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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Helping High Risk Infants and Parents Sleep Better: ATS Guidelines for Outpatient Care of Premature Infants

Premature infants, particularly born before 30 weeks gestation who have been given a diagnosis of chronic lung disease, bronchopulmonary dysplasia, or post-prematurity respiratory disease face significant challenges in transition from the NICU environment to life at home.  The lack of guidelines to help focus care and quality medical literature differentiating outcomes is stark.  Parents and physicians need tools to care for these high risk infants. These new ATS guidelines nicely evaluate the role of inhaled medications, swallowing assessment, airway endoscopy, and especially sleep testing and provide timely recommendations.

Outpatient Respiratory Management of Infants, Children, and Adolescents with Post-Prematurity Respiratory Disease: An Official American Thoracic Society Clinical Practice Guideline

New recommendations are available to help guide physicians who must determine when and how to treat infants, children and adolescents with post-prematurity respiratory disease (PPRD). The American Thoracic Society has published an official clinical practice guideline in which a multidisciplinary panel of experts provide 13 conditional recommendations on the diagnostic testing and clinical management of these young people. The complete guideline detailing these recommendations was posted online ahead of print in the American Journal of Respiratory and Critical Care Medicine.

Worldwide, approximately 12 million infants—10 percent of live births—are born prematurely and are at risk for respiratory disease, the most common of which is bronchopulmonary dysplasia (BPD). However, all premature infants, even those who do not meet the criteria for having BPD, may develop poor respiratory health later in life with signs and symptoms including cough, recurrent wheezing, exercise intolerance, low blood oxygen (hypoxemia) and reduced pulmonary function. These individuals are classified as having PPRD.

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SARS-CoV-2 associated respiratory illnesses may include pneumonia, asthma exacerbations and acute bronchiolitis among others.  Risk to children in comparison to adults is remarkably low.  However, acute bronchiolitis is the most common cause of hospitalization in infants.  This study assessed frequency of hospitalization due to SARS-CoV-2 and found frequency and severity to be low, estimated at less than 2% of all hospitalized children.

SARS-CoV-2 acute bronchiolitis in hospitalized children: Neither frequent nor more severe

Introduction

Endemic coronaviruses have been found in acute bronchiolitis, mainly as a coinfecting virus. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has been responsible for respiratory illness in hospitalized children. The characteristics of patients with bronchiolitis have not been extensively described.

Methods

Cross-sectional study of patients with bronchiolitis and SARS-CoV-2 infection enrolled in a prospective multicenter cohort of children hospitalized with COVID-19 in Spain from March 1, 2020 to February 28, 2021.

Results

Twelve of 666 children infected with SARS-CoV-2 who required hospital admission met the diagnostic criteria for bronchiolitis (1.8%). Median age was 1.9 months (range: 0.4–10.1). Six cases had household contact with a confirmed or probable COVID-19 case. Main complaints were cough (11 patients), rhinorrhea (10), difficulty breathing (8), and fever (8). Eleven cases were classified as mild or moderate and one as severe. Laboratory tests performed in seven patients did not evidence anemia, lymphopenia, or high C-reactive protein levels. Chest X-rays were performed in six children, and one case showed remarkable findings. Coinfection with metapneumovirus was detected in the patient with the most severe course; Bordetella pertussis was detected in another patient. Seven patients required oxygen therapy. Albuterol was administered in four patients. One patient was admitted to the pediatric intensive care unit. Median length of admission was 4 days (range: 3–14). No patient died or showed any sequelae at discharge. Two patients developed recurrent bronchospasms.

Conclusion

SARS-CoV-2 infection does not seem to be a main trigger of severe bronchiolitis, and children with this condition should be managed according to clinical practice guidelines. 

Pediatric Pulmonology

Volume57, Issue1

January 2022

Pages 57-65

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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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FDA approves dupilumab for children aged 6 to 11 with moderate to severe asthma

Now that another biologic therapy is available for pediatric severe asthma, it is important to look at the indications for add on biologic therapy for asthma.  In general, there are 2 broad categories of asthma that may warrant adding an injectable biologic therapy:

1) Children and adolescents with severe asthma, poorly controlled despite compliance with high dose asthma therapy.  Here, poorly controlled may indicate frequent hospitalization, ER, or urgent care visits.  In addition, systemic steroid use and symptoms that affect quality of life (school, exercise, etc) are important considerations.

2) Children and adolescents with severe asthma that is controlled, but requires high dose asthma controller medication.  This is an important consideration because high dose inhaled glucocorticoids have been associated with a numbers of risks including reduced growth velocity, obesity, adrenal insufficiency, and ocular side effects like cataracts.

The FDA has approved dupilumab as an add-on maintenance treatment for children aged 6 to 11 years with moderate to severe asthma characterized by an eosinophilic phenotype or with oral corticosteroid-dependent asthma.
The expanded approval of dupilumab (Dupixent, Regeneron/Sanofi) to children aged 6 to 11 was based on data from the phase 3, double-blind, placebo-controlled LIBERTY ASTHMA VOYAGE trial that evaluated efficacy and safety of dupilumab compared with standard care in children with uncontrolled moderate to severe asthma. More than 90% of children in the trial had at least one concurrent type 2 inflammatory condition, according to a company press release.
“I was impressed that dupilumab met not only its primary endpoint of reduction in asthma exacerbations, but also all key secondary endpoints in the pediatric ASTHMA VOYAGE trial,” Leonard B. Bacharier, MD, professor of pediatrics at Monroe Carell Jr. Children’s Hospital at Vanderbilt University Medical Center and principal investigator of the ASTHMA LIBERTY VOYAGE trial, told Healio. “I anticipate that clinicians will begin to include dupilumab in their discussions with families of children with uncontrolled moderate-severe asthma. Many children in this age group continue to experience repeated asthma exacerbations, and experience side effects from frequent courses of systemic corticosteroids. Dupilumab’s demonstrated efficacy in significantly reducing exacerbations will allow such children greater disease control.” 

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COVID 19 Risk With Asthma

Good News (Mostly) for Asthma Patients During Pandemic

COVID 19 has not shown the risk to asthma sufferers that many experts anticipated.  The role of biologic use and risk may still be unclear.  However, COVID 19 is a mucosal respiratory virus and can likely trigger a viral asthma exacerbation especially for those that are uncontrolled.  This is why it's important to work with your asthma specialist to optimize control especially in the problem seasons.  These include:
1) Having a written asthma action plan with clear recommendations for flare ups
2) Regular follow up with asthma specialist to monitor asthma control
3) Becoming familiar with symptoms of poor control, including frequent SABA use and exercise intolerance

Two studies presented at the European Respiratory Society (ERS) virtual meeting should reassure asthma patients and their physicians about their risks from COVID-19.

On the one hand, "no evidence of excess deaths was directly attributed to asthma" in a study of Scottish data on hospital admissions and death certificates during the first COVID-19 wave in early 2020, said Steven Smith, MRCP, of Gartnavel General Hospital in Glasgow.

And on the other, analysis of asthma patients receiving biologic drugs in Greek clinics showed no overall increase in COVID infection rates relative to the general population through April of this year, reported Andriana Papaioannou, MD, PhD, of Attikon University Hospital in Athens.

These encouraging results come against a backdrop of worry about how patients with preexisting respiratory disease, who may also be taking immune-modulating drugs, would fare during the pandemic.

There were two concerning blips in the Greek data, however. Papaioannou's group found that, among the 26 biologic-treated patients who did come down with COVID-19, nine needed hospitalization -- a considerably higher proportion than among COVID patients in the general Greek population, she said.

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