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Objectives: Children with status asthmaticus refractory to first-line therapies of systemic corticosteroids and inhaled beta-agonists often receive additional treatments. Because there are no national guidelines on the use of asthma therapies in the PICU, we sought to evaluate institutional variability in the use of adjunctive asthma treatments and associations with length of stay (LOS) and PICU use., Design: Multicenter retrospective cohort study., Setting: Administrative data from the Pediatric Health Information Systems (PHIS) database., Patients: All inpatients 2-18 years old were admitted to a PHIS hospital between 2013 and 2021 with a diagnostic code for asthma., Interventions: None., Measurements and Main Results: This study included 213,506 inpatient encounters for asthma, of which 29,026 patient encounters included care in a PICU from 39 institutions. Among these PICU encounters, large variability was seen across institutions in both the number of adjunctive asthma therapies used per encounter (min: 0.6, median: 1.7, max: 2.5, p < 0.01) and types of adjunctive asthma therapies (aminophylline, ipratropium, magnesium, epinephrine, and terbutaline) used. The center-level median hospital LOS ranged from 1 (interquartile range [IQR]: 1, 3) to 4 (3, 6) days. Among all the 213,506 inpatient encounters for asthma, the range of asthma admissions that resulted in PICU admission varied between centers from 5.2% to 47.3%. The average number of adjunctive therapies used per institution was not significantly associated with hospital LOS ( p = 0.81) nor the percentage of encounters with PICU admission ( p = 0.47)., Conclusions: Use of adjunctive therapies for status asthmaticus varies widely among large children's hospitals and was not associated with hospital LOS or the percentage of encounters with PICU admission. Wide variance presents an opportunity for standardizing care with evidence-based guidelines to optimize outcomes and decrease adverse treatment effects and hospital costs., Competing Interests: Dr. Shein received funding from Ceribell and Hill Ward Henderson. The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2023 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.)

Acute severe asthma describes serious asthmatic attacks, which remain a major treatment challenge and a significant source of morbidity in adults. It places the patient in danger of developing respiratory failure, a condition known as status asthmaticus. It is often fatal if not recognized and treated early. Many patients are at risk for numerous reasons; thus, the key issues are early detection, assessment and management. A multidisciplinary and collaborative approach is needed to effectively treat acute respiratory failure (ARF). Considerable research has investigated the range of opportunities available for treating asthma. Current treatment options include conventional agents, such as inhalational corticosteroids, â-agonists, leukotriene modulators, monoclonal antibodies, and oral corticosteroids (OCS). Nurses are in a perfect position to assess patients' risk of developing respiratory failure, monitor them, evaluate their care, and coordinate a multidisciplinary approach. In this review, we discuss acute asthma and the role of the nursing officer (NO) in the management of the illness. The review will also emphasize various current treatment approaches available for the NO that can effectively target and prevent respiratory failure. This review provides nurses and other healthcare workers with updated information on timely, effective and safe supportive management of patients with asthma.

One-third of women with asthma have deterioration of their asthma during pregnancy, and one-fourth of pregnant women with asthma will experience severe exacerbations necessitating emergency department (ED) visits or hospitalizations. Early recognition of acute severe asthma, including life-threatening status asthmaticus, and aggressive medical interventions with β2-agonists, anticholinergic agents, and systemic corticosteroids are necessary to treat maternal airway bronchoconstriction, support maternal and fetal oxygenation, and avoid adverse fetal outcomes. This review describes management of acute severe asthma in pregnancy, including status asthmaticus, in the ED and intensive care unit., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Introduction: Noninvasive ventilation (NIV) is sometimes used in refractory pediatric status asthmaticus for its potential benefits of stenting airways and dispersing albuterol. However, its effectiveness in pediatric asthma remains unproven. The usage pattern, outcomes, and safety of NIV in pediatric status asthmaticus are described., Methods: Patients 1 to 21 years of age admitted to a tertiary hospital's pediatric intensive care unit (PICU) with status asthmaticus between January 2016 and December 2018 were eligible. Children with tracheostomies and baseline NIV were excluded. Medical history, vital signs, imaging, therapy, type of NIV administered and adverse events were extracted from the electronic medical record., Results: 101 unique admissions were identified. The mean age was 7 years, 63% had previously diagnosed asthma and 27% had prior PICU admissions. 54% received NIV in the form of bilevel positive airway pressure (BPAP) or continuous positive airway pressure (CPAP) with 20 (37%) commencing in the emergency department (ED). Oxygen saturation at presentation was significantly lower in the NIV vs the non NIV group (P < 0.05). Rhinovirus/enterovirus was identified in 82% of the cohort. No pneumothoraces, pneumomediastinum, or aspiration pneumonias were documented on available chest radiographs ( n  = 83)., Discussion: NIV was common in pediatric status asthmaticus and often started in the ED. No major adverse events were observed. Prospective, randomized control trials are needed to determine if NIV affects duration of continuous albuterol or PICU length of stay.

Introduction: Electronic nicotine delivery systems (ENDS) use is on the rise in the adolescent and young adult populations, especially in the wake of sweet flavored ENDS solutions and youth-targeted marketing. While the extent of effect of ENDS use and aerosolized flavorings on airway epithelium is not known, there remains significant concern that use of ENDS adversely affects airway epithelial function, particularly in populations with asthma. Case Study: In this case series, we review two cases of adolescents with history of recent and past ENDS use and asthma who required veno-venous extracorporeal membrane oxygenation (VV-ECMO) for status asthmaticus in the year 2018. Results: Both patients experienced hypercarbic respiratory failure requiring VV-ECMO secondary to their status asthmaticus, with slow recovery on extensive bronchodilator and steroid regimens. They both recovered back to respiratory baseline and were counseled extensively on cessation of ENDS use. Conclusion: While direct causation by exposure to ENDS cannot be determined, exposure likely contributed to symptoms. Based on the severity of these cases and their potential relationship with ENDS use, we advocate for increased physician screening of adolescents for ENDS use, patient and parent education on the risks of use, and family cessation counseling.

Objectives : Continuous nebulized albuterol is frequently used to treat children with status asthmaticus in the pediatric intensive care unit (PICU) but can have cardiovascular side effects. Limited data exist comparing different dosages. The purpose of this study was to compare hemodynamic side effects of two continuous albuterol doses (10 vs. 25 mg/h). Our hypothesis was that lower dose albuterol would be associated with lower toxicity without increased need for adjunctive therapies. Methods : We conducted a retrospective cohort study of all children over 2 years old receiving continuous nebulized albuterol for status asthmaticus in our PICU from 2011 to 2013. Standard initial therapy was intravenous steroids and continuous nebulized albuterol. Patients receiving 10 mg/h albuterol were compared to those receiving 25 mg/h. Clinical outcomes, including the need for additional asthma therapies as well as hypotension requiring fluid resuscitation, were evaluated. Results : About 632 patients were studied (342 received 10 mg/h, 290 received 25 mg/h). Children in the lower-dose group received less fluid resuscitation without increased adjunctive therapies when adjusted for confounders. Those in the 25 mg/h group receiving 17% higher bolus volume. Those receiving lower-dose albuterol had shorter adjusted PICU and hospital lengths of stay. Conclusions : In our PICU cohort of children with status asthmaticus, use of 10 mg/h continuous albuterol was associated with lower fluid bolus resuscitation without more adjunctive therapies. These findings support the safety of lower doses in this population. Prospective studies evaluating the efficacy and toxicity of specific continuous albuterol dosages in critically ill children with status asthmaticus are warranted.

Introduction: In severe asthma, management of life-threatening air trapping that persists despite initiation of standard asthma treatment is difficult in the absence of extracorporeal membranous oxygenation. Case study: Three children with life-threatening asthma could not be adequately ventilated despite maximum conventional treatment because of severe air trapping. A novel method of active expiration by abdominal compression with a standard ventilator was adopted with immediate effect with significant improvement in ventilation. Conclusion: Synchronized abdominal compression is a novel and simple method that allows an effective treatment of severe air trapping in an intubated paralyzed asthma child.

Acute severe asthma, formerly known as status asthmaticus, is defined as severe asthma unresponsive to repeated courses of beta-agonist therapy. It is a medical emergency that requires immediate recognition and treatment. Albuterol in combination with ipratropium bromide in the emergency department (ED) has been shown to decrease the time spent in the ED and the hospitalization rates. The benefits of ipratropium are not sustained after admission to the hospital. Oral or parenteral corticosteroids should be administered to all patients with acute severe asthma as early as possible because clinical benefits may not occur for a minimum of 6 to 12 hours. Viral respiratory infections are a common trigger for acute asthma; other causes include medical nonadherence, allergen exposure (especially pets and mold [e.g., Alternaria species]) in individuals who are severely atopic, nonsteroidal anti-inflammatory exposure in patients with aspirin allergy, irritant inhalation (e.g., smoke, paint), exercise, and insufficient use of inhaled or oral corticosteroids. The patient's history should focus on the acute assessment of asthma control and morbidity, including current use of oral or inhaled corticosteroids; the number of hospitalizations, ED visits, intensive care unit admissions, and intubations; the frequency of albuterol use; the presence of nighttime symptoms; activity intolerance; current medications; exposure to allergens; and other significant medical conditions. Severe airflow obstruction may be predicted by accessory muscle use, difficulty speaking, refusal to recline < 30°, a pulse of >120 beats/min, and decreased breath sounds. More objective measures of airway obstruction via peak flow or forced expiratory volume in 1 second and pulse oximetry before oxygen administration usually are helpful. Pulse oximetry values of >90% are reassuring, although CO₂ retention and a low partial pressure of oxygen may be missed.

Background: Asthma is a common reason for admissions to the pediatric intensive care unit (PICU). Since June 2014, our institution has used a pediatric asthma clinical pathway for all patients, including those in PICU. The pathway promotes respiratory therapist-driven bronchodilator weaning based on the Modified Pulmonary Index Score (MPIS). This pathway was associated with decreased hospital length of stay (LOS) for all pediatric asthma patients; however, the effect on PICU patients was unclear. We hypothesized that the implementation of a pediatric asthma pathway would reduce hospital LOS for asthmatic patients admitted to the PICU., Methods: We retrospectively reviewed the medical records of all pediatric asthma subjects 2-17 y old admitted to our PICU before and after pathway initiation. Primary outcome was hospital LOS. Secondary outcomes were PICU LOS and time on continuous albuterol. Data were analyzed using the chi-square test for categorical data, the t test for normally distributed data, and the Mann-Whitney test for nonparametric data., Results: A total of 203 eligible subjects (49 in the pre-pathway group, 154 in the post group) were enrolled. There were no differences between groups for age, weight, gender, home medications, cause of exacerbation, medical history, or route of admission. There were significant decreases in median (interquartile range) hospital LOS (4.4 [2.9-6.6] d vs 2.7 [1.6-4.0] d, P < .001), median PICU LOS (2.1 [1.3-4.0] d vs 1.6 [0.8-2.4] d, P = .003), and median time on continuous albuterol (39 [25-85] h vs 27 [13-42] h, P = .001). Significantly more subjects in the post-pathway group were placed on high-flow nasal cannula (32% vs 6%, P = .001) or noninvasive ventilation (10% vs 4%, P = .02)., Conclusion: The implementation of an asthma pathway was associated with decreased hospital LOS, PICU LOS, and time on continuous albuterol. There was also an increase in the use of high-flow nasal cannula and noninvasive ventilation after the implementation of this clinical pathway., Competing Interests: The authors have disclosed no conflicts of interest., (Copyright © 2019 by Daedalus Enterprises.)

Background: Status asthmaticus is one of the most frequent admission diagnoses in the pediatric ICU (PICU). Collaboration between respiratory therapists (RTs) and physicians may help efficiently deliver care to a patient in status asthmaticus. The Pediatric Asthma Severity Score (PASS) is a measure of severity of a patient's asthma exacerbation at a point in time. The aim of this quality improvement initiative was to establish an RT-driven continuous albuterol weaning protocol using the PASS score. We hypothesized that this would decrease the duration of continuous albuterol without increasing adverse events., Methods: This was a single-center implementation study in the PICU of a quaternary care children's hospital. Patients with a diagnosis of status asthmaticus who met criteria on continuous albuterol between September 2015 and September 2017 were included. An interdisciplinary team established the protocol, order sets, documentation, and education for involved staff. Qualifying subjects were assessed by an RT per protocol and assigned a PASS score, and the albuterol dose was adjusted on the basis of the PASS score., Results: We compared 104 subjects studied before the implementation of this protocol (September 2015 to August 2016) to 117 subjects after the implementation of this protocol (September 2016 to October 2017). Median (interquartile range) duration of continuous albuterol in the PICU post-implementation was unchanged compared to pre-implementation: 12.1 (7.2-21.0) h versus 11.1 (6-19) h ( P = .22). Median PICU length of stay was also unchanged post-implementation compared to pre-implementation: 19.5 (14.3-29.7) h versus 23.2 (15.2-31.3) h ( P = .16). Using control charts, these processes were stable. There was no difference in adverse events., Conclusions: An interprofessionally-developed, RT-driven continuous albuterol weaning protocol can be implemented without negatively impacting duration of continuous albuterol or PICU length of stay and without increasing adverse events., Competing Interests: The authors have disclosed no conflicts of interest., (Copyright © 2019 by Daedalus Enterprises.)

Introduction: The characteristics and treatment outcomes of status asthmaticus patients in emergency department (ED) have not been described previously especially in Thailand., Objective: To describe the characteristics, treatment outcomes and factors associated with status asthmaticus in Thai patients presenting to a single center ED., Methods: A prospective observational study was performed at Thammasat University hospital, Thailand. The data collected included demographics, asthma history and control, previous ED attendances and hospital admissions, presenting clinical, laboratory and radiographic features, treatments given, and outcomes. Multivariable regression was used to determine independent factors associated with status asthmaticus., Results: Over one year (2015-16), 209 patients were recruited, aged 6 - 54 years (median 33 y), of whom 145 (69.3%) had status asthmaticus. The factors associated with status asthmaticus were: (i) age > 60 y, (ii) presence of a comorbidity, (iii) having uncontrolled asthma, (iv) hospitalizations or visits to the ED in the last year, and (v) using > 1 metered dose inhaler canister per month. Status asthmaticus patients were significantly less likely to speak in sentences (p=0.001) and more likely to have poor air entry and chest wall retraction (p<0.0001), an abnormal chest X ray (p=0.011), receive magnesium sulphate and be admitted into hospital (p<0.0001). No patients died., Conclusions: Status asthmaticus was common in this cohort of patients in our setting. Our findings are consistent with previous studies and underscore the need for better patient management.

Objectives: Pediatric asthma is a leading cause of emergency department (ED) utilization and hospitalization. Earlier identification of need for hospital-level care could triage patients more efficiently to high- or low-resource ED tracks. Existing tools to predict disposition for pediatric asthma use only clinical data, perform best several hours into the ED stay, and are static or score-based. Machine learning offers a population-specific, dynamic option that allows real-time integration of available nonclinical data at triage. Our objective was to compare the performance of four common machine learning approaches, incorporating clinical data available at the time of triage with information about weather, neighborhood characteristics, and community viral load for early prediction of the need for hospital-level care in pediatric asthma., Methods: Retrospective analysis of patients ages 2 to 18 years seen at two urban pediatric EDs with asthma exacerbation over 4 years. Asthma exacerbation was defined as receiving both albuterol and systemic corticosteroids. We included patient features, measures of illness severity available in triage, weather features, and Centers for Disease Control and Prevention influenza patterns. We tested four models: decision trees, LASSO logistic regression, random forests, and gradient boosting machines. For each model, 80% of the data set was used for training and 20% was used to validate the models. The area under the receiver operating characteristic (AUC) curve was calculated for each model., Results: There were 29,392 patients included in the analyses: mean (±SD) age of 7.0 (±4.2) years, 42% female, 77% non-Hispanic black, and 76% public insurance. The AUCs for each model were: decision tree 0.72 (95% confidence interval [CI] = 0.66-0.77), logistic regression 0.83 (95% CI = 0.82-0.83), random forests 0.82 (95% CI = 0.81-0.83), and gradient boosting machines 0.84 (95% CI = 0.83-0.85). In the lowest decile of risk, only 3% of patients required hospitalization; in the highest decile this rate was 100%. After patient vital signs and acuity, age and weight, followed by socioeconomic status (SES) and weather-related features, were the most important for predicting hospitalization., Conclusions: Three of the four machine learning models performed well with decision trees preforming the worst. The gradient boosting machines model demonstrated a slight advantage over other approaches at predicting need for hospital-level care at the time of triage in pediatric patients presenting with asthma exacerbation. The addition of weight, SES, and weather data improved the performance of this model., (© 2018 by the Society for Academic Emergency Medicine.)

Background: Despite effective treatments and long-standing management guidelines, there are approximately 1400 hospital admissions for asthma weekly in the United Kingdom (UK), many of which could be avoided. In our previous research, a secondary analysis of the intervention (ARRISA) suggested an improvement in the management of at-risk asthma patients in primary care. ARRISA involved identifying individuals at risk of adverse asthma events, flagging their electronic health records, training practice staff to develop and implement practice-wide processes of care when alerted by the flag, plus motivational reminders. We now seek to determine the effectiveness and cost-effectiveness of ARRISA in reducing asthma-related crisis events., Methods: We are undertaking a pragmatic, two-arm, multicentre, cluster randomised controlled trial, plus health economic and process evaluation. We will randomise 270 primary care practices from throughout the UK covering over 10,000 registered patients with 'at-risk asthma' identified according to a validated algorithm. Staff in practices randomised to the intervention will complete two 45-min eLearning modules (an individually completed module giving background to ARRISA and a group-completed module to develop practice-wide pathways of care) plus a 30-min webinar with other practices. On completion of training at-risk patients' records will be coded so that a flag appears whenever their record is accessed. Practices will receive a phone call at 4 weeks and a reminder video at 6 weeks and 6 months. Control practices will continue to provide usual care. We will extract anonymised routine patient data from primary care records (with linkage to secondary care data) to determine the percentage of at-risk patients with an asthma-related crisis event (accident and emergency attendances, hospitalisations and deaths) after 12 months (primary outcome). We will also capture the time to crisis event, all-cause hospitalisations, asthma control and any changes in practice asthma management for at-risk and all patients with asthma. Cost-effectiveness analysis and mixed-methods process evaluations will also be conducted., Discussion: This study is novel in terms of using a practice-wide intervention to target and engage with patients at risk from their asthma and is innovative in the use of routinely captured data with record linkage to obtain trial outcomes., Trial Registration: ISRCTN95472706 . Registered on 5 December 2014.

Background: Status asthmaticus (SA) is a common reason for admission to the pediatric emergency department (ED). Assessing asthma severity efficiently in the ED can be challenging for clinicians. Adjunctive tools for the clinician have demonstrated inconsistent results. Studies have shown that pulsus paradoxus (PP) correlates with asthma severity. Pleth Variability Index (PVI) is a surrogate measure of PP., Objective: We investigated whether PVI at triage correlates with disposition from the ED., Methods: We recruited children aged 2-18 years old who presented to the pediatric ED of a tertiary care children's hospital with SA. PVI, Respiratory Severity Score, and vital signs were documented at triage and 2 hours into each patient's ED stay. PVI was measured using the Masimo Radical-7 ® monitor (Masimo Corp., Irvine, CA)., Results: Thirty-eight patients were recruited. Twenty-seven patients were discharged home, 10 patients were admitted to the general pediatrics floor and 1 patient was admitted to the intensive care unit. PVI values at triage did not correlate with disposition from the ED (p = 0.63). Additionally, when trending the change in PVI after 2 hours of therapy in the ED, no statistically significant patterns were demonstrated., Conclusions: Our study did not demonstrate a correlation between PVI and clinical course for asthmatics. PVI may be more clinically relevant in sicker children. Furthermore, it is possible that continuous monitoring of PVI may demonstrate more unique trends in relation to asthma severity versus single values of PVI. Additional studies are necessary to help clarify the relationship between PVI and the clinical course of children with SA., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objectives: Evaluate the effects of an asthma de-escalation clinical pathway on selected outcomes for patients admitted to a PICU with status asthmaticus., Design: Time series quality improvement trial., Setting: PICU in a tertiary care children's hospital., Patients: Children age 2-18 years old with a known diagnosis of asthma presenting with status asthmaticus., Intervention: One-hundred five admissions to a PICU for status asthmaticus were treated according to a new de-escalation pathway between August 15, 2015, and August 30, 2016. This group was compared with a prepathway group of 141., Measurements and Main Results: Primary outcome was variability in PICU length of stay. Secondary outcomes were median PICU length of stay, median hospital length of stay, and median duration a patient received continuous nebulized albuterol. The effectiveness of the intervention was tracked using control charts. The postpathway group demonstrated decreased variability of PICU length of stay and time receiving continuous albuterol. Statistically significant decreases were seen in median PICU length of stay (16 vs 13 hr; p = 0.0009), median duration a child spent receiving continuous nebulized albuterol (10.8 vs 7.3 hr; p = 0.0008), and median hospital length of stay (37 vs 31 hr; p = 0.02). Total number of asthma assessments completed by respiratory therapists increased from 741 to 1,087., Conclusions: Implementation of a PICU asthma de-escalation pathway demonstrated statistical decrease in the reported measures for children with status asthmaticus. Although the clinical significance of these changes may be debatable, the results demonstrate that efforts to standardize asthma care in the PICU setting is an area in need of further study.

A 24-year-old woman with history of asthma was intubated emergently for acute status asthmaticus triggered by acute respiratory syncytial virus infection and treated with permissive hypercapnia. Her ventilation was complicated by auto-positive end-expiratory pressure and elevated peak airway, plateau, and central venous pressures. On hospital day 2, she was noted to have anisocoria. Imaging showed diffuse cerebral edema with central herniation. Difficult ventilation and hypercapnia directly contributed to her severe cerebral edema. Comanagement between neurologic and medical/pulmonary intensivists enabled the management of the competing treatment requirements for status asthmaticus and cerebral edema. This case highlights the importance of balancing conflicting physiologic needs and collaboration between teams.

Background and Objective: Reduction of critical asthma management time can reduce intensive care utilization. The goal of this study was to determine whether a Critical Asthma Standardized Clinical Assessment and Management Plan (SCAMP) can decrease length of critical asthma management time., Methods: This retrospective study compared critical asthma management times in children managed before and after implementation of a Critical Asthma SCAMP. The SCAMP used an asthma severity score management scheme to guide stepwise escalation and weaning of therapies. The SCAMP guided therapy until continuous albuterol nebulization (CAN) was weaned to intermittent albuterol every 2 hours (q2h). Because the SCAMP was part of a quality improvement initiative in which all patients received a standardized therapy, informed consent was waived. The study was conducted in Medicine ICU and Intermediate Care Units in a tertiary care freestanding children's hospital. Children ≥2 years of age who had CAN initiated in the emergency department and were admitted to the Division of Medicine Critical Care with status asthmaticus were included. The time to q2h dosing from initiation of CAN was compared between the baseline and SCAMP cohorts. Adverse events were compared. The Mann-Whitney test was used for analysis; P values <.05 were considered statistically significant., Results: There were 150 baseline and 123 SCAMP patients eligible for analysis. There was a decrease in median time to q2h dosing after the SCAMP (baseline, 21.6 hours [interquartile range, 3.2-32.3 hours]; SCAMP, 14.2 hours [interquartile range, 9.0-23.1 hours]; P < .01). There were no differences in adverse events or readmissions., Conclusions: A Critical Asthma SCAMP was effective in decreasing time on continuous albuterol., (Copyright © 2017 by the American Academy of Pediatrics.)

Objective: To compare the efficacy of nebulised budesonide with that of oral prednisone in the treatment of acute severe asthma in children., Methods: Children aged 5-12 y with acute exacerbation of bronchial asthma were included. The study (budesonide) group received budesonide respirator solution (800 μg) at intervals of 20 min and a single dose of placebo tablets. The control (prednisolone) group received placebo solution at intervals of 20 min and a single dose of oral prednisolone (2 mg/kg). Both groups received three doses of nebulised salbutamol (0.15 mg/kg). Heart rate, respiratory rate, oxygen saturation, PEFR (Peak Expiratory Flow Rate) and fitness for discharge were assessed., Results: Both groups showed a progressive decrease in tachycardia with treatment, but it was significantly greater in study group (p = 0.0002). There was significant decrease in tachypnea and improvement in oxygen saturation in both groups, but the difference between the groups (p = 0.334 and p = 0.814 respectively) was not significant. There was significant improvement in PEFR values in budesonide group (p = 0.024). Both groups showed significant improvement in clinical severity scores at the end of 2 h (p < 0.0001). Budesonide group had significantly higher proportion of patients fit for discharge at 2 h (based on clinical severity scores) (p = 0.0278)., Conclusions: Nebulised budesonide significantly improves PEFR levels and fitness for discharge at 2 h when compared to oral prednisolone in children between 5 and 12 y with acute severe asthma.

Introduction: The correct use of medication and the ability to assess the severity of the disease and to react appropriately in the case of exacerbation are essential objectives in the management of asthma patients. This study, conducted in a school of asthma in Seine-Saint-Denis, aims to measure the influence of socio-demographic and clinical factors, before any educational process, on these four security skills., Methods: A prospective observational study concerning 280 consecutive patients managed between 2008 and 2011 (70 % women, mean age: 44 years [14-85 years]; deprivation: 48 %; born abroad: 39 %, low level of education: 23 %). The initial educational diagnosis was compared with the clinical and socio-demographic characteristics., Results: In relation to asthma control, social characteristics (unemployment, deprivation), geographic or ethnic origin and educational level significantly influence the command of all or some of the security skills. In medical terms, a period of evolution of the disease of less than 10 years, outpatient follow-up without specialized monitoring and the absence of recent exacerbations also appear as predictors of inappropriate conduct in the management of the disease., Conclusions: This study suggests new priority targets for therapeutic education in asthma., (Copyright © 2014 SPLF. Published by Elsevier Masson SAS. All rights reserved.)

Objective: To describe the design features, utilization, and outcomes of a protocol treating children with status asthmaticus with continuous albuterol in the inpatient setting., Methods: We performed a retrospective cohort analysis of children ages 2 to 18 treated in the non-intensive care, inpatient setting on a standardized treatment protocol for status asthmaticus from July 2011 to June 2013. We assessed characteristics associated with continuous albuterol therapy and, for those treated, duration of therapy and the proportion who clinically deteriorated (ICU transfer or progression to enhanced respiratory support) or who were identified as having hypokalemia or an arrhythmia. Using multivariable logistic regression, we determined which factors were associated with clinical deterioration or prolonged (>24 hours) continuous albuterol., Results: Of 3003 children meeting study criteria, 1298 (43%) received continuous albuterol. Older age, black race, lower initial oxygen saturation, and higher initial age-standardized heart rate and respiratory rate were associated with initiation of continuous albuterol therapy (P < .001 for all). Median duration of therapy was 14.4 hours (interquartile range, 7.7, 24.6); 340 children (26%) experienced prolonged therapy. Seventy children (5%) experienced clinical deterioration, and 33 children (3%) had identified hypokalemia or arrhythmia. Comorbid pneumonia and emergency department administration of intravenous magnesium or subcutaneous terbutaline were associated with prolonged therapy and clinical deterioration., Conclusions: With appropriate support structures and care processes, continuous albuterol can be delivered effectively in the non-ICU, inpatient setting with low rates of adverse outcomes. Certain initial clinical characteristics may help identify patients needing more intensive therapy., (Copyright © 2014 by the American Academy of Pediatrics.)

Objectives: The objective was to apply quality indicators in respiratory disease triage during a set time period., Methods: This was a retrospective, descriptive, and comparative study of all patients attending the emergency department of Acosta Ñu Children's Hospital with breathing difficulty, between January 1 and July 31, 2011., Results: Two thousand five hundred eighty-two patients were included in the study. The delay in medical care according to severity of breathing difficulty was as follows: for critical patients, 1 minute (100% compliance); for emergencies, 6.4 minutes (93.4% compared with 95% standard); for urgencies, 15.8 minutes (90% compared with the standard 90%); and for semiurgencies, 35 minutes (92.4% vs. 85% standard). Regarding to the admission-triage time indicator: mean time was 6.1 minutes; 2220 patients (86%) were classified in less than 10 minutes from the time of hospital admission, and 2453 (95%) were evaluated before 15 minutes. Respiratory rate was recorded in 2368 patients (91.7%), and pulse oximetry in 2443 (94.6%). Both parameters were recorded in 2271 children (88%). Errors in classification were detected, mainly tendency to underestimate the risk or exacerbate the clinical situation; 441 patients underwent subtriage (20.5%), and 44 overtriage (1.7%). There were drawbacks to classify emergencies error rate 45.8% (P < 0.00001). Relationship between pathophysiologic diagnosis and triage level was significant (P < 0.00001)., Conclusions: Indicators of triage quality were acceptably met in respiratory disease. Breathing difficulty was identified and classified as urgent, although problems arouse at differentiation between moderate and severe dyspnea.

Status asthmaticus is a frequent cause of admission to a pediatric intensive care unit. Prompt assessment and aggressive treatment are critical. First-line or conventional treatment includes supplemental oxygen, aerosolized albuterol, and corticosteroids. There are several second-line treatments available; however, few comparative studies have been performed and in the absence of good evidence-based treatments, the use of these therapies is highly variable and dependent on local practice and provider preference. In this article the pathophysiology and treatment of status asthmaticus is discussed, and the literature regarding second-line treatments is critically assessed to apply an evidence basis to the treatment of this severe disease.

This article reviews some common conditions in adolescents that require critical care. Topics that are covered include severe sepsis and shock, acute respiratory distress syndrome, status asthmaticus, diabetic ketoacidosis, poisoning (acetaminophen, decongestants, prescription medications, selective serotonin reuptake inhibitors), and trauma. Comments about bariatric surgery are also included.

A 20-year-old woman, with intolerance to non-steroid anti-inflammatory drugs (NSAIDs) who was diagnosed of asthma 2 years earlier. Both her mother and brother were asthmatic. Non-smoker. Anosmia and rhinosinusitis symptoms. Several hospitalizations for asthmatic attacks, the last one, one month before in the ICU that did not require mechanical ventilation. Skin tests negative to aeroallergens. Better personal PEF: 450 l/min. Previous treatment: salmeterol/fluticasone 50/500 1 inh/12h. and formoterol p.r.n. She came to the emergency room by ambulance due to evolution of fever, expectoration and headache after having gone to her physician, who had prescribed metamizole and azithromycin. She returned at one hour due to difficult breathing and Sat O(2) 89%. The physical examination showed abdominal breathing, 40 rpm and Sat O(2) 92% with nebulizer at 6 bpm, PEF: 180 l/min, tachycardia at 150 bpm, generalized wheezing. Hemodynamically stable. Blood gases with O(2) to 6 bpm: 7.28 pH, 45 pCO(2), 66pO(2), 21.1 HCO(3), Chest X-ray: no consolidations., (Copyright © 2012 Elsevier España, S.L. All rights reserved.)

Acute severe asthma, formerly known as status asthmaticus, is defined as severe asthma unresponsive to repeated courses of beta-agonist therapy such as inhaled albuterol, levalbuterol, or subcutaneous epinephrine. It is a medical emergency that requires immediate recognition and treatment. Oral or parenteral corticosteroids should be administered to all patients with acute severe asthma as early as possible because clinical benefits may not occur for a minimum of 6-12 hours. Approximately 50% of episodes are attributable to upper respiratory infections, and other causes include medical nonadherence, nonsteroidal anti-inflammatory exposure in aspirin-allergic patients, allergen exposure (especially pets) in severely atopic individuals, irritant inhalation (smoke, paint, etc.), exercise, and insufficient use of inhaled or oral corticosteroids. The patient history should be focused on acute severe asthma including current use of oral or inhaled corticosteroids, number of hospitalizations, emergency room visits, intensive-care unit admissions and intubations, the frequency of albuterol use, the presence of nighttime symptoms, exercise intolerance, current medications or illicit drug use, exposure to allergens, and other significant medical conditions. Severe airflow obstruction may be predicted by accessory muscle use, pulsus paradoxus, refusal to recline below 30°, a pulse >120 beats/min, and decreased breath sounds. Physicians' subjective assessments of airway obstruction are often inaccurate. More objective measures of airway obstruction via peak flow (or forced expiratory volume in 1 second) and pulse oximetry before oxygen administration usually are helpful. Pulse oximetry values >90% are less commonly associated with problems although CO(2) retention and a low Pao(2) may be missed.

Potentially (near) fatal asthma (PFA) defines a subset of patients with asthma who are at increased risk for death from their disease. The diagnosis of PFA should motivate treating physicians, health professionals, and patients to be more aggressive in the monitoring, treatment, and control of this high-risk type of asthma. A diagnosis of PFA is made when any one of the following are present: (1) history of endotracheal intubation from asthma, (2) acute respiratory acidosis (pH < 7.35) or respiratory failure from acute severe asthma, (3) two or more episodes of acute pneumothorax or pneumomediastinum from asthma, (4) two or more episodes of acute severe asthma despite the use of long-term oral corticosteroids and other antiasthma medications. There are two predominant phenotypes of near fatal exacerbations, the "subacute" exacerbation and the "hyperacute" exacerbation. The best way to "treat" acute severe asthma is 3-7 days before it occurs (i.e., at the onset of symptoms or change in respiratory function) and to optimize control of asthma by decreasing the number of symptomatic days and days/nights requiring rescue therapy and increasing baseline respiratory status in "poor perceivers." PFA is treated with a multifaceted approach; physicians should appreciate limitations of pharmacotherapy including combination inhaled corticosteroid/long-acting beta-agonist products as well as addressing nonadherence, psychiatric, and socioeconomic issues that complicate care.

Acute asthma is the third commonest cause of pediatric emergency visits at PGIMER. Typically, it presents with acute onset respiratory distress and wheeze in a patient with past or family history of similar episodes. The severity of the acute episode of asthma is judged clinically and categorized as mild, moderate and severe. The initial therapy consists of oxygen, inhaled beta-2 agonists (salbutamol or terbutaline), inhaled budesonide (three doses over 1 h, at 20 min interval) in all and ipratropium bromide and systemic steroids (hydrocortisone or methylprednisolone) in acute severe asthma. Other causes of acute onset wheeze and breathing difficulty such as pneumonia, foreign body, cardiac failure etc. should be ruled out with help of chest radiography and appropriate laboratory investigations in first time wheezers and those not responding to 1 h of inhaled therapy. In case of inadequate response or worsening, intravenous infusion of magnesium sulphate, terbutaline or aminophylline may be used. Magnesium sulphate is the safest and most effective alternative among these. Severe cases may need ICU care and rarely, ventilatory support.

Introduction: Herein, we report a case of life-threatening status asthmaticus in a young male presented with nasal polyps but without any history of anaphylaxis or asthma., Discussion: The patient had normal results from preoperative respiratory systemic examinations. The postoperative asthma, which started after an infusion of nonsteroidal anti-inflammatory drugs (NSAIDs), was severe and difficult to manage. A relationship between the NSAID infusion and the asthma attack was indicated. Flurbiprofen axetil, a nonselective COX2 inhibitor, is most likely the causative agent in this case, although there are no prior reports of asthma caused by this agent., Conclusion: We concluded that flurbiprofen axetil evoked severe bronchospasm in this case. Patients who are sensitive to flurbiprofen axetil will usually react to other NSAIDs; therefore, other ordinary NSAIDs should be used with caution in hypersensitive patients. An intranasal ketorolac challenge in individuals with nasal polyps, which is a novel and safe alternative to aspirin challenge, may be recommended to rule out aspirin-exacerbated respiratory disease, prior to the systemic administration of NSAIDs.

Children and adolescents with pulmonary hemorrhage are infrequently encountered in the emergency department (ED). We describe a case of a 16 year-old boy who presented to a pediatric ED with pulmonary hemorrhage and respiratory distress. The patient's unusual initial presentation resulted in the consideration of a broad differential diagnosis for his symptoms, including traumatic, neurological, respiratory, and toxicological causes. After resuscitation in the ED, a prolonged admission, and extensive testing, no cause could be found other than severe opioid toxicity. This case illustrates a rare, life-threatening presentation of opiod toxicity in a healthy adolescent and underlines the potentially serious nature of such exposures.

Asthma is a common chronic inflammatory disorder of the airways characterized by recurrent wheezing, breathlessness, and coughing. Acute exacerbations of asthma can be life-threatening; annual worldwide estimated mortality is 250,000 and most of these deaths are preventable. While most of the acute exacerbations can be managed successfully in the emergency room, few children have severe exacerbations requiring intensive care. Mainstay of treatment for status asthmaticus are inhaled β2 agonist and anticholinergic agents, oxygen along with corticosteroids. Children who do not respond well to initial treatment require parenteral β2 agonist and magnesium. Rarely, sick children need parenteral aminophylline infusion and mechanical ventilation. Guidelines for diagnosis, treatment, ventilator management and supportive care for status asthmaticus in children are discussed in the protocol.

We describe a case of acute respiratory failure due to severe pneumonia triggered by the influenza A virus, rapidly evolving into a refractory status asthmaticus requiring emergent ECMO assistance, in order to facilitate the clinical management of patients suffering from this rare but life-threatening condition. This case report demonstrates that infection with influenza A virus can present with severe pneumonia and status asthmaticus refractory to medical and ventilatory treatment. When medical treatment and mechanical ventilation fail, extracorporeal membrane oxygenation therapy should not be delayed as it will avoid injury resulting from inadequate mechanical ventilation and lung hyperinflation.

Objective: The purpose of this study was to assess whether referral to a pediatric emergency department (PED) by a primary care provider was associated with greater severity of illness, as determined on the basis of clinical measures and increased resource utilization., Methods: A retrospective study of data for 121 088 children who presented to a PED with abdominal pain, fever, or respiratory complaints during a 5-year period was performed. Demographic data, referral status, and proxy markers of illness severity were collected from the medical records and analyzed., Results: A total of 26.3% of all patients seen in the PED presented with these 3 complaint categories. With adjustment for age, gender, race, and insurance class, referred patients were significantly more likely to have high triage acuity designations, higher rates of very abnormal vital signs, and higher admission rates, compared with patients who were self-referred. Referred patients were more likely to undergo testing (laboratory or radiologic), to receive intravenous fluid therapy and pain medications, and to be assigned higher-severity discharge diagnoses, such as appendicitis, septic shock, or status asthmaticus., Conclusions: Referral by a primary care provider to a PED was significantly and independently associated with greater severity of illness and resource utilization. Referral status should be considered in algorithms used to triage cases for evaluation in the PED.

Apical ballooning syndrome, or Tako-tsubo cardiomyopathy, is a peculiar form of transient left-ventricular dysfunction originally described as triggered by emotional stress. Subsequent reports indicated that physical stressors can also induce this clinical syndrome. We describe for the first time, to the best of our knowledge, a case of recurrent, severe, and quickly reversible apical ballooning syndrome provoked by the use of high-dose inhaled β-adrenergic agonists in status asthmaticus., (Copyright © 2010 Elsevier Inc. All rights reserved.)

Chronic obstructive pulmonary disease and asthma are both highly prevalent inflammatory diseases characterized by airway obstruction with distinct pathogenic mechanisms and different degrees of response to antiinflammatory therapy. However, forms of presentation that show overlap between both diseases and which are not clearly represented in clinical trials are frequently encountered in clinical practice. These patients may show accelerated loss of pulmonary function and have a worse prognosis. Therefore their early identification is essential. Biomarkers such as bronchial hyperreactivity or nitric oxide in exhaled air have yielded discrepant results. Phenotypic characterization will allow treatment with inhaled corticosteroids to be individually tailored and optimized., (Copyright © 2010 Sociedad Española de Neumología y Cirugía Torácica. Published by Elsevier Espana. All rights reserved.)

Severe exacerbations of asthma can be life-threatening if not aggressively treated. Despite the publication of therapeutic guidelines developed by experts in this field and people education programs, early recognition and characterization of patients at risk for fatal asthma remain scarce. We report the case of a young lady suffering from acute exacerbation of asthma responsible for intensive care admission with long term mechanical ventilation due to the lack in initial appropriate care.

Objective: To carry out a medical audit or evaluation and improvement procedure on the management of children with asthmatic crises in our Emergency Department (ED)., Material and Methods: We carried out a retrospective audit between January and March 2007, analysing the medical records of a random sample of 50 patients aged 2-14 years consulting our ED for asthmatic crises. Following the international guides, we first selected 17 explicit indicators divided into four domains: "evaluation", "examination", "diagnostic resources", and "treatment and conditions at discharge"., Results: Indicators' compliance proved unequal; it was scarce for cause of asthma crisis (32%); degree of severity (18%); and supportive treatment (24%). Auscultation was registered in 100%, but respiratory frequency only in 49%, and peak flow in 0%. A total of 78% of the patients were treated in the ED, in all cases with beta-mimetic agents, and with systemic corticosteroids in 12%. The result of treatment was registered in only 69% of cases. The medical documentation of resident doctors was not signed by the staff., Conclusions: We identified the following weak points: failure to determine the degree of severity; lack of specification of the details of the crisis (prior duration, treatment at home, supportive treatment); scant asthma background history; and deficient recording of respiratory frequency and peak flow. We propose improving the anamnesis, recording respiratory frequency, with the introduction of tools to measure peak flow, specification of treatment response, and the development of a simpler and more practical protocol, with the performance of a re-audit.

Preventing asthma exacerbation is an important goal of asthma management. The existing clinical tools are not good in predicting asthma exacerbations in young children. Childhood Asthma Control Test (C-ACT) was recently published to be a simple tool for assessing disease control in young children. This study investigated C-ACT and other disease-related factors for indicating longitudinal changes in asthma status and predicting asthma exacerbations. During the same clinic visit, asthma patients aged 4-11 years completed the Chinese version of C-ACT and underwent exhaled nitric oxide and spirometric measurements. Blinded to these results, the same investigator assigned Disease Severity Score (DSS) and rated asthma control according to Global Initiative for Asthma. Asthma exacerbations during the next 6 months were recorded. Ninety-seven patients were recruited, with their mean (standard deviation [SD]) age being 9.2 (2.0) years. Thirty-six (37.1%) patients had uncontrolled asthma at baseline. C-ACT, DSS, and FEV(1) differed among patients with different control status (P < 0.001 for C-ACT and DSS; P = 0.028 for FEV(1)). Thirty-two patients had asthma exacerbations during the 6-month follow-up. Changes in patients' C-ACT scores correlated with changes in asthma control status, DSS, and FEV(1) (P = 0.019, 0.034, and 0.020, respectively). C-ACT score was lower among patients with asthma exacerbations (mean [SD]: 22.9 [4.2] vs. 24.5 [2.1]; P = 0.015). Logistic regression confirmed that the occurrence of asthma exacerbations was associated only with baseline C-ACT (B = -0.203, P = 0.042). In conclusion, C-ACT is better than DSS and objective parameters in reflecting changes in asthma status and predicting asthma exacerbations in young children., ((c) 2009 Wiley-Liss, Inc.)

Objectives: To develop and validate predictive models to determine the need for hospitalization in children treated for acute asthma in the emergency department (ED)., Methods: Prospective cohort study of children aged 2 years and older treated at 2 pediatric EDs for acute asthma. The primary outcome was successful ED discharge, defined as actual discharge from the ED and no readmission for asthma within 7 days, versus need for extended care. Among those defined as requiring extended care, a secondary outcome of inpatient care (>24 hours) or short-stay care (<24 hours) was defined. Logistic regression and recursive partitioning were used to create predictive models based on historical and clinical data from the ED visit. Models were developed with data from 1 ED and validated in the other., Results: There were 852 subjects in the derivation group and 369 in the validation group. A model including clinical score (Pediatric Asthma Severity Score) and number of albuterol treatments in the ED distinguished successful discharge from need for extended care with an area under the receiver-operator characteristic curve of 0.89 (95% confidence interval [CI], 0.87-0.92) in the derivation group and 0.92 (95% CI, 0.89-0.95) in the validation group. Using a score of 5 or more as a cutoff, the likelihood ratio positive was 5.2 (95% CI, 4.2-6.5), and the likelihood ratio negative was 0.22 (95% CI, 0.17-0.28). Among those predicted to need extended care, a classification tree using number of treatments in the ED, clinical score at end of ED treatment, and initial pulse oximetry correctly classified 63% (95% CI, 56-70) of the derivation group as short stay or inpatient, and 62% (95% CI, 55-68) of the validation group., Conclusions: Successful discharge from the ED for children with acute asthma can be predicted accurately using a simple clinical model, potentially improving disposition decisions. However, predicting correct placement of patients requiring extended care is problematic.

Objective: The aim of this study was to identify risk factors for long-term adverse outcomes in children with asthma after visiting the emergency department (ED)., Methods: A prospective observational study was conducted at the ED of a pediatric tertiary hospital in Ontario, Canada. Patient outcomes (ie, acute asthma episodes and ED visits) were measured at baseline and at 1- and 6-months post-ED discharge. Time trends in outcomes were assessed using the generalized estimating equations method. Multiple conditional logistic regressions were used to model outcomes at 6 months and examine the impact of drug insurance coverage while adjusting for confounders., Results: Of the 269 children recruited, 81.8% completed both follow-ups. ED use significantly reduced from 39.4% at baseline to 26.8% at 6 months (P < .001), whereas the level of acute asthma episodes remained unchanged. Children with drug insurance coverage were less likely to have acute asthma episodes (adjusted odds ratio [AOR] = 0.36; 95% CI, 0.15-0.85; P < .02) or repeat ED visits (AOR = 0.45; 95% CI, 0.20-0.99; P < .05) at 6 months. Other risk factors for adverse outcomes included previous adverse asthma events and certain asthma triggers (eg, cold/sinus infection). Washing bed linens in hot water weekly was protective against subsequent acute asthma episodes., Conclusions: Our study demonstrated significant improvements in long-term outcomes in children seeking acute care for asthma in the ED. Future efforts remain in targeting the sustainability of improved outcomes beyond 6 months. Risk factors identified can help target vulnerable populations for proper interventions, which may include efforts to maximize insurance coverage for asthma medications and strategies to improve asthma self-management through patient and provider education.

A 56-year-old woman presented to our hospital with acute severe asthma. As a consequence of severe refractory airflow limitation, moderate hypercapnia ensued for several days. Unexpectedly, the patient died as a result of brain stem herniation, in the absence of hypoxaemia, arterial hypotension or an intracranial mass lesion. We discuss the mechanisms that may have precipitated severe intracranial hypertension resulting in brain death, and the possible methods to detect and avoid such a devastating consequence.

Purpose of Review: Near-fatal asthma continues to be a significant problem despite the decline in overall asthma mortality. The purpose of this review is to discuss recent advances in our understanding of the pathophysiology, diagnosis and treatment of near-fatal asthma., Recent Findings: Two distinctive phenotypes of near-fatal asthma have been identified: one with eosinophilic inflammation associated with a gradual onset and a slow response to therapy and a second phenotype with neutrophilic inflammation that has a rapid onset and rapid response to therapy. Patients who develop sudden-onset near-fatal asthma seem to have massive allergen exposure and emotional distress. In stable condition, near-fatal asthma frequently cannot be distinguished from mild asthma. Diminished perception of dyspnea plays a relevant role in treatment delay, near-fatal events, and death in patients with severe asthma. Reduced compliance with anti-inflammatory therapy and ingestion of medications or drugs (heroin, cocaine) have been associated with fatal or near-fatal asthma., Summary: Near-fatal asthma is a subtype of asthma with unique risk factors and variable presentation that requires early recognition and aggressive intervention.

Objectives: A noninvasive method to assess ventilation may aid in management of children with acute asthma. The purpose of this study was to evaluate the association between end-tidal carbon dioxide (EtCO2) values and disease severity among children with acute asthma., Methods: This was a prospective, blinded, observational study of children 3-17 years old treated for acute asthma in a pediatric emergency department (ED). EtCO2 measurements were taken before the initiation of therapy and after each nebulization treatment (maximum of three). Peak expiratory flow rate (PEFR), Pediatric Asthma Severity Score (PASS), oxygen saturation, and disposition were recorded. Treating physicians, unaware of the EtCO2 results, made all treatment decisions, including disposition., Results: One hundred children were enrolled. The mean initial EtCO2 value was 35 mm Hg (95% confidence interval = 34.3 to 36.1 mm Hg). The mean disposition EtCO2 value was 33.3 mm Hg (95% confidence interval = 32.6 to 34.4 mm Hg). PEFR measures were completed on 43 patients and PASS recorded on 100 patients. There was an overall trend toward lower EtCO2 values during treatment (p < 0.01). Sixteen patients were admitted. Initial EtCO2 values were lower among children admitted to the hospital (35.6 mm Hg vs. 32.9 mm Hg; Mann-Whitney U test; p < 0.02). EtCO2 values at disposition did not differ between groups based on PEFR, PASS, or hospital admission., Conclusions: Noninvasive bedside measurement of EtCO2 values among children with acute asthma is feasible. EtCO2 values did not distinguish children with mild disease from those with more severe disease. Further data are needed to clarify the association between EtCO2 values and other indicators of disease severity, particularly in children with more severe disease.

This paper is the seventh in the series on prescribing medicines for child dental patients. Here, the authors aim to describe the medical emergencies that may occur in children presenting for dental treatment and to provide guidelines on their management, with particular reference to the use of emergency drugs.