Status Asthmaticus in the Pediatric ICU: A Comprehensive Review of Management and Challenges
Round 1
Reviewer 1 Report
Comments and Suggestions for AuthorsThe manuscript thoroughly addresses the significant burden of pediatric status asthmaticus, a critical condition requiring immediate and effective intervention which may not have standard management strategies. The review is very well-written and provides a comprehensive set of status asthmaticus management strategies that clinicians can utilize in the PICU.
The literature review successfully fills an important gap in the existing literature, offering valuable insights on a very complete set of medication options (and procedures) to treat status asthmaticus in the PICU setting. An important "take-away" for the reader from the review is that there is no single best standard practice for managing status asthmaticus; rather, a series of clinical care options that must each be carefully considered and navigated based on the specific severity and circumstances of each patient.
The manuscript thoroughly outlines (the complexity and variability) of treatment approaches; in this way the authors portray and encourage a more nuanced and individualized patient approach to care in the PICU. The manuscript's clarity, thoroughness, and practical relevance are a clear contribution to the field of pediatrics care -- acceptance for publication is highly recommended. The review successfully provides a "state-of-the-art" review that will aid clinicians in improving outcomes for status asthmaticus pediatric patients.
Author Response
We would like to thank the reviewer for the positive response.
We appreciate the "take-away" message that has been summarized by the reviewer. We believe that it presents a concise summary of the management options and we have added it to the manuscript (Page 2, first paragraph of Medical Management).
Reviewer 2 Report
Comments and Suggestions for AuthorsIn this article the authors narratively review the different therapeutic resources available for the treatment of severe asthma or status asthmaticus within the PICU.
It is an easy-to-read article that starts from non-invasive therapeutic interventions and then examines the ventilation and supportive aspects of a more specific intensivistic nature. It is not a systematic review nor a meta-analysis of the evidence and from this point of view it has more significance for information and training than for real advancement of knowledge.
Since I am not an intensivist, I note that the medical treatments proposed in a pre-ventilation phase appear to have been well known for some time and now widely regulated by the numerous guidelines published in the literature. What changes, in the authors' summary, is the PICU setting, but in essence I do not detect any important innovations in the available therapeutic baggage. I would leave the evaluation of the more purely intensivistic part to others.
From a practical point of view, Table 2 is certainly useful for teaching.
In summary, an informative and educational article that examines the therapeutic possibilities in the case of severe asthma, leaving the various options open and referring, as is reasonable, to further studies on the topic. The bibliography is sufficiently updated and inevitably summarized for each topic; it does not claim to be exhaustive and, on the other hand, the overall approach is not super-specialistic.
Author Response
Comment 1: In this article the authors narratively review the different therapeutic resources available for the treatment of severe asthma or status asthmaticus within the PICU.
Response: We agree it is a narrative review, and we have added the word "narrative" in the text now.
Comment 2: It is an easy-to-read article that starts from non-invasive therapeutic interventions and then examines the ventilation and supportive aspects of a more specific intensivistic nature. It is not a systematic review nor a meta-analysis of the evidence and from this point of view it has more significance for information and training than for real advancement of knowledge.
Response: Thank you for the compliment, and yes, we agree that it is meant to be an up-to-date review for information sharing and training. We would argue that it presents the most up-to-date knowledge for bedside pediatricians who are managing these critically ill asthamtic children.
Comment 3: Since I am not an intensivist, I note that the medical treatments proposed in a pre-ventilation phase appear to have been well known for some time and now widely regulated by the numerous guidelines published in the literature. What changes, in the authors' summary, is the PICU setting, but in essence I do not detect any important innovations in the available therapeutic baggage. I would leave the evaluation of the more purely intensivistic part to others.
Response: As discussed in our review, the therapies used in the ICU for status asthmaticus have varying qualities of evidence, and very few modalities (eg. ECMO, heliox) are supported by randomized controlled trials. We as intensivists would argue (although it might be disputed by the reviewer) that these therapies like ECMO and Heliox have weak experimental evidence in status asthamticus, but strong anecdotal evidence, and we would consider these to be innovative in nature. Regardless, the goal of our review is to present all the current treatment options to a clinician that might be managing a challenging patient, and not limit ourseves to standard therapies or innovative therapies only.
Comment 4: From a practical point of view, Table 2 is certainly useful for teaching.
Review: Thank you, no changes made.
Comment 5: In summary, an informative and educational article that examines the therapeutic possibilities in the case of severe asthma, leaving the various options open and referring, as is reasonable, to further studies on the topic. The bibliography is sufficiently updated and inevitably summarized for each topic; it does not claim to be exhaustive and, on the other hand, the overall approach is not super-specialistic.
Response: Thank you, no changes made.
Reviewer 3 Report
Comments and Suggestions for AuthorsDear Authors,
I read with great interest your manuscript about the status asthmaticus.
However, there are some aspects that require your attention.
What type of review is this? I believe this is a narrative review, and you should clearly state this in the introduction.
Table 1, is original? Or you need to offer references.
Table 2, is original? or you need to offer references.
In the discussion section you need to expand on the salicaceae sensitization which is one of the triggers for status asthmaticus. Reference this to the work by Costache A, Berghi ON, Cergan R, Dumitru M, Neagos A, Popa LG, Giurcaneanu C, Vrinceanu D. Respiratory allergies: Salicaceae sensitization (Review). Exp Ther Med. 2021 Jun;21(6):609. doi: 10.3892/etm.2021.10041. Epub 2021 Apr 14. PMID: 33936266; PMCID: PMC8082596.
Before the conclusions you need to insert a small paragraph about the limitations of the present study, such as reference articles that were not available.
At the end of the manuscript you need to insert the sections regarding Author Contributions, Ethics, Acknowledgement, Funding, and others.
Please format the references according to the instructions from MDPI for authors.
Looking forward to receiving the improved version of the manuscript.
Author Response
Comment 1: What type of review is this? I believe this is a narrative review, and you should clearly state this in the introduction.
Response: Thank you for the suggestion. You are correct, it's a narrative review, and we have now clarified that in the text.
Comment 2: Table 1, is original? Or you need to offer references. Table 2, is original? or you need to offer references.
Response: These tables are original constructs, but the content has been extracted from multiple sources. For table 1, we have now provided reference for each scoring system listed (reference in red font). For table 2, we have added a line at the end of the table that clarifies it is "Summarized from multiple sources" and provides the references for these sources (red font).
Comment 3: In the discussion section you need to expand on the salicaceae sensitization which is one of the triggers for status asthmaticus. Reference this to the work by Costache A, Berghi ON, Cergan R, Dumitru M, Neagos A, Popa LG, Giurcaneanu C, Vrinceanu D. Respiratory allergies: Salicaceae sensitization (Review). Exp Ther Med. 2021 Jun;21(6):609. doi: 10.3892/etm.2021.10041. Epub 2021 Apr 14. PMID: 33936266; PMCID: PMC8082596.
Response: We read with great interest the publication suggested by the reviewer. However, the goal of this review is to discuss management of status asthmaticus in the ICU setting, and not the precipitants of asthma. To our knowledge, allergen exposure prior to status asthmaticus does influence management in the pediatric ICU setting. As such, the reference provided by the reviewer would be out of place in the 'Discussion' section. However, it can be of value to the reader to know briefly about allergens that can trigger asthma, and we have therefore referenced it in the 'Introduction' section (page 1, red font).
Comment 4: Before the conclusions you need to insert a small paragraph about the limitations of the present study, such as reference articles that were not available.
Response: Thank you for this valuable recommendation. We agree that even though limitations in a review artile are mainly limited to articles and publications that are not accessable/available, this needs to be clearly stated. We have added this statement on Page 10 (red font).
Comment 5: At the end of the manuscript you need to insert the sections regarding Author Contributions, Ethics, Acknowledgement, Funding, and others.
Response: Thank you, the sections have been added.
Comment 6: Please format the references according to the instructions from MDPI for authors.
Response: We have formatted the references, and added in some new references based on reviewer recommendations.
