Noninvasive testing of lung function and inflammation in pediatric patients with acute asthma exacerbations.
ABSTRACT There is limited information on performance rates for tests of lung function and inflammation in pediatric patients with acute asthma exacerbations. We sought to examine how frequently pediatric patients with acute asthma exacerbations could perform noninvasive lung function and exhaled nitric oxide (FE(NO)) testing and participant characteristics associated with successful performance.
We studied a prospective convenience sample aged 5-17 years with acute asthma exacerbations in a pediatric emergency department. Participants attempted spirometry for percent predicted forced expiratory volume in 1 second (%FEV(1)), airway resistance (Rint), and FE(NO) testing before treatment. We examined overall performance rates and the associations of age, gender, race, and baseline acute asthma severity score with successful test performance.
Among 573 participants, age was (median [interquartile range]) 8.8 [6.8, 11.5] years, 60% were male, 57% were African-American, and 58% had Medicaid insurance. Tests were performed successfully by the following [n (%)]: full American Thoracic Society-European Respiratory Society criteria spirometry, 331 (58%); Rint, 561 (98%); and FE(NO), 354 (70% of 505 attempted test). Sixty percent with mild-moderate exacerbations performed spirometry compared to 17% with severe exacerbations (p = .0001). Participants aged 8-12 years (67%) were more likely to perform spirometry than those aged 5-7 years (48%) (OR = 2.23, 95% CI: 1.45-3.11) or 13-17 years (58%) (OR = 1.61, 95% CI: 1.00-2.59).
There is clinically important variability in performance of these tests during acute asthma exacerbations. The proportion of patients with severe exacerbations able to perform spirometry (17%) limits its utility. Almost all children with acute asthma can perform Rint testing, and further development and validation of this technology is warranted.
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ABSTRACT: Objectives. To examine the time-dependent changes of spirometry (percent-predicted forced expiratory volume in 1 second [%FEV(1)]) and the Pediatric Respiratory Assessment Measure (PRAM) during the treatment of acute asthma exacerbations. Study design. We conducted a prospective study of participants aged 5-17 years with acute asthma exacerbations managed in a Pediatric Emergency Department. %FEV(1) and the PRAM were recorded pretreatment and at 2 and 4 hours. We examined responses at 2 and 4 hours following treatment and assessed whether the changes of %FEV(1) and of the PRAM differed during the first and the second 2-hour treatment periods. Results. Among 503 participants, median [interquartile range, IQR] age was 8.8 [6.9, 11.4], 61% were male, and 63% were African-American. There was significant mean change of %FEV(1) during the first (+15.4%; 95% CI 13.7 to 17.1; p < .0001), but not during the second (+1.5%; 95% CI -0.8 to 3.8; p = .21), 2-hour period and of the PRAM during the first (-2.1 points; 95% CI -2.3 to -1.9; p < .0001) and the second (-1.0 point; 95% CI -1.3 to -0.7; p < .0001) 2-hour periods. Conclusions. Most improvement of lung function and clinical severity occur in the first 2 hours of treatment. Among pediatric patients with acute asthma exacerbations, the PRAM detects significant and clinically meaningful change of severity during the second 2-hour treatment, whereas spirometry does not. This suggests that spirometry and clinical severity scores do not have similar trajectories and that clinical severity scores may be more sensitive to clinical change of acute asthma severity than spirometry.Journal of Asthma 12/2012; DOI:10.3109/02770903.2012.752503 · 1.83 Impact Factor
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ABSTRACT: This study examines caregiver preferences of single-dose dexamethasone (DEX) versus 5-day oral prednisolone in treating acute asthma exacerbation in a pediatric emergency department (PED). A secondary objective was preference for mode of home inhaled β-agonist administration. Caregivers of patients 2 to 18 years with an acute asthma exacerbation treated in the PED completed a 1-page questionnaire including asthma history and preferences for steroids and β-agonist administration. One hundred caregivers completed the questionnaire. Within the preceding year, 79% had an asthma exacerbation and 73.7% (n = 99) were prescribed prednisolone. DEX was preferred by 79% of caregivers. Preferences were independent of caregiver demographics except in cases of prior intensive care admission, where DEX was less favored (odds ratio = 0.27, P < .046). No difference existed in mode of home β-agonist administration. Most caregivers prefer DEX in acute asthma exacerbation management. No difference exists for home β-agonists. These results may advise clinical practice in pediatric acute asthma exacerbation.Clinical Pediatrics 07/2014; 54(1). DOI:10.1177/0009922814542482 · 1.26 Impact Factor
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ABSTRACT: Clinicians have difficulty predicting need for hospitalization of children with acute asthma exacerbations. The objective of this study was to develop and internally validate a multivariable asthma prediction rule (APR) to inform hospitalization decision making in children aged 5-17 years with acute asthma exacerbations. Between April 2008 and February 2013 we enrolled a prospective cohort of patients aged 5-17 years with asthma who presented to our pediatric emergency department with acute exacerbations. Predictors for APR modeling included 15 demographic characteristics, asthma chronic control measures, and pulmonary examination findings in participants at the time of triage and before treatment. The primary outcome variable for APR modeling was need for hospitalization (length of stay >24 h for those admitted to hospital or relapse for those discharged). A secondary outcome was the hospitalization decision of the clinical team. We used penalized maximum likelihood multiple logistic regression modeling to examine the adjusted association of each predictor variable with the outcome. Backward step-down variable selection techniques were used to yield reduced-form models. Data from 928 of 933 participants were used for prediction rule modeling, with median [interquartile range] age 8.8 [6.9, 11.2] years, 61% male, and 59% African-American race. Both full (penalized) and reduced-form models for each outcome calibrated well, with bootstrap-corrected c-indices of 0.74 and 0.73 for need for hospitalization and 0.81 in each case for hospitalization decision. The APR predicts the need for hospitalization of children with acute asthma exacerbations using predictor variables available at the time of presentation to an emergency department. Copyright © 2014 American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.11/2014; 3(2). DOI:10.1016/j.jaip.2014.09.017