Understanding the September asthma epidemic

The highly predictable increase in emergency department visits, hospital admissions, and unscheduled physician consultations for childhood asthma in North America every September is uniquely related to school return. Rhinovirus infection is likely the major trigger, initially affecting asthma in school-age children, followed by similar but lesser increases in asthma morbidity in younger children and in adults. Low use of asthma medications during summer may fuel the epidemic, which may be attenuated by the short-term addition of an effective controller therapy.     

Impact of depressive symptoms on adult asthma outcomes.

BACKGROUND: Psychological disorders, including depression, are common in adults with asthma. Although depression is treatable, its impact on longitudinal asthma outcomes is not clear. OBJECTIVE: To elucidate the impact of depressive symptoms on patient-centered outcomes and emergency health care use in adults with asthma. METHODS: We conducted a prospective cohort study of 743 adults with asthma who were recruited after hospitalization for asthma. Depressive symptoms were defined as having a score of 16 or more on the Center for Epidemiologic Studies Depression Scale. We examined the impact of depressive symptoms on patient-centered outcomes (validated severity-of-asthma score, Marks Asthma Quality of Life Questionnaire, and 12-Item Short-Form Health Survey physical component summary score) and on future emergency health care use for asthma ascertained from computerized databases. RESULTS: The prevalence of depressive symptoms was 18% (95% confidence interval [CI], 15%-21%) among adults with asthma. Depressive symptoms were associated with greater severity-of-asthma scores after controlling for age, sex, race/ ethnicity, educational attainment, and cigarette smoking (mean score increment, 2.6 points; 95% CI, 1.8-3.4 points). Furthermore, depressive symptoms were associated with poorer asthma-specific quality of life (mean score increment, 19.9 points; 95% CI, 17.7-22.1 points) and poorer physical health status (mean score decrement, 3.7 points; 95% CI, 1.5-5.8 points). Depressive symptoms were associated with a greater longitudinal risk of hospitalization for asthma (hazard ratio, 1.34; 95% CI, 0.98-1.84). After controlling for differences in preventive care for asthma, the relationship was stronger (hazard ratio, 1.45; 95% CI, 1.05-2.0). CONCLUSION: Depressive symptoms are common in adults with asthma and are associated with poorer health outcomes, including greater asthma severity and risk of hospitalization for asthma.     

How and by whom care is delivered influences anti-inflammatory use in asthma: Results of a national population survey

BACKGROUND: Studies examining the influence of provider behavior and patterns of care delivery on the use of anti-inflammatory asthma therapy have been limited to selected populations or have been unable to assess the appropriateness of therapy for individuals. We have previously reported the influence of sociodemographic variables and asthma severity on reported use of asthma medications in the United States. OBJECTIVE: We sought to examine the influence of patterns of care delivery and clinician behavioral factors on the use of anti-inflammatory medication by patients with asthma. METHODS: We performed a cross-sectional national random digit dial household telephone survey in 1998 of adult patients and parents of children with current asthma. Respondents were classified as having current asthma if they had a physician's diagnosis of asthma and were either taking medication for asthma or had asthma symptoms during the past year. RESULTS: One or more persons met the study criteria for current asthma in 3273 (7.8%) households in which a screening questionnaire was completed. Of the 2509 persons (721 children <16 years of age) with current asthma interviewed, 507 (20.1%) reported current use of anti-inflammatory medication. In a multiple logistic regression model controlling for asthma symptoms, reported anti-inflammatory use was significantly associated with patients reporting their physician having an excellent ability to explain asthma management (odds ratio [OR], 1.47; 95% CI, 1.09-1.98), scheduling regular visits to a physician for asthma (OR, 1.30; 95% CI, 1.02-1.64), having a written asthma action plan (OR, 1.63; 95% CI, 1.29-2.06), and being of white, non-Hispanic ethnicity (OR, 1.53; 95% CI, 1.19-1.98), along with markers of greater asthma morbidity, missing 6 or more days from work or school in the past year (OR, 1.29; 95% CI, 1.01-1.65), and hospitalization for asthma in the past year (OR, 1.74; 95% CI, 1.19-2.53). Anti-inflammatory use was less likely to be reported with younger age (OR, 0.82; 95% CI, 0.73-0.94), lower long-term asthma symptom burden (OR, 0.82; 95% CI, 0.71-0.94), use of 4 or fewer reliever inhaler canisters in the past year (OR, 0.50; 95% CI, 0.43-0.58), and smoking (OR, 0.50; 95% CI, 0.37-0.68). CONCLUSION: How asthma care is delivered influences the use of anti-inflammatory medication. Strategies to increase regular evaluation by a physician interested in asthma, particularly for minority patients, and to increase a physician's ability to communicate asthma management to patients might improve use of anti-inflammatory therapy among patients with asthma.     

Household mouse allergen exposure and asthma morbidity in inner-city preschool children.

BACKGROUND: Inner-city children experience disproportionate asthma morbidity, and suspected reasons include indoor environmental exposures. OBJECTIVE: To determine if mouse allergen exposure is a risk factor for asthma morbidity. METHODS: Preschool children with asthma were recruited from inner-city Baltimore, MD. Skin testing was performed and blood was collected at the baseline visit for quantification of mouse allergen specific IgE. A questionnaire evaluated symptoms, medication, and health care use at baseline, 3 months, and 6 months. A trained technician collected dust samples from the child's home for analysis of Mus m 1 at baseline, 3 months, and 6 months. Outcomes were compared between mouse-sensitized, highly exposed children and all other children. RESULTS: A total of 127 children had complete data for mouse sensitization status and bedroom settled dust mouse allergen levels at baseline. The mean age of the children was 4.4 years, 92% were African American, and 26% were sensitized to mouse. Mouse-sensitized children exposed to higher levels of Mus m 1 (>0.5 microg/g) had 50% more days of symptoms (incidence rate ratio [IRR], 1.5; 95% confidence interval [CI], 1.1-2.1) and 80% more days of beta-agonist use than other children (IRR, 1.8; 95% CI, 1.3-2.5). Children in the sensitized and highly exposed group were also more likely to have an unscheduled physician visit (odds ratio [OR], 3.1; 95% CI, 1.6-6.3), emergency department visit (OR, 2.1; 95% CI, 1.1-4.1), and hospitalization (OR, 36.6; 95% CI, 4.1-327.3) than other children. These associations between mouse allergen exposure and asthma symptoms and morbidity remained statistically significant after adjusting for potential confounders, including atopy and cockroach sensitization and exposure. CONCLUSIONS: In mouse-sensitized inner-city children, exposure to mouse allergen may be an important cause of asthma morbidity.     

Temporal change in the prevalence of respiratory symptoms and obstructive airways disease 1993–2001

BACKGROUND: There has been little available information regarding secular changes in the prevalence of respiratory symptoms since the mid-1990s. AIM: To examine changes in the prevalence of respiratory symptoms for 1993-2001. DESIGN OF STUDY: A series of postal questionnaire surveys. SETTING: Two general practice populations, including all age groups. METHOD: Four postal respiratory questionnaire surveys were conducted between 1993 and 2001. Subjects who replied to two or more surveys (8058 adults and 2350 children) were included in the main analyses. Validated scoring systems were used to define obstructive airways disease in adults and asthma in children. RESULTS: Over the 8-year observation period there were increases among adults in the crude prevalence of wheeze, being woken by cough, receipt of current asthma medication, and of obstructive airways disease, compared with decreases in children for wheeze, night cough, asthma attacks, and asthma. For adults, adjusted odds ratios per year of secular increase were 1.03 (95% confidence interval [CI] = 1.02 to 1.03) for wheeze, 1.03 (95% CI = 1.02 to 1.03) for being woken by cough, 1.03 (95% CI = 1.02 to 1.04) for asthma medication, and 1.02 (95% CI = 1.01 to 1.03) for obstructive airways disease. These increases were greater in those aged over 44 years, in males, and in those without a family history of asthma or a history of hayfever or eczema. Corresponding decreases for children were 0.94 (95% CI = 0.92 to 0.97) for wheeze, 0.93 (95% CI = 0.91 to 0.96) for night cough, 0.93 (95% CI = 0.90 to 0.95) for asthma attacks and 0.98 (95% CI = 0.95 to 1.00) for asthma. CONCLUSION: The increases found in adults are more likely to be due to chronic obstructive pulmonary disease (COPD) than asthma. This is supported by the decreases in symptom and asthma prevalence in children.     

Childhood asthma hospitalization risk after cesarean delivery in former term and premature infants.

BACKGROUND: Cesarean delivery modifies infant gut bacterial flora composition, which may result in hindered tolerance to allergenic substances, thereby increasing the risk of asthma in accordance with the hygiene hypothesis. Results of previous studies regarding an association between birth route and asthma are conflicting, and these studies have not evaluated some potential confounding effects, including prematurity and maternal asthma. OBJECTIVE: To determine whether cesarean delivery in full-term and premature infants increases the risk of subsequent childhood asthma hospitalization. METHODS: We conducted a case-control study using the Washington State Birth Events Record Database linked to statewide hospitalization data. The study included 2,028 children hospitalized for asthma (cases) and 8,292 age-matched controls. RESULTS: Cesarean delivery was modestly associated with an increased risk of asthma hospitalization (odds ratio [OR], 1.20; 95% confidence interval [CI], 1.04-1.39). However, when analyzed separately, there was an association between cesarean delivery and asthma hospitalization in premature infants (OR, 1.90; 95% CI, 1.09-3.02) but not in full-term infants (OR, 1.15; 95% CI, 0.97-1.34). CONCLUSIONS: Cesarean delivery was associated with subsequent asthma hospitalization only in premature infants. Because mothers with asthma are reported to have increased rates of cesarean delivery and premature delivery, other factors in addition to the hygiene hypothesis, including genetic and in utero influences associated with maternal asthma, may contribute to the increased risk of asthma in premature infants.     

Cost-effectiveness analysis of early intervention with budesonide in mild persistent asthma

BACKGROUND: The Inhaled Steroid as Regular Therapy in Early Asthma (START) study reported that early intervention with budesonide in mild persistent asthma reduces severe asthmatic events and improves symptom outcomes and lung function in adults and children. OBJECTIVE: We sought to estimate the incremental cost-effectiveness of early intervention with budesonide, as observed within the START study. METHODS: START was a randomized, 3-year controlled trial of budesonide in early onset mild asthma among 7165 subjects ages 5 to 66 years. Three age groups (5-10, 11-17, and >or=18 years) were studied separately and overall. Differences in the probability of emergency treatments, symptom-free days (SFDs), and costs of health care were determined. Incremental cost-effectiveness ratios were estimated from the health care payer and societal perspectives. RESULTS: Compared with usual therapy, patients receiving budesonide experienced an average of 14.1 (SE, 1.3) more SFDs per year (P <.001), fewer hospital days (69%, P <.001), and fewer emergency department visits (67%, P <.05). From the health care payer perspective, the net cost of early use of budesonide was an additional US dollars 0.42 (SE, dollars 0.04) per day, and the resultant cost-effectiveness ratio was US dollars 11.30 (95% CI, US dollars 8.60-US dollars 14.90) per SFD gained. From the societal perspective, the cost offsets of lower absence from school or work reduced the net cost of early budesonide to US dollars 0.14 (SE, US dollars 0.07) per day and decreased the cost-effectiveness ratio to US dollars 3.70 (95% CI, US dollars 0.10-US dollars 8.00). Early intervention was more effective and cost saving in the youngest age group. CONCLUSION: Long-term treatment with budesonide appears to be cost-effective in patients with mild persistent asthma of recent onset.     

Asthma prevalence among Alaska Native and nonnative residents younger than 20 years enrolled in Medicaid.

BACKGROUND: No study of childhood asthma prevalence in Alaska or among Alaska Natives has been conducted. OBJECTIVE: To determine asthma prevalence among Alaska Medicaid enrollees younger than 20 years, with an emphasis on Alaska Natives, the state's largest minority and predominant rural citizens. METHODS: A master database was obtained that included all children enrolled in Medicaid during July 1998 through June 1999. Physician, pharmacy, and hospital claims files for International Classification of Diseases codes 493.0x to 493.9x were linked to this master database. Asthma was defined as any asthma-related care or medication claim. RESULTS: Asthma prevalence among the study population was 6.9%. Alaska Natives had a lower asthma prevalence than nonnatives (risk ratio [RR], 0.70; 95% confidence interval [CI], 0.66-0.75), but among the subgroup of children residing in the state's major urban center, Alaska Natives had a higher prevalence. Overall, 0.22% of the study population experienced an asthma-related hospitalization, with Alaska Natives having a higher risk of hospitalization than nonnatives (RR, 1.6; 95% CI, 1.2-2.3). Among hospitalized children, Alaska Natives were less likely to have received a long-term control medication (RR, 0.54; 95% CI, 0.33-0.88). CONCLUSIONS: Compared with nonnatives, Alaska Natives have a lower risk of asthma but only among nonurban residents. The increased risk of hospitalization among Alaska Natives may be related to underuse of long-term control medications.     

The role of respiratory virus infections in childhood asthma inception

Viral respiratory illnesses associated with wheezing are extremely common during early life and remain a frequent cause of morbidity and hospitalization in young children. Although many children who wheeze with respiratory viruses during infancy outgrow the problem, most children with asthma and reductions in lung function at school age begin wheezing during the first several years of life. Whether symptomatic viral infections of the lower respiratory tract are causal in asthma development or simply identify predisposed children remains a controversial issue. Wheezing illnesses caused by respiratory syncytial virus (RSV), particularly those severe enough to lead to hospitalization, have historically been associated with an increased risk of asthma at school age. However, with the development of molecular diagnostics, human rhinovirus (HRV) wheezing illnesses have been recognized more recently as a stronger predictor of school-age asthma than RSV. In this article, the authors review the impact of virus infections during early life, focusing primarily on RSV and HRV, and their potential roles in asthma inception.     

Multiple microbial exposures in the home may protect against asthma or allergy in childhood

Background Experimental animal data on the gram‐negative bacterial (GNB) biomarker endotoxin suggest that persistence, dose, and timing of exposure are likely to influence its effects on allergy and wheeze. In epidemiologic studies, endotoxin may be a sentinel marker for a microbial milieu, including gram‐positive bacteria (GPB) as well as GNB, that may influence allergy and asthma through components (pathogen‐associated molecular patterns) that signal through innate Toll‐like receptor pathways. Objective To determine the influence of current GNB and GPB exposures on asthma and allergic sensitization in school‐aged children. Methods We examined the relationship between bacterial biomarkers and current asthma and allergic sensitization in 377 school‐aged children in a birth cohort study. We then evaluated the effects of school‐aged endotoxin, after controlling for exposure in early life. Results Exposure to GNB was inversely associated with asthma and allergic sensitization at school age [for >median endotoxin: prevalence odds ratio (POR)=0.34, 95% CI=0.2–0.7, for current asthma and prevalence ratio=0.77, 95% CI=0.6–0.97, for allergic sensitization]. In contrast, elevated GPB in the bed was inversely associated with current asthma (POR=0.41, 95% CI=0.2–0.9) but not with allergic sensitization (POR=1.07, 95% CI=0.8–1.4). School‐aged endotoxin exposure remained protective in models for allergic disease adjusted for early‐life endotoxin. Conclusion Both GNB and GPB exposures are associated with decreased asthma symptoms, but may act through different mechanisms to confer protection. Endotoxin exposure in later childhood is not simply a surrogate of early‐life exposure; it has independent protective effects on allergic disease.     

Consequences of antibiotics and infections in infancy: bugs,drugs, and wheezing

BackgroundThe prevalence of asthma has increased alarmingly in the past 2 to 3 decades. Increased antibiotic use in infancy has been suggested to limit exposure to gastrointestinal microbes and to predispose to asthma in later life.ObjectiveTo evaluate the association between antibiotic exposure during the first year of life and the development of asthma up to the age of 7 years.MethodsA retrospective population-based study of a cohort of children enrolled in a nationwide employer-provided health insurance plan from January 1, 1999, through December 31, 2006, in the United States (n = 62,576). We evaluated the association between antibiotic exposure during the first year of life and subsequent development of 3 asthma phenotypes: transient wheezing (began and resolved before 3 years of age), late-onset asthma (began after 3 years of age), and persistent asthma (began before 3 years of age and persisted through 4-7 years of age).ResultsAntibiotic use in the first year of life was associated with the development of transient wheezing (odds ratio [OR], 2.0; 95% confidence interval [CI], 1.9-2.2; P < .001) and persistent asthma (OR, 1.6; 95% CI, 1.5-1.7; P < .001). A dose-response effect was observed. When 5 or more antibiotic courses were received, the odds of persistent asthma doubled (OR, 1.9; 95% CI, 1.5-2.6; P < .001). There is no association between antibiotic use and late-onset asthma.ConclusionAntibiotic use in the first year life is associated with an increased risk of early-onset childhood asthma that began before 3 years of age. The apparent effect has a clear dose response. Heightened caution about avoiding unnecessary use of antibiotics in infants is warranted.     

Asthma and other allergic conditions in Colombia: a study in 6 cities.

BACKGROUND: No detailed information is available on the burden and impact of allergic diseases simultaneously for adults and children in Colombia and most Latin American countries. OBJECTIVES: To investigate the prevalence of asthma, allergic rhinitis, and atopic dermatitis symptoms in 6 cities in Colombia; to measure patient expenses and school days and workdays lost; to describe disease severity; and to determine levels of total and specific IgE in asthmatic subjects. METHODS: A multistage stratified random sample selection of schools with subjects aged 5 to 18 years in each city was used. Guardian subjects selected were contacted, and home visits were arranged. Subjects aged 1 to 4 years and older than 19 years were also selected randomly by systematic sampling based on the addresses of the subjects aged 5 to 18 years. Subjects with asthma symptoms were invited to provide a blood sample. RESULTS: Information was obtained from 6,507 subjects. The prevalence of asthma, rhinitis, and atopic dermatitis symptoms in the past 12 months was 10.4% (95% confidence interval [CI], 9.7%-11.1%), 22.6% (95% CI, 21.6%-23.6%), and 3.9% (95% CI, 3.4%-4.4%), respectively. Thirty-eight percent of asthmatic subjects had visited the emergency department or have been hospitalized, and 50% reported lost school days and workdays. Seventy-six percent of sampled asthmatic patients were considered to be atopic. CONCLUSIONS: The burden of disease and societal consequences of allergic entities in urban settings in countries such as Colombia are of concern but are largely ignored, perhaps because of the misconception that these diseases are of public health importance only in industrialized nations.     

Prenatal paracetamol exposure and risk of asthma and elevated immunoglobulin E in childhood

BACKGROUND: We recently found that paracetamol (acetaminophen) use in late pregnancy was associated with an increased risk of early wheezing in the offspring. OBJECTIVE: To see whether use of paracetamol in late pregnancy is associated with an increased risk of asthma, wheezing and other atopic outcomes in the child at school age. METHODS: In the population-based Avon Longitudinal Study of Parents and Children, we measured associations of paracetamol and aspirin use in late pregnancy (20-32 weeks) with asthma, hayfever, eczema (n = 8511) and wheezing (8381) in the offspring at 69-81 months, and with atopy (positive skin prick test to Dermatophagoides pteronyssinus, cat or grass, n = 6527) and blood total IgE (n = 5148) at 7 years. We used logistic and linear regression to analyse binary outcomes and log-transformed IgE, respectively, controlling for potential confounders. RESULTS: Use of paracetamol, but not aspirin, in late pregnancy was positively associated with asthma (odds ratios (ORs), comparing children whose mothers took paracetamol 'sometimes' and 'most days/daily' with those whose mothers never took it, 1.22 (95% confidence interval (CI): 1.06-1.41) and 1.62 (95% CI: 0.86-3.04), respectively; P trend = 0.0037), wheezing (ORs 1.20 (95% CI: 1.02-1.40) and 1.86 (95% CI: 0.98-3.55), respectively; P trend = 0.011), and total IgE (geometric mean ratios 1.14 (95% CI: 1.03-1.26) and 1.52 (95% CI: 0.98-2.38), respectively; P trend = 0.0034), but not hayfever, eczema or skin test positivity. The proportion of asthma attributable to paracetamol use in late pregnancy, assuming a causal relation, was 7%. CONCLUSION: Paracetamol exposure in late gestation may cause asthma, wheezing and elevated IgE in children of school age.     

The Association between Asthma and Invasive Pneumococcal Disease: A Nationwide Study in Korea

The purpose of this study was to investigate the association between asthma and invasive pneumococcal disease (IPD) in Korea. A retrospective population-based cohort study was conducted using the Korean Health Insurance Review and Assessment database 2010-2011. The subjects included 935,106 (2010) and 952,295 (2011), of whom 398 (2010) and 428 (2011) patients with IPD were identified. There was significant difference in the prevalence of IPD in patients with and without asthma (0.07% vs. 0.02% in 2010 and 0.08% vs. 0.01% in 2011; P<0.001). After adjusting for age and gender, patients with asthma showed over a three-fold increased risk of IPD compared with patients without asthma (adjusted odds ratio [aOR] 3.90, 95% confidence interval [CI] 3.02-5.03 in 2010 / aOR, 5.44; 95% CI, 4.10-7.22 in 2011; P<0.001). These findings were also significant in children (aOR, 2.08; 95% CI, 1.25-3.45 in 2010; P=0.005 / aOR, 3.26; 95% CI, 1.74-6.11 in 2011; P<0.001). Although diabetes mellitus was also significantly associated with IPD, relatively low ORs compared with those of asthma were noted (aOR, 1.85; 95% CI, 1.35-2.54 in 2010 / aOR, 2.40; 95% CI, 1.78-3.24 in 2011; P<0.001). Both children and adults with asthma are at increased risk of developing IPD.

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Epidemic asthma and the role of the fungal mold Alternaria alternata

BACKGROUND: After July 29, 2002, an epidemic of asthma admissions was associated with a thunderstorm in the United Kingdom. OBJECTIVE: We sought to study the cause of epidemics of asthma associated with thunderstorms. METHODS: We performed a case-control study of 26 patients presenting to Cambridge University Hospital with asthma after the thunderstorm. Control subjects were 31 patients with summer seasonal asthma. Subjects underwent skin tests and specific IgE serology to inhaled aeroallergens. Meteorologic and aerobiologic data correlated with asthma admissions were analyzed. RESULTS: Twenty-three of 26 cases had IgE sensitization to Alternaria species. Eleven of 31 control subjects gave a history of asthma exacerbation during thunderstorms. Ten of these 11 control subjects were sensitive to Alternaria species on skin testing, but Alternaria species sensitivity was only identified in 4 of the 20 remaining control subjects who did not report thunderstorm-related asthma symptoms. The odds ratio of having epidemic thunderstorm-related asthma if sensitive to Alternaria species was 9.31 (95% CI, 2.305-37.601; P = .0008) and 63.966 (95% CI, 3.577-1143.9; P < .0001) if sensitive to Alternaria species, Cladosporium species, or both. Poisson regression analysis showed that counts of broken Alternaria species and Didymella and Cladosporium species were significantly correlated with each other and with asthma admissions. The thunderstorm was associated with increased levels of Alternaria, Cladosporium, and Didymella species. CONCLUSIONS: Alternaria alternata sensitivity is a compelling predictor of epidemic asthma in patients with seasonal asthma and grass pollen allergy and is likely to be the important factor in thunderstorm-related asthma. CLINICAL IMPLICATIONS: Alternaria species sensitization in asthmatic subjects with grass pollen sensitivity predicts susceptibility to thunderstorm-associated asthma.     

Validity and responsiveness of a brief, asthma-specific quality-of-life instrument in children with acute asthma.

OBJECTIVE: To test the validity and short-term responsiveness to change of a pediatric, asthma-specific, health-related quality-of-life (HRQL) instrument. METHODS: Children 2 years and older treated in the emergency department (ED) for acute asthma were eligible for this prospective cohort study. A 10-item instrument, the Integrated Therapeutics Group Child Asthma Short Form (ITG-CASF), was administered at the time of the ED visit and again 14 days later (via telephone). At the follow-up call, parents were also asked about the child's current overall asthma status, missed school or limited activities, and persistence of asthma symptoms. RESULTS: A total of 121 children were enrolled (mean age, 7.9 years), and follow-up was complete for 96 (79%). Mean +/- SD ITG-CASF scores at follow-up were significantly higher among children reported to have improved overall (61.8 +/- 19.6) than those not improved (41.9 +/- 21.2), and there was a significant correlation between ITG-CASF score at follow-up and the number of days of school missed or limited activities (r = -0.45; 95% confidence interval [CI], -0.24 to -0.66). There was also a significant difference in improvement in ITG-CASF score from ED visit to follow-up among those improved (13.7-point improvement) compared with those not improved (3.3-point improvement; difference = 10.4; 95% CI, 1.2 to 19.5). The effect size was 0.68, indicating a large responsiveness to change. CONCLUSIONS: The ITG-CASF is a valid and responsive measure of HRQL in children with acute asthma and may be a useful outcome measure in evaluating ED treatment.