eMedicine Specialties > Pediatrics: Cardiac Disease and Critical Care Medicine > Critical Care

Status Asthmaticus: Treatment & Medication

Author: Adam J Schwarz, MD, Consulting Staff, Critical Care Division, Pediatric Subspecialty Faculty, Children's Hospital of Orange County
Contributor Information and Disclosures

Updated: Nov 19, 2009

Treatment

Medical Care

According to the most recent guidelines available from the National Asthma Education and Prevention Program (NAEPP) Expert Panel, overall care for a child with asthma includes intensive outpatient treatment with medications and alteration of the environment.2 Admission to the hospital represents a failure of outpatient management. This discussion is limited to inpatient treatment for status asthmaticus.

  • Oxygen
    • Supplemental oxygen generally must be provided in any patient who presents with status asthmaticus. Oxygen helps to correct V/Q mismatch. Oxygen can be provided via nasal cannula or face masks.
    • In the event of significant hypoxemia, nonrebreathing masks may be used to deliver as much as 98% oxygen. The goal of supplemental oxygen therapy is an oxygen saturation above 90%.
  • Inhaled beta-agonists
    • Beta-agonist agents, typically albuterol or salbutamol, and terbutaline, are the mainstays of acute therapy in asthma. Levalbuterol is also used (see Medscape Viewpoints for a discussion on the use of levalbuterol). They act via stimulation of cyclic adenosine monophosphate (AMP)–mediated bronchodilation. The airway is rich in beta-receptors; the stimulation of these receptors relaxes airway smooth muscles, increases mucociliary clearance, and decreases mucous production.
    • Andrews et al conducted a randomized, double-blind trial to compare equipotent doses of racemic albuterol (RAC) with levalbuterol in children with severe asthma exacerbation who failed initial therapy in the emergency department with RAC and steroids.3 Patients received continuous nebulized RAC at 20 mg/h (n = 40) or levalbuterol (n = 41). Results did not significantly vary between the groups for median time for continuous therapy (RAC for 18.3 h vs levalbuterol for 16 h), asthma severity scores, individual clinical measures, or time to discharge (RAC for 45 h vs levalbuterol for 46 h).
    • The nebulized inhaled route of administration is generally the most effective route of delivery, though some patients with severe refractory status asthmaticus may benefit by the addition of beta-agonists delivered intravenously. Beta-agonists are generally most effective in the early asthma reaction phase. However, patients who present with status asthmaticus despite frequent use of beta-agonists at home may have tachyphylaxis and resistance to these agents. Similar issues may be seen in patients on chronic long acting beta agonists. Therefore, these patients may not respond as well when these agents are given in the hospital. Inhaled beta-agonists can be administered intermittently or as continuous nebulized aerosol in a monitored setting.
  • Corticosteroids
    • Corticosteroids, such as methylprednisolone prednisolone or prednisone, are critical in the therapy of status asthmaticus and are used to decrease the intense airway inflammation and swelling in asthma.4 In addition, corticosteroids potentiate the effects of beta-agonist agents and improve capillary leak. Therefore, corticosteroids affect the late asthma reaction phase.
    • Corticosteroids may be administered intravenously or orally. Although most practitioners administer corticosteroids intravenously during status asthmaticus, some studies indicate that early administration of oral corticosteroids may be just as effective.
  • Anticholinergics
    • Anticholinergic agents act via inhibition of cyclic guanosine monophosphate (GMP)–mediated bronchoconstriction. They may also decrease mucus production and improve mucociliary clearance
    • Ipratropium bromide (Atrovent), a quaternary amine that does not cross the blood-brain barrier, is the recommended sympathomimetic agent of choice. Atropine, a tertiary amine, may also be used and nebulized but may cause CNS effects because it may enter the CNS. In patients with severe airflow obstruction, the combination of ipratropium and albuterol can provide better bronchodilatation than albuterol alone.
  • Further therapy: Although not as well investigated in large-scale, randomized, controlled trials, other therapies may be helpful when the standard combination of oxygen and intermittent or continuous beta-agonists (ie, albuterol), intermittent inhaled anticholinergics (ie, ipratropium bromide), and corticosteroids are insufficient in relieving significant respiratory distress in severe acute asthma. These include the following:
    • Magnesium sulfate
      • Magnesium can relax smooth muscle and hence cause bronchodilation by competing with calcium at calcium-mediated smooth muscle binding sites.
      • The published doses used range from 25-75 mg/kg infused over 20 minutes or less, with a maximum of 2-2.5 g/dose.
      • One double-blind placebo-controlled study reported a significant increase in peak expiratory flow, FEV1, and forced vital capacity in children who had asthma and were treated with a single 40-mg/kg dose of magnesium sulfate (MgSO4) infused over 20 minutes, along with steroids and inhaled bronchodilators, compared with control subjects who received saline placebo.5 In addition, patients who received intravenous magnesium (8 of 16 patients) were significantly more likely to be discharged home from the presenting ED than control subjects (0 of 14 patients; P = .002).
      • No data regarding duration of effect or efficacy with repeated doses are available, and no guidelines describe the monitoring of serum magnesium levels if more than an initial magnesium dose is administered. In one small study of 4 children who received 40-50 mg/kg MgSO4, serum magnesium levels were all less than 4 mg/dL, whereas ECG changes are generally not seen until levels exceed greater than 4-7 mg/dL. Adverse effects may include facial warmth, flushing, tingling, nausea, and hypotension.
    • Intravenous beta-agonists
      • Some patients with refractory status asthmaticus may respond to intravenous administration of beta-agonists. Intravenous albuterol and salbutamol may be administered where available but are not available in the United States. Intravenous terbutaline is most commonly used in the United States.6 Historically, isoproterenol has been used, but its potent beta1 stimulation may lead to significant tachycardia and inotropy, which has caused myocardial infarction in adults. Reported doses for intravenous terbutaline have ranged from 0.4-10 mcg/kg/min in children.
      • The dose administered should be titrated to effect and adverse cardiac effects (tachycardia, arrhythmias, ECG changes). Some practitioners advocate monitoring cardiac enzyme levels in patients who receive prolonged significant infusions of intravenous beta-agonists.
    • Ketamine
      • Ketamine is a short-acting pentachlorophenol (PCP) derivative that exerts bronchodilatory effects because it leads to an increase in endogenous catecholamine levels, which may bind to beta-receptors and cause smooth muscle relaxation and bronchodilation.
      • Case reports have also described the use of ketamine as a sedative to reduce anxiety and agitation that can exacerbate tachypnea and work of breathing and potentially obviate further respiratory failure in small children with status asthmaticus.
    • Methylxanthines
      • The role of methylxanthines, such as theophylline or aminophylline, in the treatment of severe acute asthma has been diminished since the advent of potent selective beta-agonists and their use at higher doses.7 At therapeutic doses, methylxanthines are weaker bronchodilators than beta-agonists and have many undesirable adverse effects, such as frequent induction of nausea and vomiting. Furthermore, most studies have failed to show additional benefit when methylxanthines are administered to patients who are already receiving frequent beta-agonists and steroids.
      • Nevertheless, several recent prospective, randomized, controlled studies in children with refractory status asthmaticus have reexamined the role of the methylxanthines theophylline and aminophylline and demonstrated improvement in the clinical asthma scores when compared with placebo control. One study compared intravenous theophylline with intravenous terbutaline in critically ill children with refractory asthma and demonstrated equal therapeutic efficacy but significantly lower costs associated with theophylline use.8 Among the theophylline effects that are important in managing asthma are bronchodilatation, increased diaphragmatic function, and central stimulation of breathing.
  • Other potential therapies
    • Helium
      • Helium is an inert gas that is less dense than nitrogen. The administration of a helium-oxygen mixture (heliox) reduces turbulent airflow across narrowed airways, which can help to reduce and, thus, relieve the work of breathing. This, in turn, can result in improved gas exchange and improve pH and clinical symptoms.9,10 It does not improve the caliber of the narrowed airways. Some data suggest that nebulized-size particles may be more uniformly distributed in the distal airways when nebulization treatments are administered via heliox than with a standard oxygen-nitrogen mixture.11
      • Heliox can be administered via a well-fitting face mask at flows high enough to prevent entrainment of room air. The effectiveness of heliox in reducing the density of administered gas and improving laminar airflow depends on the helium concentration of the gas; the higher the helium concentration, the more effective the result. Therefore, an 80:20 mixture of helium-oxygen is most effective, and heliox loses most of its clinical utility when the FiO2 is greater than 40%, reducing the percentage of helium to less than 60%. Therefore, the limitation to the use of heliox is the amount of supplemental oxygen the patient requires to maintain an adequate oxygen saturation. Heliox has also been used to drive mechanical ventilation with lower dynamic peak inspiratory pressures.
    • Inhaled anesthetic agents: Inhaled anesthetic agents, such as halothane, isoflurane, and enflurane, have been used with varying degrees of success in refractory intubated patients with severe asthma. The mechanism of action is unclear but they may have direct relaxant effects on airway smooth muscle.
    • Extracorporeal membrane oxygenation (ECMO): Some case reports describe instances of ECMO being successfully used in extreme cases of refractory status asthmaticus in which maximum standard pharmacotherapy and mechanical ventilation was unsuccessful, often involving significant pneumothoraces and hypoxia.12

Surgical Care

Status asthmaticus is generally managed by means of medical therapy, with some exceptions.

  • Thoracentesis or thoracostomy is indicated in pneumothoraces.
  • Some children may have asthma that is primarily exacerbated by gastroesophageal reflux disease (GERD). Some can be treated with a combination of antireflux and histamine 2 (H2)–receptor antagonist agents; however, surgery, such as Nissen fundoplication, is occasionally required.
  • Anesthesia support is needed if inhaled anesthetic agents are considered for refractory severe intubated status asthmaticus.
  • If all other support modalities fail and ECMO is required, surgical support for cannula placement at an established pediatric ECMO center should be performed as a life-saving therapy.

Consultations

  • Consult allergists or pulmonologists because these specialists can provide comprehensive follow-up care with the appropriate therapy; allergy testing, if indicated; control of environmental factors; and consistent follow-up testing and manipulation of medications as required. Admission to hospital for asthma should be considered a failure of outpatient management. Better outpatient therapy is necessary to prevent subsequent admissions.
  • Consultation with a surgeon may be required if the child can benefit from fundoplication.
  • Consultation with a member of social services can provide support in the complex management of a chronic illness.
  • Adolescents who have severe uncontrolled asthma and are nonadherent or have depression or significant behavioral issues may require the services of a psychiatrist or psychologist.

Diet

Some children with asthma may have episodes triggered by food allergies. Consultation with a nutritionist may be necessary to provide appropriate dietary management.

Medication

Management goals for status asthmaticus are (1) to reverse airway obstruction rapidly through aggressive use of beta2-agonist agents and early use of corticosteroids, (2) to correct hypoxemia by monitoring and administering supplemental oxygen, and (3) to prevent or treat complications such as pneumothorax or respiratory arrest.

Beta2-agonist agents

These agents relax airway smooth muscle, thus causing bronchodilation in patients with reversible airway obstruction such as asthma.


Albuterol (Proventil, Ventolin, ProAire)

Relaxes bronchial smooth muscle by action on beta2-receptors with little effect on cardiac muscle contractility.
Administer continuous nebulization through pump-driven aerosol or via small-particle aerosol generator

Adult

MDI: 1-2 inhalations q4-6h; 90 mcg/actuation
Nebulizer: 2.5-5 mg inhaled via nebulizer q4-6h; dilute 2.5 mg (0.5 mL of 0.5% inhalation solution) in 1-2.5 mL 0.9% sodium chloride solution or sterile water

Pediatric

MDI: Administer as in adults using a tube spacer; recent NHLBI guidelines suggest as much as 8-10 actuation/dose
Nebulizer: Administer as in adults
Continuous nebulized inhalation dose: 0.15-0.5 mg/kg/h; generally dose range is titrated between 5-25 mg/h as determined by clinical and adverse effects; maximum dose has not been determined

Beta-adrenergic blockers antagonize effects; inhaled ipratropium may increase duration of bronchodilatation by albuterol; cardiovascular effects may increase with MAOIs, inhaled anesthetics, tricyclic antidepressants, and sympathomimetic agents

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Excessive use, especially prolonged continuous use, can result in tachyphylaxis and down-regulation of beta-adrenergic receptors; caution in patients with hyperthyroidism or cardiovascular disorders; may cause diastolic hypotension with continuous high doses


Levalbuterol (Xopenex)

A selective beta2-agonist. Albuterol is a racemic mixture, while levalbuterol contains only the levo isomer of albuterol. Safety and efficacy have not been determined in children <12 y; multicenter trials in children 0-12 y are ongoing.

Adult

0.63 mg inhaled by nebulization q6-8h; dose may be increased to 1.25 mg tid

Pediatric

<6 years: Not established
6-11 years: 0.31 mg inhaled by nebulization q6-8h; may increase if needed, not to exceed 0.63 mg tid
>11 years: Administer as in adults

Decreased efficacy with beta-blockers; digoxin levels may be decreased; may potentiate the kaliuretic effects of drugs such as loop or thiazide diuretics; decreases serum digoxin levels by 16-22%; MAOIs may potentiate vascular constriction, extreme caution advised with coadministration

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Immediate hypersensitivity reactions have been reported; caution in patients with hypokalemia; may cause paradoxical bronchospasm and increased pulse rate or blood pressure


Terbutaline (Brethine)

Selective beta2-adrenergic agent produces relaxation of airway smooth muscle, resulting in bronchodilation in patients with asthma.

Adult

Nebulization: 0.01-0.03 mL/kg inhaled via nebulizer q2-4h (1 mg=1 mL); not to exceed 2.5 mg/dose
Subcutaneous: 0.01 mg/kg SC; not to exceed 0.3 mg/dose; may repeat q15-30 min for 2 doses
IV infusion: 0.1-10 mcg/kg/min IV have been used in refractory status asthmaticus; dose is titrated to effect and cardiovascular adverse effects

Pediatric

Administer as in adults

Concomitant use with beta blockers may inhibit bronchodilating, cardiac, and vasodilating effects of beta agonists; concomitant administration of MAOIs with beta sympathomimetics may result in a hypertensive crisis; concurrent administration of oxytocic drugs, such as ergonovine, may result in severe hypotension

Documented hypersensitivity; tachycardia resulting from cardiac arrhythmias; hypertension; tremors; drowsiness; headache; nausea

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Safe dosage limits have not been established, increased cardiac stimulation with higher doses; titrate infusions to effect while monitoring for additional cardiac adverse effects that include increasing tachycardia, potential for arrhythmias, and myocardial strain or ischemia with increasing myocardial oxygen consumption demand; through intracellular shunting, terbutaline may decrease serum potassium levels, which can produce adverse cardiovascular effects; decrease is usually transient and may not require supplementation

Anticholinergic agents

These agents are used for bronchodilation in patients with bronchospasm associated with asthma or chronic obstructive pulmonary disease (COPD).


Ipratropium bromide (Atrovent)

Chemically related to atropine. Has antisecretory properties and, when applied locally, inhibits secretions from serous and seromucous glands lining the nasal mucosa. Inhibits acetylcholine at parasympathetic sites in bronchial smooth muscle, resulting in bronchodilation.

Adult

MDI: 2-4 inhalations qid; not to exceed 12 inhalations/d

Pediatric

<2 years: 250 mcg (1.25 mL of 0.02% solution) inhaled by nebulization tid/qid
2-14 years:
MDI: 1-2 inhalations (MDI) tid/qid; not to exceed 12 inhalations/d;
Nebulizer: 500 mcg (2.5 mL of 0.02% solution) inhaled via nebulizer qid
Both MDI and nebulized doses may be prescribed

Potentiates effects of albuterol; toxic effects may be increased when used with other drugs with anticholinergic properties

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Not indicated as first-line therapy for acute episodes of bronchospasm; caution in narrow-angle glaucoma and bladder neck obstruction

Corticosteroids

These agents decrease inflammatory response observed in asthma. They also decrease capillary leak and augment beta-receptor response to beta-adrenergic agents.


Methylprednisolone (Solu-Medrol, Medrol); Prednisone

Interferes with arachidonic acid metabolism and production of leukotrienes, reduces microvascular leakage, reduces cytokine production, and prevents migration of inflammatory cells.

Adult

Prednisone: 2-60 mg PO qd or divided bid/qid
Methylprednisolone sodium succinate: 10-80 mg/d IV
Methylprednisolone acetate (suspension): 10-80 mg/d IM

Pediatric

Methylprednisolone sodium succinate:
Loading dose: 2 mg/kg IV
Maintenance dose: 0.5-1 mg/kg IV q6h

Coadministration with digoxin may increase digitalis toxicity secondary to hypokalemia; estrogens may increase levels of methylprednisolone; phenobarbital, phenytoin, and rifampin may decrease levels of methylprednisolone (adjust dose); monitor patients for hypokalemia when taking medication concurrently with diuretics

Documented hypersensitivity; viral, fungal, or tubercular skin infections

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution with hypertension, hyperthyroidism, thromboembolic phenomenon, peptic ulcer, diabetes mellitus, and myasthenia gravis; if patient has been receiving methylprednisolone for >3 d, abrupt cessation may result in acute adrenal insufficiency requiring gradual downward dose tapering

Other bronchodilator therapy

These agents are used as additional therapy for patients who remain in refractory status asthmaticus despite maximal inhalational therapy and the use of corticosteroids. These medications may be administered intravenously.


Theophylline or aminophylline IV

Bronchodilator in patients with reversible bronchospasm associated with asthma or COPD. Mechanism of action of theophylline is unclear, but its beneficial effects in asthma are thought to result from bronchodilation partly caused by phosphodiesterase inhibition, improved diaphragmatic inotropicity, CNS stimulation of the respiratory drive, and possible anti-inflammatory effects.
Start PO (eg, Slo-bid, Slo-Phyllin, Theolair, Theo-24, Uni-Dur, Theobid) dosing when patient is stable on continuous IV dose.
Theophylline is administered PO.
Aminophylline can be administered PO or IV. However, IV aminophylline is generally used for refractory status asthmaticus because of the severity of the patient's asthma, which results in the decision to add methylxanthines to the treatment regimen.
Aminophylline IV is 79% theophylline.

Adult

Use ideal body weight for dose calculation
Loading dose (in patients not currently receiving aminophylline or theophylline): 6 mg/kg IV aminophylline
Maintenance: 0.5-0.7 mg/kg/h IV
Patients who are elderly or have cor pulmonale, congestive heart failure, or liver failure: Limit dose to 0.25 mg/kg/h IV
Not to exceed IV infusion rate >25 mg/min

Pediatric

Loading dose (aminophylline IV): 6 mg/kg IV
Continuous IV infusion (aminophylline IV):
2-6 months: 0.4 mg/kg/h IV
6-11 months: 0.7 mg/kg/h IV
1-9 years: 1 mg/kg/h IV
9-12 years: 0.9 mg/kg/h IV
>12 years: 0.5 mg/kg/h IV
Not to exceed IV infusion rate >25 mg/min

CYP1A2 and CYP3A4 substrate; aminoglutethimide, barbiturates, carbamazepine, ketoconazole, loop diuretics, charcoal, hydantoins, phenobarbital, phenytoin, rifampin, isoniazid, and sympathomimetics may decrease effects of theophylline; theophylline effects may increase with allopurinol, beta-blockers, ciprofloxacin, corticosteroids, disulfiram, quinolones, thyroid hormones, ephedrine, carbamazepine, cimetidine, erythromycin, macrolides, propranolol, and interferon; smoking increases theophylline elimination, typically requiring an increased dose

Documented hypersensitivity; uncontrolled arrhythmias; peptic ulcers; hyperthyroidism; uncontrolled seizure disorders

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Side effects include nausea and vomiting (common), arrhythmias, seizures, tachycardia, and restlessness; caution in peptic ulcer, hypertension, tachyarrhythmias, hyperthyroidism, and compromised cardiac function; do not exceed IV infusion rate >25 mg/min; patients with pulmonary edema or liver dysfunction have increased risk of toxicity because drug clearance is reduced


Magnesium sulfate

Relaxes smooth muscle and may lead to adjunctive bronchodilation. Mechanism of action unknown, but may compete with calcium for smooth muscle binding sites leading to relaxation.

Adult

2 g IV infused over 20 min

Pediatric

25-75 mg/kg IV infused over 20 min (typical dose is 50 mg/kg); not to exceed 2 g IV infused over 20 min

Concurrent use with nifedipine may cause hypotension and neuromuscular blockade; may increase neuromuscular blockade seen with aminoglycosides and potentiate neuromuscular blockade produced by tubocurarine, vecuronium, and succinylcholine; may increase CNS effects and toxicity of CNS depressants, betamethasone, and cardiotoxicity of ritodrine; coadministration with digitalis may alter cardiac conduction and lead to heart block

Documented hypersensitivity; heart block, Addison disease, myocardial damage, coma, or severe hepatitis

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Levels may accumulate with repeated infusions and renal insufficiency; respiratory rate, deep tendon reflex, and renal function should be monitored when electrolyte is administered parenterally; caution when administering magnesium dose because may produce significant hypotension or asystole; in overdose, calcium gluconate, 10-20 mL IV of 10% solution, can be given as antidote for clinically significant hypermagnesemia; safety and efficacy of repeated infusions to treat of status asthmaticus have not been reported

More on Status Asthmaticus

Overview: Status Asthmaticus
Differential Diagnoses & Workup: Status Asthmaticus
Treatment & Medication: Status Asthmaticus
Follow-up: Status Asthmaticus
Multimedia: Status Asthmaticus
References
Further Reading
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References

  1. Gorelick M, Scribano PV, Stevens MW, Schultz T, Shults J. Predicting need for hospitalization in acute pediatric asthma. Pediatr Emerg Care. Nov 2008;24(11):735-44. [Medline].

  2. National Asthma Education and Prevention Program (NAEPP) Expert Panel. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. 2007. National Heart, Lung, and Blood Institute; August 28, 2007. [Full Text].

  3. [Best Evidence] Andrews T, McGintee E, Mittal MK, et al. High-dose continuous nebulized levalbuterol for pediatric status asthmaticus: a randomized trial. J Pediatr. Aug 2009;155(2):205-10.e1. [Medline].

  4. [Best Evidence] Castro-Rodriguez JA, Rodrigo GJ. Efficacy of inhaled corticosteroids in infants and preschoolers with recurrent wheezing and asthma: a systematic review with meta-analysis. Pediatrics. Mar 2009;123(3):e519-25. [Medline].

  5. Ciarallo L, Brousseau D, Reinert S. Higher-dose intravenous magnesium therapy for children with moderate to severeacute asthma. Arch Pediatr Adolesc Med. Oct 2000;154(10):979-83. [Medline].

  6. Stephanopoulos DE, Monge R, Schell KH, et al. Continuous intravenous terbutaline for pediatric status asthmaticus. Crit Care Med. Oct 1998;26(10):1744-8. [Medline].

  7. Ream RS, Loftis LL, Albers GM, et al. Efficacy of IV theophylline in children with severe status asthmaticus. Chest. May 2001;119(5):1480-8. [Medline]. [Full Text].

  8. Wheeler DS, Jacobs BR, Kenreigh CA, et al. Theophylline versus terbutaline in treating critically ill children with statusasthmaticus: a prospective, randomized, controlled trial. Pediatr Crit Care Med. Mar 2005;6(2):142-7. [Medline].

  9. [Best Evidence] Kim IK, Phrampus E, Venkataraman S, Pitetti R, Saville A, Corcoran T. Helium/oxygen-driven albuterol nebulization in the treatment of children with moderate to severe asthma exacerbations: a randomized, controlled trial. Pediatrics. Nov 2005;116(5):1127-33. [Medline].

  10. Kudukis TM, Manthous CA, Schmidt GA, Hall JB, Wylam ME. Inhaled helium-oxygen revisited: effect of inhaled helium-oxygen during the treatment of status asthmaticus in children. J Pediatr. Feb 1997;130(2):217-24. [Medline].

  11. Anderson M, Svartengren M, Bylin G, Philipson K, Camner P. Deposition in asthmatics of particles inhaled in air or in helium-oxygen. Am Rev Respir Dis. Mar 1993;147(3):524-8. [Medline].

  12. Hebbar KB, Petrillo-Albarano T, Coto-Puckett W, et al. Experience with use of extracorporeal life support for severe refractory status asthmaticus in children. Crit Care. Mar 2 2009;13(2):R29. [Medline].

  13. Elias JA, Zhu Z, Chupp G, Homer RJ. Airway remodeling in asthma. J Clin Invest. Oct 1999;104(8):1001-6. [Medline]. [Full Text].

  14. Pearlman DS. Pathophysiology of the inflammatory response. J Allergy Clin Immunol. Oct 1999;104(4 Pt 1):S132-7. [Medline].

  15. Asthma. In: Fuhrman B, Zimmerman J, eds. Pediatric Critical Care. 2nd ed. St. Louis, MO: Mosby; 1998:473-5.

  16. Scarfone RJ, Loiselle JM, Joffe MD, et al. A randomized trial of magnesium in the emergency department treatment of childrenwith asthma. Ann Emerg Med. Dec 2000;36(6):572-8. [Medline].

  17. Schuh S, Johnson DW, Callahan S, et al. Efficacy of frequent nebulized ipratropium bromide added to frequent high-dosealbuterol therapy in severe childhood asthma. J Pediatr. Apr 1995;126(4):639-45. [Medline].

  18. Schwarz AJ, Lubinsky PS. Acute severe asthma. In: Levin DL, Morriss FC, eds. Essentials of Pediatric Intensive Care. Vol 1. 2nd ed. 1997:143-56.

  19. Werner HA. Status asthmaticus in children: a review. Chest. Jun 2001;119(6):1913-29. [Medline]. [Full Text].

  20. Yung M, South M. Randomised controlled trial of aminophylline for severe acute asthma. Arch Dis Child. Nov 1998;79(5):405-10. [Medline]. [Full Text].

  21. Zorc JJ, Pusic MV, Ogborn CJ, et al. Ipratropium bromide added to asthma treatment in the pediatric emergency department. Pediatrics. Apr 1999;103(4 Pt 1):748-52. [Medline]. [Full Text].

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Further Reading

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Keywords

asthma, asthma unresponsive to treatment with bronchodilators, wheezing, dyspnea, cough, reactive airways disease, RAD, severe asthma, status asthmaticus, airway hyperresponsiveness, treatment, diagnosis, symptoms

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Contributor Information and Disclosures

Author

Adam J Schwarz, MD, Consulting Staff, Critical Care Division, Pediatric Subspecialty Faculty, Children's Hospital of Orange County
Adam J Schwarz, MD is a member of the following medical societies: American Academy of Pediatrics and Phi Beta Kappa
Disclosure: Nothing to disclose.

Medical Editor

G Patricia Cantwell, MD, Associate Clinical Professor, Department of Pediatrics, University of Miami; Director of Pediatric Critical Care Medicine, Miller School of Medicine, Jackson Children's Hospital
G Patricia Cantwell, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Emergency Physicians, American Heart Association, American Trauma Society, National Association of EMS Physicians, Society of Critical Care Medicine, and Wilderness Medical Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Barry J Evans, MD, Assistant Professor of Pediatrics, Temple University Medical School; Director of Pediatric Critical Care and Pulmonology, Associate Chair for Pediatric Education, Temple University Children's Medical Center
Barry J Evans, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, American Thoracic Society, and Society of Critical Care Medicine
Disclosure: Nothing to disclose.

CME Editor

Mary E Cataletto, MD, Associate Director, Division of Pediatric Pulmonology, Winthrop University Hospital; Professor of Clinical Pediatrics, State University of New York at Stony Brook; Director of Children's Sleep Services, Winthrop University Hospital
Mary E Cataletto, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Chest Physicians
Disclosure: Shering Plough Pharmaceuticals Honoraria Consulting

Chief Editor

Michael R Bye, MD, Professor of Clinical Pediatrics, Division of Pulmonary Medicine, Columbia University College of Physicians and Surgeons; Attending Physician, Pediatric Pulmonary Medicine, Morgan Stanley Children's Hospital of New York Presbyterian, Columbia University Medical Center
Michael R Bye, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, and American Thoracic Society
Disclosure: Merck Honoraria Speaking and teaching

 
 
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