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Adverse events in children withAdverse events in children with

acute asthma discharged fromacute asthma discharged fromthe hospital with supplementalthe hospital with supplemental

oxygen: a descriptive studyoxygen: a descriptive study

Pritchard J, Fassl B, Fletcher G, Nkoy F. University of Utah, SaltLake City, Utah.

Primary Childrens Medical Center, University of Utah, Department of Pediatrics,Division of Inpatient Medicine

Salt Lake City, UT

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Disclosure StatementDisclosure Statement

Dr. Fassl has no affiliations or conflicts of interest to disclose

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Background: Asthma andBackground: Asthma and

supplemental oxygensupplemental oxygen Hospital discharge with supplemental oxygen is common for other

respiratory disorders: Bronchiolitis

Safe Cost effective

Hospital discharge with supplemental oxygen for children with acuteasthma is rare as it is rare and is regarded risky even if the clinicalpicture has improved: Oxygen need is perceived as impending respiratory failure by many

clinicians

Acute asthma symptoms largely resolved Beta agonist spaced out

Prolonged hospitalization due to oxygen requirement rather than asthmasymptoms

Home Oxygen After Observation May Be Acceptable for Children With Bronchiolitis Pediatrics. 2006;117:633-640

Home oxygen for children with acute bronchiolitis Arch Dis Child. 2008 Oct 16

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Background: Asthma and hypoxiaBackground: Asthma and hypoxia

Hypoxia is common in children admitted for asthma exacerbations

Causes of hypoxia Alveolar hypoventilation Diffusion impairment transport across the blood-gas barrier

Presence of a shunt Ventilation perfusion imbalance (V/Q mismatch): most common cause

Critical asthma affects medium sized airway Decreased alveolar ventilation Decrease in alveolar pO2 and increase in pCO2

Hypoxia and hypercarbia Correlating clinical picture:

Sign of global respiratory insufficiency Critically ill patient

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Background: Asthma andBackground: Asthma and

supplemental oxygensupplemental oxygen Many children with asthma have a significant Oxygen requirement but

are clinically well appearing

Other processes besides a decrease in the minute ventilation responsible forhypoxia:

Diffusion impairment across the blood-gas barrier: viral infections

V/Q mismatch

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Study purposeStudy purpose

To describe disease and hospitalizationcharacteristics of otherwise healthy children withacute asthma discharged on home oxygen

To determine 30 day hospital readmission, EDvisits

To describe adverse events in children withdischarged on oxygen ICU admission rates, death

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Study locationStudy location

Tertiary Care Referral Center

1 million children catchmentarea

232 bed hospital

250 annual admissions for

asthma exacerbations

Primary Childrens Medical Center (PCMC)

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Study design/methodsStudy design/methods

Retrospective study Children admitted with primary dx of asthma 1997-2006, 493.xx

Inclusion criteria:

Primary dx asthma Home oxygen

Exclusion criteria: Chronic cardiopulmonary diseases

Home oxygen at baseline

Technology dependent children

Medically complex children*

Srivastava et al., Pediatr Clin North Am. 2005 Aug;52(4):1165-87

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Methods Data sources/analysisMethods Data sources/analysis

Enterprise data warehouse: administrative database for all Intermountain healthcarefacilities Admission/Readmission/ED visits Financial data, hospitalization data

3 step chart review: Step 1: Review of all charts primary dx asthma 1997-2006

Home oxygen y/n Exclusion criteria

Step 2: Detailed review of charts of children discharged on home oxygen Patient characteristics Viral co-infection: testing, documentation of URI symptoms Medications

2 reviewers: Inter-rater reliability kappa >0.8 on all data elements on 30 charts

Step 3: Review of readmissions

Descriptive data analysis

IRB approval

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Results: study populationResults: study population

Total # of admissions with primary dx asthma 1997-2006n=2056

D/c on oxygen

n=171

D/c not on oxygen

n=1885

Excluded

n=41

Study population

n=130; 6,3%

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RESULTS: Patient characteristicsRESULTS: Patient characteristics

Median age: 4y (range 2-13)

Race:

83% caucasian, 8% hispanic

Gender:

54% male

46% female

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RESULTS: HospitalizationRESULTS: Hospitalization

characteristicscharacteristics Median LOS: 63h (9-334)

Median Hospitalization cost: $ 2,952 ($ 339- $ 19,832)

APR DRG Severity of illness index: 54% SOI 1

40% SOI 2

4% SOI 3

1% SOI 4

PICU admission: 5/132 (4%)

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Results: Oxygen at dischargeResults: Oxygen at discharge

Median RangeFlow (116/130) 0.5 lpm 0.05-3.6 lpm

Highest recorded O2flow in preceding 24h

1 lpm 0-6 lpm

Last documented 0.4 lpm 0-6 lpm

While sleeping only

68/130 (52%)

Delivery route Nasal can 125/130Blow by 3/130

Not spec 2/130

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Hospitalization characteristics: ViralHospitalization characteristics: Viral

testingtesting Viral testing:

49/130 (38%): viral testing

17/49 (35%): positive viral test 9 RSV

6 Influenza 2 Parainfluenza

Viral symptoms:

75/130 (58%): URI symptoms 12/130 (9%): Clinical diagnosis bronchiolitis

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Results: Secondary DiagnosisResults: Secondary Diagnosis

Status asthmaticus (38) 31.7%

Pneumonia (18) 15.0%

Viral infection (RSV, acute URI) (27) 21%

Hypoxia/hypoxemia (15) 12.5%

Dehydration (3) 2.5% Otitis media (2) 1.7%

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Hospitalization characteristics: MedicationHospitalization characteristics: Medication

Use During HospitalizationUse During Hospitalization

Albuterol 100.0%

Systemic Steroids 90.2%

Ipratropium 65.9% Inhaled Corticosteroids: 40%

Preadmission: 22%

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Hospitalization characteristics:Hospitalization characteristics:

Medications at DischargeMedications at Discharge Albuterol 93%

Systemic Steroids 73% Ipratropium 18%

Inhaled Corticosteroids: 56%

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Results: Adverse events andResults: Adverse events and

ReadmissionReadmission Hospitalization within 30 days

5/130 (4%) 2/130 for asthma/resp diagnosis 3/130 other unrelated diagnosis (ulnar fx, hernia repair, MVA) Earliest readmission: 16 days after discharge

Re- exacerbation

ED/Urgent care visit within 30 days 13/130 (10%) patients; 15 ED/urgent care encounters 9/130 visits for asthma

Elapsed time Median 18 days 1 patient within 1 day 1 patient within 2 days

Original asthma symptoms worse

Re-exacerbation episode in 7/130

No reported death or ICU admission

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DiscussionDiscussion

Readmissions rare and late in study population Timing: not related to initial asthma episode

ED/urgent care visits frequent: 2/130 worsening of initial asthma episode 7/30 Re-exacerbation within 30 days:

Failure of preventive measures

High variability in oxygen flow and deeming someone ready for d/c on oxygen

Viral co-infections URI symptoms prevalent

Preventive measures

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LimitationsLimitations

Single center study

Retrospective

Descriptive; no control group

Administrative data for patient identification Only Intermountain facilities

SOI determined through administrative data only

No clinical information after discharge in mostchildren

No clinical information about asthma control

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ConclusionConclusion

Discharge on supplemental oxygen maybe feasible in children who have clinicallyimproved asthma symptoms but require

oxygen

Future studies:

Control group Prospective randomized controlled study

needed to confirm safety of this measure