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Asthma vital signs at triage: home or admission (ASTHmA)
Timothy Horeczko1, Garen J Wintemute
1Department of Emergency Medicine, University of California Davis Medical Center, University of California Davis School of Medicine, Sacramento, CA 95817, USA. timothy.horeczko@ucdmc.ucdavis.edu
Insights
Asthma severity in children requires age-specific assessment. Diastolic hypotension at triage is a key predictor of hospitalization, especially in younger children, guiding emergency department (ED) care.
Area of Science:
- Pediatric Emergency Medicine
- Respiratory Medicine
- Clinical Epidemiology
Background:
- Current asthma scoring systems lack age-specificity, potentially misjudging severity in children.
- Existing models may not adequately predict hospitalization needs in pediatric asthma patients.
- Physiological changes in children necessitate age-tailored approaches to asthma assessment.
Purpose of the Study:
- To identify objective, age-specific predictors of hospitalization for acute asthma at triage.
- To rapidly identify children requiring admission regardless of initial treatment response.
- To inform the development of refined pediatric asthma assessment tools.
Main Methods:
- Analysis of National Hospital Ambulatory Medical Care Survey data for children (1-18 years) with asthma diagnoses.
- Inclusion of triage vital signs, mode of arrival, and demographic factors in age-specific logistic regression models.
- Primary outcome defined as hospital admission (various levels of care).
Main Results:
- Over 2.4 million emergency department (ED) visits for asthma were analyzed.
- Predictive patterns of vital signs for admission varied significantly by age group.
- Diastolic hypotension at triage consistently predicted admission, particularly in 1-3 and 3-6 year olds.
Conclusions:
- Age-specific evaluation is crucial for pediatric acute asthma exacerbations.
- Diastolic hypotension serves as an early indicator of severe disease and potential hospitalization.
- Refinement of age-specific asthma assessment tools is warranted due to age-related predictor variability.
Objectives:
Commonly used acute asthma scoring systems assess severity of symptoms, whereas other clinical models aim to predict hospitalization; all rely on a measure of response to treatment and use the same criteria across age ranges. This may not reflect a child's changing physiology and response to illness as he or she grows older.This study aimed to find age-specific objective predictors of hospitalization readily known at triage. The goal is to identify rapidly those who will likely need admission regardless of treatment administered or response to aggressive treatment in the emergency department (ED).
Methods:
Children between 1 and 18 years of age with a final primary ED International Classification of Diseases, Ninth Revision, diagnosis of asthma or asthma-related spectrum of disease were studied using data from the National Hospital Ambulatory Medical Care Survey. The primary outcome was hospital admission (observation unit, ward, monitored, or pediatric intensive care unit).Triage vital signs, mode of arrival, recent visits, emergency severity index score, as well as demographic and socioeconomic factors were incorporated into age-specific forward-selection multiple logistic regression models.
Results:
In 2,454,983 ED visits for asthma or reactive airway disease among children 1 to 18 years of age, patterns of vital sign predictors for admission varied by age group. Across all ages, diastolic hypotension at triage was an early, consistent, independent predictor of admission, especially in 1- to 3-year-olds (odds ratio, 6.27; 95% confidence interval, 6.01-6.54) and 3- to 6-year-olds (odds ratio, 17.95; 95% confidence interval, 16.80-19.17).
Conclusions:
Age-specific assessment is important in the evaluation of acute asthma or reactive airway exacerbation. Diastolic hypotension may serve as an early warning indicator of severity of disease and need for hospitalization. Variability by age group in vital sign predictor for admission calls for further development or refinement of age-specific asthma assessment tools.
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