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Acute severe asthma exacerbations in children: Endotracheal intubation and mechanical ventilation

Joy D Howell, MD
Section Editors
Gregory Redding, MD
Adrienne G Randolph, MD, MSc
Deputy Editor
Elizabeth TePas, MD, MS


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]. Asthma mortality rates in children and adults have remained fairly constant since 1996, before which there had been a steady increase [1,2].

Endotracheal intubation and mechanical ventilation of children with acute severe asthma exacerbation (ie, status asthmaticus) are discussed here. General intensive care unit (ICU) management, primarily pharmacotherapy, and non-ICU inpatient management are discussed in greater detail separately. Mechanical ventilation for adults with severe asthma is also reviewed separately. (See "Acute severe asthma exacerbations in children: Intensive care unit management" and "Acute asthma exacerbations in children: 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: Emergency department management" and "Asthma in children younger than 12 years: Initial evaluation and diagnosis" and "Asthma in children younger than 12 years: Treatment of persistent asthma with controller medications" and "Asthma in children younger than 12 years: Rescue treatment for acute symptoms".)


Children with acute severe asthma who fail to improve with initial treatment in the emergency department should be admitted to the pediatric intensive care unit (PICU). Intensive care unit (ICU)-level management of these children entails the administration of glucocorticoids, aggressive bronchodilator therapy, and close monitoring [3]. Use of noninvasive positive pressure ventilation (NPPV) can help avoid the need for intubation in many patients who progress toward respiratory muscle fatigue by reducing the work of breathing until maximal therapeutic effects of pharmacotherapy take place. (See "Acute severe asthma exacerbations in children: Intensive care unit management", section on 'Pharmacotherapy' and "Acute severe asthma exacerbations in children: Intensive care unit management", section on 'Noninvasive positive pressure ventilation'.)

Mechanical ventilation is reserved for patients with continued progression toward respiratory failure despite maximal medical therapy. The use of mechanical ventilation during an asthma exacerbation has associated morbidities, but mortality due to complications that occurred after ICU admission is uncommon [4-7]. Mechanical ventilation rates for children with asthma vary from center to center, with published rates ranging from 1 percent to 10 to 20 percent [4,5,7]. (See 'Endotracheal intubation and mechanical ventilation' below and 'Outcomes' below and "Acute severe asthma exacerbations in children: Intensive care unit management", section on 'Prognosis'.)

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Literature review current through: Nov 2017. | This topic last updated: Jul 29, 2016.
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