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

Abstract

Rationale: Over 20,000 children are hospitalized in the United States for asthma every year. Although initial treatment guidelines are well established, there is a lack of high-quality evidence regarding the optimal respiratory support devices for these patients.Objectives: 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. Our study population included children older than 2 years old admitted to a VPS contributing pediatric intensive care unit from January 2012 to December 2021 with a primary diagnosis of asthma or status asthmaticus. We evaluated the percentage of encounters using a high-flow nasal cannula (HFNC), continuous positive airway pressure (CPAP), noninvasive bilevel positive pressure ventilation (NIV), and invasive mechanical ventilation (IMV) for all institutions, then divided institutions into quintiles based on the 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 in HFNC (28.3%, interquartile range [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 (odds ratio [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 (11.0-52.3%; P < 0.01), CPAP (1.6-5.4%; P < 0.01), and NIV (3.7-21.2%; P < 0.01), whereas there was no significant change in IMV use (6.1-4.0%; P = 0.11).Conclusions: Higher-volume centers are using noninvasive 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 in the last decade.

Keywords: asthma; critical care; high-flow nasal cannula; noninvasive respiratory support; pediatrics.

Figure 1.

Line plot illustrating percentage of encounters using each modality by year. *Statistically significant at an α-level of 0.05. CPAP = continuous positive airway pressure; HFNC = high-flow nasal cannula; IMV = invasive mechanical ventilation; NIV = noninvasive bilevel positive pressure ventilation; RA/COT = room air or conventional oxygen therapy.

Figure 2.

Boxplots of PICU length of stay in days, by institution quintile with pairwise comparisons at an α-level of 0.05. *Statistically significant difference. PICU = pediatric intensive care unit.

Figure 3.

(A–D) Bar plots illustrating the percentage of encounters using each respiratory support device by institution quintile. CPAP = continuous positive airway pressure; HFNC = high-flow nasal cannula; IMV = invasive mechanical ventilation; NIV = noninvasive bilevel positive pressure ventilation.

Figure 4.

Sankey diagram illustrating transitions in respiratory support devices for pediatric critical asthma. CPAP = continuous positive airway pressure; HFNC = high-flow nasal cannula; IMV = invasive mechanical ventilation; NIV = noninvasive bilevel positive pressure ventilation; RA/COT = room air or conventional oxygen therapy.