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

Bratton, Susan L. MD, MPH; Newth, Christopher J. L. MD, FRCPC; Zuppa, Athena F. MD, MSCE; Moler, Frank W. MD, MS; Meert, Kathleen L. MD; Berg, Robert A. MD; Berger, John MD; Wessel, David MD; Pollack, Murray MD; Harrison, Rick MD; Carcillo, Joseph A. MD; Shanley, Thomas P. MD; Liu, Teresa MPH; Holubkov, Richard PhD; Dean, J. Michael MD; Nicholson, Carol E. MD, MS; for the Eunice Kennedy Shriver National Institute of Child Health and Human Development Collaborative Pediatric Critical Care Research Network

Pediatric Critical Care Medicine: July 2012 - Volume 13 - Issue 4 - p 407–414
doi: 10.1097/PCC.0b013e318238b428
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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.

From the Department of Pediatrics (SLB, R. Harrison, TL, JMD), University of Utah, Salt Lake City, UT; Department of Anesthesiology/Critical Care Medinein (CJLN), Children’s Hospital Los Angeles, Los Angeles, CA; Department of Pediatrics (AFZ, RAB), Children’s Hospital of Philadelphia, Philadelphia, PA; Department of Pediatrics (FWM, TPS), University of Michigan, Ann Arbor, MI; Department of Pediatrics (KLM), Wayne State University, Detroit, MI; Department of Pediatrics (JB, DW), Children’s National Medical Center, Washington, DC; Department of Pediatrics (MP), Phoenix Children’s Hospital, Phoenix, AZ; Department of Pediatrics (R. Holubkov), University of California at Los Angeles, Los Angeles, CA; Eunice Kennedy Shriver National Institute of Child Health and Human Development (CEN), Washington, DC.

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Supported, in part, by cooperative agreements (U10HD500009, U10HD050096, U10HD049981, U10HD049945, U10HD049983, U10HD050012, and U01HD049934) from the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Department of Health and Human Services.

The authors have not disclosed any potential conflicts of interest.

For information regarding this article, E-mail: Susan.Bratton@hsc.utah.edu

©2012The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies