Status Asthmaticus in Children

StatusAsthmaticusinChildren
HeinrichWerner
PediatricCriticalCare
UniversityofKentuckyChildrens
Hospital
hwerner
Statusasthmaticus
Objectives
Theparticipantwillincreasehis/her
Awarenessofrisingmorbidity/mortalityofsevereasthmain
children
Abilitytodefinewhoisatriskfordying
Understandingofthepathologic,metabolicandbiomechanical
events
Abilitytopredictrespiratoryfailureandtodeterminethe
needforearlytransfer
Abilitytotailorthetherapeuticregimenaccordingtoseverity
andprogressionofstatusasthmaticus
Statusasthmaticus
Epidemiology
Pathophysiology
PresentationandAssessment
Treatment
Statusasthmaticus
Epidemiology
Prevalence
Morbidity
Mortality
Riskfactors
Pathophysiology
Presentationandassessment
Treatment
Statusasthmaticus :Epidemiology
Prevalence
Theprevalenceofpediatricasthmainthe
USisincreasing
60
50
1975
1980-81
1985
1989
1990-92
1993-95
40
30
20
10
0
0-4 yrs
5-14 yrs
Rate of self-reported asthma/1,000 population

ManninoDM.MMWR1998;47(1):127
15-34 yrs
Morbidity
Themorbidityofpediatricasthmainthe
USisincreasing
Rate per 10,000 population
70
60
50
< 1 year
1-4 years
5-14 years
15-24 years
40
30
20
10
Hospital discharge rates for asthma

MMWR1996;45(17):3503
1992
1990
1988
1986
1984
1982
1980
Mortality
ThemortalityofpediatricasthmaintheUS
isincreasing
Rate per 1,000,000 population
7
6
5
0-4 years
5-14 years
15-34 years
4
3
2
1
0
1979-80 1981-83 1984-86 1987-89 1990-92 1993-95
Rates of death in children from asthma

Mannino.MMWR1998;47(1):127
Riskfactorsforfatalasthma
Medical
Previousattackwithrapid/severedeteriorationorrespiratory
failureorseizure/lossofconsciousness
Psychosocial
Denial,noncompliance
Depressionorotherpsychiatricdisorder
Dysfunctionalfamily
Innercityresident
Ethnic
Nonwhitechild
Statusasthmaticus
Epidemiology
Pathophysiology
Cytokines
Airwaypathology
Autonomicnervoussystem
Pulmonarymechanics
Cardiopulmonaryinteractions
Metabolism
Treatment
Statusasthmaticus :Pathophysiology
Pathophysiology
Asthmaisprimarilyaninflammatorydisease
Smooth muscle
spasm
Airway edema
Mucous plugging
Inflammatorycytokines
Activatedmastcellsandlymphocytes
produceproinflammatorycytokines
(histamine,leukotrienes,PAF),whichare
increasedinasthmaticsairwaysand
bloodstream
Irritableanddamagedairway
Hypersecretion
Epithelialdamagewith
exposednerveendings
Hypertrophyofgobletcells
andmucusglands
Airway
Theirritableandinflamedairwayissusceptibleto
obstructiontriggeredby
Allergens
Infections
Irritantsincludingsmoke
Exercise
Emotionalstress
GEreflux
Drugs
Otherfactors
Autonomicnervoussystem
Bronchodilation
Sympathetic
Circulatingcatecholamines
stimulatereceptors
Parasympathetic
Vagalsignalsstimulate
bronchodilatingM2
receptors
Nonadrenergic
noncholinergic
(NANC)
Releaseofbronchodilating
neurotransmitters(VIP,NO)
Bronchoconstriction
Vagalsignalsstimulate
bronchoconstrictingM3
receptors
Releaseoftachykinins(substance
P,neurokininA)
Lungmechanics
Hyperinflation
Obstructedsmallairwayscausepremature
airwayclosure,leadingtoairtrappingand
hyperinflation
Hypoxemia
Inhomogeneousdistributionofaffectedareas
resultsinV/Qmismatch,mostlyshunt
Severeairflow
obstruction
Incomplete
exhalation
Increasedlung
volume
Increasedelastic
recoilpressure
Expandedsmall
airways
Increased
expiratoryflow
Decreasedexpiratory
resistance
Compensated:
Hyperinflation,normocapnia
Worsening
airflow
obstruction
Decompensated:
Severehyperinflation,hypercapnia
Fromtextin:
Tuxen.AmRev
RespirDis
1992;146:1136
Leftventricularload
Spontaneouslybreathingchildrenwithsevere
asthmahavenegativeintrapleuralpressure
(aslowas35cmH2O)duringalmostthe
entirerespiratorycycle
StalcupS.NEnglJMed1977;297:5926
Negativeintrapleuralpressurecauses
increasedleftventricularafterload,resulting
inriskforpulmonaryedema
BudaAJ.NEnglJMed1979;301(9):4539
Rightventricularload
Hypoxicpulmonaryvasoconstrictionandlung
hyperinflationleadtoincreasedright
ventricularafterload
DawsonCA.JApplPhysiol1979;47(3):5326
Pulsusparadoxus
P.paradoxusistheclinicalcorrelateofcardiopulmonary
interactionduringasthma.Itisdefinedasexaggerationof
thenormalinspiratorydropinsystolicBP:normally<5
mmHg,but>10mmHginpulsusparadoxus.
Nl
P.paradoxus
Expir
Inspir
Expir
Inspir
Pulsusparadoxuscorrelateswith
severity
AllpatientswhopresentedwithFEV1of<20%
(oftheirbestFEV1whilewell)hadpulsus
paradoxus
PiersonRN.JApplPhysiol1972;32(3):3916
Negative intrapleural
pressure
Hyperinflation
Altered hemodynamics
Pulmonary edema
Pulsus paradoxus
Hypotension
Metabolism
V/Q mismatch
Increased work
of breathing
Dehydration
Hypoxia
Lactate
Metabolic acidosis
Ketones
Statusasthmaticus :Presentation
Presentation
Audiblewheezes:reasonableairflow
Audiblewheezes:reasonableairflow
Cough
Silentchest:ominous!
Silentchest:ominous!
Wheezing
Increasedworkofbreathing
Anxiety
Restlessness
Oxygendesaturation
Statusasthmaticus :Assessment
Assessment
Findingsconsistentwithimpendingrespiratory
failure:
Alteredlevelofconsciousness
Inabilitytospeak
Absentbreathsounds
Centralcyanosis
Diaphoresis
Inabilitytoliedown
Markedpulsusparadoxus
5 = impending resp failure
ClinicalAsthmaScore
0
Cyanosisor None Inair In40%

PaO2 >70inair
<70inair
<70in40%
InspiratoryB/S
Nl
Unequalor
Expirwheezing
None Moderate
Marked
Cerebralfunction
Agitated
Nl
Coma
Depressed
WoodDW.AmJDisChild1972;123(3):2278
Absent
decreased
ChestXRay
Notroutinelyindicated
Exceptions:
Patientisintubated/ventilated
Suspectedbarotrauma
Suspectedpneumonia
Othercausesforwheezingarebeingsuspected
ABG
Earlystatusasthmaticus:hypoxemia,
hypocarbia
Late:hypercarbia
Decisiontointubateshouldnotdependon
ABG,butonclinicalassessment
FrequentABGsarecrucialintheventilated
asthmatic
Statusasthmaticus
Epidemiology
Pathophysiology
Treatment
Conventional
General,agonists,steroids,anticholinergics
Advanced
Mechanicalventilation,ketamine,inhalationalanesthetics
Unusual/Unproven
Theophylline,magnesium,LTRAs,heliox,bronchoscopy
Statusasthmaticus :Treatment
Oxygen
Deliverhighflowoxygen,as
severeasthmacausesV/Q
mismatch(shunt)
Oxygenwillnotsuppressrespiratorydrivein
childrenwithasthma
SchiffM.ClinChestMed1980;1(1):859
Fluid
JudicioususeofIVfluidnecessary
Mostasthmaticsaredehydratedon
presentationsrehydratetoeuvolemia
Overhydrationmayleadtopulmonary
edema
SIADHmaybecommoninsevereasthma
BakerJW.MayoClinProc1976;51(1):314
Antibiotics
Mostinfectionsprecipitatingasthma
areviral
Antibioticsarenotroutinely
indicated
JohnstonSL.PediatrPulmonolSuppl1999;18:1413
Agonists
receptoragonistsstimulate 2receptorsonbronchialsmoothmuscleandmediatemusclerelaxation
Epinephrine
Isoproterenol
Terbutaline
Albuterol
Significant1cardiovascular
effects
Relatively2selective
Agonists
Lessthan10%ofnebulizeddrugreachthe
lungunderidealconditions
BisgaardH.JAsthma1997;34(6):44367
Drugdeliverydependson
Breathingpattern
Tidalvolume
Nebulizertypeandgasflow
Agonists
Deliveryofnebulizeddrug
Onlyparticles
between m are
depositedinalveoli
Correctgasflowrateis
crucial
Mostdevicesrequire1012
L/mingasflowtogenerate
correctparticlesize
Agonists
Continuousnebulizationissuperiorto
intermittentnebulization
Morerapidimprovement
Morecosteffective
Morepatientfriendly
PapoMC.CritCareMed1993;21:147986
AckermanAD.CritCareMed1993;21:14224
Agonists
Dosage
Intermittentnebulization
2.55mg(0.51mlof0.5%solution),dilutewithNS
to3ml
Prediluted:2.5mgas3mlof0.083%solution
Highdose:useuptoundiluted5%solution
Continuousnebulization
440mg/hr
Highdose:uptoundiluted5%solution( 150mg/hr)
Agonists
IntravenousAgonist
Considerforpatientswithsevereairflow
limitationwhoremainunresponsiveto
nebulizedalbuterol
Terbutalineisi.v.agonistofchoiceinUS
Dosage:0.110 g/kg/min
StephanopoulosDE.CritCareMed1998;26(10):17448
Agonists
Sideeffects
Tachycardia
Agitation,tremor
Hypokalemia
Agonists
Cardiacsideeffects
Myocardialischemiaknowntooccurwithi.v.
isoproterenol
Nosignificantcardiovasculartoxicitywithi.v.
terbutaline(prospectivestudyinchildrenwith
severeasthma)
ChiangVW.JPediatr2000;137(1):737
Tachycardia(andtremor)showtachyphylaxis,
bronchodilationdoesnot
LipworthBJ.AmRevRespirDis1989;140(3):58692
Steroids
Asthmaisaninflammatorydisease
Steroidsareamandatoryelementoffirst
linetherapyregimen(fewexceptionsonly)
140
120
F E V 1%
100
80
Steroids
Placebo
60
40
20
Effectofi.v.
hydrocortisone
vs.placebo
0
-20
-5
12
18
24
Hours
FantaCH:AmJMed1983;74:845
Steroids
Hydrocortisone48mg/kgx1,then24
mg/kgq6
Methylprednisolone2mg/kgx1,then0.51
mg/kgq46
Steroids
Significantsideeffects
Hyperglycemia
Hypertension
Acutepsychosis
Unusualorunusuallysevereinfections
Steroidscontraindicatedwithactiveor
recentexposuretochickenpox
Allergicreaction
Reportedwithmethylprednisolone,
hydrocortisoneandprednisone*
*VanpeeD.AnnEmergMed1998;32(6):754.KammGL.AnnPharmacother1999;33(4):45160.
SchonwaldS.AmJEmergMed1999;17(6):5835.JudsonMA.Chest1995;107(2):5635.
AnticholinergicsIpratropium
Quaternaryatropinederivative
Notabsorbedsystemically
Thusminimalcardiaceffects
(Butyouwillfindafixed/dilatedpupilifthenebulizermaskslipsover
aneye!)
Anticholinergics
ChangeinFEV1issignificantlygreaterwhen
ipratropiumwasaddedtoagonists(199adults)
RebuckAS:AmJMed1987;82:59
Highlysignificantimprovementinpulmonary
functionwhenipratropiumwasaddedto
albuterol(128children).Sickestasthmatics
experiencedgreatestimprovement
SchuhS.JPediatr1995;126(4):63945
Ipratropium
DoseResponseCurveinChildren(n=19,age11
17yrs)
Average increase in FEV1 (over 4 hrs)
0.4
0.3
0.2
0.1
0
7.5
25
75
Dose (micrograms)
DavisA:JPediatr1984;105:1002
250
Ipratropium
Nebulize250500 gevery46hours
SchuhS.JPediatr1995;126(4):63945
GoodmanandGilman's.9thed.NewYork:McGrawHill;1996
Intubation,Ventilation
Absoluteindications:
Cardiacorrespiratoryarrest
Severehypoxia
Rapiddeteriorationinmentalstate
Respiratoryacidosisdoesnotdictate
intubation
Whyhesitatetointubatethe
asthmaticchild?
Trachealforeignbody
aggravatesbronchospasm
Positivepressureventilation
increasesriskofbarotrauma
andhypotension
TuxenDV.AmRevRespirDis1987;136(4):8729
>50%ofmorbidity/mortalityduringsevereasthma
occursduringorimmediatelyafterintubation
ZimmermanJL.CritCareMed1993;21(11):172730
Intubation
Preoxygenate,decompressstomach
Sedate(considerketamine)
Neuromuscularblockade(mayavoid
largeswingsinairway/pleuralpressure)
Rapidorotrachealintubation(consider
cuffedtube)
Immediatelyafterintubation
Expecthypotension,circulatorydepression
Allowlongexpiratorytime
Avoidoverzealousmanualbreaths
Considervolumeadministration
Considerpneumothorax
Considerendotrachealtubeobstruction(++
secretions)
Mechanicalventilation
Positivepressureventilationworsens
hyperinflation/riskofbarotrauma
Thoughtfulstrategiesinclude:
Pressurelimitedventilation,TV812ml/kg,shortT i,rate
812/min(permissivehypercapnia)
CoxRG.PediatrPulmonol1991;11(2):1206
PressuresupportventilationusingPS=2030cmH 2O(may
decreasehyperinflationbyallowingactiveexhalation)
WetzelRC.CritCareMed1996;24(9):16035
Ketamine
Dissociativeanestheticwithstrong
analgesiceffect
Directbronchodilatingaction
Usefulforinduction(2mg/kgi.v.)aswellas
continuousinfusion(0.52mg/kg/hr)
Inducesbronchorrhea,emergencereaction
Inhalationalanesthetics
Halothane,isofluranehavebronchodilating
effect
Halothanemaycausehypotension,
dysrhythmia
Requiresscavengingsystem,continuous
gasanalysis
Theophylline
Roleinchildrenwithsevereasthma
remainscontroversial
Narrowtherapeuticrange
Highriskofseriousadverseeffects
Mechanismofeffectinasthmaremains
unclear
Theophylline
Mayhavearoleinselected,criticallyillchildren
withasthmaunresponsivetoconventional
therapy:
Randomized,placebocontrolled,blindedtrial(n=163)inchildrenwith
severestatusasthmaticus
TheophyllinegrouphadgreaterimprovementinPFTsandO 2saturation
Nodifferenceinlength
FEV1(%)
ofPICUstay
60
Theophyllinegrouphadsignifi
50
cantlymoreN/V
40
Placebo
Theophylline
30
YungM.ArchDisChild1998;79(5):40510.
20
10
0
Prior
6hr
12hr
24hr
Magnesium
Smoothmusclerelaxationbyinhibitionof
calciumuptake(=bronchodilator)
Dosagerecommendation:2575mg/kgi.v.
over20minutes
Magnesium
Severalanecdotalreports
Onlyonerandomizedpediatrictrial
Randomized,placebocontrolled,blindedtrial(n=31)inchildren
withacuteasthmainER(MgSO425mg/kgi.v.for20min)
Magnesiumgrouphadsignificantlygreaterimprovementin
60
FEV1/PEFR/FVC
Magnesiumgroupmorelikely
50
40
tobedischargedhome
30
Noadverseeffects
20
CiaralloL.JPediatr1996;129(6):80914.
10
0
50min
80min
110min
Placebo
Magnesium
Statusasthmaticus
Leukotrienereceptorantagonists
(LTRAs)
Asthmaticchildrenhaveincreased
leukotrienelevels(blood,urine)during
anattack.Levelfallsasattackresolves
SampsonAP.AnnNYAcadSci1991;629:4379.
LTRAadministrationisassociatedwith
improvementinlungfunctionin
asthmatics
GaddyJN.AmRevRespirDis1992;146(2):35863.
Statusasthmaticus
LTRAs
Steroidadministrationtoasthmaticshas
littleeffectonleukotrienelevels
O'ShaughnessyKM.AmRevRespirDis1993;147(6Pt1):14726.
Thus,LTRAsmayofferadditionalbenefits
toasthmaticsonsteroids
ReissTF.ArchInternMed1998;158(11):121320.
Statusasthmaticus
IntravenousLTRAsinmoderate
tosevereasthma
Asingledoseofi.v.
montelukast
(Singulair)was
associatedwith
significant
improvementinlung
functioncomparedto
standardtherapy
CamargoCA,Jr.AmJRespirCritCareMed2003;167(4):52833.
Statusasthmaticus
LTRAsRemainingquestions
Willtheyofferaddedbenefitintheacute,severe
asthmaticchildalreadyonagonists,steroids,
anticholinergics?
Morerapidimprovementinlungfunction/clinicalscore?
Reduced/shortenedhospitalization?
FewerPICUadmissions?
Cost?
Adverseeffects?
HeliumOxygen(Heliox)
Heliumlowersgasdensity(ifatleast
60%heliumfraction)
Reducesresistanceduringturbulentflow
Rendersturbulentflowlesslikelyto
occur
Heliox
Anecdotalreportsofimprovedrespiratory
mechanicsinnonintubatedandintubated
asthmaticchildren
Prospective,randomized,blindedcrossover
studyofhelioxinnonintubatedchildren
withsevereasthma(n=11):noeffecton
respiratorymechanicsorasthmascore
CarterER.Chest1996;109(5):125661.
Heliox
Heliumoxygen(80:20)decreasedpulsus
paradoxusandincreasedPEFRina
controlledtrialofadultpatients
ManthousCA.AmJRespirCritCareMed1995,151:310314
Helioxmayworsendynamichyperinflation
MadisonJM.Chest1995,107:597598
Bronchoscopy,bronchial
lavage
Markedmucuspluggingmayrender
bronchodilatingandantiinflammatory
therapyineffective
Plasticbronchitishasbeendescribedin
asthmaticchildren
Combinedbronchoscopy/lavagehasbeen
usedindesperatelyillasthmaticchildren
Statusasthmaticus
Summary
Severeasthmainchildrenisincreasinginprevalence
andmortality
Aggressivetreatmentwithagonist,steroidsand
anticholinergiciswarrantedeveninthesickappearing
child
Avoidintubationifpossible
Mechanicalventilationwillworsenbronchospasmand
hyperinflation
Uselowmorbidityapproachtomechanicalventilation
Statusasthmaticus
Prevention
Stepstowardprevention
1.
Identifypatientsasatrisk
2.
Tellthemabouttheirrisks
3.
Organizetreatmentplan
4.
Facilitateaccesstocontinuedcare
Statusasthmaticus
CaseScenario(1)
A6yoblackmalewithprevioushistoryofasthmais
admittedwithsevererespiratorydistress.Heiswheezing,
RRis40/min,HR145/min.Hesitsupright,leansforward,
hasretractionsandlooksveryanxious.Hecorrectlytells
youhisnameandphone#,buthastotakeabreathafter
everyfewwords.
Discussyourinitialtherapeuticapproach.
Statusasthmaticus
CaseScenario(2)
Whichofthefollowingaremandatoryinthischildwithsevere
asthma?
(Youmaychosenone,morethanoneorall)
Arterialbloodgasanalysis(todetectonsetofrespiratory
acidosis)
Continuouspulseoximetry
Chestradiograph(toruleoutpneumomediastinum/thorax)
Frequentdeterminationofpeakexpiratoryflowrate
Whitebloodcellcountwithdifferential(toassessneedfor
antibiotics)
Statusasthmaticus
CaseScenario(3)
Givenhiscurrentpresentation:doesthischildneedtobe
intubatedandmechanicallyventilated?
Discussindicationsforintubation/mechanicalventilation
inthechildwithseverestatusasthmaticus.
Statusasthmaticus
CaseScenario(4)
Whennebulizingdrugsduringstatusasthmaticus,thefollowing
statementaboutgasflowratesisCORRECT:
A.
B.
C.
D.
Thehigherthegasflowratethroughthenebulizer,the
moreparticleswillbedepositedinthepatientsalveolar
space
Mostdevicesrequireagasflowrateof1012L/minto
generateoptimalparticlesize
Gasflowratesabove5L/minshouldbeavoidedto
maintainlaminarflowinthenebulizeroutput
Thenebulizerdeviceshouldnotbedrivenby100%oxygen
Statusasthmaticus
CaseScenario(5)
Inadditiontoadministrationofcontinuouslynebulizedbeta
agonistandintermittentanticholinergicagonist,whichofthe
followingisalmostmandatory?Discussprosandconsforeach.
A.
B.
C.
D.
E.
Intravenousbolusofaminophylline,followedby
infusion
Intravenouscorticosteroid
Intravenousbroadspectrumantibiotic
Intravenousbetaagonistinfusion
Inhaledheliumoxygenmixture
Statusasthmaticus
CaseScenario(6)
After3hoursoftherapyinthePICU,includinghighdose
continuousalbuterol,intermittentipratropium,I.v.
methylprednisoloneaswellastwoinfusionsofmagnesium
sulfate,thechildbecomesobtunded.HisO2saturations
begintodropbelow85%.Isthisanindicationfor
intubation/mechanicalventilation?
Ifso,describeyourapproachtointubatingthischild.
Howtoprepare?Drugs?ETTsize,route?Anticipatedproblems/
complications?Initialpatternofventilation?
Statusasthmaticus
CaseScenario(7)
Afteryouconnectthechildtotheventilator,hedevelops
markedarterialhypotension.
Whatisyourdifferentialdiagnosis?
Whatshouldyoudo?
Statusasthmaticus
SuggestedReading(part1):
1. LaitinenLA,HeinoM,LaitinenA,etal.Damageofairwayepitheliumandbronchialreactivityinpatientswithasthma.
AmRevRespirDis1985;131(4):599606.
2. BeakesDE.Theuseofanticholinergicsinasthma.JAsthma1997;34(5):35768.
3. BarnesPJ.Betaadrenergicreceptorsandtheirregulation.AmJRespirCritCareMed1995;152(3):83860.
4. MiroA,PinskyM.CardiopulmonaryInteractions.In:FuhrmanB,ZimmermanJ,editors.PediatricCriticalCare.
Seconded.St.Louis:Mosby;1998.p.25060.
5. StalcupSA,MellinsRB.Mechanicalforcesproducingpulmonaryedemaandacuteasthma.NEnglJMed
1977;297(11):5926.
6. RebuckAS,PengellyLD.Developmentofpulsusparadoxusinthepresenceofairwayobstruction.NEnglJMed
1973;288(2):669.
7. PapoMC,FrankJ,ThompsonAE.Aprospective,randomizedstudyofcontinuousversusintermittentnebulized
albuterolforseverestatusasthmaticusinchildren.CritCareMed1993;21:147986.
8. KatzRW,KellyHW,CrowleyMR,etal.Safetyofcontinuousnebulizedalbuterolforbronchospasmininfantsand
children[publishederratumappearsinPediatrics1994Feb;93(2):A28].Pediatrics1993;92(5):6669.
9. SchuhS,JohnsonDW,CallahanS,etal.Efficacyoffrequentnebulizedipratropiumbromideaddedtofrequenthighdose
albuteroltherapyinseverechildhoodasthma.JPediatr1995;126(4):63945.
10. FantaCH,RossingTH,McFaddenER.Glucocorticoidsinacuteasthma:Acriticalcontrolledtrial.AmJMed
1983;74:84551.
Statusasthmaticus
SuggestedReading(part2):
11. KleinGitelmanMS,PachmanLM.Intravenouscorticosteroids:adversereactionsaremorevariablethan
expectedinchildren.JRheumatol1998;25(10):19952002.
12. StephanopoulosDE,MongeR,SchellKH,etal.Continuousintravenousterbutalineforpediatricstatus
asthmaticus.CritCareMed1998;26(10):17448.
13. ChiangVW,BurnsJP,RifaiN,etal.Cardiactoxicityofintravenousterbutalineforthetreatmentofsevere
asthmainchildren:aprospectiveassessment.JPediatr2000;137(1):737.
14. CiaralloL,SauerAH,ShannonMW.Intravenousmagnesiumtherapyformoderatetoseverepediatric
asthma:resultsofarandomized,placebocontrolledtrial.JPediatr1996;129(6):80914.
15. PabonH,MonemG,KissoonN.Safetyandefficacyofmagnesiumsulfateinfusionsinchildrenwithstatus
asthmaticus.PediatrEmergCare1994;10:2003.
16. YungM,SouthM.Randomisedcontrolledtrialofaminophyllineforsevereacuteasthma.ArchDisChild
1998;79(5):40510.
17. TuxenDV,LaneS.Theeffectsofventilatorypatternonhyperinflation,airwaypressures,andcirculationin
mechanicalventilationofpatientswithsevereairflowobstruction.AmRevRespirDis1987;136(4):8729.
18. WetzelRC.Pressuresupportventilationinchildrenwithsevereasthma.CritCareMed1996;24(9):16035.
19. IbsenLM,BrattonSL.Currenttherapiesforsevereasthmaexacerbationsinchildren.NewHoriz
1999;7(3):31225.
20. WernerHA.Statusasthmaticusinchildren:areview.Chest2001;119(6):191329.

Status Asthmaticus in Children

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StatusAsthmaticusinChildren

Rate of self-reported asthma/1,000 population

Hospital discharge rates for asthma

Rates of death in children from asthma

5 = impending resp failure

Cyanosisor None Inair In40%

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