Outpatient management of childhood asthma by paediatrician or asthma nurse: randomised controlled study with one year follow up Parental education and guided self-management of asthma and wheezing in the pre-school child: a randomised controlled trial Asthma education by community child health nurses. How and by whom care is delivered influences anti-inflammatory use in asthma: Results of a national population survey. Impact of a nurse-led home management training programme in children admitted to hospital with acute asthma: a randomised controlled study. Impact of nurse-led outpatient management of children with asthma on healthcare resource utilisation and costs Peak flow diaries in childhood asthma are unreliable Demonstrated use of metered-dose inhalers and peak flow meters by children and adolescents with acute asthma exacerbations. Peak flow monitoring for guided self-management in childhood asthma: a randomized controlled trial. Symptom perception and functional morbidity across a 1-year follow-up in pediatric asthma. Structured discharge procedure for children admitted to hospital with acute asthma: a randomised controlled trial of nursing practice Determinants of correct inhalation technique in children attending a hospital‐based asthma clinic Family interaction and a supportive social network as salutogenic factors in childhood atopic illness.
Background : Until now , care provided by asthma nurses has been additional to care provided by paediatricians . A study was undertaken to compare nurse led outpatient management of childhood asthma with follow up by a paediatrician . Methods : Seventy four children referred because of insufficient control of persistent asthma were r and omly allocated to 1 year follow up by a paediatrician or asthma nurse . The main outcome measure was the percentage of symptom-free days . Additional outcome measures were airway hyperresponsiveness , lung function , daily dose of inhaled corticosteroids ( ICS ) , number of exacerbations , number of additional visits to the general practitioner , absence from school , functional health status , and disease specific quality of life . Results : There were no significant differences at the end of the 1 year study period between the two treatment groups in percentage of symptom-free days ( mean difference 2.5 % ; 95 % CI −8.8 to 13.8 ) , airway hyperresponsiveness ( log10 PD20 0.06 ; −0.19 to 0.32 ) , functional health status ( 10.1 ; −0.3 to 19.8 ) , disease specific quality of life of patients ( 0.08 ; −0.9 to 0.7 ) , and disease specific quality of life of caregivers ( 0.09 ; −0.2 to 0.3 ) , nor in any other outcome parameters . Most outcome parameters improved considerably over the 1 year study period . These improvements were achieved although the daily dose of ICS was reduced by a mean of 26 % compared with the dose received by children at referral . All parents were satisfied with the asthma care received . Conclusions : After initial assessment in a multidisciplinary clinic , childhood asthma can be successfully managed by an asthma nurse in close cooperation with a paediatrician . During close follow up by paediatrician or asthma nurse , asthma control improved despite a reduction in ICS dose Background : The effects on morbidity were examined of providing an educational intervention and a written guided self-management plan to the parents of pre-school children following a recent attendance at hospital for asthma or wheeze . Methods : A prospect i ve , r and omised , partially blinded , controlled trial was design ed at two secondary care centres . Over a 13 month period 200 children aged 18 months to 5 years at the time of admission to a children 's ward or attendance at an accident and emergency department or children 's ( emergency ) assessment unit ( A&E/CAU ) with a primary diagnosis of acute severe asthma or wheezing were recruited . 101 children were r and omised into the control group and received usual care and 99 were assigned to the intervention group and received : ( 1 ) a pre-school asthma booklet ; ( 2 ) a written guided self-management plan ; and ( 3 ) two 20 minute structured educational sessions between a specialist respiratory nurse and the parent(s ) and child . Subjects were assessed at 3 , 6 , and 12 months . The main outcomes were GP consultation rates , hospital re-admissions , and attendances at A&E/CAU . Secondary outcomes included disability score , caregivers ' quality of life , and parental knowledge of asthma . Results : There were no statistically significant differences between the two groups during the 12 month follow up period for any of the main or secondary outcome measures . Conclusions : These results do not support the hypothesis that the introduction of an educational package and a written guided self-management plan to the parents of pre-school children with asthma who had recently attended hospital for troublesome asthma or wheeze reduces morbidity over the subsequent 12 months A r and omised controlled study of an educational programme for children with asthma and their families was carried out by community child health nurses . Three hundred and sixty eight children aged 2 to 14 years were enrolled in the study after admission to hospital for asthma . The intervention group was visited monthly by a nurse for six months . The subjects were assessed six months later by a postal , self administered question naire . European children in the intervention group were taking significantly more drugs for the treatment of asthma six months after the index admission to hospital than those in the control group ( mean ( SD ) intake 2.7 ( 1.1 ) v 2.1 ( 1.0 ) , respectively ) . In particular , they were using more  theophylline  ( 56.6 % v 37.0 % ) and  inhaled steroids  ( 34.9 % v 21.0 % ) . There was no difference between the groups for parental reports of improvement , of missed schooling , and in severe attacks of asthma of not responding to the usual treatment at home . European children in the intervention group used the hospital services for severe attacks of asthma more than controls ( 34.2 % v 10.5 % ) . There were more re-admissions in the European intervention group in the subsequent six months after the index admission than in the control group ( mean ( SD ) 0.51 ( 0.97 ) v 0.29 ( 0.65 ) . Re-admission continued to be higher in the 12 months after the nurse had stopped visiting ( 0.81 ( 1.65 ) v 0.25 ( 0.65 ] . There was no difference in the duration of hospital stay between the intervention and control groups . For Polynesian children there was no difference between the groups for any outcome measures BACKGROUND Studies examining the influence of provider behavior and patterns of care delivery on the use of anti-inflammatory asthma therapy have been limited to selected population s or have been unable to assess the appropriateness of therapy for individuals . We have previously reported the influence of sociodemographic variables and asthma severity on reported use of asthma medications in the United States . OBJECTIVE We sought to examine the influence of patterns of care delivery and clinician behavioral factors on the use of anti-inflammatory medication by patients with asthma . METHODS We performed a cross-sectional national r and om digit dial household telephone survey in 1998 of adult patients and parents of children with current asthma . Respondents were classified as having current asthma if they had a physician 's diagnosis of asthma and were either taking medication for asthma or had asthma symptoms during the past year . RESULTS One or more persons met the study criteria for current asthma in 3273 ( 7.8 % ) households in which a screening question naire was completed . Of the 2509 persons ( 721 children < 16 years of age ) with current asthma interviewed , 507 ( 20.1 % ) reported current use of anti-inflammatory  medication  . In a multiple logistic regression model controlling for asthma symptoms , reported anti-inflammatory use was significantly associated with patients reporting their physician having an excellent ability to explain asthma management ( odds ratio [ OR ] , 1.47 ; 95 % CI , 1.09 - 1.98 ) , scheduling regular visits to a physician for asthma ( OR , 1.30 ; 95 % CI , 1.02 - 1.64 ) , having a written asthma action plan ( OR , 1.63 ; 95 % CI , 1.29 - 2.06 ) , and being of white , non-Hispanic ethnicity ( OR , 1.53 ; 95 % CI , 1.19 - 1.98 ) , along with markers of greater asthma morbidity , missing 6 or more days from work or school in the past year ( OR , 1.29 ; 95 % CI , 1.01 - 1.65 ) , and hospitalization for asthma in the past year ( OR , 1.74 ; 95 % CI , 1.19 - 2.53 ) . Anti-inflammatory use was less likely to be reported with younger age ( OR , 0.82 ; 95 % CI , 0.73 - 0.94 ) , lower long-term asthma symptom burden ( OR , 0.82 ; 95 % CI , 0.71 - 0.94 ) , use of 4 or fewer reliever inhaler canisters in the past year ( OR , 0.50 ; 95 % CI , 0.43 - 0.58 ) , and smoking ( OR , 0.50 ; 95 % CI , 0.37 - 0.68 ) . CONCLUSION How asthma care is delivered influences the use of anti-inflammatory medication . Strategies to increase regular evaluation by a physician interested in asthma , particularly for minority patients , and to increase a physician 's ability to communicate asthma management to patients might improve use of anti-inflammatory therapy among patients with asthma BACKGROUND Re-admissions to hospital in childhood asthma are common with studies reporting that 25 % or more of children will be re-admitted within a year . There is a need for strategies to reduce re-admissions . METHODS A prospect i ve r and omised control study of an asthma home management training programme was performed in children aged two years or over admitted with acute asthma . Two hundred and one children were r and omised at admission to either an intervention group ( n = 96 ) which received the teaching programme or a control group ( n = 105 ) . A nurse-led teaching programme used the current attack as a model for the management of future attacks and included discussion , written information , subsequent follow up and telephone advice aim ed at developing and reinforcing individualised asthma management plans . Parents were also provided with a course of oral steroids and guidance on when to start them . RESULTS The groups were similar in degree of social deprivation , length of stay , number of previous admissions , acute asthma treatment , and asthma treatment at discharge . Subsequent re-admissions were significantly reduced in the intervention group from 25 % to 8 % in individual follow up periods that ranged from two to 14 months ( chi 2 = 9.63 ; p = 0.002 ) . This reduction was not accompanied by any increase in subsequent emergency room attendances nor , in the short term , by any increase in urgent community asthma treatment . The intervention group also showed significant reductions in day and night morbidity 3 - 4 weeks after admission to hospital . CONCLUSIONS A nurse-led asthma home management training programme administered during a hospital admission can significantly reduce subsequent admissions to hospital for asthma . Acute hospitalisation may be a particularly effective time to deliver home management training The high burden of asthma on healthcare utilisation and costs warrants economic appraisal of management approaches . The authors previously demonstrated that the efficacy of nurse-led outpatient management of childhood asthma was comparable to management by a paediatrician and now report on the healthcare utilisation and costs of both management approaches . A total of 74 newly referred children with asthma were r and omly assigned to a 1‐yr follow-up by paediatricians or asthma nurse . Healthcare utilisation was recorded and associated costs calculated for both management approaches . There were no significant differences in healthcare utilisation except for the total time spent on patient contact ( 136(n=14 ) versus 187(n=41 ) min , for patients followed-up by paediatrician and an asthma nurse repectively ) . Costs within the healthcare sector were reduced by 7.2 % in favour of nurse-led care . The reduction in costs was solely attributable to a 17.5 % reduction in the costs of outpatient visits . Nurse-led care appeared to be cost-saving even if the duration of follow-up visits would be twice that of doctor 's visits . Overall healthcare costs ( within and outside the healthcare sector ) were 4.1 % lower for nurse-led outpatient management compared to traditional medical care . Nurse-led outpatient management of childhood asthma can be provided at a lower cost than medical care by paediatricians BACKGROUND A study was undertaken to investigate the compliance with and accuracy of peak flow diaries in childhood asthma . METHODS Forty asthmatic children ( 5–16 years ) were asked to perform peak flow measurements twice daily for 4 weeks by means of an electronic peak flow meter and to record values in a written diary . Patients and parents were unaware that the device stored the peak flow values on a microchip . In r and om order , half of the patients were only told that the device allowed for more accurate assessment of peak flow while the other half were told that accurate recording of peak flow was important because the results would be used in guiding adjustments to treatment . Data in the written diary ( reported data ) were compared with those from the electronic diary ( actual data ) . RESULTS In the entire study population the mean ( SD ) actual compliance ( 77.1 (20.5)% ) was much lower than the mean reported compliance ( 95.7 (9.1)% ) ( 95 % CI for difference 12.7 % to 24.4 % ) The percentage of correct peak flow entries decreased from 56 % to < 50 % from the first to the last study week ( p<0.04 ) , mainly as a result of an increase in self-invented peak flow entries . Results were comparable for both groups . For incorrect peak flow entries the mean difference between written and electronically recorded entries ranged from –72 to 34 l/min per patient . CONCLUSIONS Peak flow diaries kept by asthmatic children are unreliable . Electronic peak flow meters should be used if peak flow monitoring is required in children with asthma OBJECTIVES To determine the ability of children and adolescents with acute asthma exacerbations to adhere to national guidelines for proper metered-dose inhaler ( MDI ) and peak flow meter ( PFM ) technique and to define characteristics associated with improper use . DESIGN A prospect i ve study in which the patients were instructed to use a placebo MDI or a PFM in the emergency department exactly as at home . Technique was grade d on the basis of performance of specific steps recommended by national guidelines . SETTING AND PARTICIPANTS Children and adolescents ( aged 2 - 18 years ) with acute asthma exacerbations in the emergency department of an urban children 's hospital with acute asthma . RESULTS Thirty-three ( 45.2 % ) of 73 patients using an MDI ( MDI group ) demonstrated multiple steps improperly compared with 60 ( 44.4 % ) of 135 using an MDI with a holding chamber ( MDI-HC group ; P = .92 ) . In the MDI group , young ages of the patients ( P<.008 ) and the parents ( P<.003 ) were associated with improper use . In the MDI-HC group , factors independently and significantly associated with improper use were no hospitalizations within the past year , parent assistance of the patient with MDI-HC use , and nondaily use of the MDI-HC . Also , 165 ( 82.9 % ) of 199 children who , per national guidelines , should be using a PFM at home , did not . Eighty-two ( 73.9 % ) of 111 patients demonstrated perfect performance of all PFM steps . CONCLUSIONS Among children with acute asthma , we found high rates of improper MDI use and PFM underuse . A greater emphasis must be placed on teaching methods to optimize drug delivery and to instruct patients about the importance of self-monitoring of disease severity We asked whether the addition of PEF recordings to a symptom-based self-management plan improved outcome in school children with asthma . In an open-r and omized , parallel-group , controlled trial , we studied children aged 7 - 14 years with moderate asthma . After a 4-week run-in , 90 children were r and omized to receive either PEF plus symptom-based management or symptom-based management alone for 12 weeks . Thresholds for action based on PEF were 70 % of best ( for increasing inhaled steroids ) and 50 % of best ( for commencing prednisolone ) . Children were asked to perform twice-daily spirometry at home ( using an electronic recording spirometer that revealed only PEF to the study group alone ) and to record a symptom diary . The mean daily symptom score was the main outcome . There were no differences between groups in mean symptom score or in spirometric lung function , PEF , quality of life score , or reported use of health services over 12 weeks . During acute episodes , children responded to changes in symptoms by increasing their inhaled steroids at a mean value of PEF of greater than 70 % of best so that overall PEF did not contribute to this important self-management decision . Knowledge of PEF did not enhance self-management even during acute exacerbations The purpose of this study was to examine the association between asthma symptom perception measured during a 5 - 6 week baseline and functional morbidity measured prospect ively across a 1-year follow-up . Symptom perception was measured by comparing subjective ratings with peak expiratory flow rate ( PEFR ) and forced expiratory volume in one second ( FEV(1 ) ) . We hypothesized that accurate symptom perception ( ASP ) would be associated with less functional morbidity .  Participants consisted of 198 children with asthma ages 7 - 17 recruited from three sites . The children used a programmable electronic spirometer in the home setting to guess their PEFR prior to exhalation . Each " subjective " guess was classified as being in an ASP , dangerous symptom perception ( DSP ; underestimation of symptoms ) , or symptom magnification ( SM ; overestimation ) zone based upon the corresponding measurement of PEFR or FEV(1 ) . An index of functional morbidity was collected by parent report at baseline and across 1-year follow-up . A greater proportion of ASP blows and a lower proportion of DSP blows based on PEFR predicted less functional morbidity reported at baseline , independent of asthma severity and race/ethnicity . A greater proportion of ASP blows ( using PEFR and FEV(1 ) ) and a lower proportion of SM blows ( using FEV(1 ) ) predicted less functional morbidity across 1-year follow-up . Symptom perception was not associated with emergency department visits for asthma at baseline or across follow-up . In comparison to PEFR , FEV(1 ) more frequently detected a decline in pulmonary function that children did not report . Symptom perception measured in naturalistic setting s was associated with functional morbidity at baseline and prospect ively across 1-year follow-up . Support was found for including multiple measures of pulmonary function in the assessment of asthma symptom perception BACKGROUND Discharge planning is becoming an important part of the management of childhood asthma in hospital . Readmission to hospital , although often inevitable , might represent a failure of the opportunity for intervention presented by a brief period of supervised care in hospital . AIM To examine the impact of a structured , nurse-led discharge package for children admitted to hospital with acute asthma on readmission to hospital , reattendance at the accident and emergency ( A&E ) department , and general practitioner consultations for asthma . METHODS A structured nurse-led discharge package , consisting of a 20 minute patient education programme and self management plan for children with  asthma was developed on the wards of a busy children ’s hospital . A r and omised controlled trial was conducted involving 160 children aged 2–16 years admitted for asthma over a 12 month period . Readmission and A&E reattendance ’s over the six months after discharge from hospital were obtained from the hospital computerised information system and general practitioner consultations from practice records . RESULTS Children in the intervention group were significantly less likely to be readmitted to hospital in the next six months than those in the control group ( 12 of 80 v30 of 80 patients ) , and significantly less likely to attend the A&E department ( 6 of 80 v 31 of 80 ) . Significantly fewer children in the intervention group had visits to their general practitioner for problematic asthma ( 31 of 78v 72 of 77 for whom data were available ) . CONCLUSION By delivering the simplest form of education and support during a child ’s stay in hospital , readmissions over a six month period were reduced . The programme was design ed to be suitable for administration by nursing staff on the children ’s wards after a brief period of training Many children with asthma use their inhaler device incorrectly even after comprehensive inhalation instruction . The aim of this study was to identify factors associated with correct inhalation technique . Two hundred children with asthma demonstrated their inhalation technique . Patient characteristics and the components of inhalation instructions they had received were compared for children demonstrating a correct or incorrect inhalation technique . In addition , the inhalation technique of 47 newly referred patients was followed‐up prospect ively after repeated comprehensive instruction sessions . Seventy‐eight percent of all patients demonstrated a correct inhalation technique . Patients who had received repeated instruction sessions and patients who had previously been asked to demonstrate the use of their inhaler during an instruction session were more likely than other children to demonstrate a correct inhalation technique ( p < 0.001 and p= 0.03 , respectively ) . Multiple logistic regression analysis showed that repetition of instructions was significantly associated with a correct inhalation technique ( odds ratio ( OR ) 8.2 , 95 % CI 3.2–21.5 ; p < 0.0001 ) irrespective of type of inhaler used . Demonstration of the inhaler use by the patient was significantly associated with a correct inhalation technique for patients using a metered dose inhaler plus spacer device ( OR 3.5,95 % CI 1.0–12.6 ; p= 0.05 ) , but not for patients using a dry powder inhaler ( OR 1.6,95 % CI 0.4‐6.4 ; p= 0.54 ) . The number of newly referred patients demonstrating a correct inhalation technique improved from 57.4 % to 97.9 % after three comprehensive instruction sessions The role of psycho-social factors in the development of allergy was studied prospect ively in 82 infants with a family history of atopy . The family participated in a st and ardized family test when the children were 18 months old . The ability to adjust to dem and s of the situation (  ' adaptability '  ) , and the balance between emotional closeness and distance (  ' cohesion '  ) , were assessed from videotapes by independent raters . Families rated as functional in both of these aspects were classified as ' functional ' , otherwise as ' dysfunctional ' . The  social network , life events , atopic symptoms  ( based on postal inquiries regarding symptoms answered by the parents , and on physical examinations ) , psychiatric symptoms , and socio-economic circumstances of the families were evaluated when the children were 18 months and 3 years of age . The children were classified as atopic ( asthmatic symptoms or eczema ) or as non-atopic . All but two children with atopic disease at 3 years of age had atopic disease before 18 months of age , while 32 of 60 children with atopic disease at 18 months of age had no problems by 3 years of age . An unbalanced family interplay at 18 months was associated with a relative risk ( RR ) of 1.99 for continuing atopic illness at 3 years of age ( 1.18 < RR < 3.37 , p = 0.01 ) . There was a weak positive confounding effect for smoking ( RR reduced by 7 % ) , eczema on three or more localizations ( RR reduced by 4.5 % ) , and the amount of cat allergen in household dust ( RR reduced by 3 % ) . Recovery from atopic illness between 18 months and 3 years of age was four times as probable in families with functional interaction and a good social supportive network when children were 18 months of age , than in dysfunctional families with a poor social network ( 74 % versus 20 % p < 0.01 ) . Children with asthmatic symptoms showed more signs of emotional distress than did healthy children ( p = 0.02 ) . Dysfunctional family interaction patterns were more commonly observed in families of children who at 3 years of age still had atopic symptoms , than in children who had recovered . The patterns included expression of emotion and reaction to the needs of others , alternating between total disinterest and over-involvement ( p = 0.02 ) , lack of support and rejection of offered support ( p = 0.01 ) , a greater number of individual decisions without regard to the other family members ( p = 0.04 ) , and indistinct ' generational boundaries ' ( p = 0.04 ) . We conclude that psychosocial factors , such as family interaction and a supportive social network , play a significant role in the course of atopic illness in early childhood and that measures which enhance  family interaction  and the social network could influence the course of the disease favorably
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