Asthma is a multifactorial disease with heterogeneous clinical phenotype and complex genetic inheritance [6].

Childhood multiple environmental exposures and influences contribute to the increased incidence of asthma and excess asthma morbidity among children with asthma [7].

The primary aim of asthma management is to make an early diagnosis and to achieve a prompt control of symptoms, in order to reduce the risk of future exacerbations and progressive loss of lung function [8].

Important factors that have been reported to facilitate improvement in primary care management of asthma include the availability of good organizational support and access to resources within the practice, as well as having a dedicated asthma team [9].

Uncontrolled asthma in children is still highly prevalent despite the availability of effective asthma treatment. Uncontrolled asthma may be due to the improper dose of treatment, family negligence, improper use of inhalers, or the presence of comorbidity [10].

The aim of this study was to find a correlation between precipitating factors of acute asthma attack patients attending to the emergency department and different factors such as socioeconomic status (education, occupation, home sanitation), family negligence, or medication unaffordability and outcome.

Our study included 170 asthmatic patients (diagnosed with asthma according to Global Initiative for Asthma [5] following up in a pediatric allergy clinic in a pediatric specialized hospital at Cairo University.

The mean age of our patients at recruitment was 5 ± 2 years with a minimum of 2 years and a maximum of 12 years.

In our study, we found male predominance. This comes in agreement with Dias et al. who reported that males attended to ER more than females [11].

The majority of our cases were from urban areas (77%) where more pollution, crowdedness, and smoking. These factors may contribute to the increased prevalence of asthma in urban areas.

This is in agreement with Grant et al. study which was conducted on 1600 children were attended to ER. More than 60% of them lived in urban areas. Residence in urban or poor areas was all independently associated with an increased risk of asthma-related ED visits and hospitalizations [7].

We found out those sociodemographic characteristics of patients as age, gender did not have any statistically significant relation with more attendance to the emergency department, this is in concordance to a study by Giraud et al. who demonstrated that age and gender has no impact on attendance to ER [12].

In our study, we demonstrated that non-compliance to asthma treatment has a statistically significant relation with frequent attendance to ER in the previous 6 months (p value was 0.047).

Our study recorded that the most common causes of non-compliance to asthma treatment are family negligence (34.1%), family illiteracy (34.1%), and financial disability (17.1%).

In support of our study, Chen et al. and Ramkillawan et al. who found out that the education level of the caregivers has been reported as significant factors related to more attendance to ER [13, 14].

This is in contrast to a study by Joy et al. the mothers' educational level did not show any statistically significant association with the asthma control status of participants [15].

This is in concordance with Biagioli et al. study that was enriched on 213 families with 268 children, 150 (56.0%) reported that their household income was low. One hundred six (39.6%) missed at least one health supervision visit, and 85 (31.7%) had at least one ER visit within the past 12 months. Children who were ER users were younger (mean age 6.4 years, P < 01), more likely to live in a low-income household (65.9%, P = 0.03), and more likely to have missed health supervision appointments (65.9% P < 01). Nonadherence to health supervision visits is an independent risk factor and potentially modifiable [16].

Another study of Kheirkhahp et al. demonstrated that low income and non-adherence to health supervision visits are risk factors that increase ER utilization. Providing low-cost, reliable, and accessible continuity of care for children living in poverty, providing appointment reminders, and educating families on the importance of health maintenance visits may optimize health outcomes while decreasing the rates of ER visits [17].

In another study of Anderson et al. on 183 children, they found that under half of parents/carers in their study sample admitted, they do not refer to the prescription of a pediatric individualized asthma action plan (IAAP), as well as compliance with that plan. Plan when their child is having an exacerbation. The self-reported low rates of plan utilization and compliance support this hypothesis [18].

In our study, we demonstrated that the most presenting symptoms of patients attending to ER were cough (100%), then wheezes 88.2%, then dyspnea 85.8%, then chest tightness 21.2%, and only (0.01%) presented by cyanosis.

In support of our study, Mustafa et al. study which was conducted on 60 children attending to ER with acute asthmatic attacks. Forty-five percent of these children presented to the emergency room with cough, while 15% of them presented to the emergency room with wheezes, and only 10% of them presented to the hospital immediately by chest tightness and dyspnea [19].

In our study, regarding precipitating factors of asthma exacerbation, there is a high statistically significant relation between patients who were regularly exposed to irritant inhalers (p value was 0.041) with attending to ER in the previous 6 months.

Another study in support of our observations analyzed the synergy between environmental factors (pollutant, allergenic birch pollen, weather) and its relationship with asthma hospitalization in Montreal, Canada. Moreover, the explained variance of asthma hospitalization due to air pollution rises from about less than 7% to about 28% (R = 0.53, p < 0.05). Statistical tests for interaction and overall results point towards a synergy between environmental factors which exacerbated asthma [20].

In our study, there was a statistically significant relation between patients who practiced vigorous physical activities (P value was 0.038) and frequency of ER attendance in the previous 6 months.

This is in concordance with Aggarwal et al. study that was enriched in Children with controlled asthma (n = 101) underwent characterization and free-running exercise bronchoprovocation at a center in Nigeria. Lung function was measured before, then 5, 10, 15, and 30 min after a 6- to 8-min exercise. The result of this study was 30% had no exercise-induced bronchoconstriction (EIB), and 70% had severe EIB [21].

In our study, there was no statistically significant relation between patients who were exposed to passive smoking (p value was 0.779) and attendance to ER in the previous 6 months.

This is in disagreement with Belvisi and Newman [22] study of 276 children with asthma who were exposed to passive smoking. Belvisi et al. study found that passive smoking was positively associated with ER visits (p < 0.01), but not with hospitalizations or abnormalities in pulmonary function. The frequency of asthma symptoms per month was also directly associated with ER visits (p < 0.02). The estimated mean annual increase in ER visits is attributable to the presence of one or more smokers in the household [22].

In our study, there was no statistically significant relation between patients who were exposed to certain food (p value was 0.494) and attendance to ER in the previous 6 months.

On the other hand, Julia et al.’s [23] study of 400 children with asthma attending to ER found that there was a strong association between the presence of food sensitization and poor asthma control, including increased asthma-related health-care utilization and emergency medication use. Therefore, besides food allergy (FA) education and management, patients with FA and with asthma should optimize medical therapy for their asthma and receive asthma education [23].

Our study recorded that there was no statistically significant relation between patients exposed to upper respiratory tract infection (p value was 0.795) and attendance to ER in previous 6 months.

This is in disagreement with Jartti et al. [24] study which demonstrated that asthma exacerbation usually occurred in response to a variety of external agents, including respiratory viruses and bacteria. However, it was estimated that up to 85–95% of asthma exacerbations in children were linked to viral infections. Hospital admissions for asthma exacerbations correlated with a seasonal increase of Rhinovirus infections in autumn and in spring [24].

In our study, the majority of patients (96.5%) who could be stabilized with medications were discharged, whereas a merge proportion of critically ill patients (3.5%) required ICU admission. However, no deaths were reported.

This is in contrast to a study by Haselkorn et al. that demonstrated about 1745 ER visits admitted by asthma exacerbation were registered in the considered timeframe. A persistent and significant increase in ER admissions for asthma has been registered from 2013 to 2015, as shown in Fig. 3 [25].

Persistent and significant increase in ER admissions for asthma has been registered from 2013 to 2015

This is in concordance to Gavada et al.’s study that was enriched on 424 children with asthma exacerbation coming to ER. About 80% of them were discharged while 20% were hospitalized [26].