Systemic Beta-Agonist Use and Ventilatory Support in Pediatric Critical Asthma: A National Cohort Study

Objective: (s): To evaluate the impact of epinephrine and terbutaline use on ventilatory support in children admitted to the intensive care unit (ICU) with critical asthma. Methods: Data were obtained with the Pediatric Health Information System (PHIS) database for children aged 2 to 18 years admitted to the ICU with a diagnosis of asthma exacerbation from January 1, 2016 to December 31, 2023. Primary outcomes included non-invasive ventilation (NIV) and/or invasive mechanical ventilation (IMV) use one day after receipt of terbutaline and/or epinephrine. Secondary outcomes included adverse events from systemic beta-agonists, including arrhythmias and elevated troponins. Results: Our study population included 53,328 patient encounters. Terbutaline and epinephrine were associated with decreased odds of NIV (terbutaline: OR: 0.52, 95% CI: 0.44-0.63; epinephrine: OR: 0.49, 95% CI: 0.43-0.55) and IMV (terbutaline: OR: 0.51, 95% CI: 0.42-0.61; epinephrine: OR: 0.34, 95% CI: 0.29-0.41). There were no differences in adverse events in the terbutaline group when compared to the epinephrine group for both arrhythmia and elevated troponins (arrhythmia: terbutaline = 1.9%, epinephrine = 1.7%, p = 0.6; elevated troponins: terbutaline = 0.1%, epinephrine = 0.1%, p > 0.9). Conclusions: Systemic beta-agonist use was associated with decreased odds of receiving both NIV and IMV in pediatric critical asthma. There were low rates of arrhythmia and elevated troponin overall, with no differences found between those who received epinephrine or terbutaline. Our findings should inform future clinical trials to evaluate the use of systemic beta-agonists and implementation of guidelines in escalation in critical asthma.