Results
A total of 512 children presented to the ED for asthma related symptoms during the study periods: 273 children during 2019 (124 in 2019A, 89 in 2019B and 60 in 2019C) and 239 children during 2020 (125 in 2020A, 51 in 2020B and 63 in 2020C). Demographic data were similar except for their age, which was younger during 2019; median age of 5.2, 5.3 and 4.7 years during 2019A, 2019B and 2019C compared with 6.7, 6.7 and 6.6 years during 2020A, 2020B and 2020C, respectively (p=0.06). Male and Bedouin Arab descent were the majority of the study population in all periods. There were more visits among Bedouin patients during lockdown, compared with the parallel period in 2019 (60.7 % in 2019B vs 78.4 in 2020B, p=0.002). Similar number of patients with chronic non-respiratory diseases (e.g. epilepsy, Down syndrome) and chronic respiratory diseases (bronchopulmonary dysplasia, pulmonary hypertension and obstructive sleep apnea) or atopy was observed during 6 time periods. Data regarding the use of chronic respiratory medications; inhaled corticosteroids (ICS), long acting beta agonist (LABA), short acting beta agonists (SABA) and leukotriene receptor antagonist (LTRA) is presented intable 1 .
We identified a decrease in use of chronic respiratory treatment in 2020 compared with 2019; 17.7%, 11.2% and 20% during 2019 A, 2019B and 2019C in comparison to 11.2%, 5.9% and 6.3% during 2020A, 2020B and 2020C respectively (p= 0.013). Mean vital signs (fever, blood pressure and oxygen saturation on room air) were similar between time periods, except for heart rate (124 vs 115 beats per minute, p=0.039) and respiratory rate (30 vs 25 breaths per minute, p=0.005) that were lower during 2020, compared with 2019. Similar rate of abnormal radiological findings included bilateral hyperinflation, lobar infiltrates and atelectasis was observed (Table 2 ). Treatment during ED visit included oxygen, inhaled beta agonist and anticholinergic agents, systemic steroids, inhaled steroids, antihistamines and antibiotics (Table 3 ). Treatments were similar between periods except for sodium chloride 0.9% for inhalation, which significantly decreased during 2020 compared with 2019 (19.6% vs 48.3 %, p=0.002).
There was no difference in the triage acuity evaluation on admission to the ED. We report a significantly fewer ED visits during the lockdown period, comparing to the parallel period in 2019. A clear trend was demonstrated during 2019 with fewer visits, as time goes by, in the spring and summer time. On the contrary, during 2020 we demonstrated similar visits’ numbers prior to lockdown (124 vs 125 visits), with significant decrement during lockdown (89 vs 51 visits) and increment post lockdown (60 vs 63 visits). When standardized for number of visits per day, as the duration of each time period was different (A- 6 weeks, B- 8 weeks and C- 6 weeks), similar results were observed. Number of ED visits per day was 3.3, 1.8 and 1.7 during 2019A, 2019B and 2019C respectively, in comparison to 3.1, 1.4 and 2 during 2020A, 2020B and 2020C respectively (p <0.001), Figure 1a .
The number of visits per day increased significantly in the era after lockdown when comparing 2020C to 2020B (2 vs. 1.43 visits per day, p<0.001) as well as when compared to the same time period in 2019 (2 vs 1.76 visits per day (p<0.001) (Table 3 ).
During lockdown, hospitalization rate was higher (47.1% vs 33.7%, p=0.05) as was length of stay (3.15 vs 1.9 days, p= 0.03), possibly indicating higher severity (Figure 1b ). Only 6 patients were admitted or transferred to the PICU during 6 time periods, 4 of them necessitated high flow nasal cannula ventilation. There was no difference in PICU admissions rate or LOS in PICU, between time periods.