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Nigerian J Paediatrics 2016 Vol 43 Issue 2

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3Prevalence and pattern of asthma exacerbation in children seen at the University of Nigeria Teaching Hospital Enugu
Niger J Paediatr 2016; 43 (2): 78 – 82
ORIGINAL
Edelu BO
Prevalence and pattern of asthma
Eze JN
Ayuk AC
exacerbation in children seen at the
Oguonu T
University of Nigeria Teaching
Hospital, Enugu
DOI:http://dx.doi.org/10.4314/njp.v43i2.3
Accepted: 15th January 2016
Abstract :
Background:
Acute
dren within the study period with
exacerbation is a major cause of
eight children having multiple epi-
Edelu BO (
)
morbidity in asthmatic children. It
sodes. This represented 6.5% of
Department of Paediatrics,
can occur even in well controlled
the overall number of emergency
University of Nigeria College of
Medicine/ University of Nigeria
asthma.
cases seen during the period.
Teaching Hospital, Enugu, Nigeria.
Aim: To determine the prevalence
Nearly an equal number (ratio; 1:
Email: onyedelu@yahoo.com
and pattern of acute exacerbation
1.04) of males and females were
of asthma in children seen at the
enrolled with the mean age of 7.9
Eze JN, Ayuk AC
emergency room of the University
± 4.7 years. More children with
Department of Paediatrics,
of Nigeria Teaching Hospital
asthma exacerbations were admit-
University of Nigeria Teaching
(UNTH), Enugu.
ted during the rainy season months
Hospital, Enugu, Nigeria.
Materials and methods: This was
of May and June, while the dry
a descriptive, cross sectional
season months of December and
study in which consecutive chil-
January recorded lower number of
dren with acute exacerbation of
episodes.
Most (86.0%) cases
asthma presenting to the Children
were mild to moderate exacerba-
Emergency Room (CHER) of
tions and 16 (15.3%) were severe.
UNTH, Enugu were recruited.
Three of the 22 (13.6%) children
Information from the history and
on controller medications were
examination were documented
among the 16 that had severe exac-
with a structured questionnaire
erbation. No death was recorded
completed by the attending doc-
during the period.
tor. Severity of their exacerbation
Conclusion: The prevalence of
was determined using the Global
asthma exacerbation is relatively
Initiative for Asthma (GINA)
high in our tropical environment
guidelines. The children were
and the pattern is similar to those
treated using the written manage-
of the developed countries in terms
ment protocol used in CHER,
of age and sex distribution, how-
UNTH, Enugu which was adapted
ever, the peak period of presenta-
from GINA guidelines.
tion differ in our environment.
Results: There were a total of 114
presentations (episodes) of acute
Key words: Asthma, exacerbation,
exacerbation asthma by 104 chil-
children, prevalence, pattern
Introduction
tized asthmatics. 2 These exacerbations are characteristi-
cally worse at night and can progress to severe airflow
Asthma exacerbation is said to occur when there is an
obstruction, shortness of breath, and respiratory distress
and insufficiency. Rarely, severe sequelae such as hy-
2
acute or sub-acute deterioration in symptom control that
poxic seizures, respiratory failure, and death can occur.
2
is sufficient to cause distress or risk to health, and neces-
sitates a visit to a health care provider or requires treat-
It has also been noted that severe asthma exacerbation
They may also be
can occur in children with mild or controlled asthma.
3
ment with systemic corticosteroids.
1
referred to as “attacks”, “episodes” or “flare ups”.
1
Exacerbations of asthma symptoms produce significant
Asthma exacerbations appear to be quite common and
cost to health care systems and seriously diminish the
quality of life of patients and their families.
4,5
may occasionally be the first presentation of asthma in a
It also
child.
2
The course and severity may be difficult to pre-
accounts for disproportionate health care costs when
compared to the management of stable state asthma.
5
dict. Common respiratory viral infections and inhalant
It
allergen exposure may induce prolonged periods (i.e.,
is the most common cause of childhood emergency
from days to weeks) of asthma exacerbations in sensi-
room visits, hospitalization and school absenteeism in
79
the United States, accounting for 867,000 emergency
further management.
room visits, 166,000 hospitalizations and 10.1 million
Data collected was entered and analyzed using the IBM
school days lost annually. More so, asthmatics requir-
2
SPSS Statistics software version 20 (IBM Corp,
ing emergency room visit or hospitalization are at sig-
Armonk, NY. USA, 2011). The proportion of children
nificantly increased risk of future exacerbation which is
presenting with acute asthma exacerbation in relation to
independent of demographic and clinical factors, sever-
all childhood emergencies that were attended to during
ity and level of asthma control.
6
this period was calculated. The age, sex, clinical features
In Nigeria, it is estimated that about 5 – 10 % of the
were described with the aid of tables. The frequency of
children in any given community have asthma. This
7
presentation was plotted against the months of presenta-
study was done to find out the prevalence and pattern of
tion. Duration of hospital stay as well as outcome of
presentation of asthma exacerbation in our environment.
treatment was described. The end point was discharge
This will help improve clinical practice and management
following disappearance of symptoms or death. The
of acute asthma in Nigeria.
severity of presentation in relation to use of controller
medication was analyzed. A p value of < 0.05 was re-
garded as significant. Results were presented in prose,
tables and graph.
Subjects and Methods
This was a cross-sectional study conducted at the Chil-
dren Emergency Room (CHER) of the University of
Results
Nigeria Teaching Hospital, Ituku/Ozalla, Enugu between
May 2013 and April 2014. The hospital is located in the
The total number of children that presented at CHER
rain forest region of Nigeria, with an average annual
during the study period was 1751, of which 114 were
rainfall of 1520mm and 2030mm and average high and
cases of acute asthma giving a prevalence rate of 6.5%.
low temperatures of 22.4 C and 30.8 C respectively.
o
o
These 114 presentations were made by 104 children.
CHER is open 24hours a day and handles all cases of
There were eight multiple presentations; seven of them
emergencies in children. About one thousand two hun-
presented twice within the period, while one child pre-
dred patients are attended to annually in the Children
sented four times. Fifty-six (49.1%) of the presentations
Emergency Unit. The patients come from different parts
were made by male children while the remaining were
of Enugu metropolis as well as neighbouring towns and
by females, giving a M: F ratio of 1: 1.04. The children
states. The patient population is made up of children
were aged from one year to 18 years, with a median age
from diverse ethnicity, but predominantly Igbos.
of 7 years. Table 1 shows the ages and sex distribution
Children presenting to the Children Emergency Unit of
of the children. The frequency of presentation decreased
University of Nigeria Teaching Hospital Enugu over a
with age.
period of one year with a diagnosis of acute exacerba-
tion of asthma (based on GINA guidelines) were re-
Most (88/114, 77.2%) of the presentations were children
cruited in the study. Children with clinical features sug-
with previous diagnosis of asthma, while the remaining
gestive of alternative diagnosis such as bronchiolitis
26 (22.8%) were newly diagnosed at presentation.
were excluded from the study. Ethical approval was
Presentations were more in the heavy rainy season
obtained from the University of Nigeria Health Research
months of May (18.4%) and June (16.7%), while the dry
and Ethics Committee before the commencement of the
season months of December (3.5%) and January (1.8%)
study.
recorded the least presentations, figure 1.
Using a structured questionnaire, patient related data
Table 1: Age distribution of the children with acute
such as sex, age, place of domicile as well as other his-
exacerbations
torical data like time of onset, duration of symptoms,
Age (years)
Frequency
Percentage
Males
Females
other presenting clinical symptoms such as cough, ca-
1 – 4
36
31.6
18
18
tarrh, breathlessness and wheeze were ascertained from
5 – 8
34
29.8
16
18
the caregiver and older children. Physical examination
9 – 12
22
19.3
15
7
was done to document the vital signs such as pulse and
13 – 16
16
14.0
4
12
respiratory rates. Oxygen saturation in room air was
>16
6
5.3
3
3
Total
114
100.0
56
58
done and presence of dyspnoea, tachypnoea and pres-
ence of rhonchi sought. Using the Global Initiative for
Asthma (GINA) guidelines, the children were catego-
Fig 1: Pattern of annual presentation of acute exacerbations
rized into mild, moderate and severe based the severity
of the exacerbation.
Subsequently the patients were treated using the asthma
management protocol recommended in the GINA guide-
lines. Treatment received as well as the child’s response
and final outcome were documented. On discharge, the
children were followed up in the asthma clinic for
80
The commonest symptoms were cough and breathless-
Discussion
ness which were reported by 95.6% and 97.4% respec-
tively, while the most common signs elicited were dysp-
The prevalence of acute exacerbation of asthma among
noea and expiratory rhonchi, which were present in all
children seen at the emergency room of the University
the children. Less than two thirds (61.4%) of the pres-
of Nigeria Teaching Hospital, Enugu is 6.5%. Gener-
entations were within 24 hours of onset of symptoms
ally, data on asthma exacerbation are not very common.
while 81.6% were within 48hrs. Table 2 shows the fre-
In the United States of America (USA), the acute exac-
quency of the symptoms and signs. The oxygen satura-
erbation rate reported in 2005 was 5.2% when the over-
all asthma rate in children was 8.9%. In another report
4
tion (SpO 2 ) of the children at presentation ranged from
72% to 99% with a mean SpO 2 of 94.5 ± 5.4%. Most
also from USA, 2% of all outpatient visits and 2.3% of
(98 /114, 86.0%) of the episodes were mild to moderate
emergency room visits were for acute exacerbations
among children less than 18 years.
8
exacerbations while 16 cases (14.0%) were categorised
In a retrospective
as severe.
survey of asthmatic children in seven European coun-
tries, 18% needed one or more emergency room presen-
Table 2: Clinical features present in the children
tation as a result of exacerbation within a one year pe-
riod.
9
Symptoms
Frequency
Percentage
Cough
109
95.6
Wheeze
65
57.0
Asthma may have its onset at any age. The ages of the
Breathlessness
111
97.4
children in the current study ranged from 1 to 18years.
Chest pain
36
31.6
It has been documented that about 30% are symptomatic
Catarrh
36
31.6
by one year of age.
2
The decreasing presentation with
Fever
24
21.1
Signs
age shows that asthma exacerbation is more common
Dyspnoea
114
100.0
among the younger age group. The rate of presentation
Rhonchi
114
100.0
decreased with age as observed in several other stud-
ies.
4,10
Cyanosis
0
-
This may be explained by the fact that rhinovirus
Crepitation
13
11.4
infection which is most prevalent in children under the
age of 5 years play a significant role in asthma exacerba-
tions in children.
4,11,12
Twenty two of the 88 previously diagnosed asthmatics
(25%) were on controller medications. These were
It has been shown generally that asthma is more preva-
mainly steroid and long-acting beta2 agonist (LABA)
lent in boys than girls.
11, 13
However, in the case of ex-
combination for periods ranging from 4 months to 6
acerbation, this trend only persist in early childhood but
years. Three of the 22 (13.6%) children on controller
begin to reverse as the children get older with almost
medication had severe exacerbation as against 13/66
equal rate between 5 and 10 years and more girls be-
(19.7%) not on controller medications ( χ =0.95, p =
tween the ages of 11 to 17 years having more exacerba-
0.63).
tion than boys of same age group and females almost
In 82.8% (83/114) of cases, a reliever medication was
doubling the number of males by adulthood.
4,8
This
used at home prior to presentation. This included twelve
change in trend have been postulated to be due to hor-
(46.2%) of the 26 newly diagnosed cases. Medications
monal changes.
4
used, either singly or in combination included; inhaled
salbutamol (16.7%), Tablet salbutamol (33.3%), Predni-
Most of the children presenting were already known
solone (16.7%), Aminophyline (16.7%), and Antihista-
asthmatics but, over 20% were diagnosed at presentation
mines (33.3%) In twenty two (19.3%) cases, antibiotics
despite some of them having symptoms for several
were commenced prior to presentation.
years. Also, many of these children already received
Most (74.6%) of the subjects spent less than 12 hours in
treatments which included antibiotics, oral salbutamol
the emergency room, only 3.5% spent over 48 hours on
and theophylline before presentation. This brings to the
admission in the emergency room. Table 3. None of the
fore the need for proper education on the need to seek
children seen required admission into the intensive care
proper treatment to curb the risks of misguided treat-
unit and no death was recorded.
ment and avoidable deaths.
Table 3: Duration of admission for children with acute
Although controller medications does not prevent occur-
exacerbation
rence of acute exacerbation it reduces the severity and
Duration (hrs)
Frequency
Percentage
frequency of acute exacerbations and helps to achieve a
< 12
85
74.6
better quality life.
3,4
In this study, three (13.6%) out of
12 to <24
18
15.8
the twenty-two children on controller medications suf-
to <48
7
6.1
fered severe exacerbation, although adherence to medi-
≥48
4
3.5
Total
114
100.0
cation was not studied.
In high income countries in the Northern hemisphere as
well as in Australia and New Zealand, asthma exacerba-
tion in children is said to peak during the early autumn
(September), which is associated with lots of wind and
4
81
heavy rainfall driving pollen and respiratory viruses. In
children with cough as their only complaint, examina-
our study, the peak presentation occurred in May and
tion revealed signs of dyspnoea. This means that some
June which are also associated with heavy rainfall and
children and caregivers are either ignorant or not very
wind with the high prevalence of viral respiratory infec-
observant about the symptoms and signs of asthma.
tions. Several studies
4,11,12
have implicated respiratory
Thus, continuous asthma education is necessary to help
viruses especially rhinovirus as having a significant as-
them identify early pointers to an acute exacerbation.
sociation with childhood asthma exacerbation. A review
About 20% of the children had received antibiotics prior
by Tan
12
suggests that viruses provoke asthma attacks
to presentation.
Although antibiotics is occasionally
by additive or synergistic interactions with allergen ex-
prescribed in acute exacerbation, especially when there
posure or with air pollution.
is fever or crepitation, studies suggest that there is little
rationale for routine antibiotic use in children with acute
exacerbation in the tropics.
4,11
Weather changes may affect the airways directly by
This practice is however,
cooling or irritating them or indirectly by influencing the
not unconnected with the mentality of the caregivers that
level of airborne irritants and allergens. Exacerbations
believe that every cough should be treated with antibiot-
of asthma have been shown to correlate with low tem-
ics as well as the easy availability of antibiotics over the
perature and humidity,
14
which is similar to the climate
counters in medicine stores in the country. This practice
during the early rainy season in our environment.
can be a cause of delayed presentation.
Heavy rainfall associated with thunder has also been
associated with increased prevalence of asthma exacer-
The short duration spent in the emergency room by most
bation.
15,16
While Mark et al
15
attributed this observa-
of the children may be a pointer to the efficiency of
tion to an outflow of colder air associated with the down
good management plan which was used in all cases and
draught of thunderstorm sweeping up pollen grains and
the absence of mortality among the 114 case presenta-
particles and then concentrating them in a shallow band
tions supports the fact that although exacerbation is rela-
of air at ground level, Dales and his colleagues attrib-
16
tively common, mortality from asthma is quite rare in
children.
2,3,7
uted it to increased fungal spores released during storms.
A steady decrease in the mortality has
been reported over the years.
18
A second, though lower peak occurring in September
coincided with the resumption of school after the long
vacation in Nigeria. This trend which has also been re-
ported in England and Canada
4,17
may not be uncon-
nected with airborne substances including respiratory
Conclusion
viruses and moulds and other allergens from abandoned
classroom which can be triggers. Johnston et al on this
17
In conclusion, asthma exacerbation is relatively common
observation suggests that rhinovirus infections con-
in our tropical environment and the presentation is
tracted from school mates may play a role in this exacer-
somewhat similar to those of the developed countries in
bation.
terms of age and sex distribution, however, in our envi-
ronment, presentation is highest during the rainy season
Expectedly, the commonest presenting symptoms were
and during school resumption from long vacation.
cough and breathing difficulty which are the two cardi-
nal features that are often associated with asthma exac-
Conflict of interest: None
erbation. Chest pain/ tightness and audible wheeze were
Funding: None
not frequent presenting symptoms.
However, even in
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