1. Javier Benito-Fernández, MD Director of Paediatric Emergency Department Hospital de Cruces- Bilbao (Spain) SHORT-TERM CLINICAL OUTCOMES OF ACUTE TREATMENT OF CHILDHOOD ASTHMA

2. 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.

3. 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.

4. 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

5. Number of asthma episodes / year Hospital de Cruces 1996 - 2006

6. Hospitalization rates for asthma Hospital de Cruces

7. Hospitalization rates along 2003, 2006 and 2007 Hospital de Cruces > 2 years 0 - 2 years

8. Other parameters of outcome after ED treatment Persistence of symptoms Need for prolonging treatment Absenteeism from school Quality of life

9. Short-term outcome

11. Maesurement of health-related quality of life How often in the past two weeks has/have: AYour child complained of being short of breath? BExertion (as a running) made your child breathless? CYour child coughed at night? DYour child been woken up by wheezing or coughing? EYour child stayed indoors because of wheezing or coughing? FYour child’s education suffered due to his/her asthma during school? GYour child’s asthma interfered with his/her life? HYour child’s asthma limited your activities? IYou had to make adjustments to family life because of your child’s asthma? JTaking 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.

12. 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.

13. 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 care Gorelick 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-up Smith 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.

14. Factors predicting short-term outcome after ED visit for asthma Follow-up Age, months, mean  SD Specialist for asthma follow-up n (%) YesNoYesNo Total 48.4  39.72 54204 Day 7: Respiratory symptoms 42.36  37.1052.92  41.14 19 (35.2)92 (45.1) Day 7: Use of medication 44.7  38.4455.12  40.94 31 (57.4)126 (61.8) Day 15: Respiratory symptoms 44.39  41.1149.45  39.40 7 (13)21 (10.3) Day 15: Use of medication 48.0  41.1348.54  39.32 13 (24.1)56 (27.4) Missed school days or nursery attendance, n = 185 mean  SD 2.69  2.573.03  3.61  3 missed days, n = 7948.33  37.1961.48  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.

15. 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 (%) YesNoYesNo Total107151 107 Day 7: Respiratory symptoms38 (35.5)73 (48.3)65 (43)46 (43) Day 7: Use of medication64 (59.8)93 (61.6)98 (64.9)59 (55.1) Day 15: Respiratory symptoms24 (22.4)29 (19.2) 24 (22.4) Day 15: Use of medication29 (27.1)40 (26.5)46 (30.5)23 (21.5) Missed school days or nursery attendance, n = 185 mean  SD 2.83  3.133.05  3.263.2  3.462.9  3.34  3 missed days, n = 79 36 (50)43 (38)53 (46.5)26 (36.5)

16. 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 (%) * YesNoYesNo Total8717118415 Day 7: Respiratory symptoms35 (40.1)76 (44.4)79 (42.9)23 (51.1) Day 7: Use of medication52 (59.8)105 (61.4)114 (61.9)32 (71.1) Day 15: Respiratory symptoms16 (18.4)37 (21.6)37 (20.1)8 (17.8) Day 15: Use of medication22 (25.3)47 (27.5)50 (27.2)11 (24.4) Missed school days or nursery attendance, n = 185 mean  SD 3.44  2.284.48  3.792.90  3.304.02  4.37  3 missed days, n = 79 21 (33)58 (47.5)54 (40)21 (67.7)

17. 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”

18. Risk factors for poor outcome n = 779 Univariate anlysisMultivariate analysis Relative risk (95% CI) p valueAdjusted 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)0.0011.8 (1.1-2.8)0.01 Severe persitent asthma 2.2 (1.0-4.5)0.042.8 (1.1-7.2)0.03 Use of albuterol regularly 2.6 (1.6-4.5)<0.0012.8 (1.3-5.9)0.007 Already taking systemic corticosteroids at ED arrival 1.3 (0.95-1.7)0.121.4 (0.7-2.6)0.34 Admitted from ED 1.3 (1.0-1.6)0.111.1 (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.

19. “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?

20. 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