Pirie J, Cox P, Johnson D, Schuh S
Division of Emergency Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada.
Pediatr Emerg Care. 1998 Apr;14(2):104-8. doi: 10.1097/00006565-199804000-00004.
Significant changes have occurred in the intensity of treatment of children with severe asthma in the last decade. The objectives of this study are 1) to describe the changes in treatment of asthmatic children needing care in the intensive care unit (ICU) initially treated in our emergency department (ED) in 1983 to 1985 (I) and in 1990 to 1992 (II), and 2) to examine if these changes correspond to changes in clinical outcomes.
Retrospective descriptive study.
All asthmatic children less than 18 years old treated in the ED and admitted to the ICU directly or via the ward with a primary diagnosis of asthma.
Pediatric tertiary care hospital.
A total of 89 ICU admissions were required for patients initially treated in our ED, 54 in 1983 to 1985 and 35 in 1990 to 1992. In 1985, 29.7% of asthma patients required hospital admission and 0.5% needed ICU admission, while 30.7 and 0.7% required hospital and ICU admission, respectively, in 1992. Admissions to the ICU directly via the ED were similar in both time periods (I, 27; II, 30), while those admitted to the ICU via the ward decreased significantly (I, 27; II, 5; P < 0.01). Recently, while in the ED, these ICU patients, on average, were treated with < or =q1h albuterol inhalations longer (I, 1.7 hours; II, 3.4 hours; P < 0.001), more frequently (I, 1.8 inhalations/h; II, 3.3 inhalations/h; P < 0.001), and with greater dosages (I, 0.20 mg/kg/h; II, 0.55 mg/kg/h; P < 0.001), than previously. Only 72% of patients in 1983 to 1985 received i.v. steroids in the ED versus 100% in 1990 to 1992. Ward patients in 1990 to 1992 received < or =q1h inhalations for a greater proportion of their ward stay (I, 6.9/14.7 hours = 47%; II, 9.2/9.2 hours = 100%). There was a recent trend toward longer ICU treatment with < or =q1h albuterol inhalations (I, 8.7 hours; II, 12.3 hours; P = 0.24) and with i.v. albuterol (I, 29.4 hours; II, 37.4 hours; P = 0.26). Ventilation rates were low (I, 5/54 = 9.3%; II, 2/35 = 5.7%; P = NS) and the average duration of ICU stay remained unchanged (I, 40.6 hours; II, 42.1 hours; P = NS).
Despite recent dramatic ED and ward treatment changes, ICU admission rates for pediatric asthma remain relatively constant. However, intensive treatment may have contributed to the decrease in ICU admissions via the ED to ward route in slightly less critical cases.
在过去十年中，重度哮喘儿童的治疗强度发生了显著变化。本研究的目的是：1）描述1983年至1985年（I组）和1990年至1992年（II组）在我们急诊科（ED）最初接受治疗并需要在重症监护病房（ICU）护理的哮喘儿童的治疗变化；2）检查这些变化是否与临床结果的变化相对应。
回顾性描述性研究。
所有在ED接受治疗且直接或通过病房入住ICU的18岁以下哮喘儿童，主要诊断为哮喘。
儿科三级护理医院。
最初在我们ED接受治疗的患者共需要89次ICU入院，1983年至1985年为54次，1990年至1992年为35次。1985年，29.7%的哮喘患者需要住院，0.5%需要入住ICU，而1992年分别为30.7%和0.7%。两个时期直接通过ED入住ICU的人数相似（I组27例；II组30例），而通过病房入住ICU的人数显著减少（I组27例；II组5例；P<0.01）。最近，在ED时，这些ICU患者平均接受沙丁胺醇吸入治疗的时间更长（I组1.7小时；II组3.4小时；P<0.001）、频率更高（I组1.8次吸入/小时；II组3.3次吸入/小时；P<0.001）、剂量更大（I组0.20mg/kg/小时；II组0.55mg/kg/小时；P<0.001），均高于以前。1983年至1985年只有72%的患者在ED接受静脉注射类固醇治疗，而1990年至1992年为100%。1990年至1992年病房患者在病房停留期间接受吸入治疗的比例更高（I组6.9/14.7小时=47%；II组9.2/9.2小时=100%）。最近有延长使用沙丁胺醇吸入治疗（I组8.7小时；II组12.3小时；P=0.24）和静脉注射沙丁胺醇治疗（I组29.4小时；II组37.4小时；P=0.26）时间的趋势。通气率较低（I组5/54=9.3%；II组2/35=5.7%；P=无显著性差异），ICU平均住院时间保持不变（I组40.6小时；II组42.1小时；P=无显著性差异）。
尽管最近ED和病房治疗发生了显著变化，但儿科哮喘患者入住ICU的比例相对保持不变。然而，强化治疗可能导致病情稍轻的患者通过ED至病房途径入住ICU的人数减少。
