Efficacy of parenteral bronchodilators on ventilatory outcomes in pediatric critical asthma: a national cohort study

Objective: To evaluate the association of parenteral epinephrine and terbutaline use on ventilatory support in children admitted to the intensive care unit (ICU) with critical asthma in the United States. Methods: Data were obtained from the Pediatric Health Information System data base for children ages 2 to 18 years admitted to the ICU with a diagnosis of asthma exacerbation from January 1, 2016, to December 31, 2023. The primary outcomes included noninvasive ventilation (NIV) and/or invasive mechanical ventilation (IMV) use after receipt of terbutaline and/or epinephrine. Secondary outcomes included serious adverse events from parenteral bronchodilators, including arrhythmias and elevated troponins. Results: Our study population included 53,328 patient encounters. Terbutaline and epinephrine were associated with decreased odds of subsequent NIV (terbutaline: odds ratio [OR] 0.52 [95% confidence interval {CI}, 0.44-0.63], p < 0.001; and epinephrine: OR 0.49 [95% CI, 0.43-0.55], p  < 0.001) and subsequent IMV (terbutaline: OR 0.51 [95% CI, 0.42-0.61], p < 0.001; and epinephrine: OR 0.34 [95% CI, 0.29-0.41], p < 0.001). There were no differences in adverse events in the terbutaline group when compared with the epinephrine group for both arrhythmia and elevated troponins (arrhythmia: terbutaline = 1.9%, epinephrine = 1.7%; p = 0.6; and elevated troponins: terbutaline = 0.1%, epinephrine = 0.1%, p  > 0.9). Conclusion: Parenteral bronchodilator use was associated with decreased odds of receiving subsequent ventilatory support in critical asthma. There were low rates of arrhythmia and elevated troponin overall. Our findings should inform future clinical trials to evaluate the use of parenteral bronchodilators in critical asthma in the United States.