Randomized controlled trial of asthma education after discharge from an emergency department

OBJECTIVES: To test the hypothesis that reinforcement of the advice given at the time of discharge from the emergency department by telephone consultation would improve asthma outcomes. METHODS: A randomized controlled trial of the parents of 310 children who had been discharged from the emergency department with asthma was undertaken. The parents were randomized to receive either standard care (155 children) or standard care plus education by telephone (155 children) from a trained asthma educator. Symptoms, parental asthma knowledge, parental quality of life and use of asthma action plans and preventer therapy were collected at baseline and 6 months later. The primary measure was days of wheeze in last 3 months; intermediate measures were regular use of preventer medications, possession and use of written asthma action plan, parental asthma knowledge scores and parental quality of life scores. RESULTS: A total of 266 parents (136 intervention) completed the follow-up questionnaires after 6 months. Both groups showed similar symptoms and process measures at baseline, apart from more regular use of preventer medication in the control children. At follow up, the intervention group children were significantly more likely than controls to possess (87.5% vs 72.3%; P = 0.002) a written asthma action plan. Possession of action plans increased from baseline in the intervention group but tended to decrease in the control group. Use of action plans was greater in the intervention group but decreased from baseline in both groups. Both intervention and control groups showed significant decreases in asthma symptoms. CONCLUSIONS: Reinforcement by telephone consultation did not improve the primary outcome of wheeze in the last 3 months. However, it increased the possession and regular use of written asthma action plans in the intervention group.     

That ICS should be first line therapy for asthma--con

Asthma is a heterogeneous disease and it is therefore unrealistic to expect that inhaled corticosteroids (ICS) would be appropriate first line preventer therapy for all children with asthma. There is good theoretical and clinical trial evidence demonstrating that leukotriene receptor antagonists (LTRAs) are more effective than ICS for viral induced wheezing and equivalent to ICS for mild persistent asthma in children. LTRAS do not have the systemic adverse effects of ICS, are generally well tolerated and their once daily oral administration enhances adherence. LTRAs should therefore be first line preventer therapy for children with frequent intermittent or mild persistent asthma while ICS should be reserved as first line treatment for children with moderate to severe persistent asthma. Given the skew in paediatric asthma severity towards the milder end, this effectively means that LTRAs should be tried first in 2 of every 3 children with asthma requiring preventer treatment.     

The Natural History of Childhood Asthma Through Adolescence

A follow-up of the natural history of childhood asthma at 17-18 years in a randomly selected population of asthmatic and control children who had been studied clinically and physiologically at 7, 10 and 14 years of age, has been conducted by questionnaire. Of the sample still in the study at 14 years of age, 77% of the asthma population replied, representing 65% of the original sample. There had been significant amelioration of asthma in those children who still had asthma at 14 years of age. Of those children with episodic asthma, approximately half had ceased wheezing while the remainder had relatively infrequent episodes. Those children with chronic asthma continued to wheeze but in just over half, asthma appeared to be episodic. Of the children who had ceased wheezing before 14 years of age, 17% had recurrence in the 12 months prior to review. However, in only 1 subject were the episodes of asthma frequent.     

Factors associated with preventive asthma care in inner-city children

The goal of this cross-sectional study was to determine if the caregiver's quality of life was associated with the child receiving appropriate preventive asthma care (2 or more preventive asthma care visits per year) in a sample of inner-city children with moderate to severe persistent asthma. Our findings confirm that children with moderate to severe persistent asthma are not receiving adequate preventive asthma care despite experiencing frequent asthma symptoms. Having a recent emergency department (ED) visit and increased number of school absences due to asthma were the strongest factors associated with these children receiving guideline-based preventive asthma care. However, for a subgroup of children without recent ED care, we found that low caregiver education level, increased school absences, and decreased caregiver's quality of life, albeit a trend, were associated with the child's receiving adequate preventive asthma care. This suggests that in a subgroup of children receiving adequate preventive care, other issues beyond basic asthma management may need to be addressed.     

The usefulness of pulse oximetry in evaluating acutely ill asthmatics.

To examine the usefulness of pulse oximetry in determining the severity of acute asthma, the arterial oxygen saturation (SaO2) of 196 acutely ill asthmatic children was measured while the children were being treated in the emergency department (ED). The measure of severity used was the disposition from the ED--discharge or hospitalization--after receiving standard ED care. The mean pretreatment SaO2 of the 172 children discharged was 96.4% (range, 84-100%), and that of the 24 children admitted was 94.4% (range, 85-100%). A Receiver Operating Characteristic curve indicated that the optimal cutoff point for identifying disposition was an SaO2 of 93%. The sensitivity of an SaO2 < or = 93% was 35%, and the specificity was 92%. We conclude that SaO2 lacks the sensitivity to differentiate the child who will respond to ED therapy from the child who will require further inpatient care.     

Exhaled carbon monoxide in childhood asthma.

OBJECTIVES: Oxidative stress and inflammation induce the expression of heme oxygenase-1, which produces carbon monoxide (CO), and nitric oxide synthase, which produces nitric oxide (NO). Exhaled CO and NO levels are elevated in asthmatic patients and are decreased after corticosteroid treatment, suggesting that they may be useful as noninvasive markers of airway inflammation. STUDY DESIGN: We measured forced expiratory volume in the first second, PC(20), and exhaled CO and NO levels in 29 children (18 boys, mean age 11.5 +/- 0.53 years) with asthma of different severity and 40 nonsmoking children without asthma (21 boys, mean age 8.1 +/- 0.35 years). We also studied whether upper respiratory tract infections were associated with elevated exhaled CO. RESULTS: Exhaled CO levels (ppm) were significantly higher (2.17 +/- 0.21) in children with persistent asthma compared with those in children with infrequent episodic asthma (1.39 +/- 0.18, P <.05) and healthy children (1.01 +/- 0.12, P <.001). The CO levels in children with infrequent episodic asthma and the normal control group, however, were not different. In contrast, exhaled NO levels (ppb) were higher in children with persistent asthma (24.2 +/- 5.9, P <.001) and infrequent episodic asthma (14.5 +/- 3.73, P <.05) than in normal subjects (5.1 +/- 0.24), but no significant difference was seen between the 2 asthmatic groups. In healthy children with upper respiratory tract infections (n = 12), exhaled CO concentrations were significantly elevated (2.16 +/- 0.33) during the acute symptomatic phase. No correlation was found between exhaled CO and forced expiratory volume in the first second or PC(20). CONCLUSIONS: Noninvasive measurement of exhaled CO may provide complementary data for assessment of asthma control in children. However, elevated CO levels are nonspecific and may be found in association with an acute viral illness.     

Utilization analysis of an observation unit for children with asthma

BACKGROUND: Short-stay observation unit (OU) care for children with asthma has the potential to reduce hospitalization rates for this common pediatric condition. In the effort to increase the efficiency of such a unit, knowledge of predictive factors for successful discharge is important. OBJECTIVES: 1) To define clinical predictive factors determined at the time of initial presentation in the emergency department (ED) that would identify which children with asthma are most likely to be successfully discharged from an OU. 2) To compare the management provided in the initial 3 hours upon arrival at the ED between the children who are eventually successfully discharged from an OU to those who require an inpatient admission. 3) To compare the length of stay in the OU between the patients who eventually go home to those who require an inpatient admission. DESIGN: Case control study. SETTING: Urban, tertiary-care pediatric ED. PARTICIPANTS: From a collected database of all patients with asthma 1 to 18 years of age, presenting to the ED from July 1, 1993 to June 30, 1994 (n = 2248), a random sample of 350 patients was identified. All children meeting the definition of "case" or "control" from this sample were included. Cases were defined as children with asthma who were successfully discharged after a stay in the OU. Controls were defined as children with asthma who were not successfully discharged; that is, children who required subsequent inpatient admission. RESULTS: Of the 350 children with asthma in the randomly selected subset sample, 47 cases and 21 controls were identified. In both cases and controls, patients had similar characteristics regarding mean age, sex, mean weight, previous history of asthma, and mean length of illness. The use of medications in the 24 hours prior to presentation to the ED was similar between both groups. No differences were found in the mean respiratory rate upon presentation between the cases and the controls (40/min vs. 44/min; P = 0.2), mean oxygen saturation (95 vs. 94%; P = 0.4). However, there was a significant difference in the requirement of supplemental oxygen between cases and controls (15 vs. 43%; P = 0.01; OR = 0.23:0.07 to 0.76). No further differences were found in the first 3 hours of ED management. The number of albuterol and ipratropium nebulizations was similar. The use, dosage, and timing of systemic steroids were also similar between the groups. The cases remained in the OU for a shorter period of time (8.7 hours vs 9.2 hours; 95% C.I.: -2.8 to 1.8) than the controls. CONCLUSION: No clinical predictive factors determined at the time of arrival to the ED were identified for children with asthma who were successfully discharged from the OU except for a lesser need of oxygen supplementation. The patients observed in the OU had similar management in the initial 3 hours of arrival and similar length of stay in the OU, regardless of their disposition outcome. Maximal OU efficiency remains limited by the lack of clear predictive factors for successful discharge. Further study in this area is indicated.     

Parental asthma knowledge: Its association with readmission of children to hospital

Objectives: To assess whether poor parental knowledge about asthma was a risk factor for readmission of their children to hospital.
Methodology: Parents of children who were admitted to the paediatric facility at Newcastle Mater and John Hunter Hospitals were administered a previously validated asthma knowledge questionnaire with a maximum possible score of 31.
Results: The mean parental knowledge scores for three groups of children were determined: those with a previous diagnosis of asthma being readmitted to hospital (170 children, mean score 18.3); those with a previous diagnosis of asthma being admitted for the first time (114 children, mean score 17.2); and children being admitted with their first attack of asthma (65 children, mean score 15.6). There was a significant difference in parental asthma knowledge between the first and third group ( P <0.001) but not between the first and second group. A linear regression model with knowledge score as an outcome found that increased knowledge was associated with previously diagnosed asthma, higher parental occupation and no smoker in the home.
Conclusions: Knowledge was poor in all groups. Readmission rate was related to the severity of the child's asthma.     

青春期前后支气管哮喘患者病情缓解状况调查

目的 了解支气管哮喘(哮喘)患儿青春期前后病情缓解基本状况.方法 对501例8 ～ 26岁的哮喘患者进行有关青春期前后病情缓解基本状况的问卷调查.结果 501例哮喘患者青春期后病情缓解率为67.5％(338/501例).男性患者(66.0％)与女性患者(69.9％)缓解率比较差异无统计学意义.在青春期病情未缓解的哮喘患者哮喘首次发作年龄及末次发作年龄与缓解组比较有统计学差异(=5.82、9.90,Pa=0.00).8岁后哮喘发作仍频繁者(年最多发作6次以上)的病情在青春期后缓解的概率更小,与年发作＜6次的患者比较差异有统计学意义(x2=20.69,P=0.00).变应性鼻炎症状越严重(中-重度)的哮喘患者,青春期前后的缓解率越低,与轻度或无明显鼻炎患者比较,差异有统计学意义(x2=8.25,P=0.02).个人高发季节在春夏秋季者在青春期前后哮喘病情缓解率更低,与高发季节在冬季的患者比较差异有统计学意义(x2 =7.71,P=0.04).血总IgE水平越高的哮喘患者,青春期后哮喘病情缓解率越低(t=2.16,P=0.03).规范化吸入激素联合特异性免疫治疗的哮喘患者在青春期前后缓解率较高,与吸入激素组及未规范治疗组比较,差异有统计学意义(x2=10.25,P=0.01).经常运动健身的哮喘患者在青春期前后缓解率更高,达75.3％,与不常运动健身的哮喘患者比较,差异有统计学意义(x2=8.76,P=0.00).结论 青春期前后哮喘患者病情缓解率较高,哮喘首次发作年龄越大、8岁后哮喘急性发作仍频繁、并变应性鼻炎越严重以及血总IgE越高,其在青春期前后的哮喘病情越不易缓解.给予积极的干预治疗措施如特异性免疫治疗及运动健身等,能使青春期前后哮喘的缓解率提高.     

Risk factors for emergency department use among children with asthma using primary care in a managed care environment.

OBJECTIVE: To identify risk factors for emergency department (ED) use among children with asthma using primary care in a managed care environment. DESIGN: Using automated data sources, children with asthma were identified and followed for 2-year periods. We fit logistic regression models using generalized estimating equation approaches to identify ED risk factors. PATIENTS: Children with asthma aged 5-14 with a visit to a pediatrician practicing with a large group practice and enrolled in an HMO for 2 consecutive years between 1992 and 1996 (N = 411 children). MAIN OUTCOME MEASURES: Asthma-related ED use. RESULTS: Twenty-three percent of children incurred an asthma-related ED visit. Asthma-related ED use was greater among children with prior asthma-related ED use (OR [odds ratio] = 8.26, 95% CI [confidence interval] = 4.79-14.25), decreased with increasing age (OR = 0.87, 95% CI = 0.79-0.96) and frequency of visits to a primary care physician for asthma (OR = 0.82, 95% CI = 0.70-0.96), and tended to be less among children who saw an allergist (OR = 0.59, 95% CI = 0.33-1.04). No significant relationship was found between asthma-related ED use and race, household income, or other patient characteristics. CONCLUSIONS: Targeting children with prior asthma-related ED use and encouraging routine primary care visits as well as the use of an allergist may afford opportunities to reduce ED use among children with asthma currently receiving primary care.     

The language of breathlessness: do families and health care providers speak the same language when describing asthma symptoms?

INTRODUCTION: Effective communication about symptoms is a critical prerequisite to appropriate treatment. Study aims were to: (a) document the symptoms that children with asthma and their parents associate with asthma, (b) identify differences between the "professional model "of asthma symptoms and the "lay model," (c) describe the family's proposed action in response to symptoms, and (d) investigate the congruence between parental assessment of "good control" and severity obtained using National Asthma Education and Prevention Program criteria. METHOD: Children with asthma and their parents (N = 228) were recruited from diverse clinical practice sites. Parents and children described symptoms they associated with an asthma exacerbation and their proposed action. Perceived asthma control was compared with a structured assessment of severity. RESULTS: One hundred and thirty-six unique symptoms were reported. While 78% of parents reported at least one standard asthma symptom, 48% also reported nonstandard asthma symptoms. Sixty-five percent of parents whose children's symptoms were consistent with severe asthma reported "good control." DISCUSSION: Improved communication about symptoms would improve asthma care. Proposed strategies include standardized screening questionnaires to assess symptoms, more frequent routine visits for children with persistent asthma, and wide dissemination of realistic goals for symptom control.     

Spacer compliance after discharge following a mild to moderate asthma attack.

AIM: To assess MDIS usage in patients discharged from a children's hospital emergency department following a mild to moderate asthma attack. METHODS: Prospective observational study of 73 consecutive patients presenting to a children's hospital emergency department with a mild to moderate asthma attack. Demographic data, whether asthma literature/written MDIS instructions were provided, and who provided MDIS instructions (either a discharge coordinator or other emergency department staff) were noted. Parents of patients were telephoned after the first week following discharge and questioned about patient improvement, MDIS use/reasons for not using MDIS, and unscheduled presentations to their local doctor or hospital. RESULTS: Following discharge, 50/73 (68.5%) patients used MDIS exclusively (compliers), while 23/73 used nebulisers some or all of the time (non-compliers). There was no difference in patient improvement or unscheduled presentations between compliers and non-compliers. Most non-compliers 14/23 (60.9%) changed because of parental preference; ease of nocturnal nebuliser use was a possible factor. Compliance was associated with the age of the patient, spacer usage at hospital, the size of device used at hospital, and whether an information fact sheet was given. CONCLUSIONS: Most children discharged from the emergency department following a mild to moderate asthma attack continue MDIS use exclusively in the first week. MDIS compliance may be associated with knowledge, experience, and ease of spacer usage. The study shows that education for parents is crucial for MDIS compliance.     

Vitamin D Deficiency as a Factor Influencing Asthma Control in Children

Objective

To study the association between asthma control and serum 25OH Vitamin D levels in children with moderate persistent asthma on preventer therapy.

Methods

Children aged 6–18 years, with moderate persistent asthma, on preventer therapy for ≥2 months were included. Control was categorized as good, partial or poor as per GINA guidelines. Serum 25 (OH) Vitamin D levels were measured and their relationship with the level of control was studied.

Results

Out of 50 children enrolled, 22 had well-controlled asthma, and 21 had partially controlled asthma. Vitamin D was deficient in 30 children and insufficient in 18 children. Children with vitamin D deficiency had significantly less wellcontrolled asthma as compared to those with insufficient or sufficient levels of 25 (OH) vitamin D (13.3% vs 88.9 % vs 100%).

Conclusion

Vitamin D deficiency is associated with suboptimal asthma control.

     

Stability of respiratory symptoms in unlabelled wheezy illness and nocturnal cough

OBJECTIVE: To assess the natural history of respiratory symptoms not labelled as asthma in primary schoolchildren. DESIGN: Repeat questionnaire survey of subgroups identified from a previous questionnaire survey after a two year delay. SUBJECTS: The original population of 5321 Sheffield children aged 8-9 years yielded 4406 completed questionnaires in 1991(82.8%). After excluding children with a label of asthma, there were 370 children with current wheeze, 129 children with frequent nocturnal cough, and a random sample of 222 children with minor cough symptoms and 124 asymptomatic children. RESULTS: Response rates in the four groups were 233 (63.0%), 77 (59.7%), 160 (72.1%), and 90 (72.6%) respectively. Of those who initially wheezed, 114 (48.9%) had stopped wheezing and 42 (18.0%) had been labelled as having asthma. Those with more frequent wheezing episodes (p < 0.02) and a personal history of hay fever (p < 0.01) in 1991 were more likely to retain their wheezy symptoms. In the children with frequent nocturnal cough in 1991, 20.1% had developed wheezing, 42.9% had a reduced frequency of nocturnal coughing, and 14.2% had stopped coughing altogether two years later. One sixth had been labelled as having asthma. Children with nocturnal cough were more likely to develop wheezing if they had a family history of atopy (p = 0.02). Only 3.8% and 3.3% of those with minimal cough and no symptoms respectively in 1991 had developed wheeze by 1993 (1.9% and 1.0% labelled as asthma). CONCLUSIONS: Most unlabelled recurrent respiratory symptoms in 8-10 year olds tend to improve. Unlabelled children who have persistent symptoms have other features such as frequent wheezing attacks and a family or personal history of atopy. If a screening questionnaire were to be used to identify such children, a combination of questions should be employed.     

Use of asthma guidelines by primary care providers to reduce hospitalizations and emergency department visits in poor, minority, urban children

OBJECTIVES: To determine whether an organized, citywide asthma management program delivered by primary care providers (PCPs) increases adherence to the National Asthma Education and Prevention Program (NAEPP) Asthma Guidelines and whether adherence to the guidelines by PCPs decreases medical services utilization in low-income, minority children. STUDY DESIGN: Analysis of the utilization of medical services for a cohort of 3748 children with asthma who presented for care at one of six primary care urban clinics in Hartford, Connecticut, and who were enrolled in a disease management program (Easy Breathing) between June 1, 1998 and August 31, 2002. RESULTS: Of the 3748 children with physician-confirmed asthma, 48% had persistent disease. Paid claims for inhaled corticosteroids increased 25% ( P <.0001) after enrollment in Easy Breathing. Provider adherence to the NAEPP guidelines for anti-inflammatory therapy increased from 38% to 96%. Easy Breathing children with asthma experienced a 35% decrease in overall hospitalization rates ( P <.006), a 27% decrease in asthma emergency department (ED) visits ( P <.01), and a 19% decrease in outpatient visits ( P <.0001). CONCLUSIONS: An organized, disease management program increased adherence to the NAEPP guidelines for anti-inflammatory use by PCPs in urban clinics. Adherence to this element of the guidelines by PCPs reduced hospitalizations, ED visits, and outpatient visits for children with asthma.     

THE EFFECT ON GROWTH OF CHILDHOOD ASTHMA

ABSTRACT. Martin, A. J., Landau, L. I. and Phelan, P. D. (Department of Thoracic Medicine, Royal Children's Hospital, Melbourne, Australia). The effect on growth of childhood asthma. Acta Paediatr Scand, 70:683,.–The effect on growth of asthma has been documented in a prospective study from age 7 to 21 years in a randomly selected group of 342 subjects. These subjects covered the whole spectrum of childhood wheezing. Growth suppression was first noted at 10 years of age in the more severely affected groups and was most marked at 14 years of age. By 21 years of age, all groups had achieved a height and weight not significantly different from control subjects. Growth delay occurred in children with more persistent asthma even if they had never received oral corticosteroid therapy but growth was more delayed in those receiving oral steroids. The effect of steroids was most significant in those with frequent episodic asthma whose asthma alone was probably not sufficiently severe to retard growth.     

Stability of respiratory symptoms in unlabelled wheezy illness and nocturnal cough.

OBJECTIVE: To assess the natural history of respiratory symptoms not labelled as asthma in primary schoolchildren. DESIGN: Repeat questionnaire survey of subgroups identified from a previous questionnaire survey after a two year delay. SUBJECTS: The original population of 5321 Sheffield children aged 8-9 years yielded 4406 completed questionnaires in 1991(82.8%). After excluding children with a label of asthma, there were 370 children with current wheeze, 129 children with frequent nocturnal cough, and a random sample of 222 children with minor cough symptoms and 124 asymptomatic children. RESULTS: Response rates in the four groups were 233 (63.0%), 77 (59.7%), 160 (72.1%), and 90 (72.6%) respectively. Of those who initially wheezed, 114 (48.9%) had stopped wheezing and 42 (18.0%) had been labelled as having asthma. Those with more frequent wheezing episodes (p < 0.02) and a personal history of hay fever (p < 0.01) in 1991 were more likely to retain their wheezy symptoms. In the children with frequent nocturnal cough in 1991, 20.1% had developed wheezing, 42.9% had a reduced frequency of nocturnal coughing, and 14.2% had stopped coughing altogether two years later. One sixth had been labelled as having asthma. Children with nocturnal cough were more likely to develop wheezing if they had a family history of atopy (p = 0.02). Only 3.8% and 3.3% of those with minimal cough and no symptoms respectively in 1991 had developed wheeze by 1993 (1.9% and 1.0% labelled as asthma). CONCLUSIONS: Most unlabelled recurrent respiratory symptoms in 8-10 year olds tend to improve. Unlabelled children who have persistent symptoms have other features such as frequent wheezing attacks and a family or personal history of atopy. If a screening questionnaire were to be used to identify such children, a combination of questions should be employed.     

Prevalence of childhood asthma and control in children assessed in a pilot school-based intervention programme in Singapore

AIM: Because of a high childhood asthma burden in Singapore, assessment of disease control status is essential for formulating school-based strategy of childhood asthma control. The aim of the present study is to assess childhood asthma prevalence and control in Singapore and the socio-demographic and help-seeking correlates. METHODS: School-based survey using parental self-administered questionnaire, conducted from February to April 2004. Four mixed-gender primary schools selected from geographically distinct zones of Singapore. All primary one (modal age - 6.5 years) and six (modal age - 11.9 years) students from selected schools were invited to participate. Questionnaire respondents were the students' parents or guardians. The response rate was 75.2% (2123/2825). RESULTS: Prevalence of current asthma was 8.9% (190/2123). Among them, 26.3% (46/175) were assessed to have inadequate control. Asthma was more prevalent, and less adequately controlled in children from lower socio-economic backgrounds (lower-end housing type). Children with poorly controlled asthma were more likely to be treated by emergency room physicians and hospital specialists, and to be on preventer medications. CONCLUSIONS: In Singapore, poor asthma control is found in a sizeable proportion of school children with asthma, is identifiable for high-risk groups of children from lower socio-economic backgrounds and having asthma-related attendance at the emergency rooms.