Management of Neuromuscular Blocking Agents in Critically Ill Patients with Lung Diseases

The use of neuromuscular blocking agents (NMBAs) is common in the intensive care unit (ICU). NMBAs have been used in critically ill patients with lung diseases to optimize mechanical ventilation, prevent spontaneous respiratory efforts, reduce the work of breathing and oxygen consumption, and avoid patient-ventilator asynchrony. In patients with acute respiratory distress syndrome (ARDS), NMBAs reduce the risk of barotrauma and improve oxygenation. Nevertheless, current guidelines and evidence are contrasting regarding the routine use of NMBAs. In status asthmaticus and acute exacerbation of chronic obstructive pulmonary disease, NMBAs are used in specific conditions to ameliorate patient-ventilator synchronism and oxygenation, although their routine use is controversial. Indeed, the use of NMBAs has decreased over the last decade due to potential adverse effects, such as immobilization, venous thrombosis, patient awareness during paralysis, development of critical illness myopathy, autonomic interactions, ICU-acquired weakness, and residual paralysis after cessation of NMBAs use. The aim of this review is to highlight current knowledge and synthesize the evidence for the effects of NMBAs for critically ill patients with lung diseases, focusing on patient-ventilator asynchrony, ARDS, status asthmaticus, and chronic obstructive pulmonary disease.

Inhaled Volatiles for Status Asthmaticus, Epilepsy, and Difficult Sedation in Adult ICU and PICU: A Systematic Review

OBJECTIVES

Inhaled volatile anesthetics support management of status asthmaticus (SA), status epilepticus (SE), and difficult sedation (DS). This study aimed to evaluate the effectiveness, safety, and feasibility of using inhaled anesthetics for SA, SE, and DS in adult ICU and PICU patients.

DATA SOURCES

MEDLINE, Cochrane Central Register of Controlled Trials, and Embase.

STUDY SELECTION

Primary literature search that reported the use of inhaled anesthetics in ventilated patients with SA, SE, and DS from 1970 to 2021.

DATA EXTRACTION

Study data points were extracted by two authors independently. Quality assessment was performed using the Joanna Briggs Institute appraisal tool for case studies/series, Newcastle criteria for cohort/case-control studies, and risk-of-bias framework for clinical trials.

DATA SYNTHESIS

Primary outcome was volatile efficacy in improving predefined clinical or physiologic endpoints. Secondary outcomes were adverse events and delivery logistics. From 4281 screened studies, the number of included studies/patients across diagnoses and patient groups were: SA (adult: 38/121, pediatric: 28/142), SE (adult: 18/37, pediatric: 5/10), and DS (adult: 21/355, pediatric: 10/90). Quality of evidence was low, consisting mainly of case reports and series. Clinical and physiologic improvement was seen within 1-2 hours of initiating volatiles, with variable efficacy across diagnoses and patient groups: SA (adult: 89-95%, pediatric: 80-97%), SE (adults: 54-100%, pediatric: 60-100%), and DS (adults: 60-90%, pediatric: 62-90%). Most common adverse events were cardiovascular, that is, hypotension and arrhythmias. Inhaled sedatives were commonly delivered using anesthesia machines for SA/SE and miniature vaporizers for DS. Few (10%) of studies reported required non-ICU personnel, and only 16% had ICU volatile delivery protocol.

CONCLUSIONS

Volatile anesthetics may provide effective treatment in patients with SA, SE, and DS scenarios but the quality of evidence is low. Higher-quality powered prospective studies of the efficacy and safety of using volatile anesthetics to manage SA, SE, and DS patients are required. Education regarding inhaled anesthetics and the protocolization of their use is needed.

Outcomes of children with life-threatening status asthmaticus requiring isoflurane therapy and extracorporeal life support

BACKGROUND

Severe, refractory asthma is a life-threatening emergency that may be treated with isoflurane and extracorporeal life support. The objective of this study was to describe the clinical response to isoflurane and outcomes after discharge of children who received isoflurane and/or extracorporeal life-support for near-fatal asthma.

METHODS

This was a retrospective descriptive study using electronic medical record data from two pediatric intensive care units within a single healthcare system in Atlanta, GA.

RESULTS

Forty-five children received isoflurane, and 14 children received extracorporeal life support, 9 without a trial of isoflurane. Hypercarbia and acidosis improved within four hours of starting isoflurane. Four children died during the index admission for asthma. Twenty-seven percent had a change in Functional Status Score of three or more points from baseline to PICU discharge. Patients had median percent predicted FEV1 and FEV1/FVC ratios pre- and post-bronchodilator values below normal pediatric values.

CONCLUSION

Children who received isoflurane and/or ECLS had a high frequency of previous PICU admission and intubation. Improvement in ventilation and acidosis occurred within the first four hours of starting isoflurane. Children who required isoflurane or ECLS may develop long-lasting deficits in their functional status. Children with near-fatal asthma are a high-risk group and require improved follow-up in the year following PICU discharge.

Assessment and therapeutic management of acute asthma: The approaches of nursing staff in patient care

Acute severe asthma describes serious asthmatic attacks, which remain a major treatment challenge and a significant source of morbidity in adults. It places the patient in danger of developing respiratory failure, a condition known as status asthmaticus. It is often fatal if not recognized and treated early. Many patients are at risk for numerous reasons; thus, the key issues are early detection, assessment and management. A multidisciplinary and collaborative approach is needed to effectively treat acute respiratory failure (ARF). Considerable research has investigated the range of opportunities available for treating asthma. Current treatment options include conventional agents, such as inhalational corticosteroids, â-agonists, leukotriene modulators, monoclonal antibodies, and oral corticosteroids (OCS). Nurses are in a perfect position to assess patients' risk of developing respiratory failure, monitor them, evaluate their care, and coordinate a multidisciplinary approach. In this review, we discuss acute asthma and the role of the nursing officer (NO) in the management of the illness. The review will also emphasize various current treatment approaches available for the NO that can effectively target and prevent respiratory failure. This review provides nurses and other healthcare workers with updated information on timely, effective and safe supportive management of patients with asthma.

Pediatric extracorporeal life support for refractory status asthmaticus: ELSO Registry trends from the past decade

BACKGROUND

Extracorporeal life support (ECLS) for status asthmaticus (SA) is rare. Increased safety and experience may increase utilization of ECLS for SA.

METHODS

We reviewed pediatric (<18 years old) patients requiring ECLS for SA between 1998 and 2019 within the Extracorporeal Life Support Organization (ELSO) Registry and Nemours Children's Health (NCH) system. We compared patient characteristics, pre-ECLS medications, clinical data, complications, and survival to discharge between Early (1988-2008) and Late (2009-2019) eras.

RESULTS

From the ELSO Registry, we identified 173 children, 53 in Early and 120 in Late eras, with primary diagnosis of SA. Pre-ECLS hypercarbic respiratory failure was similar between eras (median pH 7.0 and pCO2 111 mm Hg). Venovenous mode (79% vs. 82%), median ECLS time (116 vs. 99 h), time to extubation (53 vs. 62 h), and hospital survival (89% vs. 88%) also remained similar. Intubation to cannulation time significantly decreased (20 vs. 10 h, p = 0.01). ECLS without complication occurred more in the Late era (19% vs. 39%, p < 0.01), with decreased hemorrhagic (24% vs. 12%, p = 0.05) and noncannula-related mechanical (19% vs. 6%, p = 0.008) complications. Within NCH, we identified six Late era patients. Pre-ECLS medication favored intravenous beta agonists, bronchodilators, magnesium sulfate, and steroids. One patient died from neurological complications following pre-ECLS cardiac arrest.

CONCLUSIONS

Collective experience supports ECLS as a rescue therapy for pediatric SA. Survival to discharge remains good, and complication rates have improved. Pre-ECLS cardiac arrest may potentiate neurologic injury and impact survival. Further study is needed to evaluate causal relationships between complications and outcomes.

Metabolomics identifies disturbances in arginine, phenylalanine, and glycine metabolism as differentiating features of exacerbating atopic asthma in children

Background

Asthma exacerbations are highly prevalent in children, but only a few studies have examined the biologic mechanisms underlying exacerbations in this population.

Objective

High-resolution metabolomics analyses were performed to understand the differences in metabolites in children with exacerbating asthma who were hospitalized in a pediatric intensive care unit for status asthmaticus. We hypothesized that compared with a similar population of stable outpatients with asthma, children with exacerbating asthma would have differing metabolite abundance patterns with distinct clustering profiles.

Methods

A total of 98 children aged 6 through 17 years with exacerbating asthma (n = 69) and stable asthma (n = 29) underwent clinical characterization procedures and submitted plasma samples for metabolomic analyses. High-confidence metabolites were retained and utilized for pathway enrichment analyses to identify the most relevant metabolic pathways that discriminated between groups.

Results

In all, 118 and 131 high-confidence metabolites were identified in positive and negative ionization mode, respectively. A total of 103 unique metabolites differed significantly between children with exacerbating asthma and children with stable asthma. In all, 8 significantly enriched pathways that were largely associated with alterations in arginine, phenylalanine, and glycine metabolism were identified. However, other metabolites and pathways of interest were also identified.

Conclusion

Metabolomic analyses identified multiple perturbed metabolites and pathways that discriminated children with exacerbating asthma who were hospitalized for status asthmaticus. These results highlight the complex biology of inflammation in children with exacerbating asthma and argue for additional studies of the metabolic determinants of asthma exacerbations in children because many of the identified metabolites of interest may be amenable to targeted interventions.

Case report: Foreign body aspiration requiring extracorporeal membrane oxygenation

Introduction

Foreign body aspiration is a common cause of respiratory distress in pediatrics, but the diagnosis can be challenging given aspirated objects are mostly radiolucent on chest radiographs and there is often no witnessed choking event. We present a case of a patient who was initially managed as severe status asthmaticus, requiring veno-arterial extracorporeal membrane oxygenation (VA-ECMO) for refractory hypercarbia and hypoxemia, but was later found to have bilateral bronchial foreign body aspiration. This case is unique in its severity of illness, diagnostic dilemma with findings suggesting a more common diagnosis of asthma, and use of ECMO as a bridge to diagnosis and recovery.

Patient case

A previously healthy 2-year-old boy presented during peak viral season with a 3-day history of fever, cough, coryza, and increased work of breathing over the prior 24 h. There was no reported history of choking or aspiration. He was diagnosed with asthma and treated with bronchodilator therapy. Physical examination revealed pulsus paradoxus, severe work of breathing with bilateral wheeze, and at times a silent chest. Chest radiographs showed bilateral lung hyperinflation. Following a brief period of stability on maximum bronchodilator therapies and bilevel positive pressure support, the patient had a rapid deterioration requiring endotracheal intubation, with subsequent cannulation to VA-ECMO. A diagnostic flexible bronchoscopy was performed and demonstrated bilateral foreign bodies, peanuts, in the right bronchus intermedius and the left mainstem bronchus. Removal of the foreign bodies was done by rigid bronchoscopy facilitating rapid wean from VA-ECMO and decannulation within 24 h of foreign body removal.

Conclusion

Foreign body aspiration should be suspected in all patients presenting with atypical history and physical examination findings, or in patients with suspected common diagnoses who do not progress as expected or deteriorate after a period of stability. Extracorporeal life support can be used as a bridge to diagnosis and recovery in patients with hemodynamic or respiratory instability.

Dexamethasone versus methylprednisolone for critical asthma: A single center, open-label, parallel-group clinical trial

BACKGROUND

Evidence for the use of dexamethasone for pediatric critical asthma is limited. We sought to compare the clinical efficacy and safety of dexamethasone versus methylprednisolone among children hospitalized in the pediatric intensive care unit (PICU) for critical asthma.

METHODS

A prospective, single center, open-label, two-arm, parallel-group, nonrandomized trial among children ages 5-17 years hospitalized within the PICU from April 2019 to December 2021 for critical asthma consented to receive methylprednisolone (standard care) or dexamethasone (intervention) at a 2:1 allocation ratio, respectively. The intervention arm received intravenous dexamethasone 0.25 mg/kg/dose (max: 15 mg/dose) every 6 h for 48 h and the standard care arm intravenous methylprednisolone 1 mg/kg/dose every 6 h (max dose: 60 mg/dose) for 5 days. Study endpoints were clinical efficacy (i.e., length of stay [LOS], continuous albuterol duration, and a composite of adjunctive asthma interventions) and safety (i.e., corticosteroid-related adverse events).

RESULTS

Ninety-two participants were analyzed of whom 31 were allocated to the intervention arm and 61 the standard care arm. No differences in demographics, clinical characteristics, or acute/chronic asthma severity indices were observed. Regarding efficacy and safety endpoints, no differences in hospital LOS, continuous albuterol duration, adjunctive asthma intervention rates, or corticosteroid-related adverse events were noted. Compared to the intervention arm, participants in the standard care arm more frequently were prescribed corticosteroids at discharge (72% vs. 13%, p < 0.001).

CONCLUSIONS

Among children hospitalized for critical asthma, dexamethasone appears safe and warrants further investigation to fully assess clinical efficacy and potential advantages over commonly applied agents such as methylprednisolone.

Characteristics of individuals with moderate to severe asthma who better respond to aerobic training: a cluster analysis

OBJECTIVE

To determine the characteristics of individuals with asthma who are responsive to aerobic training.

METHODS

This post hoc analysis of pooled data from previous randomized controlled trials involved 101 individuals with moderate to severe asthma who underwent aerobic training. Participants underwent a maximal cardiopulmonary exercise test and completed the Asthma Control Questionnaire and the Asthma Quality of Life Questionnaire before and after a 24-session aerobic training program. Better and worse responders to aerobic training were identified by cluster analysis.

RESULTS

Two clusters were identified according to the improvement in peak VO2 after aerobic training (better and worse responders). Characteristics of the better responder group were being older, being female, having higher BMI, and having higher cardiac reserve at baseline when compared with the worse responder group. Also, better responders had worse clinical control, worse quality of life, and lower physical capacity at baseline. After training, worse responders, in comparison with better responders, showed half the improvement in Δpeak VO2 (7.4% vs. 13.6%; 95% CI, -12.1 to -0.92%; p < 0.05) and worse asthma control. A weak, negative, but significant association (r = -0.35; p < 0.05) was observed between clinical control and aerobic fitness only in the better responder group. Both groups showed significant improvement in quality of life.

CONCLUSIONS

Obese individuals with worse exercise capacity, clinical control, and quality of life showed improvement with aerobic training. Moreover, worse responders also improved with training, but to a lesser extent.

Children with Near-Fatal Asthma: The Use of Inhaled Volatile Anesthetics and Extracorporeal Membrane Oxygenation

Background and Purpose: The use of extracorporeal membrane oxygenation (ECMO) has been described for near-fatal asthma that continues to be refractory despite maximal medical therapy. Methods: Patients admitted to the pediatric intensive care unit at Texas Children's Hospital from 2012 to 2020 with the diagnosis of asthma who were supported on ECMO or isoflurane were included in the study. Patient demographics, medication usage, and complications were compared between the case group (ECMO, n = 12) and the control group (isoflurane only, n = 8). Results: All patients survived to discharge. ECMO patients received shorter durations of albuterol (12 versus 104 h, P = 0.0002) and terbutaline (13.3 versus 31.5 h, P = 0.0250). There were no differences in complication rates between the 2 groups. Conclusion: ECMO is a reasonable and safe support method for patients with near-fatal asthma and may lead to less bronchodilator medication exposure when compared with inhaled volatile anesthetic use.

Case report: Isoflurane therapy in a case of status asthmaticus requiring extracorporeal membrane oxygenation

Volatile anesthetics have been described as a rescue therapy for patients with refractory status asthmaticus (SA), and the use of isoflurane for this indication has been reported since the 1980s. Much of the literature reports good outcomes when inhaled isoflurane is used as a rescue therapy for patients for refractory SA. Venovenous (VV) extracorporeal membrane oxygenation (ECMO) is a mode of mechanical circulatory support that is usually employed as a potentially lifesaving intervention in patients who have high risk of mortality, primarily for underlying pulmonary pathology. VV ECMO is usually only considered in cases where patients gas exchange cannot be satisfactorily maintained by conventional therapy and mechanical ventilation strategies. We report the novel use of isoflurane delivered systemically as treatment for severe refractory SA in a patient on VV ECMO. A 51-year-old male with a history of asthma was transferred from another institution for management of severe SA. He was intubated at the referring hospital after failing non-invasive ventilation. Initial arterial blood gas (ABG) showed pH 7.21, partial pressure of carbon dioxide (PCO2) >95 mmHg, and partial pressure of oxygen (PaO2) 60 mmHg. VV ECMO was initiated on hospital day (HD) 1 due to refractory respiratory acidosis. After ECMO initiation, acid-base status improved, however, severe bronchospasm persisted and intrinsic positive end expiratory pressure (PEEP) was measured at 18 cm H2O. Systemic paralysis was employed, respiratory rate (RR) was reduced to 4 breaths per minute. This degree of bronchospasm did not allow for ECMO weaning. On HD 5, the patient received systemic isoflurane via the ECMO circuit for 20 h. The following morning, intrinsic PEEP was 4 cm H2O, and wheezing improved. He was decannulated from VV ECMO on HD 10 and extubated on HD 17. Inhaled isoflurane therapy in patients on VV ECMO for refractory SA has shown good results, but requires delivery of the medication via anesthesia ventilators. Our case highlights an effective alternative, systemic delivery of anesthetic via the ECMO circuit, as it is often difficult and dangerous to transport these patients to the operating room (OR) or have an intensive care unit (ICU) room adjusted to accommodate an anesthesia ventilator.

Heliox Prescribing Trends for Pediatric Critical Asthma

BACKGROUND

Children with asthma exacerbations requiring pediatric ICU (PICU) admission, known as critical asthma (CA), are prescribed a variety of therapeutic interventions including heliox. Delivered invasively and noninvasively, heliox is employed to enhance deposition of aerosolized medications, improve obstructive pulmonary pathophysiology, and avoid complications associated with invasive mechanical ventilation. We used the Virtual Pediatric Systems database to update estimates of heliox prescription and explore for relationships between heliox and mechanical ventilation frequency and duration.

METHODS

We performed a retrospective cohort study using data from 97 PICUs among children 3-17 y of age admitted for CA from 2013-2019. The primary outcome was heliox prescribing rates and trends. Subgroup analyses assessed mechanical ventilation rates and duration by heliox exposure.

RESULTS

Of 43,238 subjects studied, 1,070 (2.5%) were prescribed heliox. Mean heliox prescribing rates fell from 4.11% in 2013 to 2.37% in 2019. Heliox use was greater from centers in the South (2.6%) and Midwest (3.3%) as compared to the West (1.6%) and Northeast United States (1.6%, P < .001). In the subgroup assessing mechanical ventilation frequency, mechanical ventilation rates were 273/39,739 (0.7%) and greater for those provided heliox (1.9% vs 0.7%, P < .001). In the subgroup assessing mechanical ventilation duration, no differences in median mechanical ventilation duration were observed (4.94 [interquartile range [IQR] 3.04-6.36] vs 4.63 [IQR 3.11-7.30] d; P = .35) for those with and without heliox. In exploratory adjusted models, noninvasive heliox was not associated with mechanical ventilation. Mortality was rare (206/43,238 [0.47%]) and predominantly among subjects intubated prehospitalization (188/206 [91.3%]).

CONCLUSIONS

Heliox as adjunctive therapy for children with CA is uncommon (2.5%) and not associated with mechanical ventilation or decreased mechanical ventilation duration in adjusted models. Updated estimates provided herein inform prospective controlled trial development to better define the role of heliox for CA.

Dexamethasone for Pediatric Critical Asthma: A Multicenter Descriptive Study

BACKGROUND

Systemic corticosteroids are vital to critical asthma management. While intravenous methylprednisolone is routinely used in the pediatric intensive care unit (PICU) setting, recent data supports dexamethasone as an alternative. Using the Pediatric Health Information System (PHIS) registry, we assessed trends and variation in corticosteroid prescribing among children hospitalized for critical asthma.

METHODS

We performed a multicenter retrospective cohort study using PHIS data among children 3-17 years of age admitted for critical asthma from 2011 through 2019. Primary outcomes were corticosteroid prescribing rates by year and participating sites. Exploratory outcomes were corticosteroid-related adverse effects, rates of adjunctive pharmaceutical and respiratory interventions, mortality and length of stay.

RESULTS

Of the 49 children's hospitals assessed, 26 907 encounters were included for study. Mean dexamethasone exposure rates were 18.1 ± 2.4% where 2.4 ± 1.2% represented dexamethasone-alone prescribing. Dexamethasone alone prescribing exhibited a linear trend (annual increase of 0.5 ± 0.1% annually R² = 0.845) without correlation to cumulative site critical asthma admission rates. Compared to encounters prescribed solely methylprednisolone or a combination of dexamethasone and methylprednisolone, subjects provided dexamethasone alone had reduced asthma severity indices, length of stay, and exposure rates to adjunctive asthma interventions. Adverse events were rare and the dexamethasone-alone group less frequently experienced gastritis and hyperglycemia.

CONCLUSIONS

In this multicenter retrospective study from 49 children's hospitals, dexamethasone prescribing rates appear increasing for pediatric critical asthma. Observed variability in corticosteroid prescribing implies a continued need for controlled prospective comparative analyses to define ideal corticosteroid regimens for pediatric critical asthma.

Endotracheal Tube Size Is Associated With Mortality in Patients With Status Asthmaticus

BACKGROUND

There is limited evidence on the clinical importance of the endotracheal tube (ETT) size selection in patients with status asthmaticus who require invasive mechanical ventilation. We set out to explore the clinical outcomes of different ETT internal diameter sizes in subjects mechanically ventilated with status asthmaticus.

METHODS

This was a retrospective study of intubated and non-intubated adults admitted for status asthmaticus between 2014-2021. We examined in-hospital mortality across subgroups with different ETT sizes, as well as non-intubated subjects, using logistic and generalized linear mixed-effects models. We adjusted for demographics, Charlson comorbidities, the first Sequential Organ Failure Assessment score, intubating personnel and setting, COVID-19, and the first PaCO2 . Finally, we calculated the post-estimation predictions of mortality.

RESULTS

We enrolled subjects from 964 status asthmaticus admissions. The average age was 46.9 (SD 14.5) y; 63.5% of the encounters were women and 80.6% were Black. Approximately 72% of subjects (690) were not intubated. Twenty-eight percent (275) required endotracheal intubation, of which 3.3% (32) had a 7.0 mm or smaller ETT (ETT ≤ 7 group), 16.5% (159) a 7.5 mm ETT (ETT ≤ 7.5 group), and 8.6% (83) an 8.0 mm or larger ETT (ETT ≥ 8 group). The adjusted mortality was 26.7% (95% CI 13.2-40.2) for the ETT ≤ 7 group versus 14.3% ([(95% CI 6.9-21.7%], P = .04) for ETT ≤ 7.5 group and 11.0% ([95% CI 4.4-17.5], P = .02) for ETT ≥ 8 group, respectively.

CONCLUSIONS

Intubated subjects with status asthmaticus had higher mortality than non-intubated subjects. Intubated subjects had incrementally higher observed mortality with smaller ETT sizes. Physiologic mechanisms can support this dose-response relationship.

Continuous Magnesium Sulfate Infusions for Status Asthmaticus in Children: A Systematic Review

OBJECTIVES

Magnesium sulfate is a second-tier therapy for asthma exacerbations in children; guidelines recommend a single-dose to improve pulmonary function and decrease the odds of admission to the in-patient setting. However, many clinicians utilize prolonged magnesium sulfate infusions for children with refractory asthma. The purpose of this review is to describe the efficacy and safety of magnesium sulfate infusions administered over ≥ 1 h in children with status asthmaticus.

METHODS

Medline was searched using the keywords "magnesium sulfate" and "children." Articles evaluating the use of magnesium sulfate infusions for ≥1 h published between 1946 and August 2021 were included. Published abstracts were not included because of lack of essential details. All articles were screened by two reviewers.

RESULTS

Eight reports including 447 children were included. The magnesium regimens evaluated included magnesium delivered over 1 h (n = 148; 33.1%), over 4-5 h (n = 105; 23.5%), and over >24 h (n = 194; 43.4%). Majority of patients received a bolus dose of 25-75 mg/kg/dose prior to initiation of a prolonged infusion (n = 299; 66.9%). For the patients receiving magnesium infusions over 4-5 h, the dosing regimen varied between 40 and 50 mg/kg/h. For those receiving magnesium infusions >24 h, the dosing varied between 18.4 and 25 mg/kg/h for a duration between 53.4 and 177.5 h. Only three reports including 186 patients (41.6%) included an evaluation of clinical outcomes including evaluation of lung function parameters, reduction in PICU transfers, and/or decrease in emergency department length of stay. Five reports including 261 patients (58.4%) evaluated magnesium serum concentrations. In most reports, the goal concentrations were between 4 and 6 mg/dL. Only 3 (1.1%) out of the 261 patients had supratherapeutic magnesium concentrations. The only reports finding adverse events attributed to magnesium were noted in those receiving infusions for >24 h. Clinically significant adverse events included hypotension (n = 74; 16.6%), nausea/vomiting (n = 35; 7.8%), mild muscle weakness (n = 22; 4.9%), flushing (n = 10; 2.2%), and sedation (n = 2; 0.4%).

CONCLUSION

Significant variability was noted in magnesium dosing regimens, with most children receiving magnesium infusions over >4 h. Most reports did not assess clinical outcomes. Until future research is conducted, the use of prolonged magnesium sulfate infusions should be reserved for refractory asthma therapy.

Efficacy and Safety of Prolonged Magnesium Sulfate Infusions in Children With Refractory Status Asthmaticus

OBJECTIVES

There is a paucity of data on the use of intravenous magnesium sulfate infusion in children with refractory status asthmaticus. The purpose of this study was to evaluate the efficacy and safety of prolonged magnesium sulfate infusion as an advanced therapy.

METHODS

This is a single center retrospective study of children admitted to our pediatric intensive care unit (PICU) with status asthmaticus requiring continuous albuterol. Treatment group included patients receiving magnesium for ≥4 h and control group included those on other therapies only. Patients were matched 1:4 based on age, sex, obesity, pediatric index of mortality III and pediatric risk of mortality III scores. Primary outcomes included PICU length of stay (LOS) and mechanical ventilation (MV) requirement. Secondary outcomes included mortality, extracorporeal membrane oxygenation (ECMO) requirement, analyses of factors associated with PICU LOS and MV requirement and safety of magnesium infusion. Logistic and linear regressions were employed to determine factors associated with MV requirement and PICU LOS, respectively.

RESULTS

Treatment and control groups included 27 and 108 patients, respectively. Median initial infusion rate was 15 mg/kg/hour, with median duration of 28 h. There was no difference in the MV requirement between the treatment and control groups [7 (25.9%) vs. 20 patients (18.5%), p = 0.39]. Median PICU LOS and ECMO use were significantly higher in treatment vs. control group [(3.63 vs. 1.09 days, p < 0.01) and (11.1 vs. 0%, p < 0.01), respectively]. No mortality difference was noted. On regression analysis, patients receiving ketamine and higher prednisone equivalent dosing had higher odds of MV requirement [OR 19.29 (95% CI 5.40-68.88), p < 0.01 and 1.099 (95% CI 1.03-1.17), p < 0.01, respectively]. Each mg/kg increase in prednisone equivalent dosing corresponded to an increase in PICU LOS by 0.13 days (95% CI 0.096-0.160, p < 0.01). Magnesium infusions were not associated with lower MV requirement or lower PICU LOS after controlling for covariates. Fourteen (51.9%) patients in the treatment group had an adverse event, hypotension being the most common.

CONCLUSION

Magnesium sulfate infusions were not associated with MV requirement, PICU LOS or mortality.

Geospatial Analysis of Social Determinants of Health Identifies Neighborhood Hot Spots Associated with Pediatric Intensive Care Use for Life-threatening Asthma

BACKGROUND

Social determinants of health are associated with asthma prevalence and healthcare use in children with asthma, but are multifactorial and complex. Whether social determinants similarly influence exacerbation severity is not clear.

OBJECTIVE

Composite measures of social determinants of health and readmission outcomes were evaluated in a large regional cohort of 1,403 school-age children admitted to a pediatric intensive care unit (PICU) for asthma.

METHODS

Residential addresses were geocoded and spatially joined to census tracts. Composite measures of social vulnerability and childhood opportunity, PICU readmission rates, and hospital length of stay were compared between neighborhood hot spots, where PICU admission rates per 1,000 children are at or above the 90th percentile, versus non-hot spots.

RESULTS

A total of 228 children resided within a neighborhood hot spot (16%). Hot spots were associated with a higher (ie, poorer) composite Social Vulnerability Index ranking, reflecting differences in socioeconomic status, household composition and disability, and housing type and transportation. Hot spots also had a lower (ie, poorer) composite Childhood Opportunity Index percentile ranking, reflecting differences in the education, health and environment, and social and economic domains. Higher social vulnerability and lower childhood opportunity were associated with PICU readmission. Residing within a hot spot was further associated with a longer duration of hospital stay, individual inpatient bed days, and total census tract inpatient bed days.

CONCLUSIONS

Social determinants of health identified by geospatial analyses are associated with more severe asthma exacerbation outcomes in children. Outpatient strategies that address both biological and social determinants of health are needed to care for and prevent PICU admissions optimally in children with asthma.

Risk Factors for Pediatric Asthma Readmissions: A Systematic Review

OBJECTIVE

To systematically review the literature on pediatric asthma readmission risk factors.

STUDY DESIGN

We searched PubMed/MEDLINE, CINAHL, Scopus, PsycINFO, and Cochrane Central Register of Controlled Trials for published articles (through November 2019) on pediatric asthma readmission risk factors. Two authors independently screened titles and abstracts and consensus was reached on disagreements. Full-text articles were reviewed and inclusion criteria applied. For articles meeting inclusion criteria, authors abstracted data on study design, patient characteristics, and outcomes, and 4 authors assessed bias risk.

RESULTS

Of 5749 abstracts, 74 met inclusion criteria. Study designs, patient populations, and outcome measures were highly heterogeneous. Risk factors consistently associated with early readmissions (≤30 days) included prolonged length of stay (OR range, 1.1-1.6) and chronic comorbidities (1.7-3.2). Risk factors associated with late readmissions (>30 days) included female sex (1.1-1.6), chronic comorbidities (1.5-2), summer discharge (1.5-1.8), and prolonged length of stay (1.04-1.7). Across both readmission intervals, prior asthma admission was the most consistent readmission predictor (1.3-5.4).

CONCLUSIONS

Pediatric asthma readmission risk factors depend on the readmission interval chosen. Prior hospitalization, length of stay, sex, and chronic comorbidities were consistently associated with both early and late readmissions.

TRIAL REGISTRATION

CRD42018107601.

A hospital-based multidimensional intervention for high risk pediatric patients with asthma

Objective: To determine the effects of a multi-dimensional intervention (consisting of education, recommendations for medical management, and short-term case management) provided by pulmonology nurse practitioners(NP) on inpatient and post-discharge outcomes for patients admitted with asthma exacerbations to a Pediatric Intensive Care Unit(PICU).Methods: A retrospective cohort study was completed on subjects with an asthma exacerbation admitted to the PICU from 01-01-2015 to 31-12-2018. Records were reviewed for 12-months post-discharge. We compared inpatient and post-discharge outcomes for those who did vs. did not receive NP consultation. The primary outcome evaluated was optimization of discharge medications. Rates of follow up, repeat ED visits and hospitalizations were also reviewed.Results: 222 subjects met inclusion and exclusion criteria; of those, 101(45.5%) patients received NP consultation and 121(54.5%) had PICU management only. Patients with NP consultation were more likely to have controllers initiated (34.6% vs. 15%) or adjusted (55.5% vs. 33.3%) per asthma guidelines (p < 0.001). The consult group were more likely to have an asthma follow-up appointment made prior to discharge (99% vs. 45%, p < 0.001), and were more likely to attend the appointment (51% vs. 21%, p < 0.001). There were no significant differences between groups for ED visits or readmission for asthma 12-months post-discharge.Conclusions: Patients with NP consultation were more likely to have controllers started or adjusted per guidelines and were more likely to attend specialty follow-up appointments post-discharge. No impact was seen on ED visits or readmissions. Implementation of such a program may aid in optimizing asthma management and continuity of care post hospitalization.

High-Flow Nasal Cannula in Pediatric Critical Asthma

BACKGROUND

High-flow nasal cannula (HFNC) has been used in the treatment of pediatric asthma, although high-quality data comparing HFNC to aerosol mask nebulizer are lacking. We hypothesized that HFNC would perform similarly to the aerosol mask for meaningful clinical outcomes in children with critical asthma.

METHODS

We retrospectively reviewed the medical records of children with critical asthma (age 2-17 y) with a modified pulmonary index score (MPIS) ≥ 8 admitted to our pediatric ICU as part of a quality improvement project. Patients were managed with our MPIS-based, respiratory therapist-driven protocol. Subjects were divided into 2 cohorts by initial respiratory support: HFNC or aerosol mask. Data included demographics, initial respiratory support, and MPIS over time. Primary outcome was hospital length of stay (LOS). Secondary outcome was difference in MPIS over time.

RESULTS

We included 171 subjects, with 104 in the HFNC group and 67 in the aerosol mask group. Median (interquartile range [IQR]) age was lower in the HFNC group (5 [IQR 4-9] vs 7 [IQR 5-10] y, P = .006)], while other demographic characteristics were similar. Initial MPIS was similar between HFNC and aerosol mask groups (11 [IQR 9-12] vs 10 [IQR 9-12], P = .15). There were no significant differences for hospital LOS (2.9 [IQR 2.1-3.9] vs 3.0 [IQR 2.3-4.4] d, P = .47), pediatric ICU LOS (1.9 [IQR 1.4-2.8] vs 1.8 [IQR 1.5-3.0] d, P = .92), or time to MPIS < 6 (1.0 [IQR 0.6-1.6] vs 1.3 [IQR 0.8-1.9) d, P = .09) between the HFNC and aerosol mask groups, respectively. Median time on continuous albuterol was shorter in the HFNC group compared to the aerosol mask group (1.0 [IQR 0.7-1.8] vs 1.5 [IQR 0.9-2.3] d, P = .048). Of note, 16 (24%) subjects in the aerosol mask group were eventually treated with HFNC. Use of a helium-oxygen mixture and noninvasive ventilation was similar between groups.

CONCLUSIONS

HFNC performed similarly to aerosol mask in pediatric patients with critical asthma.

Heliox for Pediatric Critical Asthma: A Multicenter, Retrospective, Registry-Based Descriptive Study

BACKGROUND

In cases of critical asthma (CA), heliox may be applied as an adjunctive rescue therapy to avoid invasive mechanical ventilation (MV), improve deposition of aerosolized medications, and enhance laminar airflow through obstructed airways. Using the Pediatric Health Information System (PHIS) registry, we evaluate heliox prescribing and explored for differences in MV rates and hospital length of stay (LOS) among children with and without heliox exposure.

METHODS

We performed a retrospective cohort study using PHIS data from 42 pediatric intensive care units among children 5-17 years of age admitted for CA from 2010 through 2019. Primary outcomes were heliox prescribing rates and trends. Secondary outcomes were invasive MV rates and LOS assessed in a subgroup of children receiving ≥ 1 adjunctive intervention(s).

RESULTS

Of the 19,780 studied, heliox was prescribed in 12.5% and linearly declined from 16.1% in 2010 to 5.6% in 2019. The overall MV rate was 12.8% and was lower in subjects receiving heliox alone (4.9%) compared to heliox plus alternative adjunctive therapies [31.2%] or children receiving non-heliox adjunctive therapies [22.1%], P < .01). Accounting for MV, no difference in LOS was observed. In exploratory adjusted models, MV free hospitalization was associated with heliox-only exposure (OR: 0.33, 95% CI: 0.17-0.63, P < .01) and exposure to multiple adjunctive therapies was associated with MV (OR: 2.48, 95% CI: 1.56-3.94, P < .01).

CONCLUSIONS

In this multicenter retrospective study from 42 children's hospitals, heliox prescribing for CA declined over the last decade. Subjects receiving multiple adjunctive therapies more commonly required invasive MV perhaps indicating a greater severity of illness. At this time, prospective trials needed to identify the role of heliox for pediatric CA.

Enteral Feeding for Children on Bilevel Positive Pressure Ventilation for Status Asthmaticus

A retrospective data analysis was conducted to evaluate enteral nutrition practices for children admitted with status asthmaticus in a single-center pediatric intensive care unit. Of 406 charts, 315 were analyzed (63% male); 135 on bilevel positive airway pressure ventilation (BIPAP) and 180 on simple mask. Overall median age and weight were 6.0 (interquartile range [IQR]: 6.0) years and 24.8 (IQR: 20.8) kg, respectively. All children studied were on full feeds while still on BIPAP and simple mask; 99.3 and 100% were fed per oral, respectively. Median time to initiation of feeds and full feeds was longer in the BIPAP group, 11.0 (IQR: 20) and 23.0 hours (IQR: 26), versus simple mask group, 4.3 (IQR: 7) and 12.0 hours (IQR: 15), p  = 0.001. The results remained similar after adjusting for gender, weight, clinical asthma score at admission, use of adjunct therapy, and duration of continuous albuterol. By 24 hours, 81.5% of patients on BIPAP and 96.6% on simple mask were started on feeds. Compared with simple mask, patients on BIPAP were sicker with median asthma score at admission of 4 (IQR: 2) versus 3 (IQR: 2) on simple mask, requiring more adjunct therapy (80.0 vs. 43.9%), and a longer median length of therapy of 41.0 (IQR: 41) versus 20.0 hours (IQR: 29), respectively, p  = 0.001. There were no complications such as aspiration pneumonia, and none required invasive mechanical ventilation in either group. Enteral nutrition was effectively and safely initiated and continued for children admitted with status asthmaticus, including those on noninvasive bilevel ventilation therapy.

Implementation of a Critical Asthma Protocol in a Pediatric ICU

BACKGROUND

Protocol-driven therapy has been successful in managing patients with asthma on pediatric wards, but there is wide variability in ICU-level management that is often provider-dependent. This study aimed to determine if a standardized protocol for critical asthma treatment could improve clinical outcomes.

METHODS

A pre-intervention cohort consisting of subjects age 2-18 y, excluding patients with airway obstruction that was not felt to be due to asthma, who were admitted to the ICU for critical asthma. Demographics and data along with medication administration information were gathered using the hospital electronic medical record. A post-intervention cohort was obtained over 13 months in an identical manner. The primary end point was time on continuous albuterol. Subjects adhering to the protocol were examined as a subset.

RESULTS

71 post-intervention subjects were compared with a historical cohort of 52 pre-intervention subjects over a similar time frame. There were no significant differences in demographic characteristics. Median time on continuous albuterol (14.4 h vs 8.1 h, P = .14) and secondary end points of median ICU length of stay (LOS), hospital LOS, and time from discontinuing continuous albuterol to transfer out of ICU were not significantly reduced in the post-intervention cohort. Overall adherence to the clinical protocol through completion was 42%. When comparing the pre-intervention cohort with the protocol-adherent subjects, significant reductions were seen in time on continuous albuterol (14.4 h vs 3.0 h, P < .001), ICU LOS (38.7 h vs 21.0 h, P < .001), and hospital LOS (2.8 d vs 1.7 d, P = .005).

CONCLUSIONS

Implementation of an asthma protocol in the pediatric ICU did not result in significant improvements in time on continuous albuterol or hospital and pediatric ICU LOS, likely due to low adherence to the protocol. However, in subjects who did adhere to the protocol there were significant reductions in the outcome measures.

Systemic glucocorticoid at discharge after hospitalization for pediatric asthma: a prospective pilot study

OBJECTIVE: 

We examined asthma control in children hospitalized for status asthmaticus 7-10 days after discharge with or without an additional prescription for systemic corticosteroids.

METHODS: 

This was a prospective observational study of patients aged 5-17 years with a documented history of asthma or β-agonist responsive wheezing admitted to the hospital for an acute asthma exacerbation. We compared patients who had any systemic corticosteroid prescribed at discharge with those who were not prescribed systemic corticosteroids at discharge. The primary outcomes were asthma control after discharge, as defined by the Asthma Control Test (ACT), and missed school days, which we modeled with multivariable linear and Poisson regression, respectively.

RESULTS: 

A total of 56 patients were included in the study, 29 (52%) received dexamethasone inpatient and then were discharged without additional prescribed systemic corticosteroids. Those without a corticosteroid prescription at discharge were less likely to have received noninvasive ventilation (p = 0.02), pulmonology consultation (p = 0.02), and continuous albuterol (p = 0.01) during hospitalization. These patients also tended toward shorter length of stay (p = 0.07) compared to those receiving systemic corticosteroid prescription at discharge. In multivariable models, being discharged without systemic corticosteroid prescription was associated with poorer asthma control after discharge [beta (95% CI), -2.21 (-2.65 to -1.77)] and more missed school days [coefficient estimate (95% CI), 0.87 (0.07-1.68)].

CONCLUSIONS

After hospitalization for an asthma exacerbation, patients not given systemic corticosteroids at discharge tended to have worse asthma control following discharge despite having less severe disease and requiring less aggressive inpatient management.

Supplemental data for this article can be accessed at publisher's website.

Variability in care for children with severe acute asthma in Latin America

BACKGROUND

Care variability for children with severe acute asthma has been well documented in high-income countries, yet data from low- and middle-income regions are lacking. We sought to characterize the magnitude of practice variability in the care of Latin American children to identify opportunities for standardization of care.

METHODS

A cross-sectional study performed through a retrospective analysis of contemporaneously collected data of children with severe acute asthma admitted to a center contributing to the LARed Network registry between May 2017 and May 2019. Centers were grouped by geographic location: Atlantic (AT), South Pacific (SP), and North Central (NC).

RESULTS

Among 434 children, most received care in hospitals in the AT group (54% [235/434]), followed by the NC (23% [101/434]) and SP (23% [98/434]) groups. The majority of children in the AT (92% [215/235]) and SP (91% [89/98]) groups received nebulized salbutamol/albuterol, while metered-dose inhalers were preferred in the NC group (72% [73/101]). There was a wide variation in the use of antibiotics: AT (57% [135/235]), SP (48% [47/98]), and NC (14% [14/101]). The same was true for ipratropium bromide: AT (67% [157/235]), SP (90% [88/98]), and NC (17% [17/101]), and aminophylline: AT (57% [135/235]), NC (5% [5/101]), and SP (0% [0/98]). High-flow nasal cannula was the preferred respiratory support modality in the AT (60% [141/235]) and NC (40% [40/101]) groups, while bilevel positive airway pressure (BiPAP) use was more common in the SP group (80% [78/98]).

CONCLUSION

We identified significant variability in care for severe acute asthma. Our findings will help to inform the design of future studies, quality improvement initiatives, and development of practice guidelines within Latin America.

High-flow nasal cannula and bilevel positive airway pressure for pediatric status asthmaticus: a single center, retrospective descriptive and comparative cohort study

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.

Randomized pilot trial of ipratropium versus placebo in children with critical asthma

OBJECTIVE

To test the effects of inhaled ipratropium on clinical outcomes of critical asthma in the first randomized trial of this adjunctive therapy in critically ill children.

DESIGN

Pilot, placebo-controlled, double-blinded, and randomized-controlled trial PATIENTS: Thirty children (15 per group) with critical asthma receiving high-intensity albuterol per a standardized pathway utilizing objective assessments to wean patients to less frequent albuterol administration.

INTERVENTIONS

Subjects were randomized to receive either nebulized ipratropium bromide (500 µg in 0.9% saline per dose) or an equivalent volume of nebulized 0.9% saline every 6 h until the patient was successfully weaned to albuterol doses every 2 h ("q2 albuterol").

MEASUREMENTS AND MAIN RESULTS

Demographics, initial clinical severity score, and asthma histories were similar between groups. There was no significant difference in the median duration of high-intensity albuterol between the treatment group (17.5 [10.3-22.1] h) and placebo group (14.6 [12.7-24.5] days; p = .56). Similarly, there was no significant difference in pediatric intensive care unit length of stay (22.6 [21.1-33.6] vs. 21.4 [16.1-35.8] h; p = .74) or hospital length of stay (48.0 [41.8-59.8] vs. 47.3 [37.2-63.1] h; p = .67). In multivariate linear regression adjusting for identified confounders, treatment with ipratropium was not significantly associated with any of the three outcomes. Side effects were rare and occurred with equally between both groups CONCLUSIONS: Adjunctive therapy with ipratropium was not associated with decreased duration of high-intensity albuterol or shortened length of stay when compared to placebo. A larger, multicenter trial is warranted to confirm that ipratropium does not improve clinical outcomes.

Physiologically variable ventilation in a rabbit model of asthma exacerbation

BACKGROUND

Mechanical ventilation during status asthmaticus is challenging and increases the risk of severe complications. We recently reported the value of physiologically variable ventilation (PVV) in healthy and acutely injured lungs. We investigated whether PVV provides benefits compared with pressure-controlled ventilation (PCV) in an experimental model of severe acute asthma.

METHODS

Allergen-sensitised rabbits were anaesthetised and randomised to either PCV (n=10) or PVV (n=12) during sustained bronchoconstriction induced by allergen and cholinergic stimuli for 6 h. The PVV pattern was generated from pre-recorded spontaneous breathing. Ventilation parameters, oxygenation index (PaO₂/FiO₂), and respiratory mechanics were measured hourly. Histological injury and inflammation were quantified after 6 h of ventilation.

RESULTS

PVV resulted in lower driving pressures (13.7 cm H₂O [12.5-14.9], mean [95% confidence interval]), compared with pressure-controlled ventilation (17.6 cm H₂O [15.4-19.8]; P=0.002). PVV improved PaO₂/FiO₂ (PVV: 55.1 kPa [52-58.2]; PCV: 45.6 kPa [39.3-51.9]; P=0.018) and maintained tissue elastance (PVV: +8.7% [-0.6 to 18]; PCV: -11.2% [-17.3 to -5.1]; P=0.03). PVV resulted in less lung injury as assessed by lower histological injury score (PVV: 0.65 [0.62-0.65]; PCV: 0.71 [0.69-0.73]; P=0.003), cell count (PVV: 247 10⁴ ml^-1 [189-305]; PCV: 447 10⁴ ml^-1 [324-570]; P=0.005), and protein concentration in bronchoalveolar lavage fluid (PVV: 0.14 μg ml^-1 [0.10-0.18]; PCV: 0.21 μg ml^-1 [0.15-0.27]; P=0.035).

CONCLUSIONS

Applying physiological variable ventilation in a model of asthma exacerbation led to improvements in gas exchange, ventilatory pressures, and respiratory tissue mechanics, and reduced lung injury. A global reduction in lung shear stress and recruitment effects may explain the benefits of PVV in status asthmaticus.

Quantifying continuous nebulization via high flow nasal cannula and large volume nebulizer in a pediatric model

BACKGROUND

Use of high flow nasal cannula (HFNC) to deliver aerosolized medications to children has gained considerable interest. However, data on continuous albuterol delivery (CAD) via HFNC are lacking. This study quantified CAD via HFNC/vibrating mesh nebulizer (VMN) and large-volume jet nebulizer (LVN) with face mask (FM) in a pediatric model. Aerosol delivery with two HFNC cannula designs were also compared.

METHODS

A pediatric manikin was connected to a lung simulator (Vt = 150 mL, RR = 28 breaths/minute, I:E 1:2.4) via collecting filter at the carina. XL Pediatric and SML Adult HFNC designs were tested to determine optimal cannula design for CAD. VMN was placed Before humidifier (37°C), albuterol (5 mg/mL) was nebulized at 3, 6, and 12 L/minute (n = 3). To compare HFNC/VMN with LVN and FM, albuterol (15 mg/hour) was aerosolized for 3 hours/device (n = 3). LVN was connected to FM and filled with 9 mL of albuterol (5 mg/mL) and 66 mL of normal saline to deliver 25 mL/hour at 13 L/minute. VMN was connected to the infusion pump to deliver 7.5 mL/hr of albuterol (2 mg/mL). Drug eluted from filters was assayed with UV spectrophotometry (276 nm).

RESULTS

Optimal aerosol delivery occurred at 3 L/minute (12.6% ± 0.5%) with SML Adult HFNC (P = .04). When used for CAD, inhaled drug delivery with HFNC/VMN (2.2 mg/hr ± 0.1, 14.8% ± 0.7%) was significantly greater than LVN and FM (0.48 ± 0.09 mg/hour, 3.2% ± 0.6%) (P = .001).

CONCLUSIONS

Administration of CAD via HFNC/VMN led to a greater than fourfold increase in drug delivery compared to LVN with FM. Optimal aerosol delivery occurred at 3 L/minute with SML Adult HFNC.

Factors Associated with Failure of Intermittent Nebulization with Short-Acting Beta-Agonists in Children with Severe Asthma Exacerbation

Purpose

Intermittent nebulization of short-acting beta-agonists (SABA) is the initial treatment of choice for children with asthma exacerbation. However, children with severe asthma exacerbation (SAE) may not show an adequate response and need aggressive stepwise therapy. We aimed to explore factors associated with a poor response to intermittent nebulized SABA in children with SAE.

Methods

A retrospective cohort study of children with SAE diagnosed according to the definition of the British Guidelines on the Management of Asthma, who were admitted at Hat Yai Hospital from January 1, 2015, to December 31, 2017. All children were treated with intermittent SABA nebulization. Treatment failure was defined as children needing escalated therapy. Logistic regression with confounding score adjustment was used to explore the predictors of treatment failure.

Results

One hundred thirty-three children were included in the analysis, 59 were in the failure group and 74 were in the success group. After adjusting for potential confounders, they were significantly associated with a previous history of intubation (adjusted OR 6.46, 95% CI 1.13 to 36.79, p=0.036), receiving <3 doses of nebulized salbutamol in the emergency room (ER, aOR 3.21, 95% CI 1.15 to 9.02, p=0.027), ER measured oxygen saturation (SpO₂) <92% (adjusted OR 3.02, 95% CI 1.18 to 7.75, p=0.022), and exacerbation triggered by pneumonia (adjusted OR 2.67, 95% CI 1.19 to 6.00, p=0.017).

Conclusion

We identified four prognostic factors of treatment failure in children with SAE: a previous history of intubation; receiving <3 doses of nebulized salbutamol in the ER, SpO₂ at ER <92%; and exacerbation triggered by pneumonia. Further prospective studies are required to confirm our findings before clinical implementation.

Quality of life and psychosocial outcomes in children with severe acute asthma and their parents

OBJECTIVES

To prospectively evaluate quality of life (QoL) and psychosocial outcomes in children with severe acute asthma (SAA) after pediatric intensive care (PICU) admission compared to children with SAA who were admitted to a general ward (GW). In addition, we assessed post-traumatic stress (PTS) and asthma-related QoL in the parents.

METHODS

A preplanned follow-up of 3-9 months of our nationwide prospective multicenter study, in which children with SAA admitted to a Dutch PICU (n=110) or GW (n=111) were enrolled between 2016-2018. Asthma-related QoL, PTS symptoms, emotional and behavioral problems, and social impact in children and/or parents were assessed with validated web-based questionnaires.

RESULTS

We included 100 children after PICU and 103 after GW admission, with a response rate of 50% for the questionnaires. Median time to follow-up was 5 months (range 1-12 months). Time to reach full schooldays after admission was significantly longer in the PICU group (mean of 10 vs 4 days, p=0.001). Parents in the PICU group reported more PTS symptoms (intrusion p=0.01, avoidance p=0.01, arousal p=0.02) compared to the GW group.

CONCLUSION

No significant differences were found between PICU and GW children on self-reported outcome domains, except for the time to reach full schooldays. PICU parents reported PTS symptoms more often than the GW group. Therefore, monitoring asthma symptoms and psychosocial screening of children and parents after PICU admission should both be part of standard care after SAA. This should identify those who are at risk for developing PTSD, in order to timely provide appropriate interventions. This article is protected by copyright. All rights reserved.

Terbutaline and aminophylline as second-line therapies for status asthmaticus in the pediatric intensive care unit

OBJECTIVE

Asthma is the most common chronic disease of childhood. Although asthma admissions to the pediatric intensive care unit (PICU) are increasing, there are no evidence-based guidelines on preferred escalation of therapies for patients with status asthmaticus who fail to respond to inhaled bronchodilators and systemic corticosteroids. The purpose of this study was to assess outcomes of PICU patients receiving aminophylline versus terbutaline as second-tier therapies for status asthmaticus.

DESIGN

Retrospective cohort study using Pediatric Health Information System from 2016-2019.

SETTING

Fifty-three tertiary children's hospitals.

SUBJECTS

Children aged 2 to 18 years admitted to the PICU in children's hospitals contributing data to the Pediatric Health Information System with a primary diagnosis of status asthmaticus.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of 11 133 pediatric patients treated for status asthmaticus in the PICU during the study period, 1144 received either terbutaline or aminophylline. There was no difference in intubation and mechanical ventilation between patients who received aminophylline and those who received terbutaline. However, in African American patients, those who received terbutaline had a significantly higher odds of intubation and mechanical ventilation compared to those who received aminophylline (OR, 12.41; 95%CI, 1.61,95).

CONCLUSIONS

The use of aminophylline is associated with lower odds of intubation and mechanical ventilation in African American patients with status asthmaticus as compared to terbutaline.

Residential instability, neighborhood deprivation, and pediatric asthma outcomes

INTRODUCTION

Limited work has directly compared the role of different neighborhood factors or examined their interactive effects on pediatric asthma outcomes. Our objective was to quantify the main and interactive effects of neighborhood deprivation and residential instability (RI) on pediatric asthma outcomes.

METHODS

We conducted a retrospective cross-sectional study of patients with a primary diagnosis of asthma hospitalized at a tertiary care pediatric hospital. Residential addresses at the index hospitalization were linked to the state area deprivation index (ADI). RI was coded as the number of residences in the past 4 years. Logistic and ordinal regression and Cox regression survival analyses were used to estimate the effect on the primary outcomes of chronic asthma severity (intermittent, mild persistent, moderate persistent, severe persistent/other) as defined by the National Heart, Lung, and Blood Institute, severe hospitalization (requiring continuous albuterol or intensive care unit care), and time to emergency department (ED) readmission and rehospitalization within 365 days of the index visit, respectively.

RESULTS

In the sample (N = 664), 21% had severe persistent/other asthma, 22% had severe hospitalization, 37% were readmitted to the ED, and 19% were rehospitalized. Increasing RI was independently associated with more severe chronic asthma (odds ratio = 1.18, 95% confidence interval [CI] = 1.05, 1.32, P = .004), greater risk of 365-day ED readmission (hazard ratio [HR] = 1.10, 95% CI = 1.05, 1.15, P < .0001), and greater risk of 365-day rehospitalization (HR = 1.09, 95% CI = 1.03, 1.14, P = .002). There were no significant associations between ADI and these outcomes. Further, we did not find significant evidence of interactive effects.

CONCLUSIONS

RI appears to be modestly associated with pediatric asthma outcomes, independent of current neighborhood deprivation.

Escalation in Therapy Based on Intravenous Magnesium Sulfate Dosing in Pediatric Patients With Asthma Exacerbations

OBJECTIVE

Our objective was to compare doses of intravenous magnesium sulfate and their association with escalations in therapy in children and adolescents presenting to the emergency department with an asthma exacerbation.

METHODS

This was a retrospective cohort study among children who received both magnesium sulfate and standard of care therapy for asthma exacerbations. A classification and regression tree (CART) analysis was performed to identify a breakpoint in dose in which a difference in the primary outcome was present. The primary endpoint was need for escalation in therapy within 24 hours of initial magnesium sulfate dose, defined as need for invasive or non-invasive mechanical ventilation or need for adjunctive therapy, that is, epinephrine, terbutaline, aminophylline, theophylline, ketamine, heliox, or additional doses of magnesium sulfate.

RESULTS

A total of 210 patients were included in the study. A CART analysis identified that a breakpoint of 27 mg/kg of magnesium was associated with a difference in the primary outcome of escalation in therapy in patients <40 kg. A subgroup analysis of patients <40 kg (n = 149) found patients who received magnesium doses >27 mg/kg had a higher incidence of the primary outcome of escalation in therapy, 15 patients (18.3%) versus 3 patients (4.5%) in the ≤27-mg/kg/dose group (p = 0.011).

CONCLUSIONS

Our results demonstrate larger doses of magnesium sulfate are associated with an increased need for invasive or non-invasive mechanical ventilation or need for adjunctive therapy(ies). Our findings are limited by confounding factors that may have influenced this outcome in our population.

Initial Modified Pulmonary Index Score Predicts Hospital Length of Stay for Asthma Subjects Admitted to the Pediatric Intensive Care Unit

BACKGROUND

Scoring systems are frequently used to assess the severity of pediatric asthma exacerbations. The modified pulmonary index score (MPIS) has been found to be highly correlated with length of stay (LOS) in the pediatric intensive care unit (PICU). We sought to evaluate the use of the MPIS to predict hospital LOS for patients admitted to our PICU.

METHODS

We retrospectively reviewed the medical records of pediatric asthma subjects aged 2-17 y admitted to our PICU between June 2014 and November 2017. We divided subjects a priori into 3 groups (low: MPIS 0-5; medium: MPIS 6-9; high: MPIS ≥ 10) based upon each subject's first MPIS documented in the PICU. Hospital LOS, PICU LOS, time on continuous albuterol, and increased respiratory support were compared between groups.

RESULTS

143 subjects were included. There were no differences for demographics, medical history, cause of exacerbations, or mean heart rate between groups. There were significant differences between groups for mean breathing frequency (P < .001), [Formula: see text] (P = .01), and [Formula: see text] (P < .004). There were significant differences between groups for route of admission (P = .02), high-flow nasal cannula use (P < .001), and use of a helium-oxygen mixture (P < .001). There were significant differences between groups for median hospital LOS (1.2 vs 2.3 vs 3.4 d, P < .001), PICU LOS (0.39 vs 1.3 vs 2 d, P < .001), and time on continuous albuterol (7.4 vs 20.6 vs 34.7 h, P < .001). After adjusting for demographics and medical history, the incidence risk ratio for hospital LOS was 2.09 for PICU admission for an MPIS of 6-9 and 2.68 for an MPIS ≥ 10 when compared to an MPIS < 6.

CONCLUSIONS

The MPIS thresholds used in our pathway appropriately predicted LOS in our cohort of subjects with asthma admitted to the PICU. Higher MPIS was associated with increased hospital LOS, PICU LOS, and time on continuous albuterol.

Outcome of status asthmaticus at a pediatric intensive care unit in Hong Kong

OBJECTIVES

To characterize the clinical course and outcome of children with status asthmaticus (SA) admitted to a pediatric intensive care unit (PICU) METHODS: All patients with SA who were admitted to a PICU from January 2003 to December 2018 were reviewed. Polymerase chain reaction (PCR) studies on nasopharyngeal aspirate for respiratory pathogens were performed from 2014 to 2018.

RESULTS

Sixty-seven SA admissions constituted 2.4% of total PICU admissions (n = 2788). Fifteen (22.4%) children required noninvasive ventilation (NIV), while 7 children (10%) required invasive mechanical ventilation. Nonadherence to prior asthma therapy was common. PCR was positive for enterorvirus/rhinovirus in 84% (16 out of 19) and for any virus in 95% of nasopharyngeal aspirate (NPA) samples of patients between 2014 and 2018. Over the 16-year period, increased utilization of ipratropium bromide, magnesium sulfate and NIV was noted (P < .05). Patients who required invasive mechanical ventilation had significantly higher heart rate, lower pH and longer PICU length of stay (LOS) when compared to nonintubated children (P < .05). There was no mortality, gender difference, or seasonal characteristics in these SA admissions. Median LOS in PICU was 2 days (interquartile range 1-3 days).

CONCLUSIONS

SA accounts for a small proportion of PICU admissions. LOS was short and prognosis generally good. Nonadherence to prior asthma therapy was common. The most common trigger is enterovirus/rhinovirus for children with severe asthma requiring PICU admission. A trend of increase in usage of ipratropium, magnesium sulfate and NIV was observed. Primary prevention and early treatment of exacerbation are the most important step in managing children with asthma. Regular follow-up to ensure compliance together with annual vaccination could possibly avoid PICU admissions.

Oral Dexamethasone vs. Oral Prednisone for Children With Acute Asthma Exacerbations: A Systematic Review and Meta-Analysis

Background: This systematic review and meta-analysis was conducted to compare relapse rates and adverse effects with oral dexamethasone vs. oral prednisone for acute asthma exacerbations in pediatric patients. Methods: A computerized literature search of PubMed, Embase, Scopus, CENTRAL (Cochrane Central Register of Controlled Trials) and Google scholar databases was carried out till 1st August 2019. Six Randomized controlled trials (RCTs) and 1 quasi-RCT were included. Dosage of dexamethasone and prednisone varied across studies. Studies were grouped based on the follow-up period and duration of dexamethasone administration. Results: There was no significant difference in the relapse rate between dexamethasone and prednisone at 1-5 days (RR 1.46, 95%CI 0.69-3.7, P = 0.32; I 2 = 0%) and 10-15 days of follow up (RR 1.16, 95%CI 0.80-1.68, P = 0.44; I 2 = 0%). Pooled analysis found no significant difference in relapse rates with 1-day (RR 1.15, 95%CI 0.68-1.95, P = 0.60; I 2 = 0%) and 2-day dosage of dexamethasone (RR 1.25, 95%CI 0.82-1.92, P = 0.30; I 2 = 0%) compared to prednisone. Hospital readmission rates after initial discharge were not significantly different between the two drugs (RR 1.49, 95%CI 0.56-4.01, P = 0.43; I 2 = 0%). Frequency of vomiting at ED (RR 0.21, 95%CI 0.05-0.96, P = 0.04; I 2 = 50%) and at home (RR 0.42, 95%CI 0.25-0.69, P = 0.0007; I 2 = 0%) was significantly higher with prednisone as compared to dexamethasone. Conclusion: While our results indicate that both dexamethasone and prednisone have similar relapse rates when used for acute asthmatic exacerbations, strong conclusions cannot be drawn due to paucity of large scale RCTs and limited quality of evidence. Dexamethasone is however associated with lower incidence of vomiting as compared to prednisone. Further homogenous RCTs are needed to provide robust evidence on this topic.

Safety of prolonged magnesium sulfate infusions during treatment for severe pediatric status asthmaticus

OBJECTIVE

Magnesium sulfate (Mg) is one of several "second-tier" therapies for treating severe status asthmaticus. Pediatric reports primarily describe bolus use with limited data regarding prolonged infusions. We sought to describe the safety of prolonged Mg infusions during therapy of status asthmaticus in critically ill children.

DESIGN

Single center, retrospective study.

SETTING

Thirty-four-bed tertiary level medical/surgical/cardiac surgical pediatric intensive care unit.

PATIENTS

Pediatric patients 2 to 18 years of age admitted with status asthmaticus receiving Mg infusion for more than 24 hours.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN FINDINGS

A total of 154 children received Mg infusions for a median of 53.4 hours (interquartile range = 36.6-74.8). The most common adverse event (AE) was hypotension (48.1%), almost exclusively diastolic (94%), and was mostly limited to 1 blood pressure measurement (78%). 2.9% of events required intervention (fluids, decrease Mg infusion). Other AEs included nausea/emesis (22.7%), transient weakness (14.9%), and flushing (6.5%). Five patients experienced serious AEs including hypotonia (n = 1), escalation to continuous or bilevel positive airway pressure (n = 3), and sedation (n = 1), all attributed to progression of underlying medical disease. No patient required endotracheal intubation. Supratherapeutic levels (>6 mg/dL) were uncommon (2%) and were not more likely to be associated with AEs. Most (81%) patients were therapeutic by the 2nd Mg level check.

CONCLUSION

Prolonged Mg infusions were well tolerated in pediatric status asthmaticus patients. While diastolic hypotension was not uncommon, rarely were interventions deemed necessary. No serious AEs were attributed to Mg. Toxicity was uncommon suggesting that Mg levels could potentially be checked less frequently than historically reported.

High frequency percussive ventilation as a rescue mode for refractory status asthmaticus - a case study

INTRODUCTION

A severe asthma exacerbation is called status asthmaticus when symptoms worsen despite conventional medical treatment in the hospital. If arterial blood gas (ABG) values deteriorate and this is accompanied by respiratory muscle fatigue, the patient will require mechanical ventilation. However, mechanical ventilation of the severe asthmatic presents difficult challenges.

CASE STUDY

We report on High Frequency Percussive Ventilation (HFPV) used along with continuous inhaled albuterol and neuromuscular blockade, as rescue therapy for a case of acute, severe asthma that was refractory to conventional treatment and conventional mechanical ventilation.

RESULTS

This patient's arterial pH was 6.97 when we initiated HFPV, but ten hours post-intubation her ABG values normalized. She was successfully extubated six days later and discharged from ICU the following day.

CONCLUSION

This case describes the successful use of HFPV for a status asthmaticus patient failing conventional mechanical ventilation. We have anecdotal evidence of other medical centers using HFPV for these patients but larger studies are needed to verify its efficacy.

Descriptions and outcomes of cardiac evaluations in pediatric patients hospitalized for asthma

Objective: Patients hospitalized for asthma can exhibit concurrent cardiac symptoms and undergo cardiac work up. We identify patients admitted for asthma that underwent cardiac workup and describe outcomes to evaluate the utility of cardiac testing in this population.Methods: Patients aged 4 to 17 years admitted for status asthmaticus from 2012 - 2016 were screened for EKG, ECHO, or cardiac enzyme obtainment.Results: Out of 1296 patients, 77 (6%) received cardiac testing. The most common reasons for testing were chest pain (25, 32%), blood pressure abnormalities (11, 14%), tachycardia (8, 10%), arrhythmia (6, 8%), and syncope (6, 8%). Sinus tachycardia (43, 66%) was the most common EKG finding. 4 out of 27 patients who underwent ECHOs had abnormalities: 2 with hypertrophic cardiomyopathy (HCM), 1 with vascular ring, and 1 with evidence of pulmonary hypertension. All patients who underwent an EKG to evaluate tachycardia had normalization of heart rate at discharge. Cardiac ischemia was not evident in any patients who underwent workup with cardiac enzymes to evaluate chest pain. All cases of arrhythmias resolved on discharge. Diastolic hypotension (DhTN) was found in 10 out of the 11 blood pressure abnormalities. There was mixed efficacy of fluid bolus in correcting DhTN. All DhTN resolved on discharge. One patient with syncope had a new diagnosis of HCM.Conclusions: While cardiac complications are seen in patients admitted for status asthmaticus, the etiology rarely stems from underlying cardiac disease. EKGs, ECHOs, and cardiac enzymes should have a minimal role in the management of the hospitalized asthmatic patient.

A Respiratory Therapist-Driven Asthma Pathway Reduced Hospital Length of Stay in the Pediatric Intensive Care Unit

BACKGROUND

Asthma is a common reason for admissions to the pediatric intensive care unit (PICU). Since June 2014, our institution has used a pediatric asthma clinical pathway for all patients, including those in PICU. The pathway promotes respiratory therapist-driven bronchodilator weaning based on the Modified Pulmonary Index Score (MPIS). This pathway was associated with decreased hospital length of stay (LOS) for all pediatric asthma patients; however, the effect on PICU patients was unclear. We hypothesized that the implementation of a pediatric asthma pathway would reduce hospital LOS for asthmatic patients admitted to the PICU.

METHODS

We retrospectively reviewed the medical records of all pediatric asthma subjects 2-17 y old admitted to our PICU before and after pathway initiation. Primary outcome was hospital LOS. Secondary outcomes were PICU LOS and time on continuous albuterol. Data were analyzed using the chi-square test for categorical data, the t test for normally distributed data, and the Mann-Whitney test for nonparametric data.

RESULTS

A total of 203 eligible subjects (49 in the pre-pathway group, 154 in the post group) were enrolled. There were no differences between groups for age, weight, gender, home medications, cause of exacerbation, medical history, or route of admission. There were significant decreases in median (interquartile range) hospital LOS (4.4 [2.9-6.6] d vs 2.7 [1.6-4.0] d, P < .001), median PICU LOS (2.1 [1.3-4.0] d vs 1.6 [0.8-2.4] d, P = .003), and median time on continuous albuterol (39 [25-85] h vs 27 [13-42] h, P = .001). Significantly more subjects in the post-pathway group were placed on high-flow nasal cannula (32% vs 6%, P = .001) or noninvasive ventilation (10% vs 4%, P = .02).

CONCLUSION

The implementation of an asthma pathway was associated with decreased hospital LOS, PICU LOS, and time on continuous albuterol. There was also an increase in the use of high-flow nasal cannula and noninvasive ventilation after the implementation of this clinical pathway.

Pharmacokinetics of Ketamine at Dissociative Doses in an Adult Patient With Refractory Status Asthmaticus Receiving Extracorporeal Membrane Oxygenation Therapy

PURPOSE

First-line management of severe asthma exacerbations include the use of inhaled short-acting β-agonists, anticholinergics, and systemic corticosteroids. Continuous intravenous ketamine given at dissociative doses may be a pharmacologic option in patients who are intubated with life-threatening severe bronchospasm unresponsive to standard therapy. We describe the case of a 44-year-old man admitted to the intensive care unit for status asthmaticus requiring intubation and mechanical ventilation.

METHODS

The patient developed severe refractory hypercapnic respiratory failure necessitating additional respiratory support with veno-venous extracorporeal membrane oxygenation (ECMO) therapy. Ketamine treatment was initiated at 0.5 mg/kg/h continuous infusion on the day of admission for pain control and required up-titration to 2 mg/kg/h by intensive care unit day 4 for bronchodilation. Whole blood samples were obtained for pharmacokinetic analysis of ketamine during ECMO.

FINDINGS

The plasma concentration at steady state was 1018.7 ng/mL, with an estimated clearance of 1.96 L/kg/h after up-titration. The V_d was 14.18 L/kg, the k_e was 0.14 hr^-1, and the t_½ was 5 hours.

IMPLICATIONS

Compared with healthy adults, there was a 6.5-fold increase in the V_d. However, the V_d was similar compared with critically ill patients not receiving ECMO. Further studies should focus on the effect of ECMO on ketamine pharmacokinetic properties.

Safety and effectiveness of albuterol solutions with and without benzalkonium chloride when administered by continuous nebulization

PURPOSE

The results of a study to determine if rates of poor response differ in patients receiving continuous nebulized albuterol (CNA) therapy with or without the preservative benzalkonium chloride are presented.

METHODS

A retrospective analysis of the records of all patients who received CNA therapy at a large academic medical center from July 2015 to January 2016 was conducted. Data from patient evaluations performed before and after a change to benzalkonium chloride-containing albuterol were collected. The primary outcome was the rate of poor patient response, defined as a composite endpoint. Secondary outcomes included duration of therapy, dosing requirements, and duration of supplemental oxygen therapy.

RESULTS

There was no significant difference in rates of poor response between patients exposed (n = 80) and patients not exposed (n = 48) to benzalkonium chloride (16% and 17%, respectively; p = 0.95). The cohort not exposed to benzalkonium chloride had a median CNA duration of 7.0 hours, as compared with 10.5 hours for the cohort exposed to benzalkonium chloride, but this difference was not significant (p = 0.19). There were no significant differences between the benzalkonium chloride-exposed and nonexposed cohorts in the maximum dosing requirement (12.6 mg/hr versus 12.8 mg/hr, p = 0.89) or median duration of supplemental oxygen use (27.5 hours versus 16.5 hours, p = 0.77).

CONCLUSION

A study of hospitalized patients receiving CNA detected no significant difference in the frequency of poor response to therapy between groups receiving benzalkonium chloride-free versus benzalkonium chloride-containing albuterol products.

Pleth Variability Index to Assess Course of Illness in Children with Asthma

BACKGROUND

Status asthmaticus (SA) is a common reason for admission to the pediatric emergency department (ED). Assessing asthma severity efficiently in the ED can be challenging for clinicians. Adjunctive tools for the clinician have demonstrated inconsistent results. Studies have shown that pulsus paradoxus (PP) correlates with asthma severity. Pleth Variability Index (PVI) is a surrogate measure of PP.

OBJECTIVE

We investigated whether PVI at triage correlates with disposition from the ED.

METHODS

We recruited children aged 2-18 years old who presented to the pediatric ED of a tertiary care children's hospital with SA. PVI, Respiratory Severity Score, and vital signs were documented at triage and 2 hours into each patient's ED stay. PVI was measured using the Masimo Radical-7^® monitor (Masimo Corp., Irvine, CA).

RESULTS

Thirty-eight patients were recruited. Twenty-seven patients were discharged home, 10 patients were admitted to the general pediatrics floor and 1 patient was admitted to the intensive care unit. PVI values at triage did not correlate with disposition from the ED (p = 0.63). Additionally, when trending the change in PVI after 2 hours of therapy in the ED, no statistically significant patterns were demonstrated.

CONCLUSIONS

Our study did not demonstrate a correlation between PVI and clinical course for asthmatics. PVI may be more clinically relevant in sicker children. Furthermore, it is possible that continuous monitoring of PVI may demonstrate more unique trends in relation to asthma severity versus single values of PVI. Additional studies are necessary to help clarify the relationship between PVI and the clinical course of children with SA.

The effectiveness of magnesium sulfate for status asthmaticus outside the intensive care setting

AIM

Magnesium is an adjunctive therapy used in patients with status asthmaticus who do not respond to conventional therapy. The optimal time from initiation of therapy, to determination of response and administration of magnesium has not yet been resolved. Our objective was to determine if magnesium administered in the non-intensive care setting can decrease duration of continuous albuterol and hospital length of stay.

METHODS

We performed a retrospective cohort analysis of children ages 2-18 years admitted to the pediatric unit on continuous albuterol between January 2014 and December 2015 in a tertiary care children's hospital. Cohorts were matched on respiratory assessment score (RAS) obtained at a similar duration of albuterol therapy and evaluated for the total duration of continuous albuterol, length of stay (LOS), and adverse events.

RESULTS

Thirty-three patients who received magnesium were matched to 33 patients with the same RAS at a similar duration of continuous albuterol therapy who did not receive magnesium. Those who received magnesium had longer duration on continuous albuterol (34 vs 18 h; P = 0.001; 95% confidence interval [CI] 4-20; effect size 0.41) and longer LOS (72 vs 49 h; P = 0.037; 95% confidence interval [CI] 1-33; effect size 0.26) than those who did not receive magnesium.

CONCLUSION

Children requiring continuous albuterol for status asthmaticus can be administered magnesium sulfate outside the PICU with a low incidence of adverse events; however, among a RAS matched cohort, those who received magnesium did not experience shorter time on continuous albuterol, or hospital length of stay.

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.