Search

Background: Severe asthma exacerbations in pediatric patients occur frequently and can require pediatric intensive care unit (PICU) admission., Objective: To determine if early administration of intravenous magnesium sulfate (IVMg) to pediatric patients experiencing severe asthma exacerbations, defined as a respiratory clinical score (RCS) of 9 to 12, resulted in fewer PICU admissions., Methods: Retrospective chart review of pediatric patients aged from 2 to 17 years presenting with a severe asthma exacerbation to a single tertiary care pediatric emergency department. Univariable and multivariable logistic regression analyses were used to determine if admission to the PICU was associated with early IVMg treatment, within 60 minutes of registration., Results: A total of 1911 patients were included in the study, of which 1541 received IVMg. The average time to IVMg was 79 minutes, with 35% of the patients receiving it within 60 minutes of arrival. Two hundred forty-eight (13%) were admitted to the PICU, 641 (34%) were admitted to the general inpatient floor, and 1022 (53%) were discharged home. Factors associated with increased odds ratio (OR) of PICU admission were: early IVMg (OR, 1.63; 95% CI: 1.16-2.28), arrival mode to the emergency department via ambulance (OR, 2.23; 95% CI: 1.45-3.43), history of PICU admission for asthma (OR, 1.73; 95% CI: 1.22-2.44), and diagnosis of status asthmaticus (OR, 8.88; 95% CI: 3.49-30.07). Calculated OR of PICU admission subcategorized by RCS for early IVMg patients, after controlling for PICU risk factors, are as follows: RCS 9 (reference), RCS 10 (OR, 2.52; 95% CI: 0.89-2.23), RCS 11 (OR, 2.19; 95% CI: 1.3-3.70), and RCS 12 (OR, 4.12; 95% CI: 2.13-7.95)., Conclusions: Early administration of IVMg to pediatric patients experiencing severe asthma exacerbations does not result in fewer PICU admissions., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: The study's objectives were to evaluate serial troponin concentrations as a marker of cardiac toxicity in children receiving intravenous terbutaline for status asthmaticus and to study if troponin concentrations are affected by severity of asthma and risk factors for severe asthma., Methods: This was a prospective observational study in 20 consecutive patients who were admitted to a tertiary care pediatric intensive care unit for status asthmaticus and received intravenous terbutaline. Cardiac troponin I (cTnI) concentrations were measured half an hour before the bolus of intravenous terbutaline, 4 hours after terbutaline, and then every 24 hours until discontinuation of the continuous terbutaline infusion., Results: Ten patients had cTnI concentrations greater than 0.03 ng/mL. Maximum cTnI concentrations were recorded after the terbutaline bolus in 6 patients, during terbutaline infusion in 3 patients, and before terbutaline use in 1 patient. Three of these 10 (3/10) patients showed increased cTnI concentrations before the terbutaline bolus. One patient had a significant elevation in cTnI concentration (peak level of 3.79 ng/mL) with electrocardiogram (ECG) changes of myocardial injury that normalized upon discontinuation of terbutaline. All other patients with elevated cTnI concentrations had normal ECG findings., Conclusions: Elevated cTnI concentrations were observed in 50% of patients treated with intravenous terbutaline for status asthmaticus. Clinically significant cardiotoxicity was not observed except in 1 patient in whom the abnormal ECG findings normalized upon discontinuation of terbutaline. There was no statistically significant difference in asthma severity or in the risk factors for severe asthma in children with and without elevation of cTnI concentrations.

Objectives: To develop and validate predictive models to determine the need for hospitalization in children treated for acute asthma in the emergency department (ED)., Methods: Prospective cohort study of children aged 2 years and older treated at 2 pediatric EDs for acute asthma. The primary outcome was successful ED discharge, defined as actual discharge from the ED and no readmission for asthma within 7 days, versus need for extended care. Among those defined as requiring extended care, a secondary outcome of inpatient care (>24 hours) or short-stay care (<24 hours) was defined. Logistic regression and recursive partitioning were used to create predictive models based on historical and clinical data from the ED visit. Models were developed with data from 1 ED and validated in the other., Results: There were 852 subjects in the derivation group and 369 in the validation group. A model including clinical score (Pediatric Asthma Severity Score) and number of albuterol treatments in the ED distinguished successful discharge from need for extended care with an area under the receiver-operator characteristic curve of 0.89 (95% confidence interval [CI], 0.87-0.92) in the derivation group and 0.92 (95% CI, 0.89-0.95) in the validation group. Using a score of 5 or more as a cutoff, the likelihood ratio positive was 5.2 (95% CI, 4.2-6.5), and the likelihood ratio negative was 0.22 (95% CI, 0.17-0.28). Among those predicted to need extended care, a classification tree using number of treatments in the ED, clinical score at end of ED treatment, and initial pulse oximetry correctly classified 63% (95% CI, 56-70) of the derivation group as short stay or inpatient, and 62% (95% CI, 55-68) of the validation group., Conclusions: Successful discharge from the ED for children with acute asthma can be predicted accurately using a simple clinical model, potentially improving disposition decisions. However, predicting correct placement of patients requiring extended care is problematic.

Objective: To determine if the addition of intravenous terbutaline provides any clinical benefit to children with acute severe asthma already on continuous high-dose nebulized albuterol., Methods: We conducted a prospective, randomized, double blind, placebo-controlled trial on pediatric patients with acute severe asthma presenting to a large inner city tertiary children's emergency department. Consecutive patients between 2 and 17 years of age who failed acute asthma management and needed intensive care unit admission underwent informed consent and were enrolled into the study. Patients not requiring intubation were randomized to receive either intravenous terbutaline or intravenous normal saline while on continuous high-dose nebulized albuterol, ipratropium bromide, and systemic corticosteroids. Outcome measures included a clinical asthma severity score, hours on continuous nebulized albuterol, and duration of stay in the pediatric intensive care unit. In addition, electrocardiograms, electrolytes, lactic acid, and troponin I levels were obtained at routine intervals during the first 24 hours after admission. Patients who significantly worsened while enrolled in the study received intravenous aminophylline according to protocol., Results: Forty-nine patients were enrolled in the study. Patients on terbutaline had a mean improvement in the clinical asthma severity score over the first 24 hours of 6.5 points compared with 4.8 points in the placebo group (P = 0.073). Patients on terbutaline spent 38.19 hours on continuous nebulized albuterol compared with their placebo counterparts who spent 51.93 hours (P = 0.25). The length of stay in the PICU was on average 12.95 hours longer for those patients in the placebo group as compared with the terbutaline group (P = 0.345). One patient was removed from the study for a significant cardiac dysrhythmia. This patient was in the terbutaline group and recovered without complications. Troponin I values at 12 hours and 24 hours were elevated in 3 patients each, all within the terbutaline group., Conclusions: No outcome measures demonstrated statistical significance. Outcome measures revealed a trend toward improvement in the terbutaline group. Before recommending routine use of intravenous terbutaline for acute severe asthma, further study to determine safety and efficacy is necessary.

We prospectively examined the efficacy and safety of continuous albuterol nebulization (CAN) therapy for children diagnosed with impending respiratory failure and status asthmaticus. Serum creatine phosphokinase (CPK) levels were measured, and other factors associated with cardiotoxicity were monitored. Seventeen patients (20 months to 17 years old) were enrolled in the study. No chest pain, arrhythmias, or signs of clinical deterioration occurred in any patient receiving CAN. No study subject required therapy with isoproterenol or mechanical ventilation. An elevation of total serum CPK was found in three patients; however, only one of these patients had an elevated (positive) CPK-MB isoenzyme fraction. We feel that CAN is safe for use in children diagnosed with status asthmaticus. Monitoring of serum CPK enzymes during CAN therapy is warranted until further studies have determined the significance of elevated CPK-MB isoenzymes in otherwise asymptomatic children treated for severe status asthmaticus.