Mechanical ventilation in children with severe asthma

Abstract

Hospital admissions for childhood asthma have increased during the past few decades. The aim of this study was to describe the need for mechanical ventilation for severe asthma exacerbation in children in Finland from 1976 to 1995. We reviewed medical records and collected data retrospectively from all 5 university hospitals in Finland, thus covering the entire population of about 5 million. The endpoints selected were the number of admissions and readmissions leading to mechanical ventilation, duration of stay in the hospital, and mortality. Moreover, asthma medications prescribed prior to admission and administered in the intensive care unit (ICU), as well as the etiology of the exacerbation associated with mechanical ventilation were examined. Mechanical ventilation was required in 66 ICU admissions (59 patients). This constituted approximately 10% of all 632 admissions for acute asthma to an ICU. The number of admissions decreased from 1976 to 1995: 41 admissions between 1976 and 1985 vs. 25 admissions during the next 10-year period. The mean age at admission to the ICU was 3.6 years, and 46% of the patients were boys. Prior to the index admission, 70% of the patients had used asthma medication such as oral bronchodilator (50%), inhaled bronchodilator (20%), theophylline (38%), inhaled glucocorticoid (18%), oral glucocorticoid (5%), and cromoglycate (7%). Respiratory infection was by far the most common cause of all the exacerbations (61%), followed by food allergy (8%) and gastroesophageal reflux (3%). In 28% of cases the cause of the severe asthma exacerbation could not be identified. In the mechanically ventilated patients readmissions occurred 38 times between 1976 and 1985 vs. 5 times between 1986 and 1995. Five of the patients who received mechanical ventilation died, and in 3 of these patients asthma was the event causing death. In conclusion, there has been decrease in the number of first and repeat ICU admission for asthma requiring mechanical ventilation between 1970 and 1995. This trend occurred despite a simultaneous 5% yearly increase in hospital admissions for childhood asthma during these 2 decades.

Pressure-controlled ventilation in children with severe status asthmaticus*

“…The details of the mode of ventilation or the ventilatory strategy were not mentioned. The mean duration of mechanical ventilation was 51 hrs with a range of 6 -216 hrs (24). Two other studies employing VCV as the mode of ventilation reported the mean duration of mechanical ventilation to be 23.9 hrs (range, 1.5-78 hrs) and 54 hrs (range, 20 -185 hrs) (25,26).…”

“…In pediatric studies that used VCV without controlled hypoventilation, the incidence of barotrauma was 16 -33% (25,26). Studies using permissive hypercapnia and limited peak inflation pressures reported the incidence of barotrauma ranging from zero in one study (24) to 15-20% in others (4,13,27,32). The corresponding rates of barotrauma in adults who received VCV for asthma, with and without controlled hypoventilation strategies, were 4 -27% (14, 15, 19 -21) and 2-18% (29,30), respectively.…”

Inpatient resource utilisation in younger (2–5 yrs) and older (6–14 yrs) asthmatic children in Finland

“…Hence, access may play an important role in the choice of provider type. Conversely, it has been shown that intensive care accounts for v1% of hospital admissions for childhood asthma in Finland [15], although all University hospitals are well equipped for intensive care treatment of childhood asthma. Since data on unscheduled outpatient visits and emergency room visits were not available from registries the effect of these services could not be evaluated in the context of this study.…”

Pediatric Asthma

“…Several strategies have been proposed to achieve these goals. However, most are based on expert reviews or small retrospective cohorts (Koh 2001 ;Darioli and Perret 1984 ;Sarnaik et al 2004 ;Malmstrom et al 2001 ;Shugg et al 1990 ).…”

“…Both pressure-limited and volume-limited modes have been used to ventilate children with acute asthma and respiratory failure, but neither approach has been demonstrated to be more effective than the other (Sarnaik et al 2004 ;Malmstrom et al 2001 ). However, there are important advantages and disadvantages of each therapy to consider when the clinician weighs the decision about which mode to use in a particular patient.…”