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Inflammatory and Comorbid Features of Children Admitted to a PICU for Status Asthmaticus.

ABSTRACT: OBJECTIVES:To determine risk factors associated with admission to a PICU with or without endotracheal intubation for an asthma exacerbation. We hypothesized that children with critical and near-fatal asthma would have distinguishing clinical features but varying degrees of asthma severity and measures of type 2 inflammation. DESIGN:Retrospective analysis of prospectively collected data of children with asthma recruited into outpatient asthma clinical research studies at Emory University between 2004 and 2015. SETTING:Large, free-standing academic quaternary care children's hospital in Atlanta, GA. PATIENTS:Children 6-18 years old with physician-diagnosed and confirmed asthma. INTERVENTIONS:None. MEASUREMENTS AND MAIN RESULTS:A total of 579 children were analyzed with 170 children (29.4%) being admitted to the PICU for an asthma exacerbation in their lifetime. Of these 170 children with a history of critical asthma, 24.1% were classified as having mild-to-moderate asthma, and 83 of 170 children (48.8%) had been intubated and experienced near-fatal asthma. Multiple logistic regression was used to identify risk factors associated with increased odds of PICU admission with or without endotracheal intubation. Hospitalization within the prior 12 months of survey (odds ratio, 8.19; 95% CI, 4.83-13.89), a history of pneumonia (odds ratio, 2.56; 95% CI, 1.52-4.29), having a designation of increased chronic asthma severity on high-dose inhaled corticosteroids (odds ratio, 2.76; 95% CI, 1.62-4.70), having a father with asthma (odds ratio, 2.15; 95% CI, 1.23-3.76), living in a region with a higher burden of poverty (odds ratio, 1.28; 95% CI, 1.02-1.61), and being of black race (odds ratio, 2.01; 95% CI, 1.05-3.84) were all associated with increased odds of PICU admission with or without intubation. CONCLUSIONS:Our findings suggest that there are factors associated with critical and near-fatal asthma, distinct from the chronic asthma severity designations, that should be the focus of future investigation.

SUBMITTER: Grunwell JR

PROVIDER: S-EPMC6218278 | biostudies-literature | 2018 Nov

REPOSITORIES: biostudies-literature

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Inflammatory and Comorbid Features of Children Admitted to a PICU for Status Asthmaticus.

Grunwell Jocelyn R JR Travers Curtis C Fitzpatrick Anne M AM

Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies 20181101 11

<h4>Objectives</h4>To determine risk factors associated with admission to a PICU with or without endotracheal intubation for an asthma exacerbation. We hypothesized that children with critical and near-fatal asthma would have distinguishing clinical features but varying degrees of asthma severity and measures of type 2 inflammation.<h4>Design</h4>Retrospective analysis of prospectively collected data of children with asthma recruited into outpatient asthma clinical research studies at Emory Univ ...[more]

PMID: 30106766

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Project description:BackgroundIntravenous salbutamol is used to treat children with refractory status asthmaticus, however insufficient pharmacokinetic data are available to guide initial and subsequent dosing recommendations for its intravenous use. The pharmacologic activity of salbutamol resides predominantly in the (R)-enantiomer, with little or no activity and even concerns of adverse reactions attributed to the (S)-enantiomer.ObjectiveOur aim was to develop a population pharmacokinetic model to characterize the pharmacokinetic profile for intravenous salbutamol in children with status asthmaticus admitted to the pediatric intensive care unit (PICU), and to use this model to study the effect of different dosing schemes with and without a loading dose.MethodsFrom 19 children (median age 4.9 years [range 9 months-15.3 years], median weight 18 kg [range 7.8-70 kg]) treated with continuous intravenous salbutamol at the PICU, plasma samples for R- and S-salbutamol concentrations (111 samples), as well as asthma scores, were collected prospectively at the same time points. Possible adverse reactions and patients' clinical data (age, sex, weight, drug doses, liver and kidney function) were recorded. With these data, a population pharmacokinetic model was developed using NONMEM 7.2. After validation, the model was used for simulations to evaluate the effect of different dosing regimens with or without a loading dose.ResultsA two-compartment model with separate clearance for R- and S-salbutamol (16.3 L/h and 8.8 L/h, respectively) best described the data. Weight was found to be a significant covariate for clearance and volume of distribution. No other covariates were identified. Simulations showed that a loading dose can result in higher R-salbutamol concentrations in the early phase after the start of infusion therapy, preventing accumulation of S-salbutamol.ConclusionsThe pharmacokinetic model of intravenous R- and S-salbutamol described the data well and showed that a loading dose should be considered in children. This model can be used to evaluate the pharmacokinetic-pharmacodynamic relationship of intravenous salbutamol in children, and, as a next step, the effectiveness and tolerability of intravenous salbutamol in children with severe asthma.

Project description:BackgroundThere is a limited evidence for humidified high-flow nasal cannula (HHFNC) use on inter-hospital transport. Despite this, its use during transport is increasing in children with respiratory distress worldwide. In 2015 HHFNC was implemented on a specialized pediatric retrieval team serving for Victoria. The aim of this study is to investigate the effect of the HHFNC implementation on the retrieval team on the paediatric intensive care unit (PICU) length of stay and respiratory support use.MethodsWe performed a cohort study using a comparative interrupted time-series approach controlling for patient and temporal covariates, and population-adjusted analysis. We studied 3022 children admitted to a PICU in Victoria with respiratory distress January 2010-December 2019. Patients were divided in pre-intervention era (2010-2014) and post-intervention era (2015-2019).Results1006 children following interhospital transport and 2016 non-transport children were included. Median (IQR) age was 1.4 (0.7-4.5) years. Pneumonia (39.1%) and bronchiolitis (34.3%) were common. On retrieval, HHFNC was used in 5.0% (21/420) and 45.9% (269/586) in pre- and post-intervention era. In an unadjusted model, median (IQR) PICU length of stay was 2.2 (1.1-4.2) and 1.7 (0.9-3.2) days in the pre- and post-intervention era in transported children while the figures were 2.4 (1.3-4.9) and 2.1 (1.2-4.5) days in non-transport children. In the multivariable regression model, the intervention was associated with the reduced PICU length of stay (ratio 0.64, 95% confidential interval 0.49-0.83, p = 0.001) with the predicted reduction of PICU length of stay being - 10.6 h (95% confidential interval - 16.9 to - 4.3 h), and decreased respiratory support use (- 25.1 h, 95% confidential interval - 47.9 to - 2.3 h, p = 0.03). Sensitivity analyses including a model excluding less severe children showed similar results. In population-adjusted analyses, respiratory support use decreased from 4837 to 3477 person-hour per year in transported children over the study era, while the reduction was 594 (from 9553 to 8959) person-hour per year in non-transport children. With regard to the safety, there were no escalations of respiratory support mode during interhospital transport.ConclusionsThe implementation of HHFNC on interhospital transport was associated with the reduced PICU length of stay and respiratory support use among PICU admissions with respiratory distress.

Project description:ObjectivesTo determine the long-term (> 6 mo) functional status of PICU patients with significant new functional morbidities at hospital discharge.DesignLongitudinal cohort followed-up using structured chart reviews of electronic health records.SettingElectronic health records of former PICU patients at seven sites.PatientsRandomly selected patients from the Trichotomous Outcome Prediction in Critical Care study discharged from the hospital with new functional status morbidity who had sufficient electronic health record data to determine functional status.InterventionsNone.Measurements and main resultsLong-term functional status was measured with the Functional Status Scale and categorized by comparison to hospital discharge Functional Status Scale. Improvement or new morbidity was based on a change in Functional Status Scale of greater than or equal to 2 in a single domain. Overall, 56% (n = 71) improved, 15% (n = 19) did not change, 9% (n = 11) developed a new morbidity, and 21% (n = 26) died. The shortest median follow-up time from PICU discharge was 1.4 years for those who died and the longest was 4.0 years for those improved. Functional status at baseline (pre-acute illness) was different among the outcome groups with those that improved having the highest frequency of baseline normal status or only mild dysfunction. Of the long-term survivors with improvement, 82% (n = 58) improved to normal status or mild dysfunction, 11% (n = 8) improved to moderate dysfunction, and 7% (n = 5) improved to severe dysfunction. Trauma patients improved and cancer patients died more frequently than other diagnoses. The long-term outcome groups were not associated with hospital discharge functional status.ConclusionsA majority of PICU survivors discharged with significant new functional morbidity with follow-up after 6 or more months improved, many to normal status or only mild dysfunction, while 29% died or developed new morbidity. Of the long-term survivors, 70% had significant improvement after a median follow-up time of 4.0 years.

Dataset Information

Inflammatory and Comorbid Features of Children Admitted to a PICU for Status Asthmaticus.

Publications

Inflammatory and Comorbid Features of Children Admitted to a PICU for Status Asthmaticus.

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