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Korang SK, Baker M, Feinberg J, Newth CJ, Khemani RG, Jakobsen JC. Non-invasive positive pressure ventilation for acute asthma in children. Cochrane Database Syst Rev 2024; 10:CD012067. [PMID: 39356050 PMCID: PMC11445801 DOI: 10.1002/14651858.cd012067.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/03/2024]
Abstract
BACKGROUND Asthma is one of the most common reasons for hospital admission among children, with significant economic burden and impact on quality of life. Non-invasive positive pressure ventilation (NPPV) is increasingly used in the care of children with acute asthma, although the evidence supporting it is weak, and clinical guidelines do not offer any recommendations on its routine use. However, NPPV might be an effective way to improve outcomes for some children with asthma. A previous review did not demonstrate a clear benefit, but was limited by few studies with small sample sizes. This is an update of the previous review. OBJECTIVES To assess the benefits and harms of NPPV as an add-on therapy to usual care (e.g. bronchodilators and corticosteroids) in children (< 18 years) with acute asthma. SEARCH METHODS We searched the Cochrane Airways Group Specialised Register, CENTRAL, MEDLINE, and Embase. We also conducted a search of ClinicalTrials.gov and the WHO ICTRP. We searched all databases from their inception to March 2023, with no restrictions on language of publication. SELECTION CRITERIA We included randomised clinical trials (RCTs) assessing NPPV as add-on therapy to usual care versus usual care for children hospitalised for acute asthma exacerbations. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. MAIN RESULTS We included three RCTs randomising 60 children with acute asthma to NPPV and 60 children to control. All included trials assessed the effects of bilevel positive airway pressure (BiPAP) for acute asthma in a paediatric intensive care unit (PICU) setting. None of the trials used continuous positive airway pressure (CPAP). The controls received standard care. The median age of children ranged from three to six years, and asthma severity ranged from moderate to severe. Our primary outcome measures were all-cause mortality, serious adverse events, and asthma symptom score. Secondary outcomes were non-serious adverse events, health-related quality of life, arterial blood gases and pH, pneumonia, cost, and PICU length of stay. None of the trials reported any deaths or serious adverse events (except one trial that reported intubation rate). Two trials reported asthma symptom score, each demonstrating reductions in asthma symptoms in the BiPAP group. In one trial, the asthma symptom score was (mean difference (MD) -2.50, 95% confidence interval (CI) -4.70 to -0.30, P = 0.03; 19 children) lower in the BiPAP group. In the other trial, a cross-over trial, BiPAP was associated with a lower mean asthma symptom score (MD -3.7; 16 children; very low certainty evidence) before cross-over, but investigators did not report a standard deviation, and it could not be estimated from the first phase of the trial before cross-over. The reduction in both trials was above our predefined minimal important difference. Overall, NPPV with standard care may reduce asthma symptom score compared to standard care alone, but the evidence is very uncertain. The only reported serious adverse event was intubation rate in one trial. The trial had an intubation rate of 40% and showed that BiPAP may result in a large reduction in intubation rate (risk ratio 0.47, 95% CI 0.23 to 0.95; 78 children), but the evidence is very uncertain. Post hoc analysis showed that BiPAP may result in a slight decrease in length of PICU stay (MD -0.87 day, 95% CI -1.52 to -0.22; 100 children), but the evidence is very uncertain. Meta-analysis or Trial Sequential Analysis was not possible because of insufficient reporting and different scoring systems. All three trials had high risk of bias with serious imprecision of results, leading to very low certainty of evidence. AUTHORS' CONCLUSIONS The currently available evidence for NNPV is uncertain. NPPV may lead to an improvement in asthma symptom score, decreased intubation rate, and slightly shorter PICU stay; however, the evidence is of very low certainty. Larger RCTs with low risk of bias are warranted.
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Affiliation(s)
- Steven Kwasi Korang
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region of Denmark, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Anesthesiology Critical Care Medicine, Childrens Hospital Los Angeles, Los Angeles, California, USA
| | | | - Joshua Feinberg
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region of Denmark, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Christopher Jl Newth
- Department of Anesthesiology Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Robinder G Khemani
- Department of Anesthesiology Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Janus C Jakobsen
- Cochrane Hepato-Biliary Group, Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region of Denmark, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Cardiology, Holbaek Hospital, Holbaek, Denmark
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2
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Craig S, Collings M, Gray C, Benito J, Velasco R, Lyttle MD, Roland D, Schuh S, Shihabuddin B, Kwok M, Mahajan P, Johnson M, Zorc J, Khanna K, Fernandes R, Yock-Corrales A, Santhanam I, Cheema B, Ong GYK, Jaiganesh T, Powell C, Nixon G, Dalziel S, Babl FE, Graudins A. Analysis of guideline recommendations for treatment of asthma exacerbations in children: a Pediatric Emergency Research Networks (PERN) study. Arch Dis Child 2024; 109:468-475. [PMID: 38325912 DOI: 10.1136/archdischild-2023-326739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2023] [Accepted: 01/23/2024] [Indexed: 02/09/2024]
Abstract
RATIONALE There is significant practice variation in acute paediatric asthma, particularly severe exacerbations. It is unknown whether this is due to differences in clinical guidelines. OBJECTIVES To describe and compare the content and quality of clinical guidelines for the management of acute exacerbations of asthma in children between geographic regions. METHODS Observational study of guidelines for the management of acute paediatric asthma from institutions across a global collaboration of six regional paediatric emergency research networks. MEASUREMENTS AND MAIN RESULTS 158 guidelines were identified. Half provided recommendations for at least two age groups, and most guidelines provided treatment recommendations according to asthma severity.There were consistent recommendations for the use of inhaled short-acting beta-agonists and systemic corticosteroids. Inhaled anticholinergic therapy was recommended in most guidelines for severe and critical asthma, but there were inconsistent recommendations for its use in mild and moderate exacerbations. Other inhaled therapies such as helium-oxygen mixture (Heliox) and nebulised magnesium were inconsistently recommended for severe and critical illness.Parenteral bronchodilator therapy and epinephrine were mostly reserved for severe and critical asthma, with intravenous magnesium most recommended. There were regional differences in the use of other parenteral bronchodilators, particularly aminophylline.Guideline quality assessment identified high ratings for clarity of presentation, scope and purpose, but low ratings for stakeholder involvement, rigour of development, applicability and editorial independence. CONCLUSIONS Current guidelines for the management of acute paediatric asthma exacerbations have substantial deficits in important quality domains and provide limited and inconsistent guidance for severe exacerbations.
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Affiliation(s)
- Simon Craig
- Department of Paediatrics, Monash University, Clayton, Victoria, Australia
- Department of Paediatric Emergency, Monash Health, Clayton, Victoria, Australia
| | - Madeline Collings
- Department of Paediatrics, Monash University, Clayton, Victoria, Australia
| | - Charmaine Gray
- Adelaide Medical School, Discipline of Paediatrics, The University of Adelaide, Adelaide, South Australia, Australia
- Department of Paediatric Emergency, Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - Javier Benito
- Department of Pediatric Emergency, Cruces University Hospital, Bilbao, Basque Country, Spain
- University of the Basque Country, Bilabo, Basque Country, Spain
| | - Roberto Velasco
- Pediatric Emergency Unit, Hospital Universitari Parc Taul, Sabadell, Spain
- Paediatrics and Child Health, University College Cork, Cork, Ireland
| | - Mark D Lyttle
- Emergency Department, Bristol Royal Hospital for Children, Bristol, UK
- Research in Emergency Care Avon Collaborative Hub (REACH), University of the West of England, Bristol, UK
| | - Damian Roland
- SAPPHIRE Group, Health Sciences, University of Leicester, Leicester, UK
- Paediatric Emergency Medicine Leicester Academic (PEMLA) Group, Department of Children's Emergency, Leicester Royal Infirmary, Leicester, UK
| | - Suzanne Schuh
- Division of Pediatric Emergency Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- SickKids Research Institute, Toronto, Ontario, Canada
| | - Bashar Shihabuddin
- Division of Emergency Medicine, Nationwide Children's Hospital, Colombus, Ohio, USA
- College of Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Maria Kwok
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University Irving Medical Center, New York, New York, USA
- Department of Pediatric Emergency, NewYork-Presbyterian Morgan Stanley Children's Hospital, New York, New York, USA
| | - Prashant Mahajan
- Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor, Michigan, USA
| | - Mike Johnson
- Department of Pediatrics, Division of Pediatric Emergency Medicine, The University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Joseph Zorc
- Division of Emergency Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kajal Khanna
- Department of Emergency Medicine, School of Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Ricardo Fernandes
- Department of Pediatrics, Hospital de Santa Maria, Lisboa, Portugal
- Clinical Pharmacology Unit, University of Lisbon, Lisboa, Portugal
| | - Adriana Yock-Corrales
- Department of Emergency, Hospital Nacional de Ninos Dr Carlos Saenz Herrera, C.C.S.S, San Jose, Costa Rica
| | - Indumathy Santhanam
- National Health Mission, Tamil Nadu, India
- PREM Simulation Laboratory, Institute of Child Health, Madras Medical College, Chennai, India
| | - Baljit Cheema
- Department of Paediatrics & Child Health, University of Cape Town Faculty of Health Sciences, Western Cape, South Africa
| | - Gene Yong-Kwang Ong
- Children's Emergency Department, KK Women's and Children's Hospital, Singapore
- Medical School, Duke University and the National University of Singapore, Singapore
| | | | - Colin Powell
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - Gillian Nixon
- Department of Paediatrics, Monash University, Clayton, Victoria, Australia
- Department of Respiratory Medicine, Monash Children's Hospital, Clayton, Victoria, Australia
| | - Stuart Dalziel
- Departments of Surgery and Paediatrics: Child and Youth Health, The University of Auckland, Auckland, New Zealand
- Department of Children's Emergency, Starship Children's Health, Auckland, New Zealand
| | - Franz E Babl
- Department of Paediatrics, Monash University, Clayton, Victoria, Australia
- Department of Emergency, Royal Children's Hospital, Melbourne, Victoria, Australia
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
- Departments of Paediatrics and Critical Care, University of Melbourne, Melbourne, Victoria, Australia
| | - Andis Graudins
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
- Monash Emergency Service, Emergency Department, Dandenong Hospital, Monash Health, Dandenong, Victoria, Australia
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Russi BW, Roberts AR, Nievas IF, Rogerson CM, Morrison JM, Sochet AA. Noninvasive Respiratory Support for Pediatric Critical Asthma: A Multicenter Cohort Study. Respir Care 2024; 69:534-540. [PMID: 38290751 PMCID: PMC11147613 DOI: 10.4187/respcare.11502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2024]
Abstract
BACKGROUND Noninvasive respiratory support (NRS) for pediatric critical asthma includes CPAP; bi-level positive airway pressure (BPAP); and heated, humidified, high-flow nasal cannula (HFNC). We used the Virtual Pediatric System database to estimate NRS by prescribing rates for pediatric critical asthma and characterize patient clinical features and in-patient outcomes by the initial NRS device applied. METHODS We performed a retrospective cohort study from 125 participating pediatric ICUs among children 2-17 years of age hospitalized for critical asthma and prescribed NRS from 2017 through 2021. The primary outcomes were NRS modality prescribing rates and trends. Secondary outcomes were descriptive and included demographics, comorbidities, severity of illness indices, and NRS failure rates (defined as escalation from the initial NRS modality to invasive ventilation, HFNC to BPAP or CPAP, or CPAP to BPAP). RESULTS Of the 10,083 encounters studied, the initial NRS modalities prescribed varied widely by hospital center (HFNC: 69.7 ± 29.6%; BPAP: 27.2 ± 7.1%; CPAP: 3.1 ± 5.9%). The mean rates of HFNC use increased from 59.7% in 2017 to 71.9% in 2021 (+2.5%/y). In contrast, BPAP (-1.6%/y) and CPAP (-0.8%/y) utilization declined throughout the study period. Older children who were obese and with a higher Pediatric Risk of Mortality III-Probability of Mortality score were more frequently prescribed BPAP and CPAP compared with HFNC. Those children on HFNC experienced higher noninvasive respiratory support failure rates versus BPAP (7.3% vs 2.4%; P < .001) but a lower subsequent invasive ventilation rate versus BPAP (0.8% vs 2.4%; P < .001). CONCLUSIONS In this multi-center cohort study, we observed that children with critical asthma are increasingly exposed to HFNC compared with BPAP and CPAP. Rates of HFNC failure were greater than those of BPAP failure, but a majority were transitioned to BPAP without subsequent invasive ventilation. The next steps include prospective trials, including practical end points such as patient comfort and optimal delivery of nebulized treatments to distinguish device superiority and suitable NRS utilization.
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Affiliation(s)
- Brett W Russi
- Division of Pediatric Critical Care Medicine, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - Alexa R Roberts
- Division of Pediatric Critical Care Medicine, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - Ignacio F Nievas
- Division of Pediatric Critical Care Medicine, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - Colin M Rogerson
- Division of Pediatric Critical Care Medicine, Indiana University School of Medicine and Riley Hospital for Children at IU Health, Indianapolis, Indiana
| | - John M Morrison
- Department of Pediatrics, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - Anthony A Sochet
- Department of Anesthesia and Critical Care Medicine, Johns Hopkins University School of Medicine, St. Petersburg, Florida.
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Plaza Moral V, Alobid I, Álvarez Rodríguez C, Blanco Aparicio M, Ferreira J, García G, Gómez-Outes A, Garín Escrivá N, Gómez Ruiz F, Hidalgo Requena A, Korta Murua J, Molina París J, Pellegrini Belinchón FJ, Plaza Zamora J, Praena Crespo M, Quirce Gancedo S, Sanz Ortega J, Soto Campos JG. GEMA 5.3. Spanish Guideline on the Management of Asthma. OPEN RESPIRATORY ARCHIVES 2023; 5:100277. [PMID: 37886027 PMCID: PMC10598226 DOI: 10.1016/j.opresp.2023.100277] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2023] Open
Abstract
The Spanish Guideline on the Management of Asthma, better known by its acronym in Spanish GEMA, has been available for more than 20 years. Twenty-one scientific societies or related groups both from Spain and internationally have participated in the preparation and development of the updated edition of GEMA, which in fact has been currently positioned as the reference guide on asthma in the Spanish language worldwide. Its objective is to prevent and improve the clinical situation of people with asthma by increasing the knowledge of healthcare professionals involved in their care. Its purpose is to convert scientific evidence into simple and easy-to-follow practical recommendations. Therefore, it is not a monograph that brings together all the scientific knowledge about the disease, but rather a brief document with the essentials, designed to be applied quickly in routine clinical practice. The guidelines are necessarily multidisciplinary, developed to be useful and an indispensable tool for physicians of different specialties, as well as nurses and pharmacists. Probably the most outstanding aspects of the guide are the recommendations to: establish the diagnosis of asthma using a sequential algorithm based on objective diagnostic tests; the follow-up of patients, preferably based on the strategy of achieving and maintaining control of the disease; treatment according to the level of severity of asthma, using six steps from least to greatest need of pharmaceutical drugs, and the treatment algorithm for the indication of biologics in patients with severe uncontrolled asthma based on phenotypes. And now, in addition to that, there is a novelty for easy use and follow-up through a computer application based on the chatbot-type conversational artificial intelligence (ia-GEMA).
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Affiliation(s)
| | - Isam Alobid
- Otorrinolaringología, Hospital Clinic de Barcelona, España
| | | | | | - Jorge Ferreira
- Hospital de São Sebastião – CHEDV, Santa Maria da Feira, Portugal
| | | | - Antonio Gómez-Outes
- Farmacología clínica, Agencia Española de Medicamentos y Productos Sanitarios (AEMPS), Madrid, España
| | - Noé Garín Escrivá
- Farmacia Hospitalaria, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | | | | | - Javier Korta Murua
- Neumología Pediátrica, Hospital Universitario Donostia, Donostia-San, Sebastián, España
| | - Jesús Molina París
- Medicina de familia, semFYC, Centro de Salud Francia, Fuenlabrada, Dirección Asistencial Oeste, Madrid, España
| | | | - Javier Plaza Zamora
- Farmacia comunitaria, Farmacia Dr, Javier Plaza Zamora, Mazarrón, Murcia, España
| | | | | | - José Sanz Ortega
- Alergología Pediátrica, Hospital Católico Universitario Casa de Salud, Valencia, España
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Dai J, Wang L, Wang F, Wang L, Wen Q. Noninvasive positive-pressure ventilation for children with acute asthma: a meta-analysis of randomized controlled trials. Front Pediatr 2023; 11:1167506. [PMID: 37187583 PMCID: PMC10175617 DOI: 10.3389/fped.2023.1167506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 04/10/2023] [Indexed: 05/17/2023] Open
Abstract
Background Noninvasive positive-pressure ventilation (NPPV) can be effective in children with acute asthma. However, clinical evidence remains limited. The objective of the meta-analysis was to systematically assess NPPV's effectiveness and safety in treating children with acute asthma. Methods Relevant randomized controlled trials were obtained from electronic resources, including PubMed, Embase, Cochrane's Library, Wanfang, and CNKI databases. The influence of potential heterogeneity was taken into account before using a random-effect model to pool the results. Results A total of 10 RCTs involving 558 children with acute asthma were included in the meta-analysis. Compared to conventional treatment alone, additional use of NPPV significantly improved early blood gas parameters such as the oxygen saturation (mean difference [MD]: 4.28%, 95% confidence interval [CI]: 1.51 to 7.04, p = 0.002; I2 = 80%), partial pressure of oxygen (MD: 10.61 mmHg, 95% CI: 6.06 to 15.16, p < 0.001; I2 = 89%), and partial pressure of carbon dioxide (MD: -6.29 mmHg, 95% CI: -9.81 to -2.77, p < 0.001; I2 = 85%) in the arterial blood. Moreover, NPPV was also associated with early reduced respiratory rate (MD: -12.90, 95% CI: -22.21 to -3.60, p = 0.007; I2 = 71%), improved symptom score (SMD: -1.85, 95% CI: -3.65 to -0.07, p = 0.04; I2 = 92%), and shortened hospital stay (MD: -1.82 days, 95% CI: -2.32 to -1.31, p < 0.001; I2 = 0%). No severe adverse events related to NPPV were reported. Conclusions NPPV in children with acute asthma is associated with improved gas exchange, decreased respiratory rates, a lower symptom score, and a shorter hospital stay. These results suggest that NPPV may be as effective and safe as conventional treatment for pediatric patients with acute asthma.
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Affiliation(s)
- Jiajia Dai
- Department of Respiratory Medicine, National Children's Medical Center, Children’s Hospital of Fudan University, Shanghai, China
| | - Libo Wang
- Department of Respiratory Medicine, National Children's Medical Center, Children’s Hospital of Fudan University, Shanghai, China
| | - Fang Wang
- Department of Pediatrics, Jinshan Hospital, Fudan University, Shanghai, China
| | - Lu Wang
- Department of Respiratory Medicine, National Children's Medical Center, Children’s Hospital of Fudan University, Shanghai, China
| | - Qingfen Wen
- Department of Pediatrics, Jinshan Hospital, Fudan University, Shanghai, China
- Correspondence: Qingfen Wen
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Punn D, Gill KS, Bhargava S, Pooni PA. Clinical Profile and Outcome of Children Requiring Noninvasive Ventilation (NIV). Indian J Pediatr 2022; 89:466-472. [PMID: 34812994 DOI: 10.1007/s12098-021-03965-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 08/03/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To determine the clinical profile and outcome of children requiring noninvasive ventilation (NIV) in a PICU. METHODS This prospective observational study was conducted in the PICU at Dayanand Medical College and Hospital, Punjab. Children (1 mo-18 y) with moderate-to-severe respiratory distress who received NIV during one-year period were included. Failure was defined as the need for endotracheal intubation. The patients received bilevel positive airway pressure (BiPAP) with inspiratory and expiratory positive airway pressure (8-18 cm H2O and 4-8 cm), respectively and indigenous continuous positive airway pressure (CPAP) were included. Vital signs (heart rate, respiratory rate) and gasometric parameters (pH, HCO3, pCO2, pO2) were recorded. RESULTS Out of total 115 patients, 81.7% were successfully treated by NIV whereas 18.3% constituted NIV failure group. Two types of NIV were used, 65.2% were started on BiPAP and 34.8% on indigenous bubble CPAP. Most common diagnosis was tropical fever (24.3%), bronchopneumonia (20%), and sepsis with multiple organ dysfunction syndrome (MODS) (7.8%). Commonest indication of NIV was respiratory distress (70.4%) and prevention of postextubation respiratory failure (20.8%). Seven patients (6.9%) died during the study. NIV failure is higher in children with sepsis with MODS, abnormal blood gas (acidosis), and moderate-to-severe acute respiratory distress syndrome (ARDS). CONCLUSIONS This study demonstrates that NIV is an effective form of respiratory support for children with acute respiratory distress/failure. Sepsis with MODS, acidosis and ARDS (moderate to severe) were predictors of NIV failure. Careful patient selection may help in judicious use of NIV in PICU.
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Affiliation(s)
- Daisy Punn
- Department of Pediatrics, Dayanand Medical College and Hospital, Ludhiana, Punjab, 141008, India
| | - Karambir Singh Gill
- Department of Pediatrics, Dayanand Medical College and Hospital, Ludhiana, Punjab, 141008, India.
| | - Siddharth Bhargava
- Department of Pediatrics, Dayanand Medical College and Hospital, Ludhiana, Punjab, 141008, India
| | - Puneet A Pooni
- Department of Pediatrics, Dayanand Medical College and Hospital, Ludhiana, Punjab, 141008, India
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Management of Children with Acute Asthma Attack: A RAND/UCLA Appropriateness Approach. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph182312775. [PMID: 34886505 PMCID: PMC8657661 DOI: 10.3390/ijerph182312775] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 11/25/2021] [Accepted: 11/30/2021] [Indexed: 12/22/2022]
Abstract
Bronchial asthma is the most frequent chronic disease in children and affects up to 20% of the pediatric population, depending on the geographical area. Asthma symptoms vary over time and in intensity, and acute asthma attack can resolve spontaneously or in response to therapy. The aim of this project was to define the care pathway for pediatric patients who come to the primary care pediatrician or Emergency Room with acute asthmatic access. The project was developed in the awareness that for the management of these patients, broad coordination of interventions in the pre-hospital phase and the promotion of timely and appropriate assistance modalities with the involvement of all health professionals involved are important. Through the application of the RAND method, which obliges to discuss the statements derived from the guidelines, there was a clear increase in the concordance in the behavior on the management of acute asthma between primary care pediatricians and hospital pediatricians. The RAND method was found to be useful for the selection of good practices forming the basis of an evidence-based approach, and the results obtained form the basis for further interventions that allow optimizing the care of the child with acute asthma attack at the family and pediatric level. An important point of union between the primary care pediatrician and the specialist hospital pediatrician was the need to share spirometric data, also including the use of new technologies such as teleconsultation. Monitoring the progress of asthma through spirometry could allow the pediatrician in the area to intervene early by modifying the maintenance therapy and help the patient to achieve good control of the disease.
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Van de Voorde P, Turner NM, Djakow J, de Lucas N, Martinez-Mejias A, Biarent D, Bingham R, Brissaud O, Hoffmann F, Johannesdottir GB, Lauritsen T, Maconochie I. [Paediatric Life Support]. Notf Rett Med 2021; 24:650-719. [PMID: 34093080 PMCID: PMC8170638 DOI: 10.1007/s10049-021-00887-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2021] [Indexed: 12/11/2022]
Abstract
The European Resuscitation Council (ERC) Paediatric Life Support (PLS) guidelines are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations of the International Liaison Committee on Resuscitation (ILCOR). This section provides guidelines on the management of critically ill or injured infants, children and adolescents before, during and after respiratory/cardiac arrest.
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Affiliation(s)
- Patrick Van de Voorde
- Department of Emergency Medicine, Faculty of Medicine UG, Ghent University Hospital, Gent, Belgien
- Federal Department of Health, EMS Dispatch Center, East & West Flanders, Brüssel, Belgien
| | - Nigel M. Turner
- Paediatric Cardiac Anesthesiology, Wilhelmina Children’s Hospital, University Medical Center, Utrecht, Niederlande
| | - Jana Djakow
- Paediatric Intensive Care Unit, NH Hospital, Hořovice, Tschechien
- Paediatric Anaesthesiology and Intensive Care Medicine, University Hospital Brno, Medical Faculty of Masaryk University, Brno, Tschechien
| | | | - Abel Martinez-Mejias
- Department of Paediatrics and Emergency Medicine, Hospital de Terassa, Consorci Sanitari de Terrassa, Barcelona, Spanien
| | - Dominique Biarent
- Paediatric Intensive Care & Emergency Department, Hôpital Universitaire des Enfants, Université Libre de Bruxelles, Brüssel, Belgien
| | - Robert Bingham
- Hon. Consultant Paediatric Anaesthetist, Great Ormond Street Hospital for Children, London, Großbritannien
| | - Olivier Brissaud
- Réanimation et Surveillance Continue Pédiatriques et Néonatales, CHU Pellegrin – Hôpital des Enfants de Bordeaux, Université de Bordeaux, Bordeaux, Frankreich
| | - Florian Hoffmann
- Pädiatrische Intensiv- und Notfallmedizin, Kinderklinik und Kinderpoliklinik im Dr. von Haunerschen Kinderspital, Ludwig-Maximilians-Universität, München, Deutschland
| | | | - Torsten Lauritsen
- Paediatric Anaesthesia, The Juliane Marie Centre, University Hospital of Copenhagen, Kopenhagen, Dänemark
| | - Ian Maconochie
- Paediatric Emergency Medicine, Faculty of Medicine Imperial College, Imperial College Healthcare Trust NHS, London, Großbritannien
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Miksa M, Kaushik S, Antovert G, Brown S, Ushay HM, Katyal C. Implementation of a Critical Care Asthma Pathway in the PICU. Crit Care Explor 2021; 3:e0334. [PMID: 33604577 PMCID: PMC7886451 DOI: 10.1097/cce.0000000000000334] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVES Acute asthma management has improved significantly across hospitals in the United States due to implementation of standardized care pathways. Management of severe acute asthma in ICUs is less well studied, and variations in management may delay escalation and/or deescalation of therapies and increase length of stay. In order to standardize the management of severe acute asthma in our PICU, a nurse- and respiratory therapist-driven critical care asthma pathway was designed, implemented, and tested. DESIGN Cross-sectional study of severe acute asthma at baseline followed by implementation of a critical care asthma pathway. SETTING Twenty-six-bed urban quaternary PICU within a children's hospital. PATIENTS Patients 24 months to 18 years old admitted to the PICU in status asthmaticus. Patients with severe bacterial infections, chronic lung disease, heart disease, or immune disorders were excluded. INTERVENTIONS Implementation of a nurse- and respiratory therapist-driven respiratory scoring tool and critical care asthma pathway with explicit escalation/deescalation instructions. MEASUREMENTS AND MAIN RESULTS Primary outcome was PICU length of stay. Secondary outcomes were time to resolution of symptoms and hospital length of stay. Compliance approached 90% for respiratory score documentation and critical care asthma pathway adherence. Severity of illness at admission and clinical baseline characteristics were comparable in both groups. Pre intervention, the median ICU length of stay was 2 days (interquartile range, 1-3 d) with an overall hospital length of stay of 4 days (interquartile range, 3-6 d) (n = 74). After implementation of the critical care asthma pathway, the ICU length of stay was 1 day (interquartile range, 1-2 d) (p = 0.0013; n = 78) with an overall length of stay of 3 days (interquartile range, 2-3.75 d) (p < 0.001). The time to resolution of symptoms was reduced from a median of 66.5 hours in the preintervention group to 21 hours in the postintervention compliant group (p = 0.036). CONCLUSIONS The use of a structured critical care asthma pathway, driven by an ICU nurse and respiratory therapist, is associated with faster resolution of symptoms, decreased ICU, and overall hospital lengths of stay in children admitted to an ICU for severe acute asthma.
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Affiliation(s)
- Michael Miksa
- All authors: Children's Hospital at Montefiore and Albert Einstein College of Medicine, Pediatric Critical Care Medicine, New York, NY
| | - Shubhi Kaushik
- All authors: Children's Hospital at Montefiore and Albert Einstein College of Medicine, Pediatric Critical Care Medicine, New York, NY
| | - Gerald Antovert
- All authors: Children's Hospital at Montefiore and Albert Einstein College of Medicine, Pediatric Critical Care Medicine, New York, NY
| | - Sakar Brown
- All authors: Children's Hospital at Montefiore and Albert Einstein College of Medicine, Pediatric Critical Care Medicine, New York, NY
| | - H Michael Ushay
- All authors: Children's Hospital at Montefiore and Albert Einstein College of Medicine, Pediatric Critical Care Medicine, New York, NY
| | - Chhavi Katyal
- All authors: Children's Hospital at Montefiore and Albert Einstein College of Medicine, Pediatric Critical Care Medicine, New York, NY
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10
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Russi BW, Lew A, McKinley SD, Morrison JM, Sochet AA. High-flow nasal cannula and bilevel positive airway pressure for pediatric status asthmaticus: a single center, retrospective descriptive and comparative cohort study. J Asthma 2021; 59:757-764. [PMID: 33401990 DOI: 10.1080/02770903.2021.1872085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
INTRODUCTION We aimed to describe patient characteristics and clinical outcomes for children hospitalized for status asthmaticus (SA) receiving high-flow nasal cannula (HFNC) or bilevel positive airway pressure (BiPAP). METHODS We performed a single center, retrospective cohort study among 39 children admitted for SA aged 5-17 years from January 2016 to May 2019 to a quaternary pediatric intensive care unit (PICU). Cohorts were defined by BiPAP versus HFNC exposure and assessed to determine if differences existed in demographics, anthropometrics, comorbidities, asthma severity indices, historical factors, duration of noninvasive ventilation, and asthma-related clinical outcomes (i.e. length of stay, mechanical ventilation rates, exposure to concurrent sedatives/anxiolysis, and rate of adjunctive therapy exposure). RESULTS Thirty-three percent (n = 13) received HFNC (33%) and 67% (n = 26) BiPAP. Children receiving BiPAP had greater age (10.9 ± 3.7 vs. 6.8 ± 2.2 years, P < 0.01), asthma severity (proportion with severe NHLBI classification: 38% vs. 0%, P < 0.01; median pediatric asthma severity score: 13[12,14] vs. 10[9,12], P < 0.01), previous PICU admissions (62% vs. 15%, P = 0.01), frequency of prescribed anxiolysis/sedation (42% vs. 8%, P = 0.02), and median duration of continuous albuterol (1.7[1,3.1] vs. 0.9[0.7,1.6] days, P = 0.03) compared to those on HFNC. Those on HFNC more commonly were treated comorbid bacterial pneumonia (69% vs. 19%, P < 0.01). No differences in NIV duration, mortality, mechanical ventilation rates, or LOS were observed. CONCLUSIONS Our data suggest a trial of BiPAP or HFNC appears well tolerated in children with SA. Prospective trials are needed to establish modality superiority and identify patient or clinical characteristics that prompt use of HFNC over BiPAP.
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Affiliation(s)
| | - Alicia Lew
- University of South Florida, Tampa, FL, USA
| | | | - John M Morrison
- Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA.,Johns Hopkins University, Baltimore, MD, USA
| | - Anthony A Sochet
- University of South Florida, Tampa, FL, USA.,Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA.,Johns Hopkins University, Baltimore, MD, USA
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11
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Lee MO, Sivasankar S, Pokrajac N, Smith C, Lumba‐Brown A. Emergency department treatment of asthma in children: A review. J Am Coll Emerg Physicians Open 2020; 1:1552-1561. [PMID: 33392563 PMCID: PMC7771822 DOI: 10.1002/emp2.12224] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 07/27/2020] [Accepted: 07/28/2020] [Indexed: 12/11/2022] Open
Abstract
Asthma is the most common chronic illness in children, with >700,000 emergency department (ED) visits each year. Asthma is a respiratory disease characterized by a combination of airway inflammation, bronchoconstriction, bronchial hyperresponsiveness, and variable outflow obstruction, with clinical presentations ranging from mild to life-threatening. Standardized ED treatment can improve patient outcomes, including fewer hospital admissions. Informed by the most recent guidelines, this review focuses on the optimal approach to diagnosis and treatment of children with acute asthma exacerbations who present to the ED.
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Affiliation(s)
- Moon O. Lee
- Department of Emergency MedicineStanford University School of MedicineStanfordCaliforniaUSA
| | - Shyam Sivasankar
- Department of Emergency MedicineStanford University School of MedicineStanfordCaliforniaUSA
| | - Nicholas Pokrajac
- Department of Emergency MedicineStanford University School of MedicineStanfordCaliforniaUSA
| | - Cherrelle Smith
- Department of Emergency MedicineStanford University School of MedicineStanfordCaliforniaUSA
| | - Angela Lumba‐Brown
- Department of Emergency MedicineStanford University School of MedicineStanfordCaliforniaUSA
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12
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Craig SS, Dalziel SR, Powell CV, Graudins A, Babl FE, Lunny C. Interventions for escalation of therapy for acute exacerbations of asthma in children: an overview of Cochrane Reviews. Cochrane Database Syst Rev 2020; 8:CD012977. [PMID: 32767571 PMCID: PMC8078579 DOI: 10.1002/14651858.cd012977.pub2] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Asthma is an illness that commonly affects adults and children, and it serves as a common reason for children to attend emergency departments. An asthma exacerbation is characterised by acute or subacute worsening of shortness of breath, cough, wheezing, and chest tightness and may be triggered by viral respiratory infection, poor compliance with usual medication, a change in the weather, or exposure to allergens or irritants. Most children with asthma have mild or moderate exacerbations and respond well to first-line therapy (inhaled short-acting beta-agonists and systemic corticosteroids). However, the best treatment for the small proportion of seriously ill children who do not respond to first-line therapy is not well understood. Currently, a large number of treatment options are available and there is wide variation in management. OBJECTIVES Main objective - To summarise Cochrane Reviews with or without meta-analyses of randomised controlled trials on the efficacy and safety of second-line treatment for children with acute exacerbations of asthma (i.e. after first-line treatments, titrated oxygen delivery, and administration of intermittent inhaled short-acting beta2-agonists and oral corticosteroids have been tried and have failed) Secondary objectives - To identify gaps in the current evidence base that will inform recommendations for future research and subsequent Cochrane Reviews - To categorise information on reported outcome measures used in trials of escalation of treatment for acute exacerbations of asthma in children, and to make recommendations for development and reporting of standard outcomes in future trials and reviews - To identify relevant randomised controlled trials that have been published since the date of publication of each included review METHODS: We included Cochrane Reviews assessing interventions for children with acute exacerbations of asthma. We searched the Cochrane Database of Systematic Reviews. The search is current to 28 December 2019. We also identified trials that were potentially eligible for, but were not currently included in, published reviews. We assessed the quality of included reviews using the ROBIS criteria (tool used to assess risk of bias in systematic reviews). We presented an evidence synthesis of data from reviews alongside an evidence map of clinical trials. Primary outcomes were length of stay, hospital admission, intensive care unit admission, and adverse effects. We summarised all findings in the text and reported data for each outcome in 'Additional tables'. MAIN RESULTS We identified 17 potentially eligible Cochrane Reviews but extracted data from, and rated the quality of, 13 reviews that reported results for children alone. We excluded four reviews as one did not include any randomised controlled trials (RCTs), one did not provide subgroup data for children, and the last two had been updated and replaced by subsequent reviews. The 13 reviews included 67 trials; the number of trials in each review ranged from a single trial up to 27 trials. The vast majority of comparisons included between one and three trials, involving fewer than 100 participants. The total number of participants included in reviews ranged from 40 to 2630. All studies included children; 16 (24%) included children younger than two years of age. Most of the reviews reported search dates older than four years. We have summarised the published evidence as outlined in Cochrane Reviews. Key findings, in terms of our primary outcomes, are that (1) intravenous magnesium sulfate was the only intervention shown to reduce hospital length of stay (high-certainty evidence); (2) no evidence suggested that any intervention reduced the risk of intensive care admission (low- to very low-certainty evidence); (3) the risk of hospital admission was reduced by the addition of inhaled anticholinergic agents to inhaled beta2-agonists (moderate-certainty evidence), the use of intravenous magnesium sulfate (high-certainty evidence), and the use of inhaled heliox (low-certainty evidence); (4) the addition of inhaled magnesium sulfate to usual bronchodilator therapy appears to reduce serious adverse events during hospital admission (moderate-certainty evidence); (5) aminophylline increased vomiting compared to placebo (moderate-certainty evidence) and increased nausea and nausea/vomiting compared to intravenous beta2-agonists (low-certainty evidence); and (6) the addition of anticholinergic therapy to short-acting beta2-agonists appeared to reduce the risk of nausea (high-certainty evidence) and tremor (moderate-certainty evidence) but not vomiting (low-certainty evidence). We considered 4 of the 13 reviews to be at high risk of bias based on the ROBIS framework. In all cases, this was due to concerns regarding identification and selection of studies. The certainty of evidence varied widely (by review and also by outcome) and ranged from very low to high. AUTHORS' CONCLUSIONS This overview provides the most up-to-date evidence on interventions for escalation of therapy for acute exacerbations of asthma in children from Cochrane Reviews of randomised controlled trials. A vast majority of comparisons involved between one and three trials and fewer than 100 participants, making it difficult to assess the balance between benefits and potential harms. Due to the lack of comparative studies between various treatment options, we are unable to make firm practice recommendations. Intravenous magnesium sulfate appears to reduce both hospital length of stay and the risk of hospital admission. Hospital admission is also reduced with the addition of inhaled anticholinergic agents to inhaled beta2-agonists. However, further research is required to determine which patients are most likely to benefit from these therapies. Due to the relatively rare incidence of acute severe paediatric asthma, multi-centre research will be required to generate high-quality evidence. A number of existing Cochrane Reviews should be updated, and we recommend that a new review be conducted on the use of high-flow nasal oxygen therapy. Important priorities include development of an internationally agreed core outcome set for future trials in acute severe asthma exacerbations and determination of clinically important differences in these outcomes, which can then inform adequately powered future trials.
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Affiliation(s)
- Simon S Craig
- Department of Paediatrics, School of Clinical Sciences at Monash Health, Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Australia
- Emergency Research, Murdoch Children's Research Institute, Parkville, Australia
- Paediatric Emergency Department, Monash Medical Centre, Monash Emergency Service, Monash Health, Clayton, Australia
- Paediatric Research in Emergency Departments International Collaborative (PREDICT), Melbourne, Australia
| | - Stuart R Dalziel
- Departments of Surgery and Paediatrics: Child and Youth Health, The University of Auckland, Auckland, New Zealand
- Paediatric Research in Emergency Departments International Collaborative (PREDICT), Melbourne, Australia
- Children's Emergency Department, Starship Children's Hospital, Auckland, New Zealand
| | - Colin Ve Powell
- Department of Emergency Medicine, Sidra Medciine, Doha, Qatar
- School of Medicine, Cardiff University, Cardiff, UK
| | - Andis Graudins
- Department of Medicine, Clinical Sciences at Monash Health, Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Australia
- Paediatric Research in Emergency Departments International Collaborative (PREDICT), Melbourne, Australia
- Monash Emergency Service, Monash Health, Dandenong Hospital, Dandenong, Australia
| | - Franz E Babl
- Emergency Research, Murdoch Children's Research Institute, Parkville, Australia
- Paediatric Research in Emergency Departments International Collaborative (PREDICT), Melbourne, Australia
- Emergency Department, Royal Children's Hospital, Parkville, Australia
- Department of Paediatrics and Centre for Integrated Critical Care, University of Melbourne, Parkville, Australia
| | - Carole Lunny
- Cochrane Hypertension Group, Faculty of Medicine, University of British Columbia, Vancouver, Canada
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13
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Atag E, Krivec U, Ersu R. Non-invasive Ventilation for Children With Chronic Lung Disease. Front Pediatr 2020; 8:561639. [PMID: 33262959 PMCID: PMC7687222 DOI: 10.3389/fped.2020.561639] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 10/13/2020] [Indexed: 11/24/2022] Open
Abstract
Advances in medical care and supportive care options have contributed to the survival of children with complex disorders, including children with chronic lung disease. By delivering a positive pressure or a volume during the patient's inspiration, NIV is able to reverse nocturnal alveolar hypoventilation in patients who experience hypoventilation during sleep, such as patients with chronic lung disease. Bronchopulmonary dysplasia (BPD) is a common complication of prematurity, and despite significant advances in neonatal care over recent decades its incidence has not diminished. Most affected infants have mild disease and require a short period of oxygen supplementation or respiratory support. However, severely affected infants can become dependent on positive pressure support for a prolonged period. In case of established severe BPD, respiratory support with non-invasive or invasive positive pressure ventilation is required. Patients with cystic fibrosis (CF) and advanced lung disease develop hypoxaemia and hypercapnia during sleep and hypoventilation during sleep usually predates daytime hypercapnia. Hypoxaemia and hypercapnia indicates poor prognosis and prompts referral for lung transplantation. The prevention of respiratory failure during sleep in CF may prolong survival. Long-term oxygen therapy has not been shown to improve survival in people with CF. A Cochrane review on the use NIV in CF concluded that NIV in combination with oxygen therapy improves gas exchange during sleep to a greater extent than oxygen therapy alone in people with moderate to severe CF lung disease. Uncontrolled, non-randomized studies suggest survival benefit with NIV in addition to being an effective bridge to transplantation. Complications of NIV relate mainly to prolonged use of a face or nasal mask which can lead to skin trauma, and neurodevelopmental delay by acting as a physical barrier to social interaction. Another associated risk is pulmonary aspiration caused by vomiting whilst wearing a face mask. Adherence to NIV is one of the major barriers to treatment in children. This article will review the current evidence for indications, adverse effects and long term follow up including adherence to NIV in children with chronic lung disease.
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Affiliation(s)
- Emine Atag
- Division of Pediatric Pulmonology, Medipol University, Istanbul, Turkey
| | - Uros Krivec
- Division of Pediatric Pulmonology, University Children's Hospital, University Medical Centre, Ljubljana, Slovenia
| | - Refika Ersu
- Division of Pediatric Respirology, Children's Hospital of Ontario, University of Ottawa, Ottawa, ON, Canada
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14
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Affiliation(s)
- Shilpa J Patel
- Division of Emergency Medicine, Children's National Medical Center, Washington, DC
| | - Stephen J Teach
- Division of Emergency Medicine, Children's National Medical Center, Washington, DC
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15
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Sekiguchi H, Kondo Y, Fukuda T, Hanashiro K, Baba M, Sato Y, Kukita I, Matumoto T. Noninvasive positive pressure ventilation for treating acute asthmatic attacks in three pregnant women with dyspnea and hypoxemia. Clin Case Rep 2019; 7:881-887. [PMID: 31110708 PMCID: PMC6509929 DOI: 10.1002/ccr3.2117] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2018] [Revised: 02/28/2019] [Accepted: 03/04/2019] [Indexed: 11/05/2022] Open
Abstract
In our case reports, we mentioned about the utility of NPPV therapy in addition to standard pharmacologic therapy for acute asthma exacerbations in pregnant women with dyspnea and hypoxemia compared with that of oxygen therapy alone. Careful patient selection and clinicians' NPPV experience are crucial in optimizing patient outcomes.
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Affiliation(s)
- Hiroshi Sekiguchi
- Pulmonary MedicineTomishiro Central HospitalTomigusukuJapan
- Department of Emergency and Critical Care Medicine, Graduate School of MedicineUniversity of the RyukyusNishiharaJapan
| | - Yutaka Kondo
- Department of Emergency MedicineJuntendo University Urayasu HospitalChibaJapan
| | - Tatsuma Fukuda
- Department of Emergency and Critical Care Medicine, Graduate School of MedicineUniversity of the RyukyusNishiharaJapan
| | - Kazuhiko Hanashiro
- Department of Public Health and Hygiene, Graduate School of MedicineUniversity of the RyukyusNishiharaJapan
| | - Motoo Baba
- Pulmonary MedicineOhama Daiichi HospitalNahaJapan
| | - Yoko Sato
- Pulmonary MedicineTomishiro Central HospitalTomigusukuJapan
| | - Ichiro Kukita
- Department of Emergency and Critical Care Medicine, Graduate School of MedicineUniversity of the RyukyusNishiharaJapan
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16
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Herrera AM, Brand P, Cavada G, Koppmann A, Rivas M, Mackenney J, Sepúlveda H, Wevar ME, Cruzat L, Soto S, Pérez MA, León A, Contreras I, Alvarez C, Walker B, Flores C, Lezana V, Garrido C, Herrera ME, Rojas A, Andrades C, Chala E, Martínez RA, Vega M, Perillán JA, Seguel H, Przybyzsweski I. Treatment, outcomes and costs of asthma exacerbations in Chilean children: a prospective multicenter observational study. Allergol Immunopathol (Madr) 2019; 47:282-288. [PMID: 30595390 PMCID: PMC7125869 DOI: 10.1016/j.aller.2018.10.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 10/02/2018] [Accepted: 10/08/2018] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To describe potential regional variations in therapies for severe asthma exacerbations in Chilean children and estimate the associated health expenditures. METHODS Observational prospective cohort study in 14 hospitals over a one-year period. Children five years of age or older were eligible for inclusion. Days with oxygen supply and pharmacological treatments received were recorded from the clinical chart. A basic asthma hospitalization basket was defined in order to estimate the average hospitalization cost for a single patient. Six months after discharge, new visits to the Emergency Room (ER), use of systemic corticosteroids and adherence to the controller treatment were evaluated. RESULTS 396 patients were enrolled. Patients from the public health system and from the north zone received significantly more days of oxygen, systemic corticosteroids and antibiotics. Great heterogeneity in antibiotic use among the participating hospitals was found, from 0 to 92.3% (ICC 0.34, 95% CI 0.16-0.52). The use of aminophylline, magnesium sulfate and ketamine varied from 0 to 36.4% between the different Pediatric Intensive Care Units (ICC 0.353, 95% CI 0.010-0.608). The average cost per inpatient was of $1910 USD. 290 patients (73.2%) completed the follow-up six months after discharge. 76 patients (26.2%) were not receiving any controller treatment and nearly a fourth had new ER visits and use of systemic corticosteroids due to new asthma exacerbations. CONCLUSIONS Considerable practice variation in asthma exacerbations treatment was found among the participating hospitals, highlighting the poor outcome of many patients after hospital discharge, with an important health cost.
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Affiliation(s)
- A M Herrera
- Santa María Clinic, Santa María 500, Santiago, Zip Code 7520378 Región Metropolitana, Chile; School of Medicine, Los Andes University, Monseñor Alvaro del Portillo 12455, Santiago, Zip Code 7620001 Región Metropolitana, Chile.
| | - P Brand
- Isala Women's and Children's Hospital, Zwolle, The Netherlands
| | - G Cavada
- School of Medicine, Finis Terrae University, Av Providencia 1509, Santiago, Zip Code 7501015 Región Metropolitana, Chile
| | - A Koppmann
- San Borja Arriarán Hospital, Av Santa Rosa 1234, Santiago, Zip Code 8360160 Región Metropolitana, Chile; School of Medicine, University of Chile, Chile
| | - M Rivas
- San Borja Arriarán Hospital, Av Santa Rosa 1234, Santiago, Zip Code 8360160 Región Metropolitana, Chile
| | - J Mackenney
- Roberto del Río Hospital, Av Profesor Zañartu 1085, Santiago, Zip Code 8380418 Región Metropolitana, Chile; School of Medicine, University of Chile, Chile
| | - H Sepúlveda
- Luis Calvo Mackenna Hospital, Av Antonio Varas 360, Santiago, Zip Code 7500539 Región Metropolitana, Chile
| | - M E Wevar
- Luis Calvo Mackenna Hospital, Av Antonio Varas 360, Santiago, Zip Code 7500539 Región Metropolitana, Chile
| | - L Cruzat
- Luis Calvo Mackenna Hospital, Av Antonio Varas 360, Santiago, Zip Code 7500539 Región Metropolitana, Chile
| | - S Soto
- Concepción Regional Hospital, San Martín 1436, Concepción, Zip Code 4070038 Región del Bío Bío, Chile
| | - M A Pérez
- Santa María Clinic, Santa María 500, Santiago, Zip Code 7520378 Región Metropolitana, Chile
| | - A León
- Santa María Clinic, Santa María 500, Santiago, Zip Code 7520378 Región Metropolitana, Chile
| | - I Contreras
- Padre Hurtado Hospital, Esperanza 2150, Santiago, Zip Code 8880465 Región Metropolitana, Chile
| | - C Alvarez
- Alemana Clinic, Av Vitacura 5951, Santiago, Zip Code 7650568 Región Metropolitana, Chile; School of Medicine, Desarrollo University, Av Las Condes 12496, Santiago, Zip Code 7590943 Región Metropolitana, Chile
| | - B Walker
- Alemana Clinic, Av Vitacura 5951, Santiago, Zip Code 7650568 Región Metropolitana, Chile; School of Medicine, Desarrollo University, Av Las Condes 12496, Santiago, Zip Code 7590943 Región Metropolitana, Chile
| | - C Flores
- Ovalle Hospital, Ariztía Pte. 7, Ovalle, Zip Code 1842054 Región de Coquimbo, Chile
| | - V Lezana
- Gustavo Fricke Hospital, Av Alvarez 1532, Viña del Mar, Zip Code 2570017 Región de Valparaíso, Chile
| | - C Garrido
- Gustavo Fricke Hospital, Av Alvarez 1532, Viña del Mar, Zip Code 2570017 Región de Valparaíso, Chile
| | - M E Herrera
- José Joaquín Aguirre Hospital, Santos Dumont 999, Santiago, Zip Code 8380456 Región Metropolitana, Chile
| | - A Rojas
- José Joaquín Aguirre Hospital, Santos Dumont 999, Santiago, Zip Code 8380456 Región Metropolitana, Chile
| | - C Andrades
- Valdivia Hospital, Coronel Santiago Bueras y Avaria 1003, Valdivia, Zip Code 5090146 Región de los Ríos, Chile
| | - E Chala
- Fusat Hospital, Carretera el Cobre Presidente Frei Montalva 1002, Zip Code 2820945 Rancagua, VI Región, Chile; School of Medicine, Los Andes University, Monseñor Alvaro del Portillo 12455, Santiago, Zip Code 7620001 Región Metropolitana, Chile
| | - R A Martínez
- Fusat Hospital, Carretera el Cobre Presidente Frei Montalva 1002, Zip Code 2820945 Rancagua, VI Región, Chile
| | - M Vega
- Leonardo Guzmán Hospital, Veintiuno de Mayo 1310, Zip Code 1271847 Antofagasta, Región de Antofagasta, Chile
| | - J A Perillán
- San Juan De Dios Hospital, Huérfanos 3255, Zip Code 8350488 Santiago, Región Metropolitana, Chile; School of Medicine, University of Chile, Chile
| | - H Seguel
- San Juan De Dios Hospital, Huérfanos 3255, Zip Code 8350488 Santiago, Región Metropolitana, Chile
| | - I Przybyzsweski
- San Juan De Dios Hospital, Huérfanos 3255, Zip Code 8350488 Santiago, Región Metropolitana, Chile
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Craig SS, Dalziel SR, Powell CVE, Graudins A, Babl FE, Lunny C. Interventions for escalation of therapy for acute exacerbations of asthma in children: an overview of Cochrane Reviews. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2018. [DOI: 10.1002/14651858.cd012977] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Simon S Craig
- Monash University; Department of Medicine, Clinical Sciences at Monash Health, Faculty of Medicine, Nursing and Health Sciences; Clayton Victoria Australia
- Monash Medical Centre, Monash Emergency Service, Monash Health; Paediatric Emergency Department; Clayton Australia
| | - Stuart R Dalziel
- The University of Auckland; Liggins Institute; Auckland New Zealand
| | - Colin VE Powell
- Cardiff University; Department of Child Health, The Division of Population Medicine, The School of Medicine; Cardiff UK
| | - Andis Graudins
- Monash University; Department of Medicine, Clinical Sciences at Monash Health, Faculty of Medicine, Nursing and Health Sciences; Clayton Victoria Australia
- Dandenong Hospital; Monash Emergency Service, Monash Health; Dandenong Australia
| | - Franz E Babl
- Murdoch Children's Research Institute; Emergency Research; Flemington Road Parkville Victoria Australia 3052
- Royal Children's Hospital; Emergency Department; Parkville Australia
- University of Melbourne; Department of Paediatrics; Parkville Australia
| | - Carole Lunny
- School of Public Health & Preventive Medicine, Monash University; Cochrane Australia; 553 St Kilda Road Melbourne Victoria Australia 3004
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18
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High variability of treatments for paediatric status asthmaticus: a retrospective study in PICUs. Intensive Care Med 2017. [PMID: 28634664 DOI: 10.1007/s00134-017-4864-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Korang SK, Feinberg J, Wetterslev J, Jakobsen JC. Non-invasive positive pressure ventilation for acute asthma in children. Cochrane Database Syst Rev 2016; 9:CD012067. [PMID: 27687114 PMCID: PMC6457810 DOI: 10.1002/14651858.cd012067.pub2] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Asthma is one of the most common reasons for hospital admission among children and constitutes a significant economic burden. Use of non-invasive positive pressure ventilation (NPPV) in the care of children with acute asthma has increased even though evidence supporting the intervention has been considered weak and clinical guidelines do not recommend the intervention. NPPV might be an effective intervention for acute asthma, but no systematic review has been conducted to assess the effects of NPPV as an add-on therapy to usual care in children with acute asthma. OBJECTIVES To assess the benefits and harms of NPPV as an add-on therapy to usual care (e.g. bronchodilators and corticosteroids) in children with acute asthma. SEARCH METHODS We identified trials from the Cochrane Airways Group Specialised Register (CAGR). The Register contains trial reports identified through systematic searches of bibliographic databases, including the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, AMED and PsycINFO, and by handsearching of respiratory journals and meeting abstracts. We also conducted a search of ClinicalTrials.gov (www.ClinicalTrials.gov) and the WHO trials portal (www.who.int/ictrp/en/). We searched all databases from their inception to February 2016, with no restriction on language of publication. SELECTION CRITERIA We included randomised clinical trials (RCTs) assessing NPPV as add-on therapy to usual care versus usual care for children (age < 18 years) hospitalised for an acute asthma attack. DATA COLLECTION AND ANALYSIS Two review authors independently screened titles and abstracts. We retrieved all relevant full-text study reports, independently screened the full text, identified trials for inclusion and identified and recorded reasons for exclusion of ineligible trials. We resolved disagreements through discussion or, if required, consulted a third review author. We recorded the selection process in sufficient detail to complete a PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) flow diagram and 'Characteristics of excluded studies' table. We identified the risk of bias of included studies to reduce the risk of systematic error. We contacted relevant study authors when data were missing. MAIN RESULTS We included two RCTs that randomised 20 participants to NPPV and 20 participants to control. We assessed both studies as having high risk of bias; both trials assessed effects of bilateral positive airway pressure (BiPAP). Neither trial used continuous positive airway pressure (CPAP). Controls received standard care. Investigators reported no deaths and no serious adverse events (Grades of Recommendation, Assessment, Development and Evaluation (GRADE): very low quality of evidence due to serious risk of bias and serious imprecision of results). Both trials showed a statistically significant reduction in symptom score. One trial did not report a standard deviation (SD), but by using an estimated SD, we found a statistically significantly reduced asthma symptom score (mean difference (MD) -2.50, 95% confidence interval (CI) -4.70 to -0.30, P = 0.03, 19 participants, GRADE: very low quality of evidence). In the other trial, NPPV was associated with a lower total symptom score (5.6 vs 1.9, 16 participants, very low quality of evidence) before cross-over, but investigators did not report an SD, nor could it be estimated from the first phase of the trial, before the cross-over. These gains could be clinically relevant, as a reduction of three or more points in symptom score is considered a clinically meaningful change. Researchers documented five dropouts (12.5%), four of which were due to intolerance to NPPV, and one to respiratory failure requiring intubation. Owing to insufficient reporting in the latter trial and use of different scoring systems, it was not possible to conduct a meta-analysis nor a Trial Sequential Analysis. AUTHORS' CONCLUSIONS Current evidence does not permit confirmation or rejection of the effects of NPPV for acute asthma in children. Large RCTs with low risk of bias are warranted.
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Affiliation(s)
- Steven Kwasi Korang
- Holbaek SygehusPediatric DepartmentSmedelundsgade 60HolbaekDenmark4300
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchCopenhagenDenmark
| | - Joshua Feinberg
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchCopenhagenDenmark
| | - Jørn Wetterslev
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchCopenhagenDenmark
| | - Janus C Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University HospitalThe Cochrane Hepato‐Biliary GroupBlegdamsvej 9CopenhagenSjællandDenmarkDK‐2100
- Holbaek HospitalDepartment of CardiologyHolbaekDenmark4300
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