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Childhood Asthma


Children with asthma are commonly admitted to hospital following acute attacks. Asthma re-admissions are also common, and re-admission within a year may occur in 20-25% of children who already had one admission. Clearly this is distressing to the children, their parents or carers, and produces a considerable load on hospital emergency departments.

A meta-analysis of home management training programmes [1] concluded that these programmes do not seem to reduce morbidity. So what is to be done? A study from Glasgow [2] investigated a nurse-led home management training programme instituted when a child is admitted to hospital with an acute attack.

Randomised trial

Children admitted to the Royal Hospital for Sick Children with acute asthma were randomised to usual care, or to an intervention where a nurse met parents briefly within 24 hours of admission, and followed that with two teaching discussion sessions lasting about 45 minutes in total. These meetings were centred on a booklet, "Going home with asthma", developed specifically to provide basic practical advice. In particular the symptoms and signs identified by the parent as preceding the child's present attack were used as the basis of individualised symptom-based asthma management plan. A further appointment 2-3 weeks after discharge was used to reinforce messages, and telephone advice was also available.

Each family was given oral steroids to take home, with guidance on when to use them. Children over five years could also use a peak flow meter in addition.

Outcomes

The main outcome was return to hospital - any subsequent asthma admission. Secondary outcomes were asthma morbidity - a questionnaire sent to families to assess asthma symptoms four weeks after discharge from hospital.

Results

Over a year 283 children over two years were admitted (from a population served of 173,000 children under 14 years, an incidence of admissions of 164/100,000 children aged 2-14 years).

The control group of 105 children had 26 readmissions (25%). A non-randomised group of 82 children (who were admitted when the nurse was unavailable) had 18 readmissions (22%). The intervention group of 96 children had 8 readmissions (8%). At four weeks after discharge the intervention group had significantly lower day and night morbidity scores. The intervention had a NNT of 6.1 (3.8 to 15), meaning for every six families who received nurse-led advice, one less child was subsequently admitted to hospital.

Comment

This was a fine study with a thoughtful discussion. Yes, it was one trial, and, yes, there was only one nurse. So the results may not be universally applicable. But it is a great example of how to change practice, to see whether the change is effective, and if it is, to set audit standards to see that it remains effective.

References:

  1. A-C Bernard-Bonnin, S Stachenko, S Bonnin, C Charette, E Rousseau. Self-management teaching programmes and morbidity of paediatric asthma: a meta-analysis. Journal of Allergy and Clinical Immunology 1995 95: 34-41.
  2. P Madge, J McColl, J Paton. Impact of a nurse-led home management training programme in children admitted to hospital with acute asthma: a randomised controlled study. Thorax 1997 52: 223-8.



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