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Severe acute asthma exacerbation in children: a stepwise approach for escalating therapy in a pediatric intensive
I Federico Fernandez Nievas1, Kanwaljeet J S Anand
1Departments of Pediatrics, Anesthesiology, Anatomy & Neurobiology, Division of Critical Care Medicine, University of Tennessee Health Science Center, and Le Bonheur Children's Hospital, Memphis, Tennessee.
Insights
Severe pediatric asthma exacerbations require objective assessment and a stepwise treatment approach. This evidence-based strategy, including medications and ventilation, can effectively manage critical illness in children with severe asthma.
Area of Science:
- Pediatric critical care medicine
- Respiratory medicine
- Asthma management
Background:
- Increasing prevalence of pediatric asthma leads to more severe exacerbations.
- Severe asthma attacks can cause respiratory distress, hypoxia, and failure.
Purpose of the Study:
- Review definitions, epidemiology, pathophysiology, and clinical features of severe acute asthma.
- Develop an evidence-based, stepwise approach for escalating therapy in pediatric severe asthma.
Main Methods:
- MEDLINE search (1980-2012) for asthma, status asthmaticus, critical asthma, and drug therapy.
- Manual search of personal files and cited references.
- Review of treatment algorithms from Le Bonheur Children's Hospital.
Main Results:
- Continuous cardiorespiratory monitoring and objective asthma severity scoring are essential.
- Initial treatment includes beta-agonists, ipratropium, and steroids.
- Worsening cases require progressive therapy: continuous beta-agonists, magnesium, helium-oxygen, terbutaline/aminophylline, high-flow oxygen, and non-invasive ventilation.
- Sedation with ketamine may aid ventilation and prepare for mechanical ventilation if needed.
Conclusions:
- Severe pediatric asthma is manageable with serial objective assessments and a stepwise clinical approach.
- This approach was successfully implemented in a tertiary-care children's hospital after multidisciplinary training.
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 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.
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