Blood eosinophils in managing preschool wheeze: Lessons learnt from a proof-of-concept trial.

BACKGROUND: Management of preschool wheeze is based predominantly on symptom patterns. OBJECTIVE: To determine whether personalizing therapy using blood eosinophils or airway bacterial infection results in fewer attacks compared with standard care. METHODS: A proof-of-concept, randomized trial to investigate whether the prescription of inhaled corticosteroids (ICS) guided by blood eosinophils, or targeted antibiotics for airway bacterial infection, results in fewer unscheduled healthcare visits (UHCVs) compared with standard care. Children aged 1-5 years with ≥2 wheeze attacks in the previous year were categorized as episodic viral wheeze (EVW) or multiple trigger wheeze (MTW). The intervention group was prescribed ICS if blood eosinophils ≥3%, or targeted antibiotics if there is positive culture on induced sputum/cough swab. The control group received standard care. The primary outcome was UHCV at 4 months. RESULTS: 60 children, with a median age of 36.5 (range 14-61) months, were randomized. Median blood eosinophils were 5.2 (range 0-21)%, 27 of 60 (45%) children were atopic, and 8 of 60 (13%) had airway bacterial infection. There was no relationship between EVW, MTW and either blood eosinophils, atopic status or infection. 67% in each group were prescribed ICS. 15 of 30 control subjects and 16 of 30 patients in the intervention group had UHCV over 4 months (p = .8). The time to first UHCV was similar. 50% returned adherence monitors; in those, median ICS adherence was 67%. There were no differences in any parameter between those who did and did not have an UHCV. CONCLUSION: Clinical phenotype was unrelated to allergen sensitization or blood eosinophils. ICS treatment determined by blood eosinophils did not impact UHCV, but ICS adherence was poor.

Managing problematic severe asthma: beyond the guidelines.

This review discusses issues related to managing problematic severe asthma in children and young people. A small minority of children have genuinely severe asthma symptoms which are difficult to control. Children with genuinely severe asthma need investigations and treatments beyond those described within conventional guidelines. However, the majority of children with poor symptom control despite high-intensity treatment achieve improvement in their asthma control once attention has been paid to the basics of asthma management. Basic asthma management requires optimisation of inhaler technique and treatment adherence, avoidance of environmental triggers and self-management education. It is also important that clinicians recognise risk factors that predispose patients to asthma exacerbations and potentially life-threatening attacks. These correctable issues need to be tackled in partnership with children and young people and their families. This requires a coordinated approach between professionals across healthcare settings. Establishing appropriate infrastructure for coordinated asthma care benefits not only those with problematic severe asthma, but also the wider asthma population as similar correctable issues exist for children with asthma of all severities. Investigation and management of genuine severe asthma requires specialist multidisciplinary expertise and a systematic approach to characterising patients' asthma phenotypes and delivering individualised care. While inhaled corticosteroids continue to play a leading role in asthma therapy, new treatments on the horizon might further support phenotype-specific therapy.

Simulation in undergraduate paediatrics: a cluster-randomised trial.

BACKGROUND: Medical students lack confidence in recognising, assessing and managing unwell patients, particularly children. Our aim was to evaluate the impact of a 1-day novel paediatric simulation course on medical students' ability to recognise and assess sick children, and to evaluate medical students' views on the use of simulation in child health teaching. METHODS: We conducted a cluster-randomised trial with a mixed-methods design. Students were cluster randomised into the intervention (simulation) group or control group (standard paediatric attachment). Students in the intervention group attended a 1-day simulation course during the last week of their attachment. The primary outcome measure was students' self-reported ability and confidence in recognising, assessing and managing sick children. RESULTS: There were 61 students in the study: 32 in the intervention group and 29 in the control group. Self-assessed confidence in recognising, assessing and managing a sick child was higher after the simulation course, compared with controls (p < 0.001). Six key themes were identified, including: increased confidence in emergency situations; the value of learning through participation in 'real-life' realistic scenarios in a safe environment; and an appreciation of the importance of human factors. Students found the simulation useful and wanted it offered to all undergraduates during child health attachments. DISCUSSION: A 1-day simulation course improves medical students' confidence in assessing and managing unwell children, and is highly valued by students. It could be used to complement undergraduate teaching on the management of sick children. Further studies are needed to evaluate its impact on real-life clinical performance and confidence over time. Students lack confidence in managing unwell patients, particularly children.

Endotracheal tube length for neonatal intubation.

OBJECTIVE: In the newborn infant, accurate endotracheal tube (ETT) placement is essential for adequate ventilation and surfactant delivery. This study aimed to determine the relationship between gestation, weight and endotracheal tube length, and to evaluate the promotion of gestation-based guidelines for ETT length. DESIGN: A prospective audit of endotracheal tube placement, followed by an education drive to 24 hospitals, and a subsequent repeat audit. SETTING: Neonatal intensive care transfer service. PATIENTS: Infants referred for inter-hospital transfer between 33 neonatal units. INTERVENTIONS: Education drive to local hospitals to encourage use of standardised guidelines for ETT length based on gestation. MEASUREMENTS AND MAIN RESULTS: Endotracheal tube length, radiological position with respect to thoracic vertebral bodies and radiological complications were assessed by neonatal transport team staff. The association between satisfactory ETT length and gestation was linear, whereas the relationship with weight was non-linear. In participating centres, use of gestation-based guidelines were associated with a reduction in tubes needing repositioning (8% vs. 53%, p<0.01) and in the incidence of uneven lung expansion (3% vs.17%, p<0.05). As use of gestation guidelines increased from 18% to only 32% overall, the intervention did not produce statistically significant changes in the entire patient population. CONCLUSION: Use of gestation-based guidelines on ETT length for neonatal intubation was associated with a reduction in tube malposition and uneven lung expansion. A table of ETT length against gestation and weight is provided to assist those carrying out this procedure, which could be incorporated into neonatal resuscitation training.