4 | DISCUSSION
The purpose of this study was to characterize children with asthma who
use pediatric emergency departments. One of the interests of this study
was the factors that lead seeking care in emergency departments, which
was carried out directly in the emergency department, so it represents
both children who were hospitalized and those were not hospitalized
after their passage. The high rate of participation in the study and the
complete responses to standardized questionnaires leave little missing
data overall. The number of patients included over the period is
relatively high given the number of annual treatments for asthma in the
pediatric emergency room of the hospital.
The high representation of infants in the population studied made it
possible to analyze the characteristics of this age group more
precisely, which are often less known. The results are in line with
already known data.19-21 It also confirms other known
data, including viral infections of the airways as factors triggering
exacerbations.22-24 There is also a link between
viruses and the level of allergenic exposure in sensitized
children22, 25 and more severe exacerbations in cases
of low socio-economic level.26-28
Something worth mentioning in this study is that even though it was
conducted during the COVID-19 pandemic using the national care model,
most hospitals in Mexico City requested screening for SARS-CoV-2 for
lower respiratory symptoms. Only 17.4% (n=25) of patients were found to
be positive by either an antigen test or PCR test for SARS-CoV-2. This
suggests that the involvement of traditional or already described
respiratory viruses remains preponderant in the epidemic of asthma
exacerbation.
In addition, the severity of the exacerbation was correlated with a low
economic background. About 21% of the children belonged to a family
with income less than or equal to the MMS. This high rate could come
from a deficit in monitoring, education, and therapeutic adherence of
people in this socio-economic stratum, who could have a tendency to more
easily visit the hospital without a pre-hospital medical consultation,
as well as a plus poor health status of disadvantaged
populations.29-32 It has also been shown that there is
a correlation between a low economic level and less control of
asthma.32 In addition, an inversely proportional link
was established between the level of education and the use of emergency
care .33, 34
A large majority of children consulting emergencies had a history of
asthma (85%), but our study did not really make it possible to make a
distinction between children whose asthma was already diagnosed by their
doctor and those whose symptoms of asthma were present without a
diagnosis of asthma. However, this figure is close of the estimate of
11% having inaugural crises in the emergency department according to
Khan et al.35 Only half of the children with a history
of asthma in our study had background treatment, and barely a third had
specialized follow-up. This confirms the hypothesis of advanced
treatment failure and lack of follow-up of asthma that is found in other
studies.36, 37
All crises, including inaugural ones, have been included in the study,
but statistical analysis on adherence to a background treatment, regular
follow-up of the child, existence of an action plan of what to do in the
event of a crisis, and the introduction of an individualized reception
project concerns only children with a history of asthma before
inclusion. In our study, the right adherence to background treatment had
a relatively high rate. This adherence was assessed by questioning about
regular treatment substantively when it was introduced. It is presumably
overestimated, and the actual quality of compliance remains difficult to
assess in an emergency department. In effect, the evaluation of
adherence to background treatment requires specific questions that often
appear secondary for the patient’s family and the doctor in an emergency
context. Even if several exacerbations inevitably remain, the high rate
of emergency room visits despite an observance that remains correct
could nevertheless reflect insufficient treatment of the disease.
Patients with a history of asthma had a protocol for what to do in the
event of a crisis in 36% of cases. It was in written form in only 16%
of cases, and an individualized reception project had been set up in
23% of cases. But even if the beneficial effect of the implementation
of a written action plan remains controversial in
pediatrics,38-40 in adults, a lack of implementation
of a written action plan is a factor recognized as being associated with
repeated emergency room visits, probably from a lack of knowledge of the
disease and particularly warning signs of the crisis and initial
treatment 31. Taken together, these results clearly
demonstrate that improved education of asthma patients and of their
surroundings is necessary.
Regarding the pre-hospital care, 70% of children included in our study
had received prior treatment, but this treatment was inappropriate in
53% of cases. Only 17% had received appropriate consistent treatment
with current recommendations, with a beta-2 agonist being used in 58%
of cases and in combination with oral corticosteroids in 20% of cases.
The support expected before medical consultation is of course not
identical in the case of a first attack or in the case of asthma that is
already known. These figures, however, point to a persistent use of
inappropriate treatment in the asthma crisis.
In addition, the time between the onset of respiratory symptoms and
emergency management was most often very long (in less than 10% of
cases, patients consulted the emergency department within six hours
following the onset of symptoms). Recommendations encourage taking
medical advice in the absence of improvement of symptoms after a
suitable treatment with a beta-2 agonist16. The time
between the first clinical signs and the beginning of possible
pre-hospital medical care could not be collected. This information was
non-existent for nearly 30% of patients. We did not find a relationship
between the remoteness of the domicile in relation to the pediatric
emergency department, which confirms that this very high delay does not
come from a lack of access to care but more likely from an
underestimation of symptoms by the patient or the patient’s family.
The results of our study show a flaw that is not negligible in the
recognition of the symptoms of asthmatic exacerbation and in its initial
management. It reflects a lack of knowledge of the disease in patients
and their families and insufficient awareness of health professionals
and current treatment recommendations. Concerning this last point, our
survey joins other studies conducted in different areas and testifies to
the difficulty of implementing conferences consensus. There is sometimes
a delay of several years between the development of the recommendations
and the evolution of outpatient medical
practices.41-43
We did not demonstrate a direct correlation between severity of
exacerbations and non-compliance, length of time taken to consult the
hospital, and lack of initial management of the crisis. However, it
seems obvious that the use of emergency care by these children could be
reduced through improved control of their illness. This could be done by
deliverance and explanation of written action plans of the actions to be
taken in case of crisis to families, the functional respiratory
follow-up of the patient, and encouraging attendance of asthma classes.
Our work highlights a lack of diagnosis, especially in infant asthma. It
strengthens data concerning a lack of knowledge of the disease by the
family of the asthmatic child and a poor application of treatment
recommendations from health professionals. A consultation in pediatric
emergencies can be an opportunity to start education and set up a
specialized follow-up if necessary in partnership with the pediatrician
or doctor. Improving asthma management would reduce the use of
emergencies by improving diagnosis, particularly in infants, increasing
awareness of the disease, correction of the current perception of
treatments and their use, and an optimization of coordination
hospital-city. In this regard, is important to mention the potential
interest of training in therapeutic education of doctors in the private
sector to improve the current situation. It would be interesting to
evaluate this by a new prospective study of the impact of such
therapeutic education in terms of asthma control and the use of
emergency care.