Acute severe asthma exacerbations in children: Intensive care unit management
- Joy D Howell, MD
Joy D Howell, MD
- Associate Professor of Clinical Pediatrics
- Weill Medical College of Cornell University
- Section Editors
- Gregory Redding, MD
Gregory Redding, MD
- Section Editor — Pediatric Pulmonology
- Professor of Pediatrics
- University of Washington School of Medicine
- Adrienne G Randolph, MD, MSc
Adrienne G Randolph, MD, MSc
- Section Editor — Pediatric Critical Care Medicine
- Professor of Anaesthesia and Pediatrics
- Harvard Medical School
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) . Admission to intensive care has increased in proportion to general hospital admission for asthma . 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: Endotracheal intubation and mechanical ventilation" 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".)
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)  and the Pulmonary Score, which is similar to the Pulmonary Index Score except that it scores only respiratory rate, wheezing, and accessory muscle use . 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 . The assessment of severity of acute asthma exacerbations is discussed in detail separately. (See "Acute asthma exacerbations in children: Home/office management and severity assessment", section on 'Assessment of exacerbation severity'.)
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- Severity assessment
- Risk factors
- General principles
- PREINTUBATION THERAPIES
- - Glucocorticoids
- - Bronchodilators
- Noninvasive positive pressure ventilation
- - Mechanisms of action of NPPV
- - Efficacy of NPPV
- - Possible indications for NPPV
- - Limitations of NPPV
- - NPPV settings
- INTUBATION AND MECHANICAL VENTILATION
- SUPPORTIVE CARE
- Fluid support
- ADJUNCTIVE THERAPIES
- STEPPING DOWN THERAPIES
- Discontinuing noninvasive positive pressure ventilation
- Weaning medications
- CRITERIA FOR TRANSFER OUT OF THE ICU
- SUMMARY AND RECOMMENDATIONS