Oxygen saturation as a predictor of prolonged, frequent bronchodilator therapy in children with acute asthma

doi:10.1016/j.jpeds.2004.06.072

The Journal of Pediatrics

Volume 145, Issue 5, November 2004, Pages 641-645

https://doi.org/10.1016/j.jpeds.2004.06.072 Get rights and content

Objectives

To examine if the initial oxygen saturation (Sao₂) in the Emergency Department is a useful predictor of prolonged frequent bronchodilator therapy (FBT) in children with acute asthma.

Study design

Prospective cohort study of 273 children, 1 to 17 years of age, requiring systemic corticosteroids. Patients were categorized as needing FBT for >4 hours (n = 166) versus >4 hours (n = 107) and >12 hours (n = 79) versus >12 hours (n = 194). Multiple logistic regression determined the association between Sao₂ and these outcomes.

Results

Baseline Sao₂ remains a significant independent predictor of FBT for >4 hours (OR = 0.81) and >12 hours (OR = 0.84); 91% of patients with Sao₂ of 90% to 91% had FBT >4 hours and 80% of patients with Sao₂ of ≤89% had FBT >12 hours. Children with Sao₂ of ≤91% are 14.7 and 12.0 times more likely to require FBT for >4 hours and >12 hours, respectively, than those with Sao₂ of 98% to 100%. The interval likelihood ratios for FBT >4 hours were 12.3 for Sao₂ of ≤89%, 6.5 for 90% to 91%, but only 1.8 for 92% to 93%. The likelihood ratios for FBT >12 hours decreased from 9.8 for Sao₂ of ≤89% to 3.5 for Sao₂ of 90% to 91%.

Conclusions

Sao₂ is a useful predictor of FBT >4 hours if it is ≤91% and of FBT >12 hours if it is ≤89%.

Section snippets

Patient population and study design

For this study, we used the database from a previously published, prospective cohort study.⁵ Included were children 12 months of age and older with a previous diagnosis of asthma and those older than 24 months of age with the first wheezing episode who required systemic corticosteroid therapy at presentation to the ED. Patients with comorbidities such as cardiopulmonary or neurologic disease, history of aspiration, or severe gastroesophageal reflux were excluded. Two trained research nurses

Results

Of the 278 participating children, 273 had baseline transcutaneous Sao₂ recorded and were included in the study. One hundred seven patients were discharged within 4 hours of starting corticosteroids (<4-hour group) and 166 were treated for >4 hours (>4-hour group). A total of 194 patients were in the <12-hour group and 79 were in the >12-hour group. The children in the <4-hour and >4-hour groups were significantly different with respect to the initial Sao₂ and clinical asthma score as well as

Discussion

Our study suggests that baseline Sao₂ ≤91% in acute pediatric asthma can be considered a helpful predictor of prolonged FBT for >4 hours and that Sao₂ ≤89 % is strongly associated with FBT for >12 hours.

Keahey et al,¹⁷ in a large, multicenter trial examining a similar question, reported similar conclusions. However, the outcome measure in this study was hospitalization rate. Use of hospitalization rate as an outcome measure is limited and may be dependent on the availability of observation

Acknowledgements

We thank Dr Kelly Keogh, Dr Colin Macarthur, Rita Arseneault, Olwen Tennis, and Liane Bacal for their help in data collection and Diana Cristea and Sandra Miller for preparation of this research manuscript.

References (21)

K.A. Keogh et al.
Predictors of hospitalization in children with acute asthma
J Pediatr
(2001)
G.C. Geelhoed et al.
Evaluation of Sao₂ as a predictor of outcome in 280 children presenting with acute asthma
Ann Emerg Med
(1994)
E. Kerem et al.
Predicting the need for hospitalization in children with acute asthma
Chest
(1990)
L. Keahey et al.
Initial oxygen saturation as a predictor of admission in children presenting to the emergency department with acute asthma
Ann Emerg Med
(2002)
E.J. Gallagher
Clinical utility of likelihood ratios
Ann Emerg Med
(1998)
S.R. Hayden et al.
Likelihood ratio: a powerful tool for incorporating the results of a diagnostic test into clinical decision making
Ann Emerg Med
(1999)
M.D. Brown et al.
Evidence-based emergency medicine/skills for evidence-based emergency care. Interval likelihood ratios: another advantage for the evidence-based diagnostician
Ann Emerg Med
(2003)
P.J. Gergen et al.
Changing patterns of asthma hospitalization among children: 1979 to 1987
JAMA
(1990)
K.B. Weiss et al.
An economic evaluation of asthma in the United States
N Engl J Med
(1992)
R.J. Scarfone et al.
Controlled trial of oral prednisone in the emergency department treatment of children with acute asthma
Pediatrics
(1993)

There are more references available in the full text version of this article.

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The management of paediatric asthma exacerbations is based on trials in children of all ages. Recent studies from 2009 raised the possibility that preschoolers (younger than 6 years) with viral-induced wheezing and children exposed to tobacco smoke might be at an increased risk of treatment failure. The study objective was to identify factors associated with management failure in children presenting to the emergency department with moderate or severe asthma exacerbations.
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Canadian Institutes of Health Research.
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To determine the performance characteristics of the Preschool Respiratory Assessment Measure (PRAM) in preschool and school-aged children with acute asthma.
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Original ArticleOxygen saturation as a predictor of prolonged, frequent bronchodilator therapy in children with acute asthma

Objectives

Study design

Results

Conclusions

Section snippets

Patient population and study design

Results

Discussion

Acknowledgements

J Pediatr

Ann Emerg Med

Chest

Ann Emerg Med

Ann Emerg Med

Ann Emerg Med

Ann Emerg Med

Changing patterns of asthma hospitalization among children: 1979 to 1987

JAMA

An economic evaluation of asthma in the United States

N Engl J Med

Controlled trial of oral prednisone in the emergency department treatment of children with acute asthma

Pediatrics

Original Article
Oxygen saturation as a predictor of prolonged, frequent bronchodilator therapy in children with acute asthma