Asthma treatment and outcomes for children in the emergency department and hospital

Objective: To describe and compare the treatment of acute asthma exacerbations in children given in the emergency department (ED) and admitted to acute care floor in the hospital or intensive care unit (ICU). Methods: A retrospective chart review of visits for acute exacerbation of asthma treated at Phoenix Children's Hospital between January 1, 2014 and December 31, 2016. Results: A total of 287 asthma exacerbation cases were identified including 106 (37%) ED visits, 134 (47%) hospital floor and 47 (16%) ICU admissions. A history of a previous ED visit (ED 88%, Floor 60% and ICU 68%; p < 0.0001) and prior pulmonology inpatient consultation (ED 30%, Floor 19% and ICU 15%; p = 0.05) varied significantly. Pulmonology inpatient consultations were performed more frequently in the ICU than on the hospital floor (54% versus 8%; p < 0.0001). Although overall 145 (51%) of the cases were already on inhaled corticosteroids (ICS) at the time of visit with no differences across locations, ICS initiation/step-up was greater in the ICU (72%) than on the hospital floor (54%) and ED (2%) (p < 0.0001). A recommendation given to the family for follow-up with pulmonology was more frequent for patients who had been admitted to the ICU (68%) as compared to those only admitted to the floor (31%) or ED (4%) (p < 0.0001). Readmission rates were similar for patients previously admitted to the hospital (Floor 42%; ICU 40%), but significantly higher for previous ED visits (77%) (p < 0.0001). Conclusions: Physicians in the ED have an opportunity to provide preventative care in the acute care setting and should be encouraged to initiate treatment with ICS. Consideration should be given to develop a program or clinical pathway focused on long-term asthma management and maintenance to reduce readmissions and long hospital stays.     

Relationship between exhaled nitric oxide and IgE sensitisation in patients with asthma: influence of steroid treatment

Introduction: The influence of the degree of immunoglobulin E (IgE) sensitisation on the fraction of expired nitric oxide (FE_NO) in asthma patients being treated with inhaled corticosteroids (ICS) is not well known. Objectives: To investigate the relationship between IgE sensitisation and FE_NO, and the effect of a step‐up in ICS treatment on this relationship, in patients with allergic asthma. Methods: A primary health care centre recruited 20 non‐smoking patients with perennial allergic asthma (18 years–50 years, six male) outside the pollen season. At every visit (0, 2, 4, 8 weeks), FE_NO was measured and an exposure questionnaire was completed. ICS dose was adjusted according to FE_NO (≥22 ppb prescribed increase in ICS). Quantitative analyses of serum IgE (eight common aeroallergens) confirmed allergy. Results: At baseline, FE_NO and the sum of IgE antibody titres for perennial allergens correlated significantly (r = 0.47, P = 0.04). After a step‐up in ICS treatment, this correlation had disappeared. Nine patients had persistently elevated FE_NO at last visit (mean 35 ppb vs 16 ppb). This group was more frequently exposed to relevant allergens or colds (89% vs 27% of patients, P < 0.05) and had higher IgE antibody titres (perennial allergens) compared with the normalised group (mean 28.9 kU/L vs 10.7 kU/L, P < 0.05). Conclusion: Serum IgE against perennial allergens and FE_NO correlate in patients with allergic asthma. However, this relationship disappears after a high‐dose ICS regimen, suggesting that FE_NO relates to bronchial inflammation and not IgE levels per se. High degree of IgE sensitisation together with allergen exposure may lead to ICS‐resistant airways inflammation. Please cite this paper as: Syk J, Undén AL and Alving K. Relationship between exhaled nitric oxide and IgE sensitisation in patients with asthma: influence of steroid treatment. The Clinical Respiratory Journal 2009; 3: 143–151.     

Emergency Hospital Care for Exacerbation of COPD: Is Inhaled Maintenance Therapy Modified?

Background: The impact of hospital emergency care and inward admission for acute exacerbations of COPD on inhaled maintenance treatment is not well known. Objective: Therefore, we evaluated the impact of short-stay emergency hospital care and inward admission for acute exacerbation of COPD (eCOPD) on inhaled maintenance treatment prescribed at discharge. Design: Prospective observational cohort study of patients presenting with eCOPD at emergency departments in 16 hospitals of the Spanish healthcare system. The ethics committee at each hospital approved the study and patients provided an informed consent before inclusion. We classified the patients according to the severity of COPD: mild/moderate (FEV₁ ≥ 50% predicted) or severe/very severe (FEV₁ < 50% predicted) and need of inward hospitalisation. We analysed changes to maintenance treatment on discharge according to GOLD strategy. Results: 1559 patients, 65% required hospitalisation. The most common maintenance treatment was inhaled corticoids (ICS) (80.9%) followed by long-acting beta-agonists (LABA) (75.4%). The most common combination was triple therapy (LABA+ LAMA+ICS) (56.2%) followed by LABA+ICS dual therapy (18.2%) regardless of the severity of COPD. In more than 60% of patients treatment was not changed at discharge. The most common change in treatment was a reduction when discharge was from emergency care and an increase after hospitalisation (-21.6% and +19.5% in severe/very severe COPD, respectively). Conclusions: Emergency hospital care for eCOPD does not usually induce changes in inhaled maintenance treatment for COPD regardless of the duration of the hospital stay.     

Transient sputum eosinophilia may occur over time in non‐eosinophilic asthma and this is not prevented by salmeterol

Background and Objective: Symptomatic, steroid‐naïve asthmatic patients may have low sputum eosinophil numbers. The aim of the study was to determine whether low sputum eosinophil numbers persisted over time, during treatment with salmeterol monotherapy. Methods: Forty steroid‐naïve, symptomatic asthmatic patients, with sputum eosinophils <3%, were randomized to receive open‐label salmeterol (50 µg twice a day, n = 30) or fluticasone (125 µg twice a day, n = 10) and were then assessed at 1, 3 and 6 months. All patients underwent spirometry, a methacholine challenge test and sputum induction at each visit. Symptom scores and peak expiratory flow were recorded throughout the study. Patients were permitted to withdraw from the study at any time, if they experienced exacerbations or deterioration of symptoms. Results: The average sputum eosinophil percentage remained normal (≤1.9%) in both groups over the study period. The eosinophil percentages were ≤1.9% in 65 of the 80 samples obtained from salmeterol‐treated patients throughout the study period. Eight patients had an asthma exacerbation or deterioration, during which one developed sputum eosinophilia. Twelve patients, 11 of whom were randomized to salmeterol and one to fluticasone, developed transient sputum eosinophilia at least once during the study. This was not associated with asthma exacerbation (except for one patient). Sputum neutrophil percentage did not change in either group. Conclusions: Low sputum eosinophil numbers persisted over 6 months in a majority of patients with non‐eosinophilic asthma who received salmeterol monotherapy. However, transient sputum eosinophilia occurred in 40% indicating that non‐eosinophilic asthma may not be a stable phenotype.     

Quality improvement methods improve inhaled corticosteroid prescribing in the emergency department

Objective: Inhaled corticosteroids (ICS) are underutilized among persistent asthmatics. Because of low outpatient follow-up rates after Emergency Department (ED) visits, children are unlikely to be prescribed ICS by their primary care physician after an acute exacerbation. ED physicians have the opportunity to contribute to the delivery of preventive care in the acute care setting. Our objective was to evaluate if quality improvement (QI) methods could improve the rate of ICS initiation at ED discharge. Methods: Within the Pediatric ED (PED) at a tertiary children’s hospital, QI methods were used to encourage ICS prescribing at the time of ED discharge. Interventions focused on education at both the attending physician and resident level, process improvements designed to streamline prescribing, and directed provider feedback. This involved multiple plan-do-study-act cycles. Medical records of eligible patients were reviewed monthly to determine ICS prescribing rates. The effect of our interventions on prescribing rate was tracked over time using a run chart. Results: Following our interventions, the ICS initiation rate for children seen in and discharged home from the ED with an acute asthma exacerbation increased from a baseline median rate of 11.25% to a median rate of 79% representing a significant, non-random improvement. The ICS initiation rate has been sustained for 8 months over our goal rate of 75%. Conclusions: This study demonstrates that QI methods can be used to increase inhaled corticosteroid initiation rate at the time of ED discharge and, thus, improve the delivery of preventive asthma care in the acute care setting.     

Management and survival of patients admitted with an exacerbation of COPD: comparison of two Danish patient cohorts

Introduction: The aim of this study was to describe the management and prognosis related to a hospital admission for acute exacerbation of chronic obstructive pulmonary disease and to compare results to an earlier study. Objectives and Methods: This is a retrospective study of 300 consecutively discharged patients admitted in 2006–2007 with an exacerbation of chronic obstructive pulmonary disease from three respiratory departments. Data were collected from patient charts and compared with a replicate study done in 2001. Results: The mean age was 72.1 years; 61.7% were women. Mean forced expiratory volume in 1 s was 37.6% of predicted. On admission, 11.3% were treated with non‐invasive ventilation, and 84.3% were given systemic corticosteroids. In‐hospital mortality was 4.7%. At discharge, treatment with inhaled corticosteroids or at least one long‐acting bronchodilator was given to 86.7% and 89% of patients, respectively, which was significantly higher than for similarly sampled patients in 2001. Mortality in 30 days and 1 year after discharge was 4.5% and 25.5%, respectively, compared with 5.5% and 30.3% in 2001, the 12‐month mortality being significantly lower (P = 0.03). Readmission rate in the 12 months following discharge was 42.3%. Long‐term oxygen treatment, treatment with anti‐dysrhythmic drugs and lack of outpatient follow‐up were independent predictors of 1‐year mortality. Risk of readmission was increased with dependence in self‐care activities, previous admissions and treatment with strong analgesics. Conclusions: Over a period of 6 years, a significantly higher number of patients are being treated according to guidelines. Survival following discharge increased over the same period. Please cite this paper as: Eriksen N and Vestbo J. Management and survival of patients admitted with an exacerbation of COPD: comparison of two Danish patient cohorts. The Clinical Respiratory Journal 2010; 4: 208–214.     

Problematic severe asthma in children treated at high altitude: tapering the dose while improving control

Background: Multidisciplinary treatment at high altitude is a possible treatment option for problematic severe asthma (PSA) in children. This management can result in the tapering of inhaled corticosteroids. Aim: Our aim was to analyze the effect of multidisciplinary treatment at high altitude, notably the ability to taper corticosteroids. To get an insight into possible factors influencing tapering, we examined whether demographic variables, disease control and quality of life at treatment entrance could predict the tapering of corticosteroids. Methods: This prospective open-phase cohort study analyzed the data of 43 children aged 8–17 years referred to a specialized high altitude treatment centre. Lung function (FEV₁, FEV₁/VC), inflammation (FeNO), medication level, asthma control (ACT) and quality of life [PAQLQ(S)] were evaluated on admission and at discharge. Results: Thirty-two (74%) children fulfilled PSA criteria. Three (7%) children used daily oral steroids. After 72?±?30 (mean?±?SD) days of treatment, the mean dosage of inhaled corticosteroids (ICS) could be significantly reduced from 1315?μg?±?666 budesonide equivalent to 1132 μg?±?514. Oral steroid maintenance therapy could be stopped in all patients. FeNO, asthma control and quality of life improved (p?1 was in the normal range on both occasions. Apart from ICS levels at entrance, multiple regression analyses did not show any associated factor predicting the reduction of ICS dosage during treatment. Conclusion: The results indicate that high altitude treatment may be a treatment option for children with PSA, but it is not possible to predict ICS tapering off from health status variables at treatment entrance.     

Principal findings of systematic reviews of acute asthma treatment in childhood

Objective: The objective of this study is to summarize the principal findings in the literature about acute asthma management in children. Methods: Systematic reviews of randomized clinical trials (SRCTs) with or without meta-analysis in children (1–18 years) admitted to the emergency department (ED) were retrieved using five data bases. Methodological quality was determined using the AMSTAR tool. Results: One hundred and three studies were retrieved. Among those, 28 SRCTs were included: seven SRCTs related to short-acting beta2-agonists (SABA), three to ipratropium bromide (IB), eight to corticosteroids, one to racemic adrenaline, one to leukotriene receptor antagonists (LTRA), four to magnesium sulfate, one to intravenous (IV) SABA, one to IV aminophylline, one to IV ketamine, and one to antibiotics. It was determined that administering SABA by MDI-VHC is superior to using a nebulizer, because it decreases the hospital admission rate, improves the clinical score, results in a shorter time in the ED, and causes fewer adverse effects. Levalbuterol and albuterol were similar. In patients with moderate to severe exacerbations, IB+SABA was superior to SABA, decreasing hospital admission and improving the clinical score. SABA heliox administered by nebulizer decreased exacerbation severity compared to oxygen. Inhaled corticosteroids (ICS), especially administered by nebulizer, showed results similar to oral corticosteroids (OCS) with respect to reducing hospital admission, unscheduled visits, and the requirement of additional systemic corticosteroids. ICS or OCS following ED discharge was similar with regard to relapse. Compared with a placebo, IV magnesium reduced hospital admission and improved lung function. Conclusions: SRCTs are useful for guiding decisions in acute asthma treatment.     

Prognosis of Adult Asthma After Normalization of Bronchial Hyperresponsiveness by Inhaled Corticosteroid Therapy

Background: Inhaled corticosteroids (ICSs) are the most effective anti-inflammatory drugs for adult asthma and can improve not only clinical symptoms but also bronchial hyperresponsiveness (BHR). However, the prognosis of adult asthma has not been well studied, and it remains to be elucidated precisely how long treatment with ICSs should be continued once clinical remission is achieved. Objectives: We examined whether ICS use could be withdrawn or reduced without exacerbation of disease. Methods: We retrospectively studied 374 adult patients with asthma to determine which factors predicted the elimination or reduction of ICS treatment without exacerbations of disease after the achievement of normalized BHR to acetylcholine. The patients were classified into three groups: Group 1 had symptoms within 6 months of normalization and needed to continue therapy; group 2 received the equivalent of ≥ 400 μ g fluticasone propionate until BHR normalization, did not have symptoms in the 6 months after normalization, and then had their doses of ICSs halved; and group 3 received the equivalent of ≤ 200 μ g fluticasone propionate at an enrollment, did not have symptoms in the 6 months after normalization, and then had all ICSs withdrawn. The primary outcome measure was the presence of clinical symptoms. We used multiple logistic regression and a Kaplan-Meier analysis to analyze the factors predicting remission. Results: Twenty-nine patients in group 3 remained asymptomatic for more than 30 months (mean 47.1 ± 12.4 months) after discontinuing ICS therapy. The predictive markers of remission were low levels of eosinophils in the sputum, high %V₅₀ at the first hospital visit, and the need for only a low daily dose of ICS to induce normalized BHR. Conversely, patients with severe BHR at the first hospital visit, low %FEV₁ at normalized BHR, and a need for high-dose ICSs to reach normalized BHR could not reduce or discontinue treatments. Conclusion: Some adult patients with asthma whose BHR is normalized by ICS therapy can achieve remission from disease exacerbation after discontinuation of ICSs. However, patients with severe asthma or asthma of long duration may not achieve remission even if their BHR is normalized.     

Controller adherence following hospital discharge in high risk children: A pilot randomized trial of text message reminders

Objective: To assess the feasibility of a mobile health, inhaled corticosteroid (ICS) adherence reminder intervention and to characterize adherence trajectories immediately following severe asthma exacerbation in high-risk urban children with persistent asthma. Methods: Children aged 2–13 with persistent asthma were enrolled in this pilot randomized controlled trial during an asthma emergency department (ED) visit or hospitalization. Intervention arm participants received daily text message reminders for 30 days, and both arms received electronic sensors to measure ICS use. Primary outcomes were feasibility of sensor use and text message acceptability. Secondary outcomes included adherence to prescribed ICS regimen and 30-day adherence trajectories. Group-based trajectory modeling was used to examine adherence trajectories. Results: Forty-one participants (mean age 5.9) were randomized to intervention (n = 21) or control (n = 20). Overall, 85% were Black, 88% had public insurance, and 51% of the caregivers had a high school education or less. Thirty-two participant families (78%) transmitted medication adherence data; of caregivers who completed the acceptability survey, 25 (96%) chose to receive daily reminders beyond that study interval. Secondary outcome analyses demonstrated similar average daily adherence between groups (intervention = 36%; control = 32%, P = 0.73). Three adherence trajectories were identified with none ever exceeding 80% adherence. Conclusions: Within a high-risk pediatric cohort, electronic monitoring of ICS use and adherence reminders delivered via text message were feasible for most participants, but there was no signal of effect. Adherence trajectories following severe exacerbation were suboptimal, demonstrating an important opportunity for asthma care improvement.     

A Cost‐Effectiveness Analysis of a Peak Flow‐Based Asthma Education and Self‐Management Plan in a High‐Cost Population

Background. Asthma education and action plans (AP) have been recognized as important components in the optimal management of asthma. Studies have differed on the importance of a peak flow‐based self‐management plans in reducing health care costs and use due to asthma exacerbation. Objective. To analyze the cost‐effectiveness of peak flow‐based action plans in reducing costs associated with ER visits and hospitalizations due to acute asthma exacerbation in a population of high‐risk and high‐cost patients, defined as patients with moderate to severe asthma with a history of recent urgent treatment in the ER or hospitalization due to asthma. Methods. A literature review of randomized clinical trials comparing peak flow‐based (PFB) action plans, symptom‐based (SB) action plans, and usual care/no action plan (NAP) was performed. Probability values regarding the effectiveness of each alternative (as measured by increase/decrease in ER visits and hospitalizations over a 6‐month period) were derived. Incremental cost‐effectiveness and cost‐benefit ratios were calculated for each alternative. Sensitivity analyses were performed. Results. For high‐risk and high‐cost asthma patients, our analysis revealed that the most cost‐effective alternative for reducing ER visits was a peak flow‐based self‐management plan. The peak flow‐based self‐management program had an incremental cost‐effectiveness (C/E) ratio of $ 60.57 per ER visit averted compared to usual care/NAP and a C/E ratio of $31.46 compared to the SB‐AP. The PFB‐AP was also the most cost‐effective in reducing asthma hospitalization costs with an incremental C/E ratio of $300 per hospitalization prevented, compared with usual care and a C/E ratio of $311, compared to a SB‐AP. Analysis yielded a cost‐benefit ratio of 13.79 for the PFB‐AP compared to NAP; the SB‐AP had a cost‐benefit ratio of 11.53 compared to NAP. Conclusion. Cost‐effectiveness and cost‐benefit analyses reveal that for high‐cost patients, a peak flow‐based asthma education and self‐management plan program is the most cost‐effective alternative in reducing costs associated with ER visits and hospitalizations due to asthma exacerbation. Further refinements to this cost‐effectiveness analysis including measuring changes in drug use and costs and patients' productivity losses need to be pursued and may demonstrate additional cost‐savings due to peak flow‐based asthma education plans.     

Identifying patient-specific beliefs and behaviours for conversations about adherence in asthma

Background: Asthma guidelines advise addressing adherence at every visit, but no simple tools exist to assist clinicians in identifying key adherence‐related beliefs or behaviours for individual patients. Aims: To identify potentially modifiable beliefs and behaviours that predict electronically recorded adherence with controller therapy. Methods: Patients aged ≥14 years with doctor‐diagnosed asthma who were prescribed inhaled corticosteroid/long‐acting β₂‐agonist (ICS/LABA) completed questionnaires on medication beliefs/behaviours, side‐effects, Morisky adherence behaviour score and Asthma Control Test (ACT), and recorded spirometry. Adherence with ICS/LABA was measured electronically over 8 weeks. Predictors of adherence were identified by univariate and multivariate analyses. Results: 99/100 patients completed the study (57 female; forced expiratory volume in 1 s mean ± standard deviation 83 ± 23% predicted; ACT 19.9 ± 3.8). Mean electronically recorded adherence (n= 85) was 75% ± 25, and mean self‐reported adherence was 85% ± 26%. Factor analysis of questionnaire items significantly associated with poor adherence identified seven themes: perceived necessity, safety concerns, acceptance of asthma chronicity/medication effectiveness, advice from friends/family, motivation/routine, ease of use and satisfaction with asthma management. Morisky score was moderately associated with actual adherence (r=?0.45, P < 0.0001). In regression analysis, 10 items independently predicted adherence (adjusted R²= 0.67; P < 0.001). Opinions of friends/family about the patient's medication use were strongly associated with poor adherence. Global concerns about ICS/LABA therapy were more predictive of poor adherence than were specific side‐effects; the one‐third of patients who reported experiencing side‐effects from their steroid inhaler had lower adherence than others (mean 62% vs 81%; P= 0.015). Conclusions: This study identified several specific beliefs and behaviours which clinicians could use for initiating patient‐centred conversations about medication adherence in asthma.     

Nebulizer and Spacer Device Maintenance in Children with Asthma

Objective. To evaluate inhalation device cleaning practices of children with asthma and its effect on their asthma morbidity. Methods. A survey of patients aged 4 to 18 years admitted to an urban pediatric emergency department (ED) with an acute asthma exacerbation. Questions included demographics, asthma history, preference of delivery devices, and frequency of device cleaning. Patients were followed until their disposition from the ED, or until the end of their hospitalization, if admitted. Results. 220 subjects completed the survey. Mean age was 9.2 (± 3.9) years-old. One hundred and four (47.3%) patients used both nebulizers and spacer devices, while 18 (8.1%) used spacers only and 98 (44.5%) used nebulizers alone. Seventy-seven (38.1%; 95%CI: 31.7%–45.0%) patients cleaned their nebulizers and 57 (46.7%; 95%CI: 38.1%–55.4%) cleaned their spacer devices after each use as recommended by the Centers for Disease Control. There were no detectable differences in visit admission rate, total number of previous admissions, number of asthma exacerbations per year, and number of ED visits in one year between users who cleaned their devices after every, or every other use, compared to those who cleaned their devices less frequently. Conclusion. Although the majority of patients did not follow accepted guidelines for inhalation device cleaning, further studies are necessary to correlate cleaning practices to patients' clinical outcome.     

Outcomes and health-related quality of life following hospitalization for an acute exacerbation of COPD

OBJECTIVE: The purpose of this study was to understand the outcomes for patients admitted to hospital for an acute exacerbation of COPD, and to determine the factors influencing quality of life and health service utilization of patients with COPD. METHODOLOGY: Hospital outcomes of 282 patients with moderate and severe COPD, for an acute exacerbation, were retrospectively evaluated. After 24 months of follow up, health-related quality of life (QoL) and health service utilization (emergency room (ER) visit and readmission) in 54 patients admitted previously, were surveyed by questionnaires. RESULTS: Of 282 COPD patients admitted for an acute exacerbation, 28 patients (9.9%) died during hospitalization, 241 patients (85.5%) were discharged home, and only 13 patients (4.6%) needed long-term care facilities. Although over 50% of the patients had survived over 2 years after discharge, their QoL was poor. Patients who frequently went to the ER or were admitted, were those with poor QoL, severe dyspnoea and frequent exacerbation. COPD exacerbation and dyspnoea were the main factors influencing QoL of the patients. Age, comorbidity, QoL, FEV1, frequency of COPD exacerbation, long-term oxygen therapy, and family doctor were the factors determining the likelihood of patients visiting the ER. Frequency of COPD exacerbation, family doctor and living alone were the factors determining which patients were likely to be admitted to hospital. CONCLUSION: The outcomes and QoL of patients admitted for an acute exacerbation of COPD were poor. The major factors influencing QoL were frequency of COPD exacerbation and severity of dyspnoea. Improvement of social and medical networks (e.g. reducing the number of patients living alone and providing family doctors for patients) may reduce health care service utilization.     

Influenza-Like Illness Responsible for Severe Exacerbations in Asthmatic Children During H1N1 Pandemic: A Survey Before Vaccination

Background. Asthma seems to be the more prevalent underlying condition in patients hospitalized for H1N1-related flu. Methods. A prospective survey was conducted during the early phase of H1N1 pandemic in France in asthmatic children before vaccination to assess whether severe exacerbations in childhood asthma are associated with influenza-like illness (ILI, the definition of H1N1-related flu in a pandemic). Eight pediatricians in primary care distributed in three localities (Paris, south suburb, and west suburb) conducted the survey (4 weeks/locality from week 36 to 47). At each visit, the pediatrician filled a questionnaire entering the information regarding asthma treatment, severe exacerbation (at least 3 days' use of systemic corticosteroids), and ILI (temperature ≥37.8°C, cough, and/or sore throat, in the absence of a known cause other than influenza) during the past 3 weeks. Results. The survey included 1155 asthmatic children (mean age [SD]: 7.5 years [4.1]); almost all visits were scheduled (99%). A severe exacerbation was recorded in 121 children [10.5%; 95% confidence interval (CI): 8.7–12.2%], which was concomitant with ILI in 20 children (16.5%; 95% CI: 9.9–23.2%), whereas 1034 children did not exhibit any exacerbation. In these latter children, 40 ILI were observed (3.9%; 95% CI: 2.7–5.0%), which constituted a significantly lesser percentage as compared with children with both exacerbation and ILI (p < .0001). This result remained significant in each locality. Overall, 60/1155 (5.2%; 95% CI: 3.9–6.5%) asthmatic children had an ILI. Conclusions. Our survey shows that severe exacerbation and ILI are strongly associated during the H1N1 pandemic in asthmatic children.     

Comparison of Asthma Knowledge,Management, and Psychological Burden among Parents of Asthmatic Children From Rural and Urban Neighborhoods in India

Introduction: Asthma prevalence is increasing in developing countries such as India. Little is known on parental knowledge of asthma severity, management and psychosocial impact, particularly among rural dwellers. Further, it is not known whether the female asthmatic child is particularly vulnerable. Objective: To evaluate parental asthma knowledge and psychological impact of having an asthmatic child. Methods: 134 consecutive caregivers were surveyed at the visit for their child's asthma exacerbation at an urban hospital in Kanpur, India between 3/2007–3/2008. Results: The child's age range was 5.7Â ± 2.7 years. 76% were urban city dwellers with significantly higher number having a college degree. 23% children had moderate to severe persistent asthma; however, only 42% were on inhaled steroids. Parental severity perception was comparable to National Heart, Lung and Blood Institute (NHLBI) classification. While 67% identified bronchoconstriction occurred with asthma, only 8.9% recognized that inflammation played a role. There was no difference in the perceived stress by area of residence with 89% reported not or only sometimes feeling stressed with having an asthmatic child. Similarly, the concern among those with a female asthmatic child did not differ with 73% of caregivers believing that asthma would not affect their daughter's future. Conclusion: In an urban Indian hospital, 23% of asthmatic children had moderate to severe persistent asthma but only 9% were on controllers. Their parents were well educated, able to identify asthma severity appropriately and denied being stressed with having asthmatic children, irrespective of the gender of the child. However, their understanding of asthma pathophysiology was sub-optimal. Increased disease knowledge may lead to greater medication adherence among asthmatic children in India.