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'.)
- Mannino DM, Homa DM, Akinbami LJ, et al. Surveillance for asthma--United States, 1980-1999. MMWR Surveill Summ 2002; 51:1.
- Hartman ME, Linde-Zwirble WT, Angus DC, Watson RS. Trends in admissions for pediatric status asthmaticus in New Jersey over a 15-year period. Pediatrics 2010; 126:e904.
- Scarfone RJ, Fuchs SM, Nager AL, Shane SA. Controlled trial of oral prednisone in the emergency department treatment of children with acute asthma. Pediatrics 1993; 92:513.
- Smith SR, Strunk RC. Acute asthma in the pediatric emergency department. Pediatr Clin North Am 1999; 46:1145.
- Nievas IF, Anand KJ. Severe acute asthma exacerbation in children: a stepwise approach for escalating therapy in a pediatric intensive care unit. J Pediatr Pharmacol Ther 2013; 18:88.
- Rotta AT. Asthma. In: Pediatric critical care, 3rd ed, Fuhrman BP, Zimmerman JJ (Eds), Mosby, Philadelphia 2006. p.589.
- Chipps BE, Murphy KR. Assessment and treatment of acute asthma in children. J Pediatr 2005; 147:288.
- Strunk RC, Mrazek DA, Fuhrmann GS, LaBrecque JF. Physiologic and psychological characteristics associated with deaths due to asthma in childhood. A case-controlled study. JAMA 1985; 254:1193.
- Kolbe J, Vamos M, Fergusson W, Elkind G. Determinants of management errors in acute severe asthma. Thorax 1998; 53:14.
- Ordoñez GA, Phelan PD, Olinsky A, Robertson CF. Preventable factors in hospital admissions for asthma. Arch Dis Child 1998; 78:143.
- Carr W, Zeitel L, Weiss K. Variations in asthma hospitalizations and deaths in New York City. Am J Public Health 1992; 82:59.
- Triasih R, Duke T, Robertson CF. Outcomes following admission to intensive care for asthma. Arch Dis Child 2011; 96:729.
- Engelkes M, Janssens HM, de Jongste JC, et al. Medication adherence and the risk of severe asthma exacerbations: a systematic review. Eur Respir J 2015; 45:396.
- From the Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA) 2014. Available from: http://www.ginasthma.org/ (Accessed on November 07, 2014).
- Giuliano JS Jr, Faustino EV, Li S, et al. Corticosteroid therapy in critically ill pediatric asthmatic patients. Pediatr Crit Care Med 2013; 14:467.
- National Asthma Education and Prevention Program: Expert panel report III: Guidelines for the diagnosis and management of asthma. Bethesda, MD: National Heart, Lung, and Blood Institute, 2007. (NIH publication no. 08-4051). Full text available at: www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm (Accessed on September 1, 2007).
- Vézina K, Chauhan BF, Ducharme FM. Inhaled anticholinergics and short-acting beta(2)-agonists versus short-acting beta2-agonists alone for children with acute asthma in hospital. Cochrane Database Syst Rev 2014; :CD010283.
- Roberts JS, Bratton SL, Brogan TV. Acute severe asthma: differences in therapies and outcomes among pediatric intensive care units. Crit Care Med 2002; 30:581.
- Stephanopoulos DE, Monge R, Schell KH, et al. Continuous intravenous terbutaline for pediatric status asthmaticus. Crit Care Med 1998; 26:1744.
- Wheeler DS, Jacobs BR, Kenreigh CA, et al. Theophylline versus terbutaline in treating critically ill children with status asthmaticus: a prospective, randomized, controlled trial. Pediatr Crit Care Med 2005; 6:142.
- Mitra A, Bassler D, Goodman K, et al. Intravenous aminophylline for acute severe asthma in children over two years receiving inhaled bronchodilators. Cochrane Database Syst Rev 2005; :CD001276.
- Browne GJ, Penna AS, Phung X, Soo M. Randomised trial of intravenous salbutamol in early management of acute severe asthma in children. Lancet 1997; 349:301.
- Bohn D, Kalloghlian A, Jenkins J, et al. Intravenous salbutamol in the treatment of status asthmaticus in children. Crit Care Med 1984; 12:892.
- Fortenberry JD, Del Toro J, Jefferson LS, et al. Management of pediatric acute hypoxemic respiratory insufficiency with bilevel positive pressure (BiPAP) nasal mask ventilation. Chest 1995; 108:1059.
- Padman R, Lawless ST, Kettrick RG. Noninvasive ventilation via bilevel positive airway pressure support in pediatric practice. Crit Care Med 1998; 26:169.
- Bernet V, Hug MI, Frey B. Predictive factors for the success of noninvasive mask ventilation in infants and children with acute respiratory failure. Pediatr Crit Care Med 2005; 6:660.
- Essouri S, Chevret L, Durand P, et al. Noninvasive positive pressure ventilation: five years of experience in a pediatric intensive care unit. Pediatr Crit Care Med 2006; 7:329.
- Piastra M, Conti G, Caresta E, et al. Noninvasive ventilation options in pediatric myasthenia gravis. Paediatr Anaesth 2005; 15:699.
- Sprague K, Graff G, Tobias DJ. Noninvasive ventilation in respiratory failure due to cystic fibrosis. South Med J 2000; 93:954.
- Carroll CL, Schramm CM. Noninvasive positive pressure ventilation for the treatment of status asthmaticus in children. Ann Allergy Asthma Immunol 2006; 96:454.
- Akingbola OA, Simakajornboon N, Hadley Jr EF, Hopkins RL. Noninvasive positive-pressure ventilation in pediatric status asthmaticus. Pediatr Crit Care Med 2002; 3:181.
- Thill PJ, McGuire JK, Baden HP, et al. Noninvasive positive-pressure ventilation in children with lower airway obstruction. Pediatr Crit Care Med 2004; 5:337.
- Beers SL, Abramo TJ, Bracken A, Wiebe RA. Bilevel positive airway pressure in the treatment of status asthmaticus in pediatrics. Am J Emerg Med 2007; 25:6.
- Javouhey E, Barats A, Richard N, et al. Non-invasive ventilation as primary ventilatory support for infants with severe bronchiolitis. Intensive Care Med 2008; 34:1608.
- Cambonie G, Milési C, Jaber S, et al. Nasal continuous positive airway pressure decreases respiratory muscles overload in young infants with severe acute viral bronchiolitis. Intensive Care Med 2008; 34:1865.
- Mayordomo-Colunga J, Medina A, Rey C, et al. Non-invasive ventilation in pediatric status asthmaticus: a prospective observational study. Pediatr Pulmonol 2011; 46:949.
- Najaf-Zadeh A, Leclerc F. Noninvasive positive pressure ventilation for acute respiratory failure in children: a concise review. Ann Intensive Care 2011; 1:15.
- Basnet S, Mander G, Andoh J, et al. Safety, efficacy, and tolerability of early initiation of noninvasive positive pressure ventilation in pediatric patients admitted with status asthmaticus: a pilot study. Pediatr Crit Care Med 2012; 13:393.
- Needleman J, Sykes J, Schroeder S, Singer L. Noninvasive positive pressure ventilation in the treatment of pediatric status asthmaticus. Pediatr Asthma Allergy Immunol 2004; 17:272.
- Abstracts of the 33rd International Symposium on Intensive Care and Emergency Medicine. Brussels, Belgium. March 19-22, 2013. Crit Care 2013; 17 Suppl 2:P1.
- Carroll CL. Heliox for children with acute asthma: has the sun set on this therapy? Pediatr Crit Care Med 2010; 11:428.
- Kim IK, Phrampus E, Venkataraman S, et al. Helium/oxygen-driven albuterol nebulization in the treatment of children with moderate to severe asthma exacerbations: a randomized, controlled trial. Pediatrics 2005; 116:1127.
- Rodrigo GJ, Castro-Rodriguez JA. Heliox-driven β2-agonists nebulization for children and adults with acute asthma: a systematic review with meta-analysis. Ann Allergy Asthma Immunol 2014; 112:29.
- Krishnan V, Diette GB, Rand CS, et al. Mortality in patients hospitalized for asthma exacerbations in the United States. Am J Respir Crit Care Med 2006; 174:633.
- 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