Symptomatic Improvement Following Emergency Department Management of Asthma: A Pilot Study of Intramuscular Dexamethasone Versus Oral Prednisone

Systemic corticosteroid therapy is an established adjunct to beta-adrenergic medications in acute exacerbations of asthma. To date, no study has defined the role of long-acting intramuscular preparations of corticosteroids in pediatric patients with asthma. A pilot study was conducted to prospectively compare symptomatic improvement following a single injection of intramuscular dexamethasone (IMD) to a 3-day regimen of oral prednisone (OP) for children with mild to moderate wheezing episodes that are responsive to nebulized medications in the Pediatric Emergency Department (PED). The following children presenting with acute exacerbations of asthma to the PED were eligible for enrollment: age 3-16 years; more than two prior wheezing episodes; mild to moderate wheezing; and oxygen saturation 95% or more in room air. The study patients were randomly assigned to receive either IMD (n = 21) or OP (n = 21) in addition to a standardized treatment regimen of nebulized albuterol. All of the children were clinically rated for wheezing severity by the Pulmonary Index (PI) score at regular intervals during the study. Discharge home was based on clinical improvement during treatment in the PED; patients who were admitted to the hospital were removed from the study. Follow-up was conducted the fifth day after discharge from the ED either by clinic visit or by telephone. Patients were assessed for symptomatic improvement and relapse or clinical deterioration during the study period by a clinician blinded to group assignment. Forty-two children participated in this pilot study. There were no significant differences between the IMD and OP groups for gender or age. Mean ages were: 82 months (SD 46 months), IMD group; 63 months (SD 36 months), OP group. Clinical progress (based on PI) with treatment in the PED was the same in both groups: pretreatment median, PI = 6; PED discharge median, PI = 2. None of the study patients were hospitalized during the follow-up period, and all reported symptomatic improvement since initial treatment. The data of this pilot study suggest that IMD may be a feasible alternative to OP for treatment of acute wheezing episodes in children with asthma. IMD provides sufficient treatment to prevent clinical deterioration within 5 days after initial therapy for mild to moderate pediatric exacerbations of asthma that are responsive to nebulized medications.     

Spacers versus nebulizers in treatment of acute asthma – a prospective randomized study in preschool children

Objective: To compare administration of bronchodilators by nebulizers with delivery by metered dose inhalers (MDIs) with spacers and to evaluate the clinical effect of the treatment of acute asthma in preschool children. Methods: A prospective randomized clinical trial in a pediatric emergency department (PED). Preschool children who were admitted for virus induced wheezing or acute asthma exacerbation were randomly allocated to receive bronchodilator treatment by nebulizer or by metered dose inhaler. The accompanying parents completed a questionnaire. Results: The length of stay in the PED and the hospitalization rate were similar and no difference was seen in the parents' view of ease of use and device acceptance. Baseline data were similar for both groups apart from the family history of asthma and atopic disease that was greater in the nebulizer group. No significant differences were seen in heart rate, respiratory rate and oxygen saturation at baseline and after the treatment. According to the parents 40% of the participants had asthma diagnosis though up to 66% had some kind of asthma medication. Conclusions: Our data suggests that MDIs with spacers are at least as effective as nebulizers in the delivery of beta agonists to treat preschool children with virus induced wheezing or acute exacerbations of asthma in the PED. Parents may underestimate the gravity of their children's asthma. It is mandatory to provide adequate information to the staff and parents in order to treat pediatric acute asthma successfully.     

Rhinovirus and influenza type A infections as precipitants of asthma.

Specimens from 49 persons, 3 to 60 years of age, who were prone to attacks of apparently infectious asthma were cultured for viruses and bacteria during episodes of symptomatic respiratory infection from September 1972 to June 1973. Seventy-one of 128 episodes (55 per cent) of symptomatic respiratory infection occurred with asthma. Shedding of respiratory pathogens was associated with 43 of the 128 episodes, and 19 of the 43 etiologically defined episodes occurred with wheezing. Seven of 15 rhinovirus symptomatic respiratory infections were linked with asthma, as were 4 of 5 influenza type A (H3N2) and 2 of 3 respiratory syncytial virus infections. A total of 21 different rhinovirus serotypes have been identified from asthmatic patients during 2 years of study; 14 of these were associated with wheezing, indicating that the ability to cause asthma is not restricted to only a few types. Other viruses that were shed during wheezing-associated symptomatic respiratory infections included para-influenza type 3, adenovirus type 7, and 2 unidentified viruses. Although infectious asthma was not easily defined in adults and some older children, viruses that appeared to precipitate asthma were distributed among patients of widely differing ages.     

Frequency of gastroesophageal reflux disease in nonatopic children with asthma-like airway disease

Gastroesophageal reflux disease (GERD) is commonly associated with asthma; however, frequency in nonatopic children with asthmatic symptoms is unknown. The aim of this study was to determine the frequency of gastroesophageal reflux (GER) in nonatopic children with asthma-like airway disease that recur despite conventional asthma treatment and to evaluate the clinical response to lansoprazole treatment. Twenty-five nonatopic children aged between 1 and 16 years who have asthma-like airway disease and 25 healthy children were included in the study. All cases underwent 24 h pH monitoring with dual sensor catheters. Additionally, acid suppressor treatment was administered to patients diagnosed as having GERD and clinical response was evaluated. Major symptoms encountered in the patient group included wheezing and cough (88%, and 32%, respectively). Reflux episodes were more common in distal esophagus during the prone position (reflux index (RI) of 11.5+/-10.3 vs. 16.2+/-9.4 during supine vs. prone). All distal esophageal parameters were significantly higher in the patient group except number of reflux episodes lasting longer than 5 min (RI of 13.3+/-13.1 vs. 3.9+/-2.9 in the patient vs. control groups, respectively). There was a significant improvement in symptoms and requirement for medication with treatment (number of systems decreased from 2.3+/-0.6 to 0.4+/-0.6, P=0.00). In conclusion, GERD is significantly more common in nonatopic children with asthma-like airway disease compared to the controls and clinical improvement is significant after acid suppressor treatment. Thus, we suggest that children followed-up with the diagnosis of nonatopic asthma with recurrent exacerbations despite adequate asthma treatment have a high frequency of GER and that lansoprazole treatment may be considered early in management.     

Wheeze monitoring in children for assessment of nocturnal asthma and response to therapy.

The utilisation of nocturnal wheeze monitoring and quantification for assessment of asthma activity was studied in symptomatic school-aged children before and during treatment. Twelve children 6-14 yrs of age with mild or moderate untreated asthma were studied at home three times: before, 48 h and 6 weeks into treatment with 5 mg montelukast daily. Lung sounds were recorded overnight by an automatic wheeze detection device (PulmoTrack). Per cent wheezing within each respiratory cycle was calculated every 30 s throughout the night and a Nocturnal Wheeze Index (NWI) was calculated for the total night. The results were compared with spirometric indices (forced expiratory volume in one second (FEV1), forced vital capacity), bronchial reactivity (provocative concentration causing a 20% fall in FEV1 by adenosine 5'-monophosphate (PC20)) and daily symptom scores, performed in parallel at each stage of the study. The pretreatment NWI was 814+/-898 (mean+/-SD), which declined to 318+/-199 2 days after onset, and to 137+/-101 after 6 weeks of treatment. The NWI in seven healthy children was 47+/-43. The FEV1, PC20 and symptom scores improved in parallel. Wheeze monitoring provides quantitative and noninvasive information about the extent of nocturnal wheezing in children, correlates well with conventional indices of asthma activity and can assist in assessing efficacy of treatment.     

Nebulized flunisolide in infants and young children with asthma: A pilot study

The role of nebulized flunisolide solution in controlling recurrent respiratory symptoms was assessed in a double-blind placebo-controlled parallel study on 23 infants and small children (mean age, 14 2 months) with bronchial asthma. Five of the 12 children in the placebo group and 1 of the 11 patients on active treatment had to be withdrawn from the study. Flunisolide significantly improved symptom scores of wheezing and cough. The rescue treatments with salbutamol did not differ between the two groups during the study. Parents considered the active treatment effective in all the patients, while the placebo was considered useful in 4 of 7 children. No side effects were detected with either treatments. This study indicates that nebulized flunisolide may be an effective treatment for infants with recurrent wheezing and cough. Pediatr Pulmonol. 1996; 21:310–315. © 1996 Wiley-Liss, Inc.     

Role of viruses and atypical bacteria in exacerbations of asthma in hospitalized children: a prospective study in the Nord-Pas de Calais region (France)

We studied the role of viruses and atypical bacteria in children hospitalized with exacerbated asthma by a prospective study of children with acute asthma admitted to the Department of Pediatrics in Lille, and to 15 hospitals in the Nord-Pas de Calais region, from October 1, 1998-June 30, 1999. We included children aged 2-16 years with active asthma, defined as three or more recurrent episodes of reversible wheezing. The severity of asthma and of asthmatic exacerbations was recorded. Immunofluorescence assays (IFA) on nasopharyngeal secretions (NPS), serological tests, or both, were used for detection of influenza virus, respiratory syncytial virus (RSV), adenovirus, parainfluenza virus, and coronavirus. Polymerase chain reaction (PCR) assays on NPS were used for rhinovirus and enterovirus. Serological tests for Chlamydia pneumoniae and Mycoplasma pneumoniae were performed. A control group of asymptomatic asthmatic outpatients was examined for respiratory viruses (using IFA and PCR). Eighty-two symptomatic children (mean age, 7.9 years) were examined. Viruses were detected in 38% (enterovirus, 15.8%; rhinovirus, 12%; RSV, 7.3%). Serological tests for atypical bacteria were positive in 10% of patients (C. pneumoniae, 5%; M. pneumoniae, 5%). Among the 27 control subjects (mean age, 7.9 years), one PCR was positive for enterovirus. There was no correlation between severity of chronic asthma or asthmatic exacerbations and the diagnosis of infection. Atypical bacterial pathogen infections were linked with prolonged asthmatic symptoms. In conclusion, we confirmed the high incidence of viral infection in acute exacerbations of asthma, especially enteroviruses or rhinoviruses. Persistent clinical features were more frequently associated with atypical bacterial infections, suggesting that these infections should be investigated and treated in cases of persistent asthmatic symptoms.     

Diagnosis and management of asthma in preschoolers: A Canadian Thoracic Society and Canadian Paediatric Society position paper

Asthma often starts before six years of age. However, there remains uncertainty as to when and how a preschool-age child with symptoms suggestive of asthma can be diagnosed with this condition. This delays treatment and contributes to both short- and long-term morbidity. Members of the Canadian Thoracic Society Asthma Clinical Assembly partnered with the Canadian Paediatric Society to develop a joint working group with the mandate to develop a position paper on the diagnosis and management of asthma in preschoolers.In the absence of lung function tests, the diagnosis of asthma should be considered in children one to five years of age with frequent (≥8 days/month) asthma-like symptoms or recurrent (≥2) exacerbations (episodes with asthma-like signs). The diagnosis requires the objective document of signs or convincing parent-reported symptoms of airflow obstruction (improvement in these signs or symptoms with asthma therapy), and no clinical suspicion of an alternative diagnosis. The characteristic feature of airflow obstruction is wheezing, commonly accompanied by difficulty breathing and cough. Reversibility with asthma medications is defined as direct observation of improvement with short-acting ß₂-agonists (SABA) (with or without oral corticosteroids) by a trained health care practitioner during an acute exacerbation (preferred method). However, in children with no wheezing (or other signs of airflow obstruction) on presentation, reversibility may be determined by convincing parental report of a symptomatic response to a three-month therapeutic trial of a medium dose of inhaled corticosteroids with as-needed SABA (alternative method), or as-needed SABA alone (weaker alternative method). The authors provide key messages regarding in whom to consider the diagnosis, terms to be abandoned, when to refer to an asthma specialist and the initial management strategy. Finally, dissemination plans and priority areas for research are identified.     

Anti-inflammatory pharmacotherapy for wheezing in preschool children

Accumulating evidence indicates that there are at least two phenotypes of wheezing in preschool years with distinct natural history. Frequent wheezing in the first 3 years of life with risk factors for asthma (e.g., eczema, maternal asthma) predicts symptoms in older age, while infrequent viral-associated wheezing without risk factors for asthma has a benign prognosis. This systematic review summarizes evidence on the use of anti-inflammatory medications in preschool children with wheezing. Literature search was performed using Medline and the Cochrane Library. Retrieved articles were critically appraised. Episodic use of high-dose inhaled corticosteroids (>1,600 mcg/day of beclomethasone) may ameliorate severity of intermittent viral-associated wheezing. Maintenance inhaled corticosteroids can control symptoms in children with frequent wheezing associated with risk factors for asthma. Inhaled corticosteroids do not alter the natural history of wheezing even when started early in life and could have a negative impact on linear growth rate. Short courses of oral corticosteroids have been proposed as an effective measure to control exacerbations of symptoms although there is little evidence supporting their use. Some studies support the administration of non-steroidal anti-inflammatory medications (leukotriene pathway modifiers, cromones, methylxanthines) for mild frequent wheezing. Maintenance inhaled corticosteroids is the most effective measure for controlling frequent wheezing in preschool children, especially when accompanied by risk factors for asthma. This treatment does not affect the natural history of wheezing, although deceleration of linear growth rate is the most commonly recognized systemic adverse effect.     

Recurrent Wheezing in the First Three Years of Life: Short-Term Prognosis and Risk Factors

Objective. It is difficult to determine if preschool children with recurrent wheezing are suffering from asthma or will suffer from asthma in the future. The aim of this study was to investigate the prognosis and risk factors of recurrent wheezing in children, beginning in the first 3 years of life. Method. Children who were referred because of recurrent wheezing episodes during the first 3 years of life were evaluated for the presence of asthma over a 4-year period. A child without any symptoms within the last 12 months was considered to be in remission. Results. The study included 529 (male/female: 2.17) children with a median (inter-quartile) age of 0.6 years (0.3–1.0) at symptom onset. The median follow-up and symptom durations were 2.93 years (1.74–4.76) and 4.30 years (2.91–5.97), respectively. Remission/recovery was achieved in 1.7%, 8.0%, and 14.4% of the children within 12, 24, and 36 months, respectively. A negative “stringent asthma predictive index” (API) significantly shortened the time to recovery of wheezing compared to the positive API (p = .036). Maternal smoking during pregnancy (OR = 4.35; 95% CI = 1.29–14.63); p = .018) and the number of emergency room admissions within the first 3 years of life (OR = 1.10; 95% CI = 1.01–1.19); p = .031) were found to be independent risk factors for the persistence of wheezing symptoms. Conclusion. Most of the children who were referred with frequent wheezing remain symptomatic 3 years after the initial wheezing episodes. A negative API is related to a shorter wheezing duration. Maternal smoking during pregnancy and the severity of the wheezing episodes appeared to be significant risk factors for the persistence of wheezing symptoms.     

Burden of Wheezing Illness Among U.S. Children Reported by Parents Not to Have Asthma

We examined the 12-month prevalence of asthma and wheezing among U.S. children and compared the illness-related burden of children who wheezed with and without an asthma diagnosis. Data were obtained in a cross-sectional telephone survey that tested the performance of a health interview designed to identify children with chronic health conditions. Respondents were 712 primary caretakers of 1388 children under 18 years old in a national probability sample selected by random-digit dialing. Although 51 children identified with asthma and wheezing had more episodes, sleep disturbances, and attacks that limited speech, and received more medical treatment for wheezing than 69 children with wheezing alone, the “undiagnosed” children appeared to be only somewhat less affected by their wheezing. Repeat episodes and burden experienced by children with wheezing alone suggest that the asthma prevalence may be underestimated if based only on the diagnostic label.     

Leukotriene Receptor Antagonists in Virus-Induced Wheezing

Virus-induced wheezing is a relatively benign entity that is usually transient in early childhood but is responsible for much health care utilization. The condition, seen traditionally as a subset of those children diagnosed as having frequent episodic asthma, is often treated with inhaled corticosteroids, despite their lack of efficacy. However, there remains some confusion differentiating atopic asthma from virus-induced wheezing in young children and their respective treatment strategies.The demonstration of cysteinyl leukotrienes in the nasopharyngeal secretions of infants and young children who wheeze prompted investigation of the role of leukotriene receptor antagonists in the treatment of virus-induced wheezing for young children with bronchiolitis and virus-induced wheezing.Montelukast, the only leukotriene receptor antagonist studied in young children, has been proven useful in increasing the number of symptom-free days and delaying the recurrence of wheeze in the month following a diagnosis of respiratory syncytial virus-induced wheezing in children aged 3-36 months. Subsequently, in children aged 2-5 years with frequent episodic asthma, primarily involving viral induced attacks in this age group, regular therapy with daily montelukast for 12 months reduced the rate of asthma exacerbations by 31% over placebo, delayed the time to the first exacerbation by 2 months, and lowered the need to prescribe inhaled corticosteroids as preventative therapy. Additionally, montelukast has been demonstrated to be efficacious as an acute episode modifier in children aged 2-14 years (85% children <6 years) with virus-induced wheezing where it was prescribed at the onset of a viral infection in children with an established pattern of viral induced episodes of wheeze in the preceding year. In this study, emergency department visits were reduced by 45%, visits to all health care practitioners were reduced by 23%, and time of preschool/school and parental time off work was reduced by 33% for children who took montelukast for a median of 10 days.At present, there is good evidence to support the use of bronchodilators in the acute treatment of virus- induced wheezing, and increasing evidence to support the use of leukotriene receptor antagonists, in particular montelukast, in the management of children with virus-induced wheezing.     

Asthma education: creating a partnership

This article advances the theory that the key to creating an effective partnership is teaching asthma patients what to self-treat, how to self-treat, and when to consult a clinician. The five comanaging rules that the health educator is encouraged to emphasize with the adult asthma patient are: know your own unique asthma symptoms and triggers; keep written records; see appropriate specialists; know your medicines and follow your action plan; and accept no treatment you do not understand. Current research shows asthma to be a chronic inflammatory disorder of the airways. In susceptible individuals, this inflammation causes recurrent episodes of wheezing, breathlessness, chest tightness, and cough, particularly at night and in the early morning. The stepwise approach to asthma therapy divides asthma into several levels of severity. However, patients at any level of severity can have mild, moderate, or severe exacerbations. Asthma triggers; how to use a metered dose inhaler (MDI), a dry powder inhaler (DPI), and a peak flow meter; and how to follow an asthma action plan are thoroughly covered. The last section of the article deals at length with the indications for and actions of long-term-control medications, used to achieve and maintain control of persistent asthma, and quick-relief medications, used to treat symptoms and exacerbations.     

Patient Education Provided to Asthmatic Children: A Historical Cohort Study of the Implementation of NIH Recommendations

NIH guidelines for treatment of childhood asthma emphasize educating both patients and family about avoiding triggers and providing information to support self-management of asthma. To determine the extent to which primary care providers had implemented these recommendations, we examined the patient education provided to a cohort of asthmatic children (n = 331) between January and December 1994.

During 1994 education of any type was documented for less than half the children. Provision of education was associated with asthma severity: An action plan for exacerbations was discussed with the majority with moderate or severe asthma (61%). Avoiding triggers (aOR: 2.38, 95% CI: 1.37-4.12) and treatment goals (aOR: 3.14, 95% CI: 1.46-6.75), were more likely to be discussed with children who were prescribed inhaled anti-inflammatory medication, after adjustment for asthma severity and age.

Limited implementation of the NIH recommendations by primary care providers in our study may have reduced their impact on the management of childhood asthma.     

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.     

Rôle du Montelukast dans le traitement de l'asthme de l'enfant en âge préscolaire. Réflexions sur l'étude PREVIA

Leukotriene receptor antagonists are a new class of drugs, of which, montelukast is the only one so far approved for paediatric use under the age of 12 years. Its efficacy has been demonstrated in persistent asthma in 6 to 14 and 2 to 5 year old children. The PREVIA study also recently demonstrated its potential in the prevention of viral exacerbations of mild intermittent asthma in children aged 2 to 5 years, an effect not verified for inhaled corticosteroids (IC). Montelukast may thus play a useful role in the management of asthma in young children, either as an add-on treatment to IC in persistent asthma or as single therapy in intermittent viral induced asthma. Different wheezing phenotypes in infancy and early childhood should desirably be identifiable at their onset in order to allow proper testing of the available treatments so that treatment options may in the future be rationally established.     

Hospital Admissions for Wheezing and Asthma in Childhood—Are They Avoidable?

Hospital admission rates for asthma and wheezing are still high, especially in younger children. We performed a prospective study of children admitted for asthma or wheezing to Stavanger University Hospital during one year. Prehospital emergency treatment, prophylactic asthma treatment, and possible risk factors for hospital admission were registered. A total of 337 admissions for 288 children were included. Recommended inhaled emergency treatment was administered prior to only 33% of the admissions. Inhaled steroids had been prescribed before 43% of admissions for asthma, and symptomatic treatment with a β2-agonist prior to 74% of admissions. Parental smoking was frequent. There seems to be a high potential to prevent admissions for asthma and wheezing by improving prophylactic asthma care and prehospital emergency treatment, as well as avoiding parental smoking. An increased focus should be on education and implementation of guidelines.     

Hospital Admissions for Wheezing and Asthma in Childhood—Are They Avoidable?

Hospital admission rates for asthma and wheezing are still high, especially in younger children. We performed a prospective study of children admitted for asthma or wheezing to Stavanger University Hospital during one year. Prehospital emergency treatment, prophylactic asthma treatment, and possible risk factors for hospital admission were registered. A total of 337 admissions for 288 children were included. Recommended inhaled emergency treatment was administered prior to only 33% of the admissions. Inhaled steroids had been prescribed before 43% of admissions for asthma, and symptomatic treatment with a β2-agonist prior to 74% of admissions. Parental smoking was frequent. There seems to be a high potential to prevent admissions for asthma and wheezing by improving prophylactic asthma care and prehospital emergency treatment, as well as avoiding parental smoking. An increased focus should be on education and implementation of guidelines.     

Risk factors of developing asthma in children with recurrent wheezing in the first three years of life

Introductionrecurrent wheezing is a common problem during the first years of life, but it is still difficult to identify which of these children may develop asthma in the future.ObjectivesTo study risk factors of developing asthma in a group of patients with frequent wheezing during the first three years of life.Material and methodsA prospective study was performed of a group of 60 patients, aged below three, referred to our Hospital for recurrent wheezing. Age, sex, parental and personal history of atopy, clinical features, laboratory tests, evolution and response to treatment were analyzed.Results60 patients were enrolled in study. Most of children were boys and have had the first episode of wheezing after the 6 months of life. 63 % had personal history of atopy and 55 % parental history of allergy. The group of atopic children had more wheezing exacerbations and worse evolution than the group of non atopic. They also had more treatment necessities.ConclusionsThe identification of young children at high risk of developing asthma could permit an early intervention before irreversible changes in the airway appeared.     

Portable Spirometry During Acute Exacerbations of Asthma in Children

Background. Spirometry is the gold standard for assessment of asthma and is objective and non-invasive. This is a pilot study to evaluate whether portable spirometry can be successfully performed by children in the pediatric emergency department for acute exacerbations of asthma. Methods. We enrolled children more than 6 years of age presenting to an urban pediatric emergency department with a history of asthma during an acute exacerbation. On arrival and after each bronchodilator treatment, vital signs and a clinical score were recorded. Portable spirometry was then performed. Attempts were continued until acceptable and reproducible measurements were obtained or until the patient was unable to perform further attempts. Outcomes included success at spirometry and correlation of spirometry with clinical signs. Results. Thirty-four subjects were enrolled with a median age of 12 years. Ninety-one percent of subjects completed at least one attempt at spirometry. Seventy-three percent of all spirometry attempts were reproducible. Portable spirometry demonstrated increased severity of the exacerbation in comparison to clinical signs and peak expiratory flow. Percent of predicted forced expiratory volume in 1 second, ratio of forced expiratory volume in 1 second to forced vital capacity, and peak expiratory flow are all poorly correlated with degree of wheezing, clinical score, respiratory rate, and oxygen saturation (r < 0.5). Conclusion. Portable spirometry can be successfully performed by children with acute exacerbations of asthma in the emergency department and demonstrated greater degrees of airway obstruction than did clinical signs. Spirometry provides objective, non-invasive measurements of the severity of airway obstruction in the emergency department for children with acute exacerbations of asthma.