Fatal and near-fatal asthma in children: the critical care perspective

Abstract

Objective: To characterize the clinical course, therapies, and outcomes of children with fatal and near-fatal asthma admitted to pediatric intensive care units (PICUs).

Study design: This was a retrospective chart abstraction across the 8 tertiary care PICUs of the Collaborative Pediatric Critical Care Research Network (CPCCRN). Inclusion criteria were children (aged 1-18 years) admitted between 2005 and 2009 (inclusive) for asthma who received ventilation (near-fatal) or died (fatal). Data collected included medications, ventilator strategies, concomitant therapies, demographic information, and risk variables.

Results: Of the 261 eligible children, 33 (13%) had no previous history of asthma, 218 (84%) survived with no known complications, and 32 (12%) had complications. Eleven (4%) died, 10 of whom had experienced cardiac arrest before admission. Patients intubated outside the PICU had a shorter duration of ventilation (median, 25 hours vs 84 hours; P < .001). African-Americans were disproportionately represented among the intubated children and had a shorter duration of intubation. Barotrauma occurred in 15 children (6%) before admission. Pharmacologic therapy was highly variable, with similar outcomes.

Conclusion: Of the children ventilated in the CPCCRN PICUs, 96% survived to hospital discharge. Most of the children who died experienced cardiac arrest before admission. Intubation outside the PICU was correlated with shorter duration of ventilation. Complications of barotrauma and neuromyopathy were uncommon. Practice patterns varied widely among the CPCCRN sites.

Figure 1

A, Upper left panel: the PCO₂ (arterial, capillary or corrected venous (minus 6 torr)) prior to intubation which was not different between sites. Note that only 48% of patients had a blood gas obtained prior to intubation. B, The length of mechanical ventilation which varied significantly between sites. C, The PICU length of stay which varied significantly between sites. D, the Hospital length of stay which varied significantly between sites. The mean (+), median (−), interquartile range (box) and range (whiskers) are plotted in each panel for each site. P values were obtained by Wilcoxon rank-sum test and find overall differences between the CPCCRN PICUs for lengths of PICU and hospital stay and also duration of mechanical ventilation. No multiple comparison tests were done to determine which PICUs were different from the others.