We performed a single-center, prospective, observational cohort study of children between the ages of 6–17 years who were admitted to the Emory University-affiliated Children’s Healthcare of Atlanta 36-bed PICU for severe acute asthma between July 29, 2019, and February 10, 2021. The Emory University School of Medicine Institutional Review Board (IRB00110747) approved the study. Informed consent was obtained from all participants and/or their parent or legal guardian prior to enrollment. In accord with institutional requirements, we obtained verbal assent from children 6–10 years and written assent from children 11 years of age or greater prior to enrollment and any study procedures. All study procedures were performed according to the relevant guidelines and regulations in the Declaration of Helsinki. Children are admitted to the PICU for asthma if they received any of the following interventions in the Emergency Department: (1) a third continuous nebulized albuterol treatment, (2) non-invasive respiratory support delivered by high-flow nasal cannula or bilevel positive airway pressure, (3) intubation for invasive mechanical ventilation, (4) receipt of a 80%/20% helium–oxygen mixture for hypoxemia, or (5) required greater than or equal to 50% fraction of inspired oxygen by Venturi mask or positive pressure ventilation to maintain oxygen saturations ≥ 92%. Children were excluded if they had other chronic medical conditions requiring systemic corticosteroids or had disorders necessitating immunosuppressive medications such as a history of hematopoietic stem cell or solid organ transplant, oncologic diagnoses, sickle cell anemia, or rheumatologic diagnoses. Children with respiratory comorbidities such as cystic fibrosis, pulmonary aspiration, gastroesophageal reflux requiring acid suppression medication and/or tube-feed dependence, bronchiectasis, congenital airway anomalies, bronchopulmonary dysplasia, and/or a history of premature birth before 35-week gestation were excluded. Pregnant patients and those with a personal history of any recreational smoking or vaping were also excluded.
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