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Initial emergency department vital signs may predict PICU admission in pediatric patients presenting with asthma
Michael S Freedman1,2, Erick Forno3,4
1Division of Pediatric Critical Care Medicine, Department of Pediatrics, Lucile Packard Children's Hospital, Palo Alto, CA, USA.
Insights
Early identification of severe asthma exacerbations is crucial. Vital signs like heart rate, respiratory rate, and oxygen saturation within the first hour of emergency department presentation can predict pediatric intensive care unit admission.
Area of Science:
- Pediatric Emergency Medicine
- Respiratory Medicine
- Critical Care Medicine
Background:
- Severe asthma exacerbations are a significant cause of pediatric morbidity, mortality, and healthcare costs.
- Identifying early predictors of intensive care unit admission is essential for timely intervention.
Purpose of the Study:
- To identify early predictive factors for pediatric intensive care unit (PICU) admission in children presenting with asthma exacerbations.
- To develop a predictive model for PICU admission based on initial emergency department (ED) vital signs.
Main Methods:
- Retrospective observational study of 5,185 ED encounters for asthma, bronchospasm, or wheezing.
- Analysis of vital signs (heart rate, respiratory rate, SpO2) and demographic data within the first hour of ED presentation.
- Development of a predictive index using regression models and evaluation of its accuracy (AUROC, overall accuracy).
Main Results:
- Higher mean heart rates, respiratory rates, and lower SpO2 within the first hour of ED presentation were independently associated with PICU admission.
- A predictive index using these vital signs showed high accuracy (AUROC 0.84, 80.1% accuracy) for PICU admission.
- Combining vital signs with a clinical asthma distress score significantly increased the positive predictive value for PICU admission.
Conclusions:
- A predictive index based on heart rate, respiratory rate, and SpO2 within the first hour of ED presentation accurately predicts PICU admission in pediatric asthma exacerbations.
- Automated vital signs trend analysis can facilitate rapid identification of high-risk patients upon ED presentation.
- These findings support the use of early vital sign monitoring for risk stratification in pediatric asthma emergencies.
Objective:
Severe asthma exacerbations account for a large share of asthma morbidity, mortality, and costs. Here, we aim to identify early predictive factors associated with pediatric intensive care unit (PICU) admission.
Methods:
We performed a retrospective observational study of 5,185 emergency department (ED) encounters at a large children's hospital, including 86 (1.7%) resulting in PICU admission between 10/1/2015 and 8/7/2018 with ICD9/ICD10 codes for "asthma," "bronchospasm," or "wheezing." Vital signs and demographic information were obtained from electronic health record data and analyzed for each encounter. Predictive factors were identified using adjusted regression models, and our primary outcome was PICU admission.
Results:
Higher mean heart rates (HRs) and respiratory rates (RRs), and lower SpO2 within the first hour of ED presentation were independently associated with PICU admission. Odds of PICU admission increased 70% for each 10 beats/min higher HR, 125% for each 10 breaths/min higher RR, and 34% for each 5% lower SpO2. A binary predictive index using 1-h vitals yielded OR 13.4 (95% CI 8.1-22.1) for PICU admission, area under receiver operator characteristic (AUROC) curve 0.84 and overall accuracy of 80.1%. Results were largely unchanged (AUROC 0.84-0.88) after adjusting for surrogates of asthma severity and initial ED management. In combination with a secondary standardized clinical asthma distress score, positive predictive value increased by sevenfold (6.1%-46%).
Conclusions:
A predictive index using HR, RR, and SpO2 within the first hour of ED presentation accurately predicted PICU admission in this cohort. Automated vital signs trend analysis may help identify vulnerable patients quickly upon presentation.
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