Pediatric status asthmaticus

Institutional Variability in Respiratory Support Use for Pediatric Critical Asthma: A Multicenter Retrospective Study

Rationale: Over 20,000 children are hospitalized in the United States for asthma every year. Although initial treatment guidelines are well established, there is a lack of high-quality evidence regarding the optimal respiratory support devices for these patients.Objectives: The objective of this study was to evaluate institutional and temporal variability in the use of respiratory support modalities for pediatric critical asthma.Methods: We conducted a retrospective cohort study using data from the Virtual Pediatrics Systems database. Our study population included children older than 2 years old admitted to a VPS contributing pediatric intensive care unit from January 2012 to December 2021 with a primary diagnosis of asthma or status asthmaticus. We evaluated the percentage of encounters using a high-flow nasal cannula (HFNC), continuous positive airway pressure (CPAP), noninvasive bilevel positive pressure ventilation (NIV), and invasive mechanical ventilation (IMV) for all institutions, then divided institutions into quintiles based on the volume of patients. We created logistic regression models to determine the influence of institutional volume and year of admission on respiratory support modality use. We also conducted time-series analyses using Kendall's tau.Results: Our population included 77,115 patient encounters from 163 separate institutions. Institutional use of respiratory modalities had significant variation in HFNC (28.3%, interquartile range [IQR], 11.0-49.0%; P < 0.01), CPAP (1.4%; IQR, 0.3-4.3%; P < 0.01), NIV (8.6%; IQR, 3.5-16.1%; P < 0.01), and IMV (5.1%; IQR, 3.1-8.2%; P < 0.01). Increased institutional patient volume was associated with significantly increased use of NIV (odds ratio [OR], 1.33; 1.29-1.36; P < 0.01) and CPAP (OR, 1.20; 1.15-1.25; P < 0.01), and significantly decreased use of HFNC (OR, 0.80; 0.79-0.81; P < 0.01) and IMV (OR, 0.82; 0.79-0.86; P < 0.01). Time was also associated with a significant increase in the use of HFNC (11.0-52.3%; P < 0.01), CPAP (1.6-5.4%; P < 0.01), and NIV (3.7-21.2%; P < 0.01), whereas there was no significant change in IMV use (6.1-4.0%; P = 0.11).Conclusions: Higher-volume centers are using noninvasive positive pressure ventilation more frequently for pediatric critical asthma and lower frequencies of HFNC and IMV. Treatment with HFNC, CPAP, and NIV for this population is increasing in the last decade.

Oral Albuterol Treatment in Three Pediatric Patients with Bradycardia: A Novel Therapy

Clinically significant bradycardia is an uncommon problem in children, but one that can cause significant morbidity and sometimes necessitates implantation of a pacemaker. The most common causes of bradycardia are complete heart block (CHB), which can be congenital or acquired, and sinus node dysfunction, which is rare in children with structurally normal hearts. Pacemaker is indicated as therapy for the majority of children with CHB, and while early mortality is lower in postnatally diagnosed CHB than in fetal CHB, it is still up to 16%. In young children, less invasive transvenous pacemaker systems can be technically challenging to place and carry a high risk of complications, often necessitating surgical epicardial pacemaker placement, which usually entails a median sternotomy. We report three cases of pediatric patients referred for pacemaker implantation for different types of bradycardia, treated at our institution with oral albuterol with therapeutic results that avoided the need for surgical pacemaker implantation at that time.

Wide Institutional Variability in the Treatment of Pediatric Critical Asthma: A Multicenter Retrospective Study

OBJECTIVES

Children with status asthmaticus refractory to first-line therapies of systemic corticosteroids and inhaled beta-agonists often receive additional treatments. Because there are no national guidelines on the use of asthma therapies in the PICU, we sought to evaluate institutional variability in the use of adjunctive asthma treatments and associations with length of stay (LOS) and PICU use.

DESIGN

Multicenter retrospective cohort study.

SETTING

Administrative data from the Pediatric Health Information Systems (PHIS) database.

PATIENTS

All inpatients 2-18 years old were admitted to a PHIS hospital between 2013 and 2021 with a diagnostic code for asthma.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

This study included 213,506 inpatient encounters for asthma, of which 29,026 patient encounters included care in a PICU from 39 institutions. Among these PICU encounters, large variability was seen across institutions in both the number of adjunctive asthma therapies used per encounter (min: 0.6, median: 1.7, max: 2.5, p < 0.01) and types of adjunctive asthma therapies (aminophylline, ipratropium, magnesium, epinephrine, and terbutaline) used. The center-level median hospital LOS ranged from 1 (interquartile range [IQR]: 1, 3) to 4 (3, 6) days. Among all the 213,506 inpatient encounters for asthma, the range of asthma admissions that resulted in PICU admission varied between centers from 5.2% to 47.3%. The average number of adjunctive therapies used per institution was not significantly associated with hospital LOS ( p = 0.81) nor the percentage of encounters with PICU admission ( p = 0.47).

CONCLUSIONS

Use of adjunctive therapies for status asthmaticus varies widely among large children's hospitals and was not associated with hospital LOS or the percentage of encounters with PICU admission. Wide variance presents an opportunity for standardizing care with evidence-based guidelines to optimize outcomes and decrease adverse treatment effects and hospital costs.

High flow nasal cannula use is associated with increased hospital length of stay for pediatric asthma

BACKGROUND

High flow nasal cannula (HFNC) is a respiratory device increasingly used to treat asthma. Recent mechanistic studies have shown that nebulized medications may have reduced delivery with HFNC, which may impair asthma treatment. This study evaluated the association between HFNC use for pediatric asthma and hospital length of stay (LOS).

METHODS

This was a retrospective matched cohort study. Cases included patients aged 2-18 years hospitalized between January 2010 and December 2021 with asthma and received HFNC treatment. Controls were selected using logistic regression propensity score matching based on demographics, vital signs, medications, imaging, and social and environmental determinants of health. The primary outcome was hospital LOS.

RESULTS

A total of 23,659 encounters met eligibility criteria, and of these 1766 cases included HFNC treatment with a suitable matched control. Cases were well-matched in demographics, social and environmental determinants of health, and clinical characteristics including use of adjunctive asthma therapies. The median hospital LOS for study cases was significantly higher at 87 h (interquartile range [IQR]: 61-145) compared to 66 h (IQR: 43-105) in the matched controls (p < 0.01). There was no significant difference in the rate of intubation and mechanical ventilation (8.9% vs. 7.6%, p = .18); however, the use of NIV was significantly higher in the cases than the control group (21.3% vs. 6.7%, p < .01).

CONCLUSION

In this study of children hospitalized for asthma, HFNC use was associated with increased hospital LOS compared to matched controls. Further research using more granular data and additional relevant variables is needed to validate these findings.

PICU Pharmacology

The care of the critically-ill child often includes medications used to optimize organ function, treat infections, and provide comfort. Pediatric pharmacology has some key differences that should be leveraged for safe pharmacologic management.

Hypokalemia Measurement and Management in Patients With Status Asthmaticus on Continuous Albuterol

OBJECTIVE

Status asthmaticus is commonly treated in pediatric patients by using continuous albuterol, which can cause hypokalemia. The primary aim of this study was to determine if serial potassium monitoring is necessary by examining treatment frequency of hypokalemia.

METHODS

This retrospective analysis was performed in 185 pediatric patients admitted with status asthmaticus requiring continuous albuterol between 2017 and 2019. All patients were placed on intravenous fluids containing potassium. The primary outcome measure was the treatment of hypokalemia in relation to the number of laboratory draws for potassium levels. The secondary outcome measure was hypokalemia frequency and relation to the duration and initial dose of continuous albuterol.

RESULTS

Included were 156 patients with 420 laboratory draws (average, 2.7 per patient) for potassium levels. The median lowest potassium level was 3.40 mmol/L (interquartile range, 3.2-3.7). No correlation was found between initial albuterol dose and lowest potassium level (P = .52). Patients with hypokalemia had a mean albuterol time of 12.32 (SD, 15.76) hours, whereas patients without hypokalemia had a mean albuterol time of 11.50 (SD, 12.53) hours (P = .29). Potassium levels were treated 13 separate times.

CONCLUSIONS

The number of laboratory draws for potassium levels was high in our cohort, with few patients receiving treatment for hypokalemia beyond the potassium routinely added to maintenance fluids. Length of time on albuterol and dose of albuterol were not shown to increase the risk of hypokalemia. Serial laboratory measurements may be decreased to potentially reduce health care costs, pain, and anxiety surrounding needlesticks.

High-flow nasal cannula in children with asthma exacerbation: A review of current evidence

Asthma is the commonest obstructive airway disease and the leading cause of morbidity in children. In the pediatric population, acute exacerbations of asthma are a frequent cause of presentations and hospital admissions. An acute asthma exacerbation is potentially life-threatening; it is predominantly treated using conventional oxygen therapy with bronchodilators and systemic corticosteroids. The treatment of those who do not respond to conventional therapy is escalated to noninvasive positive pressure ventilation (NIPPV) before invasive ventilation. Although NIPPV has demonstrated benefits and safety, it still has limitations such as treatment intolerance caused mainly by discomfort and complications. High-flow oxygen therapy administered through a nasal cannula (HFNC) provides respiratory support with adequate airway humidity and has demonstrated safety and benefits in clinical practice. In the present review, we discuss HFNC and variations in HFNC use, focusing on its feasibility and current evidence of using it on children with asthma exacerbations.

Frequency of persistent obesity 5 years after first time diagnosis of status asthmaticus

BACKGROUND/OBJECTIVES

When a severe asthma exacerbation occurs in an obese pediatric patient, it is unknown if this body type persists in future encounters. Persistent obesity can lead to future asthma exacerbations. The main study objective is to evaluate the persistence of a BMI percentile ≥85th in children 5 years after the first reported diagnosis of status asthmaticus. We hypothesized that a hospital admission for status asthmaticus was associated with persistence of a BMI percentile ≥85th.

METHODS

This was a long-term retrospective observational cohort study utilizing TriNetX ® electronic health record (EHR) data. We included subjects aged 2 to 18 years of age with a diagnosis of status asthmaticus. Study population was divided into two groups based on their admission body mass index percentile: (underweight/healthy weight [<85th percentile] and overweight/obese [≥85th percentile]) and evaluated for the following outcomes: age, race, ethnicity, diagnostic codes, and BMI percentiles (initially and 5 years after diagnosis of status asthmaticus).

RESULTS

A total of 129 subjects (n%) (76 [58.9%] underweight/healthy weight and 53 [41.1%] overweight/obese) were included. Children that were initially overweight/obese with status asthmaticus had significantly increased odds of continuing to be overweight/obese 5 years after diagnosis compared to children who were underweight/healthy weight at baseline (OR = 7.50 [95% confidence interval, 3.20-17.60; p < 0.001]).

CONCLUSIONS

Overweight/obese asthmatic children are at risk of continuing to be obese several years after being diagnosed with status asthmaticus. This study reinforces the notion that when an asthmatic obese child presents with status asthmaticus, a thorough evaluation of nutrition, physical activity, and asthma control should be considered to reduce the risk of persistent obesity and possibly future asthma exacerbations.

Implementation of a Critical Care Asthma Pathway in the PICU

OBJECTIVES

Acute asthma management has improved significantly across hospitals in the United States due to implementation of standardized care pathways. Management of severe acute asthma in ICUs is less well studied, and variations in management may delay escalation and/or deescalation of therapies and increase length of stay. In order to standardize the management of severe acute asthma in our PICU, a nurse- and respiratory therapist-driven critical care asthma pathway was designed, implemented, and tested.

DESIGN

Cross-sectional study of severe acute asthma at baseline followed by implementation of a critical care asthma pathway.

SETTING

Twenty-six-bed urban quaternary PICU within a children's hospital.

PATIENTS

Patients 24 months to 18 years old admitted to the PICU in status asthmaticus. Patients with severe bacterial infections, chronic lung disease, heart disease, or immune disorders were excluded.

INTERVENTIONS

Implementation of a nurse- and respiratory therapist-driven respiratory scoring tool and critical care asthma pathway with explicit escalation/deescalation instructions.

MEASUREMENTS AND MAIN RESULTS

Primary outcome was PICU length of stay. Secondary outcomes were time to resolution of symptoms and hospital length of stay. Compliance approached 90% for respiratory score documentation and critical care asthma pathway adherence. Severity of illness at admission and clinical baseline characteristics were comparable in both groups. Pre intervention, the median ICU length of stay was 2 days (interquartile range, 1-3 d) with an overall hospital length of stay of 4 days (interquartile range, 3-6 d) (n = 74). After implementation of the critical care asthma pathway, the ICU length of stay was 1 day (interquartile range, 1-2 d) (p = 0.0013; n = 78) with an overall length of stay of 3 days (interquartile range, 2-3.75 d) (p < 0.001). The time to resolution of symptoms was reduced from a median of 66.5 hours in the preintervention group to 21 hours in the postintervention compliant group (p = 0.036).

CONCLUSIONS

The use of a structured critical care asthma pathway, driven by an ICU nurse and respiratory therapist, is associated with faster resolution of symptoms, decreased ICU, and overall hospital lengths of stay in children admitted to an ICU for severe acute asthma.

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.

Continuous versus intermittent short-acting β2-agonists nebulization as first-line therapy in hospitalized children with severe asthma exacerbation: a propensity score matching analysis

Background

Short-acting β2-agonist (SABA) nebulization is commonly prescribed for children hospitalized with severe asthma exacerbation. Either intermittent or continuous delivery has been considered safe and efficient. The comparative efficacy of these two modalities is inconclusive. We aimed to compare these two modalities as the first-line treatments.

Methods

An efficacy research with a retrospective cohort study design was conducted. Hospital records of children with severe asthma exacerbation admitted to Hat Yai Hospital between 2015 and 2017 were retrospectively collected. Children initially treated with continuous salbutamol 10 mg per hour or intermittent salbutamol 2.5 mg per dose over 1–4 h nebulization were matched one-to-one using the propensity score. Competing risk and risk difference regression was applied to evaluate the proportion of children who succeeded and failed the initial treatment. Restricted mean survival time regression was used to compare the length of stay (LOS) between the two groups.

Results

One-hundred and eighty-nine children were included. Of these children, 112 were matched for analysis (56 with continuous and 56 with intermittent nebulization). Children with continuous nebulization experienced a higher proportion of success in nebulization treatment (adjusted difference: 39.5, 95% CI 22.7, 56.3, p < 0.001), with a faster rate of success (adjusted SHR: 2.70, 95% CI 1.73, 4.22, p < 0.001). There was a tendency that LOS was also shorter (adjusted mean difference − 9.9 h, 95% CI -24.2, 4.4, p = 0.176).

Conclusion

Continuous SABA nebulization was more efficient than intermittent nebulization in the treatment of children with severe asthma exacerbation.

ED chest radiography for children with asthma exacerbation is infrequently associated with change of management

BACKGROUND

Acute asthma exacerbations (AAE) account for many Pediatric Emergency Department (PED) visits. Chest radiography (CXR) is often performed in these patients to identify practice-changing findings such as pneumonia (PNA). Limited knowledge exists to balance the cost and radiation dose of CXR with expected yield of clinically meaningful information.

OBJECTIVE

To determine in children with AAE with CXR, whether patient characteristics are associated with radiographic PNA; and significant practice change by initiation of antibiotic.

DESIGN/METHODS

Retrospective chart review of AAE patients with CXR performed in a PED in 2014. We examined univariate associations between patient characteristics and PNA on CXR and administration of antibiotic. Multiple logistic regression models then subsequently examined adjusted associations between patient characteristics and both outcomes.

RESULTS

Of 288 patients, 43 (15%) had PNA on CXR and 51 (17.8%) received antibiotics. There were no statistically significant univariate associations between either outcome and age, race, gender, insurance status, mode of PED arrival, fever or hypoxia (all p>0.11). Crackles were associated with antibiotic administration (p=0.03), but not PNA on CXR (p=0.07). Only previous antibiotic use within 7days had both significant univariate associations (p=0.002) and adjusted associations with both PNA on CXR (aOR 3.6) and antibiotic administration (aOR 3.3).

CONCLUSION

CXR infrequently adds valuable information in children with AAE. Patients treated with antibiotic within 7days are more likely to have PNA identified on CXR and receive antibiotics. A larger study is needed to examine potential significance of hypoxia and crackles.

High-flow nasal cannula therapy versus non-invasive ventilation in children with severe acute asthma exacerbation: An observational cohort study

INTRODUCTION

The present study describes our experience with the high-flow humidified nasal cannula (HFNC) versus non-invasive ventilation (NIV) in children with severe acute asthma exacerbation (SA).

METHODS

An observational study of a retrospective cohort of 42 children with SA admitted to a Pediatric Intensive Care Unit (PICU) for non-invasive respiratory support was made. The primary outcome measure was failure of initial respiratory support (need to escalate from HFNC to NIV or from NIV to invasive ventilation). Secondary outcome measures were the duration of respiratory support and PICU length of stay (LOS).

RESULTS

Forty-two children met the inclusion criteria. Twenty (47.6%) received HFNC and 22 (52.3%) NIV as initial respiratory support. There were no treatment failures in the NIV group. However, 8 children (40%) in the HFNC group required escalation to NIV. The PICU LOS was similar in both the NIV and HFNC groups. However, on considering the HFNC failure subgroup, the median length of respiratory support was 3-fold longer (63h) and the PICU LOS was also longer compared with the rest of subjects exhibiting treatment success.

CONCLUSIONS

Despite its obvious limitations, this observational study could suggest that HFNC in some subjects with SA may delay NIV support and potentially cause longer respiratory support, and longer PICU LOS.

Non-invasive positive pressure ventilation for acute asthma in children

BACKGROUND

Asthma is one of the most common reasons for hospital admission among children and constitutes a significant economic burden. Use of non-invasive positive pressure ventilation (NPPV) in the care of children with acute asthma has increased even though evidence supporting the intervention has been considered weak and clinical guidelines do not recommend the intervention. NPPV might be an effective intervention for acute asthma, but no systematic review has been conducted to assess the effects of NPPV as an add-on therapy to usual care in children with acute asthma.

OBJECTIVES

To assess the benefits and harms of NPPV as an add-on therapy to usual care (e.g. bronchodilators and corticosteroids) in children with acute asthma.

SEARCH METHODS

We identified trials from the Cochrane Airways Group Specialised Register (CAGR). The Register contains trial reports identified through systematic searches of bibliographic databases, including the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, AMED and PsycINFO, and by handsearching of respiratory journals and meeting abstracts. We also conducted a search of ClinicalTrials.gov (www.ClinicalTrials.gov) and the WHO trials portal (www.who.int/ictrp/en/). We searched all databases from their inception to February 2016, with no restriction on language of publication.

SELECTION CRITERIA

We included randomised clinical trials (RCTs) assessing NPPV as add-on therapy to usual care versus usual care for children (age < 18 years) hospitalised for an acute asthma attack.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles and abstracts. We retrieved all relevant full-text study reports, independently screened the full text, identified trials for inclusion and identified and recorded reasons for exclusion of ineligible trials. We resolved disagreements through discussion or, if required, consulted a third review author. We recorded the selection process in sufficient detail to complete a PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) flow diagram and 'Characteristics of excluded studies' table. We identified the risk of bias of included studies to reduce the risk of systematic error. We contacted relevant study authors when data were missing.

MAIN RESULTS

We included two RCTs that randomised 20 participants to NPPV and 20 participants to control. We assessed both studies as having high risk of bias; both trials assessed effects of bilateral positive airway pressure (BiPAP). Neither trial used continuous positive airway pressure (CPAP). Controls received standard care. Investigators reported no deaths and no serious adverse events (Grades of Recommendation, Assessment, Development and Evaluation (GRADE): very low quality of evidence due to serious risk of bias and serious imprecision of results). Both trials showed a statistically significant reduction in symptom score. One trial did not report a standard deviation (SD), but by using an estimated SD, we found a statistically significantly reduced asthma symptom score (mean difference (MD) -2.50, 95% confidence interval (CI) -4.70 to -0.30, P = 0.03, 19 participants, GRADE: very low quality of evidence). In the other trial, NPPV was associated with a lower total symptom score (5.6 vs 1.9, 16 participants, very low quality of evidence) before cross-over, but investigators did not report an SD, nor could it be estimated from the first phase of the trial, before the cross-over. These gains could be clinically relevant, as a reduction of three or more points in symptom score is considered a clinically meaningful change. Researchers documented five dropouts (12.5%), four of which were due to intolerance to NPPV, and one to respiratory failure requiring intubation. Owing to insufficient reporting in the latter trial and use of different scoring systems, it was not possible to conduct a meta-analysis nor a Trial Sequential Analysis.

AUTHORS' CONCLUSIONS

Current evidence does not permit confirmation or rejection of the effects of NPPV for acute asthma in children. Large RCTs with low risk of bias are warranted.

Comparison of Two High-Dose Magnesium Infusion Regimens in the Treatment of Status Asthmaticus

OBJECTIVES

To determine the feasibility and safety of a simplified high-dose magnesium sulfate infusion (sHDMI) for the treatment of status asthmaticus.

METHODS

We retrospectively compared 2 different high-dose magnesium sulfate infusion regimens, as adjunctive treatment in status asthmatics, using data that were preciously collected. The initial high-dose, prolonged magnesium infusion (HDMI) regimen consisted of a loading dose of 75 mg/kg (weight ≤ 30 kg) or 50 mg/kg (weight > 30 kg) over a period of 30 to 45 minutes followed by a continuous infusion of 40 mg/kg/hr for an additional 4 hours. This was compared to the sHDMI regimen that consisted of 50 mg/kg/hr for 5 hours. No loading dose was given to the patients in the sHDMI arm. Obese patients were dosed by using ideal body weight. Physiologic parameters (i.e., heart rate, blood pressure, respiratory rate, oxygen saturation) and serum magnesium (SrMg) concentrations were monitored during administration of magnesium sulfate.

RESULTS

Nineteen patients receiving the initial HDMI regimen were compared with 10 patients who received the sHDMI regimen. There was no significant difference in SrMg concentrations or physiologic parameters between the 2 dose regimens.

CONCLUSIONS

The HDMI and sHDMI regimens both produced SrMg concentrations that are associated with bronchodilation. The safety profile was also similar for the 2 regimens. The unambiguity of sHDMI has the potential to reduce medication errors that are associated with calculation of the loading dose, product preparation, and ultimate administration.

Albuterol Use in Children Hospitalized with Human Metapneumovirus Respiratory Infection

Introduction. Human metapneumovirus (HMPV) is a paramyxovirus from the same subfamily as respiratory syncytial virus (RSV) and causes similar acute lower respiratory tract infection. Albuterol in the setting of acute RSV infection is controversial and has not yet been studied in HMPV. We sought to determine the frequency of albuterol use in HMPV infection and the association between albuterol administration and patient outcomes. Methods. We conducted a retrospective cohort study identifying all patients hospitalized in a tertiary care children's hospital with laboratory-confirmed HMPV infection between January 2010 and December 2010. Results. There were 207 patients included in the study; 57% had a chronic medical condition. The median hospital length of stay was 3 days. Only 31% of patients in the study had a documented wheezing history, while 69% of patients received at least one albuterol treatment. There was no difference in length of stay between patients who received albuterol and those who did not. Conclusion. There is a high frequency of albuterol use in children hospitalized with HMPV infection. As with RSV, evidence may not support routine use of bronchodilators in patients with acute HMPV respiratory infection. Research involving additional patient outcomes and illness severity indicators would be useful in future studies.

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.

Evaluation and treatment of critical asthma syndrome in children

The heterogeneity of asthma is illustrated by the significantly different features of pediatric asthma compared to adult asthma. One phenotype of severe asthma in pediatrics includes atopy, lack of reduction in lung function, and absence of gender bias as the main characteristics. Included in the NIH NAEPP EPR-3 are recommendations for the treatment and management of severe pediatric asthma and critical asthma syndrome, such as continuous nebulization treatments, intubation and mechanical ventilation, heliox, and magnesium sulfate. In addition, epinephrine, intravenous immunoglobulin, intravenous montelukast, extracorporeal membrane oxygenation, and many biological modulators currently under investigation are additional current and/or future treatment modalities for the severe pediatric asthmatic. But, perhaps the most important strategy for managing the severe asthmatic is preventative treatment, which can significantly decrease impairment and risk, particularly for severe acute exacerbations requiring emergency care and/or hospitalization. In order for preventative therapy to be successful, several challenges must be met, including selecting the correct therapy for each patient and then ensuring compliance or adherence to a treatment plan. The heterogeneity of asthma renders the former difficult in that not all patients will respond equally to the same treatment; the latter is only helpful if the correct treatment is employed. Strategies to ensure compliance include education of caregivers and patients and their families. As newer medications are introduced, options for individualized or customized medicine increase, and this may pave the way for significant decreases in morbidity and mortality in severe pediatric asthma.

A review of the use of adjunctive therapies in severe acute asthma exacerbation in critically ill children

Asthma is a common and potentially life threatening childhood condition. Asthma involves not only chronic airway remodeling, but may also include frequent exacerbations resulting from bronchospasm, edema, and mucus production. In children with severe exacerbations, standard therapy with β2-agonists, anti-cholinergic agents, oxygen, and systemic steroids may fail to reverse the severe airflow obstruction and necessitate use of adjunctive therapies. These therapies include intravenous or inhaled magnesium, inhaled helium-oxygen mixtures, intravenous methylxanthines, intravenous β2-agonists, and intravenous ketamine. Rarely, these measures are not successful and following the initiation of invasive mechanical ventilation, inhaled anesthetics or extracorporeal life support may be required. In this review, we discuss the mechanisms and evidence for adjunctive therapies in the setting of severe acute asthma exacerbations in children.

Pediatric asthma in a nutshell

On the basis of strong research evidence, asthma is a leading cause of emergency department visits and hospital admissions for children. On the basis of research evidence, implementation of asthma guidelines by medical professionals in not optimal. On the basis of research evidence, the Asthma Predictive Index supports a diagnosis of chronic asthma in children younger than 3 years. On the basis of strong research evidence, premedication with a short-acting β2-agonist is the preferred initial therapy for exercise-induced asthma. On the basis of strong research evidence, anti-inflammatory therapy with inhaled corticosteroids is an effective treatment for asthma. On the basis of research and consensus, assessment of impairment and risk followed by scheduled assessment for asthma control is recommended. On the basis of research and consensus, the establishment of a close cooperative relationship among medical professionals, patients with asthma, and their families is an important component of asthma management.