children with asthma exacerbations.     

Beyond the guidelines: fatal and near-fatal asthma

While asthma is extremely common, fatal and near fatal asthma is rare and often preventable if there is early recognition of symptom progression and appropriate intervention. In the past decade, asthma mortality has progressively declined in association with the widespread use of inhaled corticosteroids and asthma care plans. Management of life threatening asthma requires patient education to ensure the proper use of medications and to enable the patient to recognize when additional therapy for poorly controlled asthma is required. There is some evidence that suggests that the overly aggressive use of asthma medications when treating a severe exacerbation may contribute to morbidity. Because of the risks of air trapping and barotrauma associated with partial airway obstruction, it is best to avoid mechanical ventilation if possible but when this is used, low tidal volumes, longer exhalation times, and permissive hypercarbia can minimize these risks. There is the promise that a better understanding of asthma immunology and severe asthma "phenotypes" will lead to better prevention and therapy.     

What Is the Role for Magnesium to Treat Severe Pediatric Asthma Exacerbations?

In this review, we explore the role for intravenous magnesium sulfate (IVMg) to treat children with acute exacerbations of asthma. Children who receive care for severe acute asthma in emergency departments are often hospitalized after inadequate response to standard asthma treatment. IVMg may have a role to decrease hospitalization of children with severe acute asthma, but is in need of further research. Future exploration of IVMg should include larger randomized controlled trials of IVMg versus standard treatment, administration of IVMg with enough time to have effect on hospitalization, exploration of the pharmacology of IVMg so that the most effective dosage regimens can be selected, and use of measures and criteria to select research participants reflective of the children likely to benefit from more effective asthma treatment in clinical practice.     

Effectiveness of inhaled corticosteroids in controlling acute asthma exacerbations in children at home

Many clinicians advise their patients to increase the dose of inhaled corticosteroids during acute asthma exacerbations, without strong clinical evidence supporting this treatment. This study investigates the effectiveness of inhaled corticosteroids in controlling acute asthma exacerbations in children at home. The study population consisted of children with mild intermittent, mild and moderate persistent asthma aged 1 to 14 years who were treated in our outpatient clinic with inhaled budesonide for 1 year. After participating in an asthma education session, the parents were instructed to initiate treatment with inhaled budesonide at the first signs of asthma exacerbation, starting with 200 to 400 microg budesonide, in combination with beta-2 agonists 4 times a day and followed by a decrease in the dose in 4 to 8 days. Asthma status and peak expiratory flow rates were measured in the 3 monthly follow-up visits. Only children who complied with the treatment regimen and came for follow-up visits regularly were included in the final analysis. One hundred fifty children used our treatment protocol with inhaled budesonide to control their asthma attacks. Clinical improvement of asthma symptoms was achieved after a mean of 1.8 +/- 0.7 days from the beginning of treatment. The parents were able to control 94% of the 1,061 episodes of asthma exacerbation occurring during a cumulative follow-up period of 239 years. In the 3-month period before enrollment, 101 children (67%) had used oral corticosteroids to control their asthma attacks and 50 (33%) were hospitalized. During the entire follow-up period, only 11 children (7%) used oral corticosteroids, and none of the children were hospitalized. The present study demonstrates that children with asthma can control their exacerbations at home using inhaled corticosteroids (budesonide). Treatment, starting with relatively high doses followed by a rapid reduction in dose over 4-8 days, resulted in a decrease in the use of oral steroids and in hospitalization. To achieve good results, patient compliance is essential.     

Demonstrated use of metered-dose inhalers and peak flow meters by children and adolescents with acute asthma exacerbations

OBJECTIVES: To determine the ability of children and adolescents with acute asthma exacerbations to adhere to national guidelines for proper metered-dose inhaler (MDI) and peak flow meter (PFM) technique and to define characteristics associated with improper use. DESIGN: A prospective study in which the patients were instructed to use a placebo MDI or a PFM in the emergency department exactly as at home. Technique was graded on the basis of performance of specific steps recommended by national guidelines. SETTING AND PARTICIPANTS: Children and adolescents (aged 2-18 years) with acute asthma exacerbations in the emergency department of an urban children's hospital with acute asthma. RESULTS: Thirty-three (45.2%) of 73 patients using an MDI (MDI group) demonstrated multiple steps improperly compared with 60 (44.4%) of 135 using an MDI with a holding chamber (MDI-HC group; P =.92). In the MDI group, young ages of the patients (P<.008) and the parents (P<.003) were associated with improper use. In the MDI-HC group, factors independently and significantly associated with improper use were no hospitalizations within the past year, parent assistance of the patient with MDI-HC use, and nondaily use of the MDI-HC. Also, 165 (82.9%) of 199 children who, per national guidelines, should be using a PFM at home, did not. Eighty-two (73.9%) of 111 patients demonstrated perfect performance of all PFM steps. CONCLUSIONS: Among children with acute asthma, we found high rates of improper MDI use and PFM underuse. A greater emphasis must be placed on teaching methods to optimize drug delivery and to instruct patients about the importance of self-monitoring of disease severity.     

Acute asthma in the pediatric emergency department

The management of children with acute asthma remains a difficult and challenging process. Although newer asthma medications are being developed, they are unlikely to have a large impact on the management of children with acute asthma. The leukotriene inhibitors are new anti-inflammatory agents for asthma and are beneficial for the treatment of patients with chronic asthma but have no therapeutic effect during the acute phase of an exacerbation. Older treatments, including the use of magnesium and heliox, have been revisited. Although some children with severe asthma may respond, these do not provide relief for most children with acute exacerbation. The new challenge for asthma care is finding ways to link children with their primary care providers so that regular asthma care can be established. The NHLBI recommends that children with asthma have regular visits with their primary care providers (e.g., four times a year). Regular care results in better adherence to medical and preventive management plans and improves the relationship between patients and physicians. Instituting an asthma action plan, which instructs families on when and how to begin therapy for an acute exacerbation, may prevent progression to a more severe condition.     

A review of the role of inhaled corticosteroids in the treatment of acute asthma

Systemic corticosteroids (CSs) are generally accepted as treatment for acute exacerbations of asthma. In contrast, inhaled corticosteroids (ICs) have been used for the long-term management of asthma but are not widely accepted for the treatment of asthma exacerbations. The onset of action of ICs in acute asthma begins in 1 hour. In patients with mild to moderate exacerbation, administration of high-dose ICs may decrease the need for hospital admission and the number of symptomatic days.     

Management of acute asthma exacerbations in pediatrics

Despite the significant advances that have been produced in the management of asthma in the last few decades, crises, attacks, or asthma exacerbations (acute asthma) continue to be the most common cause of consultation in pediatric emergency units. Visits to these units and hospital admissions due to acute asthma represent three quarters of the direct costs due to this disease. Acute asthma is a medical emergency that should be rapidly diagnosed and treated. Evaluation of children with acute asthma exacerbations should consist of two phases: a static phase (determination of the severity of the crisis on admission) and a dynamic phase (treatment response). The present article provides an in-depth review and analysis of current pharmacological and nonpharmacological treatments (oxygen, bronchodilators, corticosteroids - inhaled and systemic - aminophylline, magnesium sulfate, etc.) of acute asthma exacerbations and proposes management protocols for use in both primary care and emergency units.     

A 3-day course of 1 mg/kg versus 2 mg/kg bodyweight prednisolone for 1- to 5-year-old children with acute moderate exacerbation of asthma: a randomized double-blind noninferiority trial

BackgroundEven though the guidelines on the management of preschool asthma recommend early use of corticosteroids for acute moderate-to-severe exacerbations, considerable variation exists with regard to type and dose of steroids.ObjectivesTo compare the clinical outcomes and side effect profile between 1 mg/kg/day and 2 mg/kg/day of oral prednisolone when administered for 3 days in preschool children with acute moderate asthma exacerbations.Study Design and SettingRandomized double-blind noninferiority trial was done in the paediatric emergency of a teaching hospital.Patients, Interventions, and OutcomesA total of 128 children aged 1 to 5 years who presented to the paediatric emergency with acute moderate exacerbation of asthma were enrolled. They were randomized into two groups. One group received 1 mg/kg/day and the other 2 mg/kg/day of oral prednisolone for 3 days. Severity of asthma exacerbation was measured by Pediatric Respiratory Assessment Measure (PRAM) score. The PRAM scores, wheeze recurrence, and side effect profile were compared and analyzed between the two groups.ResultsThe difference in the PRAM scores at 1, 2, 3, and 4 hours after intervention between the two groups was statistically insignificant. Need for escalation of therapy, salbutamol nebulization, time for resolution of symptoms, and recurrence of wheeze were similar between the two groups. Vomiting was significantly less frequent in low-dose group with a relative risk of 0.19 to 0.99 compared to high-dose prednisolone.ConclusionPrednisolone at a dose of 1 mg/kg/day was not inferior to 2 mg/kg/day in terms of clinical improvement and recurrence of wheeze within 1 week and has less frequent vomiting compared to higher dose.     

How does home management of asthma exacerbations by parents of inner-city children differ from NHLBI guideline recommendations? National Heart, Lung, and Blood Institute

OBJECTIVES: 1) To describe the asthma morbidity, primary care practices, and asthma home management of inner-city children with asthma; 2) to determine the responses of parental caretakers to asthma exacerbations in their child; and 3) to compare these responses to the recommendations of the National Heart, Lung, and Blood Institute (NHLBI) asthma guidelines for home management of acute exacerbations of asthma. DESIGN AND METHODS: A 64-item telephone survey was administered between July 1996 and June 1997 to 220 parental caretakers of 2- to 12-year-old children who had been hospitalized with asthma at an inner-city medical center from January, 1995 to February, 1996. Sociodemographics, primary care practices, asthma morbidity, and asthma home management were assessed. Parents were asked what they would do if their child "began wheezing and breathing faster than usual." RESULTS: Morbidity measures indicated that there were an average of 2.5 +/- 4.5 emergency department visits for asthma in the last 6 months, 1.6 +/- 2.2 hospitalizations for asthma in the last 12 months, and 18.1 +/- 17.9 asthma-related school absences in the previous school year. Most, but not all, of the families had primary care providers and most had phone access to them. Half of the families (51%) reported having been given a written asthma action plan. Only 30% of families with children age 5 years and older had peak flow meters. In contrast, almost all families (97%) had equipment for inhalation of beta-agonists. Only 39% of the 181 children with persistent symptoms were receiving daily antiinflammatory agents as recommended in the guidelines of the NHLBI. In response to the scenario of an acute exacerbation of asthma, no one mentioned that they would refer to a written plan, only 1 caretaker would measure peak flow and 36% would give beta-agonists. Two percent would give oral steroids initially, and 1 additional person would do so if wheezing continued 40 minutes later. Only 4% responded that they would contact their clinician. Reports of actual practice differed from the scenario responses in that more people began beta-agonists and oral steroids in response to an exacerbation in the past 6 months than said they would in response to the scenario. CONCLUSION: In this population of previously hospitalized inner-city children with asthma, the NHLBI guidelines for the home management of asthma exacerbations are not being followed. Interventions are needed to affect both clinician and caretaker practices.     

Filaggrin gene variants and atopic diseases in early childhood assessed longitudinally from birth

Bønnelykke K, Pipper CB, Tavendale R, Palmer CNA, Bisgaard H. Filaggrin gene variants and atopic diseases in early childhood assessed longitudinally from birth.
Pediatr Allergy Immunol 2010: 21: 954–961.
© 2010 John Wiley & Sons A/S Copenhagen Prospective Study on Asthma in Childhood (COPSAC) was one of the discovery cohorts of the association between eczema and variants in the filaggrin coding gene (FLG). Here, we study the FLG‐associated risk of asthma symptoms in early life and describe the temporal relationship in the development of the different FLG‐associated atopic outcomes: asthma, sensitization and eczema, assessed longitudinally from birth. A high‐risk cohort of 411 children was assessed in a prospective clinical study from birth to school‐age. Asthma, acute severe asthma exacerbations, sensitization and eczema were diagnosed prospectively by the investigators. FLG variants R501X and Del4 were determined in 382 Caucasians. Filaggrin variants increased risk of developing recurrent wheeze, asthma and asthma exacerbations (hazard ratio 1.82 [1.06–3.12], p = 0.03), which was expressed within the first 1.5 yr of life. Children with filaggrin variants had a marked and persistent increase in acute severe asthma exacerbations from 1 yr of age (incidence ratio 2.40 [1.19–4.81], p = 0.01) and increased risk of asthma by age 5 (odds ratio 2.62 [1.12–6.11], p = 0.03). FLG variants increased the risk of eczema, manifesting fully in the first year of life (point prevalence ratio for age 0–5 was 1.75 [1.29–2.37]; p‐value = 0.0003) contrasting the increased risk of specific sensitization by age 4 (odds ratio 3.52 [1.72–7.25], p = 0.0007) but not age 1.5. This study describes a FLG‐associated pattern of atopic diseases characterized by the early onset of asthma symptoms and eczema and later development of sensitization. The association of filaggrin variants with asthma suggests skin barrier dysfunction as a novel, and potentially modifiable, mechanism driving early childhood asthma.