A Respiratory Therapist-Driven Asthma Pathway Reduced Hospital Length of Stay in the Pediatric Intensive Care Unit.

BACKGROUND: Asthma is a common reason for admissions to the pediatric intensive care unit (PICU). Since June 2014, our institution has used a pediatric asthma clinical pathway for all patients, including those in PICU. The pathway promotes respiratory therapist-driven bronchodilator weaning based on the Modified Pulmonary Index Score (MPIS). This pathway was associated with decreased hospital length of stay (LOS) for all pediatric asthma patients; however, the effect on PICU patients was unclear. We hypothesized that the implementation of a pediatric asthma pathway would reduce hospital LOS for asthmatic patients admitted to the PICU. METHODS: We retrospectively reviewed the medical records of all pediatric asthma subjects 2-17 y old admitted to our PICU before and after pathway initiation. Primary outcome was hospital LOS. Secondary outcomes were PICU LOS and time on continuous albuterol. Data were analyzed using the chi-square test for categorical data, the t test for normally distributed data, and the Mann-Whitney test for nonparametric data. RESULTS: A total of 203 eligible subjects (49 in the pre-pathway group, 154 in the post group) were enrolled. There were no differences between groups for age, weight, gender, home medications, cause of exacerbation, medical history, or route of admission. There were significant decreases in median (interquartile range) hospital LOS (4.4 [2.9-6.6] d vs 2.7 [1.6-4.0] d, P < .001), median PICU LOS (2.1 [1.3-4.0] d vs 1.6 [0.8-2.4] d, P = .003), and median time on continuous albuterol (39 [25-85] h vs 27 [13-42] h, P = .001). Significantly more subjects in the post-pathway group were placed on high-flow nasal cannula (32% vs 6%, P = .001) or noninvasive ventilation (10% vs 4%, P = .02). CONCLUSION: The implementation of an asthma pathway was associated with decreased hospital LOS, PICU LOS, and time on continuous albuterol. There was also an increase in the use of high-flow nasal cannula and noninvasive ventilation after the implementation of this clinical pathway.

At-risk registers integrated into primary care to stop asthma crises in the UK (ARRISA-UK): study protocol for a pragmatic, cluster randomised trial with nested health economic and process evaluations.

BACKGROUND: Despite effective treatments and long-standing management guidelines, there are approximately 1400 hospital admissions for asthma weekly in the United Kingdom (UK), many of which could be avoided. In our previous research, a secondary analysis of the intervention (ARRISA) suggested an improvement in the management of at-risk asthma patients in primary care. ARRISA involved identifying individuals at risk of adverse asthma events, flagging their electronic health records, training practice staff to develop and implement practice-wide processes of care when alerted by the flag, plus motivational reminders. We now seek to determine the effectiveness and cost-effectiveness of ARRISA in reducing asthma-related crisis events. METHODS: We are undertaking a pragmatic, two-arm, multicentre, cluster randomised controlled trial, plus health economic and process evaluation. We will randomise 270 primary care practices from throughout the UK covering over 10,000 registered patients with 'at-risk asthma' identified according to a validated algorithm. Staff in practices randomised to the intervention will complete two 45-min eLearning modules (an individually completed module giving background to ARRISA and a group-completed module to develop practice-wide pathways of care) plus a 30-min webinar with other practices. On completion of training at-risk patients' records will be coded so that a flag appears whenever their record is accessed. Practices will receive a phone call at 4 weeks and a reminder video at 6 weeks and 6 months. Control practices will continue to provide usual care. We will extract anonymised routine patient data from primary care records (with linkage to secondary care data) to determine the percentage of at-risk patients with an asthma-related crisis event (accident and emergency attendances, hospitalisations and deaths) after 12 months (primary outcome). We will also capture the time to crisis event, all-cause hospitalisations, asthma control and any changes in practice asthma management for at-risk and all patients with asthma. Cost-effectiveness analysis and mixed-methods process evaluations will also be conducted. DISCUSSION: This study is novel in terms of using a practice-wide intervention to target and engage with patients at risk from their asthma and is innovative in the use of routinely captured data with record linkage to obtain trial outcomes. TRIAL REGISTRATION: ISRCTN95472706 . Registered on 5 December 2014.

Effects of a PICU Status Asthmaticus De-Escalation Pathway on Length of Stay and Albuterol Use.

OBJECTIVES: Evaluate the effects of an asthma de-escalation clinical pathway on selected outcomes for patients admitted to a PICU with status asthmaticus. DESIGN: Time series quality improvement trial. SETTING: PICU in a tertiary care children's hospital. PATIENTS: Children age 2-18 years old with a known diagnosis of asthma presenting with status asthmaticus. INTERVENTION: One-hundred five admissions to a PICU for status asthmaticus were treated according to a new de-escalation pathway between August 15, 2015, and August 30, 2016. This group was compared with a prepathway group of 141. MEASUREMENTS AND MAIN RESULTS: Primary outcome was variability in PICU length of stay. Secondary outcomes were median PICU length of stay, median hospital length of stay, and median duration a patient received continuous nebulized albuterol. The effectiveness of the intervention was tracked using control charts. The postpathway group demonstrated decreased variability of PICU length of stay and time receiving continuous albuterol. Statistically significant decreases were seen in median PICU length of stay (16 vs 13 hr; p = 0.0009), median duration a child spent receiving continuous nebulized albuterol (10.8 vs 7.3 hr; p = 0.0008), and median hospital length of stay (37 vs 31 hr; p = 0.02). Total number of asthma assessments completed by respiratory therapists increased from 741 to 1,087. CONCLUSIONS: Implementation of a PICU asthma de-escalation pathway demonstrated statistical decrease in the reported measures for children with status asthmaticus. Although the clinical significance of these changes may be debatable, the results demonstrate that efforts to standardize asthma care in the PICU setting is an area in need of further study.

Ipratropium bromide plus nebulized albuterol for the treatment of hospitalized children with acute asthma.

OBJECTIVE: To determine whether the addition of repeated doses of nebulized ipratropium bromide (IB) to a standardized inpatient asthma care algorithm (ACA) for children with status asthmaticus improves clinical outcome. STUDY DESIGN: Children with acute asthma (N = 210) age 1 to 18 years admitted to the ACA were assigned to the intervention or placebo group in randomized double-blind fashion. Both groups received nebulized albuterol, systemic corticosteroids, and oxygen according to the ACA. The intervention group received 250 microg IB combined with 2.5 mg albuterol by jet nebulization in a dosing schedule determined by the ACA phase. The placebo group received isotonic saline solution substituted for IB. Progression through each ACA phase occurred based on assessments of oxygenation, air exchange, wheezing, accessory muscle use, and respiratory rate performed at prescribed intervals. RESULTS: No significant differences were observed between treatment groups in hospital length of stay (P =.46), asthma carepath progression (P =.37), requirement for additional therapy, or adverse effects. Children >6 years (N = 70) treated with IB had shorter mean hospital length of stay (P =.03) and more rapid mean asthma carepath progression (P =.02) than children in the placebo group. However, after adjustment was done for baseline group differences, the observed benefit of IB therapy in older children no longer reached statistical significance. CONCLUSION: The routine addition of repeated doses of nebulized IB to a standardized regimen of systemic corticosteroids and frequently administered beta-2 agonists confers no significant enhancement of clinical outcome for the treatment of hospitalized children with status asthmaticus.

[Vocal cord dysfunction simulating severe corticoid-dependent asthma]. / Dysfonction des cordes vocales simulant un asthme sévère cortico-dépendant.

We report a case of severe asthma initially considered as cortico-resistant. Clinical analysis of dyspneic attacks demonstrated they were atypical, sometimes associated with dysphonia and syncopes. Severity of clinical presentation was discordant with lung function tests. The diagnosis of vocal cord dysfunction was confirmed by ENT specialized examination. It showed paradoxal inspiratory adduction of the vocal cords triggered by exercise. Treatment remained however difficult, based on speech therapy, relaxation and psychotherapy. This observation underlines the influence of searching a vocal cord dysfunction in cortico-dependent asthma, especially if clinical presentation is atypical. Treatment of this condition may allow to decrease steroid treatment in such patients.

Mechanical ventilation for children with status asthmaticus.

Status asthmaticus is the most common diagnosis leading to hospital admission in childhood. Most of these patients respond well to oxygen, steroids, beta-agonists, anticholinergics, and other medications. The few patients who develop respiratory failure from severe status asthmaticus pose many challenges to those supporting them in the intensive care unit. This Article discusses the pathophysiology of asthma and how that relates to appropriate ventilator management. Alternative therapies are briefly discussed.

Criterios para avaliaçäo de crianças em crise asmatica / Criteria for assessment of children with acute asthma attack

Os autores apresentam uma revisao sobre a avaliacao da intensidade da crise asmatica na infancia, com o objetivo de atualizar os pediatrias e destacar a importancia da monitorizacao funcional da crianca na unidade de emergencia...

Medical and ventilatory management of status asthmaticus.

Despite improved understanding of the basic mechanisms underlying asthma, morbidity and mortality remain high, especially in the "inner cities." The treatment of choice in status asthmaticus includes high doses of inhaled beta 2-agonists, systemic corticosteroids, and supplemental oxygen. The roles of theophylline and anticholinergics remain controversial, although in general these agents appear to add little to the bronchodilator effect of inhaled beta-agonists in most patients. Anti-leukotriene medications have not yet been evaluated in acute asthma. Other therapies, such as magnesium sulfate and heliox, have their advocates but are not recommended as part of routine care. If pharmacological therapy does not reverse severe airflow obstruction in the asthmatic attack, mechanical ventilation may be temporarily required. Based on our current understanding of ventilator-induced lung injury, optimal ventilation of asthmatic patients avoids excessive lung inflation by limiting minute ventilation and prolonging expiratory time, despite consequent hypercapnia. Unless respiratory function is extremely unstable, the use of paralytic agents is discouraged because of the increased risk of intensive care myopathy. Patients who have suffered respiratory failure due to asthma are at increased risk for subsequent death due to asthma (14% mortality at 3 years) and should receive very close medical follow-up. In general, severe asthmatic attacks can best be prevented by early intervention in the outpatient setting. In the words of Dr. Thomas Petty, "... the best treatment of status asthmaticus is to treat it three days before it occurs".