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Objective: To determine if children with chronic asthma hospitalized for an acute exacerbation experienced prolonged clinical recovery after hospital discharge if they returned to a home environment in which they were exposed to environmental tobacco smoke., Design: A prospective longitudinal study., Setting: Children's Hospital and Medical Center, Seattle, Wash., Patients: Patients admitted to the emergency department of the Children's Hospital and Medical Center with the single diagnosis of asthma (International Classification of Diseases, Ninth Revision [ICD-9] code 493)., Results: Twenty-two children with acute asthma were sequentially enrolled in the study and longitudinally observed between February and -June 1994. The tobacco-smoking group (n = 11) was defined as having at least 1 smoker in the home. The nonsmoking group (n = 11) had no environmental tobacco smoke exposure at home. The 2 groups were similar in age, sex, preadmission chronic asthma severity, and immediate predischarge asthma status. Discharge medication use was similar in the 2 groups During a 1 month follow-up period, the tobacco-smoking group had a significantly greater number of symptomatic days than the nonsmoking group (P < .05) Of the children in the nonsmoking group, 9 (82%) had less than 1 symptomatic day per week compared with 3 (27%) in the tobacco-smoking group. beta 2-Agonist bronchodilator use declined significantly (P < .001) during follow-up in the nonsmoking group but not in the tobacco-smoking group, despite similar anti-inflammatory drug therapy in both groups., Conclusions: Recovery by children after hospitalization for acute asthma is impaired by environmental tobacco smoke exposure when the period of recovery is characterized by persistent respiratory symptoms and use of asthma medication for symptomatic relief. These findings underscore the need to limit environmental tobacco smoke exposure in children with asthma and argue for closer physician follow-up of those children returning to a home environment in which smokers are present.

A group of 167 pediatric asthmatics were followed up over four years, and their theophylline clearance values were recorded when they were admitted for status asthmaticus. A slow and gradual decrease of the clearance value was noted in all age groups. The clearance did not change significantly between the ages of 2 and 9 years. Longitudinal intrapatient clearance changes achieved statistical significance after the age of 9 years. When the patient groups were studied according to their initial clearance values, it became evident that only the patients with clearance values of 80 mL/kg/h showed significant changes of this value. In our patient group, obesity did not play a significant role in effecting a change in theophylline clearance.

Twenty-one pediatricians specializing in allergy, pulmonology, or both were questioned about their use of adrenergic bronchodilators for treating children of different ages at home, in the emergency department, and in the hospital. Most would use inhaled medications in all settings and for all ages. Few expressed strong preference for one drug over another, but only 2 would regularly use nebulized isoproterenol hydrochloride or isoetharine hydrochloride. Dosing frequency of inhaled medication at home was usually limited to every 4 hours, but in the emergency department or hospital, intervals between doses of 20 minutes or less were common. If this treatment failed, 9 physicians would use intravenous isoproterenol, but 4 strongly opposed its use. These results indicate that substantial variation exists in current expert practice, but that inhaled albuterol, metaproterenol, or terbutaline sulfate are most often preferred for treating asthma, bronchopulmonary dysplasia, and bronchiolitis in children of all ages, and that doses and dosing intervals are frequently altered to meet patient needs.

Patients in status asthmaticus often have elevated plasma antidiuretic hormone levels. To determine if children in status asthmaticus have impaired water excretion and an increased risk of developing significant hyponatremia when given a fluid challenge, five consecutive patients who showed moderate asthmatic symptoms after taking two doses of epinephrine hydrochloride were given a fluid challenge (20 mL/kg of 5% dextrose in 0.2% normal saline solution given intravenously over 30 minutes followed by maintenance fluids [1,500 mL/sq m/24 hr] for 50 minutes). Urine was collected at 20-minute intervals for measurement of free-water clearance and percent water-load excretion in 80 minutes. This protocol was repeated 24 to 48 hours later, after clinical improvement. None of the patients was hyponatremic during status asthmaticus before water loading. However, four of five patients were mildly hyponatremic (serum sodium level between 130 and 132 mEq/L) between status asthmaticus and after clinical improvement. These same four patients also became mildly hyponatremic after fluid challenge during status asthmaticus. Maximal free-water clearance and percent water load excretion in 80 minutes were significantly lower during status asthmaticus after fluid challenge compared with results obtained after water loading when the patients' conditions were clinically improved. We conclude that patients in status asthmaticus have impaired water excretion after water loading but with a small risk of significant hyponatremia; a patient remaining in status asthmaticus and given large volumes of hypotonic fluid over a prolonged period of time may be at higher risk for significant hyponatremia.

We developed an individualized approach for determining the intravenous rate of theophylline infusion for the treatment of status asthmaticus in children. The method is based on the individual's theophylline clearance rate as determined at previous admissions. We compared the method with two standard recommended approaches used currently in clinical pediatrics--the American Academy of Pediatrics and the Food and Drug Administration guidelines.

Seventy-seven patients with status asthmaticus were prospectively studied to compare oral with intravenous methylprednisolone. Patients were given methylprednisolone, either 160 or 320 mg orally or 500 or 1000 mg intravenously, daily in equally divided doses. They were randomly assigned to either group on a daily sequential basis. Spirometry was performed within one hour of the initial dose of steroids. The mean presenting forced expiratory volume in 1 s was 26% of the predicted value. Spirometry was then repeated every six hours for the first 24 hours and then every eight to 12 hours until discharge or 72 hours, whichever occurred first. There were no significant differences in the incidence of respiratory failure, forced expiratory volume in 1 s, days of hospitalization, rate of improvement in pulmonary function, or side effects. No patient who went into respiratory failure did so more than three hours after receiving the initial dose of steroids. We conclude that oral methylprednisolone is safe and effective in the treatment of status asthmaticus.

Between January 1969 and January 1984, there were 13 deaths in ambulatory chronic asthmatics aged 9 to 19 years who had been followed up by physicians of the Allergy Section, Children's Hospital of Philadelphia. During this period, 5,686 children had been admitted to this institution for treatment of acute asthma and all had survived. Three possible causes for these deaths are suggested from a detailed review of each case. One cause may be medication-related, as exemplified by patient abuse of inhaled adrenergic drugs with concomitant erratic use of theophylline and corticosteroid drugs, or by physician failure to appreciate the need for corticosteroids. Serious behavioral disturbances account for some cases of medication misuse. A second cause of death may be an unsuspected pulmonary pathologic lesion, as revealed at autopsy, and a third cause may be sudden, intense airway narrowing, as has been reported in near deaths in hospitalized asthmatics.