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Study Objective: The variable effectiveness of clinical asthma pathways to reduce hospital admissions may be explained in part by the timing of systemic corticosteroid administration. We examine the effect of early (within 60 minutes [SD 15 minutes] of triage) versus delayed (>75 minutes) administration of systemic corticosteroids on health outcomes., Methods: We conducted a prospective observational cohort of children aged 2 to 17 years presenting to the emergency department with moderate or severe asthma, defined as a Pediatric Respiratory Assessment Measure (PRAM) score of 5 to 12. The outcomes were hospital admission, relapse, and length of active treatment; they were analyzed with multivariate logistic and linear regressions adjusted for covariates and potential confounders., Results: Among the 406 eligible children, 88% had moderate asthma; 22%, severe asthma. The median age was 4 years (interquartile range 3 to 8 years); 64% were male patients. Fifty percent of patients received systemic corticosteroids early; in 33%, it was delayed; 17% of children failed to receive any. Overall, 36% of patients were admitted to the hospital. Compared with delayed administration, early administration reduced the odds of admission by 0.4 (95% confidence interval 0.2 to 0.7) and the length of active treatment by 0.7 hours (95% confidence interval -1.3 to -0.8 hours), with no significant effect on relapse. Delayed administration was positively associated with triage priority and negatively with PRAM score., Conclusion: In this study of children with moderate or severe asthma, administration of systemic corticosteroids within 75 minutes of triage decreased hospital admission rate and length of active treatment, suggesting that early administration of systemic corticosteroids may allow for optimal effectiveness., (Copyright © 2012 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.)

Objective: To determine whether the addition of repeated doses of nebulized ipratropium bromide (IB) to a standardized inpatient asthma care algorithm (ACA) for children with status asthmaticus improves clinical outcome., Study Design: Children with acute asthma (N = 210) age 1 to 18 years admitted to the ACA were assigned to the intervention or placebo group in randomized double-blind fashion. Both groups received nebulized albuterol, systemic corticosteroids, and oxygen according to the ACA. The intervention group received 250 microg IB combined with 2.5 mg albuterol by jet nebulization in a dosing schedule determined by the ACA phase. The placebo group received isotonic saline solution substituted for IB. Progression through each ACA phase occurred based on assessments of oxygenation, air exchange, wheezing, accessory muscle use, and respiratory rate performed at prescribed intervals., Results: No significant differences were observed between treatment groups in hospital length of stay (P =.46), asthma carepath progression (P =.37), requirement for additional therapy, or adverse effects. Children >6 years (N = 70) treated with IB had shorter mean hospital length of stay (P =.03) and more rapid mean asthma carepath progression (P =.02) than children in the placebo group. However, after adjustment was done for baseline group differences, the observed benefit of IB therapy in older children no longer reached statistical significance., Conclusion: The routine addition of repeated doses of nebulized IB to a standardized regimen of systemic corticosteroids and frequently administered beta-2 agonists confers no significant enhancement of clinical outcome for the treatment of hospitalized children with status asthmaticus.

Inhaled nitric oxide (NO) was administered to 5 consecutive children with life-threatening status asthmaticus who required mechanical ventilation and did not respond to maximal medical management. Four showed a >20% decrease in baseline PaCO(2) (median PaCO(2) = 154 mm Hg, range = 95 to 229 mm Hg) occurring rapidly after the administration of inhaled NO. Three children, in addition to the index case, received continuous inhaled NO therapy, ranging from 5.5 to 21.5 hours. Systemic hypotension was not observed, and the maximum methemoglobin level was 1.9%. Four children survived to hospital discharge. Although the precise mechanism of action is not known, it appears that inhaled NO merits further study and may represent a life-saving therapy in this select patient population.

Background: Inhaled corticosteroids have a greater antiinflammatory potency and fewer systemic effects than intravenous, intramuscular, or oral corticosteroids. However, their role in acute asthma has not been established. We prospectively investigated the efficacy and safety of inhaled corticosteroids in controlling moderately severe acute asthma attacks in children who were treated in the emergency department., Methods: Children who were treated in the emergency department with moderately severe asthma attacks after receiving treatment with inhaled terbutaline were allocated by double-blind design to receive 1 dose of either 1600 micro(g) budesonide turbohaler or 2 mg/kg prednisolone. The pulmonary index score and peak expiratory flow rate were measured hourly for the first 4 hours. After discharge the children were treated with the same initial doses given 4 times daily, followed by a 25% reduction in dose every second day for 1 week. Parents recorded asthma symptoms and use of beta-2 agonists on a daily diary card. Serum cortisol concentration was measured at the end of weeks 1 and 3., Results: Twenty-two children (11 in each group) with similar baseline parameters completed the study. There was a similar improvement in pulmonary index score and peak expiratory flow rate in the 2 groups. Children treated with budesonide showed an earlier clinical response than those given prednisolone, who also showed a decrease in serum cortisol concentration., Conclusion: In children with moderately severe asthma attacks who were treated in the emergency department, a short-term dose schedule of inhaled budesonide turbohaler, starting with a high dose and followed by a decrease over 1 week, is at least as effective as oral prednisolone, without suppressing serum cortisol concentration.

Objectives: To assess the effects of breathing a low-density gas mixture on dyspnea and the pulsus paradoxus in children with status asthmaticus., Design: In an urban academic tertiary referral center, 18 patients, aged 16 months to 16 years, who were being treated for status asthmaticus with continuously inhaled beta-agonist and intravenously administered methylprednisolone and had a pulsus paradoxus of greater than 15 mm Hg received either an 80%:20% helium-oxygen gas mixture (HELIOX patients) or room air (control patients) at 10 L/min by nonrebreathing face mask in a double-blind, randomized, controlled trial. In all patients, baseline data, including pulsus paradoxus (determined by sphygmomanometer or arterial catheter blood pressure readings), respiratory rate, heart rate, investigator-scored dyspnea index, and oxygen saturation, were compared with values obtained 15 minutes during and after intervention. In a subset of patients, peak flows before and after breathing HELIOX or room air were measured. When clinically indicated, arterial blood gases were obtained., Results: The pulsus paradoxus (in millimeters of mercury) fell significantly from an initial mean value of 23.3 +/- 6.8 to 10.6 +/- 2.8 with HELIOX breathing (p < 0.001) and increased again to 18.5 +/- 7.3 after cessation of HELIOX. Peak flow increased 69.4% +/- 12.8% during HELIOX breathing (p < 0.05). The dyspnea index decreased from an initial mean value of 5.7 +/- 1.3 to 1.9 +/- 1.7 with HELIOX breathing (p < 0.0002) and increased again to 4.0 +/- 0.5 after cessation of HELIOX breathing. In control patients, there was no significant difference in pulsus paradoxus or dyspnea index at any time during the study period. Mechanical ventilation was averted in three patients in whom dyspnea lessened dramatically during breathing of HELIOX., Conclusion: During acute status asthmaticus, inhaled HELIOX significantly lowered the pulsus paradoxus, increased peak flow, and lessened the dyspnea index. Moreover, HELIOX spared three patients a planned intubation and caused no apparent side effects. Thus HELIOX reduces the work of breathing and may forestall respiratory failure in children with status asthmaticus, thus preventing the need for mechanical ventilation.

A 28-year-old woman in status asthmaticus and respiratory acidemia refused orotracheal intubation and mechanical ventilation in the emergency department. In view of this situation, a mixture of helium-oxygen gas (heliox) was initiated with a nonrebreathing oxygen mask. Within 2 hours of treatment, the patient's respiratory acidemia had been corrected, and heliox inhalation therapy was discontinued without further incident.

Five percent of children in the United States have asthma. Status asthmaticus is one of the most common conditions for which children seek care in a pediatric emergency department. beta 2-Agonists such as albuterol are the mainstay of emergency therapy for such children. We present a case of a 4-year-old boy who experienced supraventricular tachycardia (SVT) following albuterol therapy. This is believed to be the first report of adenosine being successfully used to treat a child with albuterol-induced SVT. We also briefly review the recognition and management of SVT in children and the pharmacokinetics of and indications for adenosine.

Study Objective: To examine the hypothesis that an IM long-acting steroid injection will decrease the relapse rate of asthma patients., Design: A randomized, single-blind, placebo-controlled trial., Setting: The emergency department of an urban academic medical center., Type of Participants: Acute asthma patients aged 18 to 45 years who were treated successfully in the ED., Interventions: Participants received either IM saline placebo or 240 mg methylprednisolone acetate suspension at the time of discharge. MEASUREMENTS AND MAIN OUTCOME: Relapse, defined as the need to seek nonroutine medical care for asthma within seven days of discharge, was the main outcome measure. Of 70 patients entered, 56 (80%) completed follow-up, including 30 in the steroid group and 26 in the placebo group. The groups had similar characteristics and peak expiratory flow values on arrival and at discharge. Relapse occurred in two steroid patients (6.7%) and eight placebo recipients (30.8%) (P < .05). There was one death in the placebo group. Reported side effects were similar., Conclusion: IM long-acting steroids reduced the rate of relapse in patients with acute asthma.

Magnesium, a physiologic calcium antagonist, is known to have a direct effect on calcium uptake in smooth muscle, resulting in smooth muscle relaxation. Studies of magnesium sulfate infusions in patients with mild or moderate-to-severe acute asthma have shown that it may have a significant bronchodilatory effect, similar to that of salbutamol (albuterol). We present the case of a patient with acute severe life-threatening asthma (initially in cardiorespiratory arrest) who responded to an IV infusion of magnesium sulfate after aggressive pharmacologic management failed to result in clinical improvement.

Study Objective: To compare the forced expiratory volume in one second (FEV1) response to inhaled anticholinergic with the response to beta-adrenergic solutions in adults with refractory status asthmaticus., Design: After the decision was made to hospitalize, 40 patients were prospectively randomized in a double-blind trial to receive either atropine sulfate or metaproterenol by nebulizer., Setting: A county teaching hospital emergency department., Type of Participants: Adults requiring hospitalization for refractory status asthmaticus., Interventions: Standard therapies for acute bronchospasm, followed by either 1.5 mg atropine or 15 mg metaproterenol by nebulizer., Measurements and Main Results: The two groups were similar on entry into the study, including mean FEV1 measurements (0.70 L atropine/0.60 L metaproterenol, P greater than .05). Compared with baseline, The FEV1 improvement for the metaproterenol group was statistically significant (+ 0.18 L, P = .05; + 31%, P less than .05), whereas the improvement with atropine did not reach significance (+0.09 L or +10%, P greater than .05). Comparing the two groups, statistically significant differences favoring metaproterenol were found in the percent improvement in the FEV1 (+10% atropine/+31% metaproterenol, P less than .05) and in the percentage of patients experiencing at least a 15% decrease in their FEV1 below baseline (35% atropine/10% metaproterenol, P less than .05). No patient suffered adverse side effects., Conclusion: For the majority of adults with refractory status asthmaticus, an additional beta-adrenergic inhalation treatment results in greater FEV1 improvement than that resulting from the addition of an atropine inhalation.

The various features of bronchial asthma as it pertains to infants and children are reviewed. Childhood asthma ranks among the most common causes of ill health and creates a myriad of physical and emotional problems for the child. Rarely, it may lead to death. Various anatomic and physiologic differences in children account for the increased risk to symptomatic airway obstruction and poor response to bronchodilators. Other features of childhood asthma that differ from adult asthma including the prognosis, differential diagnosis, and complications are discussed. The authors' views of the general principles, specific therapy, pharmacologic measures, and a self-management intervention program for the management of the pediatric patient with asthma are presented.

We undertook a randomized trial to compare holding room treatment vs hospitalization of patients with childhood status asthmaticus. Two thirds of 51 patients were discharged from a holding room within 24 hours (mean 11.8 +/- 4.61 hours); the others required hospitalization. One third of 52 hospitalized patients received less than or equal to 1 day of intravenously administered therapy, and two thirds received less than 2 days of therapy (mean 45.6 +/- 12 hours). There were no statistically significant differences in recurrence rates between the two groups in the 28 days following status asthmaticus. For patients receiving less than or equal to 1 day of therapy, the holding room cost was $526 +/- $226 vs $1439 +/- $339 for hospitalized patients (P less than 0.001). Thus, holding room therapy for childhood status asthmaticus is both medically and economically effective.