Adverse events in children with

acute asthma discharged from

the hospital with supplemental
oxygen: a descriptive study

Pritchard J, Fassl B, Fletcher G, Nkoy F. University of Utah, Salt

Lake City, Utah.

Primary Children’s Medical Center, University of Utah, Department of Pediatrics,

Division of Inpatient Medicine
Salt Lake City, UT
 Disclosure Statement
Dr. Fassl has no affiliations or conflicts of interest to disclose
 Background: Asthma and
supplemental oxygen
• Hospital discharge with supplemental oxygen is common for other
respiratory disorders:
– Bronchiolitis
• Safe
• Cost effective

• Hospital discharge with supplemental oxygen for children with acute

asthma is rare as it is rare and is regarded “risky” even if the clinical
picture has improved:
– Oxygen need is perceived as impending respiratory failure by many
clinicians
• Acute asthma symptoms largely resolved
• Beta agonist spaced out
– Prolonged hospitalization due to oxygen requirement rather than asthma
symptoms

Home Oxygen After Observation May Be Acceptable for Children With Bronchiolitis Pediatrics. 2006;117:633-640
Home oxygen for children with acute bronchiolitis Arch Dis Child. 2008 Oct 16
 Background: Asthma and hypoxia
• Hypoxia is common in children admitted for asthma exacerbations

• Causes of hypoxia
– Alveolar hypoventilation
– Diffusion impairment transport across the blood-gas barrier
– Presence of a shunt
– Ventilation – perfusion imbalance (V/Q mismatch): most common cause

• Critical asthma affects medium sized airway

– Decreased alveolar ventilation
– Decrease in alveolar pO2 and increase in pCO2
– Hypoxia and hypercarbia
• Correlating clinical picture:
– Sign of global respiratory insufficiency
– Critically ill patient
 Background: Asthma and
supplemental oxygen
• Many children with asthma have a significant Oxygen requirement but
are clinically well appearing
– Other processes besides a decrease in the minute ventilation responsible for
hypoxia:
• Diffusion impairment across the blood-gas barrier: viral infections
• V/Q mismatch
 Study purpose
• To describe disease and hospitalization
characteristics of otherwise healthy children with
acute asthma discharged on home oxygen

• To determine 30 day hospital readmission, ED

visits

• To describe adverse events in children with

discharged on oxygen
– ICU admission rates, death
 Study location
• Primary Children’s Medical Center (PCMC)

• Tertiary Care Referral Center

• 1 million children catchment
area

• 232 bed hospital

• 250 annual admissions for
asthma exacerbations
 Study design/methods
• Retrospective study
– Children admitted with primary dx of asthma 1997-2006, 493.xx

• Inclusion criteria:
– Primary dx asthma
– Home oxygen

• Exclusion criteria:
– Chronic cardiopulmonary diseases
– Home oxygen at baseline
– Technology dependent children
– Medically complex children*

Srivastava et al., Pediatr Clin North Am. 2005 Aug;52(4):1165-87 …

 Methods – Data sources/analysis
• Enterprise data warehouse: administrative database for all Intermountain healthcare
facilities
– Admission/Readmission/ED visits
– Financial data, hospitalization data

• 3 step chart review:

• Step 1: Review of all charts primary dx asthma 1997-2006
– Home oxygen y/n
– Exclusion criteria

• Step 2: Detailed review of charts of children discharged on home oxygen

– Patient characteristics
– Viral co-infection: testing, documentation of URI symptoms
– Medications
– 2 reviewers:
• Inter-rater reliability kappa >0.8 on all data elements on 30 charts

• Step 3: Review of readmissions

• Descriptive data analysis

• IRB approval
 Results: study population
Total # of admissions with primary dx asthma 1997-2006
n=2056

D/c not on oxygen

D/c on oxygen
n=1885
n=171

Excluded
n=41

Study population
n=130; 6,3%
 RESULTS: Patient characteristics
• Median age: 4y (range 2-13)

• Race:
– 83% caucasian, 8% hispanic

• Gender:
– 54% male
– 46% female
 RESULTS: Hospitalization
characteristics
• Median LOS: 63h (9-334)

• Median Hospitalization cost: $ 2,952 ($ 339- $ 19,832)

• APR – DRG Severity of illness index:

– 54% SOI 1
– 40% SOI 2
– 4% SOI 3
– 1% SOI 4

• PICU admission: 5/132 (4%)

 Results: Oxygen at discharge
Median Range
Flow (116/130) 0.5 lpm 0.05-3.6 lpm

Highest recorded O2 1 lpm 0-6 lpm

flow in preceding 24h

Last documented 0.4 lpm 0-6 lpm

While sleeping only

68/130 (52%)
Delivery route Nasal can 125/130
Blow by 3/130
Not spec 2/130
Hospitalization characteristics: Viral
testing
• Viral testing:
– 49/130 (38%): viral testing
– 17/49 (35%): positive viral test
• 9 RSV
• 6 Influenza
• 2 Parainfluenza

• Viral symptoms:
– 75/130 (58%): URI symptoms
– 12/130 (9%): Clinical diagnosis bronchiolitis
Results: Secondary Diagnosis

• Status asthmaticus (38) 31.7%

• Pneumonia (18) 15.0%
• Viral infection (RSV, acute URI) (27) 21%

• Hypoxia/hypoxemia (15) 12.5%

• Dehydration (3) 2.5%
• Otitis media (2) 1.7%
 Hospitalization characteristics: Medication
Use During Hospitalization

• Albuterol 100.0%
• Systemic Steroids 90.2%
• Ipratropium 65.9%
• Inhaled Corticosteroids: 40%
– Preadmission: 22%
 Hospitalization characteristics:
Medications at Discharge
• Albuterol 93%
• Systemic Steroids 73%
• Ipratropium 18%
• Inhaled Corticosteroids: 56%
 Results: Adverse events and
Readmission
• Hospitalization within 30 days
– 5/130 (4%)
• 2/130 for asthma/resp diagnosis
• 3/130 other unrelated diagnosis (ulnar fx, hernia repair, MVA)
• Earliest readmission: 16 days after discharge
– Re- exacerbation

• ED/Urgent care visit within 30 days

– 13/130 (10%) patients; 15 ED/urgent care encounters
– 9/130 visits for asthma
• Elapsed time
– Median 18 days
– 1 patient within 1 day
– 1 patient within 2 days
– Original asthma symptoms worse

– Re-exacerbation episode in 7/130

• No reported death or ICU admission

 Discussion
• Readmissions rare and late in study population
– Timing: not related to initial asthma episode

• ED/urgent care visits frequent:

– 2/130 worsening of initial asthma episode
– 7/30 Re-exacerbation within 30 days:
• Failure of preventive measures

• High variability in oxygen flow and deeming someone ready for d/c on oxygen

• Viral co-infections
– URI symptoms prevalent

• Preventive measures
 Limitations
• Single center study
• Retrospective
• Descriptive; no control group
• Administrative data for patient identification
– Only Intermountain facilities
– SOI determined through administrative data only
• No clinical information after discharge in most
children
• No clinical information about asthma control
 Conclusion
• Discharge on supplemental oxygen may
be feasible in children who have clinically
improved asthma symptoms but require
oxygen

• Future studies:
– Control group
– Prospective randomized controlled study
needed to confirm safety of this measure