Pilot Clinical Trial of High-Flow Oxygen Therapy in Children with Asthma in the Emergency Service.

OBJECTIVES: To assess the efficacy of high-flow nasal cannula (HFNC) oxygen therapy and safety in children with asthma and moderate respiratory failure in the emergency department (ED). STUDY DESIGN: This was a prospective randomized pilot trial of children (aged 1-14 years) presenting to a tertiary academic pediatric ED with moderate-to-severe asthma exacerbations between September 2012 and December 2015. Patients with a pulmonary score (PS) ≥6 or oxygen saturation <94% with a face mask despite initial treatment (salbutamol/ipratropium bromide and corticosteroids) were randomized to HFNC or to conventional oxygen therapy. Pharmacologic treatment was at the discretion of attending physicians. The primary outcome was a decrease in PS ≥2 in the first 2 hours. Secondary outcomes included disposition, length of stay, and need for additional therapies. RESULTS: We randomly allocated 62 children to receive either HFNC (n = 30) or standard oxygen therapy (n = 32). Baseline patient characteristics were similar in the 2 groups. At 2 hours after the start of therapy, PS had decreased by ≥2 points in 16 patients in the HFNC group (53%) compared with 9 controls (28%) (P = .01). Between-group differences in disposition, length of stay, and need for additional therapies were not significant. No side effects were reported. CONCLUSION: HFNC appears to be superior to conventional oxygen therapy for reducing respiratory distress within the first 2 hours of treatment in children with moderate-to-severe asthma exacerbation refractory to first-line treatment. Further studies are needed to demonstrate its overall efficacy in the management of asthma and respiratory failure in the ED. TRIAL REGISTRATION: EudraCT: 2012-001771-36.

How Do Storms Affect Asthma?

PURPOSE OF REVIEW: There are observations in various geographical areas that thunderstorms occurring during pollen seasons can induce severe asthma attacks in pollinosis patients. RECENT FINDINGS: An accredited hypothesis explaining the association between thunderstorms and asthma suggests that storms can concentrate pollen grains at ground level, which may then release allergenic particles of respirable size in the atmosphere after their imbibition of water and rupture by osmotic shock. During the first 20-30 min of a thunderstorm, patients affected by pollen allergy may inhale a high quantity of the allergenic material that is dispersed into the atmosphere as a bioaerosol of allergenic particles, which can induce asthmatic reactions, often severe. Subjects without asthma symptoms, but affected by seasonal rhinitis can also experience an asthma attack. A key message is that all subjects affected by pollen allergy should be alerted to the danger of being outdoors during a thunderstorm in the pollen season, as such events may be an important cause of severe asthma exacerbations. In light of these observations, it is useful to predict thunderstorms and thus minimize thunderstorm-related events. Patients with respiratory allergy induced by pollens and molds need to be informed about a correct therapeutic approach of bronchial asthma by inhalation, including the use of bronchodilators and inhaled corticosteroids. The purpose of this review is to focalize epidemiological, etiopathogenetic, and clinical aspects of thunderstorm-related asthma.

Randomized Trial of Dexamethasone Versus Prednisone for Children with Acute Asthma Exacerbations.

OBJECTIVE: To determine whether 2 doses of dexamethasone is as effective as 5 days of prednisolone/prednisone therapy in improving symptoms and quality of life of children with asthma exacerbations admitted to the emergency department (ED). STUDY DESIGN: We conducted a randomized, noninferiority trial including patients aged 1-14 years who presented to the ED with acute asthma to compare the efficacy of 2 doses of dexamethasone (0.6 mg/kg/dose, experimental treatment) vs a 5-day course of prednisolone/prednisone (1.5 mg/kg/d, followed by 1 mg/kg/d on days 2-5, conventional treatment). Two follow-up telephone interviews were completed at 7 and 15 days. The primary outcome measures were the percentage of patients with asthma symptoms and quality of life at day 7. Secondary outcomes were unscheduled returns, admissions, adherence, and vomiting. RESULTS: During the study period, 710 children who met the inclusion criteria were invited to participate and 590 agreed. Primary outcome data were available in 557 patients. At day 7, experimental and conventional groups did not show differences related to persistence of symptoms (56.6%, 95% CI 50.6-62.6 vs 58.3%, 95% CI 52.3-64.2, respectively), quality of life score (80.0 vs 77.7, not significant [ns]), admission rate (23.9% vs 21.7%, ns), unscheduled ED return visits (4.6% vs 3.3%, ns), and vomiting (2.1% vs 4.4%, ns). Adherence was greater in the dexamethasone group (99.3% vs 96.0%, P < .05). CONCLUSION: Two doses of dexamethasone may be an effective alternative to a 5-day course of prednisone/prednisolone for asthma exacerbations, as measured by persistence of symptoms and quality of life at day 7. CLINICAL TRIAL REGISTRATION: clinicaltrialsregister.eu: 2013-003145-42.

Prevalence of Viruses in Acute Asthma Exacerbations in Childhood in a Hospital in West Part of Turkey.

Acute asthma exacerbations (AAE) are episodes characterized by potentially life-threatening and rapidly deteriorating asthma symptoms. Viral respiratory infections are one of the major triggers in the pathophysiology of childhood asthma exacerbations. In this study, we aimed to determine the distribution of viral agents among pediatric AAE patients. One hundred and three AAE patients, aged 5 or older, hospitalized between from February 2017 through February 2020 at Pediatric Immunology and Allergic Diseases Unit were included in this study. Fifty patients (48.5%) were female, and the mean age of the patients was 108.2 months. Viruses were detected in 58 (%56.3) of the patients, in 5 of whom more than one virus type was detected. The most commonly detected virus was human rhinovirus (n=43, 67.1%). Other types included respiratory syncytial virus (n=8; 12.5%), influenza (n=6; 9.3%), human metapneumovirus (n=4; 6.2%), adenovirus (n=1; 1.5%), enterovirus (n=1; 1.5%), and parainfluenza (n=1; 1.5%). Viral agents were detected in 29 out of the 47 patients with allergic asthma, with human rhinoviruses comprising the majority (18 patients). The mean length of hospital stay was 7.89 days. Human rhinovirus is the most common virus that triggers AAE, with similar distributions in allergic and non-allergic asthma. We found no correlation between virus type and the length of hospital stay.

Development and internal validation of a pediatric acute asthma prediction rule for hospitalization.

BACKGROUND: Clinicians have difficulty predicting need for hospitalization of children with acute asthma exacerbations. OBJECTIVE: 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. METHODS: 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. RESULTS: 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. CONCLUSION: 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.

Oxigenoterapia por cánula nasal de alto flujo en pacientes con crisis asmática en un departamento de emergencia pediátrica / High flow nasal cannula oxygen therapy in patients with asthmatic crisis in the pediatric emergency department

INTRODUCCIÓN: Pocos estudios son concluyentes sobre la utilidad de la Oxigenoterapia por Cánula Nasal de Alto Flujo (CNAF) en pacientes con crisis asmática. OBJETIVO: Determinar la eficacia de la CNAF en niños mayores de 2 años con crisis asmática severa y moderada que no responde al tratamiento inicial. PACIENTES Y MÉTODO: Ensayo clínico randomizado controlado abierto de pacientes con exacerbación asmática en un Departamento de Emergencia Pediátrica. Se excluyó crisis mediadas por infecciones y comorbilidad. Los pacientes fueron aleatorizados: Grupo 1 CNAF (n: 32) y Grupo 2 Oxigenoterapia Convencional (n: 33). Ambos grupos recibieron el tratamiento farmacológico habitual. El primer punto de corte fue el descenso del PIS en más de 2 puntos a las 2 horas del tratamiento; los puntos secundarios: descenso del PIS a las 6 horas, tiempo de permanencia en la emergencia e ingreso a UCIP. RESULTADOS: Las características basales fueron similares en ambos grupos. La proporción de sujetos con disminución de más de dos puntos en el PIS a las 2 horas de tratamiento Grupo 1: 43,7% IC 95% (28-60) vs Grupo 2: 48,4%; IC 95% (32-64) p 0,447. La estadía media fue 24,8 ± 12,3 horas en el Grupo1 vs 24 ± 14,8 horas en el Grupo2; IC 95% (7,56-5,96) p 0,37. No encontramos diferencias del score y puntaje del esfuerzo respiratorio en mediciones cada 2 horas. Ningún paciente ingresó a cuidados intensivos. CONCLUSIONES: La incorporación de la CNAF al tratamiento de pacientes con crisis asmática no presentó beneficios clínicos ni disminuyó el tiempo de estadía en el DEP.

INTRODUCTION: There are few conclusive studies on the usefulness of High-Flow Nasal Cannula (HFNC) Oxygen Therapy in patients with asthmatic crises. OBJECTIVE: To determine the effectiveness of HFNC in chil dren older than 2 years of age that present severe and moderate asthmatic crises that do not respond to initial treatment. PATIENTS AND METHOD: Open controlled randomized clinical trial of patients with asthma exacerbation in the Pediatric Emergency Department. Infection- and comorbidity-media ted crises were excluded. Subjects were randomized as follows: Group 1 HFNC (n:32) and Group 2 Conventional Oxygen Therapy (n:33). Both groups received the usual pharmacological treatment. The first cut-off point was the decrease of more than 2 points of the PIS after 2 hours of treatment; secondary points were PIS decrease at 6 hours, stay time in the Emergency Room, and PICU admis sion. RESULTS: The patient's baseline characteristics were similar in both groups. The proportion of subjects with more than two points decrease in the PIS after two hours of treatment in Group 1 was 43.7% CI 95% (28-60) vs. Group 2 48.4%; CI 95% (32-64) p 0.447. The mean stay time was 24.8 ± 12.3 hours in Group 1 vs. 24 ± 14.8 hours in Group 2; CI 95% (7.56-5.96) p 0.37. We did not find differences in the respiratory effort score measurements every 2 hours. No patients were admitted to intensive care. CONCLUSIONS: The incorporation of HFNC oxygen therapy in the treatment of patients with asthmatic crises in the Pediatric Emergency Department did not show clinical benefits nor did it diminish the stay time.