short-term clinical outcomes of acute treatment of childhood asthma

Javier Benito-Fernández, MDDirector of Paediatric Emergency DepartmentHospital de Cruces- Bilbao (Spain)

SHORT-TERM CLINICAL OUTCOMES OF ACUTE TREATMENT OF CHILDHOOD ASTHMA

Background

Acute asthma exacerbations account for 6% of children’s visits to the ED with 15-20% of patients requiring admission (ED observation unit or hospital ward).

Hospitalization and relapse rates may not to be reliable indicators of true astma morbitiy in children after exacerbations.

Parameters as health-related quality of life, persistence of symptoms or the need of prolonging treatment in the weeks after consultation in ED could be more usefull.

Objectives

To show the overall morbidity and risk factors in children after an asthma exacerbation

To evaluate the factors that may contribute to improving the short-term outcome of children after discharge from an ED visit for acute asthma.

Factors that can affect hospitalization rate

Changes in the criteria of hospitalization admission

Changes in ED treatment Differences in severity of illness Acces to the health care system

Number of asthma episodes / year Hospital de Cruces 1996 - 2006

0

500

1000

1500

2000

2500

3000

3500

4000

96 97 98 99 2000 2001 2002 2003 2004 2005 2006

ASTHMA EPISODES ADMITTED

Hospitalization rates for asthma Hospital de Cruces

15,29

10,89

22,54

16,75 16,8818,21

19,05

15,2

10,93

8,26

4,265,48

11,3210,05

16,25

12,3

0

5

10

15

20

25

2000 2001 2002 2003 2004 2005 2006 2007

% 0 - 2 years % > 2 years

En Feb Mar Abr May Jun Jul Ag Set Oct Nov Dic

nºH 2003 nºH 2006 nºH 2007

Hospitalization rates along 2003, 2006 and 2007

Hospital de Cruces

> 2 years

0 - 2 years

Other parameters of outcome after ED treatment

Persistence of symptoms Need for prolonging treatment Absenteeism from school

Quality of life

Short-term outcome

Stevens WC et al Pediatrics 2001

Benito J et al Pediatr Pulmonol 2004

Symptoms at 7 days 46% 36,1%

Need of treatment at 7 days

68% 55,6%

Symptoms at 15 days 23% 19,5%

Need of treatment at 15 days

32% 27,1%

Office follow-up 33% 90%

Stevens WC et al Pediatrics 2001

Benito J et al Pediatr Pulmonol 2004

School days missed 2 días (45%, 3 or more

days)

3,1 2,7 días (48%, 3 o more days)

Caretakers work days

missed 54% al menos 1 día

(13%, 3 o más)

Short-term outcome

Maesurement of health-related quality of lifeHow often in the past two weeks has/have:

A Your child complained of being short of breath?

B Exertion (as a running) made your child breathless?

C Your child coughed at night?

D Your child been woken up by wheezing or coughing?

E Your child stayed indoors because of wheezing or coughing?

F Your child’s education suffered due to his/her asthma during school?

G Your child’s asthma interfered with his/her life?

H Your child’s asthma limited your activities?

I You had to make adjustments to family life because of your child’s asthma?

J Taking his/her inhaler or other treatments interfered with your child’s life?

-all of the time-most of the time-some of the time-a little of the time-none of the time

Gorelick MH, Brousseau DC, Stevens MW. Validity and responsiveness of a brief, asthma-specific quality-of-life instrument in children with acute asthma. Ann Allergy Asthma Immunol. 2004 Jan;92(1):47-51.

Quality of life scores according to 14-days outcomes

Variable % with outcome

Score quality of life

Mean ± SD

Δ score from ED visit to follow-up

Mean ± SD

Overall parent rating

Better

Same or worse

68

32

61,8 ± 19,6

41,9 ± 21,2

13,7 ± 22,2

3,3 ± 17,2

Asthma symptoms

Back to baseline

Still worse than baseline

70

30

61,3 ± 19,9

37,9 ± 22,2

15,0 ± 21,1

0,5 ± 21,4

Gorelick MH, Brousseau DC, Stevens MW. Validity and responsiveness of a brief, asthma-specific quality-of-life instrument in children with acute asthma. Ann Allergy Asthma Immunol. 2004 Jan;92(1):47-51.

Interventions suggested to improve patients outcome

Prolonged ED treatment or short-stay unit care Evans R 3rd. LeBailly S. Gordon KK. Sawyer A. Christoffel KK. Pearce B. Restructuring asthma care in a hospital setting to improve outcomes. Chest. 116(4 Suppl 1):210S-216S, 1999 Oct.

Changes in home careGorelick MH. Meurer JR. Walsh-Kelly CM. Brousseau DC. Grabowski L. Cohn J. Kuhn EM. Kelly KJ. Emergency department allies: a controlled trial of two emergency department-based follow-up interventions to improve asthma outcomes in children. Pediatrics. 117(4 Pt 2):S127-34, 2006 Apr.

More intensive outpatient follow-upSmith SR. Jaffe DM. Fisher EB Jr. Trinkaus KM. Highstein G. Strunk RC. Improving follow-up for children with asthma after an acute Emergency Department visitJournal of Pediatrics. 145(6):772-7, 2004 Dec.

Factors predicting short-term outcome after ED visit for asthma

Follow-upAge, months, mean SD

Specialist for asthma follow-upn (%)

Yes No Yes No

Total 48.4 39.72 54 204

Day 7: Respiratory symptoms 42.36 37.10 52.92 41.14 19 (35.2) 92 (45.1)

Day 7: Use of medication 44.7 38.44 55.12 40.94 31 (57.4) 126 (61.8)

Day 15: Respiratory symptoms

44.39 41.11 49.45 39.40 7 (13) 21 (10.3)

Day 15: Use of medication 48.0 41.13 48.54 39.32 13 (24.1) 56 (27.4)

Missed school days or nursery attendance, n = 185mean SD

2.69 2.57 3.03 3.61

3 missed days, n = 79 48.33 37.19 61.48 40.21 19 (41) 60 (49)

Benito-Fernandez J, Onis-Gonzalez E, Alvarez-Pitti J, Capape-Zache S, Vazquez-Ronco MA, Mintegi-Raso S. Factors associated with short-term clinical outcomes after acute treatment of asthma in a pediatric emergency department. Pediatr Pulmonol. 2004 Aug;38(2):123-8.



Follow-up

Maintenance therapy with inhaled steroids, n (%)

Oral steroids at discharge from emergency room, n (%)

Yes No Yes No

Total 107 151 151 107

Day 7: Respiratory symptoms 38 (35.5) 73 (48.3) 65 (43) 46 (43)

Day 7: Use of medication 64 (59.8) 93 (61.6) 98 (64.9) 59 (55.1)

Day 15: Respiratory symptoms 24 (22.4) 29 (19.2) 29 (19.2) 24 (22.4)



2.83 3.13 3.05 3.26 3.2 3.46 2.9 3.34

3 missed days, n = 79 36 (50) 43 (38) 53 (46.5) 26 (36.5)



Follow-up

Use of MDI-spacer at emergency room, n (%)

Visit with a pediatrician 48 hours after discharge, n (%)*

Yes No Yes No

Total 87 171 184 15






3.44 2.28 4.48 3.79 2.90 3.30 4.02 4.37

3 missed days, n = 79 21 (33) 58 (47.5) 54 (40) 21 (67.7)

ED strategies to improve short-term outcome Early initiation of inhaled corticosteroids

in addition to a brief course of oral corticosteroids

Educational interventions in ED (i.e: promote the use of MDI)

Close follow-up

“Objective: improve quality of life in children after an asthma exacerbation”

Risk factors for poor outcome n = 779 Univariate anlysis Multivariate analysis

Relative risk (95% CI)

p value Adjusted odds ratio (95% CI)

p value

Wheezing ≥2 d before ED visit 1.7 (1.4-2.1) < 0.001 2.1 (1.3-3.4) 0.003

>3 acute asthma visits in the past year

1.5 (1.2-1.9) 0.001 1.8 (1.1-2.8) 0.01

Severe persitent asthma 2.2 (1.0-4.5) 0.04 2.8 (1.1-7.2) 0.03

Use of albuterol regularly 2.6 (1.6-4.5) <0.001 2.8 (1.3-5.9) 0.007

Already taking systemic corticosteroids at ED arrival

1.3 (0.95-1.7) 0.12 1.4 (0.7-2.6) 0.34

Admitted from ED 1.3 (1.0-1.6) 0.11 1.1 (0.7-1.6) 0.7

Stevens MW, Scribano PV and Gorelick MH. Screening for poor short-term outcome in acute pediatric asthma. Ann Allergy Asthma Immunol. 2007;98:432-439.

“Chidren over 2 years old who attend to ED with a moderate-severe asthma reagudization should be prescribed on inhaled corticosteroids added to the standard treatment with beta-agonist and systemic corticosteroids”

In ED scenary: Who patients should be considered to start treatment with inhaled corticosteroids?

Summary

Hospitalization rates are not reliable indicators of true asthma morbitiy in children after exacerbations.

There is evidence of a poor short-term outcome in children after an ED visit for asthma mainly related to a lack of illness control

From ED, educational interventions, early indication of IC and close follow-up seems to be the best strategies to improve patients outcome

short-term clinical outcomes of acute treatment of childhood asthma

Documents

asthma hospital

asthma outcomes

asthmaspecific quality

restructuring asthma

ann allergy asthma immunol

need of treatment

ed treatmentdifferences

ed visit