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Characterization of the variability of care for acute severe asthma: An opportunity for quality improvement initiatives

Although there is recent evidence showing increases in admission for asthma in pediatric intensive care units (PICUs) in several countries across the world, current evidence‐based asthma clinical practice guidelines do not give precise recommendations on how to treat pediatric severe acute asthma (SAA) beyond the initial treatment steps, specifically sequencing and escalation of therapies. This fact may favor an unjustified variation in treatment, with the consequent risk of adversely affecting outcomes for patients and escalating costs. The evidence supporting this statement comes mainly from high‐income countries, showing that care practices vary widely across North American and European PICUs, specifically regarding medications, concomitant therapies, use of asthma severity scores, laboratory/radiographic testing, ventilator assistance strategies, complications, and outcomes measures. These variations do not seem to be entirely explained by differences in the severity of individual exacerbations and could also be due to institutional policy differences and local and physicians' practice patterns. Although numerous studies have increased our understanding of the variability in pediatric SAA care practices, it has not been sufficiently studied in low‐ to middle‐income countries (LMICs) such as those in Latin America. This is an important task, not only because of the increasing prevalence and greater clinical and economic burden of pediatric asthma in LMICs when compared to high‐income countries, but also because asthma care in the former poses a number of challenges. This is because of some particularities and difficulties that have been described in pediatric asthma care in LMICs, not only for its long‐ term management between exacerbations but also when treating acute exacerbations, including SAA. Specifically, poverty is associated with poor access to care and with more severe asthma, higher morbidity, and an increased risk of fatal asthma. In contrast to high‐ income countries, non‐atopic asthma accounts for a large proportion of children with asthma in LMICs, and children with non‐atopic asthma generally experience an earlier onset of the disease. Additionally, in LMICs there is a greater risk of under‐recognized and under‐treated disease, unaffordability and unavailability of essential medications for asthma treatment, including inhaled bronchodilators and corticosteroids, unaffordability and inaccessibility of adequate spacer devices, and health care systems with limited resources and serious constraints for financing essential health services, especially in rural areas. Finally, there is also evidence of differences in in‐hospital care (measured by rates of admission and intubation/mechanical ventilation) between Latin American and European intensive care units. For all these reasons, the study by Monteverde‐Fernandez et al. is of great interest and might be considered to be an essential first step in standardizing pediatric SAA care across PICUs in Latin America and in improving the quality of care. Several findings from this study are worth mentioning: First, although, as expected, in the vast majority of PICUs, first‐line therapies such as inhaled short‐acting beta‐agonizts (SABAs) and systemic corticosteroids (SCs) were found to be central in pediatric SAA management, there were wide variations in the medications used, as well as in the mode and route for their delivery. Specifically, in one of the three groups in which PICUs were clustered (North Central ‐ NC), metered dose inhaler (MDI) and spacer was the preferred method for administering inhaled therapy with SABAs (as opposed to nebulization in the other two groups), and oral prednisolone was the preferred route and medication for administering SCs (as opposed to parenteral hydrocortisone in the other two groups). These findings could suggest a lower asthma severity in children attended in NC PICUs because nebulization is usually recommended over MDI therapy for SABA administration in more severely affected patients (because of the possibility of simultaneous supply of oxygen and short‐acting anti‐muscarinic agents), and because the parenteral route for SC administration is generally preferred over the oral route in children who are not able to take SCs orally due to the severity of their respiratory distress or because they are vomiting. However, this does not seem to be the case, because of the significantly greater proportion of children requiring PICU management and invasive ventilation in NC PICUs when compared to the other two groups, suggesting that these variations in treatment could be due to institutional policies or physicians' practice preferences. Two particularly striking observations are that intravenous magnesium sulfate, a medication with proven efficacy and cost‐effectiveness in pediatric SAA treatment, was uniformly used in all the regions, but with fairly low rates of use, with a maximum rate of use of 21%. In addition, there was a wide variation in the use of ipratropium bromide among the three analyzed groups, with a significantly lower use in the NC group when compared with the other two groups, apparently without a lower proportion of children admitted from the emergency department (ED) in the NC group. This is important because ipratropium bromide, when added to inhaled SABAs in the ED setting, has been shown to significantly reduce the risk of hospital admission, without evidence of efficacy in the inpatient setting. As expected, there was also a wide variation in the use of some adjunctive therapies, with conflicting or even no evidence of efficacy for pediatric SAA.