javier benito-fernández, md director of paediatric emergency department hospital de cruces- bilbao...
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Javier Benito-Fernández, MDDirector of Paediatric Emergency DepartmentHospital de Cruces- Bilbao (Spain)
SHORT-TERM CLINICAL OUTCOMES OF ACUTE TREATMENT OF CHILDHOOD ASTHMA
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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.
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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.
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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
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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
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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
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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
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Other parameters of outcome after ED treatment
Persistence of symptoms Need for prolonging treatment Absenteeism from school
Quality of life
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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%
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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
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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.
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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.
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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.
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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.
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Factors predicting short-term outcome after ED visit for asthma
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)
Day 15: Use of medication 29 (27.1) 40 (26.5) 46 (30.5) 23 (21.5)
Missed school days or nursery attendance, n = 185mean SD
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)
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Factors predicting short-term outcome after ED visit for asthma
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
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
Day 7: Respiratory symptoms 35 (40.1) 76 (44.4) 79 (42.9) 23 (51.1)
Day 7: Use of medication 52 (59.8) 105 (61.4) 114 (61.9) 32 (71.1)
Day 15: Respiratory symptoms 16 (18.4) 37 (21.6) 37 (20.1) 8 (17.8)
Day 15: Use of medication 22 (25.3) 47 (27.5) 50 (27.2) 11 (24.4)
Missed school days or nursery attendance, n = 185mean SD
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)
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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”
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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.
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“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?
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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
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