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.