Emergency management of children with acute severe asthma requiring transfer to intensive care

• Published in: Emergency medicine journal : EMJ Vol. 27; no. 11; pp. 834 - 837
• Main Authors: Dehò, Anna, Lutman, Daniel, Montgomery, Mary, Petros, Andy, Ramnarayan, Padmanabhan
• Format: Journal Article
• Language: English
• Published: England BMJ Publishing Group Ltd and the British Association for Accident & Emergency Medicine 01.11.2010; BMJ Publishing Group LTD
• Subjects: Acute Disease; Acute severe asthma; Adolescent; adverse events; Age; Asthma; Child; Child, Preschool; Children & youth; complications; Confounding Factors (Epidemiology); Emergency Treatment - adverse effects; Emergency Treatment - methods; endotracheal intubation; Family medical history; Female; Humans; Intensive care; Intensive Care Units, Pediatric; interhospital transport; Intubation; Intubation, Intratracheal - adverse effects; London; Male; mechanical ventilation; Medical treatment; Mortality; Multivariate Analysis; paediatric emergency medicine; Patient Admission - statistics & numerical data; Patient Transfer - standards; Patient Transfer - statistics & numerical data; Patients; Respiration, Artificial - adverse effects; Respiratory therapy; Retrospective Studies; status asthmaticus; Status Asthmaticus - therapy; Studies; Ventilation; London; United Kingdom > UK
• ISSN: 1472-0205; 1472-0213
• DOI: 10.1136/emj.2009.082149

PurposeChildren presenting to emergency departments (ED) with acute severe asthma unresponsive to initial medical therapy may require endotracheal intubation and mechanical ventilation. There is little data on complications during the acute management of children with life-threatening asthma, particularly at hospitals where specialist paediatric staff are lacking. It was hypothesised that a better understanding of complications, particularly associated with intubation and mechanical ventilation, would improve acute management in ED, aid quality improvement initiatives at district general hospitals (DGH) and form the basis for educational interventions from regional paediatric critical care units.MethodsA retrospective case note review was performed for all children referred to a regional intensive care retrieval service with status asthmaticus over a 2-year period. Initial treatment, patient-related factors, indication for endotracheal intubation and the type and occurrence of adverse events during acute management at the DGH were studied. Bivariate and multivariate analyses were undertaken to identify factors associated with the occurrence of complications.Results51 (85%) of the 60 children transferred to a paediatric intensive care unit for acute severe asthma required intubation. 36 (70.5%) experienced one or more complications during intubation and in the early phase of mechanical ventilation. The most common complications were hypotension (requiring fluid resuscitation and/or inotropic support) and severe bronchospasm with acute hypercarbia. The indication for intubation significantly affected the chances of a complication occurring during stabilisation.ConclusionsThere is considerable morbidity in asthmatic children who are referred to paediatric intensive care. The majority of complications may be anticipated and prevented resulting in improved management at DGH.