(673) Institutional Variability in Respiratory Support Modalities for Pediatric Asthma

Introduction: Each year over 20,000 children are admitted to the hospital for status asthmaticus. Currently, no national guidelines exist regarding the optimal respiratory support for these children. We aimed to evaluate institutional and temporal variability in respiratory support modality use for pediatric critical asthma patients.

Methods: We conducted a retrospective cohort study using the Virtual Pediatric Systems Database (VPS, LLC). Our study population included children ≥ 2 years admitted to a VPS contributing intensive care unit from 1/2012 to 12/2021 with a primary diagnosis of asthma or status asthmaticus. We evaluated the percentage of encounters using high flow nasal cannula (HFNC), continuous positive airway pressure (CPAP), bi-level positive airway pressure (BiPAP), and invasive mechanical ventilation (IMV) for all institutions, then divided institutions into quintiles based on total volume of critical asthma admissions. We used chi-square tests for frequencies of use between institutions, logistic regression to determine the influence of institutional volume, and conducted a time series analysis; p< 0.01 defined significance.

Results: Among 77,115 patient encounters from 163 institutions, the median age was 7 years (IQR: 4-11), 40.9% were female, and 38.0% were of Black race. Use of respiratory support devices varied significantly by institution (presented as median [interquartile range], all p< 0.01); HFNC (28.3% (11.0%-49.0%)), CPAP (1.4% (0.3%-4.3%)), BiPAP (8.6% (3.5%-16.1%)), and IMV (5.1% (3.1%-8.2%)). Increased institutional patient volume was associated with significantly increased use of BiPAP (OR 1.33 (1.29-1.36), p< 0.01) and CPAP (OR 1.20 (1.15-1.25), p< 0.01), and significantly decreased use of IMV (OR 0.82 (0.79-0.86), p< 0.01) and HFNC (OR 0.80 (0.79-0.81), p< 0.01). Over the study period, we observed a significant increase in the use of CPAP (1.6% to 5.4%, p< 0.01), BiPAP (3.7% to 21.2%, p< 0.01), and HFNC (11.0% to 52.3%, p< 0.01), and no significant change in IMV use (6.1% to 4.0%, p=0.11).

Conclusions: Higher volume centers use CPAP and BiPAP more frequently for critical pediatric asthma, and IMV and HFNC less frequently. Treatment with CPAP, BiPAP, and HFNC for this population have increased several-fold over the last decade.