الفهرس 
BRONCHIAL ASTHMA IN PEDIATRICSOnly 14 pages are availabe for public view
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Abstract
Asthma is considered the commonest non communicable disease in children and it is one of the major causes of morbidity and mortality worldwide. Asthma prevalence is increasing globally with a rising prevalence reported annually (Asher et al., 2014).
Asthma is defined by GINA as a heterogeneous disease characterized by chronic airway inflammation. It is characterized by history of respiratory symptoms such as wheezes, shortness of breath, chest tightness and cough that vary over time and intensity, together with variable expiratory airflow limitation (GINA, 2020).
Asthma education is the cornerstone for asthma management and has been recommended by national and international guidelines. It has been cited as an essential component of any asthma management strategy by improving asthma knowledge and changing behavior (Coelho et al., 2018)
Children rely heavily on their parents for asthma management. Therefore, asthma education needs to target the entire family. There is a need for ongoing asthma education, increased sensitivity to complex home management, and family-centered interventions by caregivers of asthmatic children that enhance communication and collaboration between caregivers and providers (Bellin et al., 2016).
There are several risk factors for emergency department visits in asthmatic children, i.e. young age, duration of symptoms, high consumption of asthma medication, previous asthma hospitalizations, low parental confidence on efficacy of asthma medication, lack of use of a strict treatment plan for asthma, allergen exposures, However, there are few reports available in literature regarding the relationship of lack of asthma education with childhood asthma (Lafata and Divine, 2002).
So, this study was conducted to evaluate the effects of an educational asthma program on the frequency of emergency department visits and identifying factors associated with frequent emergency department visits by asthmatic children and determine its effect on asthma severity and quality of life among asthmatic children and their caregivers.
This one arm interventional clinical trial study has been conducted at pediatric chest clinics and emergency department of children’s hospital of Ain Shams University located in Cairo during the period from the first of January 2019 to the end of March 2020.
The study was conducted on 30 asthmatic pediatric patients aged from 1-15 years old with documented asthma diagnosis (intermittent wheezes, breathlessness, dry cough, etc) (Brigham and West, 2015).
All patients included in this study were subjected to:
I-Full medical history and physical examination with special stress on:
a. Symptoms and signs of bronchial asthma as (intermittent chest tightness, dry cough, dyspnea and wheezes), asthma triggers, asthma comorbidities and risk factors of emergency room visit and severe exacerbations as (History of previous severe exacerbation, viral URTI, misperception about severity of asthma & lack of asthma education, poor adherence with ICS, improper use of inhalers and allergen exposure).
b. Physical examination including: complete anthropometric measurements and full chest examination.
II - Investigations which included:
a. Laboratory investigations:
Complete blood count which included: the levels of (Hemoglobin (Hb), Hematocrit (Hct), Mean Corpuscular Volume (MCV), Mean Corpuscular Hemoglobin (MCH) & Red Cell Diameter Width (RDW), Platelets, Reticulocyte count).
Laboratory methods for the rest of biomedical investigations as (CRP, ESR and serum IgE level also were recorded).
b. Radiological investigations:
Plain Chest X-ray P-A view was done in asthma exacerbations to exclude complications of bronchial asthma.
III- Educational asthma program introduced to asthmatic children and their caregivers.
IV- Interventions done pre and post asthma education program:
a- Calculation of frequency of asthma exacerbations visits in last 6 months before the beginning of the study and 6 months post asthma education
b- Calculation of frequency of chest clinic visits, ER visits, hospital admissions and PICU admissions in last 6 months before the beginning of the study and 6 months post asthma education.
c- Asthma Knowledge Questionnaire.
d- Childhood asthma control test.
e- Morisky medication adherence scale to assess asthma medication adherence.
f- Pediatric asthma caregiver quality of life questionnaire.
g- Pediatric asthma quality of life questionnaire for asthmatic children.
h- Spirometric pulmonary functioning testing.
i- Asthma severity scores: which included
Pediatric clinical asthma severity score during exacerbation.
Pediatric respiratory severity score.
Pediatric asthma symptoms scale.
Pediatric respiratory assessment measure.
As regarding the results:
The current study showed that, the prevalence of bronchial asthma was higher in children less than 5 years old compared to different age groups. It was reported that the number of children with active symptoms of bronchial asthma was (53.3%) in those aged 1- 5 years and (36.7%) in those aged 6 to 11 years and (10.0%) in those aged 12 to 15 years.
Additionally, this study showed, there was no statistically significant difference between males and females as regarding the sex distribution (p>0.05) However, males (63.3%) were more prevalent than females (36.7 %).
Our study showed that there had been a positive family history of bronchial asthma in (83.3%) of asthmatic children. While (16.7%) of children have no family history.
Our study showed that, the main presenting symptoms of asthma were dyspnea, observed in 83.3% of patients, respiratory distress in 80%, dry cough in 53.3% and productive cough in 30% of patients. While the most common signs elicited were wheezes (80%), hyper inflated chest (40%), diminished air entry (20%) crepitations (10%), and cyanosis (3.3%).
In the present study, allergic conditions associated with asthma were observed in the studied patients such as allergic rhinitis (46.7%), eczema (26.7%), food allergy (20%), obesity. (13.3%), GERD (10%), allergic conjunctivitis (6.7%) and drug allergy (3.3%).
The current study showed, the most common triggering factors for asthma among studied patients were: exposure to strong odors or fumes (96.7%), exposure to viral upper respiratory tract infections (80%), exposure to cigarette smoke (66.7%), exposure to air pollution (53.3%), environmental changes in weather and spring (43.3%), cold or dry air (40%), allergen exposure (36.7%), animal exposure (33.3%), exercise (33.3%).
As regard the risk factors for ER admission and severe exacerbations, a history of night cough or dyspnea that relieved by SABA was shown to be present in 63.3% of asthmatic children. Also being a male was found to be a risk factor in 63.3%. Other important risk factors that was shown to be a cause of severe exacerbations and recurrent ER admissions were, viral upper respiratory tract infections (56.7%), misperception about severity of asthma & lack of asthma education (56.7%), improper use of inhalers (53.3%), positive asthma predictive index (46.7%), poor adherence with inhaled corticosteroids (43.3%), history of previous severe exacerbation (40%), seasonal changes in spring and weather (40%), parental smoking (40%), cost of medications (40%), allergen exposure (36.7), previous use of oral steroids for asthma (26.7%), outdoor air pollution (23.3%), low birth weight (20%) and obesity (13.3%).
In the current study, according to asthma grading guidelines and the level of asthma severity, it was found that (10%) of the patients were diagnosed as having intermittent asthma and (16.7%) were diagnosed as mild persistent asthma and (37.7%) were with moderate persistent asthma, whereas (37.7%) had severe persistent asthma.
In our study, a slight majority of patients (60%) acknowledged not receiving any asthma education or action plan.
Our study showed a statistically highly significant decrease in asthma exacerbations, where the asthmatic attacks were less frequent and less severe post asthma education. (P value= 0.000)
According to our study, there was a statistically significant decrease post asthma education in total number of ER visits, recurrence of ER visits, chest clinic visits and hospital admissions. (P value = 0.000)
According to our study, there was a statistically significant improvement post asthma education as regard asthma knowledge questionnaire score, childhood asthma control test, morisky medication adherence scale, pediatric clinical asthma severity score during exacerbation, pediatric respiratory severity score, pediatric asthma symptoms scale, pediatric respiratory assessment measure, pediatric asthma caregiver quality of life questionnaire and pediatric asthma quality of life questionnaire for asthmatic children.
Our study shows a statistically significant difference pre and post asthma education according to the forced spirometry test parameters, where, higher values of FEV1 of predicted, FEV1/FVC, MMEF 25-75% of predicted were observed post asthma education than pre asthma education, which denoted a more improvement in pulmonary functions after asthma education.
Conclusion
- In conclusion, our study demonstrated that asthmatic patients who received education about asthma had less frequent ER visits, less hospital admissions, less severe asthmatic exacerbations, better asthma control and medication adherence. Also, they had higher lung function with less obstructive pattern, and less asthma severity. In addition, asthma education improved quality of life in both asthmatic children and their caregivers. Moreover, asthma education improved the knowledge of parents about asthma, medications, and proper use of inhalers.
- So, we conclude that asthma education may be considered as a preventive factor in development of asthmatic exacerbations in children and have a positive impact on decreasing emergency room visits. Also, asthma education may have a positive effect on lung functions in asthmatic children that may lead to less severe airway disease.
RECOMMENDATIONS
- Larger multicenter studies with well-designed programs and longer follow-up of asthmatic patients are needed to evaluate the cost-effectiveness of educational programs with a different structure in various population settings.
- Increase health information about bronchial asthma and its treatment and control.
- Efforts should be invested towards educating parents and caregivers of children with asthma to recognize and avoid triggers, and to understand the use of prescribed medications, the proper use of inhalation devices, and the importance of compliance and monitoring.
- Preventing severe asthma exacerbations requires identifying and focusing on high-risk patients and patients who visit the ER frequently to develop personalized care protocols that may prevent such exacerbations.
- Continued attempts to define risk factors important in the etiology of bronchial asthma, severity of exacerbations as well as their management.
- Asthma education programs should be applied for all pediatric patients with asthma and their caregivers.