Predictors of hospitalization in children with acute asthma.

OBJECTIVE: To identify predictors of long duration of bronchodilator therapy in children with acute asthma. STUDY DESIGN: An emergency department prospective cohort study of 278 children > or =12 months of age, with clinical and socioeconomic parameters collected at baseline and 4 hours after administration of corticosteroids. Patients were classified into short and long therapy groups, with interval from first albuterol dose to initiation of administration every 4 hours < or =12 or >12 hours, respectively. Predictors significant by univariate analysis were examined by multiple logistic regression. RESULTS: Five variables were associated with long therapy (n = 85) versus short therapy (n = 193): previous intensive care unit admission (odds ratio [OR] 7.2, 95% CI = 1.85, 27.7); baseline oxygen saturation < or =92% (OR 2.6, 95% CI = 0.89, 7.4), asthma score > or =6/9 (OR 2.9, 95% CI = 1.9, 4.37), oxygen saturation < or =92% (OR 6.6, 95% CI = 1.34, 32.0), and hourly albuterol dosing interval (OR 4.3, 95% CI = 0.82, 22.12) 4 hours after administration of corticosteroids. Probability of long therapy was 91.8% to 99% for > or =3 predictors, but only 40.6% to 61.8% for individual factors. CONCLUSION: A combination of 3 or more factors predicts long bronchodilator therapy and signals the need for hospitalization. Children with only one predictor can be safely treated in the emergency department or observation unit and reevaluated.

A comparison of inhaled fluticasone and oral prednisone for children with severe acute asthma.

BACKGROUND: Inhaled corticosteroids are effective in the treatment of children with asthma. It is uncertain how inhaled corticosteroids compare with oral corticosteroids in the management of severe acute disease. METHODS: We performed a double-blind, randomized trial involving 100 children five years of age or older who had severe acute asthma (indicated by a forced expiratory volume in one second [FEV1] that was less than 60 percent of the predicted value) and in whom the results could be evaluated. All were treated with an aggressive bronchodilator regimen and received one dose of either 2 mg of inhaled fluticasone through a metered-dose inhaler with a spacer or 2 mg of oral prednisone per kilogram of body weight. They were assessed hourly for up to four hours. RESULTS: The mean (+/-SD) base-line FEV1 as a percentage of the predicted value was 46.3+/-12.5 in the fluticasone group (51 subjects) and 43.9+/-9.9 in the prednisone group (49 subjects). The FEV1 increased by a mean of 9.4+/-12.5 percentage points in the fluticasone group and by 18.9+/-9.8 percentage points in the prednisone group four hours after therapy (P< 0.001). None of the children in the prednisone group had a reduction in FEV1 as a percentage of the predicted value from base line to four hours, as compared with 25 percent of those in the fluticasone group (P<0.001). Sixteen (31 percent) of the children treated with fluticasone were hospitalized, as compared with five (10 percent) of those treated with prednisone (P=0.01). CONCLUSIONS: Children with severe acute asthma should be treated with oral prednisone and not with inhaled fluticasone or a similar inhaled corticosteroid.