Use of Continuous Albuterol in a Pathway for Treatment of Pediatric Acute Asthma

Abstract

Background:

Use of RT-driven protocols allows for standardization and improves quality of care. At our institution, inpatient treatment of acute asthma exacerbation in children ≥ 2 y old is managed with a score-based pathway that uses a modified Pediatric Asthma Score (PAS) [Qureshi et al. Effect of nebulized ipratropium on the hospitalization rates of children with asthma. N Engl J Med 1998;339(15):1030-1035]. The pathway is RT-driven and provides score-based guidance for initiation (PAS ≥ 8) and discontinuation (PAS ≤ 11) of continuous albuterol (CA). We use a vibrating mesh nebulizer (VMN) to deliver CA when patients are receiving respiratory support (HFNC, NIV), and a large volume nebulizer (LVN) otherwise. We evaluated the use of CA during asthma exacerbation treatment with the asthma pathway as part of a quality improvement process.

Methods:

First hospitalization of children ≥ 2 y old admitted to PICU or step down unit for acute asthma exacerbation between 11/2017–12/2019 who were prescribed CA as part of the asthma pathway were included in a retrospective chart review. Data collected included: age, sex, asthma severity, CA dose/duration, nebulizer type, PAS (before, during, after CA), and length of stay. Need to restart CA, transfer to PICU, and death were recorded.

Results:

We identified 412 subjects with median age of 6 years (IQR 4–10). The majority were male (61%) and admitted from the emergency department to the step down unit (71%). Asthma severity was classified as mild, moderate, severe, and unspecified in 10%, 45%, 24%, and 20% of subjects respectively. Median initial dose and time on CA were 15 mg/h (IQR 10–20) and 9 h 20 min (IQR 5 h 55 min–16 h 38 min). PAS before, during, and after CA was 11 (IQR 10–12), 11 (IQR 9–12) and 6 (IQR 5–8) respectively. One type of device was used in 85% (LVN 71%, VMN 14%). PAS documentation was missing in 16%, 2%, and 2% before, during, and after CA respectively. 28% received respiratory support (HFNC or NIV). Median length of stay was 1.4 d (IQR 0.8–2.3). CA was restarted in 3% of subjects, and 2% required transfer to PICU due to escalation of care. No deaths were reported.

Conclusions:

The use of a score-based pathway for initiation/discontinuation of CA for treatment of pediatric asthma exacerbation was safe with low complication rates at our institution. Efforts towards increasing documentation before starting CA are warranted.