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Severe acute asthma exacerbation in children: a stepwise approach for escalating
therapy in a pediatric intensive care unit
#MMPMID23798903
Nievas IF
; Anand KJ
J Pediatr Pharmacol Ther
2013[Apr]; 18
(2
): 88-104
PMID23798903
show ga
OBJECTIVES: An increasing prevalence of pediatric asthma has led to increasing
burdens of critical illness in children with severe acute asthma exacerbations,
often leading to respiratory distress, progressive hypoxia, and respiratory
failure. We review the definitions, epidemiology, pathophysiology, and clinical
manifestations of severe acute asthma, with a view to developing an
evidence-based, stepwise approach for escalating therapy in these patients.
METHODS: Subject headings related to asthma, status asthmaticus, critical asthma,
and drug therapy were used in a MEDLINE search (1980-2012), supplemented by a
manual search of personal files, references cited in the reviewed articles, and
treatment algorithms developed within Le Bonheur Children's Hospital. RESULTS:
Patients with asthma require continuous monitoring of their cardiorespiratory
status via noninvasive or invasive devices, with serial clinical examinations,
objective scoring of asthma severity (using an objective pediatric asthma score),
and appropriate diagnostic tests. All patients are treated with ?-agonists,
ipratropium, and steroids (intravenous preferable over oral preparations).
Patients with worsening clinical status should be progressively treated with
continuous ?-agonists, intravenous magnesium, helium-oxygen mixtures, intravenous
terbutaline and/or aminophylline, coupled with high-flow oxygen and non-invasive
ventilation to limit the work of breathing, hypoxemia, and possibly hypercarbia.
Sedation with low-dose ketamine (with or without benzodiazepines) infusions may
allow better toleration of non-invasive ventilation and may also prepare the
patient for tracheal intubation and mechanical ventilation, if indicated by a
worsening clinical status. CONCLUSIONS: Severe asthma can be a devastating
illness in children, but most patients can be managed by using serial objective
assessments and the stepwise clinical approach outlined herein. Following
multidisciplinary education and training, this approach was successfully
implemented in a tertiary-care, metropolitan children's hospital.
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