Respiratory support device odds in pediatric asthma differ based on patient volume, time

Key takeaways:

• From 2012 to 2021, use of high-flow nasal cannula, noninvasive positive pressure ventilation and CPAP significantly rose.
• The odds for device use also changed based on age, sex and acuity score.

Children with critical asthma in higher vs. lower volume institutions had a greater likelihood of receiving noninvasive positive pressure ventilation and CPAP, according to results published in Annals of the American Thoracic Society.

Further, as time progressed between 2012 and 2021, pediatric patients had significantly heightened odds for high-flow nasal cannula (HFNC), noninvasive bilevel positive pressure ventilation (NIV) and CPAP, according to researchers.

“Although advanced respiratory support devices are a common intensive care therapy for children with critical asthma, high-quality evidence is lacking regarding the optimal use of these devices for this population,” Colin M. Rogerson, MD, MPH, assistant professor of pediatrics at Indiana University School of Medicine, and colleagues wrote. “Because of this lack of evidence, there is a high degree of institutional variability in the use of these respiratory devices, which can lead to decreased value in health care delivery.”

Using the Virtual Pediatrics Systems database, Rogerson and colleagues analyzed 77,115 encounters of pediatric patients (59.1% male; 38% Black) aged older than 2 years with critical asthma/status asthmaticus from 163 institutions to assess how the odds for use of different respiratory support modalities — HFNC, CPAP, NIV and invasive mechanical ventilation (IMV) — differ based on higher vs. lower institutional volume and admission year (2012 vs. 2021).

Within the total cohort, 56.9% of encounters did not use any of the four respiratory support modalities.

Of the four respiratory support modalities, HFNC was used the most in 28.8% of encounters. NIV came in second with use in 15.7% of encounters, IMV came in third (5.3% of encounters) and CPAP came in fourth (4.7% of encounters).

The group/quintile capturing the highest volume institutions had an average of 135.7 encounters per year, whereas the quintile capturing the lowest volume institutions had an average of 2.2 encounters per year.

Compared with institutions with a lower encounter volume, institutions with a higher encounter volume had significantly elevated odds for NIV use (OR = 1.27; 95% CI, 1.24-1.3) and CPAP use (OR = 1.17; 95% CI, 1.13-1.22). In contrast, higher vs. lower volume institutions had a significantly lower likelihood of using HFNC (OR = 0.8; 95% CI, 0.79-0.82) and IMV (OR = 0.84; 95% CI, 0.8-0.87).

From 2012 to 2021, use of three support modalities significantly rose: HFNC (11% to 52.3%), NIV (3.7% to 21.2%) and CPAP (1.6% to 5.4%; P < .01 for all). IMV use did not significantly change between the two years, according to researchers.

Similarly, as time progressed, researchers observed a significantly heightened likelihood for HFNC (OR = 1.31; 95% CI, 1.3-1.32), NIV (OR = 1.16; 96% CI, 1.15-1.17) and CPAP use (OR = 1.11; 95% CI, 1.09-1.12) and a reduced likelihood for IMV use (OR = 0.98; 95% CI, 0.97-0.99).

Additional analyses revealed that the odds for use of different respiratory support devices also significantly changed based on age, sex and Pediatric Risk of Mortality III (PRISM 3) acuity scores.

The likelihood for NIV (OR = 1.06; 95% CI, 1.06-1.07) and CPAP (OR = 1.03; 95% CI, 1.02-1.03) use went up as age went up, whereas the likelihood for HFNC (OR = 0.93; 95% CI, 0.93-0.94) and IMV (OR = 0.98; 95% CI, 0.97-0.98) use went down.

A significant link was found between male sex and lower odds for HFNC (OR = 0.86; 95% CI, 0.83-0.89) and NIV use (OR = 0.96; 95% CI, 0.92-0.99) use, as well as higher odds for IMV use (OR = 1.3; 95% CI, 1.2-1.4).

Researchers also observed that as PRISM 3 scores rose, so did the odds for HFNC (OR = 1.01; 95% CI, 1-1.01), CPAP (OR = 1.04; 95% CI, 1.03-1.05), NIV (OR = 1.07; 95% CI, 1.07-1.08) and IMV use (OR = 1.49; 95% CI, 1.48-1.51).

Lastly, the likelihood for IMV use following noninvasive respiratory support failure was significantly heightened with several factors:

• higher PRISM 3 score (OR = 1.37; 95% CI, 1.35-1.4);
• non-Black race (OR = 1.21; 95% CI, 1.04-1.42);
• earlier admission (OR = 1.08; 95% CI, 1.06-1.11); and
• younger age (OR = 1.05; 95% CI, 1.03-1.06).

“Institutional volume and multiple patient factors influence the use of respiratory devices, and further research is needed to determine optimal patient-specific device selection,” Rogerson and colleagues wrote.