Asthma Education Reduces Hospitalization and Emergency Room Risk

 

Asthma is a complex respiratory disorder that significantly raises risk for ER visits and hospitalizations.  Despite it's complexity, there is a consistent knowledge gap that can put patients and parents at a significant disadvantage.  Following a consistent strategy grounded in evidenced based practice can make a difference in reducing chaos and preventing frequent sick visits.  This study demonstrated that a focused asthma education program consistently reduced these risks.

Background It remains unknown whether child-oriented asthma education is associated with better health outcomes. This meta-analysis investigated the effects of asthma education on hospitalisation and emergency department and clinic visits.

Methods We searched the Cochrane Library, PubMed and EMBASE for relevant studies from inception to 4 July 2021, and selected studies that reported hospitalisation or emergency department or clinic visits as outcomes. The participants were only children. Two authors independently selected the studies, assessed the quality of the included studies and retrieved the data. A third senior author was engaged to resolve disagreements. Fifteen longitudinal studies were included for the systematic review and meta-analysis. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 was used as the standard of reporting (PRISMA registration ID is 284509).

Findings Compared with the control group, the asthma education group had 54% lower hospitalisation risk (95% CI 0.32 to 0.66), and 31% lower emergency department visit risk (95% CI 0.59 to 0.81). Sensitivity analysis showed that the asthma education group had a reduced clinic visit risk (risk ratio (RR)=0.80, 95% CI 0.67 to 0.97). Subgroup analysis showed that asthma education involving both children and parents/guardians was associated with fewer hospitalisations (RR=0.38, 95% CI 0.24 to 0.59) and emergency department visits (RR=0.69, 95% CI 0.57 to 0.83). Asthma education in hospitals or non-hospitals can reduce the risk of hospitalisation and emergency department visits. However, only education in the hospitals was associated with the reduction of clinical visits (RR=0.45, 95% CI 0.22 to 0.92).

Interpretation Education is effective for controlling asthma, especially for reducing hospitalisation and emergency department and clinic visits. Education involving both children and parents/guardians is more effective than that involving only children. The setting of asthma education does not impact its effect to a large extent.

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Hypoxemia and Risk for Bronchopulmonary Dysplasia In Preterm Infants

Bronchopulmonary dysplasia (BPD) is a chronic lung disease in infants associated with extreme prematurity.  Understanding contributing factors is important since there is a strong link between this condition and neurodevelopmental impairment and other childhood disease.  This study demonstrated a strong association between frequency and severity of oxygen desaturations in the development of severe BPD.  Importantly, oxygen desaturations of 1 minute or longer were significantly correlated.  

Abstract

Rationale: Bronchopulmonary dysplasia increases the risk of disability in extremely preterm infants. Although the pathophysiology remains uncertain, prior exposure to intermittent hypoxemia may play a role in this relationship. Objectives: To determine the association between prolonged episodes of intermittent hypoxemia and severe bronchopulmonary dysplasia. Methods: A post hoc analysis of extremely preterm infants in the Canadian Oxygen Trial who survived to 36 weeks' postmenstrual age was performed. Oxygen saturations <80% for ⩾1 minute and the proportion of time per day with hypoxemia were quantified using continuous pulse oximetry data that had been sampled every 10 seconds from within 24 hours of birth until 36 weeks' postmenstrual age. The study outcome was severe bronchopulmonary dysplasia as defined in the 2001 NIH Workshop Summary. Measurements and Main Results: Of 1,018 infants, 332 (32.6%) developed severe bronchopulmonary dysplasia. The median number of hypoxemic episodes ranged from 0.8/day (interquartile range, 0.2-1.1) to 60.2/day (interquartile range, 51.4-70.3) among the least and most affected 10% of infants. Compared with the lowest decile of exposure to hypoxemic episodes, the adjusted relative risk of severe bronchopulmonary dysplasia increased progressively from 1.72 (95% confidence interval, 1.55-1.90) at the 2nd decile to 20.40 (95% confidence interval, 12.88-32.32) at the 10th decile. Similar risk gradients were observed for time in hypoxemia. Significant differences in the rates of hypoxemia between infants with and without severe bronchopulmonary dysplasia emerged within the first week after birth. Conclusions: Prolonged intermittent hypoxemia beginning in the first week after birth was associated with an increased risk of developing severe bronchopulmonary dysplasia among extremely preterm infants. Clinical trial registered with www.isrctn.com (ISRCTN62491227) and www.clinicaltrials.gov 

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Setting Discharge Goals for High Risk Infants

 A useful and much study needed since neonatologists and consulting pediatric pulmonologists rely on few reliable indicators to judge discharge readiness.  And with little guidance, often managed care restrictions may prompt premature discharge.  A baseline CO2 retention above a certain threshold always seemed like at least 1 useful measure, now supported by this South Korean study.

Children with chronic lung disease of prematurity tend to have reduced lung function, increased susceptibility to respiratory viral illness, and elevated risk for rehospitalization.  Setting goals for discharge are greatly needed in this high risk population.

Capillary partial pressure of carbon dioxide for predicting rehospitalization in preterm infants under noninvasive respiratory support with severe bronchopulmonary dysplasia

Abstract

Background

The severity of bronchopulmonary dysplasia (BPD) is an important predictor of prognosis in preterm infants. However, the severity of BPD was determined mainly by the degree of oxygen supplementation and mode of respiratory support.

Objectives

This retrospective study aimed to examine the role of partial pressure of carbon dioxide (pCO2) in predicting rehospitalization among preterm infants with severe BPD without invasive ventilation at 36 weeks' postmenstrual age (PMA).

Methods

We assessed preterm infants aged <32 gestational weeks with severe BPD who were receiving noninvasive respiratory support at 36 weeks' PMA. Patients were compared after stratifying them according to the history of rehospitalization owing to respiratory infection before a corrected age (CA) of 1 year and pCO2 measured by capillary blood gas analysis at 36 weeks' PMA.

Results

Among 54 infants who had severe BPD with noninvasive respiratory support at 36 weeks' PMA, 16 (29.6%) experienced rehospitalization due to respiratory problems. At 36 weeks' PMA, the amount of oxygen supplementation (0.30 vs. 0.28, p = 0.021) and pCO2 (62.1 vs. 53.6 mmHg, p = 0.006) were higher in the rehospitalization group than in the no rehospitalization group. Multivariate logistic analysis findings indicated that pCO2 ≥ 57.4 mmHg was the only factor associated with rehospitalization (adjusted odds ratio: 8.017, 95% confidence interval 1.239–51.859).

Conclusion

High pCO2 during noninvasive respiratory support at 36 weeks' PMA in severe BPD was associated with rehospitalization. Consideration of the degree of impairment in ventilatory capacity may improve the prediction of later respiratory outcomes in infants with BPD.

Pediatric Pulmonology

Volume56, Issue12

December 2021

Pages 3863-3869

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New Severe Asthma Guidelines Recommend FeNO Monitoring

If your patients end up on high dose asthma therapy or have frequent exacerbations, reassessment is needed.  Exhaled nitric oxide testing provides a method for non-invasive point of care assessment for asthma and asthma control and can help direct therapy for severe asthma.  The latest iteration of GINA guidelines acknowledges this. Dr. Susarla

In a significant advancement in the treatment of severe asthma, the latest diagnosis and management guide from the Global Initiative for Asthma (GINA) makes new recommendations for assessment tools.

The new guide now recommends fractional exhaled nitric oxide (FeNO) monitoring as an assessment tool to determine whether patients who are on high-dose inhaled corticosteroids or low-dose oral corticosteroids have residual inflammation.

In a statement accompanying the new guidelines, Dr. Helen Reddel, Chair of the GINA Science Committee and a research leader at the Woolcock Institute of Medical Research in Sydney, Australia, explained that difficult-to-treat and severe asthma are currently high priority due to their “physical, emotional and financial burden for patients and their families.”

 “Clinicians in both low and high income countries need practical advice about how to assess and treat patients for whom conventional asthma therapies don’t seem to be working, and about how treatment strategies, including biologic therapies if available, can be implemented into patient care,” Reddel said.

Utilizing FeNO measurements can provide a potential predictor of positive responses to anti-immunoglobulin E (anti-IgE) therapy for patients with severe, allergic asthma, and is a tool to identify refractory type 2 inflammation in patients on high-dose inhaled corticosteroids therapy.

“The new GINA guidelines build on an earlier US Agency for Healthcare Research and Quality (AHRQ) report in terms of the strength of FeNO as a practical tool that improves outcomes for asthma patients,” said David Acheson, Senior Vice President of US Commercial at Circassia Pharmaceuticals, Inc., a specialty pharmaceutical company focused on respiratory disease which announced the new recommendations on December 5.

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