Near-fatal and fatal asthma and air pollution: are we missing an opportunity to ask key questions?

There is an increasing body of evidence supporting the link between asthma attacks and air pollution in children. To our knowledge, there has only been one reported case of a fatal asthma attack in a child associated with air pollution and this was in the UK. This article considers why there is a lack of evidence on fatal/near-fatal asthma and air pollution. We also explore three challenges. First, fatal and near-fatal asthma events are rare and not yet well understood. Second, measuring and interpreting personal exposure to air pollution with sufficient temporal and spatial detail are challenging to interpret in the context of individual fatal or near-fatal asthma attacks. Third, current studies are not designed to answer the question of whether or to what extent air pollution is associated with fatal/near-fatal asthma attacks in children. Conclusive evidence is not yet available and systems of data collection for both air pollution and fatal and near-fatal asthma attacks should be enhanced to ensure risk can be determined and impact minimised.

A young child with a history of wheeze.

The parents of a 3-year old boy are anxious about their son who has recurring episodes of wheezing. They are frustrated that no one seems to be able to give them answers to their questions and would like a referral to a specialist. Does their son have asthma and what is the prognosis; how can the recurrent wheezing be managed and can the risk of asthma be reduced; are there lifestyle changes that could improve the environment and avoid triggers? Communication and support from the family practice team were essential. Listening to the parents' concerns, explaining the diagnostic uncertainty, being realistic about what drug treatments could achieve, and providing practical advice on inhaler use and trigger avoidance reassured the parents that there was a strategy for managing their son's wheeze. The specialist referral was postponed.

Attentional bias to respiratory- and anxiety-related threat in children with asthma.

This study investigated attentional biases in children with asthma. The study aimed at testing whether children with asthma are vigilant to asthma and/or anxiety cues. Thirty-six children (18 with asthma and 18 healthy controls) aged 9-12 completed a computerised dot probe task designed to measure attentional bias to three different categories of words: asthma, anxiety symptom and general negative emotion. Main caregiver anxiety was also assessed, as was frequency of inhaler use for those with asthma. Children with asthma showed an attentional bias towards asthma words but not anxiety or general negative emotion words. Children without asthma showed no significant attentional biases to any word categories. Caregiver anxiety was correlated with asthma word attentional bias in the asthma group. The findings indicate that attentional bias is present in children with asthma. Further research is required to ascertain if this exacerbates or maintains health-related problems.

Observational study of two oxygen saturation targets for discharge in bronchiolitis.

OBJECTIVES: To assess the potential effect of two guideline discharge oxygen saturation (SpO(2)) recommendations (≥90% and ≥94%) in recovering bronchiolitis. METHODS AND PATIENTS: Infants aged up to 18 months requiring therapeutic oxygen for SpO(2) (≤93%) had SpO(2) assessed in air every 2 h. Time from admission to re-establish feeding (>75% normal) and for SpO(2) to become stable for at least 4 h at ≥90% and ≥94% were noted. RESULTS: 68 infants, median age 14 weeks, were included. Feeding problems resolved at a median of 11 h (inter-quartile range, IQR 0-47). SpO(2) became stable for at least 4 h at 17 h (IQR 0-49) for ≥90% and 63 h (IQR 34-105) for ≥94%. Time for infants to achieve a stable SpO(2)≥90% and resolve feeding difficulties was a median of 22 h (IQR 7-39 h) sooner than the equivalent for stable SpO(2)≥94%. CONCLUSIONS: Accepting lower SpO(2) at discharge could significantly reduce length of stay, but require the clinical and safety effects to be studied.

Effect of an integrated care pathway on acute asthma/wheeze in children attending hospital: cluster randomized trial.

OBJECTIVE: To determine whether an integrated care pathway (ICP) could improve care delivered to patients coming to an emergency department only or to patients who were subsequently admitted. STUDY DESIGN: Children (age, 2-16 years; n = 298) coming to the ED with acute asthma/wheeze, were randomized by using a cluster design to either standard care or care delivered by an ICP. RESULTS: Children discharged from the ED who received care with an ICP (n = 118) received more prednisolone (81%; standard, 63%; P = .03) and increased advice to obtain primary care review (72%; standard, 33%; P < .0001). A total of 180 children were admitted (94 ICP, 86 standard). The rate of recovery was unchanged by ICP. The mean ICP length of stay (37.6 hours; range, 33.5-42.4 hours), was 93% of the mean standard length of care (40.7 hours; range, 35.9-46; P = .36). When a discharge checklist was completed (60 of 94 cases), the mean ICP length of stay was 34.2 hours (range, 30.5-38.4 hours; P = .07 versus standard). An ICP resulted in a 30% reduction in prescribing errors (mean, 10.4; standard, 14.8; P = .002). Eighty-four of 94 children with an ICP received a 48-hour discharge plan (89%) versus 35 of 86 children with standard care (41%). More clinical contacts were observed in children receiving care by an ICP (mean, 22, versus standard, 19.2: P = .0004). CONCLUSION: An acute asthma/wheeze ICP improved education and prescribing errors, modestly reduced the length of stay when discharge criteria were adhered to, but did not influence recovery time. Further consideration of the effect on staff workload is required.

The availability and use of oxygen saturation monitoring in primary care in order to assess asthma severity.

INTRODUCTION: The BTS/SIGN guideline recommends oxygen saturation (SaO2) monitoring as an objective measure of acute asthma severity, particularly in children, in both primary and secondary care. We assessed the availability and use of SaO2 monitoring for acute asthma assessment in primary care. METHODS: Fax and telephone questionnaire of Primary Care services in the Edinburgh region to assess use of SaO2 monitoring in the past 24 months, in association with a 24-month retrospective assessment of A&E attendances with acute wheeze. Children over 12 months of age registered with eligible general practices attending A&E with wheeze and/or asthma were included. RESULTS: There were replies from 103 general practices (100%) and eight Out-of-hours cooperatives (100%). Oxygen saturation monitoring was available in four general practices (3.9%) and three Out-of-hours cooperatives (37.5%). 1408 children attended A&E with wheeze/asthma, 721 referred by primary care. Oxygen saturation monitoring was available to 7.9% of A&E attendees from primary care, but documented in only 1.8% of primary care referrals. CONCLUSIONS: SaO2 monitoring is not widely available in primary care and is infrequently used for the assessment of acute asthma. SaO2 measurement as an adjunct to clinical assessment of asthma in primary care needs encouragement.