Protocols and Pathways in Pediatric Critical Asthma: A Systematic Review and Meta-Analysis

Background: Pediatric critical asthma is one of the most frequent reasons for presentation to the emergency department and admission to the floor or pediatric ICU (PICU) in pediatric patients. Clinical pathways and protocols have been used frequently in respiratory care, and many have been associated with an improvement in outcomes. We performed a systematic review on the use of protocols or pathways in the treatment of critical asthma. Methods: MEDLINE, Embase, and CINAHL were searched with no date limits; last search was completed in July 2024 to identify randomized controlled trials, crossover studies, observational studies, and quality improvement (QI) studies comparing the use of a protocol or pathway in the treatment of pediatric critical asthma to the standard of care. Abstracts were screened by a subgroup of the clinical practice guidelines committee, and subsequently full-text articles were screened and data were extracted. A fixed-effect meta-analysis was performed for each outcome. Results: We included 23 studies, with the majority being observational or QI studies. The outcomes included in this analysis were hospital stay, PICU stay, intubation rate, noninvasive respiratory support (NRS) usage, and rate of escalation of respiratory support. Use of clinical pathways and/or protocols was associated with a shorter hospital stay (mean difference [MD] -0.77 d [95% CI -0.81 to -0.73]) and PICU stay (MD -0.31 d [95% CI -0.37 to -0.26]). There was a decreased incidence of the need for increased respiratory support (odds ratio [OR] 0.59 [95% CI 0.39-0.59]). There was no change in the need for intubation (OR 0.4 [95% CI 0.12-1.34]) or incidence of NRS usage (OR 1.12 [95% CI 0.76-1.63]). Conclusions: Pediatric asthma protocols were associated with reductions in hospital stay, PICU stay, and decreased need for respiratory support escalation but not intubation or NRS use.