Institutional Variability in Respiratory Support use for Pediatric Critical Asthma: A Multicenter Retrospective Study 

Published in the Annals of the American Thoracic Society. Here is a link to the article.  

Regenstrief Institute authors:  Colin M Rogerson, M.D., MPH 

Abstract 

Rationale: Over 20,000 children are hospitalized in the US for asthma every year. While initial treatment guidelines are well established, there is a lack of high-quality evidence regarding the optimal respiratory support devices for these patients. 

Objective: The objective of this study was to evaluate institutional and temporal variability in the use of respiratory support modalities for pediatric critical asthma. 

Methods: We conducted a retrospective cohort study using data from the Virtual Pediatrics Systems Database (VPS, LLC). Our study population included children older than 2 years old admitted to a VPS contributing PICU from January 2012 to December 2021 with a primary diagnosis of asthma or status asthmaticus. We evaluated the percentage of encounters using high flow nasal cannula (HFNC), continuous positive airway pressure (CPAP), non-invasive bi- level positive pressure ventilation (NIV), and invasive mechanical ventilation (IMV) for all institutions, then divided institutions into quintiles based on volume of patients. We created logistic regression models to determine the influence of institutional volume and year of admission on respiratory support modality use. We also conducted time series analyses using Kendall’s Tau. 

Results: Our population included 77,115 patient encounters from 163 separate institutions. Institutional use of respiratory modalities had significant variation; HFNC [28.3%, IQR (11.0%- 49.0%), p<0.01], CPAP [1.4%, IQR (0.3%-4.3%), p<0.01], NIV [8.6%, IQR (3.5%-16.1%), p<0.01], and IMV [5.1%, IQR (3.1%-8.2%), p<0.01]. Increased institutional patient volume was associated with significantly increased use of NIV (OR 1.33 [1.29-1.36], p<0.01) and CPAP (OR 1.20 [1.15-1.25], p<0.01), and significantly decreased use of HFNC (OR 0.80 [0.79-0.81], p<0.01) and IMV (OR 0.82 [0.79-0.86], p<0.01). Time was also associated with a significant increase in the use of HFNC (11.0% to 52.3%, p<0.01), CPAP (1.6% to 5.4%, p<0.01), and NIV (3.7% to 21.2%, p<0.01), while there was no significant change in IMV use (6.1% to 4.0%, p=0.11). 

Conclusion: Higher volume centers are using non-invasive positive pressure ventilation more frequently for pediatric critical asthma, and lower frequencies of HFNC and IMV. Treatment with HFNC, CPAP, and NIV for this population is increasing the last decade.

Colin M Rogerson ¹, Benjamin R White ², Michele Smith ³, Alexander H Hogan ⁴, Samer Abu-Sultaneh ⁵, Christopher L Carroll ⁶, Steven L Shein ⁷

Affiliations

¹Indiana University School of Medicine, 12250, Pediatrics, Indianapolis, Indiana, United States; crogerso@iupui.edu.