Bilevel positive airway pressure in the treatment of status asthmaticus in pediatrics

doi:10.1016/j.ajem.2006.07.001

The American Journal of Emergency Medicine

Volume 25, Issue 1, January 2007, Pages 6-9

https://doi.org/10.1016/j.ajem.2006.07.001 Get rights and content

Abstract

Objectives

The aim of this study was to examine the safety, patient tolerance, and possible benefit of bilevel positive airway pressure (BiPAP) in conjunction with β-2 agonist therapy in the treatment of pediatric patients with status asthmaticus who were refractory to conventional medical therapy.

Methods

This descriptive retrospective chart review examined all patients with the diagnosis of acute asthma treated with BiPAP in an urban academic pediatric emergency department (ED) from April 1, 2003, to August 31, 2004.

Results

Eighty-three patients with status asthmaticus refractory to conventional pharmacological treatment were placed on BiPAP with β-2 agonist nebulization in the ED. The number of subjects tolerating BiPAP was 73 (88%) of 83 patients. All patients placed on BiPAP in the ED were initially designated for admission to the pediatric intensive care unit (PICU). However, only 78% (57/73) were actually admitted to the PICU. Sixteen patients on BiPAP were admitted to a ward service; of these patients, none were subsequently transferred to the PICU. In addition, there was an immediate improvement in subjects' clinical status upon initiation of BiPAP, with 77% showing a decrease in respiratory rate, averaging 23.6% (range, 4%-50%), and 88% showing an improved oxygen saturation, averaging 6.6 percentage points (1-28 percentage points). There were no adverse events due to the use of BiPAP.

Conclusions

These results suggest that the addition of BiPAP in treating pediatric status asthmaticus is safe and well tolerated. This intervention shows promise as a beneficial adjunct to conventional medical treatments. However, further prospective investigation is warranted to confirm these findings.

Introduction

The National Institutes of Health guidelines recommend use of continuous or intermittent nebulized β-2 agonist medications and systemic corticosteroids to treat the symptoms of acute asthma [1]. However, approximately 5% to 10% of patients with acute asthma fail to respond to this conventional therapy and become candidates for other treatment options [2]. When first-line treatment fails, clinicians often add other therapeutic modalities such as aerosolized anticholinergics or epinephrine, and intravenous magnesium, theophylline, or terbutaline. Mechanical airway support such as bilevel positive airway pressure (BiPAP) and, ultimately, intubation with mechanical ventilation can be used if all other medical management has failed.

Using BiPAP to treat status asthmaticus is a concept that has its origin from intermittent positive pressure breathing (IPPB). Both IPPB and BiPAP are similar in that they both provide noninvasive positive pressure support. However, BiPAP expands on this concept with continuous flow alternating between a higher inspiratory pressure and a lower end-expiratory pressure. Previous studies have looked at the use of IPPB in patients with an acute asthma exacerbation receiving nebulized β-agonist therapy [3], [4], [5], [6], [7], [8], [9], [10], [11], [12]. Most of these studies found no significant benefit with the use of IPPB [6], [7], [8], [9], [10], [11], [12]. The problem with these early studies was that the range in disease severity was varied and the studies were not controlled. However, 2 studies concluded there is evidence that in severe asthma failing to respond to other methods of β agonist inhalation, there is benefit of IPPB [3], [5].

To date, the information available on the use of BiPAP to treat status asthmaticus in the pediatric population is a limited to a single brief report describing its use in 3 patients. This report in the intensive care setting expressed a positive outcome [13]. It has been our experience that pediatric patients with acute asthma who do not respond to conventional medical management benefit clinically from the implementation of BiPAP. Thus, the purpose of this investigation was to examine the safety, patient tolerance, and possible benefit of BiPAP in conjunction with β-2 agonist therapy in the treatment of pediatric patients with status asthmaticus who were refractory to conventional asthma therapy.

Section snippets

Methods

The study was approved by the institutional review board of the University of Texas Southwestern Medical Center. The study population was drawn from patients seen in the emergency department (ED) of a large urban pediatric specialty hospital. Charts reviewed were those of all patients with the diagnosis of acute asthma treated with BiPAP from April 1, 2003, to August 31, 2004. These charts were retrospectively identified by reviewing the charts of all patients who were billed for BiPAP. Charts

Results

Eighty-three patients with acute asthma were placed on BiPAP during the designated period. The median age was 8 years (25th quartile, 5 years; 75th quartile, 11 years) with a range of 2 to 17 years. Sixty-four percent were male. Average length of time on BiPAP was 5.8 hours. Subjects tolerating BiPAP were 73 (88%) of 83. For patients not tolerating BiPAP, intolerance was established within 10 minutes of the nasal mask application. Of the 10 patients not tolerating BiPAP, there were no

Discussion

Traditionally, there has been a fear of using BiPAP, particularly in the pediatric population, because of the potential complications. However, our series had no adverse outcomes or deaths. In addition, we showed in our study that BiPAP is very well tolerated with an almost 90% success rate, even in children as young as 2 years. The positive benefit of BiPAP can be attributed to the significant improvement in the child's work of breathing, which then reduces the level of patient anxiety.

The

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Original ContributionBilevel positive airway pressure in the treatment of status asthmaticus in pediatrics

Abstract

Objectives

Methods

Results

Conclusions

Introduction

Section snippets

Methods

Results

Discussion

J Allergy Clin Immunol

Br J Dis Chest

Br J Dis Chest

Chest

J Allergy Clin Immunol

Chest

Expert panel report 2: guidelines for the diagnosis and management of asthma

Comparison of two methods of administering bronchodilator aerosol to asthmatic patients

Br Med J

The effect of a nebulized bronchodilator administered with or without intermittent positive pressure breathing on ventilatory function in children with cystic fibrosis and asthma

Am Rev Respir Dis

Original Contribution
Bilevel positive airway pressure in the treatment of status asthmaticus in pediatrics