Acute severe asthma exacerbations in children

younger than 12 years: Intensive care unit

management
AUTHOR:
Joy D Howell, MD
SECTION EDITORS:
Gregory Redding, MD
Adrienne G Randolph, MD, MSc
DEPUTY EDITOR:
Elizabeth TePas, MD, MS
Contributor Disclosures
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Sep 2023.
This topic last updated: Jan 30, 2023.

INTRODUCTION Asthma is the most frequent cause of hospitalization

among children in the United States and is the source of nearly 500,000
admissions to pediatric intensive care units (PICUs) [1]. Admission to intensive care
has increased in proportion to general hospital admission for asthma [2]. Mortality
rates in children are lower than adults, but males and African Americans have a
higher risk for death compared with girls and white Americans.
Intensive care unit (ICU) management of children with acute severe asthma
exacerbation (ie, status asthmaticus) is discussed here, with the exception that
endotracheal intubation and mechanical ventilation are discussed separately. Non-
ICU inpatient management is also discussed in detail separately. Mechanical
ventilation for adults with severe asthma is also reviewed separately. (See "Acute
severe asthma exacerbations in children younger than 12 years: Endotracheal
intubation and mechanical ventilation" and "Acute asthma exacerbations in
children younger than 12 years: Inpatient management" and "Invasive mechanical
ventilation in adults with acute exacerbations of asthma".)
Pharmacologic management of acute asthma exacerbations and management of
chronic childhood asthma also are discussed separately. (See "Acute asthma
exacerbations in children younger than 12 years: Emergency department
management" and "Asthma in children younger than 12 years: Initial evaluation
and diagnosis" and "Asthma in children younger than 12 years: Management of
persistent asthma with controller therapies" and "Asthma in children younger
than 12 years: Quick-relief (rescue) treatment for acute symptoms".)

OVERVIEW The pathologic hallmarks of asthma are airway inflammation,

excessive mucus production, mucus plugging, and airway bronchospasm, all of

which may lead to severe airflow obstruction. Airflow obstruction produces varying
degrees of respiratory insufficiency and can progress to respiratory failure. Both
the severity of the exacerbation and presence of risk factors associated with the
need for ICU management are taken into account when admitting a child with an
acute asthma exacerbation.
Severity assessment — Severe acute asthma is somewhat loosely defined based
upon presenting signs and symptoms and response to therapy (table 1). There are
several scoring systems to help assess asthma severity in children. Examples
include the Pulmonary Index Score (table 2) [3] and the Pulmonary Score, which is
similar to the Pulmonary Index Score except that it scores only respiratory rate,
wheezing, and accessory muscle use [4]. Another is the Pediatric Intensive Care
Unit Pediatric Asthma Score, which factors in respiratory rate relative to age,
oxygen requirement, presence of retractions, breathlessness during speech, and
presence of wheezing [5]. The assessment of severity of acute asthma
exacerbations is discussed in detail separately. (See "Acute asthma exacerbations
in children younger than 12 years: Overview of home/office management and
severity assessment", section on 'Assessment of exacerbation severity'.)
Risk factors — Boys, children living in poverty, African Americans, and some
Hispanics (especially Puerto Ricans) have high rates of asthma and severe asthma.
Patients who are at risk for requiring ICU management for asthma include those
who have a history of [6-13]:
●ICU admissions, mechanical ventilation, or rapidly progressive and sudden
respiratory deterioration
●Seizures or syncope during an asthma exacerbation
●Exacerbations precipitated by food
●Use of more than two beta-agonist metered-dose inhaler (MDI) canisters per
month
●Insufficient controller therapy or poor adherence to controller therapy
●Denial of or failure to appreciate the severity of illness
●Associated depression or other psychiatric disorder
Although these factors are frequently present in patients who require ICU
management, they fail to prospectively identify a significant number of cases [6]
and should not be interpreted as absolute indications for admission to an ICU. As
many as one-third of children who die from asthma would not have been classified
as at risk for fatal asthma based upon these risk factors. Risk factors for fatal
asthma are discussed in greater detail separately. (See "Identifying patients at risk
for fatal asthma", section on 'Identifying high-risk patients'.)
General principles — Children with acute severe asthma who fail to improve with
initial treatment in the emergency department should be admitted to the pediatric
ICU (PICU). ICU level management of these children entails the administration of
glucocorticoids, aggressive bronchodilator therapy, and close monitoring [5].
Mechanical ventilation is reserved for patients with continued progression toward
respiratory failure despite maximal medical therapy.
(See 'Pharmacotherapy' below and "Acute severe asthma exacerbations in
children younger than 12 years: Endotracheal intubation and mechanical
ventilation".)
The need for mechanical ventilation should be considered early in the course of
illness. Mechanical ventilation in a child with an asthma exacerbation is always
challenging, usually due to airway obstruction and difficulty with exhalation. The
best way to avoid intubation is to rapidly escalate the preintubation therapies
discussed below in patients with a worsening trajectory indicated by increased
work of breathing or carbon dioxide (CO2) retention. The decision to intubate a
patient should be made with great care since tracheal stimulation often worsens
the asthma exacerbation and, in some cases, makes the situation worse.
In many patients who are progressing toward respiratory muscle fatigue,
noninvasive positive pressure ventilation (NPPV) can avoid the need for intubation
by easing the work of breathing while awaiting the maximal therapeutic effects of
pharmacotherapy. NPPV in conjunction with pharmacologic therapy is effective in
improving gas exchange in children and adults with asthma. NPPV can be used in
school-aged children with relative ease, but light sedation may be required to
facilitate tolerance in younger children [5]. (See 'Noninvasive positive pressure
ventilation' below.)
Adjunctive therapies may be necessary for children who do not improve despite
aggressive pharmacologic therapy and mechanical ventilation. (See 'Adjunctive
therapies' below and "Acute severe asthma exacerbations in children younger
than 12 years: Endotracheal intubation and mechanical ventilation", section on
'Adjunctive therapies'.)
There are no widely used, evidence-based treatment algorithms or pathways for
the management of acute severe asthma in children, and there is considerable
variability in care. The use of an algorithm for escalation and weaning of therapy
was applied to 385 children older than two years of age with status asthmaticus
admitted on continuous albuterol to the medical ICU of one center [14]. The use of
this protocol was associated with a decrease in the duration of continuous
albuterol therapy and reduced length of hospital stay. Although the findings
require replication in other centers, standardized-care protocols could improve
outcomes in the future.

PREINTUBATION THERAPIES The primary preintubation therapies are

supplemental oxygen, glucocorticoids, bronchodilators, inhaled anticholinergics,

and systemic magnesium sulfate [15]. Noninvasive positive pressure ventilation
(NPPV) may help to avoid endotracheal intubation in select patients who continue
to have severe or unabated increased work of breathing while awaiting the
maximum therapeutic benefit of pharmacotherapy. It is important to determine
whether the inhaled bronchodilators can be delivered via the noninvasive
ventilation device since this is often not the case and intravenous bronchodilators
can be started.
Pharmacotherapy — The goal of pharmacologic therapy for acute severe asthma
exacerbations is to ensure adequate oxygenation and ventilation and ease the
work of breathing. Pharmacologic therapy of children who are admitted to the ICU
with acute severe asthma exacerbation entails the administration of
glucocorticoids and aggressive bronchodilator therapy (algorithm 1). We
recommend the administration of intravenous glucocorticoids and
inhaled albuterol. We also suggest inhaled ipratropium and
intravenous magnesium sulfate if the patient was not already treated with these
medications.
For those who fail to respond to these interventions, we suggest the
administration of parenteral beta2-agonists. The efficacy of these interventions has
been documented in meta-analyses and/or randomized, controlled trials, which
are described separately. (See "Acute asthma exacerbations in children younger
than 12 years: Emergency department management", section on 'Severe
exacerbation' and "Acute asthma exacerbations in children younger than 12 years:
Emergency department management", section on 'Elements of treatment'.)
Glucocorticoids — Glucocorticoids are usually administered intravenously in
children who are admitted to the ICU with acute asthma exacerbation.
●Methylprednisolone (loading dose 2 mg/kg, then 0.5 to 1 mg/kg/dose every
six hours, with a maximum dose of 60 mg/day) [16]. (See "Acute asthma
exacerbations in children younger than 12 years: Emergency department
management", section on 'Management of inflammation'.)
Bronchodilators — The primary bronchodilator therapy is inhaled albuterol.
Inhaled ipratropium bromide and intravenous magnesium sulfate are adjunctive
therapies that are often also used because they have been shown to decrease the
risk of hospitalization for children treated in the emergency department. They
have not been shown to offer further benefit in hospitalized patients, but they
have not been studied in the pediatric ICU (PICU) population [5]. Additional
intravenous bronchodilators may be used in patients who do not respond to initial
bronchodilatory therapy.
●Hourly or continuously delivered albuterol via nebulizer (see "Acute asthma
exacerbations in children younger than 12 years: Emergency department
management", section on 'Inhaled short-acting beta-2 agonists'):
•For hourly administration, albuterol (0.15 mg/kg every hour, minimum
2.5 mg; maximum 5 mg), or
•For continuous administration, albuterol (10 mg/hour for children who
weigh 5 to 10 kg, 15 mg/hour for children who weigh 10 to 20 kg, and 20
mg/hour for children who weigh >20 kg). Alternatively, continuous
albuterol can be dosed 0.15 to 0.5 mg/kg/hour, up to a maximum dose of
30 mg/hour [5].
●Magnesium sulfate (25 to 75 mg/kg intravenously; maximum 2 grams) is
administered over 20 to 30 minutes upon arrival to the ICU if it has not been
administered earlier. Patients should be monitored for hypotension,
especially if they have received terbutaline and are vasodilated, although this
complication is rare [17]. If hypotension does occur, the magnesium sulfate
infusion should be paused, a fluid bolus administered, and then the infusion
resumed at a lower rate [18]. (See "Acute asthma exacerbations in children
younger than 12 years: Emergency department management", section on
'Magnesium sulfate'.)
●Evidence of benefit for ipratropium bromide has not been demonstrated in
hospitalized patients, and, therefore, it is not recommended for hospitalized
patients by the National Heart Lung and Blood Institute (NHLBI) asthma
guidelines [19]. However, it has not yet been specifically studied in the PICU
population, and one review found no trials reporting any serious adverse
events associated with its use [20]. Thus, some experts will use ipratropium
bromide as an adjunctive therapy in hospitalized children with impending
respiratory failure due to asthma who fail to respond to the usual therapies.
A dosing regimen extrapolated from management of children with chronic
lung disease can be used in a child with severe status asthmaticus and
impending respiratory failure (250 microgram per dose every 6 hours for 24
hours for children who weigh <20 kg or ≤6 years of age; 500 microgram per
dose every 6 hours for 24 hours for children who weigh >20 kg or ≥6 years of
age) [5,21]. (See "Acute asthma exacerbations in children younger than 12
 years: Emergency department management", section on 'Ipratropium
bromide'.)
For patients who fail to respond to the bronchodilator therapy reviewed above, we
suggest the transition to intravenous bronchodilators [22,23]. Terbutaline is most
commonly used. Theophylline and aminophylline (the water-soluble,
ethylenediamine salt of theophylline), methylxanthines with phosphodiesterase
inhibitor activity, were historically a standard component of acute asthma
management but over the past 30 years have essentially been eliminated from
standard treatment algorithms for acute asthma. Evidence in support of their use
in the inpatient population is limited at best. Thus, these agents are infrequently
used in PICUs for status asthmaticus. However, we reserve aminophylline as an
option for the child with severe status asthmaticus and impending respiratory
failure who has not responded to terbutaline. Extreme caution should be
employed in the patient with risk factors for myocardial ischemia since tachycardia
increases myocardial oxygen demand. In addition, children who present with
status asthmaticus are predisposed to dehydration/intravascular depletion. Thus,
fluid loading may be necessary to blunt some of the tachycardia associated with
use of intravenous bronchodilators. (See 'Fluid support' below and "Acute asthma
exacerbations in children younger than 12 years: Emergency department
management", section on 'Parenteral beta-agonists'.)
●Terbutaline (10 microgram/kg intravenous loading dose administered over
10 minutes, followed by an infusion of 0.1 to 10 microgram/kg/minute). The
dosing range found in most references for intravenous terbutaline is
remarkably wide. Although dosing as low as 0.1 microgram/kg/minute are
suggested, experienced intensivists usually begin with a dose of 0.5
micrograms/kg/minute. The infusion can be increased in 0.1 to 1
microgram/kg/minute increments every 30 minutes, depending upon the
patient's degree of respiratory distress, heart rate, perfusion, and quality of
aeration, to a maximum dose of 5 to 10 micrograms/kg/minute (the author
rarely exceeds a dose of 3 to 5 micrograms/kg/minute) until aeration and
work of breathing improve. Continuous albuterol should be discontinued
once terbutaline is initiated.
Terbutaline causes tachycardia and, in turn, increases myocardial oxygen
consumption. In general, the younger the age, the better tachycardia is
tolerated. At the author's center, patients with severe status asthmaticus
requiring terbutaline infusion receive fluid boluses in an effort to blunt some
of the tachycardia. Serial troponin levels and electrocardiograms are
sometimes obtained, particularly in adolescent and preadolescent patients
on both terbutaline and aminophylline infusions, to monitor for evidence of
myocardial ischemia. Terbutaline infusions may be associated with
hypotension, hyperglycemia, hypokalemia, and arrhythmias [23].
●Aminophylline (6 mg/kg intravenous loading dose, followed by infusion of
0.5 to 1 mg/kg/hour that is titrated based upon levels). The recommended
starting dose of the infusion (after the loading dose) varies by age for
patients:
•6 weeks to 6 months – 0.5 mg/kg/hour
•6 to 12 months – 0.6 to 0.7 mg/kg/hour
•1 to 9 years – 1 mg/kg/hour
•9 to 16 years – 0.8 mg/kg/hour
Aminophylline has a mean volume of distribution of 0.5 L/kg. Thus, a loading
dose of 6 mg/kg should generate a serum level of approximately 12
microgram/mL. Therapeutic levels range between 10 and 20 microgram/mL.
We suggest target levels of 12 to 15 microgram/mL, particularly upon
initiation of therapy. Steady-state levels are checked 6 to 12 hours following
the bolus/initiation of the infusion. If the patient's respiratory status does not
improve and the six-hour theophylline level is below 15 microgram/mL, then
the infusion is increased proportionately to a target level of 15
microgram/mL. Serum levels of aminophylline should be measured once
daily (after desired level or response to therapy achieved) and as needed
when toxicity is suspected (severe tachycardia, anxiety, persistent emesis,
dysrhythmias, and seizures).
A review published in 2005 explored the efficacy of aminophylline in children
with acute severe asthma [24]. Improvement in lung function within six hours
was demonstrated, but there was no apparent reduction in the number of
nebulized treatments given or length of hospital stay. There was insufficient
evidence to assess its impact on oxygenation, PICU admissions, and
mechanical ventilation. One randomized trial
compared terbutaline, theophylline, and combination therapy with both
drugs in a cohort of PICU patients [23]. Theophylline was as effective as
terbutaline in treating critically ill children with asthma and was more cost
effective. Despite the lack of consistent evidence of benefit and the fact that
aminophylline is not recommended by National Asthma Education and
Prevention Program (NAEPP) guidelines, 59 percent of respondents to a
survey administered to pediatric critical care medicine fellowship program
directors (academic intensivists), reported using aminophylline for children
with severe status asthmaticus refractory to other therapies [25].
(See "Theophylline use in asthma".)
 ●Intravenous albuterol is not available in the United States. However, in
countries where it is available, efficacy in patients with acute severe asthma
has been demonstrated in randomized and observational studies [26,27]. The
dose is 0.5 to 5 microgram/kg/minute [27]. Subcutaneous or
intramuscular epinephrine or terbutaline are additional options if
intravenous terbutaline is not available [19]. Dosing for subcutaneous or
intramuscular epinephrine is 0.01 mg/kg (0.01 mL/kg of 1:1000 solution [1
mg/mL]) every 20 minutes for up to three doses, maximum dose 0.5 mg.
Dosing of subcutaneous or intramuscular terbutaline is 0.01 mg/kg (0.01
mL/kg of a 1 mg/mL solution) every 20 minutes for up to three doses and
then every two to six hours as needed, maximum dose 0.25 mg.
Noninvasive positive pressure ventilation — NPPV eases the work of breathing
in patients who are progressing toward respiratory muscle fatigue. Thus, NPPV
may help to avoid endotracheal intubation in select patients who continue to have
severe or unabated symptoms after intravenous bronchodilators or while awaiting
the maximum therapeutic benefit of pharmacotherapy. NPPV has been used to
treat children with respiratory failure from a number of causes, including
neuromuscular disorders, cystic fibrosis, bronchiolitis, and status asthmaticus [28-
40]. The benefits for children with status asthmaticus are thus far favorable, with
retrospective and prospective studies documenting clinical improvement in the
pediatric emergency department and ICU settings [5]. (See "Noninvasive
ventilation for acute and impending respiratory failure in children".)
NPPV involves the delivery of positive airway pressure, either as continuous
pressure (continuous positive airway pressure [CPAP]) or as mechanically assisted
breaths (bilevel positive airway pressure [BiPAP]), without placement of an artificial
airway. In most cases, ventilation is delivered via full facial mask. Patients who
receive NPPV must be awake and cooperative, have a patent airway, and have
spontaneous respirations. Toddlers and small children may require mild sedation
to tolerate the mask. (See "Noninvasive ventilation for acute and impending
respiratory failure in children".)
Mechanisms of action of NPPV — NPPV may be useful as a temporizing measure
while awaiting the maximal therapeutic benefit of pharmacotherapy and may help
patents avoid the need for intubation. During an asthma attack, bronchospasm
and increased mucus production result in airflow obstruction in the distal airways
that cause increased airway resistance and development of long expiratory time
constants in lung units. This leads to the development of air trapping and dynamic
hyperinflation, also known as auto-PEEP. The development of auto-PEEP
necessitates an increase in the work of breathing since a greater negative force
must be generated for inspiration to begin in the context of air trapping. NPPV
may improve this phenomenon by stenting open collapsing or narrowed airways,
thereby allowing for more complete exhalation. This in turn reduces the
inspiratory work of breathing. Additionally, the application of inspiratory positive
airway pressure (IPAP) further unloads the muscles of respiration [41].
(See "Noninvasive ventilation for acute and impending respiratory failure in
children", section on 'Physiology'.)
Efficacy of NPPV — Evidence supporting the benefit of NPPV in children with acute
severe asthma is accruing, although further trials are still needed [42].
The safety, efficacy, and tolerability of BiPAP in children admitted to the PICU with
status asthmaticus was evaluated in a randomized trial of standard therapy versus
standard therapy plus NPPV for 24 hours [43]. The outcome measures included
change in clinical asthma score, respiratory rate, oxygen saturation, and oxygen
requirement. Adjunctive therapies could be employed, at the discretion of the
attending clinician, only if patients experienced an increase in their clinical asthma
score beyond two hours after enrollment. Rapid and significant improvements in
clinical asthma score were reported at each time point studied, although no
significant differences between the two groups were seen for the other outcome
measures. NPPV was well tolerated, and no major complications were reported.
In a prospective study, 20 children (median age 4.8 years) admitted to the PICU
with acute lower airway obstruction were randomly assigned to two hours of NPPV
followed by two hours of standard therapy or to two hours of standard therapy
followed by two hours of NPPV [36]. Compared with standard therapy, NPPV
decreased respiratory rate, accessory muscle use, and dyspnea. No serious
morbidity was noted, but five patients were unable to tolerate NPPV for the
duration of the study.
In several observational studies and case series, treatment with NPPV was
associated with improved clinical and ventilatory parameters in children with
asthma [34,35,37,40,44,45]. A reduction in PICU admissions was reported when
BiPAP was used in the pediatric emergency department setting [37]. However, four
of five patients in one of the smallest case series were morbidly obese (body mass
index ≥30). Thus, the improvement in their respiratory status with NPPV may have
been related to underlying obesity hypoventilation syndrome, although none of
them reported a previous history [34]. (See "Noninvasive positive airway pressure
therapy for the obesity hypoventilation syndrome".)
Possible indications for NPPV — The use of NPPV in children with status
asthmaticus varies from center to center. We suggest a trial of NPPV in the
following situations, provided that the child is alert, cooperative, and without
increased airway secretions:
 ●The child remains hypoxemic despite high flow oxygen and/or has
documented hypercarbia.
●The child is progressing toward respiratory muscle fatigue, but the
maximum therapeutic effects of glucocorticoids and bronchodilators have
not been reached.
Limitations of NPPV — The use of NPPV is limited because it:
●Requires patient cooperation
●Impairs ability to clear secretions from the respiratory tract
●Does not provide definitive control of the airway
●May cause gastric distension with increased risk of aspiration
●May cause heightened sense of air hunger upon initiation
●Patients may feel claustrophobic
An experienced nurse or respiratory therapist who can coach the patient through
the initiation of NPPV is invaluable. Mild sedatives are sometimes used to facilitate
the patient's tolerance of NPPV [35], but great care must be taken to avoid
diminishing airway protective reflexes and respiratory drive.
NPPV settings — NPPV can begin as CPAP with a pressure of 5 cm H2O in patients
with moderately increased work of breathing (table 1) or relatively mild-moderate
degrees of hypoxemia (those who can maintain oxygen saturation greater than 92
percent with the provision of simple face mask oxygen at fraction of inspired
oxygen [FiO2] of 0.25 to 0.7) or hypercarbia (partial pressure of carbon dioxide in
arterial blood [PaCO2] of 45 to 50 mmHg).
BiPAP provides a greater level of support and decreases the work of breathing
more efficiently in patients with significantly increased work of breathing and
moderate or severe hypoxemia (patients requiring FiO2 >70 percent by simple face
mask or nonrebreather mask) and/or hypercarbia (PaCO2 >50 mmHg). The initial
BiPAP settings should be relatively low and should be titrated to patient comfort,
oxygenation, and ventilation. The inspiratory pressure may start at 8 to 10 cm H2O
and the expiratory pressure at 5 cm H2O. These settings may be titrated up to an
inspiratory pressure of 10 to 12 cm H2O, and the expiratory pressure may be
carefully titrated up to 7 to 8 cm H2O.
High-flow nasal cannula — High-flow nasal cannula (HFNC) is becoming widely
available in patients with respiratory embarrassment from a variety of sources
including status asthmaticus. There is sparse literature evaluating the use of HFNC
specifically in children with status asthmaticus. In a single-center retrospective
study evaluating the use of HFNC in children with status asthmaticus, investigators
demonstrated the safety and feasibility of HFNC in this setting, with rare instances
of treatment failure (progression to NPPV or intubation) and pneumothorax
[46,47].
Heliox — Heliox is supplied in fixed gas mixtures 20 percent oxygen and 80
percent helium so that hypoxic gas mixtures are not inadvertently administered to
patients. Additional oxygen can be blended and the oxygen concentration
measured proximal to the patient. The physiochemical principles of heliox increase
laminar flow, as well as lower viscosity, compared with nitrogen and oxygen.
However, concentrations of oxygen >40 percent limit the beneficial effects of
helium.
There are limited and conflicting data regarding the efficacy of heliox in the
treatment of children with acute severe asthma [48]. Clinical improvement based
upon a pulmonary index score was reported in a small, prospective study of heliox-
driven nebulizer treatments [49]. A subsequent review concluded that heliox may
have a role in the initial management of asthma in patients with more severe
obstruction based upon available data from a series of small studies [50]. Use of
heliox is reviewed in greater detail separately. (See "Physiology and clinical use of
heliox", section on 'Use in children'.)

INTUBATION AND MECHANICAL VENTILATION Mechanical

ventilation is reserved for patients with continued progression toward respiratory

failure despite maximal medical therapy. Endotracheal intubation should be
approached cautiously in patients with status asthmaticus because manipulation
of the airway can cause increased airflow obstruction due to exaggerated
bronchial responsiveness. Intubation and mechanical ventilation are discussed in
detail separately. (See "Acute severe asthma exacerbations in children younger
than 12 years: Endotracheal intubation and mechanical ventilation".)
Indications for endotracheal intubation and mechanical ventilation include
(see "Acute severe asthma exacerbations in children younger than 12 years:
Endotracheal intubation and mechanical ventilation", section on 'Indications'):
●Hypoxia
●Altered mental status, including agitation and obtundation
●Persistent, severe hypercarbia

SUPPORTIVE CARE Children admitted to the ICU with severe asthma

require close cardiopulmonary monitoring, particularly those on mechanical

ventilation. Supportive measures for children with asthma who require mechanical
ventilation include analgesia, sedation, and muscle relaxation [6]. These measures
help to prevent tachypnea, breath stacking, and ventilator dyssynchrony,
particularly in the setting of hypercapnia. Most patients are also given intravenous
fluids to treat dehydration and prevent hypotension. Sedation and paralysis are
reviewed in detail separately. (See "Acute severe asthma exacerbations in children
younger than 12 years: Endotracheal intubation and mechanical ventilation",
section on 'Sedation and paralysis'.)
Monitoring — Children who are admitted to the ICU for management of acute
severe asthma are usually monitored with a cardiorespiratory monitor that
displays a continuous electrocardiogram tracing, noninvasive blood pressure,
oxygen saturation, and respiratory rate [6].
Additional monitoring includes frequent auscultation. Auscultation provides
important information regarding aeration, optimal duration of exhalation
(wheezing should terminate before the onset of the next inhalation), and the
presence of pneumothorax or mucus plugging (indicated by asymmetric breath
sounds) [6].
Fluid support — The fluid status of children with acute severe asthma
exacerbation who are admitted to the ICU must be carefully monitored. Many
patients are hypovolemic on presentation (related to poor intake and increased
insensible fluid loss from the respiratory tract) [6]. The risk of hypotension is
increased in patients who are mechanically ventilated and who receive sedatives
and paralytics. Intravenous fluids should be administered to replace losses and
optimize intravascular volume. However, overhydration should be avoided since it
may result in pulmonary edema. (See "Acute severe asthma exacerbations in
children younger than 12 years: Endotracheal intubation and mechanical
ventilation", section on 'Hypotension'.)

ADJUNCTIVE THERAPIES In extreme cases, airflow obstruction is so

severe that sufficient ventilation cannot be achieved despite intensive

bronchodilator therapy, intravenous glucocorticoids, ventilatory support, sedation,
and paralysis. In such cases, adjunctive therapies, such as inhalational anesthetics
or extracorporeal membrane oxygenation (ECMO), may be successful as rescue
measures. However, the routine use of these therapies cannot be recommended
on the basis of existing clinical studies. They remain heroic rescue maneuvers for
the extremely refractory patient. These therapies are discussed in greater detail
separately. (See "Acute severe asthma exacerbations in children younger than 12
years: Endotracheal intubation and mechanical ventilation", section on 'Adjunctive
therapies'.)
 COMPLICATIONS Complications can result from the asthma

exacerbation itself or the treatments. Patients with an acute severe asthma

exacerbation are at risk for progressive air trapping and alveolar hyperinflation,
which may lead to alveolar rupture and hemodynamic compromise. Endotracheal
intubation with mechanical ventilation in the child with asthma can be associated
with significant morbidity including hypotension, barotrauma (including
pneumothorax), and myopathy. These and other complications are reviewed in
detail separately. (See "Acute severe asthma exacerbations in children younger
than 12 years: Endotracheal intubation and mechanical ventilation", section on
'Complications'.)

STEPPING DOWN THERAPIES Interventions should gradually be

weaned as the patient improves.

Discontinuing noninvasive positive pressure ventilation — Bilevel positive
airway pressure (BiPAP) can be weaned to continuous positive airway pressure
(CPAP) when the patient's work of breathing and respiratory rate are minimally
elevated (table 1) and the oxygen requirement is <50 percent. CPAP can be
withdrawn when the work of breathing and respiratory rate have normalized and
the oxygen requirement is ≤40 percent.
Weaning medications — In the absence of evidenced-based guidelines for many
of the adjunctive therapies contained in this topic review, we must acknowledge
that clinical judgment and local practice patterns often dictate how patients are
weaned from intravenous bronchodilator therapy. More important than the
precise order in which medications are discontinued is the careful monitoring of
the patient as therapy is withdrawn. Patients treated with
intravenous terbutaline should have the medication weaned to 0.5 to 1
mcg/kg/minute once clinical improvement is demonstrated and from there may be
transitioned to continuous nebulized albuterol with one hour of overlapping
therapy. Thereafter, they may be weaned to hourly nebulizer treatments as
tolerated. Although not evidenced based, at the author's institution,
if aminophylline is employed, it is generally continued until patients are
consistently tolerating intermittent inhaled albuterol at a frequency of every one to
two hours.
 CRITERIA FOR TRANSFER OUT OF THE ICU Criteria for transitioning

patients from the pediatric ICU (PICU) to the general pediatric ward undoubtedly
vary among institutions and are largely a matter of clinical judgment. However,
several general criteria are useful to consider when making this decision,
including:
●Successful weaning from invasive or noninvasive positive pressure
ventilation (NPPV)
●Successful weaning/cessation of intravenous bronchodilators
●Requirement of aerosolized bronchodilators at a frequency that can be
safely delivered on the general pediatric ward
●Oxygen requirement within the range of what can be safely and locally
appropriate to deliver on the general pediatric ward
●Cardiopulmonary monitoring needs within the range of what can be safely
delivered on the general pediatric ward
●Minimal increased work of breathing

PROGNOSIS While overall mortality is low (0.5 percent in one survey [51]),

patients with status asthmaticus who require mechanical ventilation have

increased in-hospital mortality compared with patients who do not require
mechanical ventilation. Outcomes in ventilated patients are reviewed in detail
separately. (See "Acute severe asthma exacerbations in children younger than 12
years: Endotracheal intubation and mechanical ventilation", section on
'Outcomes'.)

Patients who have required an ICU admission for an asthma exacerbation are at
risk for having another life-threatening or fatal asthma exacerbation. Thus, they
should be closely followed by an asthma specialist in the outpatient setting.

SOCIETY GUIDELINE LINKS Links to society and government-

sponsored guidelines from selected countries and regions around the world are
provided separately. (See "Society guideline links: Asthma in children".)
SUMMARY AND RECOMMENDATIONS

●Indications for admission to PICU – An acute severe asthma exacerbation

is somewhat loosely defined based upon presenting signs and symptoms and
response to therapy (eg, a Pulmonary Index Score of ≥12 (table 2) or peak
flow rate <40 percent of the predicted value for age, sex, and height or
personal best (table 1)). Children with an acute severe asthma exacerbation
who fail to improve with initial treatment in the emergency department
should be admitted to the pediatric intensive care unit (PICU).
(See 'Overview' above and "Acute asthma exacerbations in children younger
than 12 years: Emergency department management".)
●Approach to pharmacotherapy – Intensive care unit (ICU) management of
children with acute severe asthma entails aggressive pharmacotherapy. We
recommend the administration of intravenous glucocorticoids and
inhaled albuterol (Grade 1A), and we suggest the administration of
inhaled ipratropium (Grade 2C) and intravenous magnesium sulfate (Grade
2A). For patients who fail to respond to these measures, we suggest the
administration of parenteral beta2-agonists (Grade 2B).
(See 'Pharmacotherapy' above and "Acute asthma exacerbations in children
younger than 12 years: Emergency department management", section on
'Elements of treatment'.)
●Noninvasive positive pressure ventilation – In select patients, noninvasive
positive pressure ventilation (NPPV) may avoid the need for intubation. We
suggest a trial of NPPV in the following situations, provided that the child is
alert, cooperative, and without increased airway secretions (Grade 2C)
(see 'Noninvasive positive pressure ventilation' above):
•The child remains hypoxemic despite high-flow oxygen and/or has
documented hypercarbia.
•The child is progressing toward respiratory muscle fatigue, but the
maximum therapeutic effects of glucocorticoids and bronchodilators have
not been reached.
●Monitoring and fluid support – Children admitted to the ICU with severe
asthma require close cardiopulmonary monitoring. Most patients are also
given intravenous fluids to treat dehydration and prevent hypotension.
(See 'Supportive care' above.)
●Stepping down therapies – Interventions should gradually be weaned as
the patient improves. More important than the precise order in which
 medications are discontinued is the careful monitoring of the patient as
therapy is withdrawn. (See 'Stepping down therapies' above.)
●Prognosis – Overall mortality in children with acute severe asthma
exacerbations is approximately 0.5 percent. (See 'Prognosis' above.)
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