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Pediatric Critical Care Medicine www.pccmjournal.org 797 on the work of others including Nievas and Anand (2) to standardize therapy in the PICU in order to reduce variation and improve quality measures and outcomes. The quality improvement methodology demonstrated by Brennan et al (1) is outstanding, and we applaud the work and are eager to understand the nuances of their process. However, there appear to be important data points missing from the study report that warrant comment. Integral to the success of the new pathway, Brennan et al (1) rely on an unpublished “Clinical Asthma Score (CAS)” which appears to be a modification of previously published clinical asthma scoring systems (3, 4). The listed categories in the CAS do not directly align with but most resemble the Pediatric Asthma Score (PAS) by Kelly et al (3) The PAS was first validated in patients who do not require ICU care. As the CAS was applied to patients at admission to the PICU, it is unclear how this score was calculated for patients who required, for example, high-flow oxygen therapy immediately at admission. Additionally, the PAS allows for a score range of 5–15, yet in the current study by Brennan et al (1), nearly one third of patients had a score of 4 or less. Recognizing that a patient with no significant respiratory abnormalities could receive a score of 5 on the PAS, it is unclear how patients in the present study by Brennan et al (1) were scored to receive CAS less than 5. Clarification of the scoring system would be valuable for the reader to attempt to replicate and truly understand the severity of illness of patients in this particular PICU with respect to their presentation and symptomology. The authors also note that any patient requiring “positive pressure ventilation” was excluded from the study. We believe that this is a significant limitation to a study on PICU patients with status asthmaticus as noninvasive positive pressure ventilation can be used safely and may positively impact pediatric patients with status asthmaticus who are refractory to initial therapy (5). Finally, we would respectfully note that although the authors state that “there are no specific PICU-based studies available for comparison,” we would refer the authors to our previously published work on the impact of a severitytiered pathway for PICU management of status asthmatics (6). Our findings revealed that the implementation of a modified asthma severity scoring tool in the PICU along with a severity-tiered approach to therapy resulted in a reduction in transition time from continuous to intermittent inhaled bronchodilator therapy and a significant reduction in total hospital length of stay. We hope that the omission of this reference was an oversight and are pleased that the findings in the work by Brennan et al (1) are consistent with those previously found in our study. The authors have disclosed that they do not have any potential conflicts of interest.