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Changes in treatment and outcomes of children receiving care in the intensive care unit for severe acute asthma

Objective Significant changes have occurred in the intensity of treatment of children with severe asthma in the last decade. The objectives of this study are 1) to describe the changes in treatment of asthmatic children needing care in the intensive care unit (ICU) initially treated in our emergency department (ED) in 1983 to 1985 (I) and in 1990 to 1992 (II), and 2) to examine if these changes correspond to changes in clinical outcomes. Design Retrospective descriptive study. Patients. All asthmatic children less than 18 years old treated in the ED and admitted to the ICU directly or via the ward with a primary diagnosis of asthma. Setting. Pediatric tertiary care hospital. Results. A total of 89 ICU admissions were required for patients initially treated in our ED, 54 in 1983 to 1985 and 35 in 1990 to 1992. In 1985, 29.7% of asthma patients required hospital admission and 0.5% needed ICU admission, while 30.7 and 0.7% required hospital and ICU admission, respectively, in 1992. Admissions to the ICU directly via the ED were similar in both time periods (I, 27; II, 30), while those admitted to the ICU via the ward decreased significantly (I, 27; II, 5; p < 0.01). Recently, while in the ED, these ICU patients, on average, were treated with ≤qlh albuterol inhalations longer (I, 1.7 hours; II, 3.4 hours; P < 0.001), more frequently (I, 1.8 inhalations/h; II, 3.3 inhalations/h; P <0.001), and with greater dosages (I, 0.20 mg/kg/h; II, 0.55 mg/kg/h; P < 0.001), than previously. Only 72% of patients in 1983 to 1985 received i.v. steroids in the ED versus 100% in 1990 to 1992. Ward patients in 1990 to 1992 received ≤q1h inhalations for a greater proportion of their ward stay (I, 6.9/14.7 hours = 47%; II, 9.2/9.2 hours = 100%). There was a recent trend toward longer ICU treatment with ≤q1h albuterol inhalations (I, 8.7 hours; II, 12.3 hours; P = 0.24) and with i.v. albuterol (I, 29.4 hours; II, 37.4 hours; P = 0.26). Ventilation rates were low (I, 5/54 = 9.3%; II, 2/35 = 5.7%; P = NS) and the average duration of ICU stay remained unchanged (I, 40.6 hours; II, 42.1 hours; P = NS). Conclusions. Despite recent dramatic ED and ward treatment changes, ICU admission rates for pediatric asthma remain relatively constant. However, intensive treatment may have contributed to the decrease in ICU admissions via the ED to ward route in slightly less critical cases.