背景:小儿危重哮喘的无创呼吸支持(NRS)包括CPAP;双水平气道正压通气(BPAP);和加热,加湿,高流量鼻插管(HFNC)。我们使用虚拟儿科系统数据库通过儿科危重哮喘的处方率评估NRS,并通过应用的初始NRS设备表征患者临床特征和住院结局。
方法:我们在2017年至2021年期间,对125名参与儿科ICU的儿童进行了回顾性队列研究,这些儿童因危重哮喘住院并规定了NRS。主要结果是NRS模式处方率和趋势。次要结果是描述性的,包括人口统计学,合并症,疾病严重程度指数,和NRS失败率(定义为从初始NRS模式升级到有创通气,HFNC到BPAP或CPAP,或CPAP到BPAP)。
结果:在研究的10083次相遇中,最初规定的NRS模式因医院中心而异(HFNC:69.7±29.6%;BPAP:27.2±7.1%;CPAP:3.1±5.9%).HFNC的平均使用率从2017年的59.7%上升到2021年的71.9%(每年+2.5%)。相比之下,在整个研究期间,BPAP(-1.6%/y)和CPAP(-0.8%/y)的利用率下降。与HFNC相比,肥胖且儿科死亡风险较高的年龄较大的儿童III-死亡概率评分更频繁地使用BPAP和CPAP。与BPAP相比,那些HFNC患儿的无创呼吸支持衰竭发生率更高(7.3%vs2.4%;P<.001),但与BPAP相比,随后的有创通气率更低(0.8%vs2.4%;P<.001)。
结论:在这项多中心队列研究中,我们观察到,与BPAP和CPAP相比,危重型哮喘患儿更多暴露于HFNC.HFNC故障率大于BPAP故障率,但大多数患者转用BPAP而没有随后的有创通气.下一步包括前瞻性试验,包括实际终点,如患者的舒适度和雾化治疗的最佳交付,以区分设备的优越性和适当的NRS利用率。
BACKGROUND: Noninvasive respiratory support (NRS) for pediatric critical asthma includes CPAP; bi-level positive airway pressure (BPAP); and heated, humidified, high-flow nasal cannula (HFNC). We used the Virtual Pediatric System database to estimate NRS by prescribing rates for pediatric critical asthma and characterize patient clinical features and in-patient outcomes by the initial NRS device applied.
METHODS: We performed a retrospective cohort study from 125 participating pediatric ICUs among children 2-17 years of age hospitalized for critical asthma and prescribed NRS from 2017 through 2021. The primary outcomes were NRS modality prescribing rates and trends. Secondary outcomes were descriptive and included demographics, comorbidities, severity of illness indices, and NRS failure rates (defined as escalation from the initial NRS modality to invasive ventilation, HFNC to BPAP or CPAP, or CPAP to BPAP).
RESULTS: Of the 10,083 encounters studied, the initial NRS modalities prescribed varied widely by hospital center (HFNC: 69.7 ± 29.6%; BPAP: 27.2 ± 7.1%; CPAP: 3.1 ± 5.9%). The mean rates of HFNC use increased from 59.7% in 2017 to 71.9% in 2021 (+2.5%/y). In contrast, BPAP (-1.6%/y) and CPAP (-0.8%/y) utilization declined throughout the study period. Older children who were obese and with a higher Pediatric Risk of Mortality III-Probability of Mortality score were more frequently prescribed BPAP and CPAP compared with HFNC. Those children on HFNC experienced higher noninvasive respiratory support failure rates versus BPAP (7.3% vs 2.4%; P < .001) but a lower subsequent invasive ventilation rate versus BPAP (0.8% vs 2.4%; P < .001).
CONCLUSIONS: In this multi-center cohort study, we observed that children with critical asthma are increasingly exposed to HFNC compared with BPAP and CPAP. Rates of HFNC failure were greater than those of BPAP failure, but a majority were transitioned to BPAP without subsequent invasive ventilation. The next steps include prospective trials, including practical end points such as patient comfort and optimal delivery of nebulized treatments to distinguish device superiority and suitable NRS utilization.