StatusAsthmaticusinChildren

HeinrichWerner
PediatricCriticalCare
UniversityofKentuckyChildrens
Hospital
hwerner

Statusasthmaticus

Objectives
Theparticipantwillincreasehis/her

Awarenessofrisingmorbidity/mortalityofsevereasthmain
children
Abilitytodefinewhoisatriskfordying
Understandingofthepathologic,metabolicandbiomechanical
events
Abilitytopredictrespiratoryfailureandtodeterminethe
needforearlytransfer
Abilitytotailorthetherapeuticregimenaccordingtoseverity
andprogressionofstatusasthmaticus

Statusasthmaticus

StatusAsthmaticusinChildren
Epidemiology
Pathophysiology
PresentationandAssessment
Treatment

Statusasthmaticus

StatusAsthmaticusinChildren
Epidemiology
Prevalence
Morbidity
Mortality
Riskfactors

Pathophysiology
Presentationandassessment
Treatment

Statusasthmaticus :Epidemiology

Prevalence

Theprevalenceofpediatricasthmainthe
USisincreasing
60
50
1975
1980-81
1985
1989
1990-92
1993-95

40
30
20
10
0

0-4 yrs

5-14 yrs

Rate of self-reported asthma/1,000 population

ManninoDM.MMWR1998;47(1):127

15-34 yrs

Statusasthmaticus :Epidemiology

Morbidity

Themorbidityofpediatricasthmainthe
USisincreasing
Rate per 10,000 population

70
60
50

< 1 year
1-4 years
5-14 years
15-24 years

40
30
20
10

Hospital discharge rates for asthma

MMWR1996;45(17):3503

1992

1990

1988

1986

1984

1982

1980

Statusasthmaticus :Epidemiology

Mortality

ThemortalityofpediatricasthmaintheUS
isincreasing
Rate per 1,000,000 population

7
6
5

0-4 years
5-14 years
15-34 years

4
3
2
1
0
1979-80 1981-83 1984-86 1987-89 1990-92 1993-95

Rates of death in children from asthma

Mannino.MMWR1998;47(1):127

Statusasthmaticus :Epidemiology

Riskfactorsforfatalasthma
Medical
Previousattackwithrapid/severedeteriorationorrespiratory
failureorseizure/lossofconsciousness

Psychosocial
Denial,noncompliance
Depressionorotherpsychiatricdisorder
Dysfunctionalfamily
Innercityresident

Ethnic
Nonwhitechild

Statusasthmaticus

StatusAsthmaticusinChildren
Epidemiology
Pathophysiology
Cytokines
Airwaypathology
Autonomicnervoussystem
Pulmonarymechanics
Cardiopulmonaryinteractions
Metabolism

Presentationandassessment
Treatment

Statusasthmaticus :Pathophysiology

Pathophysiology
Asthmaisprimarilyaninflammatorydisease
Smooth muscle
spasm

Airway edema

Mucous plugging

Statusasthmaticus :Pathophysiology

Inflammatorycytokines
Activatedmastcellsandlymphocytes
produceproinflammatorycytokines
(histamine,leukotrienes,PAF),whichare
increasedinasthmaticsairwaysand
bloodstream

Statusasthmaticus :Pathophysiology

Irritableanddamagedairway
Hypersecretion
Epithelialdamagewith
exposednerveendings

Hypertrophyofgobletcells
andmucusglands

Statusasthmaticus :Pathophysiology

Airway

Theirritableandinflamedairwayissusceptibleto
obstructiontriggeredby
Allergens
Infections
Irritantsincludingsmoke
Exercise
Emotionalstress
GEreflux
Drugs
Otherfactors

Statusasthmaticus :Pathophysiology

Autonomicnervoussystem
Bronchodilation
Sympathetic

Circulatingcatecholamines
stimulatereceptors

Parasympathetic

Vagalsignalsstimulate
bronchodilatingM2
receptors

Nonadrenergic
noncholinergic
(NANC)

Releaseofbronchodilating
neurotransmitters(VIP,NO)

Bronchoconstriction

Vagalsignalsstimulate
bronchoconstrictingM3
receptors
Releaseoftachykinins(substance
P,neurokininA)

Statusasthmaticus :Pathophysiology

Lungmechanics
Hyperinflation
Obstructedsmallairwayscausepremature
airwayclosure,leadingtoairtrappingand
hyperinflation

Hypoxemia
Inhomogeneousdistributionofaffectedareas
resultsinV/Qmismatch,mostlyshunt

Statusasthmaticus :Pathophysiology
Severeairflow
obstruction

Incomplete
exhalation

Increasedlung
volume

Increasedelastic
recoilpressure

Expandedsmall
airways

Increased
expiratoryflow

Decreasedexpiratory
resistance

Compensated:
Hyperinflation,normocapnia
Worsening
airflow
obstruction

Decompensated:
Severehyperinflation,hypercapnia

Fromtextin:
Tuxen.AmRev
RespirDis
1992;146:1136

Statusasthmaticus :Pathophysiology

Cardiopulmonaryinteractions
Leftventricularload
Spontaneouslybreathingchildrenwithsevere
asthmahavenegativeintrapleuralpressure
(aslowas35cmH2O)duringalmostthe
entirerespiratorycycle

StalcupS.NEnglJMed1977;297:5926

Negativeintrapleuralpressurecauses
increasedleftventricularafterload,resulting
inriskforpulmonaryedema
BudaAJ.NEnglJMed1979;301(9):4539

Statusasthmaticus :Pathophysiology

Cardiopulmonaryinteractions
Rightventricularload
Hypoxicpulmonaryvasoconstrictionandlung
hyperinflationleadtoincreasedright
ventricularafterload
DawsonCA.JApplPhysiol1979;47(3):5326

Statusasthmaticus :Pathophysiology

Cardiopulmonaryinteractions
Pulsusparadoxus
P.paradoxusistheclinicalcorrelateofcardiopulmonary
interactionduringasthma.Itisdefinedasexaggerationof
thenormalinspiratorydropinsystolicBP:normally<5
mmHg,but>10mmHginpulsusparadoxus.
Nl
P.paradoxus

Expir

Inspir

Expir

Inspir

Statusasthmaticus :Pathophysiology

Pulsusparadoxuscorrelateswith
severity
AllpatientswhopresentedwithFEV1of<20%
(oftheirbestFEV1whilewell)hadpulsus
paradoxus
PiersonRN.JApplPhysiol1972;32(3):3916

Statusasthmaticus :Pathophysiology

Cardiopulmonaryinteractions
Negative intrapleural
pressure

Hyperinflation

Altered hemodynamics
Pulmonary edema

Pulsus paradoxus

Hypotension

Statusasthmaticus :Pathophysiology

Metabolism
V/Q mismatch

Increased work
of breathing

Dehydration

Hypoxia
Lactate

Metabolic acidosis

Ketones

Statusasthmaticus :Presentation

Presentation
Audiblewheezes:reasonableairflow
Audiblewheezes:reasonableairflow

Cough
Silentchest:ominous!
Silentchest:ominous!
Wheezing
Increasedworkofbreathing
Anxiety
Restlessness
Oxygendesaturation

Statusasthmaticus :Assessment

Assessment
Findingsconsistentwithimpendingrespiratory
failure:
Alteredlevelofconsciousness
Inabilitytospeak
Absentbreathsounds
Centralcyanosis
Diaphoresis
Inabilitytoliedown
Markedpulsusparadoxus

Statusasthmaticus :Assessment

5 = impending resp failure

ClinicalAsthmaScore
0

Cyanosisor None Inair In40%

PaO2 >70inair
<70inair
<70in40%
InspiratoryB/S

Nl

Unequalor

Expirwheezing

None Moderate

Marked

Cerebralfunction
Agitated

Nl

Coma

Depressed

WoodDW.AmJDisChild1972;123(3):2278

Absent

decreased

Statusasthmaticus :Assessment

ChestXRay
Notroutinelyindicated
Exceptions:

Patientisintubated/ventilated
Suspectedbarotrauma
Suspectedpneumonia
Othercausesforwheezingarebeingsuspected

Statusasthmaticus :Assessment

ABG
Earlystatusasthmaticus:hypoxemia,

hypocarbia
Late:hypercarbia
Decisiontointubateshouldnotdependon
ABG,butonclinicalassessment
FrequentABGsarecrucialintheventilated
asthmatic

Statusasthmaticus

StatusAsthmaticusinChildren
Epidemiology
Pathophysiology
Presentationandassessment
Treatment
Conventional
General,agonists,steroids,anticholinergics

Advanced
Mechanicalventilation,ketamine,inhalationalanesthetics

Unusual/Unproven
Theophylline,magnesium,LTRAs,heliox,bronchoscopy

Statusasthmaticus :Treatment

Oxygen
Deliverhighflowoxygen,as
severeasthmacausesV/Q
mismatch(shunt)

Oxygenwillnotsuppressrespiratorydrivein
childrenwithasthma
SchiffM.ClinChestMed1980;1(1):859

Statusasthmaticus :Treatment

Fluid
JudicioususeofIVfluidnecessary
Mostasthmaticsaredehydratedon

presentationsrehydratetoeuvolemia
Overhydrationmayleadtopulmonary
edema
SIADHmaybecommoninsevereasthma
BakerJW.MayoClinProc1976;51(1):314

Statusasthmaticus :Treatment

Antibiotics
Mostinfectionsprecipitatingasthma
areviral
Antibioticsarenotroutinely
indicated
JohnstonSL.PediatrPulmonolSuppl1999;18:1413

Statusasthmaticus :Treatment

Agonists
receptoragonistsstimulate 2receptorsonbronchialsmoothmuscleandmediatemusclerelaxation
Epinephrine
Isoproterenol
Terbutaline
Albuterol

Significant1cardiovascular
effects

Relatively2selective

Statusasthmaticus :Treatment

Agonists
Lessthan10%ofnebulizeddrugreachthe
lungunderidealconditions
BisgaardH.JAsthma1997;34(6):44367

Drugdeliverydependson
Breathingpattern
Tidalvolume
Nebulizertypeandgasflow

Statusasthmaticus :Treatment

Agonists
Deliveryofnebulizeddrug
Onlyparticles

between m are
depositedinalveoli
Correctgasflowrateis
crucial
Mostdevicesrequire1012
L/mingasflowtogenerate
correctparticlesize

Statusasthmaticus :Treatment

Agonists

Continuousnebulizationissuperiorto
intermittentnebulization
Morerapidimprovement
Morecosteffective
Morepatientfriendly
PapoMC.CritCareMed1993;21:147986
AckermanAD.CritCareMed1993;21:14224

Statusasthmaticus :Treatment

Agonists
Dosage
Intermittentnebulization
2.55mg(0.51mlof0.5%solution),dilutewithNS

to3ml
Prediluted:2.5mgas3mlof0.083%solution
Highdose:useuptoundiluted5%solution
Continuousnebulization
440mg/hr

Highdose:uptoundiluted5%solution( 150mg/hr)

Statusasthmaticus :Treatment

Agonists
IntravenousAgonist
Considerforpatientswithsevereairflow
limitationwhoremainunresponsiveto
nebulizedalbuterol
Terbutalineisi.v.agonistofchoiceinUS
Dosage:0.110 g/kg/min
StephanopoulosDE.CritCareMed1998;26(10):17448

Statusasthmaticus :Treatment

Agonists
Sideeffects
Tachycardia
Agitation,tremor
Hypokalemia

Statusasthmaticus :Treatment

Agonists
Cardiacsideeffects
Myocardialischemiaknowntooccurwithi.v.

isoproterenol
Nosignificantcardiovasculartoxicitywithi.v.
terbutaline(prospectivestudyinchildrenwith
severeasthma)

ChiangVW.JPediatr2000;137(1):737

Tachycardia(andtremor)showtachyphylaxis,

bronchodilationdoesnot

LipworthBJ.AmRevRespirDis1989;140(3):58692

Statusasthmaticus :Treatment

Steroids
Asthmaisaninflammatorydisease
Steroidsareamandatoryelementoffirst
linetherapyregimen(fewexceptionsonly)

140
120

F E V 1%

100
80
Steroids
Placebo

60
40
20

Effectofi.v.
hydrocortisone
vs.placebo

0
-20

-5

12

18

24

Hours

FantaCH:AmJMed1983;74:845

Statusasthmaticus :Treatment

Steroids
Hydrocortisone48mg/kgx1,then24
mg/kgq6
Methylprednisolone2mg/kgx1,then0.51
mg/kgq46

Statusasthmaticus :Treatment

Steroids
Significantsideeffects

Hyperglycemia
Hypertension
Acutepsychosis
Unusualorunusuallysevereinfections
Steroidscontraindicatedwithactiveor
recentexposuretochickenpox

Allergicreaction
Reportedwithmethylprednisolone,
hydrocortisoneandprednisone*

*VanpeeD.AnnEmergMed1998;32(6):754.KammGL.AnnPharmacother1999;33(4):45160.
SchonwaldS.AmJEmergMed1999;17(6):5835.JudsonMA.Chest1995;107(2):5635.

Statusasthmaticus :Treatment

AnticholinergicsIpratropium
Quaternaryatropinederivative
Notabsorbedsystemically
Thusminimalcardiaceffects

(Butyouwillfindafixed/dilatedpupilifthenebulizermaskslipsover
aneye!)

Statusasthmaticus :Treatment

Anticholinergics
ChangeinFEV1issignificantlygreaterwhen
ipratropiumwasaddedtoagonists(199adults)
RebuckAS:AmJMed1987;82:59

Highlysignificantimprovementinpulmonary
functionwhenipratropiumwasaddedto
albuterol(128children).Sickestasthmatics
experiencedgreatestimprovement
SchuhS.JPediatr1995;126(4):63945

Statusasthmaticus :Treatment

Ipratropium

DoseResponseCurveinChildren(n=19,age11
17yrs)
Average increase in FEV1 (over 4 hrs)
0.4
0.3
0.2
0.1
0
7.5

25

75

Dose (micrograms)
DavisA:JPediatr1984;105:1002

250

Statusasthmaticus :Treatment

Ipratropium
Nebulize250500 gevery46hours

SchuhS.JPediatr1995;126(4):63945
GoodmanandGilman's.9thed.NewYork:McGrawHill;1996

Statusasthmaticus :Treatment

Intubation,Ventilation
Absoluteindications:
Cardiacorrespiratoryarrest
Severehypoxia
Rapiddeteriorationinmentalstate
Respiratoryacidosisdoesnotdictate
intubation

Statusasthmaticus :Treatment

Whyhesitatetointubatethe
asthmaticchild?

Trachealforeignbody
aggravatesbronchospasm
Positivepressureventilation
increasesriskofbarotrauma
andhypotension

TuxenDV.AmRevRespirDis1987;136(4):8729

>50%ofmorbidity/mortalityduringsevereasthma
occursduringorimmediatelyafterintubation
ZimmermanJL.CritCareMed1993;21(11):172730

Statusasthmaticus :Treatment

Intubation
Preoxygenate,decompressstomach
Sedate(considerketamine)
Neuromuscularblockade(mayavoid
largeswingsinairway/pleuralpressure)
Rapidorotrachealintubation(consider
cuffedtube)

Statusasthmaticus :Treatment

Immediatelyafterintubation
Expecthypotension,circulatorydepression
Allowlongexpiratorytime
Avoidoverzealousmanualbreaths
Considervolumeadministration
Considerpneumothorax
Considerendotrachealtubeobstruction(++
secretions)

Statusasthmaticus :Treatment

Mechanicalventilation
Positivepressureventilationworsens
hyperinflation/riskofbarotrauma
Thoughtfulstrategiesinclude:

Pressurelimitedventilation,TV812ml/kg,shortT i,rate
812/min(permissivehypercapnia)
CoxRG.PediatrPulmonol1991;11(2):1206

PressuresupportventilationusingPS=2030cmH 2O(may
decreasehyperinflationbyallowingactiveexhalation)
WetzelRC.CritCareMed1996;24(9):16035

Statusasthmaticus :Treatment

Ketamine
Dissociativeanestheticwithstrong
analgesiceffect
Directbronchodilatingaction
Usefulforinduction(2mg/kgi.v.)aswellas
continuousinfusion(0.52mg/kg/hr)
Inducesbronchorrhea,emergencereaction

Statusasthmaticus :Treatment

Inhalationalanesthetics
Halothane,isofluranehavebronchodilating
effect
Halothanemaycausehypotension,
dysrhythmia
Requiresscavengingsystem,continuous
gasanalysis

Statusasthmaticus :Treatment

Theophylline
Roleinchildrenwithsevereasthma
remainscontroversial
Narrowtherapeuticrange
Highriskofseriousadverseeffects
Mechanismofeffectinasthmaremains
unclear

Statusasthmaticus :Treatment

Theophylline
Mayhavearoleinselected,criticallyillchildren
withasthmaunresponsivetoconventional
therapy:

Randomized,placebocontrolled,blindedtrial(n=163)inchildrenwith
severestatusasthmaticus
TheophyllinegrouphadgreaterimprovementinPFTsandO 2saturation
Nodifferenceinlength
FEV1(%)
ofPICUstay
60
Theophyllinegrouphadsignifi
50
cantlymoreN/V
40

Placebo
Theophylline

30

YungM.ArchDisChild1998;79(5):40510.

20
10
0

Prior

6hr

12hr

24hr

Statusasthmaticus :Treatment

Magnesium
Smoothmusclerelaxationbyinhibitionof
calciumuptake(=bronchodilator)
Dosagerecommendation:2575mg/kgi.v.
over20minutes

Statusasthmaticus :Treatment

Magnesium

Severalanecdotalreports
Onlyonerandomizedpediatrictrial

Randomized,placebocontrolled,blindedtrial(n=31)inchildren
withacuteasthmainER(MgSO425mg/kgi.v.for20min)
Magnesiumgrouphadsignificantlygreaterimprovementin
60
FEV1/PEFR/FVC
Magnesiumgroupmorelikely
50
40
tobedischargedhome
30
Noadverseeffects

20

CiaralloL.JPediatr1996;129(6):80914.

10
0

50min

80min

110min

Placebo
Magnesium

Statusasthmaticus

Leukotrienereceptorantagonists
(LTRAs)
Asthmaticchildrenhaveincreased
leukotrienelevels(blood,urine)during
anattack.Levelfallsasattackresolves
SampsonAP.AnnNYAcadSci1991;629:4379.

LTRAadministrationisassociatedwith
improvementinlungfunctionin
asthmatics
GaddyJN.AmRevRespirDis1992;146(2):35863.

Statusasthmaticus

LTRAs
Steroidadministrationtoasthmaticshas
littleeffectonleukotrienelevels
O'ShaughnessyKM.AmRevRespirDis1993;147(6Pt1):14726.

Thus,LTRAsmayofferadditionalbenefits
toasthmaticsonsteroids
ReissTF.ArchInternMed1998;158(11):121320.

Statusasthmaticus

IntravenousLTRAsinmoderate
tosevereasthma
Asingledoseofi.v.
montelukast
(Singulair)was
associatedwith
significant
improvementinlung
functioncomparedto
standardtherapy
CamargoCA,Jr.AmJRespirCritCareMed2003;167(4):52833.

Statusasthmaticus

LTRAsRemainingquestions

Willtheyofferaddedbenefitintheacute,severe
asthmaticchildalreadyonagonists,steroids,
anticholinergics?

Morerapidimprovementinlungfunction/clinicalscore?
Reduced/shortenedhospitalization?
FewerPICUadmissions?

Cost?
Adverseeffects?

Statusasthmaticus :Treatment

HeliumOxygen(Heliox)
Heliumlowersgasdensity(ifatleast
60%heliumfraction)
Reducesresistanceduringturbulentflow
Rendersturbulentflowlesslikelyto
occur

Statusasthmaticus :Treatment

Heliox
Anecdotalreportsofimprovedrespiratory
mechanicsinnonintubatedandintubated
asthmaticchildren
Prospective,randomized,blindedcrossover
studyofhelioxinnonintubatedchildren
withsevereasthma(n=11):noeffecton
respiratorymechanicsorasthmascore
CarterER.Chest1996;109(5):125661.

Statusasthmaticus :Treatment

Heliox
Heliumoxygen(80:20)decreasedpulsus
paradoxusandincreasedPEFRina
controlledtrialofadultpatients
ManthousCA.AmJRespirCritCareMed1995,151:310314

Helioxmayworsendynamichyperinflation
MadisonJM.Chest1995,107:597598

Statusasthmaticus :Treatment

Bronchoscopy,bronchial
lavage

Markedmucuspluggingmayrender
bronchodilatingandantiinflammatory
therapyineffective
Plasticbronchitishasbeendescribedin
asthmaticchildren
Combinedbronchoscopy/lavagehasbeen
usedindesperatelyillasthmaticchildren

Statusasthmaticus

Summary

Severeasthmainchildrenisincreasinginprevalence
andmortality
Aggressivetreatmentwithagonist,steroidsand
anticholinergiciswarrantedeveninthesickappearing
child
Avoidintubationifpossible
Mechanicalventilationwillworsenbronchospasmand
hyperinflation
Uselowmorbidityapproachtomechanicalventilation

Statusasthmaticus

Prevention
Stepstowardprevention
1.
Identifypatientsasatrisk
2.
Tellthemabouttheirrisks
3.
Organizetreatmentplan
4.
Facilitateaccesstocontinuedcare

Statusasthmaticus

CaseScenario(1)
A6yoblackmalewithprevioushistoryofasthmais
admittedwithsevererespiratorydistress.Heiswheezing,
RRis40/min,HR145/min.Hesitsupright,leansforward,
hasretractionsandlooksveryanxious.Hecorrectlytells
youhisnameandphone#,buthastotakeabreathafter
everyfewwords.
Discussyourinitialtherapeuticapproach.

Statusasthmaticus

CaseScenario(2)

Whichofthefollowingaremandatoryinthischildwithsevere
asthma?
(Youmaychosenone,morethanoneorall)

Arterialbloodgasanalysis(todetectonsetofrespiratory
acidosis)
Continuouspulseoximetry
Chestradiograph(toruleoutpneumomediastinum/thorax)
Frequentdeterminationofpeakexpiratoryflowrate
Whitebloodcellcountwithdifferential(toassessneedfor
antibiotics)

Statusasthmaticus

CaseScenario(3)
Givenhiscurrentpresentation:doesthischildneedtobe
intubatedandmechanicallyventilated?

Discussindicationsforintubation/mechanicalventilation
inthechildwithseverestatusasthmaticus.

Statusasthmaticus

CaseScenario(4)
Whennebulizingdrugsduringstatusasthmaticus,thefollowing
statementaboutgasflowratesisCORRECT:
A.

B.
C.
D.

Thehigherthegasflowratethroughthenebulizer,the
moreparticleswillbedepositedinthepatientsalveolar
space
Mostdevicesrequireagasflowrateof1012L/minto
generateoptimalparticlesize
Gasflowratesabove5L/minshouldbeavoidedto
maintainlaminarflowinthenebulizeroutput
Thenebulizerdeviceshouldnotbedrivenby100%oxygen

Statusasthmaticus

CaseScenario(5)
Inadditiontoadministrationofcontinuouslynebulizedbeta
agonistandintermittentanticholinergicagonist,whichofthe
followingisalmostmandatory?Discussprosandconsforeach.
A.
B.
C.
D.
E.

Intravenousbolusofaminophylline,followedby
infusion
Intravenouscorticosteroid
Intravenousbroadspectrumantibiotic
Intravenousbetaagonistinfusion
Inhaledheliumoxygenmixture

Statusasthmaticus

CaseScenario(6)
After3hoursoftherapyinthePICU,includinghighdose
continuousalbuterol,intermittentipratropium,I.v.
methylprednisoloneaswellastwoinfusionsofmagnesium
sulfate,thechildbecomesobtunded.HisO2saturations
begintodropbelow85%.Isthisanindicationfor
intubation/mechanicalventilation?
Ifso,describeyourapproachtointubatingthischild.
Howtoprepare?Drugs?ETTsize,route?Anticipatedproblems/
complications?Initialpatternofventilation?

Statusasthmaticus

CaseScenario(7)
Afteryouconnectthechildtotheventilator,hedevelops
markedarterialhypotension.
Whatisyourdifferentialdiagnosis?
Whatshouldyoudo?

Statusasthmaticus

SuggestedReading(part1):

1. LaitinenLA,HeinoM,LaitinenA,etal.Damageofairwayepitheliumandbronchialreactivityinpatientswithasthma.
AmRevRespirDis1985;131(4):599606.
2. BeakesDE.Theuseofanticholinergicsinasthma.JAsthma1997;34(5):35768.
3. BarnesPJ.Betaadrenergicreceptorsandtheirregulation.AmJRespirCritCareMed1995;152(3):83860.
4. MiroA,PinskyM.CardiopulmonaryInteractions.In:FuhrmanB,ZimmermanJ,editors.PediatricCriticalCare.
Seconded.St.Louis:Mosby;1998.p.25060.
5. StalcupSA,MellinsRB.Mechanicalforcesproducingpulmonaryedemaandacuteasthma.NEnglJMed
1977;297(11):5926.
6. RebuckAS,PengellyLD.Developmentofpulsusparadoxusinthepresenceofairwayobstruction.NEnglJMed
1973;288(2):669.
7. PapoMC,FrankJ,ThompsonAE.Aprospective,randomizedstudyofcontinuousversusintermittentnebulized
albuterolforseverestatusasthmaticusinchildren.CritCareMed1993;21:147986.
8. KatzRW,KellyHW,CrowleyMR,etal.Safetyofcontinuousnebulizedalbuterolforbronchospasmininfantsand
children[publishederratumappearsinPediatrics1994Feb;93(2):A28].Pediatrics1993;92(5):6669.
9. SchuhS,JohnsonDW,CallahanS,etal.Efficacyoffrequentnebulizedipratropiumbromideaddedtofrequenthighdose
albuteroltherapyinseverechildhoodasthma.JPediatr1995;126(4):63945.
10. FantaCH,RossingTH,McFaddenER.Glucocorticoidsinacuteasthma:Acriticalcontrolledtrial.AmJMed
1983;74:84551.

Statusasthmaticus

SuggestedReading(part2):
11. KleinGitelmanMS,PachmanLM.Intravenouscorticosteroids:adversereactionsaremorevariablethan
expectedinchildren.JRheumatol1998;25(10):19952002.
12. StephanopoulosDE,MongeR,SchellKH,etal.Continuousintravenousterbutalineforpediatricstatus
asthmaticus.CritCareMed1998;26(10):17448.
13. ChiangVW,BurnsJP,RifaiN,etal.Cardiactoxicityofintravenousterbutalineforthetreatmentofsevere
asthmainchildren:aprospectiveassessment.JPediatr2000;137(1):737.
14. CiaralloL,SauerAH,ShannonMW.Intravenousmagnesiumtherapyformoderatetoseverepediatric
asthma:resultsofarandomized,placebocontrolledtrial.JPediatr1996;129(6):80914.
15. PabonH,MonemG,KissoonN.Safetyandefficacyofmagnesiumsulfateinfusionsinchildrenwithstatus
asthmaticus.PediatrEmergCare1994;10:2003.
16. YungM,SouthM.Randomisedcontrolledtrialofaminophyllineforsevereacuteasthma.ArchDisChild
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