A randomized trial of oral prednisone for cystic fibrosis pulmonary exacerbation treatment.

BACKGROUND: Elevated markers of systemic and pulmonary inflammation are associated with failure to recover lung function following pulmonary exacerbations (PExs) in people with cystic fibrosis (pwCF). Our aim was to determine whether adjuvant oral prednisone treatment would improve recovery of forced expiratory volume in 1 second (ppFEV1) in CF PExs not responding to antibiotic therapy. METHODS: This was a randomized, double-blind, placebo-controlled trial in pwCF treated with intravenous (IV) antibiotics for a PEx. At Day 7, those who had not returned to >90% baseline ppFEV1 were randomized to adjuvant prednisone 1 mg·kg-1 twice daily (max 60 mg/day) or placebo for 7 days. The primary outcome was the difference in proportion of subjects who recovered >90% baseline ppFEV1 at Day 14 of IV antibiotic therapy. RESULTS: 173 subjects were enrolled, with 76 randomized. 50% of subjects in the prednisone group recovered baseline FEV1 on Day 14 compared to 39% of subjects in the placebo group for a difference of 11% (95% CI -11, 34%, p=0.34). The mean (sd) change in ppFEV1 from Day 7 to Day 14 was 6.8% predicted (8.8) in the prednisone group and 4.6% (6.9) in the placebo group (mean difference 2.2% predicted 95% CI -1.5, 5.9%, p=0.24). Time to subsequent exacerbation was not prolonged in prednisone treated subjects (HR 0.83, 95% CI 0.45, 1.53; p=0.54). CONCLUSIONS: This study failed to detect a difference in ppFEV1 recovery between adjuvant oral prednisone and placebo treatment in pwCF not responding at day 7 of IV antibiotic therapy for PExs.

Caregivers' Perceptions, Needs, and Data Sharing Concerns in mHealth Research on Pediatric Asthma: Cross-Sectional Survey Study.

Background: Pediatric asthma is the most common chronic respiratory disease of childhood. Caregivers often report lacking knowledge in several aspects of asthma management at home. Although the use of mobile health (mHealth) tools, such as mobile apps, could facilitate asthma self-management and, simultaneously, the collection of data for research, few studies have explored the features that caregivers would like to see in such a tool and their perceptions on data sharing. Objective: This study evaluates caregivers' perceived knowledge gaps in asthma management; their perceptions of certain features and resources that should be included in a potential mobile app; and any concerns that they may have regarding data sharing for research, including privacy and security concerns. Methods: In this cross-sectional study, we surveyed 200 caregivers of children (aged 1-13 y) with asthma who were followed at a pediatric tertiary care center in Montreal, Canada. Anonymous data were collected through the institutional web-based survey platform. We collected the participants' answers by using a 5-category Likert scale ("completely agree," "agree," "neither agree nor disagree," "disagree," and "completely disagree"), multiple-choice questions, and free-text questions on the abovementioned topics. Descriptive statistics were performed, and answers were compared between caregivers of preschool-aged children and caregivers of school-aged children. Results: Participating children's mean age was 5.9 (SD 3.4) years, with 54% (108/200) aged ≤5 years and 46% (92/200) aged >6 years. Overall, caregivers reported having adequate knowledge about asthma and asthma self-management. Nonetheless, they identified several desirable features for a mobile app focused on asthma self-management. The most frequently identified features included receiving alerts about environmental triggers of asthma (153/199, 76.9%), having videos that demonstrate symptoms of asthma (133/199, 66.8%), and being able to log children's asthma action plans in the app (133/199, 66.8%). Interestingly, more caregivers of preschool-aged children preferred textual information when compared to caregivers of school-aged children (textual information for explaining asthma: P=.008; textual information for the symptoms of asthma: P=.005). Caregivers were generally highly in favor of sharing data collected through a mobile app for research. Conclusions: Caregivers of children with asthma in our study identified several desirable educational and interactive features that they wanted to have in a mobile app for asthma self-management. These findings provide a foundation for designing and developing mHealth tools that are relevant to caregivers of children with asthma.

Impact of Unmet Social Needs, Scarcity, and Future Discounting on Adherence to Treatment in Children With Asthma: Protocol for a Prospective Cohort Study.

BACKGROUND: Asthma is one of the most prevalent chronic diseases of childhood and disproportionately affects children with lower socioeconomic status. Controller medications such as inhaled corticosteroids significantly reduce asthma exacerbations and improve symptoms. However, a large proportion of children still have poor asthma control, in part owing to suboptimal adherence. Financial barriers contribute to hindering adherence, as do behavioral factors related to low income. For example, unmet social needs for food, lodging, and childcare may create stress and worry in parents, negatively influencing medication adherence. These needs are also cognitively taxing and force families to focus on immediate needs, leading to scarcity and heightening future discounting; thus, there is the tendency to attribute greater value to the present than to the future in making decisions. OBJECTIVE: In this project, we will investigate the relationship between unmet social needs, scarcity, and future discounting as well as their predictive power over time on medication adherence in children with asthma. METHODS: This 12-month prospective observational cohort study will recruit 200 families of children aged 2 to 17 years at the Asthma Clinic of the Centre Hospitalier Universitaire Sainte-Justine, a tertiary care pediatric hospital in Montreal, Canada. The primary outcome will be adherence to controller medication, measured using the proportion of prescribed days covered during follow-up. Exploratory outcomes will include health care use. The main independent variables will be unmet social needs, scarcity, and future discounting, measured using validated instruments. These variables will be measured at recruitment as well as at 6- and 12-month follow-ups. Covariates will include sociodemographics, disease and treatment characteristics, and parental stress. Primary analysis will compare adherence to controller medication, measured using the proportion of prescribed days covered, between families with versus those without unmet social needs during the study period using multivariate linear regression. RESULTS: The research activities of this study began in December 2021. Participant enrollment and data collection began in August 2022 and are expected to continue until September 2024. CONCLUSIONS: This project will allow the documentation of the impact of unmet social needs, scarcity, and future discounting on adherence in children with asthma using robust metrics of adherence and validated measures of scarcity and future discounting. If the relationship between unmet social needs, behavioral factors, and adherence is supported by our findings, this will suggest the potential for novel targets for integrated social care interventions to improve adherence to controller medication and reduce risk across the life course for vulnerable children with asthma. TRIAL REGISTRATION: ClinicalTrials.gov NCT05278000; https://clinicaltrials.gov/ct2/show/NCT05278000. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/37318.

The effect of the COVID-19 pandemic on pediatric asthma-related emergency department visits and hospital admissions in Montréal, Quebec: a retrospective cohort study.

BACKGROUND: Asthma is a chronic respiratory condition that affects 10% of Canadian children and is often exacerbated by viral respiratory infections, prompting concerns about the severity of SARS-CoV-2 disease in children with asthma. We compared sociodemographic and clinical characteristics of children presenting to the emergency department and the incidence of these visits, before and during the pandemic. METHODS: We included children aged 0 to 17 years presenting with asthma to 2 tertiary pediatric emergency departments in Montréal, Quebec, between the prepandemic (Jan. 1, 2017, to Mar. 31, 2020) and pandemic (Apr. 1, 2020, to June 30, 2021) periods. We compared the number of emergency department visits and hospital admissions with an interrupted time series analysis and compared the sociodemographic characteristics based on the Canadian Index of Multiple Deprivation (CIMD) and clinical characteristics (including triage level, intensive care admissions, etc.) with Mann-Whitney and χ2 tests. RESULTS: We examined 22 746 asthma-related emergency department visits. During the pandemic, a greater proportion of patients presented a triage level 1 or 2 (19.3% v. 14.7%) and were admitted to the intensive care unit (2.5% v. 1.3%). The patients' CIMD quintile distributions did not differ between the 2 periods. We found a 47% decrease (relative risk [RR] 0.53, 95% confidence interval [CI] 0.37 to 0.76) in emergency department visits and a 49% decrease (RR 0.51, 95% CI 0.34 to 0.76) in hospital admissions during the pandemic. INTERPRETATION: The decrease in asthma-related emergency department visits was observed through the third wave of the pandemic, but children presented with a higher acuity and with no identified sociodemographic changes. Future studies are required to understand individual behaviours that may have led to the increased acuity at presentation observed in this study.

Physical activity levels, pulmonary function, and MRI in children born extremely preterm: A comparison between children with and without bronchopulmonary dysplasia.

INTRODUCTION: Children with a history of bronchopulmonary dysplasia (BPD) may have lower physical activity levels, but evidence to date is mixed. This study compared physical activity levels between children born extremely preterm with and without history of BPD, and examined their associations with pulmonary magnetic resonance imaging (MRI) and pulmonary function test (PFT) indices. METHODS: This multicentre cross-sectional study included children aged 7-9 years born extremely preterm, with and without BPD. Children wore a pedometer for 1 week, then completed the Physical Activity Questionnaire (PAQ), pulmonary MRI, and PFT. Spearman correlations and multivariable linear regression modeling were performed. RESULTS: Of 45 children, 28 had a history of moderate-severe BPD. There were no differences in any physical activity outcomes by BPD status. Higher average daily step count and higher average daily moderate-to-vigorous physical activity (MVPA) were each correlated with greater forced vital capacity (r = 0.41 and 0.58), greater MRI lung proton density at full expiration (r = 0.42 and 0.49), and lower lung clearance index (r = -0.50 and -0.41). After adjusting for MRI total proton density and BPD status, a 5% increase in forced expiratory volume at 1 s was associated with 738 (95% CI: 208, 1268) more steps per day and 0.1 (0.0, 0.2) more hours of MVPA, respectively. CONCLUSION: School-aged children born extremely preterm have similar physical activity levels to their peers, regardless of history of BPD. MRI and PFT measures suggestive of gas trapping and/or airflow obstruction are associated with lower physical activity levels.

Executive Summary of the Second International Guidelines for the Diagnosis and Management of Pediatric Acute Respiratory Distress Syndrome (PALICC-2).

OBJECTIVES: We sought to update our 2015 work in the Second Pediatric Acute Lung Injury Consensus Conference (PALICC-2) guidelines for the diagnosis and management of pediatric acute respiratory distress syndrome (PARDS), considering new evidence and topic areas that were not previously addressed. DESIGN: International consensus conference series involving 52 multidisciplinary international content experts in PARDS and four methodology experts from 15 countries, using consensus conference methodology, and implementation science. SETTING: Not applicable. PATIENTS: Patients with or at risk for PARDS. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Eleven subgroups conducted systematic or scoping reviews addressing 11 topic areas: 1) definition, incidence, and epidemiology; 2) pathobiology, severity, and risk stratification; 3) ventilatory support; 4) pulmonary-specific ancillary treatment; 5) nonpulmonary treatment; 6) monitoring; 7) noninvasive respiratory support; 8) extracorporeal support; 9) morbidity and long-term outcomes; 10) clinical informatics and data science; and 11) resource-limited settings. The search included MEDLINE, EMBASE, and CINAHL Complete (EBSCOhost) and was updated in March 2022. Grading of Recommendations, Assessment, Development, and Evaluation methodology was used to summarize evidence and develop the recommendations, which were discussed and voted on by all PALICC-2 experts. There were 146 recommendations and statements, including: 34 recommendations for clinical practice; 112 consensus-based statements with 18 on PARDS definition, 55 on good practice, seven on policy, and 32 on research. All recommendations and statements had agreement greater than 80%. CONCLUSIONS: PALICC-2 recommendations and consensus-based statements should facilitate the implementation and adherence to the best clinical practice in patients with PARDS. These results will also inform the development of future programs of research that are crucially needed to provide stronger evidence to guide the pediatric critical care teams managing these patients.

Outcomes of Children Surviving Pediatric Acute Respiratory Distress Syndrome: From the Second Pediatric Acute Lung Injury Consensus Conference.

OBJECTIVES: To summarize the evidence for the Second Pediatric Acute Lung Injury Consensus Conference-2 (PALICC-2) recommendations for assessment of outcomes among patients surviving pediatric acute respiratory distress syndrome (PARDS). DATA SOURCES: MEDLINE (Ovid), Embase (Elsevier), and CINAHL Complete (EBSCOhost). STUDY SELECTION: We conducted a scoping review to identify studies evaluating outcomes following PARDS. We included studies of survivors of PARDS, acute respiratory failure with a high proportion of PARDS patients, or other critical illnesses if PARDS-specific outcomes could be extracted. DATA EXTRACTION: Title/abstract review, full-text review, and data extraction using a standardized data collection form. DATA SYNTHESIS: The Grading of Recommendations Assessment, Development and Evaluation approach was used to identify and summarize evidence and develop recommendations. Of 8,037 abstracts screened, we identified 20 articles for inclusion. Morbidity following PARDS was common and affected multiple domains of pulmonary and nonpulmonary function. There was insufficient evidence to generate any evidence-based recommendations. We generated eight good practice statements and five research statements. A panel of 52 experts discussed each proposed good practice statement and research statement, and the agreement rate was measured with an online voting process. Good practice statements describe the approach to clinical outcome assessment, assessment of pulmonary outcomes of children surviving PARDS, and assessment of nonpulmonary outcomes of children surviving PARDS including health-related quality of life and physical, neurocognitive, emotional, family, and social functioning. The five research statements relate to assessment of patient preillness status, use of postdischarge endpoints for clinical trials, the association between short-term and longer term outcomes, the trajectory of recovery following PARDS, and practices to optimize follow-up. CONCLUSIONS: There is increasing evidence that children are at risk for impairments across a range of pulmonary and nonpulmonary health domains following hospitalization for PARDS. The results of this extensive scoping review and consensus conference involving experts in PARDS research, clinical care, and outcomes assessment provide guidance to clinicians and researchers on postdischarge follow-up to optimize the long-term health of patients surviving PARDS.

Pre and post-COVID 19 infection pulmonary functions in children with chronic respiratory disease: A case series.

As functional respiratory impairment following COVID-19 infection (COVID-19) is increasingly reported in adult, data regarding children especially with pre-existing chronic respiratory disease (PCRD) remain scarce. We retrospectively assessed clinical presentation, duration of symptoms related to COVID-19 from paediatric patients with PCRD and compared their pre/post COVID-19-I spirometry values. Data from 12 patients were analysed. Timing between COVID-19 diagnosis and subsequent functional evaluation ranged from 26 to 209 days (mean 77). The PCRD in these patients included asthma, cystic fibrosis, bronchiolitis obliterans and bronchomalacia. During COVID-19, all clinical presentations were mild. One patient displayed persistent post-COVID-19 symptoms for 8 weeks after infection. Two patients presented significant deterioration of post-COVID-19 spirometric values with a return to pre-COVID-19 values in subsequent measures. We concluded that children with PCRD are not at increased risk for severe COVID disease and that most of them have no or only transient pulmonary functional impairment 1 to 7 months after COVID-19.

Acceptability of Serious Games in Pediatric Asthma Education and Self-management: Pilot Study.

BACKGROUND: Asthma is the most common chronic pediatric disease. Despite existing tools to manage asthma, 40%-55% of children with asthma experience uncontrolled asthma. Serious games (SGs) represent a novel approach in promoting asthma education and self-management for children. OBJECTIVE: In this qualitative pilot study with an embedded quantitative design, we aim to use focus groups and questionnaires to describe the perceived role of SGs in different aspects of asthma self-management by children and their parents. These aspects include asthma perception and knowledge, the impact of asthma and barriers to asthma self-management, and the support system for asthma self-management. METHODS: A total of 5 children with asthma and their parents were invited to participate in an organized gaming session. Children and their parents completed a pregaming questionnaire on their medical history and asthma knowledge. Then, they were invited to test 4 original SG prototypes, after which the children answered a postgaming questionnaire on their asthma knowledge and perception of the SGs. Children and their parents subsequently participated in parallel focus groups, which were video-recorded or audio-recorded, transcribed verbatim, and analyzed by reaching consensus among members of the research team. RESULTS: The mean age of the children was 10.3 (SD 1.5) years, with 20% (1/5) of the children being male. Qualitative data from the transcripts were coded into three separate domains: asthma self-management perception and knowledge, impact of asthma and barriers to asthma self-management, and support system for asthma self-management. We specifically explored the perceived roles of SGs within each domain. A key takeaway message was identified for each of these three domains: heterogeneity of asthma knowledge and the ability of SGs to encourage knowledge transfer through games, consequences and limitations of asthma and the ability of SGs to allow for identification and management of real-life situations through games, and insufficient support system and the ability of SGs to encourage playing with others for support and shared knowledge. CONCLUSIONS: Our pilot study explored the role of SGs in the self-management of asthma, as perceived by children and their parents. Our findings support the acceptability of SGs in asthma education and self-management in pediatrics and the necessity for future development in this field.

Are primary care and continuity of care associated with asthma-related acute outcomes amongst children? A retrospective population-based study.

BACKGROUND: Having a primary care provider and a continuous relationship may be important for asthma outcomes. In this study, we sought to determine the association between 1) having a usual provider of primary care (UPC) and asthma-related emergency department (ED) visits and hospitalization in Québec children with asthma and 2) UPC continuity of care and asthma outcomes. METHODS: Population-based retrospective cohort study using Québec provincial health administrative data, including children 2-16 years old with asthma (N = 39, 341). Exposures and outcomes were measured from 2010-2011 and 2012-2013, respectively. Primary exposure was UPC stratified by the main primary care models in Quebec (team-based Family Medicine Groups, family physicians not in Family Medicine Groups, pediatricians, or no assigned UPC). For those with an assigned UPC the secondary exposure was continuity of care, measured by the UPC Index (high, medium, low). Four multivariate logistic regression models examined associations between exposures and outcomes (ED visits and hospitalizations). RESULTS: Overall, 17.4% of children had no assigned UPC. Compared to no assigned UPC, having a UPC was associated with decreased asthma-related ED visits (pediatrician Odds Ratio (OR): 0.80, 95% Confidence Interval (CI) [0.73, 0.88]; Family Medicine Groups OR: 0.84, 95% CI [0.75,0.93]; non-Family Medicine Groups OR: 0.92, 95% CI [0.83, 1.02]) and hospital admissions (pediatrician OR: 0.66, 95% CI [0.58, 0.75]; Family Medicine Groups OR: 0.82, 95% CI [0.72, 0.93]; non-Family Medicine Groups OR: 0.76, 95% CI [0.67, 0.87]). Children followed by a pediatrician were more likely to have high continuity of care. Continuity of care was not significantly associated with asthma-related ED visits. Compared to low continuity, medium and high continuity of care decreased asthma-related hospital admissions, but none of these associations were significant. CONCLUSION: Having a UPC was associated with reduced asthma-related ED visits and hospital admissions. However, continuity of care was not significantly associated with outcomes. The current study provides ongoing evidence for the importance of primary care in children with asthma.

Pulmonary Magnetic Resonance Imaging of Ex-Preterm Children with and without Bronchopulmonary Dysplasia.

Rationale: Children born prematurely, particularly those with bronchopulmonary dysplasia, have persisting lung abnormalities requiring longitudinal monitoring. Pulmonary ultrashort echo time magnetic resonance imaging (MRI) measurements may provide sensitive markers of persisting lung abnormalities and have not been evaluated in school-aged children born prematurely. Objectives: To compare pulmonary MRI and pulmonary function test measurements in preterm-born school-aged children with and without bronchopulmonary dysplasia. Methods: Children aged 7-9 years, born extremely preterm, with and without bronchopulmonary dysplasia, were recruited from three centers. Participants underwent pulmonary ultrashort echo time MRI and pulmonary function tests. Primary outcomes included total proton density and proton density at full expiration, measured using MRI. Multiple linear regression analysis was performed, adjusting for gestational age and bronchopulmonary dysplasia. Associations between MRI and pulmonary function were tested. Results: Thirty-five children were included in the primary analysis (24 with bronchopulmonary dysplasia, 11 without); 29 completed pulmonary function tests, of whom 11 (38%) had airflow limitation. Children with bronchopulmonary dysplasia had 44% (95% confidence interval [CI], 10-66%) lower mean total proton density (mean ± standard deviation, 3.6 ± 2.6) than those without (6.1 ± 4.0). Those with bronchopulmonary dysplasia had 25% (95% CI, 3-42%) lower proton density at full expiration than those without. Lower total proton density and proton density at full expiration were moderately correlated with greater residual volume, residual volume/total lung capacity, and lung clearance index (Spearman correlations for total proton density: -0.42, -0.57, and -0.53, respectively. Spearman correlations for proton density at full expiration: -0.28, -0.57, and -0.45, respectively). Conclusions: School-aged preterm-born children with bronchopulmonary dysplasia have parenchymal tissue abnormalities measured using ultrashort MRI proton density, compared with those without. MRI proton density correlated with pulmonary function measures indicative of gas trapping. Clinical trial registered with www.clinicaltrials.gov (NCT02921308).

The Biobanque québécoise de la COVID-19 (BQC19)-A cohort to prospectively study the clinical and biological determinants of COVID-19 clinical trajectories.

SARS-CoV-2 infection causing the novel coronavirus disease 2019 (COVID-19) has been responsible for more than 2.8 million deaths and nearly 125 million infections worldwide as of March 2021. In March 2020, the World Health Organization determined that the COVID-19 outbreak is a global pandemic. The urgency and magnitude of this pandemic demanded immediate action and coordination between local, regional, national, and international actors. In that mission, researchers require access to high-quality biological materials and data from SARS-CoV-2 infected and uninfected patients, covering the spectrum of disease manifestations. The "Biobanque québécoise de la COVID-19" (BQC19) is a pan-provincial initiative undertaken in Québec, Canada to enable the collection, storage and sharing of samples and data related to the COVID-19 crisis. As a disease-oriented biobank based on high-quality biosamples and clinical data of hospitalized and non-hospitalized SARS-CoV-2 PCR positive and negative individuals. The BQC19 follows a legal and ethical management framework approved by local health authorities. The biosamples include plasma, serum, peripheral blood mononuclear cells and DNA and RNA isolated from whole blood. In addition to the clinical variables, BQC19 will provide in-depth analytical data derived from the biosamples including whole genome and transcriptome sequencing, proteome and metabolome analyses, multiplex measurements of key circulating markers as well as anti-SARS-CoV-2 antibody responses. BQC19 will provide the scientific and medical communities access to data and samples to better understand, manage and ultimately limit, the impact of COVID-19. In this paper we present BQC19, describe the process according to which it is governed and organized, and address opportunities for future research collaborations. BQC19 aims to be a part of a global communal effort addressing the challenges of COVID-19.

Lung Function of Children Following an Intensive Care Unit Admission for Asthma.

Background: To determine the lung function of children admitted to the intensive care unit (ICU) for a severe asthma exacerbation in the medium- to long-term following hospital discharge. Methods: We performed a retrospective chart review of children ≥6 years of age admitted to the ICU for a severe asthma exacerbation at a tertiary care center from January 1, 2000, to December 31, 2013. Lung function was ascertained during outpatient follow-up visits at 3-12 months and 12-24 months postdischarge. A total of 72 subjects met the inclusion criteria. Results: Subjects were predominantly boys (56.9%) and had a mean (standard deviation [SD]) age at admission of 10.3 years (3.4 years). The median (interquartile range) length of stay in the ICU was 1 day (1-3 days). Thirty-eight and 28 subjects performed pulmonary function tests with acceptable technique at the 3-12 months and 12-24 months postdischarge visits, respectively. At 3-12 months, the mean (SD) predicted forced expiratory volume in 1 s (FEV1) and forced expiratory flow between 25% and 75% of vital capacity (FEF25-75) percent were 95.9 (16.7) and 76.7 (25.8), respectively, and 97.4 (17.6) and 70.5 (24.9), respectively, at 12-24 months. FEV1/forced vital capacity (FEV1/FVC) was 81.7 (8.3) at 3-12 months and 79.3 (7.7) at 12-24 months. A paired t-test on 20 subjects who performed acceptable spirometry at both visits showed a significant intraindividual decrease in FEV1 (P = 0.008), FEF25-75 (P = 0.02), and FEV1/FVC (P = 0.01) between the 2 time points. Conclusion: Although prospective studies are required to confirm our findings, our study suggests that children admitted to the ICU for severe asthma exacerbations may be at risk for declining pulmonary function in the medium- to long-term postdischarge.

Validation of a Portable Game Controller to Assess Peak Expiratory Flow Against Conventional Spirometry in Children: Cross-sectional Study.

BACKGROUND: International asthma guidelines recommend the monitoring of peak expiratory flow (PEF) as part of asthma self-management in children and adolescents who poorly perceive airflow obstruction, those with a history of severe exacerbations, or those who have difficulty controlling asthma. Measured with a peak flow meter, PEF represents a person's maximum speed of expiration and helps individuals to follow their disease evolution and, ultimately, to prevent asthma exacerbations. However, patient adherence to regular peak flow meter use is poor, particularly in pediatric populations. To address this, we developed an interactive tablet-based game with a portable game controller that can transduce a signal from the user's breath to generate a PEF value. OBJECTIVE: The purpose of this study was to evaluate the concordance between PEF values obtained with the game controller and various measures derived from conventional pulmonary function tests (ie, spirometry) and to synthesize the participants' feedback. METHODS: In this cross-sectional multicenter study, 158 children (aged 8-15 years old) with a diagnosis or suspicion of asthma performed spirometry and played the game in one of two hospital university centers. We evaluated the correlation between PEF measured by both the game controller and spirometry, forced expiratory volume at 1 second (FEV1), and forced expiratory flow at 25%-75% of pulmonary volume (FEF25-75), using Spearman correlation. A Bland-Altman plot was generated for comparison of PEF measured by the game controller against PEF measured by spirometry. A post-game user feedback questionnaire was administered and analyzed. RESULTS: The participants had a mean age of 10.9 (SD 2.5) years, 44% (71/158) were female, and 88% (139/158) were White. On average, the pulmonary function of the participants was normal, including FEV1, PEF, and FEV1/forced vital capacity (FVC). The PEF measured by the game controller was reproducible in 96.2% (152/158) of participants according to standardized criteria. The PEF measured by the game controller presented a good correlation with PEF measured by spirometry (r=0.83, P<.001), with FEV1 (r=0.74, P<.001), and with FEF25-75 (r=0.65, P<.001). The PEF measured by the game controller presented an expected mean bias of -36.4 L/min as compared to PEF measured by spirometry. The participants' feedback was strongly positive, with 78.3% (123/157) reporting they would use the game if they had it at home. CONCLUSIONS: The game controller we developed is an interactive tool appreciated by children with asthma, and the PEF values measured by the game controller are reproducible, with a good correlation to values measured by conventional spirometry. Future studies are necessary to evaluate the clinical impact this novel tool might have on asthma management and its potential use in an out-of-hospital setting.

Long-term asthma-related readmissions: comparison between children admitted and not admitted to the intensive care unit for critical asthma.

OBJECTIVES: To compare the time to asthma-related readmission between children admitted to the intensive care unit (ICU) for asthma and those with a non-ICU hospitalization in the United States and to explore risk factors associated with readmission among children admitted in the ICU. METHODS: In this retrospective cohort study, we included children aged 2-17 years in the State Inpatient Database (2005-2014) from four U.S. states who were hospitalized for asthma. We compared the time to asthma-related readmissions and emergency department (ED) visit between children admitted and not admitted to the ICU using the log-rank test. Among those admitted to the ICU, we explored factors associated with readmission using Cox regression. RESULTS: 66 835 children were hospitalized for asthma, with 14.0% admitted to the ICU, and 12 844 were readmitted for asthma while 22 915 had an asthma-related ED visit. The time to asthma-related readmission was shorter in the ICU group compared to the non-ICU group (p < 0.001), but the time to asthma-related ED visit did not differ between the two groups (p = 0.43). Being preschool-aged, female, Black, and having lower household income and a longer length of stay during the initial hospitalization conferred a higher risk of asthma-related readmission among children admitted to the ICU. Preschool age and Medicaid were Florida-specific risk factors while Hispanic ethnicity was New York-specific. CONCLUSION: Compared to children not admitted to the ICU, children admitted to the ICU for asthma were at increased risk of asthma-related readmission, with certain risk factors conferring an even higher risk.

Asthma-related hospitalizations following critical asthma in children: A comparison between Canada and the United States.

INTRODUCTION: Children admitted to the intensive care unit (ICU) for asthma are at higher risk of future morbidity and mortality. Although Canada and the United States (US) may have different population compositions, studies have documented that up to 34% of American children hospitalized for asthma require ICU admission, compared to 4.5% in Canada. However, whether there are differences in the post-ICU asthma-related morbidity between the two countries is not known. This study compared the post-ICU asthma-related readmissions and ICU readmissions in children with critical asthma between Canada and the US. METHODS: In this retrospective cohort study, we included children aged 2-17 years with an ICU admission for asthma in a pan-Canadian database (2008-2014) and a 4-state American database (2005-2014). The time to the first asthma-related readmission, the distribution of asthma-related readmissions within 1 year, and the proportion of ICU readmissions within 1 year were compared between the 2 countries. RESULTS: 1055 Canadian and 9377 American children were admitted to the ICU for asthma during the study period. The time to asthma-related readmission (p = 0.29) and the frequency of asthma-related readmissions within 1 year (p = 0.73) did not differ between Canada and the US. However, the proportion of children readmitted to the ICU for asthma within 1 year was significantly higher in the US (US: 40.1%, Canada: 28.9%; p = 0.02). CONCLUSION: While the overall asthma-related readmissions in children with critical asthma did not differ between Canada and the US, a greater proportion of children were readmitted to the ICU in the US. Future studies should elucidate the causes underlying this difference.

Predictive factors for a shortened methacholine challenge protocol in children.

RATIONALE: Although the methacholine challenge test is useful in the diagnosis of asthma, it is time-consuming in children. While protocols that quadruple methacholine concentrations are widely used in adults to shorten testing time, this has not been evaluated in children. Studies have not identified predictors associated with the safe use of a quadrupled concentration protocol. OBJECTIVES: To identify clinical predictors associated with the preclusion of a quadrupled concentration protocol in children. METHODS: We included subjects <18 years who performed a methacholine challenge tests between April 2016 to February 2017 (derivation cohort) and March 2017 to September 2017 (validation cohort). We determined the eligibility of a subject to omit the 0.5 mg/ml and 2.0 mg/ml concentrations based on their PC20 and identified baseline characteristics that are associated with the preclusion of the quadrupled protocol using bivariate analysis. The derived algorithm was applied to the validation cohort. RESULTS: We included 399 and 195 patients in the derivation and validation cohorts, respectively. A baseline FEV1 ≤90% predicted, FEV1/FVC ≤0.8, FEF25-75 ≤70% predicted, and a decrease in FEV1 ≥10% with the previous concentration significantly precluded the omission of the 0.5 mg/ml concentration. A baseline FEF25-75 ≤70% predicted and a drop in FEV1 ≥10% with the previous concentration significantly precluded the omission of the 2.0 mg/ml concentration. Applying these 4 criteria to the validation cohort resulted in an overall sensitivity and specificity of 74.0% and 84.6%, respectively. CONCLUSIONS: We identified objective pulmonary function measures that may personalize and shorten the methacholine challenge protocol in children by quadrupling concentrations.