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Management of Hospitalized Asthmatic Children Before Transport
Air Medical Journal 36 (2017) 30e33
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Air Medical Journal journal homepage: http://www.airmedicaljournal.com/
Original Research
Management of Hospitalized Asthmatic Children Before Transport Brande Mazzeo, RN, BSN, Rami Bzeih, MS, Robert Schultz, RN, BSN, Melissa Tavolieri, RN, BSN, Alicia Fraser, RN, BSN, Sabrina M. Heidemann, MD Department of Pediatrics, Wayne State University, Detroit, MI
a b s t r a c t Asthmatic children are at risk for respiratory failure and should be appropriately treated before transport. The objectives were to find out if the Pediatric Advanced Life Support guidelines for asthma treatment were followed in the emergency department (ED); to determine if additional treatment during transport or within the first 2 hours of admission was needed; and to compare the management of intubated asthmatics by the ED, transport team, and the intensive care unit (ICU) physician. The records for children diagnosed with acute asthma over 7 years who were transported by the intensive care transport team were reviewed. The use of albuterol, steroids, oxygen, heliox, continuous positive airway pressure or bilevel positive airway pressure, and ventilator settings was recorded. Two hundred seventy-nine children were transported during a 7-year time period (age, 5 mo-17 y), and 62% were male. Eighty percent received oxygen, albuterol, and steroids in the ED. Heliox was initiated more often by the transport team when compared with the ED or hospital physician (77% vs. 7.7% vs. 15.3%, P < .0001). Forty-five were mechanically ventilated and were more likely to receive volume control (P < .0001) and higher rates (P ¼ .007) in the ED than the ICU. We conclude that most children with acute asthma were treated with oxygen, albuterol, and steroids in the ED. If used, heliox was most likely started during transport. Intubated children were more likely to receive volume control with higher rates compared with lower rates and pressure control in the ICU. Copyright © 2016 by Air Medical Journal Associates
Asthma is a chronic disease affecting the airways. Asthma exacerbation consists of coughing, wheezing, and difficulty in breathing. The National Surveillance of Asthma reports that from 2001 to 2010, 25.7 million people in the United States suffered from asthma, 7 million being children.1 In 2009, 1 in 5 children with asthma was reported to have an emergency room visit. The Centers for Disease Control and Prevention found that 10.7 asthma visits per 100 children occurred between 2007 and 2009, with the highest number of visits in the 0- to 4-year age group.1 In this same period, hospitalizations occurred in 2.1 per 100 cases of children with asthma exacerbation.1 Classification and treatment guidelines for the emergency management of pediatric asthma are published in the provider manual of Pediatric Advanced Life Support (PALS), which is endorsed by the American Heart Association and the American Academy of Pediatrics.2 Most physicians who treat pediatric patients in an emergency department (ED) are PALS certified and have had the opportunity to review these treatment guidelines. Humidified oxygen delivered by a nasal cannula or mask, albuterol administered by a nebulizer or a metered dose inhaler, and corticosteroids are recommended for mild to moderate asthma.
E-mail address: [email protected] (S.M. Heidemann). 1067-991X/$36.00 Copyright © 2016 by Air Medical Journal Associates http://dx.doi.org/10.1016/j.amj.2016.11.006
Ipratropium bromide and magnesium sulfate are recommendations for moderate to severe asthma in addition to those recommendations for mild to moderate asthma. In severe asthma, all of the previously mentioned recommendations should be considered in addition to terbutaline subcutaneously or by intravenous infusion or epinephrine subcutaneously or intramuscularly and bilevel positive airway pressure ventilation. Intubation and mechanical ventilation may be considered in children with refractory hypoxemia and/or worsening clinical conditions such as a decreasing level of consciousness or irregular breathing. The intensive care transport team routinely transports children from multiple EDs, with asthma exacerbation requiring specialty care transport to Children's Hospital of Michigan where the child is admitted to the pediatric intensive care unit (ICU) or general ward. The primary objective was to find out if the PALS guidelines for asthma treatment were followed in the ED. The secondary objectives were first to determine if additional treatment during transport or within the first 2 hours of admission was needed and second to compare the management of intubated asthmatics by the ED, transport team, and ICU physician. Material and Methods This study was approved by the Institutional Review Board at Wayne State University, Detroit, MI. The records for all children
B. Mazzeo et al. / Air Medical Journal 36 (2017) 30e33
through December 31, 2012. All children were seen initially in an ED that cared for both adults and children.
Table 1 Demographic Data Total Number Age (y) Median (range) Sex Race
Allergies Previous hospitalizations for asthma
Days of illness before admission Median (range) Albuterol at home Steroid at home (inhaled) Steroid at home (oral) Intubated for asthma in the past
31
279 7 (0.4-17.8) 62% male Black: 76.3% White: 19.7% Other: 4% 24.7% total 12.4% environmental None: 42.8% 1: 24.1% 2: 13.7% 3: 19.45 1 (0-21) 91% 37% 11% 15.8% total 1: 72% 2: 23% 3: 5%
diagnosed with acute asthma over a 7-year time period who were transported by ICTT were reviewed for the study. Children were excluded if they were transported by ICTT but not admitted to the hospital or transported by ICTT to another institution. The ICCT was established at Children's Hospital of Michigan in the Detroit Medical Center in 1985 as a dedicated critical care transport team providing advanced pediatric and neonatal life support to children in the state of Michigan; surrounding states; and Ontario, Canada. The team transports more than 1,200 patients per year by ground, helicopter, or Learjet. Team members are registered nurses with prior extensive experience in 1 or more of the following 3 areas: neonatal ICU, pediatric ICU, or pediatric ED. The first 10 charts reviewed by each investigator were then double checked by 1 of the investigators (R.B.) for inconsistencies. Age, race, weight, allergies, number of days ill in conjunction with home care management of maintenance and rescue medications, and past history of prior asthma exacerbation hospitalizations and intubations were obtained. Physical assessment findings such as wheezing, retractions, rales/crackles, and oxygen saturations on arrival to the referral hospital were recorded as well as chest roentgenographic findings of hyperinflation, perihilar infiltrates, or pneumonia. Treatments including albuterol; corticosteroids; supplemental oxygen; magnesium; terbutaline; subcutaneous epinephrine; helium oxygen administration; the need for continuous positive airway pressure or bilevel positive airway pressure; intubation; and, if applicable, ventilator settings were noted. Barotraumas and the need for cardiopulmonary resuscitation were documented. Statistical Analysis Descriptive statistics were used for demographic data and clinical variables. Categoric data were expressed in absolute counts and percentages. For continuous data, the mean and standard deviation were used if normally distributed, whereas median and interquartile range were used for skewed data. Unavailable values were excluded. The chi-square or Fisher exact test were used for categoric variables and the Wilcoxon rank sum test for continuous variables. Significance was determined at P < .05. Results Two hundred seventy-nine children with asthma were transported from multiple referring hospitals in the metropolitan Detroit area over a 7-year time period from January 1, 2005,
Demographic Data Demographic data are presented in Table 1. Initial Treatment Of 279 children, 45 (16%) were intubated before transport, and none were intubated during transport or within 2 hours after admission to the hospital. The decision to intubate was made by the ED physician before the arrival of the transport team. Of these intubated children, 36 (80%) were black. Five of 279 children required cardiopulmonary resuscitation, 4 in the ED and 1 during transport. Basic therapies included albuterol, oxygen, and steroids, which are recommended for all asthma classifications according to PALS. Only 80.3% of the patients received all 3 of these therapies. The transport team gave these therapies if not given in the ED. Secondary Treatment Seventy percent received ipratropium in the ED. Magnesium was administered in 39% of the asthmatics who presented to the ED. This therapy was not usually given by the transport team or within 2 hours of hospitalization. Subcutaneous epinephrine was administered in 25% of the asthmatics presenting to the ED. Rarely did the children require epinephrine by the transport team or after hospitalization. Only 3 patients of the 279 were treated with noninvasive positive pressure ventilation, all of whom had this therapy started in the ED. Children who required intubation initially were intubated in the ED. A helium-oxygen mixture (heliox) was used in 78 (28%) and was most commonly instituted by the transport team (77%) and not in the ED (7.7%) or at the time of hospital admission (15.3%) (P < .0001, Table 2 [a]). Fluid boluses were commonly given in patients with asthma in the ED, by the transport team, and after hospital admission (Table 2). Intubated Asthmatics Forty-five children required intubation in the ED, whereas none of the children were intubated initially during transport or within the first 2 hours of intensive care treatment. In the emergency department, volume control ventilation was more likely used compared with pressure control ventilation. The transport team usually used hand bagging rather than the ventilator because the transport ventilator did not give the same effect. In the ICU, nearly all of the children received pressure control ventilation over volume control ventilation. A child was more likely to receive pressure control rather than volume control ventilation in the ICU than in the ED (P < .0001, Table 3). The ordered respiratory rate for mechanically ventilated patients was lower in the ICU when compared with the ED (P < .007, Table 3 [a]). Intubated asthmatics were more likely to receive fluid boluses than nonintubated asthmatics in the ED, during transport, and within 2 hours of hospital admission (P .002). Blood glucose levels were higher initially in the ED when comparing the intubated with the nonintubated group (206 ± 67 [n ¼ 16] vs. 141 ± 40 [n ¼ 70], P .002). Discussion The treatment and stabilization of asthmatic children are important before transporting these children from a referring emergency department to a pediatric hospital. Supplemental oxygen, a bronchodilator, and corticosteroid administration are recommended to treat children who are sick enough to be admitted to the hospital because of asthma. In our study, 80% of the children received this therapy in the ED before the arrival of the transport team. Several recent studies support the early administration of
32
B. Mazzeo et al. / Air Medical Journal 36 (2017) 30e33
Table 2 Secondary Treatment Used in the Emergency Department by the Transport or Hospital Teams
ED therapy Transport team therapy Therapy within 2 hours of hospital admission
Ipratropium, n (%)
Magnesium, n (%)
Subcutaneous Epinephrine, n (%)
Fluid Bolus, n (%)
Heliox, n (%)
CPAP or BiPAP, n (%)
Intubation, n (%)
196 (70.3) 167 (59.9) 42 (15.1)
110 (39.4) 4 (1.4) 24 (8.6)
80 (28.7) 3 (1.1) 11 (3.9)
146 (52.3) 114 (40.9) 74 (26.5)
6 (2.2) 60 (21.5) 12 (4.3)a
3 (1.1) 0 0
45 (16.1) 0 0
BiPAP ¼ bilevel positive airway pressure; CPAP ¼ continuous positive airway pressure; ED ¼ emergency department; heliox ¼ helium-oxygen mixture. a P < .0001; the helium-oxygen mixture was most commonly instituted by the transport team and not in the ED or at the time of hospital admission.
Table 3 Ventilator Settings for Intubated Children Used in the Emergency Department by the Transport Team and in the Intensive Care Unit Rate bpm (Ventilator or Hand Bagging), Total N ¼ 45 ED
Transport team
ICU
7-14, n ¼ 22 (55%) 16-40, n ¼ 18 (45%) Unknown, n ¼ 5 8-14, n ¼ 27 (75%) 15-30, n ¼ 9 (25%) Unknown n ¼ 9 8-14, n ¼ 37 (83%)a 15-20, n ¼ 8 (17%)
Pressure Control, n (%)
Volume Control, n (%)
Hand bagging, n (%)
Unknown Control, n (%)
9 (20)
29 (64)
4 (9)
3 (7)
5 (11)
12 (27)
28 (62)
0
43 (96)b
2 (4)
0
0
bpm ¼ breaths per minute; ED ¼ emergency department; ICU ¼ intensive care unit. a P < .0007; lower ventilator rates were used in the ICU when compared with the ED. b P < .0001; pressure control ventilation is more likely to be used in the ICU compared with the ED.
albuterol or corticosteroids in the treatment of asthma. In 1 study, after the initiation of an asthma treatment protocol, a bronchodilator, ipratropium, and corticosteroids were given quicker, and there was better adherence to the recommended guidelines.3 Bekmezian et al4 showed that educating medical staff with a 1-page guideline for asthma treatment resulted in quicker administration of bronchodilators and steroids, which led to fewer admissions. An asthma protocol starting with triage nurse administration of corticosteroids before physician assessment was shown to reduce admission rates in children with moderate to severe asthma. This analysis identifies an opportunity for the standardization of asthma care to improve the rate of adherence to PALS guidelines for asthma care in the ED setting. Secondary treatments of ipratropium, magnesium, and subcutaneous epinephrine are reserved for moderate to severe asthmatics.2,5 The retrospective nature of this study makes it difficult to determine if some of these children who did not receive secondary treatments would have benefited by them. However, on review of transport team therapies, only 1.4% of the children were given magnesium and 1.1% subcutaneous epinephrine, thus suggesting that most of these children were treated adequately. Ipratropium was given by the transport team in 60% of the children, but this might have been an appropriate dosing interval based on the previous dose of ipratropium provided by the ED physician. In our study, the most significant change to care was made by the transport team with respect to the use of heliox. In the ED, 2.2% of the asthmatic children were prescribed heliox. There is a local preference toward heliox therapy for transported asthmatics. Heliox was used by the transport team under the direction of an ICU physician if the child was reported to have significant respiratory distress despite adequate treatment of albuterol, ipratropium, oxygen, steroids, and magnesium. The length of the transport was not a factor, and heliox was continued in the ICU setting for at least 2 hours if started before ICU admission. A Cochrane review in 2006 showed insufficient evidence for its use in acute asthma in the ED although the implementation of heliox for transport was not studied.6 The transport team initiated heliox in an additional 60 children (21.5%), whereas 12 (4.3%) more received heliox within 2 hours of admission to the
hospital. During a 10-year time period from 1996 to 2006, several studies suggested a benefit to heliox in treating asthmatics, whereas other studies showed no benefit.7-10 One study suggested that heliox may be beneficial early in the treatment of asthma and that the benefit was no longer observed later on after the corticosteroid effect was observed.8 However, the Cochrane review in 2006 showed insufficient evidence for its use in the nonintubated asthmatic.6 There are no large studies supporting the use of heliox in transporting moderate to severely ill asthmatic children. Noninvasive positive pressure ventilation was initiated in the ED in relatively few children, and no child was started on this treatment by the transport team or within 2 hours of admission to the hospital. Noninvasive positive pressure ventilation has been shown to be beneficial for treating patients with moderate or severe asthma as shown by the improvement in asthma scores.11-13 This therapy may prevent the need for mechanical ventilation in asthma but has not been well studied. All of the children requiring mechanical ventilation were intubated in the ED. Most of these children received mechanical ventilation, but a few were hand bagged. It is recommended that lower respiratory rates be used in children with asthma to allow exhalation to be completed. Lower ventilator rates were used in the ICU when compared with the ED. Accurate blood gas data, before and after intubation, could not be obtained, and the effect of the higher rates on worsening ventilation is presumed. Pressure control ventilation was much more likely to be used in the ICU and volume control ventilation in the ED, which is a similar finding when compared with another large study involving severely ill asthmatics.14 Future studies may examine the need for the use of an ED protocol for the treatment of children with asthma to aid in more consistent care of these children according to the PALS guidelines. Larger studies examining the use of heliox, noninvasive ventilation, and optimal ventilator settings for ED management and transport are needed. Limitations This is a retrospective study with limitations. It is possible that some of the patients received all 3 recommended initial therapies (ie, oxygen, albuterol, and corticosteroids), but these were not
B. Mazzeo et al. / Air Medical Journal 36 (2017) 30e33
documented in the medical record. It was also difficult to determine if the children presented with mild, moderate, or severe asthma and if the child improved with treatment over time. Therefore, we could not assess the need for secondary therapies. In the intubated asthmatics, it was difficult to tell if ventilator changes made a difference in the ED. References 1. Moorman JE, Akinbami LJ, Bailey CM, et al. National surveillance of asthma: United States, 2001-2010. Vital Health Stat 3. 2012;35:1e58. 2. Pediatric Advanced Life Support. Dallas, Texas: American Heart Association; 2011. 3. Miller AG, Breslin ME, Pineda LC, Fox JW. An asthma protocol improved adherence to evidence-based guidelines for pediatric subjects with status asthmaticus in the emergency department. Respir Care. 2015;60:1759e1764. 4. Bekmezian A, Fee C, Weber E. Clinical pathway improves pediatrics asthma management in the emergency department and reduces admissions. J Asthma. 2015;52:806e814. 5. Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma-Summary Report 2007. J Allergy Clin Immunol. 2007;120(suppl):S94eS138. 6. Rodrigo G, Pollack C, Rodrigo C, Rowe BH. Heliox for nonintubated acute asthma patients. Cochrane Database Syst Rev. 2006;4:CD002884.
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7. Kudukis TM, Manthous CA, Schmidt GA, Hall JB, Wylam ME. Inhaled heliumoxygen revisited: effect of inhaled helium-oxygen during the treatment of status asthmaticus in children. J Pediatr. 1997;130:217e224. 8. Carter ER, Webb CR, Moffitt DR. Evaluation of heliox in children hospitalized with acute severe asthma. A randomized crossover trial. Chest. 1996;109: 1256e1261. 9. Kim IK, Phrampus E, Venkataraman S, et al. Helium/oxygen-driven albuterol nebulization in the treatment of children with moderate to severe asthma exacerbations: a randomized, controlled trial. Pediatrics. 2005;116: 1127e1133. 10. Frazier MD, Cheifetz IM. The role of heliox in paediatric respiratory disease. Paediatr Respir Rev. 2010;11:46e53. quiz 53. 11. Mayordomo-Colunga J, Medina A, Rey C, et al. Non-invasive ventilation in pediatric status asthmaticus: a prospective observational study. Pediatr Pulmonol. 2011;46:949e955. 12. Thill PJ, McGuire JK, Baden HP, Green TP, Checchia PA. Noninvasive positivepressure ventilation in children with lower airway obstruction. Pediatr Crit Care Med. 2004;5:337e342. 13. Basnet S, Mander G, Andoh J, Klaska H, Verhulst S, Koirala J. Safety, efficacy, and tolerability of early initiation of noninvasive positive pressure ventilation in pediatric patients admitted with status asthmaticus: a pilot study. Pediatr Crit Care Med. 2012;13:393e398. 14. Newth CJ, Meert KL, Clark AE, et al. Fatal and near-fatal asthma in children: the critical care perspective. J Pediatr. 2012;161:214e221.e213.
Contents lists available at ScienceDirect
Air Medical Journal journal homepage: http://www.airmedicaljournal.com/
Original Research
Management of Hospitalized Asthmatic Children Before Transport Brande Mazzeo, RN, BSN, Rami Bzeih, MS, Robert Schultz, RN, BSN, Melissa Tavolieri, RN, BSN, Alicia Fraser, RN, BSN, Sabrina M. Heidemann, MD Department of Pediatrics, Wayne State University, Detroit, MI
a b s t r a c t Asthmatic children are at risk for respiratory failure and should be appropriately treated before transport. The objectives were to find out if the Pediatric Advanced Life Support guidelines for asthma treatment were followed in the emergency department (ED); to determine if additional treatment during transport or within the first 2 hours of admission was needed; and to compare the management of intubated asthmatics by the ED, transport team, and the intensive care unit (ICU) physician. The records for children diagnosed with acute asthma over 7 years who were transported by the intensive care transport team were reviewed. The use of albuterol, steroids, oxygen, heliox, continuous positive airway pressure or bilevel positive airway pressure, and ventilator settings was recorded. Two hundred seventy-nine children were transported during a 7-year time period (age, 5 mo-17 y), and 62% were male. Eighty percent received oxygen, albuterol, and steroids in the ED. Heliox was initiated more often by the transport team when compared with the ED or hospital physician (77% vs. 7.7% vs. 15.3%, P < .0001). Forty-five were mechanically ventilated and were more likely to receive volume control (P < .0001) and higher rates (P ¼ .007) in the ED than the ICU. We conclude that most children with acute asthma were treated with oxygen, albuterol, and steroids in the ED. If used, heliox was most likely started during transport. Intubated children were more likely to receive volume control with higher rates compared with lower rates and pressure control in the ICU. Copyright © 2016 by Air Medical Journal Associates
Asthma is a chronic disease affecting the airways. Asthma exacerbation consists of coughing, wheezing, and difficulty in breathing. The National Surveillance of Asthma reports that from 2001 to 2010, 25.7 million people in the United States suffered from asthma, 7 million being children.1 In 2009, 1 in 5 children with asthma was reported to have an emergency room visit. The Centers for Disease Control and Prevention found that 10.7 asthma visits per 100 children occurred between 2007 and 2009, with the highest number of visits in the 0- to 4-year age group.1 In this same period, hospitalizations occurred in 2.1 per 100 cases of children with asthma exacerbation.1 Classification and treatment guidelines for the emergency management of pediatric asthma are published in the provider manual of Pediatric Advanced Life Support (PALS), which is endorsed by the American Heart Association and the American Academy of Pediatrics.2 Most physicians who treat pediatric patients in an emergency department (ED) are PALS certified and have had the opportunity to review these treatment guidelines. Humidified oxygen delivered by a nasal cannula or mask, albuterol administered by a nebulizer or a metered dose inhaler, and corticosteroids are recommended for mild to moderate asthma.
E-mail address: [email protected] (S.M. Heidemann). 1067-991X/$36.00 Copyright © 2016 by Air Medical Journal Associates http://dx.doi.org/10.1016/j.amj.2016.11.006
Ipratropium bromide and magnesium sulfate are recommendations for moderate to severe asthma in addition to those recommendations for mild to moderate asthma. In severe asthma, all of the previously mentioned recommendations should be considered in addition to terbutaline subcutaneously or by intravenous infusion or epinephrine subcutaneously or intramuscularly and bilevel positive airway pressure ventilation. Intubation and mechanical ventilation may be considered in children with refractory hypoxemia and/or worsening clinical conditions such as a decreasing level of consciousness or irregular breathing. The intensive care transport team routinely transports children from multiple EDs, with asthma exacerbation requiring specialty care transport to Children's Hospital of Michigan where the child is admitted to the pediatric intensive care unit (ICU) or general ward. The primary objective was to find out if the PALS guidelines for asthma treatment were followed in the ED. The secondary objectives were first to determine if additional treatment during transport or within the first 2 hours of admission was needed and second to compare the management of intubated asthmatics by the ED, transport team, and ICU physician. Material and Methods This study was approved by the Institutional Review Board at Wayne State University, Detroit, MI. The records for all children
B. Mazzeo et al. / Air Medical Journal 36 (2017) 30e33
through December 31, 2012. All children were seen initially in an ED that cared for both adults and children.
Table 1 Demographic Data Total Number Age (y) Median (range) Sex Race
Allergies Previous hospitalizations for asthma
Days of illness before admission Median (range) Albuterol at home Steroid at home (inhaled) Steroid at home (oral) Intubated for asthma in the past
31
279 7 (0.4-17.8) 62% male Black: 76.3% White: 19.7% Other: 4% 24.7% total 12.4% environmental None: 42.8% 1: 24.1% 2: 13.7% 3: 19.45 1 (0-21) 91% 37% 11% 15.8% total 1: 72% 2: 23% 3: 5%
diagnosed with acute asthma over a 7-year time period who were transported by ICTT were reviewed for the study. Children were excluded if they were transported by ICTT but not admitted to the hospital or transported by ICTT to another institution. The ICCT was established at Children's Hospital of Michigan in the Detroit Medical Center in 1985 as a dedicated critical care transport team providing advanced pediatric and neonatal life support to children in the state of Michigan; surrounding states; and Ontario, Canada. The team transports more than 1,200 patients per year by ground, helicopter, or Learjet. Team members are registered nurses with prior extensive experience in 1 or more of the following 3 areas: neonatal ICU, pediatric ICU, or pediatric ED. The first 10 charts reviewed by each investigator were then double checked by 1 of the investigators (R.B.) for inconsistencies. Age, race, weight, allergies, number of days ill in conjunction with home care management of maintenance and rescue medications, and past history of prior asthma exacerbation hospitalizations and intubations were obtained. Physical assessment findings such as wheezing, retractions, rales/crackles, and oxygen saturations on arrival to the referral hospital were recorded as well as chest roentgenographic findings of hyperinflation, perihilar infiltrates, or pneumonia. Treatments including albuterol; corticosteroids; supplemental oxygen; magnesium; terbutaline; subcutaneous epinephrine; helium oxygen administration; the need for continuous positive airway pressure or bilevel positive airway pressure; intubation; and, if applicable, ventilator settings were noted. Barotraumas and the need for cardiopulmonary resuscitation were documented. Statistical Analysis Descriptive statistics were used for demographic data and clinical variables. Categoric data were expressed in absolute counts and percentages. For continuous data, the mean and standard deviation were used if normally distributed, whereas median and interquartile range were used for skewed data. Unavailable values were excluded. The chi-square or Fisher exact test were used for categoric variables and the Wilcoxon rank sum test for continuous variables. Significance was determined at P < .05. Results Two hundred seventy-nine children with asthma were transported from multiple referring hospitals in the metropolitan Detroit area over a 7-year time period from January 1, 2005,
Demographic Data Demographic data are presented in Table 1. Initial Treatment Of 279 children, 45 (16%) were intubated before transport, and none were intubated during transport or within 2 hours after admission to the hospital. The decision to intubate was made by the ED physician before the arrival of the transport team. Of these intubated children, 36 (80%) were black. Five of 279 children required cardiopulmonary resuscitation, 4 in the ED and 1 during transport. Basic therapies included albuterol, oxygen, and steroids, which are recommended for all asthma classifications according to PALS. Only 80.3% of the patients received all 3 of these therapies. The transport team gave these therapies if not given in the ED. Secondary Treatment Seventy percent received ipratropium in the ED. Magnesium was administered in 39% of the asthmatics who presented to the ED. This therapy was not usually given by the transport team or within 2 hours of hospitalization. Subcutaneous epinephrine was administered in 25% of the asthmatics presenting to the ED. Rarely did the children require epinephrine by the transport team or after hospitalization. Only 3 patients of the 279 were treated with noninvasive positive pressure ventilation, all of whom had this therapy started in the ED. Children who required intubation initially were intubated in the ED. A helium-oxygen mixture (heliox) was used in 78 (28%) and was most commonly instituted by the transport team (77%) and not in the ED (7.7%) or at the time of hospital admission (15.3%) (P < .0001, Table 2 [a]). Fluid boluses were commonly given in patients with asthma in the ED, by the transport team, and after hospital admission (Table 2). Intubated Asthmatics Forty-five children required intubation in the ED, whereas none of the children were intubated initially during transport or within the first 2 hours of intensive care treatment. In the emergency department, volume control ventilation was more likely used compared with pressure control ventilation. The transport team usually used hand bagging rather than the ventilator because the transport ventilator did not give the same effect. In the ICU, nearly all of the children received pressure control ventilation over volume control ventilation. A child was more likely to receive pressure control rather than volume control ventilation in the ICU than in the ED (P < .0001, Table 3). The ordered respiratory rate for mechanically ventilated patients was lower in the ICU when compared with the ED (P < .007, Table 3 [a]). Intubated asthmatics were more likely to receive fluid boluses than nonintubated asthmatics in the ED, during transport, and within 2 hours of hospital admission (P .002). Blood glucose levels were higher initially in the ED when comparing the intubated with the nonintubated group (206 ± 67 [n ¼ 16] vs. 141 ± 40 [n ¼ 70], P .002). Discussion The treatment and stabilization of asthmatic children are important before transporting these children from a referring emergency department to a pediatric hospital. Supplemental oxygen, a bronchodilator, and corticosteroid administration are recommended to treat children who are sick enough to be admitted to the hospital because of asthma. In our study, 80% of the children received this therapy in the ED before the arrival of the transport team. Several recent studies support the early administration of
32
B. Mazzeo et al. / Air Medical Journal 36 (2017) 30e33
Table 2 Secondary Treatment Used in the Emergency Department by the Transport or Hospital Teams
ED therapy Transport team therapy Therapy within 2 hours of hospital admission
Ipratropium, n (%)
Magnesium, n (%)
Subcutaneous Epinephrine, n (%)
Fluid Bolus, n (%)
Heliox, n (%)
CPAP or BiPAP, n (%)
Intubation, n (%)
196 (70.3) 167 (59.9) 42 (15.1)
110 (39.4) 4 (1.4) 24 (8.6)
80 (28.7) 3 (1.1) 11 (3.9)
146 (52.3) 114 (40.9) 74 (26.5)
6 (2.2) 60 (21.5) 12 (4.3)a
3 (1.1) 0 0
45 (16.1) 0 0
BiPAP ¼ bilevel positive airway pressure; CPAP ¼ continuous positive airway pressure; ED ¼ emergency department; heliox ¼ helium-oxygen mixture. a P < .0001; the helium-oxygen mixture was most commonly instituted by the transport team and not in the ED or at the time of hospital admission.
Table 3 Ventilator Settings for Intubated Children Used in the Emergency Department by the Transport Team and in the Intensive Care Unit Rate bpm (Ventilator or Hand Bagging), Total N ¼ 45 ED
Transport team
ICU
7-14, n ¼ 22 (55%) 16-40, n ¼ 18 (45%) Unknown, n ¼ 5 8-14, n ¼ 27 (75%) 15-30, n ¼ 9 (25%) Unknown n ¼ 9 8-14, n ¼ 37 (83%)a 15-20, n ¼ 8 (17%)
Pressure Control, n (%)
Volume Control, n (%)
Hand bagging, n (%)
Unknown Control, n (%)
9 (20)
29 (64)
4 (9)
3 (7)
5 (11)
12 (27)
28 (62)
0
43 (96)b
2 (4)
0
0
bpm ¼ breaths per minute; ED ¼ emergency department; ICU ¼ intensive care unit. a P < .0007; lower ventilator rates were used in the ICU when compared with the ED. b P < .0001; pressure control ventilation is more likely to be used in the ICU compared with the ED.
albuterol or corticosteroids in the treatment of asthma. In 1 study, after the initiation of an asthma treatment protocol, a bronchodilator, ipratropium, and corticosteroids were given quicker, and there was better adherence to the recommended guidelines.3 Bekmezian et al4 showed that educating medical staff with a 1-page guideline for asthma treatment resulted in quicker administration of bronchodilators and steroids, which led to fewer admissions. An asthma protocol starting with triage nurse administration of corticosteroids before physician assessment was shown to reduce admission rates in children with moderate to severe asthma. This analysis identifies an opportunity for the standardization of asthma care to improve the rate of adherence to PALS guidelines for asthma care in the ED setting. Secondary treatments of ipratropium, magnesium, and subcutaneous epinephrine are reserved for moderate to severe asthmatics.2,5 The retrospective nature of this study makes it difficult to determine if some of these children who did not receive secondary treatments would have benefited by them. However, on review of transport team therapies, only 1.4% of the children were given magnesium and 1.1% subcutaneous epinephrine, thus suggesting that most of these children were treated adequately. Ipratropium was given by the transport team in 60% of the children, but this might have been an appropriate dosing interval based on the previous dose of ipratropium provided by the ED physician. In our study, the most significant change to care was made by the transport team with respect to the use of heliox. In the ED, 2.2% of the asthmatic children were prescribed heliox. There is a local preference toward heliox therapy for transported asthmatics. Heliox was used by the transport team under the direction of an ICU physician if the child was reported to have significant respiratory distress despite adequate treatment of albuterol, ipratropium, oxygen, steroids, and magnesium. The length of the transport was not a factor, and heliox was continued in the ICU setting for at least 2 hours if started before ICU admission. A Cochrane review in 2006 showed insufficient evidence for its use in acute asthma in the ED although the implementation of heliox for transport was not studied.6 The transport team initiated heliox in an additional 60 children (21.5%), whereas 12 (4.3%) more received heliox within 2 hours of admission to the
hospital. During a 10-year time period from 1996 to 2006, several studies suggested a benefit to heliox in treating asthmatics, whereas other studies showed no benefit.7-10 One study suggested that heliox may be beneficial early in the treatment of asthma and that the benefit was no longer observed later on after the corticosteroid effect was observed.8 However, the Cochrane review in 2006 showed insufficient evidence for its use in the nonintubated asthmatic.6 There are no large studies supporting the use of heliox in transporting moderate to severely ill asthmatic children. Noninvasive positive pressure ventilation was initiated in the ED in relatively few children, and no child was started on this treatment by the transport team or within 2 hours of admission to the hospital. Noninvasive positive pressure ventilation has been shown to be beneficial for treating patients with moderate or severe asthma as shown by the improvement in asthma scores.11-13 This therapy may prevent the need for mechanical ventilation in asthma but has not been well studied. All of the children requiring mechanical ventilation were intubated in the ED. Most of these children received mechanical ventilation, but a few were hand bagged. It is recommended that lower respiratory rates be used in children with asthma to allow exhalation to be completed. Lower ventilator rates were used in the ICU when compared with the ED. Accurate blood gas data, before and after intubation, could not be obtained, and the effect of the higher rates on worsening ventilation is presumed. Pressure control ventilation was much more likely to be used in the ICU and volume control ventilation in the ED, which is a similar finding when compared with another large study involving severely ill asthmatics.14 Future studies may examine the need for the use of an ED protocol for the treatment of children with asthma to aid in more consistent care of these children according to the PALS guidelines. Larger studies examining the use of heliox, noninvasive ventilation, and optimal ventilator settings for ED management and transport are needed. Limitations This is a retrospective study with limitations. It is possible that some of the patients received all 3 recommended initial therapies (ie, oxygen, albuterol, and corticosteroids), but these were not
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documented in the medical record. It was also difficult to determine if the children presented with mild, moderate, or severe asthma and if the child improved with treatment over time. Therefore, we could not assess the need for secondary therapies. In the intubated asthmatics, it was difficult to tell if ventilator changes made a difference in the ED. References 1. Moorman JE, Akinbami LJ, Bailey CM, et al. National surveillance of asthma: United States, 2001-2010. Vital Health Stat 3. 2012;35:1e58. 2. Pediatric Advanced Life Support. Dallas, Texas: American Heart Association; 2011. 3. Miller AG, Breslin ME, Pineda LC, Fox JW. An asthma protocol improved adherence to evidence-based guidelines for pediatric subjects with status asthmaticus in the emergency department. Respir Care. 2015;60:1759e1764. 4. Bekmezian A, Fee C, Weber E. Clinical pathway improves pediatrics asthma management in the emergency department and reduces admissions. J Asthma. 2015;52:806e814. 5. Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma-Summary Report 2007. J Allergy Clin Immunol. 2007;120(suppl):S94eS138. 6. Rodrigo G, Pollack C, Rodrigo C, Rowe BH. Heliox for nonintubated acute asthma patients. Cochrane Database Syst Rev. 2006;4:CD002884.
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7. Kudukis TM, Manthous CA, Schmidt GA, Hall JB, Wylam ME. Inhaled heliumoxygen revisited: effect of inhaled helium-oxygen during the treatment of status asthmaticus in children. J Pediatr. 1997;130:217e224. 8. Carter ER, Webb CR, Moffitt DR. Evaluation of heliox in children hospitalized with acute severe asthma. A randomized crossover trial. Chest. 1996;109: 1256e1261. 9. Kim IK, Phrampus E, Venkataraman S, et al. Helium/oxygen-driven albuterol nebulization in the treatment of children with moderate to severe asthma exacerbations: a randomized, controlled trial. Pediatrics. 2005;116: 1127e1133. 10. Frazier MD, Cheifetz IM. The role of heliox in paediatric respiratory disease. Paediatr Respir Rev. 2010;11:46e53. quiz 53. 11. Mayordomo-Colunga J, Medina A, Rey C, et al. Non-invasive ventilation in pediatric status asthmaticus: a prospective observational study. Pediatr Pulmonol. 2011;46:949e955. 12. Thill PJ, McGuire JK, Baden HP, Green TP, Checchia PA. Noninvasive positivepressure ventilation in children with lower airway obstruction. Pediatr Crit Care Med. 2004;5:337e342. 13. Basnet S, Mander G, Andoh J, Klaska H, Verhulst S, Koirala J. Safety, efficacy, and tolerability of early initiation of noninvasive positive pressure ventilation in pediatric patients admitted with status asthmaticus: a pilot study. Pediatr Crit Care Med. 2012;13:393e398. 14. Newth CJ, Meert KL, Clark AE, et al. Fatal and near-fatal asthma in children: the critical care perspective. J Pediatr. 2012;161:214e221.e213.