Factors Associated with the Development of Severe Asthma Exacerbations in Children

Background. Asthma exacerbations are one of the most common causes of hospitalization in children and account for approximately 10,000 intensive care unit (ICU) admissions per year in the United States. Despite the prevalence of this disease in children, the factors associated with the development of these severe exacerbations are largely unknown. Methods. A retrospective case–control study was conducted involving all eligible children admitted to the hospital with asthma for a 1-year period. Potential associated factors and outcomes of children admitted to the ICU with a severe exacerbation (cases) were compared to those of children with acute asthma admitted to the ward (controls). Results. A total of 188 children were hospitalized with asthma during the study period, 57 (30%) of whom required admission to the ICU. There were no differences in age, gender, or race between cases and controls. Children admitted to the ICU were significantly more likely to have an allergy or irritant-triggered exacerbation than children admitted to the ward (OR 3.9; 95% CI 1.9–8.2; p = .0003). Additionally, children in the ICU had a significantly shorter duration of illness before being admitted to the hospital compared to those admitted to the ward (1.7 ± 2.3 vs. 3.4 ± 4.8 days; p = .002). Conclusions. In this retrospective review, severe asthma exacerbations in children are associated with a more rapid onset of symptoms and are more likely to be associated with allergens or irritants, supporting the importance of atopy in this population.     

The role of human rhinovirus (HRV) species on asthma exacerbation severity in children and adolescents

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.     

Factors associated with length of stay for pediatric asthma hospitalizations

Objective: Asthma is a leading cause of pediatric hospitalizations, but little is known about factors associated with length of stay (LOS) for asthma hospitalizations. The aim of this study was to identify factors associated with LOS for pediatric asthma hospitalizations. Methods: The Pediatric Health Information System (PHIS) was used to cohort patients 2–17 years old with a primary asthma diagnosis discharged from 42 PHIS hospitals in 2011. Sociodemographic, temporal and health-status factors were examined. Bivariate and generalized-estimating-equation logistic regression analyses were performed to identify factors associated with LOS, after adjusting for severity of illness (SOI). Results: In total, 25?900 children were hospitalized, with a mean LOS of 1.9 days. In bivariate analysis, mean LOS was longer (p?<?0.01) for patients with complex chronic conditions (CCC) (3.1 days versus 1.8 for non-CCC) and adolescents (2.3 versus 1.8 for 2–5 years old). In multivariable analysis, obstructive sleep apnea (OSA; OR 2.3; 95% CI: 1.8–2.9), older age (OR 1.3; 95% CI: 1.2–1.4), obesity (OR 1.3; 95% CI: 1.1–1.4), CCC (OR 1.3; 95% CI: 1.1–1.4), winter admissions (OR 1.2; 95% CI: 1.1–1.4), female gender (OR 1.1; 95% CI: 1.1–1.3), and weekend admissions (OR 1.1; 95% CI: 1.03–1.2) had higher odds of asthma LOS >2 days. Conclusions: OSA, older age, obesity, CCC, winter and weekend admissions, and female gender are associated with longer LOS for pediatric asthma hospitalizations, after adjustment for SOI. The study findings suggest that interventions focused on these at-risk groups may prove most useful in reducing LOS for pediatric asthma hospitalizations.     

Long-Acting Beta-Agonists and the Risk of Intensive Care Unit Admission in Children

Objective. A possible association between long-acting beta-agonists (LABA) and severe asthma exacerbations including death remains controversial. We examined whether LABA in the setting of combination therapy with inhaled corticosteroids (ICS) increase the risk of near-fatal asthma in children using a case–control study design. Methods. Medical records from admissions for asthma exacerbations in children 4–18 years of age during the 2005 calendar year at Children’s Hospital of Pittsburgh of UPMC were reviewed. Cases and controls were determined by pediatric intensive care unit (PICU) and floor admission, respectively. Exposure was defined by LABA use in combination with ICS versus ICS alone. Results. Records from 85 PICU and 96 pediatric floor admissions were reviewed. LABA use in combination with ICS did not increase the risk of PICU admission (odds ratio 1.07, 95% CI 0.46–2.52) compared to ICS only without LABA. After adjusting for demographics, asthma severity, history of PICU admissions, and concurrent infection, LABA/ICS use still did not increase the risk of PICU admission (adjusted odds ratio 0.84, 95% CI 0.26–2.76) compared to ICS alone. There were no deaths and five intubations within the study period. Conclusions. The combination of LABA and ICS did not appear to increase the risk of near-fatal asthma in children.     

Severe Exacerbations in Children with Mild Asthma: Characterizing a Pediatric Phenotype

Background: NHLBI guidelines classify asthma in children as intermittent, mild persistent, moderate persistent, and severe persistent asthma based on baseline symptoms and pulmonary function. However, this may not capture the spectrum of asthma in children, since even mild baseline disease can have significant effects on quality of life. Our objective was to describe a population of children with mild asthma admitted to the ICU with severe exacerbations. Methods: We examined data from all children with asthma who were admitted to the ICU with an acute exacerbation between April 1997, and December 2006. Children were defined as having mild asthma if their disease was classified as intermittent or mild persistent according to NHLBI criteria. Results: Of the 298 children admitted to the ICU with asthma, 164 (55%) were classified as having mild baseline asthma. Compared with children with more severe baseline asthma, mild asthmatic children were younger and less likely to have been previously admitted to the hospital for asthma. Other demographics, including admission severity of illness, gender, and prevalence of overweight, were similar in the two groups. There were no differences between the groups in ICU length of stay, hospital length of stay or types of therapies received. Thirteen children with mild asthma were intubated, although less frequently than those with more severe disease. Conclusions: Children with mild asthma have severe exacerbations. This suggests that chronic asthma severity does not necessarily predict asthma phenotypes during acute exacerbations.     

Bedroom air quality and vacuuming frequency are associated with repeat child asthma hospital admissions

Objective: Indoor environment factors have been associated with risk of asthma exacerbations in children but little is known about their role on asthma hospital readmissions. As children in Western societies continually spend more time indoors, understanding the influence of these factors on asthma exacerbation is important. We examined the role of indoor environmental and lifestyle characteristics on child asthma readmissions. Methods: A hospital-based case–control study recruited 22 children readmitted for asthma and 22 controls not readmitted for asthma. Logistic regression models were used to examine the association between aeroallergens and fungi in the bedroom and indoor lifestyle characteristics factors for asthma readmissions. To determine the best possible set of predictors among a large set of risk factors, we used random forests (RF) techniques. Results: Higher levels of airborne Cladosporium and yeast in the child’s bedroom increased risk of readmission (OR?=?1.68, 95% CI 1.04–2.72 and OR?=?1.52, 95% CI 0.99–2.34, respectively). Carpeted floors in the bedroom and synthetic doonas were also associated with increase in asthma readmissions (OR?=?4.07, 95% CI 1.03–16.06 and OR?=?14.6, 95% CI 1.26–169.4, respectively). In the home, frequent vacuuming using bagged cleaners increased risk of asthma readmission OR?=?15.7 (95% CI 2.82–87.2). Conclusions: Factors in the child’s bedroom play an important role in increasing the risk of asthma hospital readmissions. These findings have major clinical implications as the identified potential risk factors may be modifiable. Further epidemiological studies with larger samples are necessary to evaluate these associations further.     

Socioeconomic deprivation, readmissions, mortality and acute exacerbations of bronchiectasis

Background: Bronchiectasis is known to cause significant morbidity in children in New Zealand. Little is known of the disease in adults. Aim: Our objective was to characterise a cohort of adults who presented to hospital with acute exacerbations of the disease. Methods: We retrospectively collected information on all exacerbations treated as inpatients from a single hospital in South Auckland, New Zealand during 2002. Results: We collected information on 307 exacerbations in 152 patients. Twenty‐seven per cent were of Maaori ethnic origin, and 44% Pacific. Seventy per cent lived in areas categorised as the 20% most deprived in New Zealand. Comorbid conditions were present in 80% of patients – most commonly chronic obstructive pulmonary disease, asthma, diabetes and cardiac disease. Seventy (46%) patients had at least one readmission and 32 patients (21%) died within 12 months of admission to hospital. Greater deprivation was associated with increased mortality at 12 months after admission after adjusting for other factors (OR 11, 95% CI 2.0–61, P= 0.006). In the subgroup who underwent high‐resolution computed tomographic scanning (93), increasing severity of bronchiectasis (modified Bhalla score) was associated with readmission within 12 months (P= 0.004), but not mortality (P= 0.419). Conclusions: We have shown that exacerbations of bronchiectasis in South Auckland are more common in patients who are predominantly of Maaori or Pacific descent and are socioeconomically deprived. Admission to hospital for an exacerbation is associated with high readmission and mortality rates.     

Does Pre-hospital Telephone Communication with a Clinician Result in More Appropriate Medication Administration by Parents during Childhood Asthma Exacerbations?

Background. The National Heart, Lung and Blood Institute asthma guidelines recommend that parents communicate with a clinician during childhood asthma exacerbations when symptoms worsen or do not improve with initial therapy. This study tested the hypothesis that communication by parents with a clinician before an Emergency Department visit was associated with more appropriate medication administration for children with asthma exacerbations. Methods. This was a retrospective cohort study using data gathered from parents of children presenting with an asthma exacerbation to the emergency department. The communicating cohort included parents who communicated by telephone with a clinician during the exacerbation and the non-communicating cohort included parents who did not. Multivariate logistic regression models were used to test three hypotheses; communication with a clinician is associated with (1) administration of short-acting β-agonists (SABAs), (2) increased dosing frequency of SABAs, and (3) administration of an oral corticosteroid. Results. A total of 199 subjects were enrolled, with 104 (52.3%) in the communicating and 95 (47.7%) in the non-communicating cohort. There was an association between communication and provider practice type, with children who received routine care from a private practice provider more likely to communicate with the clinician than children in hospital-based clinics or community health centers (Adjusted OR 1.9, 95% CI 1.0–3.7). Impoverished children and children insured by Medicaid were less likely to communicate with a clinician (controlling for provider type). Parents who communicated with a clinician were more likely to administer a SABA (adjusted OR 3.6, 95% CI 1.3–9.4) and an oral corticosteroid (adjusted OR 3.3, 95% CI 1.3–8.4) but were not more likely to administer a SABA with increased dosing frequency (adjusted OR 0.9, 95% CI 0.5–1.6). Conclusions. Parents of children with asthma exacerbations who communicated with clinicians were more likely to administer SABAs and an oral corticosteroid before bringing their child to an emergency department. Frequency of SABA dosing was not associated with communication. Clinicians providing telephone advice to parents need to provide explicit instructions about medication administration, emphasizing the frequency with which SABAs should be administered.     

Frequency of health service use in the year prior to asthma death

Objective: High frequency health service use (HSU) is associated with poorly controlled asthma, and is a recognized risk factor for near-fatal or fatal asthma. The objective of this study was to describe the frequency of HSU in the year prior to asthma death. Methods: Individuals aged 0–99 years who died from asthma from April 1996 to December 2011 in Ontario, Canada were identified as cases. Cases were matched to 4–5 live asthma controls by age, sex, rural/urban residence, socioeconomic status, duration of asthma and a co-diagnosis of COPD. HSU records in the year prior to death [hospitalization, emergency department (ED) and outpatient visits] were assembled. The association of prior HSU and asthma death was measured by conditional logistic regression models. Results: From 1996 to 2011, 1503 individuals died from asthma. While the majority of cases did not have increased HSU as defined in the study, compared to matched live asthma controls, the cases were 8-fold more likely to have been hospitalized two or more times (OR?=?7.60; 95% CI: 4.90, 11.77), 13-fold more likely to have had three or more ED visits (OR?=?13.28; 95% CI: 7.55, 23.34) and 4-fold more likely to have had five or more physician visits for asthma (OR?=?4.41; 95% CI: 3.58, 5.42). Conclusions: Frequency of HSU in the year prior was substantially higher in those died from asthma. Specifically, more than one asthma hospital admission, three ED visits or five physician visits increased the asthma mortality risk substantially and exponentially.     

National estimates of 30-day readmissions among children hospitalized for asthma in the United States

Objective: Previous single-center studies have reported that up to 40% of children hospitalized for asthma will be readmitted. The study objectives are to investigate the prevalence and timing of 30-day readmissions in children hospitalized with asthma, and to identify factors associated with 30-day readmissions. Methods: Data (n = 12,842) for children aged 6–18 years hospitalized for asthma were obtained from the 2013 Nationwide Readmission Database (NRD). The primary study outcome was time to readmission within 30 days after discharge attributable to any cause. Several predictors associated with the risk of admission were included: patient (age, sex, median household income, insurance type, county location, and pediatric chronic complex condition), admission (type, day, emergency services utilization, length of stay (LOS), and discharge disposition), and hospital (ownership, bed size, and teaching status). Cox's proportional hazards model was used to identify predictors. Results: Of 12,842 asthma-related index hospitalizations, 2.5% were readmitted within 30-days post-discharge. Time to event models identified significantly higher risk of readmission among asthmatic children aged 12–18 years, those who resided in micropolitan counties, those with >4-days LOS during index hospitalization, those who were hospitalized in an urban hospital, who had unfavorable discharge (hazard ratio 2.53, 95% confidence interval 1.33–4.79), and those who were diagnosed with a pediatric complex chronic condition, respectively, than children in respective referent categories. Conclusion: A multi-dimensional approach including effective asthma discharge action plans and follow-up processes, home-based asthma education, and neighborhood/community-level efforts to address disparities should be integrated into the routine clinical care of asthma children.     

Trends in asthma readmissions among children and adolescents over time by age,gender and season

Objectives: Little is known about asthma readmissions within 28 days over time by age or gender. We explored trends in childhood asthma hospital readmission rates over time by age, gender and season. Methods: Using a large database of 53?156 childhood admissions with a primary diagnosis of asthma from the Department of Health Victoria Australia for 1997–2009, we explored asthma hospital readmissions rates by seasonality, gender and age (2–18 years) using chi square tests, logistic regression models and graphical techniques. Results: Approximately 9459 (28%) of the children had two or more admissions over the whole study period, contributing to 55% (29?056/53?156) of all admissions. Approximately 5% of admissions were repeat admission within 28 days. Over time, despite a decline in asthma incidence, the rate of readmission within 28 days increased, particularly in the 2–12 year age groups. Girls were at greater risk of readmission within 28 days (odds ratio [OR]?=?1.15; 95% CI: 1.004–1.32; p?=?0.04) and 12 months (OR?=?1.11; 95% CI: 1.05–1.19; p?=?0.001). Grass pollen season was associated with readmissions within 28 days, but only in boys (p?=?0.01). Conclusion: Over time, despite a fall in asthma incidence, readmission rates for childhood asthma significantly increased in younger age groups with girls at a higher risk of being readmitted than boys. Increased risk of repeat admission for boys was observed during the grass pollen season. These findings highlight high-risk groups, which has implications for both clinical services and patient care. More detailed monitoring of readmission rates amongst various risk groups over time is required.     

Clinical pathway improves pediatrics asthma management in the emergency department and reduces admissions

Objective: Poor adherence to the National Institute of Health (NIH) Asthma Guidelines may result in unnecessary admissions for children presenting to the emergency department (ED) with exacerbations. We determine the effect of implementing an evidence-based ED clinical pathway on corticosteroid and bronchodilator administration and imaging utilization, and the subsequent effect on hospital admissions in a US ED. Methods: A prospective, interventional study of pediatric (≤21 years) visits to an academic ED between 2011 and 2013 with moderate-severe asthma exacerbations has been conducted. A multidisciplinary team designed a one-page clinical pathway based on the NIH Guidelines. Nurses, respiratory therapists and physicians attended educational sessions prior to the pathway implementation. By adjusting for demographics, acuity and ED volume, we compared timing and appropriateness of corticosteroid and bronchodilator administration, and chest radiograph (CXR) utilization with historical controls from 2006 to 2011. Subsequent hospital admission rates were also compared. Results: A total of 379 post-intervention visits were compared with 870 controls. Corticosteroids were more likely to be administered during post-intervention visits (96% vs. 78%, adjusted OR 6.35; 95% CI 3.17-12.73). Post-intervention, median time to corticosteroid administration was 45?min faster (RR 0.74; 95% CI 0.67-0.81) and more patients received corticosteroids within 1?h of arrival (45% vs. 18%, OR 3.5; 95% CI 2.50-4.90). More patients received?>?1 bronchodilator dose within 1?h (36% vs. 24%, OR 1.65; 95% CI 1.23-2.21) and fewer received CXRs (27% vs. 42%, OR 0.7; 95% CI 0.52-0.94). There were fewer admissions post-intervention (13% vs. 21%, OR 0.53; 95% CI 0.37-0.76). Conclusion: A clinical pathway is associated with improved adherence to NIH Guidelines and, subsequently, fewer hospital admissions for pediatric ED patients with asthma exacerbations.     

Factors associated with disease severity in children with bronchiolitis

Objective: Bronchiolitis is one of the top causes of hospitalization of infants in the United States. Several clinical factors have been associated with hospitalization; however, few studies have examined factors related to severe disease. Our goal was to describe the clinical characteristics and hospital course of children admitted with bronchiolitis and to identify factors related to intensive care unit (ICU) admission in this population. Methods: We conducted a retrospective review of all children less than 2 years of age admitted to a children’s hospital with bronchiolitis between July 2008 and July 2011. Demographic and clinical data were collected including information regarding hospital course, treatments received and respiratory pathogens. Results: During the study period, 734 children were admitted to the hospital with bronchiolitis, 22% of whom were admitted to the ICU and 10% of whom were intubated and mechanically ventilated. Admission to the ICU was associated with younger age [110 (45–210) days versus 69 (35–149) days, p?<?0.001] and history of premature birth (OR 1.7, 95% CI 1.1–2.4, p?=?0.01), but not with race or ethnicity. The use of respiratory treatments was common in the children admitted to the ICU but was not associated with shortened durations of hospitalization. In addition, neither prematurity nor young age were associated with either increased duration of hospitalization or with increased likelihood of mechanical ventilation. Conclusions: During acute bronchiolitis infections, younger children and those with a history of prematurity were more likely to be admitted to the ICU with severe disease.     

Hospital readmissions for childhood asthma: a 10-year metropolitan study

Studies of asthma admissions in the St. Louis metropolitan area have disclosed substantial numbers of children with readmissions. To determine the magnitude of readmissions and attributes of children with readmissions, a retrospective analysis of 8,761 children with 14,905 asthma hospitalizations for January 1, 1990 through December 31, 1999 at the two university affiliated children's hospitals in St. Louis was undertaken. Patient attributes of age, sex, race/ethnicity, residence, payor status, length of stay, and month of admission were compared between patients admitted once during that period and patients admitted multiple times. Main outcome measures were the total number of admissions and time to readmission during the study interval. A Lin, Wei, Yang, and Ying model of time to readmission showed that African-American children with Medicaid or no insurance are at higher risk of readmission (risk ratio 1.28) than are African-American patients with commercial insurance or white/other race/ethnicity patients regardless of insurance. Probability of readmission increased from 30% after a first admission, 46% after a second, and 59% after a third. Prior admission was a more specific indicator of readmission with greater positive predictive value than ethnicity or insurance status or their combination.     

Risk factors for an intensive care unit admission in children with asthma

An admission to an intensive care unit (ICU) with asthma is a marker of asthma severity and may be a precursor of asthma death. The aim of this study was to investigate risk factors for acute severe asthma needing an ICU admission. We hypothesized that children admitted to the ICU represent a severe phenotype with identifiable premorbid clinical features. The study was case-control in design. One hundred and forty-one children were studied. Seventy children admitted to the ICU and 71 children admitted to the general medical ward served as cases and controls, respectively. Children were aged between 1-16 years. They underwent skin prick allergy testing, and had a nasopharyngeal aspirate and serology performed to screen for respiratory pathogens. Their parents completed an asthma and allergy symptom questionnaire and the Newcastle Asthma Knowledge Questionnaire (NAKQ). On univariate analysis, an admission to the ICU was more likely in children with 1) "frequent episodic" or "persistent" background asthma; 2) three or more previous admissions for asthma; 3) one or more asthma admissions in the previous 12 months; 4) three or more presentations to the Emergency Department (ED) in the preceding 12 months; 5) three or more positive responses on skin prick allergy testing; 6) an elevated IgE level; 7) oxygen saturation on presentation < or =91%; 8) longer duration of asthma; 9) lower level of maternal education; 10) an admission during autumn; 11) three or more siblings; and 12) being prescribed antibiotics. Risk factors that remained significant on multivariate analysis were three or more presentations to the ED in the preceding 12 months (P=0.003), an elevated IgE level (P=0.01), oxygen saturation on presentation < or =91% (P=0.003), and longer asthma duration (P=0.02). ICU patients took longer to see a doctor and to commence oral steroids. No differences were found between cases and controls in the proportion taking preventer therapy (58% vs. 52%), provided with a written asthma action plan (32% vs. 25%), or in whom spirometry or peak flow was measured (28% vs. 42%). However, rates were low in both groups. Parental asthma knowledge was generally poor. This study identified risk factors for an ICU admission in children with asthma. A potentially preventable risk factor is a history of multiple ED presentations in the past year. Specialist referral of children with multiple ED presentations may improve asthma control and reduce the risk of an ICU admission. Background asthma management remains suboptimal in children needing hospitalization.     

Pediatric Asthma Admissions: Chronic Severity and Acute Exacerbations

Factors resulting in intensive care unit (ICU) admissions for asthma exacerbations remain largely unclear. We compared ICU and general pediatric ward admissions for asthma exacerbations. Charts of 56 (2- to 18-year-old) patients admitted consecutively to the ICU during a 1-year period for asthma exacerbations were compared with charts of 56 age-, sex-, race-, and era-matched patients admitted to a general pediatric ward. Few patients in both groups received oral steroids before admission. Children with different chronic asthma severities had comparable severities of acute exacerbation. In conclusion, acute asthma exacerbations dissociate in severity from chronic asthma and are under-treated with systemic corticosteroids.     

Pediatric Asthma Admissions: Chronic Severity and Acute Exacerbations

Factors resulting in intensive care unit (ICU) admissions for asthma exacerbations remain largely unclear. We compared ICU and general pediatric ward admissions for asthma exacerbations. Charts of 56 (2- to 18-year-old) patients admitted consecutively to the ICU during a 1-year period for asthma exacerbations were compared with charts of 56 age-, sex-, race-, and era-matched patients admitted to a general pediatric ward. Few patients in both groups received oral steroids before admission. Children with different chronic asthma severities had comparable severities of acute exacerbation. In conclusion, acute asthma exacerbations dissociate in severity from chronic asthma and are under-treated with systemic corticosteroids.     

Relevance of chest radiography in pediatric inpatients with asthma

Introduction: The goals of this study are to identify factors associated with ordering of chest radiographs (CXR’s) in children hospitalized with acute asthma exacerbations and determine the overall clinical impact of these CXR’s. Methods: A retrospective study was performed with children?≥?2 years of age admitted from our emergency department (ED) between 6/1/2011 and 5/31/2012 with a primary diagnosis of acute asthma exacerbation or status asthmaticus. Patients were excluded if they had been on antibiotics prior to the emergency visit, received continuous albuterol or intravenous magnesium during the hospitalization, or had another chronic disease affecting lung function. Results: 180 of the 405 children in the study (44%) had CXR’s ordered, of which 18 (10%) had imaging that altered the patient’s treatment plan. There were six cases of radiologist-diagnosed pneumonia, nine cases of atelectasis treated with antibiotics and three cases of pneumothorax. Factors associated with CXR ordering were: fever at home or in the ED (OR 4.5, 95% CI 2.8–7.4), triage oxygen saturation less than or equal to 92% (OR 1.8, 95% CI 1.2–2.7) and age 4 years or less (OR 2.3, 95% CI 1.4–3.7). Patients with treatment-altering CXR’s were more likely to have oxygen saturations less than or equal to 92% (OR 4.2, 95% CI 1.4–13.0; p?=?0.006) or fever in the ED (OR 3.8, 95% CI 1.0–13.6; p?Conclusions: The majority of CXR’s ordered in pediatric inpatients with asthma exacerbation do not provide clinically relevant information.     

Barotrauma Not Related to Type of Positive Pressure Ventilation During Severe Asthma Exacerbations in Children

Background: Children with impending respiratory failure due to severe asthma may be treated with endotracheal intubation and mechanical ventilation. Barotrauma occurs in a significant number of these children. Non-invasive positive pressure ventilation (NPPV) has been used as an alternative intermediary therapy and potentially prevents intubation. However, the comparative risk of barotrauma associated with the use of NPPV has not been evaluated in this population. Objective: To determine if the mode of positive pressure delivery per se affects the likelihood of development of barotrauma. Methods: We retrospectively examined data from all children older than 2 years of age admitted to the Intensive Care Unit (ICU) with an asthma exacerbation between April 1997 and August 2006. Results: Of the 293 children admitted to the ICU with asthma, 45 (17%) received treatment with positive pressure ventilation: 11 received only NPPV, 29 were intubated and mechanically ventilated, and 7 children received both of these therapies. Compared with those not requiring positive pressure, children receiving positive pressure were significantly more likely to develop barotrauma during hospitalization (OR 8.9; 95% CI 2.4–32.7). However, the incidence of barotrauma did not significantly differ according to the mode of positive pressure delivery: 9% in those who received only NPPV, 14% in those who were intubated, and 14% in those who received both therapies (p = 0.92). Conclusions: The use of positive pressure is associated with an increased risk of barotrauma in children with asthma, regardless of the mode of delivery.     

Pediatric Emergency Departments are More Likely Than General Emergency Departments to Treat Asthma Exacerbation With Systemic Corticosteroids

Objective. To determine whether systemic corticosteroids are under-prescribed (as measured by current NIH treatment guidelines) for children in the United States seen in the emergency department (ED) for acute asthma, and to identify factors associated with prescribing systemic corticosteroids. Methods. We used data from the 2001–2007 National Hospital Ambulatory Medical Care Survey. The study population was children ≤18 years old in the ED with a primary diagnosis of asthma (ICD-9-CM code 493.xx) who received bronchodilator(s). The primary outcome was receipt of a systemic corticosteroid in the ED. Independent variables included patient-level (e.g., demographics, insurance, fever, admission), physician-level (provider type, ancillary medications and tests ordered), and system-level factors (e.g., ED type, geographic location, time of day, season, year). We used multivariable logistic regression techniques to identify factors associated with systemic corticosteroid treatment. Results. Systemic corticosteroids were prescribed at only 63% of pediatric acute asthma visits to EDs. Over the study period, there was a trend toward increasing systemic corticosteroid use (p for trend = .05). After adjusting for potential confounders, patients were more likely to receive systemic corticosteroids when treated in pediatric EDs than in general EDs (OR = 2.45; 95% CI: 1.26–4.77).Conclusion. Systemic corticosteroids are under-prescribed for children who present to EDs with acute asthma exacerbations. Pediatric EDs are more likely than general EDs to treat asthma exacerbations with systemic corticosteroids. Differences in the process of care in pediatric ED settings (compared to general EDs) may increase the likelihood of adherence to NIH treatment guidelines.