Development and Utilization of a Diagnostic Support Tool for Asthma within the Electronic Medical Record.

Asthma in childhood is a common and costly chronic disease. Quality asthma care can lead to better control of asthma thus decreasing use of health services. The gold standard for pediatric asthma diagnosis and management is the National Heart, Lung and Blood Institute (NHLBI) guidelines for Diagnosis and Management of Asthma which center on precisely establishing the severity of asthma, as this precise classification delineates appropriate therapy. However, navigating these guidelines is a challenge for primary care providers that creates a barrier to providing quality care. We aim to improve precision in asthma severity classification in the community healthcare setting through the development of an electronic asthma decision support tool (eADST) incorporating NHLBI guidelines embedded within the electronic health record system. We developed an algorithm for the eADST to guide the health care provider to the appropriate classification and subsequent therapy. We engaged our health system's electronic health record informatics team and together developed and revised the tool. We launched the tool in three academic community clinics and measured precision in asthma classification in the twelve months prior to the availability of the tool and the twelve months following the launch. We found a significant improvement in precision of asthma severity classification following the launch, a necessary first step in improvement of asthma care. The next step will be to evaluate the impact of the tool on asthma outcomes.

Pediatric sleep questionnaire predicts more severe sleep apnea in children with uncontrolled asthma.

OBJECTIVE: While up to 35% of children with asthma have evidence of sleep disordered breathing (SDB), it is unclear if nocturnal symptoms stem from asthma itself or SDB. The Pediatric Sleep Questionnaire (PSQ) is a validated tool for identifying SDB in childhood asthma. We hypothesize children with asthma and abnormal PSQ demonstrate decreased asthma control and are at higher risk of obstructive sleep apnea (OSA). METHODS: We performed a retrospective, chart review of children and young adults referred to our tertiary children's hospital severe asthma clinic. Data collection included age, gender, BMI percentile, spirometry, PSQ, asthma control questionnaires, asthma severity, control, and impairment. These data were evaluated in the context of polysomnography, when available. RESULTS: 205 inner-city children were included; 37.2% female, median age 6.4 y, and mean BMI of 71.3%ile. Rhinitis (p = 0.028), eczema (p = 0.002), and reflux (p = 0.046) were associated with abnormal PSQ; however, overweight/obese status, spirometry, asthma severity, and serologic markers were not. After correcting for comorbidities, abnormal PSQ score was associated with poor asthma control based on validated measures (p < 0.001). In patients with polysomnography, we confirmed abnormal PSQ was associated with increased OSA severity (apnea-hypopnea index 9.1/hr vs. 3.6/hr; p = 0.027). CONCLUSIONS: In pediatric asthma, positive PSQ was associated with significantly decreased asthma control. Additionally, children with normal PSQ demonstrated mild OSA, while children with abnormal PSQ had increased severity of OSA. This demonstrates that PSQ can be used to screen children for more severe sleep apnea.

Peak Cough Flow in Children with Neuromuscular Disorders.

PURPOSE: Patients with neuromuscular disease (NMD) experience weakened cough due to progressive respiratory muscle weakness. Peak cough flow (PCF) measurements derived from adult populations are used to recommend initiation of assisted cough therapies. The objective of this study was to characterize PCF values among pediatric patients with NMD. METHODS: Retrospective chart review was performed for patients seen in the multidisciplinary pediatric muscular dystrophy clinic from 2010 to 2016. Clinical and demographic variables included age, gender, ambulation status, and PCF measurements. RESULTS: 366 patients with an established diagnosis of NMD (median age 11.8 years) were included in this study. 102 (27.8%) out of the 366 patients were affected by Duchenne muscular dystrophy (DMD), 42 (11.5%) by congenital muscular dystrophy (CMD), 42 (11.5%) by Charcot Marie Tooth disease (CMT) and 24 (6.5%) by Becker's muscular dystrophy (BMD). The mean PCF values in DMD (255.8 L/min) and CMD (249.1 L/min) were lower than CMT (321.5 L/min) with p-values of 0.007 and 0.02, respectively. The mean PCF of BMD (333.3 L/min) was higher than that of DMD and CMD but the difference was not statistically significant. PCFs were not statistically different between ambulatory and non-ambulatory status (263.0 L/min versus 290.8 L/min, p = 0.12). Children under 10 years of age had lower PCF relative to older subjects (179.5 L/min versus 300.9 L/min, p < 0.0001). CONCLUSION: Baseline PCF values in young children are below the adult-specific values suggested for starting assisted cough techniques. Further longitudinal trials are required to derive pediatric-specific reference values for PCF in patients with NMD.

Antibiotic Use by Pediatric Residents: Identifying Opportunities and Strategies for Antimicrobial Stewardship.

OBJECTIVES: To determine the antibiotic prescribing practices of pediatric residents and assess how they acquire knowledge leading to prescribing behaviors. METHODS: We performed a cross-sectional electronic survey of all pediatric residents at the Children's National Medical Center and Nicklaus Children's Hospital, assessing antibiotic prescribing patterns for common pediatric infections, use of antibiograms, and factors influencing antibiotic choice. RESULTS: Eighty-five surveys (45%) were returned complete and included in the analysis. Increased deviations from clinical guideline recommendations were observed for antibiotic treatments of sinusitis and community-acquired pneumonia as compared with otitis media and group A streptococcal pharyngitis. Only 57% of residents reported having used antibiograms. General pediatric inpatient attending physicians were identified as the most influential source for house staff antibiotic knowledge. CONCLUSIONS: Results illustrate the need for better promotion and integration of clinical guidelines with antibiograms when developing antibiotic education programs for residents in training. In addition, pediatric hospitalists should play an active role in the implementation of these programs and can provide valuable insight into the development of educational programs in conjunction with graduate medical education divisions.

Sino-Nasal 5 Questionnaire is Associated with Poor Asthma Control in Children with Asthma.

Up to 80% of asthmatic children may experience upper airway symptoms which are often perceived as coming from the lower airways. Currently, there are no validated questionnaires to assess upper airway contribution to pediatric asthma symptoms. The Sino-Nasal 5 (SN-5) questionnaire was previously validated for identifying radiographic confirmed sinus disease in children. In this study, we hypothesize that significant SN-5 scores (≥3.5) are associated with abnormal National Asthma Education and Prevention Program (NAEPP) based asthma impairment and control in asthmatic children. Retrospective data collected on children with asthma referred for pulmonary evaluation included age, gender, ethnicity, NAEPP asthma severity, asthma control (Test for Respiratory and Asthma Control in Kids (TRACK) < 5 years, Asthma Control Test (ACT) 5 years) and pulmonary function testing. Associations between SN-5 scores and asthma impairment and control were identified. Seventy-six children were evaluated; 38% were female with a mean age of 6.9 years. Significant SN-5 scores were associated with decreased control of daytime symptoms (odds ratio (OR): 0.16 (95% confidence interval (CI): 0.06-0.44)), night time awakenings (0.09 (0.03-0.29)), activity interference (0.2 (0.06-0.68)), NAEPP defined asthma control (0.32 (0.12-0.85)) and poor asthma control based on TRACK (p < 0.001) and ACT (p < 0.001). This suggests upper airways may play a larger role in perceived lower airway symptoms, and SN-5 may be beneficial in assessing the contribution of upper airway conditions on asthma control.