Cardiac toxicity of intravenous terbutaline for the treatment of severe asthma in children: a prospective assessment

Paediatrics: how to manage acute asthma exacerbations

Background

Asthma is the most common chronic disease of childhood and a major source of childhood health burden worldwide. These burdens are particularly marked when children experience characteristic ‘symptom flare-ups’ or acute asthma exacerbations (AAEs). AAE are associated with significant health and economic impacts, including acute Emergency Department visits, occasional hospitalizations, and rarely, death. To treat children with AAE, several medications have been studied and used.

Methods

We conducted a narrative review of the literature with the primary objective of understanding the evidence of their efficacy. We present this efficacy evidence in the context of a general stepwise management pathway for paediatric AAEs. This framework is developed from the combined recommendations of eight established (inter)national paediatric guidelines.

Discussion

Management of paediatric AAE centres around four major care goals: (1) immediate and objective assessment of AAE severity; (2) prompt and effective medical interventions to decrease respiratory distress and improve oxygenation; (3) appropriate disposition of patient; and (4) safe discharge plans. Several medications are currently recommended with varying efficacies, including heliox, systemic corticosteroids, first-line bronchodilators (salbutamol/albuterol), adjunctive bronchodilators (ipratropium bromide, magnesium sulfate) and second-line bronchodilators (aminophylline, i.v. salbutamol, i.v. terbutaline, epinephrine, ketamine). Care of children with AAE is further enhanced using clinical severity scoring, pathway-driven care and after-event discharge planning.

Conclusions

AAEs in children are primarily managed by medications supported by a growing body of literature. Continued efforts to study the efficacy of second-line bronchodilators, integrate AAE management with long-term asthma control and provide fair/equitable care are required.

Safety of Terbutaline for Treatment of Acute Severe Pediatric Asthma

OBJECTIVES

The use of continuous intravenous terbutaline treatment in severe asthma attacks has been hampered by the lack of well-powered clinical trials where effects of such treatment are described in detail. Here, we aimed to provide a descriptive report on the largest cohort of severe pediatric asthma patients treated with terbutaline.

METHODS

The study was conducted in a pediatric intensive care unit in a large metropolitan tertiary care university hospital on 124 patients receiving terbutaline infusion. To stratify the effect of, and determine any age-related differences of, terbutaline, the patients were divided into 3 age groups (0-6 years, 7-12 years, and 13-18 years). Clinical response and the potential harmful effects of terbutaline infusion were determined.

RESULTS

There were significant reductions in systolic (varying between 86% and 93% of the baseline) and diastolic blood pressures (varying between 74% and 86% of the baseline level). However, the values returned to baseline level shortly after discontinuation of infusion. Terbutaline increased heart rates in all groups shortly after initiation (9%-13% above baseline), which returned to below baseline levels 1 hour after discontinuation. Serum potassium levels were also reduced in all patients compared to their baseline values after initiation of terbutaline infusion. However, none of the subjects required potassium replacement.

CONCLUSIONS

The results indicate that overall, terbutaline infusion was well tolerated without irreversible adverse effects of the treatment. Although hemodynamic and metabolic disturbances occurred, these were clinically easily managed and posed little risk in emergency department or pediatric intensive care unit.

A systematic review of adverse drug events associated with administration of common asthma medications in children

Objective

To systematically review the literature and determine frequencies of adverse drug events (ADE) associated with pediatric asthma medications.

Methods

Following PRISMA guidelines, we systematically searched six bibliographic databases between January 1991 and January 2017. Study eligibility, data extraction and quality assessment were independently completed and verified by two reviewers. We included randomized control trials (RCT), case-control, cohort, or quasi-experimental studies where the primary objective was identifying ADE in children 1 month– 18 years old exposed to commercial asthma medications. The primary outcome was ADE frequency.

Findings

Our search identified 14,540 citations. 46 studies were included: 24 RCT, 15 cohort, 4 RCT pooled analyses, 1 case-control, 1 open-label trial and 1 quasi-experimental study. Studies examined the following drug classes: inhaled corticosteroids (ICS) (n = 24), short-acting beta-agonists (n = 10), long-acting beta-agonists (LABA) (n = 3), ICS + LABA (n = 3), Leukotriene Receptor Antagonists (n = 3) and others (n = 3). 29 studies occurred in North America, and 29 were industry funded. We report a detailed index of 406 ADE descriptions and frequencies organized by drug class. The majority of data focuses on ICS, with 174 ADE affecting 13 organ systems including adrenal and growth suppression. We observed serious ADE, although they were rare, with frequency ranging between 0.9–6% per drug. There were no confirmed deaths, except for 13 potential deaths in a LABA study including combined adult and pediatric participants. We identified substantial methodological concerns, particularly with identifying ADE and determining severity. No studies utilized available standardized causality, severity or preventability assessments.

Conclusion

The majority of studies focus on ICS, with adrenal and growth suppression described. Serious ADE are relatively uncommon, with no confirmed pediatric deaths. We identify substantial methodological concerns, highlighting need for standardization with future research examining pediatric asthma medication safety.

The effects of preceding exercise on myocardial damage in rats

[Purpose] The purpose of this study was to investigate the effects of exercise on myocardial injury in male Sprague-Dawley rats. Two groups of rats were trained with either moderate- or high-intensity treadmill running for four weeks. Subsequently, the concentrations of cardiac troponin and the N-terminal of prohormone brain natriuretic peptide (NT-proBNP) were examined following a single bout of prolonged intensive exercise (lasting 3 h). [Subjects and Methods] The study included 40 six-week-old male Sprague-Dawley rats weighing 150-180 g each. The aerobic exercise group was divided into high-intensity (28 m/min) and moderate-intensity (15 m/min) subgroups. Both subgroups were trained for 35 min daily for six days per week (excluding Sunday) over a four-week period. Following training, the high- and moderate-intensity exercise groups and a nonexercise group performed one bout of prolonged treadmill exercise for 3 h at a speed of 15 m/min. [Results] The cardiac troponin and NT-proBNP levels differed significantly between the groups. [Conclusion] The exercise groups showed lower levels of cardiac troponin and NT-proBNP than the nonexercise group after the bout of prolonged intensive exercise.

Diastolic Hypotension, Troponin Elevation, and Electrocardiographic Changes Associated With the Management of Moderate to Severe Asthma in Children

OBJECTIVE

The objective was to determine the occurrence of, and the factors associated with, diastolic hypotension and troponin elevation or electrocardiogram (ECG) ST-segment changes in a convenience sample of children with moderate to severe asthma receiving continuous albuterol nebulization.

METHODS

This was a prospective, descriptive study in a pediatric emergency department and an intensive care unit of a tertiary academic center. Fifty children with moderate to severe asthma (clinical asthma score > 8) who received 10 to 15 mg/hour continuous albuterol for >2 hours between June 5, 2007, and February 4, 2008, were approached. Hourly diastolic blood pressures were recorded. Cardiac troponin I (cTnI) and ECG tracings were obtained following the first 2 hours of albuterol and then subsequently every 12 hours while receiving continuous albuterol. Main outcome measures were: 1) incidence of diastolic hypotension, 2) incidence of troponin elevation, and 3) incidence of ECG ST-depression.

RESULTS

Fifty patients were enrolled. Thirty-three (66%) patients developed diastolic hypotension during the first 6 hours of continuous albuterol. Diastolic blood pressure declined from baseline at 1-6 hours (p < 0.01 vs. baseline). Twelve patients (24%) had elevated cTnI, 15 patients (30%) had ST-segment change, four patients (8%) had both, and 23 patients (46%, 95% confidence interval [CI] = 32 to 60) had either a cTnI elevation or an ECG ST-segment change. Troponin elevation and diastolic hypotension were not associated (RR = 1.2, 95% CI = 0.6 to 2.3).

CONCLUSIONS

In a subset of children with moderate to severe asthma, diastolic hypotension, troponin elevation, and ECG ST-segment change occur during administration of continuous albuterol. Future studies are necessary to determine the clinical significance of these findings.

Cardiotoxicodynamics: Toxicity of Cardiovascular Xenobiotics

Maintaining adequate tissue perfusion depends on a variety of factors, all of which can be influenced by xenobiotics (substances foreign to the body, including pharmaceuticals, chemicals, and natural compounds). Volume status, systemic vascular resistance, myocardial contractility, and cardiac rhythm all play a significant role in ensuring hemodynamic stability and proper cardiovascular function. Direct effects on the nervous system, the vasculature, or the heart itself as well as indirect metabolic effects may play a significant role in the development of cardiotoxicity. This article is dedicated to discussion of the disruption of cardiovascular physiology by xenobiotics.

Transient occult cardiotoxicity in children receiving continuous beta-agonist therapy

BACKGROUND

Continuous beta-agonist therapy, typically in the form of inhaled albuterol, is the first line therapy for the treatment of acute and severe bronchospasm in children. Although this treatment is commonly used, concerns about cardiotoxicity have been raised. We aimed to investigate the cardiotoxic effects of continuous beta-agonist therapy in children.

METHODS

We conducted a retrospective review of children admitted to the intensive care unit (ICU) between May 2008 and April 2009, who were treated with continuous beta-agonist therapy (intravenous and nebulized).

RESULTS

Twenty of the 36 children treated with continuous albuterol had repeated serum troponin-T and lactate levels measured. Eleven patients (55%) were also treated with continuous intravenous terbutaline. Elevated levels of troponin-T levels were found in 25% of children, and elevated lactate levels were found in 60%. However, all returned to normal levels within 48 hours of ICU admission, despite continued beta-agonist therapy. No children experienced arrhythmias during therapy. There was no association between intravenous terbutaline use and elevated troponin-T [odds ratio (OR), 1.3; 95% CI, 0.2-10.3] or with elevated serum lactate (OR, 0.6; 95% CI, 0.1-3.7). There was also no association between elevated troponin-T or lactate and ICU or hospital length of stay.

CONCLUSIONS

In this small study, a significant proportion of children had elevated serum troponin-T and lactate levels while receiving inhaled continuous beta-agonist therapy, irrespective of intravenous therapy. However, these abnormal values all returned to normal within 48 hours of ICU admission and were not associated with increased duration of hospitalization.

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.

Cardiac output assessed by non-invasive monitoring is associated with ECG changes in children with critical asthma

The primary aim of this study was to determine changes in CI and SI, if any, in children hospitalized with status asthmatics during the course of treatment as measured by non-invasive EC monitoring. The secondary aim was to determine if there is an association between Abnormal CI (defined as <5 or >95 % tile adjusted for age) and Abnormal ECG (defined as ST waves changes) Non-invasive cardiac output (CO) recordings were obtained daily from admission (Initial) to discharge (Final). Changes in CI and SI measurements were compared using paired t tests or 1-way ANOVA. The association between Abnormal CI on Initial CO recording and Abnormal ECG was analyzed by Fischer's exact test. Data are presented as mean ± SEM with mean differences reported with 95 % confidence interval; p < 0.05 was considered significant. Thirty-five children with critical asthma were analyzed. CI decreased from 6.2 ± 0.2 to 4.5 ± 0.1 [-1.6 (-0.04 to -0.37)] L/min/m(2) during hospitalization. There was no change in SI. There was a significant association between Abnormal Initial CI and Abnormal ECG (p = 0.02). In 11 children requiring prolonged hospitalization CI significantly decreased from 7.2 ± 0.5 to 4.0 ± 0.2 [-3.2 (-4.0 to -2.3)] L/min/m(2) and SI decreased from 51.2 ± 3.8 to 40.3 ± 2.0 [-11.0 (-17.6 to -4.4)] ml/beat/m(2) There was a significant decrease in CI in all children treated for critical asthma. In children that required a prolonged course of treatment, there was also a significant decrease in SI. Abnormal CI at Initial CO recording was associated with ST waves changes on ECG during hospitalization. Future studies are required to determine whether non-invasive CO monitoring can predict which patients are at risk for developing abnormal ECG.

Diastolic hypotension is an unrecognized risk factor for β-agonist-associated myocardial injury in children with asthma

OBJECTIVES

Tachycardia and diastolic hypotension have been associated with β-2 agonist use. In the setting of β-agonist-induced chronotropy and inotropy, diastolic hypotension may limit myocardial blood flow. We hypothesized that diastolic hypotension is associated with β-agonist use and that diastolic hypotension and tachycardia are associated with biochemical evidence of myocardial injury in children with asthma.

DESIGN

Two patient cohorts were collected. The first, consisting of patients transported for respiratory distress having received at least 10 mg of albuterol, was studied for development of tachycardia and hypotension. The second, consisting of patients who had troponin measured during treatment for status asthmaticus with continuous albuterol, was studied for factors associated with elevated troponin. Exclusion criteria for both cohorts included age younger than 2 years old, sepsis, pneumothorax, cardiac disease, and antihypertensive use. Albuterol dose, other medications, and vital signs were collected. Diastolic and systolic hypotension were defined as an average value below the fifth percentile for age and tachycardia as average heart rate above the 98th percentile for age.

PATIENTS

Ninety of 1,390 children transported for respiratory distress and 64 of 767 children with status asthmaticus met inclusion criteria.

MEASUREMENTS AND MAIN RESULTS

Diastolic hypotension occurred in 56% and 98% of the first and second cohorts, respectively; tachycardia occurred in 94% and 95% of the first and second cohorts, respectively. Diastolic hypotension and tachycardia had a weak linear correlation with albuterol dose (p = 0.02 and p = 0.005, respectively). Thirty-six percent had troponin > 0.1 ng/mL (range, 0-12.6). In multivariate analysis, interaction between diastolic hypotension and tachycardia alone was associated with elevated troponin (p = 0.02).

CONCLUSIONS

Diastolic hypotension and tachycardia are dose-dependent side effects of high-dose albuterol. In high-risk patients with status asthmaticus treated with albuterol, diastolic hypotension and tachycardia are associated with biochemical evidence of myocardial injury. Diastolic hypotension, especially combined with tachycardia, could be a reversible risk factor for myocardial injury related to β-agonist use.

Severe acute asthma exacerbation in children: a stepwise approach for escalating therapy in a pediatric intensive care unit

OBJECTIVES

An increasing prevalence of pediatric asthma has led to increasing burdens of critical illness in children with severe acute asthma exacerbations, often leading to respiratory distress, progressive hypoxia, and respiratory failure. We review the definitions, epidemiology, pathophysiology, and clinical manifestations of severe acute asthma, with a view to developing an evidence-based, stepwise approach for escalating therapy in these patients.

METHODS

Subject headings related to asthma, status asthmaticus, critical asthma, and drug therapy were used in a MEDLINE search (1980-2012), supplemented by a manual search of personal files, references cited in the reviewed articles, and treatment algorithms developed within Le Bonheur Children's Hospital.

RESULTS

Patients with asthma require continuous monitoring of their cardiorespiratory status via noninvasive or invasive devices, with serial clinical examinations, objective scoring of asthma severity (using an objective pediatric asthma score), and appropriate diagnostic tests. All patients are treated with β-agonists, ipratropium, and steroids (intravenous preferable over oral preparations). Patients with worsening clinical status should be progressively treated with continuous β-agonists, intravenous magnesium, helium-oxygen mixtures, intravenous terbutaline and/or aminophylline, coupled with high-flow oxygen and non-invasive ventilation to limit the work of breathing, hypoxemia, and possibly hypercarbia. Sedation with low-dose ketamine (with or without benzodiazepines) infusions may allow better toleration of non-invasive ventilation and may also prepare the patient for tracheal intubation and mechanical ventilation, if indicated by a worsening clinical status.

CONCLUSIONS

Severe asthma can be a devastating illness in children, but most patients can be managed by using serial objective assessments and the stepwise clinical approach outlined herein. Following multidisciplinary education and training, this approach was successfully implemented in a tertiary-care, metropolitan children's hospital.

Anaesthetic management of the child with co-existing pulmonary disease

Children with co-existing pulmonary disease have a wide range of clinical manifestations with significant implications for anaesthetists. Although there are a number of pulmonary diseases in children, this review focuses on two of the most common pulmonary disorders, asthma and bronchopulmonary dysplasia (BPD). These diseases share the physiology of bronchoconstriction and variably decreased flow in the airways, but also have unique physiological consequences. The anaesthetist can make a difference in outcomes with proper preoperative evaluation and appropriate preparation for surgery in the context of a team approach to perioperative care with implementation of a stepwise approach to disease management. An understanding of the importance of minimizing the risk for bronchoconstriction and having the tools at hand to treat it when necessary is paramount in the care of these patients. Unique challenges exist in the management of pulmonary hypertension in BPD patients. This review covers medical treatment, intraoperative management, and postoperative care for both patient populations.

Pediatric status asthmaticus

Status asthmaticus is a frequent cause of admission to a pediatric intensive care unit. Prompt assessment and aggressive treatment are critical. First-line or conventional treatment includes supplemental oxygen, aerosolized albuterol, and corticosteroids. There are several second-line treatments available; however, few comparative studies have been performed and in the absence of good evidence-based treatments, the use of these therapies is highly variable and dependent on local practice and provider preference. In this article the pathophysiology and treatment of status asthmaticus is discussed, and the literature regarding second-line treatments is critically assessed to apply an evidence basis to the treatment of this severe disease.

Addition of intravenous beta(2)-agonists to inhaled beta(2)-agonists for acute asthma

BACKGROUND

Inhaled beta-agonist therapy is central to the management of acute asthma. This review evaluates the benefit of an additional use of intravenous beta(2)-agonist agents.

OBJECTIVES

To determine the benefit of adding intravenous (IV) beta(2)-agonists to inhaled beta(2)-agonist therapy for acute asthma treated in the emergency department.

SEARCH METHODS

Randomised controlled trials (RCTs) were identified using the Cochrane Airways Group Register which is a compilation of systematic searches of MEDLINE, EMBASE, CINAHL, and CENTRAL as well as handsearching of 20 respiratory journals. Bibliographies from included studies and known reviews were also searched. Primary authors and content experts were contacted to identify eligible studies. The search was performed in September 2012.

SELECTION CRITERIA

Only RCTs were considered for inclusion. Studies were included if patients presented to the emergency department with acute asthma and were treated with IV beta(2)-agonists with inhaled beta(2)-agonist therapy and existing standard treatments versus inhaled beta(2)-agonists and existing standard treatments.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and confirmed their findings with corresponding authors of trials. We obtained missing data from authors or calculated from data present in the papers. We used fixed-effect model for odds ratios (OR) and for mean differences (MD) we used both fixed-effect and random-effects models and reported 95% confidence intervals (CI).

MAIN RESULTS

From 109 potentially relevant studies only three (104 patients) met our inclusion criteria: Bogie 2007 (46 children), Browne 1997 (29 children) and Nowak 2010 (29 adults). Bogie 2007 investigated the addition of intravenous terbutaline to high dose nebulised albuterol in children with acute severe asthma, requiring intensive care unit (ICU) admission. Browne 1997 investigated the benefit of adding intravenous salbutamol to inhaled salbutamol in children with acute severe asthma in the emergency department. Nowak 2010 investigated addition of IV bedoradrine to standard care (nebulised albuterol, ipratropium and oral corticosteroids) among adults, and was reported as a conference abstract only.There was no significant advantage (OR 0.29; 95%CI 0.06 to 1.38, one trial, 29 adults) for adding IV bedoradrine to standard care (nebulised albuterol, ipratropium and oral corticosteroids) with regard to hospitalisation rates.Various outcome indicators for the length of stay were reported among the trials. Browne 1997 reported a significantly shorter recovery time (in terms of cessation of 30 minute salbutamol) for children in the IV salbutamol with inhaled salbutamol group (four hours) versus the 11.1 hours for the inhaled salbutamol group (P = 0.03). Time to cessation of hourly nebuliser was also significantly shorter (P = 0.02) for the IV plus inhaled salbutamol group (11.5 hours versus 21.2 hours), and they were ready for emergency patient discharge on average 9.7 hours earlier than the inhaled salbutamol group (P < 0.05). In a paediatric ICU study Bogie 2007 reported no significant advantage in length of paediatric ICU admission (hours) for adding IV terbutaline to nebulised albuterol (MD -12.95, 95% CI: -38.74, 12.84).Browne 1997 reported there were only six out of 14 children with a pulmonary index score above six in the IV plus inhaled salbutamol group at two hours compared with 14 of the 15 in the inhaled salbutamol group (P = 0.02)In Browne 1997 there was a higher proportion of tremor in the IV plus inhaled salbutamol group than in the inhaled salbutamol group (P < 0.02). Nowak 2010 did not report any statistically significant adverse effects associated with adding IV bedoradrine to standard care (nebulised albuterol, ipratropium and oral corticosteroids). Troponin levels were elevated in three children in the IV terbutaline + nebulised albuterol group at 12 and 24 hours in Bogie 2007

AUTHORS' CONCLUSIONS

There is very limited evidence from one study (Browne 1997) to support the use of IV beta(2)-agonists in children with severe acute asthma with respect to shorter recovery time, and similarly there is limited evidence (again from one study Browne 1997) suggesting benefit with regard to pulmonary index scores; however this advantage needs to be considered carefully in relation to the increased side effects associated with IV beta(2)-agonists. We identified no significant benefits for adults with severe acute asthma. Until more, adequately powered, high quality clinical trials in this area are conducted it is not possible to form a robust evaluation of the addition of IV beta(2)-agonists in children or adults with severe acute asthma.

Intravenous beta(2)-agonists versus intravenous aminophylline for acute asthma

BACKGROUND

Inhaled beta(2)-agonist therapy is central to the management of acute asthma. For rapid bronchodilation in severe cases, penetration of inhaled drug to the affected small conducting airway may be impeded, and the intravenous (IV) rather than inhaled administration of bronchodilators may provide an earlier response. IV beta(2)-agonist agents and IV aminophylline may also be considered as additional interventions in this setting and this review compares IV beta-agonist agents and IV aminophylline in the treatment of people with acute asthma.

OBJECTIVES

To compare the benefit of IV beta(2)-agonists versus IV aminophylline for acute asthma treated in the emergency department and in patients admitted to hospital with acute severe asthma.

SEARCH METHODS

Randomised controlled trials (RCTs) were identified using the Cochrane Airways Group Register, which is compiled from systematic searches of bibliographic databases as well as handsearching of respiratory journals and conference abstracts. The latest search was run in September 2012. We searched bibliographies from included studies and known reviews were also searched. Primary authors and content experts were contacted to identify eligible studies.

SELECTION CRITERIA

We included RCTs of patients who presented to the emergency department with acute asthma, and patients admitted to hospital with acute severe asthma, and were treated with IV beta(2)-agonists versus IV aminophylline. Two review authors independently selected potentially relevant articles and selected articles for inclusion. Methodological quality was independently assessed using two scoring systems and two review authors.

DATA COLLECTION AND ANALYSIS

Data were extracted independently by two review authors. Missing data were obtained from authors or calculated from data present in the papers. Trials were combined using a random-effects model for odds ratios (OR) or mean differences (MD) and reported with 95% confidence intervals (95% CI).

MAIN RESULTS

Eleven studies met our inclusion criteria and in total they included 350 patients. However, opportunities to combine these studies in meta-analyses were limited by the variations in the range of outcomes reported in the trials.Length of stayTwo studies reported length of stay. They were both paediatric trials (with one in paediatric intensive care unit), and there was no significant difference between the two groups (MD 23.19 hours; 95% CI -2.40 to 48.77 hours; 2 studies; N = 73). Individual separate MD analyses for the two studies also indicated no significant difference between the aminophylline and beta(2)-agonist on this outcome. However, this finding should be interpreted with caution owing to the small number of trials and participants the analysis.Pulmonary functionThere were no significant differences in the sequential or summative pulmonary function demonstrated across the studies.Heart rateData for serial heart rates were reported in three studies at various points from 15 to 60 minutes and in each case there were no significant differences between people in the IV aminophylline or beta(2)-agonist groups. The difference between the two groups with respect to final heart rate was statistically significant (MD 10.00; 95% CI 0.99 to 19.01), although these data are from a single, small study and should be interpreted with caution.Adverse effectsThe analyses for giddiness (OR 59.22; 95% CI 2.80 to 1253.05; 1 study; N = 30), nausea/vomiting (where reported as a combined outcome) (OR 14.18; 95% CI 1.62 to 124.52; 2 studies; N = 96) and nausea (OR 6.53; 95% CI 1.60 to 26.72; 2 studies; N = 49) all significantly favoured beta(2)-agonists. In view of the very small number of studies and number of patients contributing to these analyses these results should be interpreted with caution. A closely related review considering the possible benefits of adding IV aminophylline to beta-agonists in adults with acute asthma also indicates a higher incidence of adverse effects associated with IV aminophylline.

AUTHORS' CONCLUSIONS

In the included RCTs there was no consistent evidence favouring either IV beta(2)-agonists or IV aminophylline for patients with acute asthma. The opportunity to draw clear conclusions is limited by the heterogeneity of outcomes evaluated and the small sample sizes in the included studies. It is recommended that these data should be viewed carefully alongside the conclusions from separate Cochrane reviews comparing IV beta(2)-agonists plus inhaled beta(2)-agonists versus inhaled beta(2)-agonists alone and IV aminophylline plus inhaled beta(2)-agonists versus inhaled beta(2)-agonists alone.

Fatal and near-fatal asthma in children: the critical care perspective

OBJECTIVE

To characterize the clinical course, therapies, and outcomes of children with fatal and near-fatal asthma admitted to pediatric intensive care units (PICUs).

STUDY DESIGN

This was a retrospective chart abstraction across the 8 tertiary care PICUs of the Collaborative Pediatric Critical Care Research Network (CPCCRN). Inclusion criteria were children (aged 1-18 years) admitted between 2005 and 2009 (inclusive) for asthma who received ventilation (near-fatal) or died (fatal). Data collected included medications, ventilator strategies, concomitant therapies, demographic information, and risk variables.

RESULTS

Of the 261 eligible children, 33 (13%) had no previous history of asthma, 218 (84%) survived with no known complications, and 32 (12%) had complications. Eleven (4%) died, 10 of whom had experienced cardiac arrest before admission. Patients intubated outside the PICU had a shorter duration of ventilation (median, 25 hours vs 84 hours; P < .001). African-Americans were disproportionately represented among the intubated children and had a shorter duration of intubation. Barotrauma occurred in 15 children (6%) before admission. Pharmacologic therapy was highly variable, with similar outcomes.

CONCLUSION

Of the children ventilated in the CPCCRN PICUs, 96% survived to hospital discharge. Most of the children who died experienced cardiac arrest before admission. Intubation outside the PICU was correlated with shorter duration of ventilation. Complications of barotrauma and neuromyopathy were uncommon. Practice patterns varied widely among the CPCCRN sites.

Critical care for pediatric asthma: wide care variability and challenges for study

OBJECTIVES

To describe pediatric severe asthma care, complications, and outcomes to plan for future prospective studies by the Collaborative Pediatric Critical Care Research Network.

DESIGN

Retrospective cohort study.

SETTING

: Pediatric intensive care units in the United States that submit administrative data to the Pediatric Health Information System.

PATIENTS

Children 1-18 yrs old treated in a Pediatric Health Information System pediatric intensive care unit for asthma during 2004-2008.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Thirteen-thousand five-hundred fifty-two children were studied; 2,812 (21%) were treated in a Collaborative Pediatric Critical Care Research Network and 10,740 (79%) were treated in a non-Collaborative Pediatric Critical Care Research Network pediatric intensive care unit. Medication use in individual Collaborative Pediatric Critical Care Research Network centers differed widely: ipratropium bromide (41%-84%), terbutaline (11%-74%), magnesium sulfate (23%-64%), and methylxanthines (0%-46%). Complications including pneumothorax (0%-0.6%), cardiac arrest (0.2%-2%), and aspiration (0.2%-2%) were rare. Overall use of medical therapies and complications at Collaborative Pediatric Critical Care Research Network centers were representative of pediatric asthma care at non-Collaborative Pediatric Critical Care Research Network pediatric intensive care units. Median length of pediatric intensive care unit stay at Collaborative Pediatric Critical Care Research Network centers was 1 to 2 days and death was rare (0.1%-3%). Ten percent of children treated at Collaborative Pediatric Critical Care Research Network centers received invasive mechanical ventilation compared to 12% at non-Collaborative Pediatric Critical Care Research Network centers. Overall 44% of patients who received invasive mechanical ventilation were intubated in the pediatric intensive care unit. Children intubated outside the pediatric intensive care unit had significantly shorter median ventilation days (1 vs. 3), pediatric intensive care unit days (2 vs. 4), and hospital days (4 vs. 7) compared to those intubated in the pediatric intensive care unit. Among children who received mechanical respiratory support, significantly more (41% vs. 25%) were treated with noninvasive ventilation and significantly fewer (41% vs. 58%) were intubated before pediatric intensive care unit care when treated in a Pediatric Health Information System hospital emergency department.

CONCLUSIONS

Marked variations in medication therapies and mechanical support exist. Death and other complications were rare. More than half of patients treated with mechanical ventilation were intubated before pediatric intensive care unit care. Site of respiratory mechanical support initiation was associated with length of stay.

Severe Asthma

Despite vast improvements in the care of children with asthma over the past decades, asthma remains a common cause of admission to pediatric intensive care units. During the 1990s asthma prevalence and hospital admissions increased in the United States and worldwide. The increase occurred in both males and females and across all ethnic groups. However, the largest increases occurred in children of low socioeconomic status living in urban settings. Recent asthma statistics should be interpreted with consideration of changes made in the method for reporting asthma prevalence (Fig. 23-1). From 1980 to 1996, the National Health Interview Survey (NHIS) conducted by the CDC measured pediatric asthma prevalence as the percentage of children with asthma in the past 12 months. Since 1997, asthma prevalence estimates have been defined as: having received an asthma diagnosis, currently having the disease at the time of the interview, and experiencing an attack in the past year. The more specific definition may have led to a reduction in the number of children reported to have asthma.

Serial cardiac troponin concentrations as marker of cardiac toxicity in children with status asthmaticus treated with intravenous terbutaline

OBJECTIVES

The study's objectives were to evaluate serial troponin concentrations as a marker of cardiac toxicity in children receiving intravenous terbutaline for status asthmaticus and to study if troponin concentrations are affected by severity of asthma and risk factors for severe asthma.

METHODS

This was a prospective observational study in 20 consecutive patients who were admitted to a tertiary care pediatric intensive care unit for status asthmaticus and received intravenous terbutaline. Cardiac troponin I (cTnI) concentrations were measured half an hour before the bolus of intravenous terbutaline, 4 hours after terbutaline, and then every 24 hours until discontinuation of the continuous terbutaline infusion.

RESULTS

Ten patients had cTnI concentrations greater than 0.03 ng/mL. Maximum cTnI concentrations were recorded after the terbutaline bolus in 6 patients, during terbutaline infusion in 3 patients, and before terbutaline use in 1 patient. Three of these 10 (3/10) patients showed increased cTnI concentrations before the terbutaline bolus. One patient had a significant elevation in cTnI concentration (peak level of 3.79 ng/mL) with electrocardiogram (ECG) changes of myocardial injury that normalized upon discontinuation of terbutaline. All other patients with elevated cTnI concentrations had normal ECG findings.

CONCLUSIONS

Elevated cTnI concentrations were observed in 50% of patients treated with intravenous terbutaline for status asthmaticus. Clinically significant cardiotoxicity was not observed except in 1 patient in whom the abnormal ECG findings normalized upon discontinuation of terbutaline. There was no statistically significant difference in asthma severity or in the risk factors for severe asthma in children with and without elevation of cTnI concentrations.

Management of status asthmaticus in children

Asthma is a common chronic inflammatory disorder of the airways characterized by recurrent wheezing, breathlessness, and coughing. Acute exacerbations of asthma can be life-threatening; annual worldwide estimated mortality is 250,000 and most of these deaths are preventable. While most of the acute exacerbations can be managed successfully in the emergency room, few children have severe exacerbations requiring intensive care. Mainstay of treatment for status asthmaticus are inhaled β2 agonist and anticholinergic agents, oxygen along with corticosteroids. Children who do not respond well to initial treatment require parenteral β2 agonist and magnesium. Rarely, sick children need parenteral aminophylline infusion and mechanical ventilation. Guidelines for diagnosis, treatment, ventilator management and supportive care for status asthmaticus in children are discussed in the protocol.

Status asthmaticus in children

PURPOSE OF REVIEW

The prevalence of severe asthma in children has risen in the past few decades. The present review explores our current understanding of epidemiology, pathophysiology and treatment of status asthmaticus in children.

RECENT FINDINGS

The pathophysiology of inflammation and airway hyperactivity continues to be a source of research. Early initiation of inhaled beta-agonists and oral or parenteral steroids remain the standard of care in the treatment of status asthmaticus. Other treatment modalities such as magnesium and intravenous beta-agonists show some benefit. There is a resurgence of interest in the use of methylxanthines. Alternatives to endotracheal intubation show some promise in preventing respiratory failure.

SUMMARY

Asthma remains the third leading cause of hospitalization in children younger than 15 years old. Researchers continue to explore the efficacy of old and new treatment modalities. Future research efforts targeting at-risk populations could dramatically decrease asthma morbidity and mortality.

Comparison of intravenous terbutaline versus normal saline in pediatric patients on continuous high-dose nebulized albuterol for status asthmaticus

OBJECTIVE

To determine if the addition of intravenous terbutaline provides any clinical benefit to children with acute severe asthma already on continuous high-dose nebulized albuterol.

METHODS

We conducted a prospective, randomized, double blind, placebo-controlled trial on pediatric patients with acute severe asthma presenting to a large inner city tertiary children's emergency department. Consecutive patients between 2 and 17 years of age who failed acute asthma management and needed intensive care unit admission underwent informed consent and were enrolled into the study. Patients not requiring intubation were randomized to receive either intravenous terbutaline or intravenous normal saline while on continuous high-dose nebulized albuterol, ipratropium bromide, and systemic corticosteroids. Outcome measures included a clinical asthma severity score, hours on continuous nebulized albuterol, and duration of stay in the pediatric intensive care unit. In addition, electrocardiograms, electrolytes, lactic acid, and troponin I levels were obtained at routine intervals during the first 24 hours after admission. Patients who significantly worsened while enrolled in the study received intravenous aminophylline according to protocol.

RESULTS

Forty-nine patients were enrolled in the study. Patients on terbutaline had a mean improvement in the clinical asthma severity score over the first 24 hours of 6.5 points compared with 4.8 points in the placebo group (P = 0.073). Patients on terbutaline spent 38.19 hours on continuous nebulized albuterol compared with their placebo counterparts who spent 51.93 hours (P = 0.25). The length of stay in the PICU was on average 12.95 hours longer for those patients in the placebo group as compared with the terbutaline group (P = 0.345). One patient was removed from the study for a significant cardiac dysrhythmia. This patient was in the terbutaline group and recovered without complications. Troponin I values at 12 hours and 24 hours were elevated in 3 patients each, all within the terbutaline group.

CONCLUSIONS

No outcome measures demonstrated statistical significance. Outcome measures revealed a trend toward improvement in the terbutaline group. Before recommending routine use of intravenous terbutaline for acute severe asthma, further study to determine safety and efficacy is necessary.

Cardiac troponin T and cardiac dysfunction in extremely low-birth-weight infants

Extremely low-birth-weight (ELBW) infants frequently manifest signs of cardiac dysfunction requiring inotropic support. It is not clear if this is due to cardiac injury, which can be monitored by measuring cardiac troponin T (cTnT). We performed a nested prospective cohort study at a university level III neonatal intensive care unit. The study included 27 infants weighing between 500 and 999 g. Exclusion criteria included evidence of sepsis, use of postnatal steroids, and cardiac anomalies. Measurements included serum cTnT and echocardiogram in the first 48 hours of life. The mean serum cTnT level of the study population was 0.52 +/- 0.38 ng/ml. It was higher in those with lower Apgar scores (0.89 +/- 0.37 if 5-minute Apgar < 4 vs 0.36 +/- 0.26 ng/ml, p < 0.001) and correlated to initial base deficit (r = -0.37, p < 0.05). Infants who required inotropic support had higher cTnT levels than those who did not (0.73 +/- 0.43 vs 0.39 +/- 0.29 ng/ml, p < 0.03). cTnT concentrations did not relate to simultaneous echocardiographic measures of cardiac function. In ELBW infants, serum cTnT levels are higher than normally seen in term infants and adults, and they are higher in infants with greater perinatal stress as well as those who show evidence of cardiac dysfunction requiring pressor support.

Frequency of clinically unsuspected myocardial injury at a children's hospital

BACKGROUND

Ill children are at risk but rarely screened for myocardial injury. The frequency of such injury in ill children is unknown. Elevated levels of plasma cardiac troponin I (cTnI) can detect subclinical myocardial injury.

METHODS

We measured cTnI levels from 283 Children's Hospital, Boston patients (median age 2.10 years, range 0.13-22.4 years) seen in an outpatient or emergency clinic without clinically apparent cardiac disease. We took > or = 0.5 ng/mL as an indication of myocardial injury. We also measured plasma creatine kinase-MB, total creatine kinase, and myoglobin, and performed a chart review.

RESULTS

Fifteen (7.8%) of the 193 acutely ill children and 4 (4.4%) of the 90 well children had an elevated cTnI level (P = .44). Within the acutely ill group, the children with elevated cTnI were younger and had lower mean hemoglobin and hematocrit levels. Cardiac troponin I levels correlated with creatine kinase-MB (r = 0.22; P < .001) but not with creatine kinase or myoglobin. The 4 children with cTnI > 0.89 ng/mL, who also had plasma cardiac troponin T measured, showed cardiac troponin T elevations that were consistent with unstable angina levels in adults. Four children had high-level cTnI elevations (> 2 ng/mL) consistent with acute myocardial infarction levels in adults.

CONCLUSIONS

Elevated cTnI levels occur in children without clinically apparent cardiac disease and can be at adult unstable angina or acute myocardial infarction levels. Prospective studies to determine the clinical significance of these findings and their relationship to the development of cardiomyopathy are warranted.

Protocol-based titration of intravenous terbutaline decreases length of stay in pediatric status asthmaticus

Although frequently used to treat status asthmaticus in children, intravenous (IV) terbutaline has not been shown to decrease hospital length of stay (LOS). We theorized that this lack of demonstrable benefit resulted from variations in dosing and titration, rather than the drug per se, and that intensive care unit (ICU) LOS would be shortened by the administration of terbutaline according to a protocol incorporating a quantitative assessment of severity of illness. We prospectively treated 20 consecutive children with status asthmaticus with IV terbutaline according to a protocol that titrated the dose based on a clinical asthma score, the Modified Pulmonary Index Score (MPIS). Data were compared to a historic cohort of the previous 20 consecutive ICU patients with status asthmaticus who were treated with IV terbutaline prior to initiation of the protocol. Patients who received terbutaline by standardized protocol had significantly shorter ICU LOS (3.5 +/- 1.1 vs. 5.0 +/- 2.0 days, P = 0.01), shorter hospital LOS (5.5 +/- 1.3 vs. 8.3 +/- 2.7 days, P < 0.01), and reduced hospital charges ($19,298 +/- $10,516 vs. $26,528 +/- $12,328, P = 0.04). The method of administration of IV terbutaline significantly influenced ICU length of stay and hospital charges.

Current management of status asthmaticus in the pediatric ICU

Status asthmaticus (SA) in the pediatric ICU (PICU) can progress to a life-threatening emergency. The goal of management is to improve hypoxemia, improve bronchoconstriction, and decrease airway edema through the administration of continuous nebulized beta2 adrenergic agonist with intermittent anticholinergics, corticosteroids, and oxygen. Adjunctive therapies, such as magnesium, methylxanthines, intravenous beta-agonists, heliox, and noninvasive ventilation should be considered in the child who fails to respond to initial therapies. The restoration of adequate pulmonary functions, resolution of airway obstruction, and avoidance of mechanical ventilation should guide management. This article reviews the pathophysiology, assessment, and management of the child who has SA in the PICU to provide the critical care nurse with current information to facilitate optimal care.

Troponin as a marker of myocardiac damage in drug-induced cardiotoxicity

Cardiac troponins T and I (cTnT and cTnI) are becoming the serum biomarkers of choice for monitoring potential drug-induced myocardial injury in both clinical and preclinical studies. The utility of cardiac troponins has been mainly demonstrated following the administration of antineoplastic drugs and beta-sympathomimetics, although the routine use of these markers in the monitoring in patients who received anthracyclines therapy is far from settled. Unlike the previous markers, which suffered from numerous shortages, the main advantages of cardiac troponins are their high specificity and sensitivity, wide diagnostic window and the possibility to use commercially available assays in clinical settings as well as in a broad range of laboratory animals. Nevertheless, in spite of vigorous research in this area, a number of questions are still unanswered and these are discussed in this review. The main problems seem to be the lack of standardisation of variety of troponin immunoassays, the assessment of suitable cutoff for drug-induced cardiotoxicity and determination of critical diagnostic window related to the optimal timing of sample collection, which may be drug-dependent.

Cardiac troponins as biomarkers of drug- and toxin-induced cardiac toxicity and cardioprotection

Cardiac troponin T and I (cTnT, cTnI) are sensitive biochemical markers of myocardial cell necrosis and have been adopted as the gold standard tests for acute myocardial infarction. Subtle elevations in cTn above the detection limits of the currently available commercial assays confers poor prognosis. These markers are superior to classical enzyme markers of necrosis due to their cardiospecificity. The diagnosis of drug-induced cardiac toxicity using the classical enzymes is problematic due to the high elevations of these markers in skeletal muscle necrosis. cTnT and cTnI are now being adopted as sensitive biomarkers of drug-induced cardiac toxicity.

Safety of intravenous terbutaline in acute severe asthma: a retrospective study

OBJECTIVE

(1) To determine the effect of intravenous terbutaline in children with acute severe asthma on parameters like heart rate, blood pressure, electrocardiogram and serum electrolytes; (2) to assess the safety profile and to evaluate the outcome of children treated with intravenous terbutaline for acute severe asthma.

DESIGN

Retrospective study of admission records of children admitted with acute severe asthma who needed intravenous terbutaline.

SETTING

Children's Hospital at the Leicester Royal Infirmary, UK.

PATIENTS

77 children with acute severe asthma admitted between April 1999 and October 2002.

RESULTS

There was a significant increase in heart rate and significant fall in diastolic blood pressure in this cohort. Four patients required inotropic support. None of the patients had cardiac arrhythmias. Potassium supplements were required in 10 patients due to hypokalaemia. All patients improved and none required initiation of ventilation after commencing terbutaline. There was no mortality in this cohort.

CONCLUSIONS

Terbutaline was found to be safe for use in this patient group in doses ranging between 1 and 5 microg/kg/min. Intravenous terbutaline was found to be a useful adjunct in those who failed to respond to standard initial therapy.

Theophylline versus terbutaline in treating critically ill children with status asthmaticus: a prospective, randomized, controlled trial

OBJECTIVE

To compare the efficacy of theophylline, terbutaline, or theophylline combined with terbutaline treatment in critically ill children with status asthmaticus who are already receiving continuous nebulized albuterol and intravenous corticosteroids.

DESIGN

Randomized, prospective, controlled, double-blind trial.

SETTING

Pediatric intensive care unit of a tertiary-care children's medical center.

PATIENTS

Forty critically ill children between the ages of 3 and 15 yrs with impending respiratory failure secondary to status asthmaticus.

INTERVENTIONS

All patients received intravenous methylprednisolone and continuous nebulized albuterol. The three study groups received theophylline plus placebo (group 1), terbutaline plus placebo (group 2), or theophylline and terbutaline together (group 3).

MEASUREMENTS AND MAIN RESULTS

Differences in baseline characteristics, change in clinical asthma score over time, length of pediatric intensive care unit stay, and incidence of adverse events were determined. The three study groups were similar in age, gender, race, asthma severity, and treatment. There were no differences in clinical asthma score over time, length of pediatric intensive care unit stay, or incidence of adverse events between the three groups, with the exception of a higher incidence of nausea in children in group 3. The median hospital cost of medication and theophylline blood levels was significantly lower in group 1 compared with groups 2 and 3 (280 US dollars vs. 3,908 US dollars vs. 4,045 US dollars, respectively, p < .0001).

CONCLUSIONS

Theophylline, when added to continuous nebulized albuterol therapy and intravenous corticosteroids, is as effective as terbutaline in treating critically ill children with status asthmaticus. The addition of theophylline to baseline therapy is more cost-effective when compared with terbutaline alone or terbutaline and theophylline together. Theophylline should be considered for use early in the management of critically ill asthmatic children.

Management of acute pediatric asthma

Pediatric asthma prevalence, morbidity, and severity are increasing. Direct costs associated with providing emergency department and inpatient care account for more than 40% of overall dollars spent for this disease in the United States. Physicians in many health care settings may be required to treat a child in severe respiratory distress caused by acute asthma. This article reviews the pathophysiology, evaluation, and treatment of severe asthma exacerbations, or status asthmaticus.

The management of acute severe asthma

Asthma is a common cause of morbidity and mortality in the United States, with over two million Emergency Department (ED) visits each year. Airway inflammation is recognized as a major component in the pathophysiology of asthma. The classic presentation of asthma is that of wheezing, cough, and dyspnea, however, the severity of airflow limitation correlates poorly with clinical signs. Forced exhaled volume in 1 s (FEV(1)) and the peak expiratory flow rate (PEFR) are direct reflections of the severity of airflow obstruction and are the standard measures used in the ED to assess the severity of airflow obstruction and the response to therapy. Beta2-adrenergic bronchodilators, ipratropium bromide, and corticosteroids form the cornerstone of therapy. Inhaled corticosteroids, leukotriene modifying drugs, and noninvasive positive pressure ventilation should be considered in patients with severe disease and in those who have responded poorly to standard therapy. Mechanical ventilation is usually well tolerated and may be lifesaving in patients with refractory asthma. Precautions are required to prevent dynamic hyperinflation during assisted ventilation.

Contemporary approach to the emergency department management of pediatric asthma

Asthma continues to be an enormous health problem and economic burden in US society. EDs probably will continue to provide a substantial amount of care for those affected by the disease. Pediatric asthma patients frequently are encountered in EDs. Emergency physicians must remain current in their approach to providing expert care while the management of acute asthma exacerbations continues to evolve, older therapies are challenged and new therapies are developed, tested, and implemented.

Status asthmaticus in children: a review

About 10% of American children have asthma, and its prevalence, morbidity, and mortality have been increasing. Asthma is an inflammatory disease with edema, bronchial constriction, and mucous plugging. Status asthmaticus in children requires aggressive treatment with beta-agonists, anticholinergics, and corticosteroids. Intubation and mechanical ventilation should be avoided if at all possible, as the underlying dynamic hyperinflation will worsen with positive-pressure ventilation. If mechanical ventilation becomes necessary, controlled hypoventilation with low tidal volume and long expiratory time may lessen the risk of barotrauma and hypotension. Unusual and nonestablished therapies for severe asthma are discussed.

Acute asthma

OBJECTIVE: Asthma is the most common medical emergency in children. It is associated with significant morbidity and mortality rates and poses a tremendous societal burden worldwide. Management of the acute attack involves a stepwise approach that includes beta-agonist and steroid therapy, the mainstay of emergency treatment. Most patients will respond to this regime and can be discharged from the emergency department. Failure to respond to treatment necessitates hospital admission and sometimes admission to the intensive care unit (ICU). Management in the ICU involves intensification of pharmacologic therapy, including nonstandard therapies, in an attempt to avoid intubation and ventilation. When needed, mechanical ventilatory support can be rendered fairly safe with little morbidity if the likely cardiorespiratory physiologic derangements are appreciated and if appropriate ventilatory strategies are used. In the past two decades, the availability of newer potent medications and changes in approach to monitoring and ventilatory strategies have resulted in a decrease in ICU morbidity and mortality rates. Research endeavors are presently underway to further characterize the underlying mechanisms of the disease and are likely to lead to novel therapies. This article reviews the approach to management of acute severe asthma.

Ventricular dysfunction clinical research in infants, children and adolescents

These two issues of Progress in Pediatric Cardiology comprehensively illustrate the wealth of currently available information on the pathophysiology of heart failure, age-related myocardial responsiveness, energy metabolism, cardiopulmonary interactions, the pressure-volume relationship, the systemic inflammatory response, the management of heart failure, pediatric pharmacology, the use of heart failure therapies including digoxin, ACE inhibitors, beta-adrenergic blockers, inotropic agents, diuretics, vasodilators, calcium sensitizers, angiotensin and aldosterone receptor blockers, growth hormone, and future gene therapy. The etiology and course of ventricular dysfunction in children is poorly characterized. Furthermore, many changing developmental properties of the pediatric myocardium and differences in the etiologies of ventricular dysfunction in children compared with adults are illustrated in these articles, invalidating the concept that children can safely be considered small adults for the purpose of understanding heart failure pathophysiology and treatment. However, these articles reveal that strikingly little research in children with ventricular dysfunction exists in terms of well-designed large-scale studies of the epidemiology or multicenter controlled clinical therapeutic trials. A future research agenda is proposed to improve understanding etiologies, course and treatment of ventricular dysfunction in children that is based on organized and funded cooperative groups since no one pediatric cardiac center treats enough children with a particular etiology of ventricular dysfunction. In conclusion, significant understanding of basic mechanisms of pediatric ventricular dysfunction and effective therapies for adults with ventricular dysfunction exist. A multicenter pediatric cardiac ventricular dysfunction network would allow improved understanding of diseases and treatments, and result in evidence-based medicine for pediatric patients with ventricular dysfunction.