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PurposeA lack of quality measures aligned with residents' work led to the development of resident-sensitive quality measures (RSQMs). This study sought to describe how often residents complete RSQMs, both individually and collectively, when they are implemented in the clinical environment.MethodDuring academic year 2017-2018, categorical pediatric residents in the Cincinnati Children's Hospital Medical Center pediatric emergency department were assessed using RSQMs for acute asthma exacerbation (21 RSQMs), bronchiolitis (23 RSQMs), and closed head injury (19 RSQMs). Following eligible patient encounters, all individual RSQMs for the illnesses of interest were extracted from the health record. Frequencies of 3 performance classifications (opportunity and met, opportunity and not met, or no opportunity) were detailed for each RSQM. A composite score for each encounter was calculated by determining the proportion of individual RSQMs performed out of the total possible RSQMs that could have been performed.ResultsEighty-three residents cared for 110 patients with asthma, 112 with bronchiolitis, and 77 with closed head injury during the study period. Residents had the opportunity to meet the RSQMs in most encounters, but exceptions existed. There was a wide range in the frequency of residents meeting RSQMs in encounters in which the opportunity existed. One closed head injury measure was met in all encounters in which the opportunity existed. Across illnesses, some RSQMs were met in almost all encounters, while others were met in far fewer encounters. RSQM composite scores demonstrated significant range and variation as well-asthma: mean = 0.81 (standard deviation [SD] = 0.11) and range = 0.47-1.00, bronchiolitis: mean = 0.62 (SD = 0.12) and range = 0.35-0.91, and closed head injury: mean = 0.63 (SD = 0.10) and range = 0.44-0.89.ConclusionsIndividually and collectively, RSQMs can distinguish variations in the tasks residents perform across patient encounters.

Background The role of bacterial pathogens in exacerbations of bronchial asthma is unclear as that of viral infections. Aim To identify sputum bacteria and antibiotic sensitivity in patients with bronchial asthma exacerbation. Patients and methods A descriptive cross-sectional study was conducted on 50 patients with acute bronchial asthma exacerbation. Spirometeric pulmonary function tests, total and differential leukocyte count, sputum Gram stain, culture, and sensitivities were done for all patients. Results Of the studied patients, 50% have growth of normal flora, 12% have fungal growth, and 38% have bacterial growth (63.6 and 36.4% of them have Gram-negative and Gram-positive bacteria, respectively). The most predominant bacteria were Klebsiella pneumoniae (31.8%) and Streptococcal pneumoniae (18.2%), while Staphylococcus aureus, methicillin-resistant Staphylococcus aureus, Pseudomonas aeruginosa, Acinetobacter baumannii complex, and Enterobacter aerogenes are equally distributed (9.1%). There was a significant decrease of vital capacity %, forced vital capacity %, and forced expiratory volume in the 1 s % in bronchial asthma with Gram-negative bacteria compared with those with Gram-positive bacteria. The total and differential leukocytic counts nonsignificantly differed between both subgroups. Among the studied patients with bacterial growth, Amikacin, Quinupristin/Dalfopristin, Linezolid, Vancomycin, and Tigecycline were the most common sensitive antibiotics (100%), followed by Tobramycin, Ciprofloxacin, Levofloxacin, and Gentamicin (95.5%). On the other hand, Benzylpenicillin and Oxacillin were the most common resistant antibiotics (100%), followed by Ampicillin (92.3%). Conclusion Bacterial organisms were responsible for only about one-third of bronchial asthma exacerbation, with predominance of Gram-negative organisms. Amikacin, Quinupristin/Dalfopristin, Linezolid, Vancomycin, and Tigecycline, Tobramycin, Ciprofloxacin, Levofloxacin, and Gentamicin were the most common sensitive antibiotics. Benzylpenicillin, Oxacillin and Ampicillin were the most common resistant antibiotics.

Background/purpose: Asthma and allergic rhinitis (AR) frequently coexist in the same individuals in childhood and adolescence. We evaluated whether AR had an impact on acute exacerbation (AE) and whether intranasal corticosteroid (INCS) and second-generation antihistamines (SGH) for AR modified the association of AR with AE in asthmatics aged 2–6 years and 7–18 years. Methods: Using the National Health Research Institutes (NHRI) Database 2005 of Taiwan, we investigated patients who had been diagnosed with asthma in the years 2000 through 2012 and who had then been followed-up with for at least one year. The risk factors of AE were evaluated using multiple Cox proportional hazards regression analysis. Results: The incidence of AE was higher in the preschool group than the older group (adj. HR: 1.68, 95% CI: 1.44–1.95). The AR with INCS and/or SGH group was found to have a lower risk of AE than the non-AR group (adj. HR: 0.32, 0.44 and 0.30), but the AR without treatment group did not have a significant difference with the non-AR group. After propensity score matching, the use of INCS and/or SGH was associated with a significant reduction in the occurrence of AE among AR patients aged 2–6 years old (adj. HR: 0.38, 0.57 and 0.45) and 7–18 years old (adj. HR: 0.50, 0.52 and 0.35). Conclusion: The preschool patients had a higher incidence of AE than the older patients in general. Adequate treatment with INCS and/or SGH in asthma with AR patients is important for reducing the incidence of AE of asthma. Keywords: Allergic rhinitis, Asthma, Asthma acute exacerbations, Intranasal corticosteroid, Preschool children

Children and youth with acute asthma exacerbations frequently present to an emergency department with signs of respiratory distress. The most severe episodes are potentially life-threatening. Effective treatment depends on the accurate and rapid assessment of disease severity at presentation. This statement addresses the assessment, management, and disposition of paediatric patients with a known diagnosis of asthma who present with an acute asthma exacerbation. Guidance includes the assessment of asthma severity, treatment considerations, proper discharge planning, follow-up, and prescription for inhaled corticosteroids to prevent exacerbation and decrease chronic morbidity.

The objective measurement of the cough severity and the assessment of the pattern of nocturnal coughing could be useful in the treatment of respiratory diseases in children.In children with respiratory syncytial virus (RSV)-induced acute bronchiolitis, coughs were recorded using our original system with a microphone and accelerometer, and analyzed using our customized software program. The number of coughs in every 30-minute interval was measured in patients with acute bronchiolitis (n = 20), and their results were compared with those of infants with asthma exacerbation (n = 16).The cough count in children with acute bronchiolitis (median: 108.0/night) was almost as high as that in children with asthma exacerbation (median: 119/night). However, the time-dependent pattern of overnight cough was different in infants with acute bronchiolitis and those with asthma exacerbation. In the infants with asthma exacerbation, cough frequency significantly increased while falling asleep and waking up as compared to midnight (p0.001 and p0.001, respectively). However, these differences were not found in infants with acute bronchiolitis.Our data demonstrated that the number of coughing events due to acute bronchiolitis was similar to that of acute asthma exacerbation, although the acute bronchiolitis did not show a characteristic overnight cough pattern.

Key Clinical Message In our case reports, we mentioned about the utility of NPPV therapy in addition to standard pharmacologic therapy for acute asthma exacerbations in pregnant women with dyspnea and hypoxemia compared with that of oxygen therapy alone. Careful patient selection and clinicians’ NPPV experience are crucial in optimizing patient outcomes.

Objective Albuterol is a β2‐agonist and causes an intracellular shift of potassium from the interstitium. Whole‐body hypokalemia is known to cause skeletal muscle weakness, but whether this occurs as a result of hypokalemia from the intracellular shift during albuterol treatment is unknown. We sought to determine if albuterol total dose or route of administration (nebulization and/or metered‐dose inhaler) is associated with skeletal muscle weakness. Methods This was a prospective observational study using convenience sampling. Skeletal muscle strength was measured before and after 1 hour of albuterol treatment using a hand‐grip dynamometer in participants aged 5–17 years with acute asthma exacerbation in the emergency department. We examined associations of albuterol dose and route of administration with changes in grip strength. Results Among 50 participants, 10 received continuous albuterol by nebulizer and 40 received albuterol by metered‐dose inhaler. The median (interquartile range) in change of grip was ‐7.8% (interquartile range, ‐23.3, +5.1) for those treated with a nebulizer and +2.4% (interquartile range, ‐5%, +12.7%) for those treated with a metered‐dose inhaler (P = 0.036 for the difference). In a multiple linear regression model adjusted for the pretreatment Acute Asthma Intensity Research Score and age, participants treated with a nebulizer had a 12.9% decrease in skeletal muscle strength compared with those treated with a metered‐dose inhaler. Conclusion Higher doses of albuterol administered via nebulization result in decreased skeletal muscle strength in patients with acute asthma; whereas, albuterol administration via metered‐dose inhalers showed no effect on skeletal muscle strength.

We examined asthma control in children hospitalized for status asthmaticus 7–10 days after discharge with or without an additional prescription for systemic corticosteroids. This was a prospective observational study of patients aged 5–17 years with a documented history of asthma or β-agonist responsive wheezing admitted to the hospital for an acute asthma exacerbation. We compared patients who had any systemic corticosteroid prescribed at discharge with those who were not prescribed systemic corticosteroids at discharge. The primary outcomes were asthma control after discharge, as defined by the Asthma Control Test (ACT), and missed school days, which we modeled with multivariable linear and Poisson regression, respectively. A total of 56 patients were included in the study, 29 (52%) received dexamethasone inpatient and then were discharged without additional prescribed systemic corticosteroids. Those without a corticosteroid prescription at discharge were less likely to have received noninvasive ventilation (p = 0.02), pulmonology consultation (p = 0.02), and continuous albuterol (p = 0.01) during hospitalization. These patients also tended toward shorter length of stay (p = 0.07) compared to those receiving systemic corticosteroid prescription at discharge. In multivariable models, being discharged without systemic corticosteroid prescription was associated with poorer asthma control after discharge [beta (95% CI), –2.21 (–2.65 to –1.77)] and more missed school days [coefficient estimate (95% CI), 0.87 (0.07–1.68)]. After hospitalization for an asthma exacerbation, patients not given systemic corticosteroids at discharge tended to have worse asthma control following discharge despite having less severe disease and requiring less aggressive inpatient management. Supplemental data for this article can be accessed at publisher’s website.

Background Severe exacerbations of asthma are potentially life-threatening events associated with hospitalisation and significant healthcare costs. We sought to identify whether certain clinical and demographic characteristics are associated with the need for hospital admission versus Emergency Department discharge. Methods We conducted a retrospective review of all adult patients presenting to our Emergency Department with an asthma exacerbation over a 12-week period from January to March 2019. Patient‘s age, gender, background asthma treatment according to GINA, and baseline investigations including blood eosinophil count, CRP, results of throat swabs for respiratory pathogens (AusDiagnostics RPS Panel Upper Respiratory Pathogens), Peak Flow tests and exhaled fraction of nitric oxide (FENO) were reviewed. Patients were stratified according to those who needed admission and those who were discharged directly from the Emergency Department. Results 172 patients (70% female) with a mean age of 49±18.4 were included in the analysis. 98/172 (57%) patients, of which 70% were female, needed hospital admission. Patients admitted to hospital were significantly older (52±17.6 vs 43±18.8 years, p Conclusion Patients who require hospital admission for an acute asthma exacerbation are more likely to be older and to have signs of infection. In our patient group, type 2 biomarkers known to be associated with asthma exacerbation risk, did not predict need for hospital admission.

Asthma is associated with increased rate of acute chest syndrome (ACS), pain episodes and premature death. Differentiating between an acute asthma exacerbation and ACS is a challenge clinically as they can present with similar symptoms. Clinicians should be aware of symptoms of asthma or broncho spasm in any children with sickle cell disease, as adequate treatments are required. In this mini-review, we selected 16 clinical studies, published in English between 2004 and 2016, and reviewed all of the abstracts and references of the selected articles. We subsequently selected articles that were focused on asthma in children with sickle cell disease. Given the pathophysiological mechanisms of ACS and the association between asthma and sickle cell disease, the management approach of asthmatic children should be clarified. Bronchodilators should be used if there are clinical features suggestive of a history of asthma or evidence of acute broncho spasm. The indication for cortisone should be reassessed. This literature review failed to conclude on therapeutic modalities of ACS in asthmatic children with sickle cell disease. Only a well designed, multicenter adequately-powered randomized controlled study of each of them will allow assessing their real benefits and risks.

Asthma is a common chronic respiratory disease with acute exacerbations recognized clinically by the signs and symptoms of dyspnea, cough, chest tightness, and wheezing. In the United States approximately 25 million individuals currently have asthma and in 2017, asthma exacerbations accounted for approximately 1.8 million emergency department (ED) visits and 3,500 deaths.

The effects of fluid administration during acute asthma exacerbation are likely unique in this patient population: highly negative inspiratory intrapleural pressure resulting from increased airway resistance may interact with excess fluid administration to favor the accumulation of extravascular lung water, leading to worse clinical outcomes.Investigate how fluid balance influences clinical outcomes in children hospitalized for asthma exacerbation.We analyzed the association between fluid overload and clinical outcomes in a retrospective cohort of children admitted to an urban children's hospital with acute asthma exacerbation. These findings were validated in two cohorts: a matched retrospective and a prospective observational cohort. Finally, ultrasound imaging was used to identify extravascular lung water and investigate the physiological basis for the inferential findings.In the retrospective cohort, peak fluid overload [(fluid input - output)/weight] is associated with longer hospital length of stay, longer treatment duration, and increased risk of supplemental oxygen use (P values 0.001). Similar results were obtained in the validation cohorts. There was a strong interaction between fluid balance and intrapleural pressure: the combination of positive fluid balance and highly negative inspiratory intrapleural pressures is associated with signs of increased extravascular lung water (P 0.001), longer length of stay (P = 0.01), longer treatment duration (P = 0.03), and increased risk of supplemental oxygen use (P = 0.02).Excess volume administration leading to fluid overload in children with acute asthma exacerbation is associated with increased extravascular lung water and worse clinical outcomes.

Persistent tachypnoea despite resolution of bronchospasm in a patient with acute asthma exacerbation after administration of inhaled short acting β2-receptor agonist should alert the clinician to this potential diagnosis. https://bit.ly/385VU2Q

We present an uncommon case of H1N1 triggered thyroid storm in a patient with previously undiagnosed Grave's Disease. This case illustrates the challenges of diagnosing thyroid storm in the emergency department and the importance of including it in the differential when treating more common diagnoses that fail to respond to usual therapies. Thyroid storm is an endocrinologic emergency and requires prompt recognition and treatment. However, it remains a diagnostic challenge as there is no laboratory test specific to thyroid storm. Diagnosis relies on clinical suspicion in corroboration with patient presentation, laboratory findings and response to therapy.

Asthma is a common diagnosis or preexisting condition, and many patients with acute asthma exacerbation may present to the emergency department with wheezing and respiratory distress. However, many conditions may mimic this presentation.This review provides an overview of common asthma mimics and an approach to evaluation and management.Asthma is characterized by an obstructive pulmonary disease with recurrent exacerbations. The disease may present with a variety of symptoms, including wheezing, chest tightness, shortness of breath, and even respiratory failure. Mimics include anaphylaxis, angioedema, central airway obstruction, heart failure, allergic reaction, foreign body aspiration, pulmonary embolism, and vocal cord dysfunction. The approach to evaluation and management of these patients includes assessment for life-threatening conditions while treatment and resuscitation is underway. Providers should assess for red flags, including no history of asthma, lack of severe asthma, and no improvement with standard treatments. Focused assessment with history, physical examination, chest imaging, electrocardiogram, and laboratory studies may provide benefit. Through consideration of these mimics and treatment, providers can provide rapid management.While asthma is a common disease, many asthma mimics exist. Through consideration of other diseases with wheezing and assessing for red flags, such as patients presenting without a history of asthma or patients with a history of only mild asthma presenting with severe symptoms, emergency providers may decrease the chance of early diagnostic closure and anchoring while improving the care of these patients.

Introduction We previously reported the outcome of a retrospective evaluation of asthma care for patients attending three emergency departments (ED) in England. 1 We demonstrated that components of the BTS Asthma Care Bundle were completed in less than a third of patients attending the ED with an acute exacerbation. We now report prospective data from two of the participating trusts following implementation of interventions designed to improve asthma care for patients attending the ED. Methods Setting: Two NHS hospital trusts in England over a six-month period. Design: Prospective evaluation of asthma care for patients attending the ED with asthma exacerbation. Intervention: Both trusts implemented electronic systems to identify asthma patients attending ED. All patients were contacted by an asthma nurse by telephone following their attendance. In Trust 1, contacted patients were invited to attend a specialist nurse-led clinic within 2 working days of ED attendance. In Trust 2, a specialist nurse-led telephone consultation was undertaken and patients were triaged for follow-up using a standard protocol. Data collection: A standard dataset was collected for each patient event, including demographics and delivery of asthma care with reference to the BTS asthma Care Bundle. Data analysis: Data are presented descriptively. Results This study includes 120 patient events (26% male, 17–81 years). Significant improvements in asthma care were observed in both trusts. Attendance in nurse-led clinics in Trust 1 led to completion of care elements set-out in the BTS asthma bundle in almost all patients. Follow-up arrangements improved in both Trusts. Data are presented in Table 1. Conclusion Electronic systems can be used to identify patients attending ED with asthma exacerbations for review by specialist asthma services. Elements of asthma care described in the BTS bundle are infrequently performed in the ED. Early specialist nurse-led clinic review can address this. Identifying patients and arranging review in specialist nurse-led clinics offer a way of providing optimal asthma care for patients discharged from ED.

Asthma is the most common pediatric chronic illness and acute asthma exacerbations in children lead to numerous emergency department (ED) visits each year. Current methods to gauge a child’s response to treatment rely on a mixture of qualitative and quantitative measures and require experienced practitioners. In this work, we present a child-friendly acoustic device developed with the aim of expediting and quantifying assessment of treatment responsiveness for this vulnerable population. The device acquires measurements from a digital stethoscope as sound is sent through the chest using a custom chest exciter. In this work, we compared sound transmission from patients before and after administration of hospital albuterol sulfate nebulizer. One hundred and forty recordings were collected from ten children that presented to the ED for acute asthma exacerbation. Preliminary data is presented for these patients, demonstrating a shift of approximately 2 dB after treatment and relief of symptoms. This improvement was also validated using an established asthma assessment scoring system.

Introduction: The commonality of shared comorbidities and potential predisposition for those patients suffering from asthma or diabetes to develop the other provides an opportunity to maximise early detection and increase the effectiveness of current treatment. Early detection of both is essential in allowing vital interventions to take place that can improve health outcomes. Aim: Ascertain whether the prehospital treatment of acute asthma exacerbation with nebulised Salbutamol results in increased blood glucose levels that may be used as treatment markers. Method: All pre-coded asthma calls were collated over a 12-month period from one UK ambulance service. These calls were filtered to identify those where nebulised Salbutamol was used as part of their treatment, with a particular focus on those patients that demonstrated a post nebulisation blood glucose level of above 5.5 mmol/L, or any increase between pre and post levels. Results: Over the timeframe ambulance clinicians administered nebulised Salbutamol to a total of 1,465 asthma patients. Of these 1,134 (77%) had their blood glucose recorded at least once, with 241 (13%) demonstrating a post nebulisation level in excess of 5.5 mmol/l. Where a pre and post blood glucose measurement was taken 92 (8%) patients showed a rise in their levels. In total where a post nebulisation measurement was taken 106 (9%) patients demonstrated a level of 10 mmol/l or above. Conclusion: The potential for asthmatics to have an underlying predisposition for diabetes and need for further development is highlighted by the number of patients that demonstrated a high or increase in blood glucose levels following nebulisation.

With our study, we searched the medical literature to find magnesium (Mg) correlation with Emergency situations or its use in Emergency Medicine. Our aim is to fill the gap that we find in our daily routine between Mg studies on its role in Emergency and the real conception that doctors have of it in medical practice. We searched the literature for terms as magnesium or magnesium sulphate, magnesium in emergency, eclampsia, arrhythmias, acute asthma exacerbation, magnesium, and pediatric population. After a thorough research, we divided our discoveries into chapters to sort out a large amount often discordant articles.

Introduction The UK National Review of Asthma Deaths (NRAD) found that 21% of patients had attended an emergency department (ED) due to asthma at least once in the year before their death. National guidelines have set out a series of recommendations to improve outcomes following admission with an asthma exacerbation. The following five elements of care now form the basis of the British Thoracic Society (BTS) Asthma Care Bundle: (1) inhaler technique assessment; (2) medication review; (3) written action plan; (4) consideration of trigger factors; and (5) arrangement of follow-up (within two working days in the community and two weeks with a specialist). Three NHS hospital trusts present baseline (interim) data, both as an assessment against the current care bundle elements and to allow the trusts to undertake a targeted approach of addressing internal processes to improve patient outcomes. Methods Setting: Three NHS hospital trusts in England over a six-month period. Design: A retrospective review of asthma care and subsequent discharge follow-up arrangements for patients attending ED with an asthma exacerbation. Participants were identified using electronic systems and eligibility confirmed by case note review. Data collection: Patient demographics and clinical measurements were recorded according to local requirements/protocols. Data analysis: Descriptive interim data are presented to date. Results The review included 319 eligible patients/admission events. Participant demographics and data on the asthma care received in the ED are summarised in table 1. Interim data from all three trusts showed only 46 (14.4%) records of inhaler technique assessment, the existence/provision of 36 (15.7%) personalised asthma action plans and 103 (32.3%) recorded instances of follow-up with the General Practitioner (GP) being arranged/recommended. No discharge follow-up GP events were recorded. Conclusion Four years after NRAD, it appears that their recommendations and elements of the relevant BTS Care Bundle seems to only be undertaken in a small proportion of patients attending ED with asthma exacerbation. It is likely that a range of barriers exist preventing guideline and care bundle implementation in this setting. This highlights the need for asthma services to work with EDs, acute and primary care colleagues/providers to develop flexible and scalable solutions.

Asthma exacerbations remain a leading cause of hospitalization in the pediatric population, and many children who require hospitalization for status asthmaticus are managed using clinical care pathways (CPGs). Clinical care pathways are often created or adopted by healthcare systems in order to establish specific, evidence-based guidelines that standardize and coordinate quality care in both the emergency room and inpatient settings. This paper reviews the use of these guidelines and the updated evidence-based recommendations regarding best-practice for acute asthma care of hospitalized children, including the 2020 recommendations from the National Asthma Education and Prevention Program Expert Panel (NAEPP).

Scarce evidence existed on the association between short-term exposure to fine particulate matter (PM2.5) and asthma in China. In this study, we aimed to explore the relationship of PM2.5 with acute asthma exacerbation in a coastal city of China. Cases of acute asthma exacerbation were identified from hospital outpatient visits in Yancheng, China, from 2015 to 2018. We utilized the generalized additive model linked by a quasi-Poisson distribution to assess the association between PM2.5 and daily acute asthma exacerbation. Different lag structures were built, and we conducted stratification analyses by gender, age, and season. Two-pollutant models were fitted, and concentration-response (C-R) curves were pooled. A total of 3,520 cases of acute asthma exacerbation were recorded, with a daily average of 3. We observed positive and significant associations of PM2.5 on lag 1, 2, lag 02, and lag 03 day. For each 10-μg/m3 increase in PM2.5 (lag 02), the associated increment in asthma was 3.15% (95% CI: 0.99%, 5.31%). The association remained after adjusting for gaseous co-pollutants. We observed significant PM2.5-asthma associations in males, patients ≤64 years, and during cold seasons. The C-R curves were positive and almost linear for total and strata-specific associations. In conclusion, this study provided robust evidence on the association of PM2.5 with acute asthma exacerbation, which may benefit future prevention strategy and policy making.

BACKGROUND Wood's score, the assessment of childhood respiratory failure, has been used to assess childhood acute asthma severity in Thailand since 19th century. However, PRAM score, which is increasingly used in Western countries has not been evaluated among Thai children with asthma. OBJECTIVES This study aims to determine whether Wood or PRAM score is better prediction of severity of childhood asthma exacerbation. METHODS The prospective comparative study of severity asthma score was performed in asthmatic children, 2-18 years old, with acute asthma exacerbation at Queen Sirikit National Institute of Child Health. PRAM and Wood's score were separately determined by 2 physicians. The patients were further assessed at 0, 4 or 24 hours after their admissions. The asthma treatment followed GINA guideline. RESULTS There were 80 asthmatic patients, mean aged 5.71 ± 2.95 years. The admission rate was 28.8% with the mean length of stay = 4 ± 1 days. PRAM was correlated with Wood's score (Spearman's correlation p = 0.900, p < 0.001 at triage, and = p0.981, p < 0.001). The highlight of this study is the finding that intraclass correlation of PRAM is better than Wood asthma score (ICC = 0.944; 95%CI 0.913-0.964, 0.898; 95%CI 0.841-0.935, respectively). ROC indicated Wood's score ≤ 4 and PRAM ≤ 5, in the requirement for admission. CONCLUSION PRAM and Wood's score are both promising in prediction of severity and outcome of childhood asthma exacerbation.

Background: Antipyretics are frequently used in pediatric practice. Both acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) have been reported to increase the risk of asthma exacerbation. The study investigated antipyretic use during respiratory infection in children and analyzed the risk of acetaminophen and NSAID for severe asthma exacerbation (AE) in asthmatic children in Taiwan. Methods: We used the data from the National Health Insurance Research Database in 2005. There were 27,095 pediatric asthmatic patients having at least one respiratory infection episode, and 27,095 age- and sex-matched non-asthmatic children with respiratory infection served as controls. These patients were divided into groups with acetaminophen use, NSAID cyclooxygenase-1 (COX-1) use, and no antipyretic use. The rate of AE occurrence within the first 7 days after respiratory infection diagnosis was compared among the groups. Results: During a single episode of respiratory infection, asthmatic patients used fewer antipyretics than controls (48.51% vs. 55.50%, p

Asthma is a common chronic illness of childhood and represents the leading cause of childhood morbidity as measured by school absence,emergency department visit,and hospitalization. Budesonide is an inhaled corticosteroid used as controller agent and recently introduced as an adjuvant treatment in acute attacks of asthma.To evaluate the effect of combination of budesonide plus salbutamol nebulizer versus salbutamol nebulizer monotherapy in children with acute attack of asthma. A randomized double blind standard control clinical study was done in Karbala teaching hospital for children from1st of November 2015 to the end of November 2016 on patients aged 1-12 years presented to emergency department with mild to moderate acute attack of asthma. The patients randomly divided into salbutamol group (50) patients and salbutamol plus budesonide group (50) patients. For each patient the severity of asthma attack was determined by pulmonary index score (PIS) before initiation of treatment,then assessment done each 30 minutes up to 90 minute to detect the decrement in severity of attack and response to treatment. There was significant reduction in PIS (p

Pneumomediastinum is a rare disorder with a good prognosis. The authors present the case of a spontaneous extensive uncomplicated pneumomediastinum following an asthma exacerbation. The diagnosis was prompt with simple chest radiography and chest computed tomography (CT) excluded complications. The patient was treated with high concentration oxygen and on the 5th day repeated the CT, which revealed absence of pneumomediastinum. Pneumomediastinum has a benign course, unwarranting follow-up.

N Navanandan, M Federico, RD Mistry. J Pediatr. 2017;185:142–154.e2 To evaluate the effectiveness of positive expiratory pressure (PEP) in children presenting to the emergency department (ED) with moderate-to-severe asthma exacerbations. The study included children, 2 to 18 years old, who presented to a tertiary-care children’s hospital ED for an acute asthma exacerbation. This was a single-blinded, randomized study …

Introduction The purposes of this project were (a) to examine criteria derived from evidence-based pediatric acute asthma exacerbation assessment tools, asthma scores, and the acute asthma prediction rule validated and used in the emergency department and (b) to adapt these criteria for pediatric primary care. Method The three stages of the project included (a) identification of criteria in a literature review, (b) validation of the criteria by an expert panel, and (c) adaptation of the criteria in the design of an assessment tool. Results The criteria were validated and adapted in the design of The Pediatric Acute Asthma Exacerbation Severity Assessment and Disposition Decision-Making Tool for Pediatric Primary Care. Discussion The adaptation of criteria derived from the evidence and validated by an expert panel will inform and guide clinicians in assessing severity and support decision making in determining disposition of pediatric patients presenting with an acute asthma exacerbation in primary care.

Herein, we review the current guidelines for the management of children with an acute asthma exacerbation. We focus on management in the emergency department, inpatient, and ICU settings.The most recent statistics show that the prevalence of asthma during childhood has decreased in certain demographic subgroups and plateaued in other subgroups. However, acute asthma accounts for significant healthcare expenditures. Although there are few, if any, newer therapeutic agents available for management of acute asthma exacerbations, several reports leveraging quality improvement science have shown significant reductions in costs of care as well as improvements in outcome.Asthma is one of the most common chronic conditions in children and the most common reason that children are admitted to the hospital. Nevertheless, the evidence to support specific agents in the management of acute asthma exacerbations is surprisingly limited. The management of acute exacerbations focuses on reversal of bronchospasm, correction of hypoxia, and prevention of relapse and recurrence. Second-tier and third-tier agents are infrequently used outside of the ICU setting. Reducing the variation in treatment is likely to lead to lower costs and better outcomes.

Background: In September 2015, Japan experienced an unusual increase in acute asthma hospitalizations of children that coincided with an enterovirus D68 (EV-D68) epidemic. The objective of this study is to investigate whether EV-D68 had a causal relationship with the spike in asthma hospitalizations. Methods: A nation-wide retrospective survey of asthma hospitalizations of children was performed for the period from January 2010 through October 2015. The Japanese Society of Pediatric Allergy and Clinical Immunology asked its affiliated hospitals to report monthly numbers of hospitalizations, ICU admissions and mechanical ventilations due to acute asthma exacerbation. The data were retrieved from medical databases using predefined search criteria: diagnosis of asthma or asthmatic bronchitis, admission, and age

OBJECTIVES: The standard of care for treatment of an asthma exacerbation includes oxygen, inhaled short-acting bronchodilators, and systemic corticosteroids; adjunctive therapies, such as intravenous magnesium sulfate, can be used for patients who are having life-threatening exacerbations. The purpose of this study was to analyze the prescribing patterns as well as the safety of intravenous magnesium sulfate for the treatment of acute asthma exacerbations in pediatric patients across multiple hospitals in New Jersey. METHODS: This retrospective chart review was conducted at 4 medical centers in New Jersey on patients who presented to the emergency department between January 1, 2010, and December 31, 2010. RESULTS: Fifty-three patients were included in the study. In the emergency department, 98% of patients received inhaled albuterol plus ipratropium and 85% received systemic corticosteroids before intravenous magnesium sulfate administration. The median dose of magnesium sulfate was 40 mg/kg with a median time of administration of 20 minutes. One patient experienced hypotension that was thought to be related to magnesium sulfate administration. CONCLUSIONS: This study demonstrates that weight-based dosage, as well as time of administration of magnesium sulfate for pediatric patients with an acute asthma exacerbation, varies across different institutions in New Jersey. Magnesium sulfate use was safe in this patient population.

Rationale: The effects of fluid administration during acute asthma exacerbation are likely unique in this patient population: highly negative inspiratory intrapleural pressure resulting from increased airway resistance may interact with excess fluid administration to favor the accumulation of extravascular lung water, leading to worse clinical outcomes. Objectives: Investigate how fluid balance influences clinical outcomes in children hospitalized for asthma exacerbation. Methods: We analyzed the association between fluid overload and clinical outcomes in a retrospective cohort of children admitted to an urban children’s hospital with acute asthma exacerbation. These findings were validated in two cohorts: a matched retrospective and a prospective observational cohort. Finally, ultrasound imaging was used to identify extravascular lung water and investigate the physiological basis for the inferential findings. Measurements and Main Results: In the retrospective cohort, peak fluid overload [(fluid input − output)/weight] is associated with longer hospital length of stay, longer treatment duration, and increased risk of supplemental oxygen use (P values

D Kantor, EL Hirshberg, MC McDonald. Am J Respir Crit Care Med . 2018;197(9):1228–1135 To investigate the effect of fluid overload on clinical outcomes in children hospitalized for an asthma exacerbation. The retrospective cohort included children >6 years with only 1 admission to a single center for an asthma exacerbation during a 7-year period ( n = 1175). Patients had to receive intravenous fluids within 24 hours of presentation and could not have chronic lung disease or acute pneumonia. From this same cohort, a quasitreatment group of children with multiple admissions, as defined by receiving ≥7% peak fluid overload, was compared with a matched quasicontrol …

Background Early identification of the severity of asthma exacerbation would be helpful for the management of patients. We aimed to evaluate the correlation of morphological change in activated eosinophils and the severity of an asthma exacerbation. Methods Blood was collected from 55 asthmatic children: 40 of whom were having an exacerbation, 15 symptom-free, and 15 healthy controls. The percentage of eosinophils with morphological changes (emission of single or multiple pseudopods, presence of cytoplasmic vacuoles, releasing a small, moderate, or large quantity of granules, spreading, eosinophil death, and presence of cluster of free eosinophil granules) was quantified after the adherence to a slide and compared using the Mann–Whitney test. The correlation between the severity of the asthma exacerbation and the percentage changed eosinophils was tested with Spearman's correlation. Results The proportion of activated eosinophils was higher in asthmatic symptom-free children than in the control group, and acute asthma exacerbation produced an additional increase in eosinophil activation (P

Introduction The modified pulmonary index score (MPIS) has been estimated as a reliable assessment tool for children with acute asthma exacerbation. Objective To evaluate the usefulness of MPIS as an indicator of hospitalization in acute asthma exacerbation of children. Method MPIS values were measured in 154 asthmatic children (median age 5 years (1-15); 110 males and 44 females) at outpatient emergency department from November 2014 to November 2015. MPIS was calculated by adding the sum of scores for 6 items (scores of 0-3 were given for each item). These consisted of heart rate, respiratory rate, accessory muscle use, inspiratory-to-expiratory flow ratio, degree of wheezing, and oxygen saturation in room air. Measurements were made at visits and at hospitalization until discharge. All of the raters previously completed training with the originally developed digital learning software for the MPIS. Result 39 out of 154 asthmatic children were hospitalized, and the average of the MPIS was 9.7 point. The cut-off point was considered to be 7 or >7, with sensitivity of 74.3% and specificity 84.3%, respectively. This means 74.3% of children with acute exacerbation of asthma with MPIS > 7 points were hospitalized, while 84.3% with MPIS Conclusion MPIS is a useful assessment tool in deciding whether to hospitalize for children with acute asthma exacerbation.