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Endotracheal intubation and pediatric status asthmaticus: site of original care affects treatment
Christopher L Carroll1, Sharon R Smith, Melanie S Collins
1Pediatric Critical Care, Connecticut Children's Medical Center, Hartford, CT, USA.
Insights
Children with severe asthma (status asthmaticus) requiring intensive care were more likely to be intubated at community hospitals compared to children's hospitals. This suggests potential differences in treatment aggressiveness for pediatric asthma patients.
Area of Science:
- Pediatric Intensive Care
- Emergency Medicine
- Pulmonology
Background:
- Status asthmaticus is a frequent reason for pediatric intensive care unit (PICU) admission.
- Endotracheal intubation is a high-risk procedure for children with severe asthma unresponsive to medical therapy.
- Thresholds for intubation in pediatric status asthmaticus vary, potentially influenced by healthcare setting.
Purpose of the Study:
- To test the hypothesis that children with status asthmaticus treated at community hospitals receive less aggressive care and undergo intubation more frequently than those treated at children's hospitals.
- To compare intubation rates, timing, and outcomes for pediatric patients with status asthmaticus based on initial hospital presentation.
Main Methods:
- Retrospective cohort study design.
- Analysis of data from children over 2 years old admitted to a university-affiliated children's hospital PICU with status asthmaticus between April 1997 and July 2005.
- Comparison of outcomes between patients initially presenting to a children's hospital versus a community hospital.
Main Results:
- Children presenting to community hospitals were significantly more likely to be intubated (17% vs. 5%) despite similar illness severity.
- Intubation occurred sooner after presentation at community hospitals (2.4 hours vs. 7.5 hours).
- Patients intubated at community hospitals experienced shorter durations of intubation and shorter PICU lengths of stay.
Conclusions:
- Pediatric patients with status asthmaticus face a higher likelihood of intubation, and earlier intubation, when initially treated at community hospitals.
- Shorter intubation durations suggest that some children might have avoided intubation with presentation to a children's hospital or more aggressive initial therapy.
- Findings highlight potential disparities in the management of severe pediatric asthma based on healthcare facility type.
Objectives:
Status asthmaticus is a common cause of admission to a pediatric intensive care unit (PICU). Children unresponsive to medical therapies may require endotracheal intubation; however, this treatment carries significant risk, and thresholds for intubation vary. Our hypothesis was that children who sought care at community hospitals received less aggressive treatment and more frequent intubation than children who sought care at a children's hospital.
Design:
Retrospective cohort study.
Setting:
A university-affiliated children's hospital PICU.
Patients:
We retrospectively examined data from all children older than 2 yrs admitted to the PICU with status asthmaticus between April 1997 and July 2005.
Interventions:
None.
Measurements And Main Results:
Of the 251 children admitted to the PICU with status asthmaticus, 130 initially presented to the emergency department of a children's hospital and 116 presented to the emergency department of a community hospital. Despite similar illness severity, children presenting to a community hospital were significantly more likely to be intubated than those presenting to a children's hospital (17% vs. 5%; p = .004). In addition, those children intubated at community hospitals were intubated sooner after presentation (2.4 +/- 5.2 vs. 7.5 +/- 5.8 hrs; p = .009), had shorter durations of intubation (71 +/- 73 vs. 151 +/- 81 hrs; p = .02), and had shorter PICU length of stays (129 +/- 82 vs. 230 +/- 84 hrs; p = .01).
Conclusions:
Children with status asthmaticus are more likely to be intubated, and intubated sooner, at a community hospital. The shorter duration of intubation suggests that some children may not have been intubated had they presented to a children's hospital or received more aggressive therapy at their community hospital.
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