Severe Acute Asthma Exacerbation in Children: A Stepwise Approach for Escalating Therapy in a Pediatric Intensive Care Unit

Abstract

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 , 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 β-agonists, ipratropium, and steroids (intravenous preferable over oral preparations). Patients with worsening clinical status should be progressively treated with continuous β-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. INDEX TERMS asthma, child, critical care, infant, respiratory failure, status asthmaticus J Pediatr Pharmacol Ther 2013;18(2):88-104

Acute exacerbation in COPD and asthma

“…"Status astmaticus"; yirmi dört saatten uzun süren, ağır, hayatı tehdit eden astım ataklarının genel terminolojisi olarak kullanılmıştır, hızlı etkili beta agonistlere cevapsız, yoğun mukus artışı saptanan, hızlı veya yavaş başlayabilen ataklardır (25)(26)(27) %40'dan fazla PEF variabilitesi olması, Tip 2; önce-sinde, tetikleyen bulunmaması ve normal solunum fonksiyonları olmasına rağmen üç saat içinde gelişen ani ağır atak ile karakterizedir (28).…”

“…Bunların erişkinlerde %13'ünün hafif, %22'sinin orta ve %6'sının ağır astım olguları olduğu gözlenirken, çocuklarda %23'ü hafif, %41'i orta ve % 36'sı ağır olgu olarak bildirilmiştir (25,30).…”

An Asthma Protocol Improved Adherence to Evidence-Based Guidelines for Pediatric Subjects With Status Asthmaticus in the Emergency Department

“…[1][2][3] Bronchodilator and systemic cortico-steroid therapies are the mainstays of emergency department management of asthma exacerbations. Despite appropriate emergency department treatment, up to 27% of these patients require admission, making asthma the most common reason for pediatric hospitalization.…”

“…Despite appropriate emergency department treatment, up to 27% of these patients require admission, making asthma the most common reason for pediatric hospitalization. 3 Status asthmaticus represents an important subset of pediatric asthma exacerbations, with nearly 500,000 patients requiring admission to the pediatric ICU each year. 3 An analysis of our institution's emergency department asthma management revealed that adherence to evidencebased asthma guidelines was suboptimal.…”

“…3 Status asthmaticus represents an important subset of pediatric asthma exacerbations, with nearly 500,000 patients requiring admission to the pediatric ICU each year. 3 An analysis of our institution's emergency department asthma management revealed that adherence to evidencebased asthma guidelines was suboptimal. Areas identified for potential improvement are detailed in Figure 1.…”