963: PREHOSPITAL INHALED CORTICOSTEROIDS MAY BE PROTECTIVE IN CHILDREN WITH DIRECT LUNG INJURY

Abstract

Introduction: Trials looking at systemic corticosteroid use in acute respiratory failure demonstrate unclear mortality benefit, in part due to side effects. Inhaled corticosteroids (ICS) confer local anti-inflammatory benefit in adults with direct lung injury, with minimal systemic absorption. However, this has not been studied in children. We hypothesized that ICS protect against progression to respiratory failure in children with direct lung injury. Methods: We performed a retrospective, single center cohort study at the Children’s Hospital of Philadelphia. Using ICD10, we identified children (6 months to 21 years old) who presented to the emergency department with direct lung injury with reliable pre-presentation medication records. We excluded subjects with care limitations and transfers. The primary outcome was intubation; secondary outcomes were non-invasive ventilatory (NIV) support, hospital and ICU admission, length of stay, and mortality. Logistic regression was performed, with age, sex, race, ethnicity, socioeconomic status, and medical complexity chosen as confounders. We a priori planned stratified analyses based on prior history of asthma given the relationship between ICS and asthma. Results: Of 35,220 eligible patients, 17,649 (50%) were prescribed ICS. Intubation occurred in 169 patients (73 on ICS, 96 not on ICS; unadjusted OR 0.76, 95% CI 0.56-1.03) and NIV was required in 3,582 patients (1,336 on ICS, 2,245 not on ICS; unadjusted OR 0.56, 95% CI 0.52-0.60). After adjusting for confounders, ICS was associated with lower intubation (adjusted OR 0.46, 95% CI 0.31-0.67) and lower NIV use (aOR 0.45, 95% CI 0.40-0.49). When stratified on history of asthma, the aOR remained significant for intubation (aOR 0.49,95% CI 0.33-0.72) and NIV (aOR 0.41, 95% CI 0.37-0.46) in patients with a history of asthma, but no longer for patients without a history of asthma (intubation aOR 0.38, 95% CI 0.05-2.8; NIV aOR 0.89, 95% CI 0.61-1.30). Hospital and ICU admission, length of stay, and mortality were similar between groups. Conclusions: ICS may reduce escalation to intubation and NIV for children with direct lung injury, with an effect strongest in those with a history of asthma. Future studies should test whether there is a role for early prophylactic ICS, stratified by history of asthma.