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Acute severe asthma: differences in therapies and outcomes among pediatric intensive care units
Joan S Roberts1, Susan L Bratton, Thomas V Brogan
1Department of Pediatrics, University of Washington School of Medicine, Children's Hospital, Seattle, USA.
Insights
Pediatric intensive care units vary widely in invasive intervention use for severe asthma. Higher use of mechanical ventilation correlated with longer intensive care and hospital stays, suggesting potential for improved management through less invasive practices.
Area of Science:
- Pediatric Critical Care Medicine
- Respiratory Medicine
- Health Services Research
Background:
- Acute severe asthma in children necessitates intensive care, but management strategies and outcomes can differ significantly across pediatric intensive care units (PICUs).
- Understanding variations in the use of invasive interventions is crucial for optimizing care for critically ill asthmatic children.
Purpose of the Study:
- To investigate and compare therapeutic approaches and patient outcomes in PICUs for children experiencing acute severe asthma.
- To identify institutional differences in the utilization of invasive interventions and their impact on length of stay and treatment duration.
Main Methods:
- A retrospective cohort study was conducted involving 1528 pediatric patients diagnosed with asthma across eleven PICUs.
- Data collected included severity of illness, length of intensive care and hospital stays, and the application of invasive interventions such as mechanical ventilation and vascular monitoring.
- Statistical analysis compared outcomes between centers with high versus low utilization of mechanical ventilation, adjusting for patient and illness severity factors.
Main Results:
- Significant institutional variability was observed in the use of invasive interventions, including mechanical ventilation (3%–47%) and vascular monitoring (4%–51%).
- PICUs with higher rates of mechanical ventilation use (>20%) exhibited longer intensive care and hospital stays for asthmatic patients, irrespective of individual ventilation requirement.
- High mechanical ventilation use was an independent predictor of longer intensive care stays, hospital stays, and duration of mechanical ventilation.
Conclusions:
- Institutional practices regarding invasive interventions, particularly mechanical ventilation and vascular monitoring, show substantial variation in pediatric severe asthma management.
- Centers employing higher rates of mechanical ventilation are associated with prolonged patient stays, indicating a potential for optimizing care.
- Further research into institutional practices at centers using fewer invasive interventions may reveal strategies to improve outcomes for children with acute severe asthma.
Objective:
To determine differences in therapies and outcomes among pediatric intensive care units for patients with acute severe asthma.
Design:
Retrospective cohort study.
Setting:
Eleven pediatric intensive care units participating in the Pediatric Intensive Care Evaluations.
Patients:
Patients were 1528 children with a primary diagnosis of asthma.
Interventions:
None.
Measurements And Main Results:
We studied severity of illness, length of stay, and use of invasive interventions. The patients at the centers had similar median physiologic measures of illness and Pediatric Risk of Mortality III scores. The patients received a wide range of invasive interventions depending on institution, including mechanical ventilation (3% to 47%), arterial catheter placement (4% to 46%), central venous catheter (2% to 51%), and determination of a blood gas (24% to 70%). At institutions where mechanical ventilation was used more commonly (>20%, high use), intensive care and hospital stays were longer for asthmatic patients regardless of mechanical ventilation requirement compared with centers with lower use of mechanical ventilation. The status of "high-use center" was an independent predictor for intensive care stay (p = .005) and hospital length of stay (p = .017) as well as duration of mechanical ventilation (p = .014) after adjustment for age, degree of hypercarbia, maximal respiratory rate, use of an arterial catheter, and Pediatric Risk of Mortality III scores among ventilated children.
Conclusions:
We found that use of invasive interventions including mechanical ventilation and vascular monitoring varied greatly by institution. Centers with higher use of mechanical ventilation had longer median intensive care stay and hospital stays. Pediatric asthma management for acute severe asthma may be improved by clear elucidation of the institutional practices where fewer invasive interventions were used to achieve better outcomes.
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