Demographics, clinical course, and outcomes of children with status asthmaticus treated in a pediatric intensive care unit: 8-year review

Asthma in paediatric intensive care in England residents: observational study

Despite high prevalence of asthma in children in the UK, there were no prior report on asthma admissions in paediatric intensive care units (PICU). We investigated the epidemiology and healthcare resource utilisation in children with asthma presenting to PICUs in England. PICANet, a UK national PICU database, was queried for asthma as the primary reason for admission, of children resident in England from April 2006 until March 2013. There were 2195 admissions to PICU for a median stay of 1.4 days. 59% were males and 51% aged 0–4 years. The fourth and fifth most deprived quintiles represented 61% (1329) admissions and 73% (11) of the 15 deaths. Deaths were most frequent in 10–14 years age (n = 11, 73%), with no deaths in less than 5 years age. 38% of admissions (828/2193) received invasive ventilation, which was more frequent with increasing deprivation (13% (108/828) in least deprived to 31% (260/828) in most deprived) and with decreasing age (0–4-year-olds: 49%, 409/828). This first multi-centre PICU study in England found that children from more deprived neighbourhoods represented the majority of asthma admissions, invasive ventilation and deaths in PICU. Children experiencing socioeconomic deprivation could benefit from enhanced asthma support in the community.

Development and validation of a risk score to identify children at risk of life-threatening asthma

OBJECTIVE

To develop and validate a prediction risk score for identification of children at risk of developing life-threatening asthma (LTA).

METHODS

Our study utilized existing medical records and retrospective analysis to develop and validate a risk score. The study population included children aged 2-17 years, admitted with a primary diagnosis of asthma, to Sydney Children's Hospital between 2011-2016. Children admitted in the intensive care unit with asthma at risk of LTA (cases) and those admitted into general ward (comparison group), were randomly divided into a derivation and a validation cohort. Candidate predictors from derivation cohort were selected through multivariable regression, which were used to estimate each child's risk of developing LTA in the validation cohort. Predictive performance of the risk score was evaluated by the area under the receiver operating characteristic curve (AUROC) and Hosmer-Lemeshow goodness-of-fit test.

RESULTS

The study population comprised of 1171 children; 586 in the derivation and 585 in the validation cohort. Four independent candidate variables from derivation cohort (age at admission, socioeconomic status, a family history of asthma/atopy and previous asthma hospitalizations) were retained in the predictive model (AUROC 0.759; 95% CI, 0.694-0.823), with a sensitivity of 78.5% and specificity of 46.6%.

CONCLUSIONS

Our risk algorithm based on routinely collected clinical data may be used to develop a user-friendly risk score for early identification and monitoring of children at risk of developing LTA.

Risk factors for intensive care admission in children with severe acute asthma in the Netherlands: a prospective multicentre study

Rationale

Severe acute asthma (SAA) can be fatal, but is often preventable. We previously observed in a retrospective cohort study, a three-fold increase in SAA paediatric intensive care (PICU) admissions between 2003 and 2013 in the Netherlands, with a significant increase during those years of numbers of children without treatment of inhaled corticosteroids (ICS).

Objectives

To determine whether steroid-naïve children are at higher risk of PICU admission among those hospitalised for SAA. Furthermore, we included the secondary risk factors tobacco smoke exposure, allergic sensitisation, previous admissions and viral infections.

Methods

A prospective, nationwide multicentre study of children with SAA (2–18 years) admitted to all Dutch PICUs and four general wards between 2016 and 2018. Potential risk factors for PICU admission were assessed using logistic regression analyses.

Measurements and main results

110 PICU and 111 general ward patients were included. The proportion of steroid-naïve children did not differ significantly between PICU and ward patients. PICU children were significantly older and more exposed to tobacco smoke, with symptoms >1 week prior to admission. Viral susceptibility was not a significant risk factor for PICU admission.

Conclusions

Children with SAA admitted to a PICU were comparable to those admitted to a general ward with respect to ICS treatment prior to admission. Preventable risk factors for PICU admission were >7 days of symptoms without adjustment of therapy and exposure to tobacco smoke. Physicians who treat children with asthma must be aware of these risk factors.

Preventable risk factors for PICU admission among those with severe acute asthma are >7 days of symptoms without adjustment of therapy and environmental exposure to tobacco smoke, underlining the importance of smoking cessation of caregivershttps://bit.ly/3ezPzxT

Randomized clinical trial of high concentration versus titrated oxygen use in pediatric asthma

OBJECTIVE

To compare the effects of high concentration to titrated oxygen therapy (HCOT) on transcutaneous carbon dioxide (PtCO₂ ) level in pediatric asthma exacerbation. Titrated oxygen therapy (TOT) in acute asthma will avoid a rise in PtCO ₂ in the pediatric population.

METHOD

The study design is a prospective, randomized, clinical trial comparing HCOT (maintain SpO2 92-95%) while being treated for asthma exacerbation in the emergency department (ED).

INCLUSION CRITERIA

2 to 18 years, previously diagnosed asthma with acute exacerbation (asthma score >5). PtCO₂ and asthma scores were measured at 0, 20, 40, 60 minutes and then every 30 minutes until disposition decision. The primary outcome was a change in PtCO ₂ . Secondary outcomes were admission rate and change in asthma score.

RESULTS

A total of 96 patients were enrolled in the study with a mean age of 8.27 years; 49 in HCOT and 47 in the TOT group. The 0 minute PtCO₂ was similar (35.33 + 3.88 HCOT vs 36.66 + 4.69 TOT, P = 0.13); whereas, the 60 minutes PtCO ₂ was higher in the HCOT (38.08 + 5.11 HCOT vs 35.51 + 4.57 TOT, P = 0.01). The asthma score was similar at 0 minute (7.55 + 1.34 HCOT vs 7.30 + 1.18 TOT, P = 0.33); whereas, the 60 minutes asthma score was lower in the TOT (4.71 + 1.38 HCOT vs 3.57 + 1.25 TOT, P = 0.0001). The rate of admission to the hospital was 40.5% in HCOT vs 25.5% in the TOT (P = 0.088).

CONCLUSIONS

HCOT in pediatric asthma exacerbation leads to significantly higher carbon dioxide levels, which increases asthma scores and trends towards the increasing rate of admission. Larger studies are needed to explore this association.

Children with severe acute asthma admitted to Dutch PICUs: A changing landscape

The number of children requiring pediatric intensive care unit (PICU) admission for severe acute asthma (SAA) around the world has increased.

OBJECTIVES

We investigated whether this trend in SAA PICU admissions is present in the Netherlands.

METHODS

A multicenter retrospective cohort study across all tertiary care PICUs in the Netherlands. Inclusion criteria were children (2-18 years) hospitalized for SAA between 2003 and 2013. Data included demographic data, asthma diagnosis, treatment, and mortality.

RESULTS

In the 11-year study period 590 children (660 admissions) were admitted to a PICU with a threefold increase in the number of admissions per year over time. The severity of SAA seemed unchanged, based on the first blood gas, length of stay and mortality rate (0.6%). More children received highflow nasal cannula (P < 0.001) and fewer children needed invasive ventilation (P < 0.001). In 58% of the patients the maximal intravenous (IV) salbutamol infusion rate during PICU admission was 1 mcg/kg/min. However, the number of patients treated with IV salbutamol in the referring hospitals increased significantly over time (P = 0.005). The proportion of steroid-naïve patients increased from 35% to 54% (P = 0.004), with a significant increase in both age groups (2-4 years [P = 0.026] and 5-17 years [P = 0.036]).

CONCLUSIONS

The number of children requiring PICU admission for SAA in the Netherlands has increased. We speculate that this threefold increase is explained by an increasing number of steroid-naïve children, in conjunction with a lowered threshold for PICU admission, possibly caused by earlier use of salbutamol IV in the referring hospitals.

Critical Care Interventions for Asthmatic Patients Admitted From the Emergency Department to the Pediatric Intensive Care Unit

OBJECTIVES

The aim of this study was to assess the frequency and predictors of critical interventions in asthmatic patients admitted to the pediatric intensive care unit (PICU) at a tertiary-care pediatric hospital.

METHODS

We conducted a retrospective chart review of patients admitted from our emergency department (ED) to the PICU for treatment of status asthmaticus between January 1, 2008, and March 31, 2013. Patients with concomitant medical conditions and those who received a critical intervention, other than continuously aerosolized albuterol, in the ED before admission were excluded. Data collected included patient demographics, clinical characteristics including clinical asthma scores (CASs), hospital course, and adverse events.

RESULTS

A total of 384 patients were included in the analyses (mean age, 8.2 ± 4.5 years). Thirty-four patients (8.9%) received at least 1 critical intervention. No patients were intubated, had central venous catheter placement, and developed circulatory collapse or pneumothoraxes. Independent predictors associated with an increased likelihood of receiving a critical intervention included age above 8 years (odds ratio [OR], 4.3; 95% confidence interval [CI], 1.9-9.4), previous PICU admission (OR, 3.2; 95% CI, 1.5-6.6), altered mental status on ED arrival (OR, 4.5; 95% CI, 1.5-13.4), CAS on ED arrival of 5 or greater (OR, 3.4; 95% CI, 1.3-9.1), and CAS on PICU admission of 5 or greater (OR, 4.3; 95% CI, 1.8-10.2).

CONCLUSIONS

Patients admitted to the PICU for status asthmaticus infrequently require critical interventions if they have not been initiated in the ED. Patients with a CAS of less than 5 may be safely managed with continuously aerosolized albuterol on non-critical care units with low risk for clinical deterioration.

The Seven Stages of Man: The Role of Developmental Stage on Medication Adherence in Respiratory Diseases

The circumstances and drivers of the decision to initiate, implement, or persist with a medication differ for individuals at each developmental stage. For school-age children with asthma, the social environment of their family's cultural beliefs and the influence of peer networks and school policies are strong determinants of medication adherence. The stage of adolescence can be a particularly challenging time because there is a reduction in parental supervision of asthma management as the young person strives to become more autonomous. To illustrate the importance of such factors, adherence interventions in children and young adults with asthma have used peer-based supports and social supports, particularly social media platforms. In older patients, it is internal rather than external factors and age-related decline that pose challenges to medication adherence. Seniors face the challenges of polypharmacy, reduced social support, increased isolation, and loss of cognitive function. Strategies to promote adherence must be tailored to the developmental stage and respective behavioral determinants of the target group. This review considers the different attitudes toward medication and the different adherence behaviors in young and elderly patients with chronic respiratory conditions, specifically asthma and chronic obstructive pulmonary disease. Opportunities to intervene to optimize adherence are suggested.

Medical and Social Determinants of Health Associated with Intensive Care Admission for Asthma in Children

RATIONALE

Risk factors for severe asthma exacerbations in children requiring admission to the intensive care unit (ICU) may occur in variety of medical, environmental, economic, and socioeconomic domains.

OBJECTIVES

We sought to characterize medical and sociodemographic risk factors among children who required admission to the intensive care unit for asthma.

METHODS

Data were obtained from the Greater Cincinnati Asthma Risk Study, a population-based, prospective, observational cohort of children admitted for treatment of acute asthma or bronchodilator-responsive wheezing. Data collected on 774 children included race, socioeconomic status, allergen sensitization, environmental exposures, psychosocial strain, and financial hardship. Analyses compared children admitted to the ICU to those admitted to a medical inpatient unit.

MEASUREMENTS AND MAIN RESULTS

One hundred sixty-one (20.9%) children required admission to intensive care. There was no difference in sex, race, insurance status, caregiver educational level, income, financial strain, psychological distress, or marital status between the ICU and non-ICU cohorts. Risk for medication nonadherence assessed by parent report was not different between groups. Although previous hospital admission or emergency department visit history did not differ between the groups, prior ICU admission was more common among those admitted to the ICU at the index admission (27 vs. 16%, P = 0.002). Children requiring intensive care admission were more likely to be sensitized to multiple aeroallergens. Exposure to cigarette smoke (measured as salivary cotinine), although a risk factor for hospital admission, was negatively associated with risk of ICU admission.

CONCLUSIONS

Social and economic risk factors typically predictive of increased asthma morbidity, including exposure to tobacco smoke, were not associated with ICU admission among a population of children admitted to the hospital for treatment of acute asthma. Intrinsic disease factors, including allergic sensitization, may be more important predictors of ICU admission.

Asthma changes at a pediatric intensive care unit after 10 years: Observational study

OBJECTIVES:

To describe the change in the management, and outcome of children with acute severe asthma (ASA) admitted to Pediatric Intensive Care Unit (PICU) at tertiary institute, as compared to previously published report in 2003.

METHODS:

This is a retrospective observational study. All consecutive pediatric ASA patients who were admitted to PICU during the study period were included. The data were extracted from PICU database and medical records. The Cohort in this study (2013 Cohort) was compared with the Cohort of ASA, which was published in 2003 from the same institution (2003 Cohort).

RESULTS:

In comparison to previous 2003 Cohort, current Cohort (2013) revealed higher mean age (5.5 vs. 3.6 years; P ≤ 0.001), higher rate of PICU admission (20.3% vs. 3.6%; P ≤ 0.007), less patients who received maintenance inhaled steroids (43.3% vs. 62.4%; P ≤ 0.03), less patients with pH <7.3 (17.9% vs. 42.9%; P ≤ 0.001). There were more patients in 2013 Cohort who received: Inhaled Ipratropium bromide (97% vs. 68%; P ≤ 0.001), intravenous magnesium sulfate (68.2% vs. none), intravenous salbutamol (13.6% vs. 3.6%; P ≤ 0.015), and noninvasive ventilation (NIV) (35.8% vs. none) while no patients were treated with theophylline (none vs. 62.5%). The median length of stay (LOS) was 2 days while mean LOS was half a day longer in the 2013 Cohort. None of our patients required intubation, and there was no mortality.

CONCLUSION:

We observed slight shift toward older age, considerably increased the rate of PICU admission, increased utilization of Ipratropium bromide, magnesium sulfate, and NIV as important modalities of treatment.

Safety and effectiveness of continuous aerosolized albuterol in the non-intensive care setting

OBJECTIVE

To describe the design features, utilization, and outcomes of a protocol treating children with status asthmaticus with continuous albuterol in the inpatient setting.

METHODS

We performed a retrospective cohort analysis of children ages 2 to 18 treated in the non-intensive care, inpatient setting on a standardized treatment protocol for status asthmaticus from July 2011 to June 2013. We assessed characteristics associated with continuous albuterol therapy and, for those treated, duration of therapy and the proportion who clinically deteriorated (ICU transfer or progression to enhanced respiratory support) or who were identified as having hypokalemia or an arrhythmia. Using multivariable logistic regression, we determined which factors were associated with clinical deterioration or prolonged (>24 hours) continuous albuterol.

RESULTS

Of 3003 children meeting study criteria, 1298 (43%) received continuous albuterol. Older age, black race, lower initial oxygen saturation, and higher initial age-standardized heart rate and respiratory rate were associated with initiation of continuous albuterol therapy (P < .001 for all). Median duration of therapy was 14.4 hours (interquartile range, 7.7, 24.6); 340 children (26%) experienced prolonged therapy. Seventy children (5%) experienced clinical deterioration, and 33 children (3%) had identified hypokalemia or arrhythmia. Comorbid pneumonia and emergency department administration of intravenous magnesium or subcutaneous terbutaline were associated with prolonged therapy and clinical deterioration.

CONCLUSIONS

With appropriate support structures and care processes, continuous albuterol can be delivered effectively in the non-ICU, inpatient setting with low rates of adverse outcomes. Certain initial clinical characteristics may help identify patients needing more intensive therapy.

Hospitalization rate and 30-day mortality among patients with status asthmaticus in Denmark: a 16-year nationwide population-based cohort study

Objective

Current data on hospitalization and prognosis of acute asthma and status asthmaticus are inconclusive. We aim to analyze the rate of first-time hospitalizations for status asthmaticus among patients of all ages, the proportion admitted to intensive care units (ICU), and the 30-day mortality over a 16-year period.

Methods

In this population-based cohort study, we used medical registries to identify all first-time status asthmaticus hospitalizations in Denmark from 1996 through 2011. Data on comorbidities were also obtained. We computed yearly hospitalization rates overall and by gender and age groups, and estimated the proportion requiring ICU admission. We estimated 30-day age- and gender-standardized mortality. We examined potential misclassification from acute exacerbation of chronic obstructive pulmonary disease (COPD) by excluding patients with preexisting or concurrent COPD.

Results

Of the 5,001 patients identified with a first-time status asthmaticus hospitalization, 50.5% were male, 40.3% were <15 years old, and 12.4% had comorbidity. The hospitalization rate increased from 48.0 per 1,000,000 person-years (PY) (95% confidence interval [CI]: 45.1–51.1 PY) during 1996–1999 to 70.1 per 1,000,000 PY (95% CI: 66.7–73.7 PY) during 2008–2011. This may be explained by an increased hospitalization rate of children. The standardized 30-day mortality risk declined from 3.3% (95% CI: 2.5%–4.1%) in 1996–1999 to 1.5% (95% CI: 0.9%–2.1%) in 2008–2011. During 2005–2011, 10.1% of status asthmaticus patients were admitted to the ICU. Hospitalization rates and mortality risk decreased by excluding 939 patients also registered with COPD, but overall temporal changes did not change.

Conclusion

From 1996 to 2011, status asthmaticus hospitalization rate increased but remained below 100 hospitalizations per 1,000,000 PY. Thirty-day mortality risk was halved to less than 2%.