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Background: Current knowledge of the impact of socioeconomic factors on the risk of admission to the pediatric intensive care unit (PICU) for asthma is limited. Using composite measures of social vulnerability-Social Vulnerability Index (SVI) and Child Opportunity Index (COI) 2.0-we compared patients admitted for status asthmaticus to the PICU and pediatric ward at Children's Hospital Los Angeles (CHLA). We hypothesized patients with a high SVI and low COI are at higher risk for PICU admission., Methods: Patients were identified using ICD-10 codes for asthma. Primary outcome was admission to PICU versus ward for status asthmaticus. Patient-registered residential street addresses were geocoded and spatially joined to SVI and COI 2.0 data at the census tract level. Univariate and regression analyses using the patient's SVI, COI 2.0, and admission location were conducted., Results: From January 2017 to March 2022, there were 2458 admissions matched to addresses from 1983 distinct patients. The overall median SVI for all patients was 0.86 (IQR 0.6, 0.9). Overall median COI was 25.0 (IQR 10, 50). There was no difference in SVI or COI for admission to the PICU versus the ward. However, children requiring multiple hospital admissions for asthma were associated with higher SVI and lower COI., Conclusions: Children admitted to CHLA for asthma had an elevated SVI and low COI. There was no difference between admission locations based on SVI or COI scores. This indicates we care for children at increased socioeconomic risk, but this did not increase PICU use for asthma., (© 2024 European Academy of Allergy and Clinical Immunology and John Wiley & Sons Ltd.)

Objective: The ability to predict impending asthma exacerbations may allow better utilization of healthcare resources, prevention of hospitalization and improve patient outcomes. We aimed to develop models using machine learning to predict risk of exacerbations., Methods: Data from 29,396 asthma patients was collected from electronic medical records and national registers covering clinical and epidemiological factors (e.g. comorbidities, health care contacts), between 2000 and 2013. Machine-learning classifiers were used to create models to predict exacerbations within the next 15 days. Model selection was done using the mean cross validation score of area under precision-recall curve (AUPRC)., Results: The most important predictors of exacerbation were comorbidity burden and previous exacerbations. Model validation on test data yielded an AUPRC = 0.007 (95% CI: ± 0.0002), indicating that historic clinical information alone may not be sufficient to predict a near future risk of asthma exacerbation., Conclusions: Supplementation with additional data on environmental triggers, (e.g. weather, pollen count, air quality) and from wearables, might be necessary to improve performance of the short-term predictive model to develop a more clinically useful tool., (Copyright © 2021 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Competing Interests: Competing interests: ML reports personal fees from Clement Clarke International, personal fees from Teva, personal fees from Astra Zeneca, non-financial support and other from Global Initiative on Asthma (GINA), USA, personal fees from Chiesi, grants from Consorcio Ricerca in Futura, personal fees from Soar Beyond, personal fees from Orion Pharmaceuticals, other from Napp Pharmaceuticals, personal fees from National Services for Health Improvement, a company providing services for practices (Nurse asthma Reviews), personal fees from Novartis Pharmaceuticals, personal fees from GLaxo Smith Klein, non-financial support from Asthma and COPD (Joint) Lead for Whole Systems Integrated Care (WSIC) NorthWest London, personal fees from Trudel Pharmaceuticals, personal fees from AstraZeneca, outside the submitted work.

Beta-adrenergic blocking agents (abbreviated as beta-blockers) have been used for treating various cardiovascular diseases. However, the potential for asthma exacerbation is one of the major adverse effects of beta-blockers. This study aimed to compare the level of risk for an asthma attack in patients receiving various beta-blockers. We searched for randomized controlled trials (RCTs) of either placebo-controlled or active-controlled design. The current network meta-analysis (NMA) was conducted under a frequentist model. The primary outcome was the incidence of asthmatic attack. A total of 24 RCTs were included. Overall NMA revealed that only oral timolol [risk ratio (RR) = 3.35 (95% confidence interval (CI) 1.04-10.85)] and infusion of propranolol [RR = 10.19 (95% CI 1.29-80.41)] were associated with significantly higher incidences of asthma attack than the placebo, whereas oral celiprolol [RR = 0.39 (95% CI 0.04-4.11)], oral celiprolol and propranolol [RR = 0.46 (95% CI 0.02-11.65)], oral bisoprolol [RR = 0.46 (95% CI 0.02-11.65)], oral atenolol [RR = 0.51 (95% CI 0.20-1.28)], infusion of practolol [RR = 0.80 (95% CI 0.03-25.14)], and infusion of sotalol [RR = 0.91 (95% CI 0.08-10.65)] were associated with relatively lower incidences of asthma attack than the placebo. In participants with a baseline asthma history, in addition to oral timolol and infusion of propranolol, oral labetalol, oxprenolol, propranolol, and metoprolol exhibited significantly higher incidences of asthma attack than did the placebo. In conclusion, oral timolol and infusion of propranolol were associated with a significantly higher risk of developing an asthma attack in patients, especially in those with a baseline asthma history, and should be avoided in patients who present a risk of asthma.Trial registration: PROSPERO CRD42020190540.

Rationale: Noninvasive ventilation decreases the need for invasive mechanical ventilation and mortality among patients with chronic obstructive pulmonary disease but has not been well studied in asthma. Objectives: To assess the association between noninvasive ventilation and subsequent need for invasive mechanical ventilation and in-hospital mortality among patients admitted with asthma exacerbation to the ICU. Methods: We performed a retrospective cohort study using administrative data collected during 2010-2017 from 682 hospitals in the United States. Outcomes included receipt of invasive mechanical ventilation and in-hospital mortality. Generalized estimating equations, propensity-matched models, and marginal structural models were used to assess the association between noninvasive ventilation and outcomes. Measurements and Main Results: The study population included 53,654 participants with asthma exacerbation. During the study period, 13,540 patients received noninvasive ventilation (25.2%; 95% confidence interval [CI], 24.9-25.6%), 14,498 underwent invasive mechanical ventilation (27.0%; 95% CI, 26.7-27.4%), and 1,291 died (2.4%; 95% CI, 2.3-2.5%). Among those receiving noninvasive ventilation, 3,013 patients (22.3%; 95% CI, 21.6-23.0%) required invasive mechanical ventilation after first receiving noninvasive ventilation, 136 of whom died (4.5%; 95% CI, 3.8-5.3%). Across all models, the use of noninvasive ventilation was associated with a lower odds of receiving invasive mechanical ventilation (adjusted generalized estimating equation odds ratio, 0.36; 95% CI, 0.32-0.40) and in-hospital mortality (odds ratio, 0.48; 95% CI 0.40-0.58). Those who received noninvasive ventilation before invasive mechanical ventilation were more likely to have comorbid pneumonia and severe sepsis. Conclusions: Noninvasive ventilation use during asthma exacerbation was associated with improved outcomes but should be used cautiously with acute comorbid conditions.

Background: Little is known about the concordance of atopy with asthma COPD overlap. Among individuals with COPD, a better understanding of the phenotypes characterized by asthma overlap and atopy is needed to better target therapies., Research Question: What is the overlap between atopy and asthma status among individuals with COPD, and how are categories defined by the presence of atopy and asthma status associated with clinical and radiologic phenotypes and outcomes in the Genetic Epidemiology of COPD Study (COPDGene) and Subpopulation and Intermediate Outcome Measures in COPD Study (SPIROMICS)?, Study Design and Methods: Four hundred three individuals with COPD from SPIROMICS and 696 individuals from COPDGene with data about specific IgEs to 10 common allergens and mixes (simultaneous assessment of combination of allergens in similar category) were included. Comparison groups were defined by atopic and asthma status (neither, atopy alone, atopic asthma, nonatopic asthma, with atopy defined as any positive specific IgE (≥0.35 KU/L) to any of the 10 allergens or mixes and asthma defined as self-report of doctor-diagnosed current asthma). Multivariable regression analyses (linear, logistic, and zero inflated negative binomial where appropriate) adjusted for age, sex, race, lung function, smoking status, pack-years smoked, and use of inhaled corticosteroids were used to determine characteristics of groups and relationship with outcomes (exacerbations, clinical outcomes, CT metrics) separately in COPDGene and SPIROMICS, and then adjusted results were combined using meta-analysis., Results: The prevalence of atopy was 35% and 36% in COPD subjects from SPIROMICS and COPDGene, respectively, and less than 50% overlap was seen between atopic status with asthma in both cohorts. In meta-analysis, individuals with nonatopic asthma had the most impaired symptom scores (effect size for St. George's Respiratory Questionnaire total score, 4.2; 95% CI, 0.4-7.9; effect size for COPD Assessment Test score, 2.8; 95% CI, 0.089-5.4), highest risk for exacerbations (incidence rate ratio, 1.41; 95% CI, 1.05-1.88) compared with the group without atopy or asthma. Those with atopy and atopic asthma were not at increased risk for adverse outcomes., Interpretation: Asthma and atopy had incomplete overlap among former and current smokers with COPD in COPDGene and SPIROMICS. Nonatopic asthma was associated with adverse outcomes and exacerbation risk in COPD, whereas groups having atopy alone and atopic asthma had less risk., (Copyright © 2020 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)

Background: Children with status asthmaticus (SA) often present with fever and are evaluated with chest radiographs (CXRs). In the absence of a confirmatory test for bacterial infection, antibiotics are started whenever there are radiological infiltrates or if there is a suspicion of pneumonia. We undertook this study to determine if serum procalcitonin (PCT) levels at admission are altered in critically ill children with SA. We also sought to determine if serum PCT levels are elevated in children with radiological infiltrates or in children who were treated with antibiotics., Methods: This is a prospective single-center observational study evaluating serum PCT levels in critically ill children with SA. Study subjects included children 1 to 21 years old, admitted to a pediatric intensive care unit (PICU) with SA between March 2012 and April 2013. For the purposes of this study, patients whose CXRs were read by the radiologist as probable bacterial pneumonia was defined as having "radiological bacterial pneumonia," whereas patients who received antibiotics by the treating physician were defined as having "clinician-diagnosed pneumonia.", Results: Sixty-one patients with a median age of 7.3 years (interquartile range, 4-10 years) were included in the study. Fifty-one percent were male. Average Pediatric Risk of Mortality III score was 2.7 (SD, 2.9). Three patients (5%) were determined to have radiological bacterial pneumonia, whereas 52 (85%) did not. Six patients (10%) were indeterminate. The mean PCT level for all patients was 0.65 (SD, 1.54) ng/mL, whereas the median PCT level was 0.3 ng/mL. There was no significant difference in the mean PCT levels between the patients with and without clinician-diagnosed pneumonia (0.33 [SD, 0.36] vs 0.69 [SD, 1.67], P = 0.44). Using a PCT cutoff level of 0.5 ng/mL, a significant association was found with the presence of fever (P = 0.004), but no significant association was found with the presence of CXR infiltrates, radiological bacterial pneumonia, hospital length of stay, PICU length of stay, Pediatric Risk of Mortality III scores, or receipt of antibiotics., Conclusions: Serum PCT level was not elevated to greater than 0.5 ng/mL in 75% of this cohort of critically ill children with SA admitted to PICU. Presence of CXR infiltrates was not associated with higher PCT levels. Large clinical trials are needed to study the diagnostic and predictive role of PCT in this patient population.

Introduction: The characteristics and treatment outcomes of status asthmaticus patients in emergency department (ED) have not been described previously especially in Thailand., Objective: To describe the characteristics, treatment outcomes and factors associated with status asthmaticus in Thai patients presenting to a single center ED., Methods: A prospective observational study was performed at Thammasat University hospital, Thailand. The data collected included demographics, asthma history and control, previous ED attendances and hospital admissions, presenting clinical, laboratory and radiographic features, treatments given, and outcomes. Multivariable regression was used to determine independent factors associated with status asthmaticus., Results: Over one year (2015-16), 209 patients were recruited, aged 6 - 54 years (median 33 y), of whom 145 (69.3%) had status asthmaticus. The factors associated with status asthmaticus were: (i) age > 60 y, (ii) presence of a comorbidity, (iii) having uncontrolled asthma, (iv) hospitalizations or visits to the ED in the last year, and (v) using > 1 metered dose inhaler canister per month. Status asthmaticus patients were significantly less likely to speak in sentences (p=0.001) and more likely to have poor air entry and chest wall retraction (p<0.0001), an abnormal chest X ray (p=0.011), receive magnesium sulphate and be admitted into hospital (p<0.0001). No patients died., Conclusions: Status asthmaticus was common in this cohort of patients in our setting. Our findings are consistent with previous studies and underscore the need for better patient management.

Background: Asthma is a common cause of pediatric hospitalization. Nonadherence to asthma medications is associated with worse outcomes; however, there is a paucity of data regarding posthospitalization prescription filling and hospital reuse. Our objective was to identify patients at risk for hospital reuse after being hospitalized for asthma., Methods: This is a retrospective study of patients with asthma who were discharged from a children's hospital in which we use Medicaid claims data to evaluate prescription fills within 30 days and 12 months. Chart reviews were used for demographics, chronic asthma severity, admission severity, and hospital reuse. t and χ 2 tests were performed for continuous and categorical variables. A generalized linear mixed model was fitted to predict the odds of hospital reuse, which was defined as requiring an emergency department visit or rehospitalization. Survival analysis using log-rank testing was used for modeling the time to hospital reuse., Results: Fifty-four percent of patients discharged with asthma had hospital reuse within 1 year of discharge. There was no association between hospital reuse and prescription filling for systemic steroids (odds ratio [OR] 1.30; confidence interval [CI]: 0.85-2.00; P = .21) or controller medications (OR 1.5; CI: 0.92-2.52; P = .10). There was a higher number of controller and systemic steroid prescription fills over 12 months for patients with hospital reuse. The factors associated with greater odds of hospital reuse were severity of chronic asthma diagnosis ( P = .03) as well as African American race (OR 1.92; CI: 1.17-3.13; P = .01)., Conclusions: For Medicaid-insured patients discharged with asthma, worse chronic asthma severity and African American race were associated with greater odds of hospital reuse. Decreased prescription filling was not associated with greater odds of hospital reuse., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2019 by the American Academy of Pediatrics.)

Objectives : The real incidence of pneumomediastinum (PNM) in adult patients with severe acute asthma exacerbation continues to be unknown. The current study aims to investigate the occurrence of PNM in an adult population of patients presenting a severe asthma attack and to evaluate the risk factors associated to its development. Methods : The 45 consecutive subjects who were admitted to our Division between January 1, 2015 and December 31, 2016 for severe acute asthma exacerbation underwent a diagnostic protocol including a standard chest X-ray and continuous monitoring of arterial oxygen saturation (SaO 2 ) during the first 24 hours following admission. The patients showing persistence or deterioration of oxyhemoglobin desaturation were prescribed a chest Computed Tomographic (CT) scan. Results : Five out of the 45 patients (11.1%) with severe acute asthma exacerbation were diagnosed with PNM, in one case on the basis of an X-ray image and in four on the basis of a chest CT scan. Data analysis showed that the PNM patients were younger [21 (17-21) vs 49.5 (20-73) yrs; p < 0.001] and more likely to show sensitization to Alternaria (2/5 vs 0/40; p = 0.0101) with respect to their non-PNM counterparts. The duration of hospital stay was similar in the two groups [8 (4-12) vs 7 (3-15) days; p = 0.6939]. Conclusions : PNM is a common clinical entity in young adults with severe acute asthma exacerbation, particularly in those with unsatisfactory response to initial medical therapy. Although generally benign, patients with suspected PNM should be closely monitored because of the risk of developing severe hypoxemia.

Objective: To describe the use of non-invasive ventilation (NIV) in adults presenting with status asthmaticus to Middlemore Hospital Critical Care Complex (CCC, South Auckland, New Zealand) from 2000 to 2015., Method: Retrospective review of all adult asthma admissions to the Hospital CCC between 2000 and 2015. Demographic, physiological, treatment data and blood gas results were recorded., Results: There were 265 asthma admissions to Middlemore Hospital CCC during the study period. The median age was 34 years; 64% were female. NIV was used in 186 admissions, of which eight went on to require intubation and invasive mechanical ventilation (IMV). Twenty-three other admissions received IMV without a trial of NIV and a further 58 were managed with medical care only. The average pH for all admissions was 7.23 and the IMV group had an average pH of 6.99. Forty-five admissions presented with a Glasgow Coma Scale (GCS) score of ≤10. Twenty-five of these were managed with NIV with only one requiring subsequent intubation. The mean duration of NIV in this group was 5 h (range 1-17 h) with a mean ICU and hospital length of stay of 17 h and 3.5 days, respectively. All patients in this group effectively lowered the pCO 2 over a 2 h period with NIV having an average drop of 5.9 kPa and IMV 3.4 kPa., Conclusion: The use of NIV appears to be safe and effective in patients with severe asthma, including selected patients with an altered level of consciousness. NIV was well tolerated with a low need for subsequent intubation., (© 2017 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine.)

Objective: To investigate whether there is a difference in the risk of asthma exacerbations between children with pre-existing asthma who receive live attenuated influenza vaccine (LAIV) compared with inactivated influenza vaccine (IIV)., Material and Methods: We identified IIV and LAIV immunizations occurring between July 1, 2007 and March 31, 2014 among Kaiser Permanente Northern California members aged 2 to <18years with a history of asthma, and subsequent asthma exacerbations seen in the inpatient or Emergency Department (ED) setting. We calculated the ratio of the odds (OR) of an exacerbation being in the risk interval (1-14days) versus the comparison interval (29-42days) following immunization, separately for LAIV and IIV, and then examined whether the OR differed between children receiving LAIV and those receiving IIV ("difference-in-differences")., Results: Among 387,633 immunizations, 85% were IIV and 15% were LAIV. Children getting LAIV vs. IIV were less likely to have "current or recent, persistent" asthma (25% vs. 47%), and more likely to have "remote history" of asthma (47% vs. 25%). Among IIV-vaccinated asthmatic children, the OR of an inpatient/ED asthma exacerbation was 0.97 (95% CI: 0.82-1.15). Among LAIV-vaccinated asthmatic children the OR was 0.38 (95% CI: 0.17-0.90). In the difference-in-differences analysis, the odds of asthma exacerbation following LAIV were less than IIV (Ratio of ORs: 0.40, CI: 0.17-0.95, p value: 0.04)., Conclusion: Among children ≥2years old with asthma, we found no increased risk of asthma exacerbation following LAIV or IIV, and a decreased risk following LAIV compared to IIV., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Background: While research has demonstrated increasing risk for severe maternal morbidity in the United States, risk at lower volume hospitals remains poorly characterized. More than half of all obstetric units in the United States perform <1000 deliveries per year and improving care at these hospitals may be critical to reducing risk nationwide., Objective: We sought to characterize maternal risk profiles and severe maternal morbidity at low-volume hospitals in the United States., Study Design: We used data from the Nationwide Inpatient Sample to evaluate trends in severe maternal morbidity and comorbid risk during delivery hospitalizations in the United States from 1998 through 2011. Comorbid maternal risk was estimated using a comorbidity index validated for obstetric patients. Severe maternal morbidity was defined as the presence of any 1 of 15 diagnoses representative of acute organ injury and critical illness., Results: A total of 2,300,279 deliveries occurred at hospitals with annual delivery volume <1000, representing 20% of delivery hospitalizations overall. There were 7849 cases (0.34%) of severe morbidity in low-volume hospitals and this risk increased over the course of the study from 0.25% in 1998 through 1999 to 0.49% in 2010 through 2011 (P < .01). The risk in hospitals with ≥1000 deliveries increased from 0.35-0.62% during the same time periods. The proportion of patients with the lowest comorbidity decreased, while the proportion of patients with highest comorbidity increased the most. The risk of severe morbidity increased across all women including those with low comorbidity scores. Risk for severe morbidity associated with obstetric hemorrhage, infection, hypertensive diseases of pregnancy, and medical conditions all increased during the study period., Conclusion: Our findings demonstrate increasing maternal risk at hospitals performing <1000 deliveries per year broadly distributed over the patient population. Rates of morbidity in centers with ≥1000 deliveries have also increased. These findings suggest that maternal safety improvements are necessary at all centers regardless of volume., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: In the setting of persistently high risk for maternal death and severe obstetric morbidity, little is known about the relationship between hospital delivery volume and maternal outcomes., Objective: The objectives of this analysis were (1) to determine maternal risk for severe morbidity during delivery hospitalizations by hospital delivery volume in the United States and (2) to characterize, by hospital volume, the risk for death in the setting of severe obstetric morbidity, a concept known as failure to rescue., Study Design: This cohort study evaluated 50,433,539 delivery hospitalizations across the United States from 1998-2010. The main outcome measures were (1) severe morbidity that was defined as a composite of any 1 of 15 diagnoses that are representative of acute organ injury and critical illness and (2) failure to rescue that was defined as death in the setting of severe morbidity., Results: The prevalence of severe morbidity rose from 471.2-751.5 cases per 100,000 deliveries from 1998-2010, which was an increase of 59.5%. Failure to rescue was highest in 1998 (1.5%), decreased to 0.6% in 2007, and rose to 0.9% in 2010. In models that were adjusted for comorbid risk and hospital factors, both low and high annualized delivery volume were associated with increased risk for failure to rescue and severe morbidity. However, the relative importance of hospital volume for both outcomes compared with other factors was relatively small., Conclusion: Although low-and high-delivery volume are associated with increased risk for both failure to rescue and severe maternal morbidity, other factors, in particular characteristics of individual centers, may be more important in the determination of outcomes., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background and Objective: The prevalence of both childhood asthma and obesity remain at historically high levels and disproportionately affect urban children. Asthma is a common and costly cause for pediatric hospitalization. Our objective was to determine the effect of obesity on outcomes among urban children hospitalized with status asthmaticus., Methods: A retrospective cohort study was performed by using billing system data and chart review to evaluate urban children admitted for asthma. Demographics, asthma severity, reported comorbidities, and outcomes were assessed. Obesity was defined by BMI percentile (lean<85%, overweight 85%-95%, obese≥95%). Outcomes were length of stay, hospitalization charges, ICU stay, repeat admissions, and subsequent emergency department (ED) visits. Bivariate analysis assessed for differences between overweight/obese and lean children. Multivariable regression assessed the relationship between overweight status and primary outcomes while controlling for other variables. Post hoc age-stratified analysis was also performed., Results: The study included 333 subjects; 38% were overweight/obese. Overweight/obese children admitted with asthma were more likely than lean children to have subsequent ED visits (odds ratio 1.6, 95% confidence interval 1.0-2.6). When stratified by age, overweight/obese preschool-age children (<5 years) were >2 times as likely to have repeat ED visits than lean preschool-age children (odds ratio 2.3, 95% confidence interval 1.0-5.6). There were no differences in the other outcomes between overweight/obese and lean individuals within the entire cohort or within other age groups., (Copyright © 2016 by the American Academy of Pediatrics.)

Objective: To assess the efficacy and safety profile of omalizumab treatment. The conditions under which omalizumab was prescribed agreed with those in Xolair® drug information: age > 12 years old, severe uncontrolled asthma, FEV1 < 80%, IgE 30-700 UI/ml and positive test results for perennial allergens., Methods: Asthmatic patients treated with omalizumab between January 2010 and July 2011 were evaluated retrospectively. Age, sex, weight, IgE level, concomitant asthma medications, change in FEV1, emergency department visits, hospitalizations, asthma exacerbations and corticosteroids bursts were recorded before and after omalizumab initiation. A 1.5- year period was chosen., Results: A total of 22 patients were included. The mean weight of subjects was 73 Kg (range, 51-102). Mean IgE was 203 UI/ml (range, 30-992) and mean FEV1 60% (range, 30-93%) at baseline. Adverse events were observed in 4 patients. There were no significant changes in FEV1 values after omalizumab treatment but omalizumab was associated with a reduction in concomitant asthma medications use in 14 patients and improvements in global asthma control in 12., Conclusion: In these patients add-on therapy with omalizumab reduced asthma exacerbations and emergency visits or hospitalizations. Only 55% of patients significantly improved global asthma control and no significant changes in FEV1 were observed., (Copyright © 2013 SEFH. Published by AULA MEDICA. All rights reserved.)

Objectives: The objective was to apply quality indicators in respiratory disease triage during a set time period., Methods: This was a retrospective, descriptive, and comparative study of all patients attending the emergency department of Acosta Ñu Children's Hospital with breathing difficulty, between January 1 and July 31, 2011., Results: Two thousand five hundred eighty-two patients were included in the study. The delay in medical care according to severity of breathing difficulty was as follows: for critical patients, 1 minute (100% compliance); for emergencies, 6.4 minutes (93.4% compared with 95% standard); for urgencies, 15.8 minutes (90% compared with the standard 90%); and for semiurgencies, 35 minutes (92.4% vs. 85% standard). Regarding to the admission-triage time indicator: mean time was 6.1 minutes; 2220 patients (86%) were classified in less than 10 minutes from the time of hospital admission, and 2453 (95%) were evaluated before 15 minutes. Respiratory rate was recorded in 2368 patients (91.7%), and pulse oximetry in 2443 (94.6%). Both parameters were recorded in 2271 children (88%). Errors in classification were detected, mainly tendency to underestimate the risk or exacerbate the clinical situation; 441 patients underwent subtriage (20.5%), and 44 overtriage (1.7%). There were drawbacks to classify emergencies error rate 45.8% (P < 0.00001). Relationship between pathophysiologic diagnosis and triage level was significant (P < 0.00001)., Conclusions: Indicators of triage quality were acceptably met in respiratory disease. Breathing difficulty was identified and classified as urgent, although problems arouse at differentiation between moderate and severe dyspnea.

Objectives: To investigate the characteristics, trends in management (permissive hypercapnia; mechanical ventilation (MV); neuromuscular blockade) and their impact on complications and outcomes in Status Asthmaticus (SA)., Methods: We performed a retrospective observational study of subjects admitted with SA to a single multidisciplinary MICU over a 30-year period. All laboratory, radiologic, respiratory care, physician notes and orders were extracted from an electronic medical record (EMR) maintained during the entire duration of the study., Results: Two hundred and twenty-seven subjects were admitted with 280 episodes of SA. While subjects reflected our regional population (52% Hispanic), African Americans were over-represented (22%) and Caucasians under-represented (21%). Thirty-eight percent reported childhood asthma, 27% were steroid dependent (10% in the last 10 years), and 18% had a recent steroid taper. One hundred and thirty-nine (61.2%) required intubation. The duration of hospitalization was similar between mechanically ventilated and non-ventilated subjects (5.8±4.41 vs. 6.8±7.22 days; p=0.07). The overall complication rate remained low irrespective of the use of permissive hypercapnia or mode of mechanical ventilation (overall mortality 0.4%; pneumothorax 2.5%; pneumonia 2.9%). The frequency of SA declined significantly in the last 10 years of the study (12.4 vs. 3.2 cases/year)., Conclusions: Despite the frequent use of mechanical ventilation, mortality/complication rates remained extremely low. MV did not significantly increase the duration of hospitalization. At our institution, the frequency of SA significantly decreased despite an increase in emergency room visits for asthma., (Published by Elsevier Ltd.)

Introduction: Environmental tobacco smoke (ETS) and allergens are risk factors in children with critical status asthmaticus. Genetic studies support that ETS-associated asthma is a special inflammatory entity, causing significant number of hospital admissions and relapses. Accordingly, the course and outcome of patients with ETS-induced status asthmaticus might also be different., Hypothesis: We hypothesized that the progression, course, and outcome of patients with ETS-induced status asthmaticus would be worse than those of patients without ETS exposure., Methods: Medical records of children who were admitted to the Pediatric Intensive Care Unit (PICU) with the diagnosis of asthma at the Children's Hospital of Winnipeg, Manitoba, over 10 years were audited after Institutional Review Board (IRB) approval. Two hundred thirty records were reviewed. We extracted data including demographics and analyzed the patient's deterioration defined as clinical asthma score (CAS) drift between the ED and PICU. We computed the treatment response, expressed as length of stay (LOS) in the PICU and in hospital. The risk factors were stratified as none, ETS exposure, allergies, and ETS with allergies., Results: There were 55 (25%) patients with no risk factors, 66 (30%) with ETS exposure only, 46 (21%) with allergies only, and 53 (24%) with both. There was a 25% decrease in CAS deterioration when patients were exposed to ETS (P < 0.05). For patients with or without allergies but with exposure to ETS, both the PICU and overall hospital LOS were ∼15% longer (P < 0.05) than for those not exposed to ETS. Stratifying for gender and race in multivariate analysis did not alter the results., Conclusions: Patients with ETS-associated critical status asthmaticus deteriorate and recover slower than non-ETS-exposed patients., (Copyright © 2010 Wiley-Liss, Inc.)

Objective: The purpose of this study was to assess whether referral to a pediatric emergency department (PED) by a primary care provider was associated with greater severity of illness, as determined on the basis of clinical measures and increased resource utilization., Methods: A retrospective study of data for 121 088 children who presented to a PED with abdominal pain, fever, or respiratory complaints during a 5-year period was performed. Demographic data, referral status, and proxy markers of illness severity were collected from the medical records and analyzed., Results: A total of 26.3% of all patients seen in the PED presented with these 3 complaint categories. With adjustment for age, gender, race, and insurance class, referred patients were significantly more likely to have high triage acuity designations, higher rates of very abnormal vital signs, and higher admission rates, compared with patients who were self-referred. Referred patients were more likely to undergo testing (laboratory or radiologic), to receive intravenous fluid therapy and pain medications, and to be assigned higher-severity discharge diagnoses, such as appendicitis, septic shock, or status asthmaticus., Conclusions: Referral by a primary care provider to a PED was significantly and independently associated with greater severity of illness and resource utilization. Referral status should be considered in algorithms used to triage cases for evaluation in the PED.

Objective: Status asthmaticus accounts for a large portion of the morbidity and mortality associated with asthma, but we know little about its epidemiology. We describe here the hospitalization characteristics of children with status asthmaticus, how they changed over time, and how they differed between hospitals with and without PICUs., Patients and Methods: We used administrative data from New Jersey that included all hospitalizations in the state from 1992, 1995, and 1999-2006. We identified children with status asthmaticus by using International Classification of Diseases, Ninth Revision, diagnosis codes that indicate status asthmaticus and the use of mechanical ventilation by using procedure codes. We designated hospitals with a PICU as "PICU hospitals" and those without as "adult hospitals.", Results: We identified 28 309 admissions of children with status asthmaticus (22.8% of all asthma hospitalizations). From 1992 to 2006, the rate of hospital admissions decreased by half (from 1.98 in 1000 to 0.93 in 1000 children), and there was a 70% decrease in the number of children admitted to adult hospitals. The rate of ICU care in PICU hospitals more than tripled. However, the rate of mechanical ventilation remained low, and the number of deaths was small and unchanged (n=14 total). Hospital costs climbed from $6.6 million to $9.5 million., Conclusions: Although fewer children are being admitted with status asthmaticus, the proportion of patients managed in PICUs is climbing. There has been no substantial change in rates of mechanical ventilation or death. Additional research is needed to better understand how patients and physicians decide on the appropriate site for hospital care and how that choice affects outcome.

Background and Purpose: The purpose of this study was to analyze the clinical course and outcomes of children with status asthmaticus treated in a pediatric intensive care unit (PICU) in Taiwan., Methods: The medical charts of all patients aged from 2 to 18 years with status asthmaticus who were admitted to the PICU National Taiwan University Hospital, Taipei, Taiwan, from 1990 to 2006 were reviewed retrospectively., Results: Twenty eight children were admitted on 33 occasions; 4 patients had more than 1 admission. The mean age was 6.23 years (range, 2-17 years). No control medication was regularly used prior to admission for 81.8% of the episodes. The mean PICU stay was 2.55 days (range, 1-13 days) and, for 78.8% of episodes, the patients were discharged from the ICU within 2 days. For 11 episodes (33.3%), the patients required mechanical ventilation for a mean duration of 3.6 days. The mortality rate was 3.3% (n = 1). Complications included bronchopneumonia (57.6%), hemodynamic compromise (9.1%), neurologic symptoms (6.1%), and air leak (3.3%). Patients requiring mechanical ventilation had significantly lower initial pulse oximeter oxygen saturation (<90%), lower blood gas pH (<7.25), higher partial pressure of carbon dioxide, and longer duration of PICU and hospital stay (p < 0.05) when compared with patients not requiring mechanical ventilation. For patients with a history of repeated PICU admissions for asthma, the intubation rate was 77.7%., Conclusions: The prognosis for childhood status asthmaticus is favorable. The most common trigger factors were respiratory tract infection and poor asthma control.

This study examined the covariation of negative emotions with airflow among 48 persons with asthma and their partners as they discussed relationship problems. Measures included self-reported questionnaires, airflow and behavior coded from videotaped discussions. Significantly increased self-reported hostility and statistically but not clinically significant declines in airflow were found post- versus pre-discussion. Self-reported responses to asthma symptoms of more anger and less loneliness predicted lower post-discussion airflow after accounting for pre-discussion airflow. The use of effort-independent measures of airflow and autonomic nervous system monitoring may inform future research regarding the physiological mechanisms through which mood and behavior affect airflow.

Objective: Studies assessing the characteristics and management of patients hospitalized with asthma have been limited to a small number of facilities and have evaluated short time periods. The present study evaluated long-term changes among hospitalized asthma patients at a large number of facilities., Methods: This was a retrospective, hospital-based observational case series, designated the Study of Severe Asthma in Latin America and Spain, which was conducted in Spain and in eight Latin-American countries. We reviewed the hospital records of 3,038 patients (age range, 15-69 years) hospitalized with acute severe asthma at one of nineteen tertiary-care hospitals in 1994, 1999 and 2004., Results: Over time, the use of inhaled corticosteroids and long-acting beta2 agonists increased significantly, whereas the use of theophylline as a controller medication decreased. The utilization of pulmonary function tests also increased. There was a significant reduction in the mean hospital stay (8.5 days, 7.4 days and 7.1 days in 1994, 1999 and 2004, respectively, p = 0.0001) and a significant increase in the mean of the lowest arterial pH at hospital admission. In contrast, there was a significant decrease in the proportion of cases in which PEF was determined in the emergency room (48.6% in 1994 vs. 43.5% in 2004, p = 0.0001). We found the quality of asthma management and care to be generally better in Spain than in Latin America., Conclusions: Although there have been certain improvements in the management of asthma between severe exacerbations and during hospitalization, asthma management remains suboptimal in Spain and, especially, in Latin America.

Background: There is conflicting evidence that traffic-related air pollution is a risk factor for allergic conditions. Few studies have investigated this in adults. In adults, a high proportion of asthma, rhinitis and eczema is triggered by non-allergic factors. We investigated traffic as a risk factor for allergic versus non-allergic asthma and rhinitis, and eczema, in adults. A questionnaire from 2000 (n = 9319, 18-77 years) provided individual data about disease outcome and self-reported traffic exposure. Additional exposure assessments were obtained using Geographical Informations Systems (GIS). Residential addresses were linked to the national Swedish Road Database and to a pollutant database with modelled annual means of NOx (Nitrogen Oxids)., Results: Living within 100 m from a road with a traffic intensity of >10 cars/min (24 hour mean) was associated with prevalence of current asthma reported to be triggered by allergic factors (OR = 1.83, 95% CI = 1.23-2.72) and with allergic rhinitis (OR = 1.30, 95%CI = (1.05-1.61). No relation was seen with asthma or rhinitis triggered by other factors. Living within 100 m of a road with >10 cars/min was also associated with hand-eczema during the last 12 months (OR = 1.63, 95% CI = 1.19-2.23), but not with allergic eczema or diagnosed hand-eczema. Consistent results were seen using self-reported traffic, but the associations with NOx were less consistent., Conclusion: Exposure to traffic was associated with a higher prevalence of allergic asthma and allergic rhinitis, but not with asthma or rhinitis triggered by non-allergic factors. This difference was suggested by the overall pattern, but only clear using GIS-measured traffic intensity as a proxy for traffic exposure. An association was also found with hand-eczema during the last 12 months. We suggest that asthma and rhinitis should not be treated as homogenous groups when estimating effects from traffic in adults.

Asthma morbidity and mortality have increased in the past two decades; Puerto Rican children have the highest prevalence of asthma in the United States. An asthma admission to PICU is a marker of asthma severity. This study describes the profile of the pediatric population admitted with status asthmaticus during a three year period to PICU at Hospital Episcopal San Lucas. An ambispective cohort chart review of 46 cases was performed; there was a mean average age of 6.2 years, male predominance (70%) and a strong family and personal history of asthma and allergies. 48% were classified as persistent asthmatics, only 19% of these received preventive mediation regimens. 72% of patients were covered under Puerto Rico's Health Care Reform and 28% had private insurance. Of the patients covered by Puerto Rico's Health Care Reform, classified as persistent asthmatics, 79% did not receive preventive treatment medication compared to 46% in private insurance. Background asthma management remains suboptimal in children needing hospitalization. Lack of preventive medication appears to be related to the type of health insurance.

Gaps in understanding of how area-based differences in exposure to violence are associated with asthma prevalence may limit the development of effective prevention programs and the identification of risk for asthma episodes. The current investigation examines the associations between sexual violence victimization and asthma episodes among US adult women across three different metropolitan settings. The association between sexual assault victimizations and asthma attacks in the past year was examined using data from the 2005, 2006, and 2007 Behavioral Risk Factor Surveillance System surveys. Cross-sectional analyses were based on adult women with current asthma (n = 4,099). Multivariate logistic regression models were used to identify associations between four categories of sexual violence victimization and asthma episodes across three categories of metropolitan and non-metropolitan settings. Our findings show that unwanted touching, attempted unwanted intercourse, forced unwanted intercourse, and any sexual violence victimization (touching, attempted intercourse, or forced intercourse) were significantly associated with asthma episodes (OR(adj.) = 3.67, 95% CI, 1.76-7.69; OR(adj.) = 1.77, 95% CI, 1.32-2.37; OR(adj.) = 2.24, 95% CI, 1.64-3.05, and OR(adj.) = 1.93, 95% CI, 1.47-2.53, respectively). While no significant differences in the associations between asthma episodes and metropolitan status were found, a significant interaction between non-metropolitan areas and attempted sexual intercourse was identified (OR(adj) = 0.53, 95% CI, 0.29-0.96). Sexual victimization appears to be an important, but understudied, correlate of asthma morbidity among adult women in the USA, suggesting that additional research is needed to better understand the associations between sexual violence, psychological distress, and asthma.

Background: Asthma is a severe health problem all over the world about morbidity and mortality, whose repercussions on the patients and their family require coordinated actions., Objective: To know the characteristics of hospitalizations due to asthma severe crises in pediatric intensive care units of a Cuban province., Material and Methods: A prospective and retrospective study was done with 40 pediatric patients with discharge diagnosis of severe crisis of asthma coming from the pediatric intensive care unit of Hospital Jose Marti y Perez, from January 1st, 1996 to December 31st, 2005. Main variables were: patients' origin, age at the moment of diagnosis and hospitalization, sex, familial history of atopy, triggering factors, previous inter-crises treatments, complications and hospitalization time., Results: Patients discharged due to this disease are little respect to other causes. Municipalities of higher prevalence of severe crisis were Fomento and Sancti Spiritus. Generally, patients had lesser than five years of age at the beginning of the disease and at the moment of hospitalization; male sex predominated and showed positive history of allergy. The most frequent triggering factors were respiratory infections and atmospheric changes. Most patients did not receive inter-crises treatments. The most common complications were: acid-base balance disorders and broncopneumonias. Hospitalization time was lesser than three days., Conclusions: Acute crises of asthma in pediatric patients should be identified early to initiate the proper treatment and prevent complications.

Objectives: To develop and validate predictive models to determine the need for hospitalization in children treated for acute asthma in the emergency department (ED)., Methods: Prospective cohort study of children aged 2 years and older treated at 2 pediatric EDs for acute asthma. The primary outcome was successful ED discharge, defined as actual discharge from the ED and no readmission for asthma within 7 days, versus need for extended care. Among those defined as requiring extended care, a secondary outcome of inpatient care (>24 hours) or short-stay care (<24 hours) was defined. Logistic regression and recursive partitioning were used to create predictive models based on historical and clinical data from the ED visit. Models were developed with data from 1 ED and validated in the other., Results: There were 852 subjects in the derivation group and 369 in the validation group. A model including clinical score (Pediatric Asthma Severity Score) and number of albuterol treatments in the ED distinguished successful discharge from need for extended care with an area under the receiver-operator characteristic curve of 0.89 (95% confidence interval [CI], 0.87-0.92) in the derivation group and 0.92 (95% CI, 0.89-0.95) in the validation group. Using a score of 5 or more as a cutoff, the likelihood ratio positive was 5.2 (95% CI, 4.2-6.5), and the likelihood ratio negative was 0.22 (95% CI, 0.17-0.28). Among those predicted to need extended care, a classification tree using number of treatments in the ED, clinical score at end of ED treatment, and initial pulse oximetry correctly classified 63% (95% CI, 56-70) of the derivation group as short stay or inpatient, and 62% (95% CI, 55-68) of the validation group., Conclusions: Successful discharge from the ED for children with acute asthma can be predicted accurately using a simple clinical model, potentially improving disposition decisions. However, predicting correct placement of patients requiring extended care is problematic.

Background: Life-threatening status asthmaticus (SA) requiring intensive care is a major concern given the rising prevalence of asthma. We examined episodes of SA requiring admission to the medical intensive care unit (MICU) of an urban hospital center., Methodology: The charts of patients admitted to the MICU of an urban hospital center with a diagnosis of SA during the 5-year period 2002-2006 were reviewed retrospectively. These results were compared with those of a previously published experience at our institution from 1995 to 1999., Results: The medical records of 84 MICU admissions for SA were reviewed. There were 61 women (5 pregnant). The mean age was 44 years. Use of cigarettes or illicit drugs was found in 51% and 30%, respectively. Mechanical ventilation (MV) was required in 76% of admissions. Noninvasive ventilation was used in 10 patients. Neuromuscular blockade (NMB) was needed in 9% of admissions. The highest average PaCO2 during the first 24 hours was 67 mm Hg. Median duration of MV was 4.4 days. Six patients died, 3 of whom sustained prehospital cardiac arrest. Compared with the patients in the preceding 5-year period, the more recent patients had greater use of illicit drug and cigarettes. Patients presented with more severe asthma, as reflected by a higher PaCO2 and an increased duration of MV., Conclusions: During the recent 5-year period, we found a trend toward increasing severity of SA, as indicated by the degree of respiratory acidosis, need for NMB, and longer duration of MV. Access to medical care and cigarette and illicit drug use remain potential targets of primary intervention., ((c) 2008 Society of Hospital Medicine)

Introduction: Recurrent emergency department (ED) visits for asthma exacerbations produce anxiety as well as high costs to the health system and the family., Objective: To identify factors associated with recurrent ED visits for asthma exacerbations in children in Bogotá, Colombia., Methods: Data obtained from a survey of parents of 223 patients with asthma (mean +/- SD: 4.8+/-3.5 years of age) attending an asthma clinic were analysed. Demographic data and a broad asthma knowledge and attitudes questionnaire were completed by the parents., Results: Of the 223 asthmatic patients enrolled, 60 (26.9 %) had 3 or more visits to the ED for asthma in the last 6 months ("recurrent ED visits"). After controlling by age, educational level of the father, and severity of the disease; parents of children with "recurrent ED visits" were more prone to report that they attended ED because the asthma exacerbations were severe enough to go to the primary care physician (OR, 2.45; CI 95 %, 1.13-5.30; p=0.02); that asthma medications should be administered only when the children are symptomatic (OR, 3.26; CI 95 %, 1.45-7.36; p=0.004), and conversely they were less prone to have knowledge that asthma exacerbations can be avoided if medications are administered in the asymptomatic periods (OR, 0.31; CI 95 %, 0.14-0.68; p=0.003)., Conclusions: An educational programme intended to reduce the recurrent ED visits for asthma exacerbations should consider the inclusion of an explanation about the chronic nature of the disease and the importance of long-term therapy.

Several factors have been accused for asthma exacerbations, however, very few studies have evaluated whether different factors predict severity of asthma exacerbation. We aimed to determine the predictive factors for severity of asthma exacerbation. Retrospective analysis of data on 93 patients visited our emergency-department because of asthma exacerbation was reviewed. Hospitalization in intensive care unit and/or intubation because of asthma was accepted as the criteria for severe exacerbation. Logistic regression analysis estimated the strength of association of each variable, potentially related to severe asthmatic exacerbation, with severe/very severe as compared to mild/moderate asthmatic exacerbation. Independent variables included in the analysis were age, sex, smoking history, inhaler steroid using, compliance with medication, chronic asthma severity, presence of additional atopic diseases, prick test positivity, provocative factors, number of short-acting beta(2)-agonist using, number of visits to emergency department for asthma over one year period, previous severe exacerbation, pulmonary functions, and blood eosinophil count. 20 were severe/very severe and 73 mild/moderate asthmatic exacerbation. Frequent using of short-acting beta(2)-agonist (OR= 1.5, 95% CI= 1.08-5.3, p= 0.003), noncompliance with medication (OR= 3.6, 95% CI= 1.3-9.9, p= 0.013), previous severe asthmatic exacerbation (OR= 3.8, 95% CI= 1.48-10.01, p= 0.005) and recent admission to hospital (OR= 2.9, 95% CI= 1.07-8.09, p= 0.037) were found to be predictive factors for severe asthmatic exacerbation. Different predictive factors, in particular frequent using of short-acting beta(2)-agonist and noncompliance with medication may be associated with severe asthma exacerbations compared to milder exacerbations. This suggests different mechanisms are responsible for severity of asthma exacerbation.

Asthma is an important public health challenge. The objective of this research was to investigate the relationship of air pollution and weather to adolescent asthma prevalence and attack rate. A 6-month mass screening asthma study was conducted from October 1995 to March 1996 in Taiwan. The study population included junior high school students from throughout the country (1,139,452 students). Eighty-nine percent of students completed questionnaires (International Study of Asthma and Allergies in Childhood-ISAAC and New England Core Questionnaires) and passed a logical screening error program. Lung function data was collected to assist in the diagnosis of asthma status. From the students screened during this mass survey, a stratified random sample of 64,660 students was analyzed for asthma prevalence and attack rate. Using a regression model to compare the USEPA National Ambient Air Quality Standards 2000 (NAAQS, 2000) to asthma prevalence, this investigation found that the standards may not provide enough protection for adolescents after controlling for age, rhinitis, eczema, urban birth location, parental education level, exercise, cigarette smoking, environmental tobacco smoking, alcohol beverage consumption and weather factors. The general estimating equations (GEE) model, a repeated measurement regression model, was used to examine the relationship between the monthly asthma attack rate among asthma patients and air pollution (nitrogen oxides; nitrogen dioxide; nitric oxide; Ozone; PM10) while controlling for household smoking. The GEE model demonstrated that air pollution is related to asthma attack rate. Air pollution factors also interacted with weather parameters when related to asthma attack rate.

Purpose of Review: The prevalence of severe asthma in children has risen in the past few decades. The present review explores our current understanding of epidemiology, pathophysiology and treatment of status asthmaticus in children., Recent Findings: The pathophysiology of inflammation and airway hyperactivity continues to be a source of research. Early initiation of inhaled beta-agonists and oral or parenteral steroids remain the standard of care in the treatment of status asthmaticus. Other treatment modalities such as magnesium and intravenous beta-agonists show some benefit. There is a resurgence of interest in the use of methylxanthines. Alternatives to endotracheal intubation show some promise in preventing respiratory failure., Summary: Asthma remains the third leading cause of hospitalization in children younger than 15 years old. Researchers continue to explore the efficacy of old and new treatment modalities. Future research efforts targeting at-risk populations could dramatically decrease asthma morbidity and mortality.

The aim of the paper was to describe and compare the seasonal hospital admissions among different subgroups of patients due to bronchial asthma with a special focus on demographic characteristic. Data were collected during the calendar year 2003. Data were gathered for 32,933 patients from 522 hospitals across Poland with confirmed diagnosis of bronchial asthma or status asthmaticus. We noticed a distinct seasonal patterns in the number of hospitalizations due to asthma. Most cases clustered in the beginning and the end of the calendar year. Beside these hospitalization peaks, we observed a less pronounced increase of hospital admissions in spring and through summer months. It was most distinctly pronounced in children. It was also shown that gender of patients did not affect seasonal variability in our study. Emergency admissions to hospitals were less frequent in summer months, whereas elective admissions presented no such distinct pattern. The data revealed differences in seasonality in asthma hospital admissions in various age groups.

Background: The request in the urgency service for attention in acute asthma is determined by multiple factors as the medical handling, the constancy and the pursuance of the patient in the adequate follow up of the treatment, the climate, the food hygienic habits and the allergies., Objective: To determine in one year period, the frequency, recurrence of medical attention for acute asthma and the cost in the hospital urgency service of second level in medical attention., Material and Methods: We made an analysis of a secondary study done in 1999 in pediatric patients younger than 16 years with diagnosis of acute asthma., Results: From 6,912 consultations given in the pediatric emergency area, 2,586 were from acute asthma, the half was 5.2 years old patients, the minimal average time a patient had to stay in the hospital per month was of 7.36 hours in January and the maximum average time was of 22.10 hours in the month of September. Regarding the frequency of attendance in the service for a new event, the following distribution was found: from two to three 25.72%, from 4 to 6 10.1% and from 7 to 15 0.96%. The cost of the attention had a total cost of 5'787,494.82 pesos., Conclusions: The frequency of acute asthma was 41.58% and this figure was considered high in comparison to similar studies. The clinic evolution and the treatment response are related to the age, and, in the study results, the patients younger than 3 years had a longer stay in the hospital, also, there was an increase of patients in the rainy months. The frequency of patients who assisted between 2 or 3 times and the cost was 387,123.00 pesos. That frequency may be due to patients did not receive a long-term treatment provision, or because of ignorance in the initial rescue treatment, ignorance in the factors that raise the sickness, as well as patients not taking their treatment the way it was asked by the doctors. These factors increase the cost, which is feasible to be modifyied, if the patients and their families get acknowledge on the importance of respecting the instructions on the proper way of treating the acute asthma, and all the triggering factors of it.

Status asthmaticus (SA) in the pediatric ICU (PICU) can progress to a life-threatening emergency. The goal of management is to improve hypoxemia, improve bronchoconstriction, and decrease airway edema through the administration of continuous nebulized beta2 adrenergic agonist with intermittent anticholinergics, corticosteroids, and oxygen. Adjunctive therapies, such as magnesium, methylxanthines, intravenous beta-agonists, heliox, and noninvasive ventilation should be considered in the child who fails to respond to initial therapies. The restoration of adequate pulmonary functions, resolution of airway obstruction, and avoidance of mechanical ventilation should guide management. This article reviews the pathophysiology, assessment, and management of the child who has SA in the PICU to provide the critical care nurse with current information to facilitate optimal care.

Recurrent exacerbations are a major cause of morbidity and medical expenditure in patients with asthma. Various exogenous and endogenous factors are thought to influence the level of asthma control, but systematical data on the involvement of these factors in the recurrence of asthma exacerbations are scarce. In this study, 13 clinical and environmental factors potentially associated with recurrent exacerbations were investigated in 136 patients with difficult-to-treat asthma. Patients with more than three severe exacerbations (n = 39) in the previous year were compared with those with only one exacerbation per year (n = 24). A systematic diagnostic protocol was used to assess 13 potential risk factors. Factors significantly associated with frequent exacerbations included: severe nasal sinus disease (adjusted odds ratio (OR) 3.7); gastro-oesophageal reflux (OR 4.9); recurrent respiratory infections (OR 6.9); psychological dysfunctioning (OR 10.8); and obstructive sleep apnoea (OR 3.4). Severe chronic sinus disease and psychological dysfunctioning were the only independently associated factors (adjusted OR 5.5 and 11.7, respectively). All patients with frequent exacerbations exhibited at least one of these five factors, whilst 52% showed three or more factors. In conclusion, the results show that recurrent exacerbations in asthma are associated with specific co-morbid factors that are easy to detect and that are treatable. Therapeutic interventions aimed at correcting these factors are likely to reduce morbidity and medical expenditure in these patients.

Objective: The prevalence and associated health cost of asthma have been increasing in developed countries, and 70% of the overall disease cost is due to exacerbations. The primary objective of this study was to determine the hospital cost of an asthma exacerbation in Spain. The secondary objective was to determine what maintenance treatments patients were using to control asthma before the exacerbation and how the exacerbation was treated. The study formed part of a broader study (COAX II), with the same objectives in each of the 8 participating European countries., Patients and Methods: Prospective observational study that enrolled 126 patients with an asthma exacerbation treated in the usual way in 6 Spanish hospitals over a 3-month period (from January 1 to March 31, 2000)., Results: According to the criteria of the Global Initiative for Asthma, 33.3% of the exacerbations were mild, 38.9% moderate, 26.2% severe, and 1.6% were associated with risk of imminent respiratory arrest. Use of corticosteroids was widespread among patients with moderate and severe asthma, but only 68% of the patients with severe asthma used long-acting beta2 agonists. The mean cost was 1555.70 Euros (95% confidence interval [CI], 1237.60 Euros-1907.00 Euros), of which 93.8% (1460.60 Euros; 95% CI, 1152.50 Euros-1779.40 Euros) was due to direct costs, and 6.2% (95.10 Euros; 95% CI, 35.50 Euros-177.00 Euros) to indirect costs. Cost rose with increasing severity of the exacerbation--292.60 Euros for a mild exacerbation, 1230.50 Euros for a moderate exacerbation, and 3543.10 Euros for a severe exacerbation., Conclusions: The mean cost was 1555.70 Euros. The costs of moderate and severe exacerbations were 4 and 12 times that of a mild exacerbation, respectively. Long-acting beta2 agonists were less widely used than recommended by the guidelines for treatment of moderate and severe persistent asthma leading to asthma exacerbations.

Background: Although the economic burden of pediatric asthma is a significant public health issue, the loss of workdays by caregivers because of their children's asthma remains scarcely investigated., Objectives: To evaluate asthma-related loss of workdays incurred by caregivers of asthmatic children and its association with the level of asthma control., Methods: A retrospective observational study was conducted based on a French computerized general practitioners' database and a survey questionnaire. Children aged 6 to 16 years with persistent asthma (Global Initiative for Asthma grade > or = 2) were included in the study. Level of children's asthma control was evaluated from recent asthma symptoms. Caregivers reported the number of workdays lost because of their child's asthma during the 12-month study., Results: Nearly 30% of caregivers lost workdays during the study because of their children's asthma. More than 13% of caregivers lost more than 5 days. Caregiver absenteeism significantly correlated with all components of asthma control (use of relievers, nocturnal symptoms, impairment of activities, and asthma crises). A significant 8-fold risk of losing more than 5 workdays by caregivers was observed when the child's asthma was poorly controlled (odds ratio, 8.6; 95% confidence interval, 2.4-30.5); caregivers' absenteeism also increased significantly with the number of episodes of oral corticosteroid use during the study., Conclusions: Caregivers' loss of workdays owing to their children's asthma is substantial and is highly correlated with the level of asthma control. These findings highlight the necessity of educational programs for children with poor asthma control and their caregivers to prevent severe asthma attacks that lead to caregiver absenteeism.

Background: The acute asthma crisis in emergency services of second level hospitals represents one of the highest levels of intake, generating a high number of hospitalizations., Objective: To determine, in emergency service medical attention, the frequency and direct cost related generated by the hospitalization of pediatric patients with acute asthma crisis in second level attention of Social Security Service (Instituto Mexicano del Seguro Social, IMSS)., Materials and Method: In 2000, a cohort study was done on pediatric patients with acute asthma crisis in a second level hospital., Results: In the cohort of 2,277 patients, the response to treatment was adequate in 94% (2,141) of the cases, the consultation predominated in September (13.6%) and October (12%). The average patient was 3 years old and the patients were predominantly male (63.4%). The direct cost generated from attending these patients totaled to 342,989.80 USD, the monthly cost average was of 28,582.48 USD., Discussion: The use of health services is an indirect indicator of morbidity, also referred to as the increase of hospitalization and rehospitalization in children between 0 and 4 years old. The knowledge of leading factors, the education on long term control, and the handling of initial rescue in asthmatic patients are modifiable factors that can help reduce the costs generated by the hospitalization of acute cases of this disease.

Introduction: This report describes the case mix, outcome and activity (duration of intensive care unit [ICU] and hospital stay, inter-hospital transfer, and readmissions to the ICU) for admissions to ICUs for acute severe asthma, and investigates the effect of case mix factors on outcome., Methods: We conducted a secondary analysis of data from a high-quality clinical database (the Intensive Care National Audit and Research Centre [ICNARC] Case Mix Programme Database) of 129,647 admissions to 128 adult, general critical care units across England, Wales and Northern Ireland over the period 1995-2001., Results: Asthma accounted for 2152 (1.7%) admissions, and in 57% mechanical ventilation was employed during the first 24 hours in the ICU. A total of 147 (7.1%) patients died in intensive care and 199 (9.8%) died before discharge from hospital. The mean age was 43.6 years, and the ratio of women to men was 2:1. Median length of stay was 1.5 days in the ICU and 8 days in hospital. Older age, female sex, having received cardiopulmonary resuscitation (CPR) within 24 hours before admission, having suffered a neurological insult during the first 24 hours in the ICU, higher heart rate, and hypercapnia were associated with greater risk for in-hospital death after adjusting for Acute Physiology and Chronic Health Evaluation II score. CPR before admission, neurological insult, hypoxaemia and hypercapnia were associated with receipt of mechanical ventilation after adjusting for Acute Physiology and Chronic Health Evaluation II score., Conclusion: ICU admission for asthma is relatively uncommon but remains associated with appreciable in-hospital mortality. The greatest determinant of poor hospital survival in asthma patients was receipt of CPR within 24 hours before admission to ICU. Clinical management of these patients should be directed at preventing cardiac arrest before admission.

Background: Asthma is one of the most frequent illnesses in the pediatric age, the exacerbations account for one of the main consult causes to the emergency services., Objective: To determine the frequency of the consultation demand and the recurrence of patients with acute crisis of asthma., Material and Method: A transverse study, performed at the service of pediatric emergencies, included pediatric patients with acute crisis of asthma from January to December, 2000., Results: In this study 20.3% of the consultations were due to acute crisis of asthma, 54.29% needed handling in the service of pediatric emergencies with inhalotherapy; 94.3% responded to the treatment. The gender masculine-feminine relationship was of 1.7:1. The predominant ages were from 3 to 5 years. The consultation increased in September, October and November., Conclusions: When asthma is mistreated may present exacerbations.

Objectives: Rhinoviruses are the most common aetiological agents of colds, but the frequency and the severity of other locations of the infection are not well known. This study describes the clinical aspects and the severity of rhinovirus infections in hospitalised children., Methods: Isolation in culture and a RT-PCR were performed for the detection of rhinovirus in nasal aspirates from hospitalised children from September 1998 to October 2000. A group of 211 children found to be positive for rhinovirus was studied., Results: Rhinovirus-infected children suffered from the following clinical syndromes: 60 (28.4%) upper airway infections, 81 (38.4%) bronchiolitis, 25 (11.9%) pneumonias and 12 (4.7%) acute attacks of asthma. Clinical symptoms were wheezing (32%), ronchi (37%) and 29% of children presented with acute distress respiratory syndrome; 40% of the available chest X-Ray were abnormal. Eight children were hospitalised in the intensive care unit and two children died. Twenty-five children (10.9%) had a nosocomial infection; a dual infection was observed in 19 cases (9%) with the following viruses: RSV (3), influenza (2) parainfluenza (8), adenovirus (2), enterovirus (4); 19 (9%) children had a secondary bacterial infection. Rhinoviruses were detected in nasal aspirates in 112 cases (53%) according to the culture and in the rhinovirus culture-negative samples in 99 cases (47%) according to the RT-PCR assay., Conclusion: After eliminating cases of bacterial or viral dual infections, the clinical aspects of rhinovirus infections in children are the following: upper respiratory tract infections (25.6%), bronchiolitis ou bronchitis (25.6%), pneumonia (6.2%), acute attack of asthma (5.7%). The virological diagnosis according to culture is mainly improved by molecular techniques.

Background: Adult women may be more susceptible to asthma than men., Hypothesis: Women are more likely to develop status asthmaticus (SA) requiring critical care., Methods: The medical records of patients admitted to our medical intensive care unit (ICU) for SA between 1994 and 2000 were examined. A number of demographic and physiologic variables were extracted from the medical records., Results: Of 103 total admissions, 53 (of 37 patients) were age < 50 years and had clinical evidence suggesting SA. Among these 37 patients, the average (+/-SE) age was 30.8 +/- 1.0 y with average acute physiology and chronic health evaluation (APACHE) II of 9.5 +/- 0.8. Seventeen patients were Hispanic, 13 were black, and 7 were white. Twenty-four patients (accounting for 37 admissions) were female and 13 patients (16 admissions) were male. Although women accounted for a greater absolute number of endotracheal intubations (ETI; 17 vs. 12) and were more likely to be admitted to ICU more than once (7 vs. 3), men had a higher incidence of ETI (RR=1.6; 95%CI=1.04-2.6). The need for using therapeutic permissive hypercapnia and lengths of stay (ventilator, ICU, and hospital) were similar between men and women. Two patients, both women, died of causes not related to treatment of SA., Conclusions: These data suggest that although women accounted for more ICU admissions for SA, men were more likely to require ETI.

During the last 10 years 342 patients with status asthmaticus were admitted (mean age 42 years, 63% female) to ICU of Pneumonology Department in Warsaw Medical University. After admission respiratory rate (mean 28/min), heart rate (mean 121 beats/min), blood pressure (mean 139/83 mmHg), pulsus paradoxus (mean 19.9 mmHg) and peak expiratory flow rate (mean 109.3 L/min) were recorded. Arterial blood gas tension was analyzed as well. Mean PaO2 was 65.7 mmHg (range 31.4-128 mmHg) and mean PaCO2 was 39.1 mmHg (range 18-130.9 mmHg). Electrocardiography showed p-pulmonale in 24.4% of cases. 18.9% of the patients had ST-T changes and rotation of heart axis in 9% of cases. X-ray examination performed on admission showed changes characteristic for pneumonia in 15 patients. Status asthmaticus was caused by infection in 57.6%, exercise 6.1%, emotion and stress 3.2%, allergens 2.3% of cases. Underlying factors were unknown in 24.3%.

This study analyzes the evolution of a group of children under 10 years of age with asthma over a period of 20 years. We selected a random group of 32 children with asthma and compared it with a control group composed of 33 children without asthma, similar in age, sex, and socio-economic characteristics. Throughout the 20 years we analyzed the number of ambulatory visits, morbidity, environmental tobacco smoke (ETS) as well as social and economic characteristics. The results after 20 years of evaluation showed that inflammatory and infectious processes in the airways (upper and lower) were more frequent among asthmatics than in the control group. ENT infections were more predominant in the group with inadequate sanitary conditions. There were no significant differences for the other pathologies. We studied the frequency of asthmatic crises requiring emergency care according to age and sex. Clinical ambulatory visits in asthmatic children were 2.8 times more frequent than in the control group. We found no differences between males and females, either in terms of global morbidity or the worsening of their asthmatic disease e.g., crises, going to emergency services and hospitalization. In the asthmatic group, the frequency of asthma crises, visits to emergency services and hospitalization were analyzed, with no differences being found between the sexes. We measured the PEFR, FEV1, and FEF25-75 in both groups for 20 years and compared those values to age, weight, height, and sex. We found that the parameters of lung function were lower in the asthmatic group than in the control group. We used as statistical method the chi 2 test, and regression analyses were made to relate the PEFR, FEV1, and FEF25-75 values to age and gender. A paired t-test was used to compare ambulatory visits, morbidity, emergency care, ETS, and sanitary housing conditions to age and sex in both groups. A p value < or = 0.05 was taken as indicating statistical significance.

Many clinicians advise their patients to increase the dose of inhaled corticosteroids during acute asthma exacerbations, without strong clinical evidence supporting this treatment. This study investigates the effectiveness of inhaled corticosteroids in controlling acute asthma exacerbations in children at home. The study population consisted of children with mild intermittent, mild and moderate persistent asthma aged 1 to 14 years who were treated in our outpatient clinic with inhaled budesonide for 1 year. After participating in an asthma education session, the parents were instructed to initiate treatment with inhaled budesonide at the first signs of asthma exacerbation, starting with 200 to 400 microg budesonide, in combination with beta-2 agonists 4 times a day and followed by a decrease in the dose in 4 to 8 days. Asthma status and peak expiratory flow rates were measured in the 3 monthly follow-up visits. Only children who complied with the treatment regimen and came for follow-up visits regularly were included in the final analysis. One hundred fifty children used our treatment protocol with inhaled budesonide to control their asthma attacks. Clinical improvement of asthma symptoms was achieved after a mean of 1.8 +/- 0.7 days from the beginning of treatment. The parents were able to control 94% of the 1,061 episodes of asthma exacerbation occurring during a cumulative follow-up period of 239 years. In the 3-month period before enrollment, 101 children (67%) had used oral corticosteroids to control their asthma attacks and 50 (33%) were hospitalized. During the entire follow-up period, only 11 children (7%) used oral corticosteroids, and none of the children were hospitalized. The present study demonstrates that children with asthma can control their exacerbations at home using inhaled corticosteroids (budesonide). Treatment, starting with relatively high doses followed by a rapid reduction in dose over 4-8 days, resulted in a decrease in the use of oral steroids and in hospitalization. To achieve good results, patient compliance is essential.