الفهرس 
INTRODUCTIONOnly 14 pages are availabe for public view
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Abstract
Asthma is the most common chronic illness in children and the leading reason for hospitalization among children in most nations, In addition to the chronic symptoms of asthma with different grades of severity, asthmatic child can experience one or more attacks of acute exacerbation which are also of varying degree of severity ranging from mild worsening of the chronic symptoms to a life threatening condition.
Acute asthma exacerbation is one of the most common medical emergency situations in childhood, and physicians caring for acutely ill children are regularly faced with this condition, where accurate assessment and management is of extreme importance and may be life saving.
Assessment of severity of the acute asthma attack in children is important both for clinical decision making and evaluation of treatment effectiveness and management plans. Underestimation of severity may result in inadequate treatment which may be associated with further deterioration of the patient, premature discharge and a possible return visit, while overestimation of severity may result in an extended emergency department stay and unnecessary utilization of hospital resources.
Given that pulmonary function testing is often neither feasible nor reliable in young acutely ill children, many clinical scores of asthma severity have been developed to be used in assessment of severity of acute asthma attack. Unfortunately many of these scores developed without formal validation and displayed weakness in their validity and reliability.
Pediatric Respiratory Assessment Measure (PRAM) is one of these scores which showed good measurement properties and high predictive ability in both preschool and school aged children. It is a 12 points score consists of five items namely; Suprasternal retraction, Scalene muscle contraction, air entry, wheezes and finally the unique objective criterion which is the O2 saturation.
The aim of this work was to test the PRAM score as an objective and valid tool for assessment of severity of acute asthma exacerbation, and hence helping the application of the guidelines for asthma management in asthmatic children presenting with acute attack.
This study was conducted on 100 asthmatic patients who attended the emergency department of Alexandria University Children’s hospital for acute asthma exacerbation in the period from January to September 2010. Demographic data of the patients namely age, sex and family history of asthma as well as data related to their disease status namely grade of asthma severity, intake of controller medications, previous ED visits for acute asthma and history of previous hospital admission for acute asthma were initially taken. PRAM score of each patient was measured at triage, after initial bronchodilator therapy, and at discharge, and then all these data and recorded scores were studied statistically in relation to the fate of the patients. Disposition (admission or discharge) was used as criterion of fate.
The results showed that 31% of the studied cases were admitted, of them 4 cases admitted in PICU. Demographically, this study included 58 boys and 42 girls, with mean age of 5.50±2.80 years. Age of the studied cases was significantly related to admission so that the admitted cases were younger than the discharged cases. Large percent of the studied cases (47%) had positive family history of asthma, as well as (61.3%) of the admitted cases had positive history but there was no statistically significant difference between admitted and discharged cases in relation to the family history.
Grade of asthma severity varied significantly among admitted and discharged cases most of the admitted cases were of the moderate persistent grade (38.7%) while most of the discharged cases (55%) had mild intermittent asthma.
Lack of compliance to asthma controller medication was the rule among the studied cases, as only (25.8%) of those who were in need for controller medication were on controller drugs, and there is no significant difference among admitted and discharged cases as regard intake of controller drugs.
Repeated ED visits was a common history in about (74%) of cases, and it didn’t differ significantly among admitted and discharged cases. Previous history of hospital admission for asthma was positive in about ( 34%) of cases, and it was significantly related to admission as(51.6%) of the admitted cases had positive history while only (26.1%) of the discharged cases had the same history.
Total PRAM scores and the grade of the scores were significantly higher in admitted cases than in discharged cases both at triage and after initial bronchodilator therapy. Furthermore the total scores were significantly higher incases admitted to PICU than in those admitted to ward. This signifies the predictive ability of the score.
The change in PRAM score after initial bronchodilator therapy presented by the percent of reduction was significantly less in admitted than discharged cases, and was less in cases admitted to PICU than those admitted to the ward which signified the good responsiveness criteria of the score. PRAM score was also directly related to the duration of hospital stay in admitted cases. When all the significant variants were entered in logistic regression model, the percent of reduction in the PRAM score was the only remaining significant variant.
Not only the total score but also each individual sign of the PRAM score were significantly different among admitted and discharged cases both at triage and after initial bronchodilator therapy, with suprasternal retraction being the most sign related to admission at triage by the logistic regression model.
Scalene muscle contraction was also significantly related to admission at triage and after initial therapy; however it remains anon familiar sign to most physicians and somewhat clinically confusing to detect its contraction.
O2saturation, the unique objective sign of the PRAM score, was also significantly related to admission both at triage and after initial therapy. Given that measuring O2 saturation by pulse oximetry is easy and available in ED situation, makes this sign a golden sign to assess in every asthmatic patient presenting by acute exacerbation.