Prehospital Management of Pediatric Asthma Patients in a Large Emergency Medical Services System
Authors: Ramgopal S, Mazzarini A, Martin-Gill C, Owusu-Ansah S
Published in: Pediatric Pulmonology, 2020; 55: 83–9
While calls involving them are common, some might be surprised to learn there is limited research describing the prehospital management of pediatric asthma patients. This is despite the fact that asthma is the most common chronic pediatric respiratory disease. What research has been conducted suggests there is wide variation in treatment protocols.
To add to the limited literature on the topic, authors led by Northwestern University’s Sriram Ramgopal retrospectively reviewed electronic medical records from 24 EMS agencies in southwest Pennsylvania. Their objective was to describe the prehospital management of pediatric patients with suspected asthma exacerbation.
The study period was from January 1, 2014 to December 31, 2017. Patients were identified initially by electronically searching PCRs for any documentation of the word wheeze or its variants. The authors then manually reviewed PCRs to identify any additional patient transports due to potential asthma exacerbation. Patients were included if they were 2–17 years of age. Records that did not have the patient’s age documented were excluded. The authors explained they excluded patients less than 2 years of age because wheezing at this age is often due to bronchiolitis. They also excluded cardiac arrests, nontransports, scene assists, interfacility transports, patients with documented allergies, and calls where no patient was found.
Patients were further classified as severe and nonsevere. The authors defined severe asthma by records that included either agitation, fatigue, grunting, labored breathing, nasal flaring, retractions, assisted breathing, hypoxia, oxygen saturation less than 90%, or cyanosis.
The independent variables of interest included systolic blood pressure, heart rate, respiratory rate, pulse oximetry, and lung sounds. The authors also evaluated patient age, gender, race, ethnicity, weight, and height. Race and ethnicity were categorized as white, black, and other. Age was categorized as early childhood (2–5 years old), middle childhood (6–11 years old), and adolescent (12–17 years old). When evaluating transport characteristics, the authors included the year, season, time of day, response time, scene time, transport time, provider certification level, and use of a cardiac monitor.
The authors also used scene zip codes to evaluate socioeconomic status. They identified median household incomes for each zip code based the 2012–2016 American Community Survey five-year estimates. Income data were stratified by quartiles—in other words, they categorized the data into four equal groups.
The outcomes of interest were interventions for pediatric asthma management. This included inhaled medications such as albuterol, ipratropium, and oxygen. These medications were evaluated when administered alone and in combination formulations. Intravenous medications (methylprednisolone and magnesium sulfate) and intramuscular epinephrine were also included as medication interventions. Procedures assessed included peripheral IV placement, endotracheal intubation, supraglottic airway placement, and use of CPAP. The authors also evaluated albuterol administered prior to arrival.
There were 19,246 pediatric transports during the study period. Of those 1,078 (5.6%) were included in the analysis. Most patients were male (58%), and the average age was 8.5 years.
About half the patients included in the study met the criteria for severe asthma. While males were more common in both groups, they represented a higher percentage of nonsevere asthma (62% vs. 54%). There were more patients 12 or older (50%) in the severe asthma group when compared to patients 2–5 (30%) and 6–11 years of age (20%). Patients 12 or older only accounted for 6% (33) of patients in the nonsevere asthma group (2–5: 49%, 6–11: 45%). This difference was statistically significant. There was no statistically significant difference (p > 0.05) noted when evaluating race/ethnicity.
Patients in the severe asthma group were more likely to present with age-adjusted tachypnea (p < 0.001), tachycardia (p < 0.001), and SpO2 below 90% (p = 0.03). There was no statistically significant difference noted when evaluating hypotension and fever among the severe and nonsevere asthma groups (p > 0.05).
The authors also found no statistically significant difference in year, season, time of day, income, provider certification level, response time, or transport time (p > 0.05). A difference in scene time when comparing the severe asthma group to the nonsevere asthma group was statistically significant; however, scene times for severe asthma patients were only a minute longer. There were also more patients in the severe asthma group who had monitor use documented in the PCR (49% vs. 35%).
When evaluating medications given, results indicated 65% were given at least one dose of albuterol by EMS. Patients with severe asthma were given higher amounts of albuterol and ipratropium bromide compared to those with nonsevere asthma (p < 0.001). Patients with severe asthma also more frequently had a peripheral IV placed (p < 0.001), were administered IV methylprednisolone (p < 0.001), were administered IM epinephrine (p = 0.03), and were placed on oxygen (p = 0.05). There were only two patients placed on CPAP, and no patients required intubation or placement of a supraglottic airway.
There were 631 records that had available data regarding albuterol administration prior to arrival. Over two-thirds of those patients received it.
As all studies do, this one has limitations, including potentially failing to capture all possible patients during the chart review, collecting data from only one region, and an inability to link with outcome data. But this is an important study that significantly adds to the available literature for prehospital management of pediatric asthma patients.
The authors correctly note the results of their study can facilitate future efforts in quality improvement, research, and protocol development for the management of pediatric asthma in the prehospital setting. Read the manuscript—the authors included some important figures and tables that assist in evaluating their results. They also further describe their chart review and clearly explain their inclusion and exclusion criteria.
Antonio R. Fernandez, PhD, NRP, FAHA, is a research scientist at ESO and an assistant professor in the department of emergency medicine at the University of North Carolina–Chapel Hill. He is on the board of advisors of the Prehospital Care Research Forum at UCLA.