Introduction: Pediatric asthma exacerbations sometimes require aggressive intervention including continuous albuterol, a cornerstone therapy for reversing airway obstruction. However, pediatric dosing typically follows adult guidelines, with limited evidence for specific dosing ranges. This study aimed to compare the clinical outcomes of a reduced initial dose (10 mg/hr) of continuous albuterol with a standard dose (15 mg/hr) in children hospitalized for critical asthma exacerbations. Methods: This retrospective cohort study was conducted at Riley Hospital for Children, analyzing pediatric patients (ages 2-18) admitted with critical asthma exacerbations between 2014 and 2022. Stabilized inverse probability weighting (SIPW) was used to adjust for confounding factors between groups. The primary outcome was the percentage change in the Pediatric Asthma Severity Score (PASS) at 24 hours, with secondary outcomes including the duration of continuous albuterol, PICU length of stay, and hospital length of stay. Results: Analysis of 1,486 encounters revealed no significant difference in percent PASS changes at 24 hours between the 10 mg/hr and 15 mg/hr groups (Additive Treatment Effect of 1.69, 95% CI: -0.93-4.31, p = 0.207). PICU and hospital lengths of stay were also similar. However, the 10 mg/hr group showed a significantly shorter duration of continuous albuterol therapy compared to the 15 mg/hr group (Multiplicative Treatment Effect of 1.29, 95% CI: 1.14-1.45, p < 0.001). Conclusions: Findings suggested that starting continuous albuterol at 10 mg/hr provides clinical outcomes comparable to 15 mg/hr in managing pediatric critical asthma exacerbations. A lower starting dose may optimize resource use and reduce treatment-related adverse effects.

Introduction: This study aimed to determine if a respiratory therapist (RT)-driven high flow nasal cannula (HFNC) protocol could decrease duration of HFNC use, pediatric intensive care unit (PICU) and hospital length of stay (LOS), and duration of continuous albuterol use in pediatric patients with critical asthma. Methods: This was a quality improvement project performed at a quaternary academic PICU. Patients admitted to the PICU between 2 and 18 years of age with a diagnosis of asthma requiring continuous albuterol and HFNC were included. Implementation of a RT-driven HFNC protocol [Plan-Do-Study-Act (PDSA) 1] occurred in October 2017. Additional interventions included weaning continuous albuterol and HFNC simultaneously (PDSA 2; March 2019), adjusting HFNC wean rate (PDSA 3; July 2020), and a HFNC holiday (PDSA 4; October 2021). HFNC duration was the primary outcome. Secondary outcomes included LOS data and continuous albuterol duration. Noninvasive ventilation (NIV), invasive mechanical ventilation (IMV), and 7-day PICU and hospital readmission rates were balancing measures. Results: 410 patients were included. Patient demographics and adjunct therapy use did not differ among the groups. HFNC duration decreased from 26.8 to 18.1 hours, both PICU and hospital LOS were decreased (41 to 31.8 hours, and 86.5 to 68 hours respectively) after PDSA 2. These outcomes remained stable during PDSA 3 and 4. Continuous albuterol duration and NIV use remained stable, while IMV use decreased throughout the study. Conclusions: An RT-driven HFNC protocol led to an improvement in clinical outcomes for pediatric patients with critical asthma without an increase in adverse events.