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International perspective on the care of children with acute exacerbations of asthma

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Simon Craig provides an insight into what research questions and outcome measures clinicians view as important. In addition, information on how clinicians define asthma severity and measure treatment success will assist with methodological design in future trials

Image courtesy of interviewee. March 26, 2024

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This video video discusses asthma as a prevalent condition, especially in young children, characterized by symptoms like cough, wheezing, and shortness of breath. Exacerbations can be triggered by viral infections, lack of medication, or exposure to allergens and severe weather. Treatment typically involves bronchodilators, such as Ventolin, and corticosteroids to reduce inflammation, which are effective for most children in emergency departments.

The speaker, an emergency doctor, notes challenges faced when initial treatments fail and emphasizes the need for better research on second-line treatments for severe asthma exacerbations. International research networks have collaborated to investigate acute asthma management across various countries.

The ongoing studies involve interviews with clinicians, patients, and families to gather insights on important treatment outcomes. These studies aim to identify common outcome measures for clinical trials, facilitating more reliable comparisons and evaluations of asthma treatments. Key outcomes highlighted include hospital length of stay, the necessity for intensive care, breathing difficulties, treatment side effects, and overall satisfaction with care.

The ultimate goal is to establish a core outcome set that standardizes outcome measures across clinical trials for children with severe asthma exacerbations, allowing for a more cohesive analysis of the effectiveness of various treatments.

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Asthma's a really common illness, right?

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Asthma, of course, is cough and whe

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and so on in young children.

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Um, and exacerbation of asthma is really just defined

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by something when it gets worse acutely.

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And so usually, in young children, that'll be shortness

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of breath, coughing, wheezing, and chest tightness.

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And that's often due to a viral infection.

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Uh, sometimes it's due to, you know,

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not taking usual medications

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or exposure to, significant weather events

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or allergens and things like that.

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But most of the time it's a viral illness,

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which makes the asthma worse,

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particularly in young children.

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Um, I'm an emergency doctor,

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and you know, from our point of view,

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asthma treatment most of the time is pretty straightforward.

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There's what we call first line treatment of asthma,

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which involves giving some medicines to treat,

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the underlying problems with asthma,

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which then makes the child better and they can go home.

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Um, so asthma is really a problem

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of inflammation in the lungs.

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Uh, and the other problem is

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that you've got these little tubes that you breathe through,

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called bronchi,

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and within, a child with asthma,

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those bronchi can constrict

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and they can also get a lot

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of mucus and other things in there.

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But the net result is instead of breathing

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through nice clean pipes, you're breathing through pipes

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that are a bit squished down, and they're a bit,

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congested.

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So normal asthma treatment, Ventolin

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or Salbutamol, which is a, a better agonist,

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dilates the bronchi, so you can breathe a little bit easier,

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and the corticosteroids, such as pregnesone

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or dexamethasone reduce the inflammation.

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So, FirstLine treatment for asthma, steroids

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and bronchodilators fix most children with asthma,

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and that does not cause problems

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in the emergency department.

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The, the issue then is that kids, kids

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that you give the FirstLine treatment to,

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and they know better or they're getting worse,

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or they come in really, really sick

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and they need more than first line treatment.

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And we, we've done a lot of work through an international,

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group of researchers looking at, different angles on

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how this is best treated.

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Um, where I work in Australia, there's a network

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of pediatric emergency departments, which spans Australia,

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New Zealand, called the Predict Network.

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And there are similar research networks in the UK

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and Ireland in the USA in Canada, in central

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and South America and across Europe.

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So these different pediatric emergency research networks are

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all interested in, and we've put together a working group

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for the last 5, 6, 7 years,

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we've been doing different projects

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around acute severe exacerbations of asthma in kids.

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Um, these projects have included doing what's called a

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Cochrane review, where you go back to

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through all the literature

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and find all the different, studies that have been done.

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And essentially we found that there's very good evidence

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for first line treatment

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and not great evidence for second line

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or ongoing treatment for asthma.

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And really, we found that all

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of the different inter interventions we're

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using, there's not

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A, a great deal of proof

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that one's any better than the other.

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There's quite a lot of variation

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between treatments in different countries

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and different parts of the world,

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and the clinical trials that have been done,

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each trial's managed to look at the outcomes

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or how, whether we've decided someone's better

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or worse in a different way.

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So you do one clinical trial

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and you measure how long it takes for someone

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to go home from hospital.

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You do another trial and you measure

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how long they're in intensive care for,

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or whether they go to intensive care,

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you'll do another trial

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and you'll measure some score where you put together

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how fast they're breathing and you know

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how their chest sounds and fewer things.

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So the problem is there's not been a consistent way

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of measuring the outcomes of these kids,

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so we can't even put the research together.

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So that's led us to do a number of projects including,

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some interview studies around, what clinicians think

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and what patients and families think are important

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outcomes in kids with asthma.

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So for these two specific projects, we'll talk about that.

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The interview studies, the objectives really were to get

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the views of clinicians and patients

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and families through doing semi-structured interviews

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around asthma.

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So talking to clinicians in emergency departments,

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intensive care and on the children's ward,

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and talking to patients

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and families who've been admitted to hospital

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with severe asthma

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and saying, well, what's important to you?

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What, what, what are the things that matter

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to you when you're caring for a child with asthma?

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Or if you were a parent of a child

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with asthma, and what are these things?

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And can we turn these things that matter into things

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that we can measure in terms of,

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clinical trial outcomes in future studies?

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So I'll start with the patients and families.

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Uh, and, and in, in this way, we decided

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to do a qualitative study, which in views,

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it involves clinicians interviewing patients

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and families, recording them

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and doing some analysis of a transcription of the text.

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How do we find the patients? How do we find the hospitals?

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We went through the research networks that were established

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around the asthma work and tried to recruit patients

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and families who had been in, in hospital

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with asthma in the, in, you know, a fairly recent period

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of time had been sick enough

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to need more than just first line treatment.

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So some had ended up in intensive care,

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some had needed intravenous treatment and so on,

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and were thought to then be stable enough

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to have a conversation about their, their experiences.

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Um, we interviewed by clinicians

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or researchers that were in the, in the hospital,

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recorded them all, translated them if they weren't done in

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English, and then transcribed them.

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And for the patients

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and families, we interviewed across South America, Paraguay,

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Argentina, central America, Costa Rica.

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We did USA, Australia, Canada, uk,

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but also Singapore, Nigeria and Qatar.

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So we sort of looked at really a global, sample.

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Uh, most of the people we interviewed were, parents,

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and most of those were mothers or a few fathers.

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And there was a couple of other, relatives involved.

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And, and the interviews

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occurred mostly in the hospital ward, some

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of them in the emergency department,

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and some of times in intensive care.

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A few children were interviewed and patients

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and families were interviewed after leaving hospital,

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but most were done within the hospital in terms of

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what patients and families thought.

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We ended up with 54 interviews across 12 countries.

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Um, most of the children were around six

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to eight years of age.

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Uh, about one in five had been in intensive care before.

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Uh, and those that have been in hospital had everything from

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two thirds, had intravenous treatment.

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Uh, and some of them have been quite unwell.

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The things that we found that were sort of important

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to the patient and family experience really related to,

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a whole sort of thing around the experience

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of seeking care, and then some things around outcomes.

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So the experience

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of seeking care really came from even the point of deciding

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that they were sick enough to need to go to hospital

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to get into hospital.

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And in some countries they've got a very well organized

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ambulance, pre-hospital system,

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and there's talk in other, countries where there's less,

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healthcare infrastructure, finding some of the car

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that could get me to hospital with my sick child,

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waiting times for an issue

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and then recognizing

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that we've spoken a bit about this first line treatment,

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inhaled treatment and, and medicine.

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But then the fact that you,

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you're putting a drip in a child's hand

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or you're giving them a needle, it, it's distressing,

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but it's also notably a step up in treatment.

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And for these kids that are sick, recognizing that

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that's important, patients

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and families are really keen to describe the, the benefits

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of good communication

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and being checked on frequently as well in terms of things

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that come into both experience.

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And the outcome is recognizing that no one wants

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to be in hospital longer than they need to be.

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So hospital length of stay is something that was highlighted

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by families, really is part of the patient experience.

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But there's also really robust outcome measure

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because you can measure that in clinical trials, right?

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Whether or not you went

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to intensive care is something that's measurable.

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You either went to intensive care or you didn't.

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And again, that, that's got some implications in terms of

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how serious things are, how supportive people feel,

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and also the costs of care.

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And depending on which part of the world you're in,

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being in hospital costs money,

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being in intensive care costs, money, treatments cost money,

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so costs of care

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and health economics is actually a really important thing.

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Other things that really came out of more

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of the outcomes were how fast children got better,

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any side effects they had, how hard they were

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to work with their breathing.

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So if a child was really struggling for breath, they wanted

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that sort of be to be recognized.

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And also just satisfaction with treatment.

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So were they satisfied with the treatment that they got?

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Were they happy with the, you know, the interactions

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with staff and patient and so on.

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So what we've got here is a, a good understanding

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that hospital length of stay going to intensive care

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and treatment costs are things that impact on patients

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and families, not only from an experience point of view,

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but a robust outcome measures.

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The other important clinical trial outcome measures are

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worker breathing and side effects and so on,

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and patient family experience.

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Um, what we are doing with this data, as well

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as similar data we've gotten from, clinicians, is

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to bring that together into what's called a Delphi study,

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where we then, administer these outcomes to a group,

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a larger group of patients and families and clinicians

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and researchers to try

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and prioritize a set of outcomes

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for further clinical research.

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Our hope is that we'll move towards what's called a core

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outcome set for acute severe asthma research,

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where every clinical trial, that involves children

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with severe exacerbations

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of asthma in the emergency department will measure the

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same outcome measures.

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Now, these outcomes will then be able

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to be combined when you're bringing data from different

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studies together and allow a much more robust way

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of working at what the best treatment is.

Understanding Asthma Treatment in Children

00:00:00 - Asthma's a really common illness, right? Asthma, of course, is cough and whe and so on in young children. and exacerbation of asthma is really just defined by something when it gets worse acutely. And so usually, in young children, that'll be shortness of breath, coughing, wheezing, and chest tightness. And that's often due to a viral infection. sometimes it's due to, you know, not taking usual medications or exposure to, significant weather events or allergens and things like that. But most of the time it's a viral illness,
00:00:32 - particularly in young children. I'm an emergency doctor, and you know, from our point of view, asthma treatment most of the time is pretty straightforward. There's what we call first line treatment of asthma, which involves giving some medicines to treat, the underlying problems with asthma, which then makes the child better and they can go home. so asthma is really a problem of inflammation in the lungs. and the other problem is
00:01:04 - called bronchi, and within, a child with asthma, those bronchi can constrict and they can also get a lot of mucus and other things in there. But the net result is instead of breathing through nice clean pipes, you're breathing through pipes that are a bit squished down, and they're a bit, congested. So normal asthma treatment, Ventolin or Salbutamol, which is a, a better agonist, dilates the bronchi, so you can breathe a little bit easier, and the corticosteroids, such as pregnesone
00:01:36 - So, FirstLine treatment for asthma, steroids and bronchodilators fix most children with asthma, and that does not cause problems in the emergency department. The, the issue then is that kids, kids that you give the FirstLine treatment to, and they know better or they're getting worse, or they come in really, really sick and they need more than first line treatment. And we, we've done a lot of work through an international, group of researchers looking at, different angles on how this is best treated.
00:02:07 - of pediatric emergency departments, which spans Australia, New Zealand, called the Predict Network. And there are similar research networks in the UK and Ireland in the USA in Canada, in central and South America and across Europe. So these different pediatric emergency research networks are all interested in, and we've put together a working group for the last 5, 6, 7 years, we've been doing different projects around acute severe exacerbations of asthma in kids.
00:02:38 - Cochrane review, where you go back to through all the literature and find all the different, studies that have been done. And essentially we found that there's very good evidence for first line treatment and not great evidence for second line or ongoing treatment for asthma. And really, we found that all of the different inter interventions we're using, there's not A, a great deal of proof that one's any better than the other. There's quite a lot of variation between treatments in different countries and different parts of the world,

Inconsistent Measurement of Asthma Treatment Outcomes

00:03:10 - each trial's managed to look at the outcomes or how, whether we've decided someone's better or worse in a different way. So you do one clinical trial and you measure how long it takes for someone to go home from hospital. You do another trial and you measure how long they're in intensive care for, or whether they go to intensive care, you'll do another trial and you'll measure some score where you put together how fast they're breathing and you know how their chest sounds and fewer things. So the problem is there's not been a consistent way of measuring the outcomes of these kids,
00:03:41 - So that's led us to do a number of projects including, some interview studies around, what clinicians think and what patients and families think are important outcomes in kids with asthma. So for these two specific projects, we'll talk about that. The interview studies, the objectives really were to get the views of clinicians and patients and families through doing semi-structured interviews around asthma. So talking to clinicians in emergency departments,
00:04:13 - and talking to patients and families who've been admitted to hospital with severe asthma and saying, well, what's important to you? What, what, what are the things that matter to you when you're caring for a child with asthma? Or if you were a parent of a child with asthma, and what are these things? And can we turn these things that matter into things that we can measure in terms of, clinical trial outcomes in future studies? So I'll start with the patients and families. and, and in, in this way, we decided
00:04:44 - it involves clinicians interviewing patients and families, recording them and doing some analysis of a transcription of the text. How do we find the patients? How do we find the hospitals? We went through the research networks that were established around the asthma work and tried to recruit patients and families who had been in, in hospital with asthma in the, in, you know, a fairly recent period of time had been sick enough to need more than just first line treatment. So some had ended up in intensive care,
00:05:16 - and were thought to then be stable enough to have a conversation about their, their experiences. we interviewed by clinicians or researchers that were in the, in the hospital, recorded them all, translated them if they weren't done in English, and then transcribed them. And for the patients and families, we interviewed across South America, Paraguay, Argentina, central America, Costa Rica. We did USA, Australia, Canada, uk,
00:05:48 - So we sort of looked at really a global, sample. most of the people we interviewed were, parents, and most of those were mothers or a few fathers. And there was a couple of other, relatives involved. And, and the interviews occurred mostly in the hospital ward, some of them in the emergency department, and some of times in intensive care. A few children were interviewed and patients and families were interviewed after leaving hospital, but most were done within the hospital in terms of

Insights from Global Pediatric Asthma Interviews

00:06:18 - We ended up with 54 interviews across 12 countries. most of the children were around six to eight years of age. about one in five had been in intensive care before. and those that have been in hospital had everything from two thirds, had intravenous treatment. and some of them have been quite unwell. The things that we found that were sort of important
00:06:52 - a whole sort of thing around the experience of seeking care, and then some things around outcomes. So the experience of seeking care really came from even the point of deciding that they were sick enough to need to go to hospital to get into hospital. And in some countries they've got a very well organized ambulance, pre-hospital system, and there's talk in other, countries where there's less, healthcare infrastructure, finding some of the car
00:07:21 - waiting times for an issue and then recognizing that we've spoken a bit about this first line treatment, inhaled treatment and, and medicine. But then the fact that you, you're putting a drip in a child's hand or you're giving them a needle, it, it's distressing, but it's also notably a step up in treatment. And for these kids that are sick, recognizing that that's important, patients and families are really keen to describe the, the benefits
00:07:49 - and being checked on frequently as well in terms of things that come into both experience. And the outcome is recognizing that no one wants to be in hospital longer than they need to be. So hospital length of stay is something that was highlighted by families, really is part of the patient experience. But there's also really robust outcome measure because you can measure that in clinical trials, right? Whether or not you went to intensive care is something that's measurable. You either went to intensive care or you didn't. And again, that, that's got some implications in terms of
00:08:23 - and also the costs of care. And depending on which part of the world you're in, being in hospital costs money, being in intensive care costs, money, treatments cost money, so costs of care and health economics is actually a really important thing. Other things that really came out of more of the outcomes were how fast children got better, any side effects they had, how hard they were to work with their breathing. So if a child was really struggling for breath, they wanted
00:08:52 - And also just satisfaction with treatment. So were they satisfied with the treatment that they got? Were they happy with the, you know, the interactions with staff and patient and so on. So what we've got here is a, a good understanding that hospital length of stay going to intensive care and treatment costs are things that impact on patients and families, not only from an experience point of view, but a robust outcome measures. The other important clinical trial outcome measures are

Prioritizing Outcomes for Pediatric Asthma Research

00:09:22 - and patient family experience. what we are doing with this data, as well as similar data we've gotten from, clinicians, is to bring that together into what's called a Delphi study, where we then, administer these outcomes to a group, a larger group of patients and families and clinicians and researchers to try and prioritize a set of outcomes for further clinical research. Our hope is that we'll move towards what's called a core
00:10:10 - where every clinical trial, that involves children with severe exacerbations of asthma in the emergency department will measure the same outcome measures. Now, these outcomes will then be able to be combined when you're bringing data from different studies together and allow a much more robust way of working at what the best treatment is.

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