Differences in asthma prevalence between samples of American Indian and Alaska Native children.

OBJECTIVES: To better understand the prevalence of asthma among American Indian and Alaska Native (AI/AN) children and to explore the contribution of locale to asthma symptoms and diagnostic assignment, the authors surveyed AI/AN middle school students, comparing responses from metropolitan Tacoma, Washington (metro WA) and a non-metropolitan area of Alaska (non-metro AK). METHODS: Students in grades 6-9 completed an asthma screening survey. The authors compared self-reported rates of asthma symptoms, asthma diagnoses, and health care utilization for 147 children ages 11-16 self-reporting as AI/AN in metro WA and 365 in non-metro AK. RESULTS: The prevalences of self-reported asthma symptoms were similar for the metro WA and non-metro AK populations, but a significantly higher percentage of metro WA than of non-metro AK respondents reported having received a physician diagnosis of asthma (OR 2.33; 95% CI 1.23, 4.39). The percentages of respondents who reported having visited a medical provider for asthma-like symptoms in the previous year did not differ. CONCLUSIONS: The difference in rates of asthma diagnosis despite similar rates of asthma symptoms and respiratory-related medical visits may reflect differences in respiratory disease patterns, diagnostic labeling practices, or environmental factors. Future attempts to describe asthma prevalence should consider the potential contribution of non-biologic factors such as diagnostic practices.

The impact of asthma and asthma-like illness in Seattle school children.

The impact of asthma and asthma-like illness was measured in a population of 5-9-year-old Seattle public school children. Child health information was obtained from a survey of 1665 parents of first and second grade students to assess medical services use and impaired physical functioning among diagnosed asthmatics and those with current wheezing, defined as wheezing in the past 12 months without a diagnosis of asthma, relative to an asymptomatic population with neither condition. Relative to the asymptomatic population, the prevalence of respiratory-related activity limitation, and perception of poorer child health was larger among diagnosed asthmatics than children with current wheezing. However, the prevalence of sleep disturbances, school absences, medical services use, and parental concern over their child's health was similar for both the asthmatic and wheezing groups relative to the asymptomatic group. Also, in both symptomatic groups, a history of moderate or severe wheezing was associated with an increased prevalence of respiratory-related sleep disturbances and activity limitation. The similarity between the impact of diagnosed asthma and undiagnosed asthma-like illness suggests that the overall social and economic burden of asthma may be higher than previously estimated.

The Asthma Outreach Project: a promising approach to comprehensive asthma management.

We describe a pilot system of coordinated asthma care emphasizing home visits by a community-based lay worker collaborating with a pediatrician, pharmacist, and public health nurse. Study participants included 23 low-income children with moderate to severe asthma and their families at an inner-city pediatric clinic. This system was successfully implemented, and client satisfaction was extremely high. Utilization review showed a reduction in hospitalizations, emergency department visits, and unscheduled clinic visits, and an increase in follow-up clinic visits. This model of care may reduce unscheduled service use and deserves further study as an alternative for asthma management among similar patient populations.

Passive smoke exposure impairs recovery after hospitalization for acute asthma.

OBJECTIVE: To determine if children with chronic asthma hospitalized for an acute exacerbation experienced prolonged clinical recovery after hospital discharge if they returned to a home environment in which they were exposed to environmental tobacco smoke. DESIGN: A prospective longitudinal study. SETTING: Children's Hospital and Medical Center, Seattle, Wash. PATIENTS: Patients admitted to the emergency department of the Children's Hospital and Medical Center with the single diagnosis of asthma (International Classification of Diseases, Ninth Revision [ICD-9] code 493). RESULTS: Twenty-two children with acute asthma were sequentially enrolled in the study and longitudinally observed between February and -June 1994. The tobacco-smoking group (n = 11) was defined as having at least 1 smoker in the home. The nonsmoking group (n = 11) had no environmental tobacco smoke exposure at home. The 2 groups were similar in age, sex, preadmission chronic asthma severity, and immediate predischarge asthma status. Discharge medication use was similar in the 2 groups During a 1 month follow-up period, the tobacco-smoking group had a significantly greater number of symptomatic days than the nonsmoking group (P < .05) Of the children in the nonsmoking group, 9 (82%) had less than 1 symptomatic day per week compared with 3 (27%) in the tobacco-smoking group. beta 2-Agonist bronchodilator use declined significantly (P < .001) during follow-up in the nonsmoking group but not in the tobacco-smoking group, despite similar anti-inflammatory drug therapy in both groups. CONCLUSIONS: Recovery by children after hospitalization for acute asthma is impaired by environmental tobacco smoke exposure when the period of recovery is characterized by persistent respiratory symptoms and use of asthma medication for symptomatic relief. These findings underscore the need to limit environmental tobacco smoke exposure in children with asthma and argue for closer physician follow-up of those children returning to a home environment in which smokers are present.

Indoor risk factors for asthma and wheezing among Seattle school children.

Indoor risk factors for physician-diagnosed asthma and wheezing in the past 12 months without previous asthma diagnosis were assessed in a survey of parents of 5-9-year-old Seattle primary school students. Among the 925 respondents, 106 (11%) reported a physician diagnosis of asthma, 66 (7%) had wheezing without diagnosis, and 753 (82%) were asymptomatic. After adjusting for age, sex, gender, ethnicity, medical history, socioeconomic status (SES) and parental asthma status, an increased risk of physician diagnosis of asthma was associated with household water damage, the presence of one or more household tobacco smokers, and at least occasional environmental tobacco smoke (ETS) exposure. Similarly, an increased risk of wheezing in the past 12 months among children without diagnosed asthma was associated with household water damage, presence of one or more household tobacco smokers, and occasional or more frequent ETS exposure. No increased risk of either condition was associated with gas, wood, or kerosene stove use, household mold, basement water, or wall/window dampness. Similarities in the indoor risk factors patterns between diagnosed asthma and wheezing without diagnosis suggested a similar etiology of these two conditions. The slightly higher association between ETS and asthma may indicate that parents of diagnosed asthmatics were more conscious of ETS, and were more likely to prohibit household smoking by resident smokers. Future research is needed to quantify which aspects of household water damage are related to respiratory illness.

The lottery of life: should organ transplants be used to even the odds?

Life is not always fair and the advantages of health and well-being are not equally distributed. Unfortunately, children can be the innocent victim of their families' misfortune. In the realm of health care, should a child be denied a specific medical treatment because his or her parents are not capable of providing the care necessary to promote a successful outcome of that treatment? How should we as health care professionals make those difficult choices? The following case and the ethical analysis describes a scenario where there was disagreement if a child's family situation should be considered in the decision to list the child for a liver transplant.

Factors associated with prolonged hospitalization of children with asthma.

OBJECTIVE: To identify clinical features of asthma present before arrival in the emergency department, at the time of emergency department treatment, and during hospitalization that differ between children with asthma hospitalized for a prolonged period and those hospitalized for an average duration. DESIGN: Retrospective chart review. PATIENTS AND SETTING: Hospital records of patients with asthma (International Classification of Diseases, Ninth Revision, code 493) admitted to Children's Hospital and Medical Center, Seattle, Wash, from October 1989 to September 1991. RESULTS: The medical records of 23 children hospitalized from October 1989 to September 1991 for more than 4 days with acute asthma were compared with those of 62 sex- and age-matched children hospitalized for 2 days. Patients in the long-stay and short-stay groups had similar histories of home medication use. The presence of asthma symptoms before arrival in the emergency department was prolonged in the long-stay group (P < .001). Only one of the 23 patients in the long-stay group had augmented asthma treatment within 24 hours before hospitalization, compared with 39 of the 62 patients with short stays (P < .001). During hospitalization, a greater proportion of children in the long-stay group than the short-stay group received supplemental oxygen (P < .01). More children in the long-stay group than the short-stay group had residual hypoxemia (arterial oxygen saturation, < 94%) in room air at discharge, suggesting that hospital stay was not prolonged to reach normal oxygen saturations. None of the children were readmitted within 1 month of their index admission. CONCLUSIONS: Early augmentation of home therapy for acute asthma is associated with a reduced duration of hospitalization for children admitted with asthma. In addition, hypoxemia in children with acute asthma on presentation and during hospitalization is associated with prolonged hospital stay.

Pain medication for the patient following treatment withdrawal.

What is nursing's responsibility for pain control following the decision to withdraw life support? Should nurses be free to administer whatever amount of sedation they feel is necessary to provide adequate pain control for their patient? What should the nurse do if the physician prescribes a subtherapeutic dose of pain medication? The following article presents a case and analyses the nurse's moral duty to do no harm in this type of situation.