Core outcomes and factors influencing the experience of care for children with severe acute exacerbations of asthma: a qualitative study.

OBJECTIVE: To identify the outcomes considered important, and factors influencing the patient experience, for parents and caregivers of children presenting to hospital with a severe acute exacerbation of asthma. This work contributes to the outcome-identification process in developing a core outcome set (COS) for future clinical trials in children with severe acute asthma. DESIGN: A qualitative study involving semistructured interviews with parents and caregivers of children who presented to hospital with a severe acute exacerbation of asthma. SETTING: Hospitals in 12 countries associated with the global Pediatric Emergency Research Networks, including high-income and middle-income countries. Interviews were conducted face-to-face, by teleconference/video-call, or by phone. FINDINGS: Overall, there were 54 interviews with parents and caregivers; 2 interviews also involved the child. Hospital length of stay, intensive care unit or high-dependency unit (HDU) admission, and treatment costs were highlighted as important outcomes influencing the patient and family experience. Other potential clinical trial outcomes included work of breathing, speed of recovery and side effects. In addition, the patient and family experience was impacted by decision-making leading up to seeking hospital care, transit to hospital, waiting times and the use of intravenous treatment. Satisfaction of care was related to communication with clinicians and frequent reassessment. CONCLUSIONS: This study provides insight into the outcomes that parents and caregivers believe to be the most important to be considered in the process of developing a COS for the treatment of acute severe exacerbations of asthma.

A cross-sectional analysis of medical conditions and environmental factors associated with fractional exhaled nitric oxide (FeNO) in women and children from the ISA birth cohort, Costa Rica.

BACKGROUND: Fractional exhaled nitric oxide (FeNO) is a marker of airway inflammation. Elevated FeNO has been associated with environmental exposures, however, studies from tropical countries are limited. Using data from the Infants' Environmental Health Study (ISA) birth cohort, we evaluated medical conditions and environmental exposures' association with elevated FeNO. METHODS: We performed a cross-sectional analysis of 277 women and 293 8-year old children who participated in the 8-year post-partum visit in 2019. We measured FeNO and collected information on medical conditions and environmental exposures including smoke from waste burning, work in banana plantations, and home pesticide use. We defined elevated FeNO as >25 ppb for women and >20 ppb for children. To evaluate factors associated with elevated FeNO, we used logistic regression models adjusted for obesity in women and unadjusted in children. RESULTS: Overall elevated FeNO was common (20% of women, 13% of children). Rhinitis diagnosis was significantly associated with elevated FeNO in both women (odds ratio (OR): 3.67 95% Confidence Interval (CI): 1.81,7.35) and children (OR: 8.18 95%CI: 3.15, 21.22); wheeze was associated with elevated FeNO in women (OR: 4.50 95% CI: 2.25, 8.99). Environmental exposures were associated with elevated FeNO, but not significantly. Waste burning was associated with elevated FeNO in both women (OR: 1.58 95%CI 0.68, 4.15) and children (OR: 2.49 95%CI:0.82, 10.79). Para-occupational pesticide exposures were associated with elevated FeNO in women and children. For women, having a partner working in agriculture was associated with elevated FeNO (OR: 1.61 95%CI:0.77, 3.58) and for children, maternal work in agriculture was associated with elevated FeNO. (OR 2.08 95%CI 0.86, 4.67) CONCLUSION: Rhinitis and wheeze were associated with elevated FeNO in this rural, agricultural population. Smoke from waste burning as well as para-occupational pesticide exposure may contribute to elevated FeNO in rural communities.

Respiratory and allergic outcomes among 5-year-old children exposed to pesticides.

BACKGROUND: Little is known about the effects of pesticides on children's respiratory and allergic outcomes. We evaluated associations of prenatal and current pesticide exposures with respiratory and allergic outcomes in children from the Infants' Environmental Health Study in Costa Rica. METHODS: Among 5-year-old children (n=303), we measured prenatal and current specific gravity-corrected urinary metabolite concentrations of insecticides (chlorpyrifos, pyrethroids), fungicides (mancozeb, pyrimethanil, thiabendazole) and 2,4-D. We collected information from caregivers on respiratory (ever doctor-diagnosed asthma and lower respiratory tract infections (LRTI), wheeze and cough during last 12 months) and allergic (nasal allergies, itchy rash, ever eczema) outcomes. We fitted separate multivariable logistic regression models for high (≥75th percentile (P75)) vs low (

The Use of Bacterial Lysate for the Prevention of Wheezing Episodes in Preschool Children: A Cost-Utility Analysis.

BACKGROUND: Although increasing recent evidence has shown the efficacy of bacterial lysate therapy for the prevention of wheezing episodes and asthma exacerbations in pediatric patients, evidence of its cost-effectiveness in preschool patients is scarce. OBJECTIVES: To evaluate the cost-utility of bacterial lysate therapy as an add-on to standard care of preschool children with recurrent wheezing. METHODS: To achieve the objectives of the study, we used a Markov simulation model with 3 mutually exclusive nonabsorbent states (regular Markov chain). Effectiveness parameters were obtained from a recent systematic review of the literature with meta-analyses (5 randomized controlled trials, 433 children). Cost data were obtained from hospital bills and from the national manual of drug prices in Colombia. The study was carried out from the perspective of the national health care system in Colombia. The main outcome of the model was quality-adjusted life-years. To assess the robustness of the model's results, we performed deterministic and probabilistic sensitivity analysis. RESULTS: Compared with standard care, bacterial lysate add-on therapy to standard care was associated with lower overall treatment costs (US $694.03 vs $830.71 average cost per patient) and the greatest gain in QALYs (0.9211 vs 0.9154 QALYs on average per patient), thus showing dominance. CONCLUSIONS: In Colombia, compared with standard care, bacterial lysate add-on therapy to standard care for treating preschool children with recurrent wheezing is a dominant strategy because it showed a greater gain in QALYs at lower total treatment costs.

Childhood Asthma: Low and Middle-Income Countries Perspective.

Our aim is to review current asthma epidemiology, achievements from the last 10 years, and persistent challenges of asthma management and control in low-middle income countries (LMICs). Despite global efforts, asthma continues to be an important public health problem worldwide, particularly in poorly resourced settings. Several epidemiological studies in the last decades have shown significant variability in the prevalence of asthma globally, but generally a marked increase in LMICs resulting in significant morbidity and mortality. Poverty, air pollution, climate change, exposure to indoor allergens, urbanization and diet are some of the factors that contribute to inadequate control and poor outcomes in developing countries. Although asthma guidelines have been developed to raise awareness and improve asthma diagnosis and treatment, problems with underdiagnosis and undertreatment are still common. In addition, important social, financial, cultural and healthcare barriers are common obstacles in LMICs in achieving control. Given the high burden of asthma in these countries, adaptation and implementation of national asthma guidelines tailored to local needs should be a public health priority. Governmental commitment, education, better health system infrastructure, access to care and effective asthma medications are the cornerstone of achieving success. CONCLUSION: Asthma poses significant challenges to LMICs. Whilst there are ongoing efforts in improving asthma diagnosis and decreasing asthma burden in LMICs; reasons for inadequate asthma control are also common and difficult to tackle. Improving asthma diagnosis, access to appropriate treatment and decreasing risk factors should be key goals to reduce asthma morbidity and mortality worldwide.

Nonspecific immunomodulators for recurrent respiratory tract infections, wheezing and asthma in children: a systematic review of mechanistic and clinical evidence.

PURPOSE OF REVIEW: To provide an overview of the mechanistic and clinical evidence for the use of nonspecific immunomodulators in paediatric respiratory tract infection (RTI) and wheezing/asthma prophylaxis. RECENT FINDINGS: Nonspecific immunomodulators have a long history of empirical use for the prevention of RTIs in vulnerable populations, such as children. The past decade has seen an increase in both the number and quality of studies providing mechanistic and clinical evidence for the prophylactic potential of nonspecific immunomodulators against both respiratory infections and wheezing/asthma in the paediatric population. Orally administered immunomodulators result in the mounting of innate and adaptive immune responses to infection in the respiratory mucosa and anti-inflammatory effects in proinflammatory environments. Clinical data reflect these mechanistic effects in reductions in the recurrence of respiratory infections and wheezing events in high-risk paediatric populations. A new generation of clinical studies is currently underway with the power to position the nonspecific bacterial lysate immunomodulator OM-85 as a potential antiasthma prophylactic. SUMMARY: An established mechanistic and clinical role for prophylaxis against paediatric respiratory infections by nonspecific immunomodulators exists. Clinical trials underway promise to provide high-quality data to establish whether a similar role exists in wheezing/asthma prevention.

Hydropneumothorax in Children: A Rare Complication of a Bacterial Pneumonia.

Hydropneumothorax is an uncommon presentation of a complicated pneumonia, and very few cases in the pediatric population have been reported. This is a case of a 5-month-old patient who presented to the emergency department (ED) with a three-day history of fever, diarrhea, and respiratory distress. His initial assessment suggested a lower respiratory tract infection and because of his respiratory distress and hypoxia a chest X-ray was performed. Other clinical information and radiologic studies will be discussed further, but his chest X-ray suggested a right-sided hydropneumothorax secondary to a complicated pneumonia. He completed 12 days of IV antibiotic treatment and required a chest tube for drainage. Patient was discharged home with a full recovery.

Spontaneous chylothorax in a 2-year-old child.

A previously well 2-year-old girl presented with acute respiratory distress. After multiple investigations she was diagnosed with spontaneous chylothorax, attributed to strenuous vomiting. To our knowledge, this is the second reported case of spontaneous chylothorax occurring after the neonatal period.

Asthma, current wheezing, and tobacco use among adolescents and young adults in Costa Rica.

OBJECTIVES: To examine the prevalence of asthma and the relation between tobacco use and asthma among university students in Costa Rica. METHODS: Cross-sectional study of 1279 adolescents and young adults enrolled in careers in the health sciences in public and private universities in Costa Rica. RESULTS: Of the 1279 study participants, 105 (8.2%) had current asthma, and 136 (10.6%) reported wheezing in the previous 12 months (current wheezing). Among individuals with either current wheezing or current asthma, none was using anti-inflammatory medications for asthma (e.g., inhaled corticosteroids). Approximately one third of the study participants reported any cigarette smoking. Young adults who had current wheezing were 5.8 times more likely to smoke at least 10 cigarettes per day than those who had no current wheezing [95% confidence interval (CI) for odds ratio (OR) = 3.3-10.2, p < 0.001]. Similar results were observed when an alternative definition of asthma (current asthma) was used in the analysis (OR for smoking at least 10 cigarettes per day = 4.4, 95% CI = 2.3-8.5, p < 0.001). CONCLUSIONS: Adequate public health measures are needed to prevent tobacco use in Costa Rican adolescents and to promote smoking cessation among young adults. Young adults with asthma living in Latin American countries with high asthma prevalence, such as Costa Rica, should be better educated with regard to asthma and the risks of tobacco use.