Research ArticleOriginal Research

Safe and Effective Use of Score-Based Continuous Albuterol Therapy in a Pathway for Treatment of Pediatric Asthma Exacerbation

L Denise Willis, Nikki P Danner, Tera L Lloyd, Naisha L Carper and Ariel Berlinski
Respiratory Care November 2022, 67 (11) 1396-1404; DOI: https://doi.org/10.4187/respcare.10083

Abstract

BACKGROUND: Standardized acute asthma management with score-based, respiratory therapist (RT)–driven pathways and protocols improves outcomes including decreased length of stay (LOS) and time on continuous albuterol therapy. Limited data are available for the safety of continuous albuterol used outside of pediatric ICU (PICU). We use a modified pediatric asthma score (PAS) for the asthma pathway at our institution. The safety and effectiveness of using PAS to initiate/stop continuous albuterol as part of a score-based, RT-driven asthma pathway were evaluated.

METHODS: A retrospective review of children ≥ 2 y admitted for asthma exacerbation to the PICU and step-down unit who received continuous albuterol as part of the asthma pathway during 2017–2019 was completed. Demographic and clinical data were extracted including PAS, dose and duration of continuous albuterol, LOS, and complications. Outcomes of subjects admitted to the PICU and step-down unit were compared.

RESULTS: Results are expressed as median (interquartile range). The study included 412 children (61% male, 59.9% Black, 92.7% non-Hispanic, 44.9% moderate persistent asthma) with age and weight of 6.4 (4.0–10.0) y and 24.8 (17.3–39.5) kg, respectively. Most children were admitted to step-down unit (71.1%). Initial albuterol dose, duration, and LOS were 15 (10–20) mg/h, 9.1 (5.7–16.0) h, and 1.4 (0.9–2.3) d, respectively. Respiratory support was required by 29% of subjects. Need to restart therapy (2.9%), transfer to PICU (1.7%), and intubation (0.5%) were infrequent. No pneumothoraces or deaths were reported. Emergency department visits (3.9%) or readmissions (0.7%) within 30 d of discharge were low. Subjects admitted to the PICU were sicker and required more therapies and respiratory support than those admitted to the step-down unit.

CONCLUSIONS: Use of an RT-driven, score-based pathway for initiation and discontinuation of continuous albuterol for treatment of pediatric asthma exacerbation was safe and effective in the PICU and step-down unit.

Introduction

Asthma is the leading cause of chronic respiratory disease in children.1 The prevalence of pediatric asthma in the United States during 2016–2018 was approximately 8.1%.2 Nearly half of all individuals with asthma have experienced an exacerbation in the past 12 months, with many seeking care in an emergency department (ED) or urgent care center.2 Severe asthma frequently results in hospitalization, with many requiring admission to the ICU.3

The treatment of status asthmaticus in children includes bronchodilators (frequently or continuously administered), systemic steroids, intravenous magnesium, and respiratory support.4 Management of acute asthma with pathways and protocols has become a common practice in many institutions. These tools help standardize care, improve patient outcomes, enhance quality of care, and reduce unnecessary therapy and costs. Pediatric asthma pathways and protocols have been shown to decrease length of stay (LOS) and shorten the duration of continuous albuterol therapy.5-14 Respiratory therapist (RT)–driven asthma protocols have been utilized successfully with favorable results.10,11,14

Continuous albuterol nebulization for the treatment of severe asthma exacerbation is generally safe and well tolerated with few adverse events.12-15 The safety of this therapy has been mainly demonstrated in the pediatric ICU (PICU) setting with few reports outside of the PICU.12-14 Scoring tools are used to determine placement and to decide type, dose, and frequency of therapies. Several scoring tools have been validated for asthma management including the Pediatric Asthma Severity Score, Preschool Assessment Measure, and other variations.16-18 A previous study reported that subjects with scores in the severe range upon admission to PICU had longer duration of continuous albuterol and LOS.19 Whereas several studies have evaluated outcomes of asthma pathways that employ score-based treatment, none has specifically evaluated safety of using the pediatric asthma score (PAS) to initiate and discontinue continuous albuterol. The aim was to evaluate the safety and effectiveness of the RT-driven, score-based asthma pathway used to initiate and discontinue continuous albuterol treatment for quality assurance.

At our institution, treatment of acute asthma in children 2 y and older is managed with an RT-driven, score-based pathway that is utilized in both ED and in-patient settings including PICU and step-down unit. The scoring system allows for initiation/discontinuation of continuous albuterol at specific scores. The aim of the study was to evaluate the safety and effectiveness in the PICU and in step-down unit of an RT-driven, score-based asthma pathway to manage use of continuous albuterol in children experiencing status asthmaticus.

QUICK LOOK

Current Knowledge

Score-based, respiratory therapist (RT)–driven asthma pathways are used to treat pediatric asthma exacerbation. Asthma pathways and protocols have shown to decrease length of stay and shorten the duration of continuous albuterol therapy. Safety and effectiveness of using the pediatric asthma score to initiate and discontinue continuous albuterol have not been previously described.

What This Paper Contributes to Our Knowledge

The use of a score-based, RT-driven pathway to decide initiation and discontinuation of continuous albuterol for the treatment of pediatric status asthmaticus was found to be safe and effective based on low rates of reinitiation of therapy, escalation of care, intubation, and emergency department visits or readmissions within 30 d of discharge. In addition, no pneumothoraces or deaths were reported. These findings held true for children admitted to step-down unit.

Methods

The institutional review board at the University of Arkansas for Medical Sciences determined the study was not human subject research. This review was performed at Arkansas Children’s Hospital as part of a quality assurance component of the asthma pathway. Arkansas Children’s Hospital is a tertiary-care, free-standing children’s hospital with 336 beds located in Little Rock, Arkansas. This was a single-center, retrospective review of children admitted for asthma exacerbation between November 2017–December 2019 who were treated with the asthma pathway and received continuous albuterol. Inclusion criteria were children age 2 y and older admitted to PICU or step-down unit with diagnosis of asthma, managed with the asthma pathway, and treated with continuous albuterol.1 Continuous albuterol is not administered in the pediatric wards at our institution. Only the first hospitalization during the study period was included. If a subject required restarting continuous therapy after initial discontinuation, only the first treatment was included in the analysis. Exclusion criteria were subsequent admissions for asthma exacerbation during the study period, children discharged from the ED or for whom continuous albuterol was discontinued in the ED and admitted to a medical-surgical ward, and children with a primary diagnosis other than asthma. Staffing of RTs was similar in PICU and step-down unit (4–5 patients/RT).

The following demographic data were collected: age, sex, race, and ethnicity. The following clinical data were collected: asthma severity classification; weight; continuous albuterol dose and duration; nebulizer type; PAS before, during, right before discontinuation, and after continuous albuterol; admit location; respiratory support while receiving continuous albuterol; prescription for inhaled corticosteroids (ICS) or ICS long-acting bronchodilator (LABA) combination prior to admission; LOS; and readmissions or ED visits within 30 d of discharge. The following safety measures were recorded: transfer to PICU, restarting continuous albuterol after discontinuation, need for intubation and invasive mechanical ventilation, pneumothorax, and deaths.

The pathway uses a modified PAS to determine exacerbation severity and treatment through clinical evaluation of breathing frequency, SpO2, breath sounds, retractions, and dyspnea.18 The electronic medical record automatically calculates the score based on the selections made by the RT. The pathway is used in children 2 y old or older who are admitted with an asthma exacerbation. The score ranges from 0–15, with scores 8–11 and 12–15 indicating moderate and severe exacerbations, respectively, (Table 1). The asthma pathway directs placement (PICU, step-down unit, or pediatric ward) and frequency of assessment and treatment, including guidance for initiation and discontinuation of continuous albuterol. However, the pathway does not regulate the use of oxygen. Admission to PICU is guided by a combination of PAS score 12–15 after 4 h of treatment in ED and need for magnesium, noninvasive ventilation (NIV), epinephrine, terbutaline, and/or persistent need for continuous albuterol. For in-patients, PAS is reassessed every 2–4 h, depending on the phase of the protocol, with evaluation every 2 h during administration of continuous therapy. Continuous albuterol is discontinued after 4 h of treatment when PAS score is ≤ 11. The in-patient asthma pathway is included in Figure 1. Children administered continuous albuterol also receive intravenous fluids containing 20 or 40 mEq/L of potassium to prevent hypokalemia.

View this table:
Table 1.

Pediatric Asthma Score Used With Asthma Pathway

Fig. 1.
Fig. 1.

Asthma pathway for in-patient management. Adapted from the Arkansas Children’s Asthma Pathway. IV= intravenous; PICU = pediatric ICU; SQ = subcutaneous; PAS = pediatric asthma score; NIV = noninvasive ventilation; ED = emergency department; PRN = as needed.

A large-volume nebulizer (LVN) (HOPE, B & B Medical Technologies, Carlsbad, California) with a face mask was used to deliver continuous albuterol in children not requiring high-flow nasal cannula (HFNC) or ventilator support.20 A vibrating mesh nebulizer (VMN) (Solo, Aerogen, Galway, Ireland) placed on the dry side of the humidifier was used when the child was receiving HFNC or NIV. A low-flow small-volume nebulizer (SVN) (MiniHeart, SunMed, Grand Rapids, Michigan) placed after the circuit’s leak valve was also occasionally used during NIV.

Outcomes between subjects admitted to PICU and step-down unit were compared. Duration of continuous albuterol and LOS was compared between subjects with a PAS < 12 and > 11 for each of the admission locations. Descriptive statistics including frequency and percentage were used to summarize categorical data. Chi-square statistics were used to compare categorical data. Normally distributed data from PICU and step-down unit admissions were compared with unpaired t test with unequal variances. Mann-Whitney test was used to compare unpaired outcomes that were not normally distributed, and confidence around the median was also reported. Continuous data were expressed as median (interquartile range [IQR]). Analysis of variance followed by Tukey test was used to compare PAS documented at different times. A statistical software package was used for data analysis (Prism 9.3.0, GraphPad Software, San Diego, California).

Results

There were 571 admissions for acute asthma requiring continuous albuterol during the study period for 493 unique patients. Seventy-eight subsequent admissions were excluded per protocol. Eighty-one patients were excluded for the following reasons: 49 did not have the asthma pathway ordered; 24 were admitted to a medical surgical ward; 4 were discharged from ED, and 4 did not have a primary diagnosis of asthma. Four hundred twelve subjects were included in the study (see Fig. 2). Therefore, a total of 412 subjects was included in the analysis.

Fig. 2.
Fig. 2.

Flow chart. ED = emergency department; PICU = pediatric ICU.

Table 2 shows demographic characteristics of all subjects and divided by initial placement (PICU vs step-down unit). Median (IQR) age and weight at the time of admission were 6.4 (4.0–10.0) y and 24.8 (17.3–39.5) kg, respectively. The majority of subjects was male (251/412, 61%), Black (247/412, 59.9%), and non-Hispanic (382/412, 92.7%). Most subjects had moderate persistent asthma (185/412, 44.9%) and were admitted from ED to step-down unit (293/412, 71.1%). Two-hundred two subjects (49%) were prescribed ICS or ICS LABA combination prior to admission. Of those subjects on ICS (176/202, 87.1%), fluticasone was the most commonly prescribed (167/176, 96%). Of those subjects on ICS LABA (26/202, 12.9%), budesonide/formoterol fumarate dehydrate was the most commonly prescribed (20/26, 76.9%).

View this table:
Table 2.

Subject Characteristics

Subjects admitted to the PICU had greater proportion of females (P < .001), greater proportion of whites (P = .01), greater proportion of subjects with severe asthma (42% vs 16.7% in PICU and step-down unit, respectively; P < .001), and greater proportion of prescriptions for ICS LABA (P = .002) than subjects admitted to step-down unit. Subjects admitted to the PICU had lower proportion of individuals with moderate asthma (35.3% vs 48.8% in PICU and step-down unit, respectively; P = .02) and lower proportion of prescriptions for ICS (P = .002) than subjects admitted to step-down unit. No differences in age, weight, ethnicity, mild and unspecified asthma classification, and previous prescription of ICS were found between both groups (step-down unit and PICU).

Table 3 shows the outcomes for all subjects and divided by initial placement (PICU vs step-down unit). The median (IQR) initial dose of continuous albuterol was 15 (10–20) mg/h, and total duration of administration was 9.1 (5.7–16.0) h. Most subjects used one type of nebulizer (295/412, 71.6% and 59/412, 14.3% for LVN and VMN, respectively). Almost 30% (121/412) of subjects received respiratory support, with HFNC being the most commonly used (86/121, 71.1%). Children in the PICU received NIV followed by HFNC more often than children admitted to step-down unit (27.8% and 6.1%, respectively, P =.002). Only 2 subjects (0.5%) required intubation and invasive mechanical ventilation. Few subjects (12, 2.9%) required a restart of continuous albuterol after discontinuation. No subjects experienced pneumothorax or death. Only 1.7% (5/293) required transfer from step-down unit to PICU. Median LOS was 1.4 (0.9–2.3) d. Readmissions and ED within 30 d were low (0.7 and 3.9%, respectively).

View this table:
Table 3.

Outcomes for All Subjects and According to Initial Placement

The median (IQR) PAS before, during, at time of discontinuation, and after continuous therapy was discontinued was 11 (10–12), 11 (9–12), 8 (6–10), and 6 (5–8), respectively. All scores were significantly different (P < .001) except for before and during (P = .98). The overall documentation of PAS was high (91.4%). The score was documented 83.4, 90.0, 89.8, and 89.1% of the times before, during, at time of discontinuation, and after continuous albuterol was discontinued, respectively. PAS before initiation of continuous albuterol was documented less frequently than at other times (P = .03). The overall documentation of PAS was higher in step-down unit than in PICU (93.2% vs 87%, respectively, P < .001). PAS was recorded in PICU less frequently than in step-down unit before (70.6% vs 88.7%, P = .006) and at time of stopping continuous therapy (90.8% vs 98%, P = .002). No differences in PAS documentation between PICU and step-down unit were found during (91.6% vs 89.4%, P = .58) and after continuous albuterol (95% vs 96%, P = .41).

Subjects admitted to the PICU had longer duration of continuous albuterol, longer LOS, higher PAS before initiation of continuous, higher proportion of VMN use, and overall higher use of respiratory support than subjects admitted to step-down unit (see Figs. 3 and 4 and Table 3). All subjects with combined respiratory support were started on NIV and subsequently weaned to HFNC. Most of these subjects were admitted to PICU (20/23, 87%). No differences in initial albuterol dose, proportion of use of NIV and invasive ventilation, need to restart continuous therapy, ED visits and admission after 30 d, and PAS at time and after discontinuation of continuous albuterol were found between subjects admitted to step-down unit and PICU (see Table 3).

Fig. 3.
Fig. 3.

Duration of continuous albuterol. Duration of continuous albuterol in subjects admitted to PICU and step-down units treated with asthma pathway (P < .001). PICU = pediatric ICU.

Fig. 4.
Fig. 4.

Length of stay (LOS). LOS for subjects admitted to PICU and step-down units who received continuous albuterol via asthma pathway (P < .001). PICU = pediatric ICU.

Subjects admitted to PICU with PAS > 11 before initiation of continuous albuterol had longer LOS than those with PAS < 12 (2.8 [1.64–4.23] d and 2.16 [1.61–3.44] d, respectively, P = .002) (see Fig. 5). However, there was no difference in duration of continuous albuterol (14.1 [7.7–35.3] h and 17.1 [11.6–36.6] h for PAS < 12 and >11, respectively, P = .75) (see Fig. 5). Subjects admitted to step-down unit with PAS > 11 before initiation of continuous albuterol had longer LOS than those with PAS < 12 (1.39 [0.86–1.94] d and 0.93 [0.74–1.37] d, respectively, P = .006) (see Fig. 6). Similarly, subjects admitted to step-down unit with PAS > 11 before initiation of continuous albuterol received therapy longer than those with PAS < 12 (8.9 [6.15–13.75] h and 6.5 [4.2–9.8] h, respectively, P = .002) (see Fig. 6).

Fig. 5.
Fig. 5.

Comparison length of stay (LOS) and duration of continuous albuterol in subjects admitted to the pediatric ICU with low (< 12) and high (> 11) pediatric asthma scores. A: LOS for subjects admitted to PICU who had low and high pediatric asthma score (PAS) scores before starting continuous albuterol via asthma pathway (P = .002). B: Duration of continuous albuterol for subjects admitted to PICU who had low and high PAS scores before starting continuous albuterol via asthma pathway (P = .75). PICU = pediatric ICU; LOS = length of stay; PAS = pediatric asthma score.

Fig. 6.
Fig. 6.

Comparison length of stay (LOS) and duration of continuous albuterol in subjects admitted to step-down unit with low (< 12) and high (> 11) pediatric asthma scores (PASs). A: LOS for subjects admitted to step-down unit who had low and high PAS score before starting continuous albuterol via asthma pathway (P = .006). B: Duration of continuous albuterol in subjects admitted to step-down unit who had low and high PAS score before starting continuous albuterol via asthma pathway (P = .002). PAS = pediatric asthma score; LOS = length of stay; PICU = pediatric ICU.

Discussion

The quality assurance review of our asthma pathway showed that an RT-driven, score-based pathway for initiation and discontinuation of continuous albuterol for treatment of pediatric asthma exacerbation was safe and effective. This was true both for children admitted to PICU and to step-down unit. Children admitted to PICU had a higher PAS before initiation of continuous albuterol, longer duration of continuous therapy, required more respiratory support, and had longer LOS than those admitted to step-down unit. Those admitted to PICU also had a greater proportion of children with severe asthma and prescribed ICS LABA as compared to step-down unit. Children with PAS > 11 before initiation of continuous albuterol had longer LOS than those with PAS < 12 irrespective of admission site but received continuous albuterol received therapy longer when admitted to step-down unit. Comparison to previous work is challenging since most studies reported pre- and post-pathway implementation data.5-14 Nevertheless, our LOS and time on continuous albuterol were similar to the reported post-implementation pathways by several groups.5-14

This review showed that the use of continuous albuterol in step-down unit was safe. There were no intubations, pneumothoraxes, or deaths in that group. Only 1.7% required transfer to PICU due to worsening of respiratory status. This could be considered a surrogate for appropriate placement based on the PAS what has been reported by others.21 In addition, only 2.7% of subjects admitted to step-down unit had to restart continuous therapy after discontinuation. The latter in addition to LOS, time on continuous albuterol, and low 30-d ED/readmissions are surrogates for effectiveness of the pathway. Data from this review provide additional valuable information regarding safety of use of continuous albuterol outside of PICU.12-13 Similar to other reports, adverse events in PICU were low, with 3.4% requiring restart of continuous albuterol after discontinuation, 2.8% requiring intubation, and no pneumothoraces or deaths reported.5-14 These data confirm the safety and effectiveness of the score-based pathway to start and stop continuous albuterol therapy.

We found that children with higher PAS before initiation of continuous albuterol were admitted longer than those with lower scores irrespective of site of admission (PICU or step-down unit). However, duration of continuous therapy was longer for those with higher scores before initiation of continuous albuterol than for those with lower scores. The latter was true for those admitted to step-down unit but not for those admitted to PICU. In addition, children admitted to PICU required more respiratory support than those admitted to step-down unit. Overall, there was partial agreement with Maue et al19 who reported that severity score was associated with critical care interventions. However; they reported longer time on continuous albuterol and longer LOS for those with higher severity scores. Our findings were similar to Maue et al19 who reported higher rates use of NIV for sicker subjects but similar rates for use of HFNC between the sicker and the other subjects.

The success of asthma management tools is dependent upon adherence to the treatment protocol. Kucher et al7 reported a significant reduction in time on continuous albuterol and LOS when an asthma protocol was followed. However, these improved outcomes were not achieved for all subjects due to low adherence to the protocol.7 We found a very high overall completion rate of documented scoring that was slightly better in step-down unit. We think that the high degree of adherence is responsible in part for the success of the pathway. This review adds further data to the body of knowledge supporting RT-driven pathways and protocols. Most of the previously published asthma pathways led to improved outcomes and optimization of resource utilization.5-14,22

This study had several limitations stemming from its retrospective nature. The authors did not extract data on use of hypokalemia and arrhythmias. However, their occurrence has been reported to be low.15 Moreover, a report from our institution on children receiving continuous albuterol and presenting scores 12–15 revealed an 8% treatment of hypokalemia.15 In that study, all subjects were receiving supplemental potassium with intravenous fluids (20 or 40 mEq/L). Another limitation is that the authors did not extract data on magnesium use and that prescription of ICS or ICS LABA combination does not mean that the subjects were receiving the medication.

Conclusions

An RT-driven, score-based pathway for initiation and discontinuation of continuous albuterol therapy for treatment of pediatric asthma exacerbation was safe and effective. More importantly, these findings held true for children admitted to step-down unit.

Footnotes

  • Correspondence: Ariel Berlinski MD FAARC, 1 Children’s Way, Slot 512–17, Little Rock, AR 72202. E-mail: BerlinskiAriel{at}uams.edu

  • Dr Berlinski discloses relationships with Cystic Fibrosis Foundation, Mylan, National Institutes of Health, Therapeutic Development Network, Trudell Medical International, Vertex, and the International Pharmaceutical Aerosol Consortium on Regulation and Science. Ms Willis is a section editor for Respiratory Care. The remaining authors have disclosed no conflicts of interest.

  • Ms Danner presented a version of this paper as an Editor’s Choice abstract at AARC Congress 2021 LIVE!, held virtually December 1, 2021.

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