{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,4,8]],"date-time":"2026-04-08T16:33:03Z","timestamp":1775665983019,"version":"3.50.1"},"reference-count":168,"publisher":"The Pediatric Pharmacy Association","issue":"2","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2013,1]]},"abstract":"<jats:sec>\n          <jats:title>OBJECTIVES<\/jats:title>\n          <jats:p>An increasing prevalence of pediatric asthma has led to increasing burdens of critical illness in children with severe acute asthma exacerbations, often leading to respiratory distress, progressive hypoxia, and respiratory failure. We review the definitions, epidemiology, pathophysiology, and clinical manifestations of severe acute asthma, with a view to developing an evidence-based, stepwise approach for escalating therapy in these patients.<\/jats:p>\n        <\/jats:sec>\n        <jats:sec>\n          <jats:title>METHODS<\/jats:title>\n          <jats:p>Subject headings related to asthma, status asthmaticus, critical asthma, and drug therapy were used in a MEDLINE search (1980\u20132012), supplemented by a manual search of personal files, references cited in the reviewed articles, and treatment algorithms developed within Le Bonheur Children's Hospital.<\/jats:p>\n        <\/jats:sec>\n        <jats:sec>\n          <jats:title>RESULTS<\/jats:title>\n          <jats:p>Patients with asthma require continuous monitoring of their cardiorespiratory status via noninvasive or invasive devices, with serial clinical examinations, objective scoring of asthma severity (using an objective pediatric asthma score), and appropriate diagnostic tests. All patients are treated with \u03b2-agonists, ipratropium, and steroids (intravenous preferable over oral preparations). Patients with worsening clinical status should be progressively treated with continuous \u03b2-agonists, intravenous magnesium, helium-oxygen mixtures, intravenous terbutaline and\/or aminophylline, coupled with high-flow oxygen and non-invasive ventilation to limit the work of breathing, hypoxemia, and possibly hypercarbia. Sedation with low-dose ketamine (with or without benzodiazepines) infusions may allow better toleration of non-invasive ventilation and may also prepare the patient for tracheal intubation and mechanical ventilation, if indicated by a worsening clinical status.<\/jats:p>\n        <\/jats:sec>\n        <jats:sec>\n          <jats:title>CONCLUSIONS<\/jats:title>\n          <jats:p>Severe asthma can be a devastating illness in children, but most patients can be managed by using serial objective assessments and the stepwise clinical approach outlined herein. Following multidisciplinary education and training, this approach was successfully implemented in a tertiary-care, metropolitan children's hospital.<\/jats:p>\n        <\/jats:sec>","DOI":"10.5863\/1551-6776-18.2.88","type":"journal-article","created":{"date-parts":[[2013,5,30]],"date-time":"2013-05-30T16:00:55Z","timestamp":1369929655000},"page":"88-104","source":"Crossref","is-referenced-by-count":36,"title":["Severe Acute Asthma Exacerbation in Children: A Stepwise Approach for Escalating Therapy in a Pediatric Intensive Care Unit"],"prefix":"10.5863","volume":"18","author":[{"given":"I. Federico Fernandez","family":"Nievas","sequence":"first","affiliation":[{"name":"Departments of Pediatrics, Anesthesiology, Anatomy & Neurobiology, Division of Critical Care Medicine, University of Tennessee Health Science Center, and Le Bonheur Children's Hospital, Memphis, Tennessee"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Kanwaljeet J. S.","family":"Anand","sequence":"additional","affiliation":[{"name":"Departments of Pediatrics, Anesthesiology, Anatomy & Neurobiology, Division of Critical Care Medicine, University of Tennessee Health Science Center, and Le Bonheur Children's Hospital, Memphis, Tennessee"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"3883","reference":[{"issue":"5","key":"i1551-6776-18-2-88-b1","series-title":"Ann Allergy Asthma Immunol","first-page":"509","article-title":"Improved outcomes for hospitalized asthmatic children using a clinical pathway","volume":"84","year":"2000","unstructured":"Kelly\n              CS\n            , AndersenCL, PestianJP, \n          et al. Improved outcomes for hospitalized asthmatic children using a clinical pathway. 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Chest. 1990;98(3):651\u2013655."},{"issue":"4","key":"i1551-6776-18-2-88-b60","series-title":"Am J Med","first-page":"580","article-title":"Lactic acidosis in severe asthma","volume":"75","year":"1983","unstructured":"Appel\n              D\n            , RubensteinR, SchragerK, \n          et al. Lactic acidosis in severe asthma. Am J Med. 1983;75(4):580\u2013584."},{"issue":"3","key":"i1551-6776-18-2-88-b61","series-title":"Pediatr Emerg Care","first-page":"206","article-title":"Management of children with acute asthma in the emergency department","volume":"15","year":"1999","unstructured":"Qureshi\n              F.\n            \n          \n          Management of children with acute asthma in the emergency department. 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Arch Dis Child. 1988;63(8):900\u2013904."},{"issue":"1","key":"i1551-6776-18-2-88-b64","series-title":"Clin Chest Med","first-page":"85","article-title":"Control of breathing in asthma","volume":"1","year":"1980","unstructured":"Schiff\n              M.\n            \n          \n          Control of breathing in asthma. Clin Chest Med. 1980;1(1):85\u201389."},{"issue":"1","key":"i1551-6776-18-2-88-b65","series-title":"Pediatr Pulmonol","first-page":"1","article-title":"Third International Pediatric Consensus statement on the management of childhood asthma: International Pediatric Asthma Consensus Group","volume":"25","year":"1998","unstructured":"Warner\n              JO\n            , NaspitzCK.\n          Third International Pediatric Consensus statement on the management of childhood asthma: International Pediatric Asthma Consensus Group. 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Trends Pharmacol Sci. 1993;14(12):436\u2013441."},{"issue":"4","key":"i1551-6776-18-2-88-b68","series-title":"Clin Chest Med","first-page":"669","article-title":"Corticosteroid therapy in asthma","volume":"5","year":"1984","unstructured":"Dunlap\n              NE\n            , FulmerJD.\n          Corticosteroid therapy in asthma. Clin Chest Med. 1984;5(4):669\u2013683."},{"issue":"4 Pt 1","key":"i1551-6776-18-2-88-b69","series-title":"Am J Respir Crit Care Med","first-page":"953","article-title":"Effect of oral prednisone on airway inflammatory mediators in atopic asthma","volume":"149","year":"1994","unstructured":"Dworski\n              R\n            , FitzgeraldGA, OatesJA, \n          et al. Effect of oral prednisone on airway inflammatory mediators in atopic asthma. Am J Respir Crit Care Med. 1994;149(4 Pt 1):953\u2013959."},{"issue":"1","key":"i1551-6776-18-2-88-b70","series-title":"Cochrane Database Syst Rev","first-page":"CD002178","article-title":"Early emergency department treatment of acute asthma with systemic corticosteroids","year":"2001","unstructured":"Rowe\n              BH\n            , SpoonerC, DucharmeFM, \n          et al. Early emergency department treatment of acute asthma with systemic corticosteroids. Cochrane Database Syst Rev. 2001(1):CD002178."},{"issue":"2","key":"i1551-6776-18-2-88-b71","series-title":"Pediatrics","first-page":"225","article-title":"Intravenous methylprednisolone efficacy in status asthmaticus of childhood","volume":"80","year":"1987","unstructured":"Younger\n              RE\n            , GerberPS, HerrodHG, \n          et al. Intravenous methylprednisolone efficacy in status asthmaticus of childhood. Pediatrics. 1987;80(2):225\u2013230."},{"issue":"1","key":"i1551-6776-18-2-88-b72","series-title":"Am Fam Physician","first-page":"169","article-title":"NAEPP updates guidelines for the diagnosis and management of asthma","volume":"68","year":"2003","unstructured":"Ressel\n              GW.\n            \n          \n          NAEPP updates guidelines for the diagnosis and management of asthma. Am Fam Physician. 2003;68(1):169\u2013170."},{"issue":"2","key":"i1551-6776-18-2-88-b73","series-title":"Ann Emerg Med","first-page":"212","article-title":"Intravenous versus oral corticosteroids in the management of acute asthma in children","volume":"29","year":"1997","unstructured":"Barnett\n              PL\n            , CaputoGL, BaskinM, \n          et al. Intravenous versus oral corticosteroids in the management of acute asthma in children. 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J Rheumatol. 1998;25(10):1995\u20132002."},{"issue":"4","key":"i1551-6776-18-2-88-b78","series-title":"Ann Pharmacother","first-page":"451","article-title":"Allergic-type reactions to corticosteroids","volume":"33","year":"1999","unstructured":"Kamm\n              GL\n            , HagmeyerKO.\n          Allergic-type reactions to corticosteroids. Ann Pharmacother. 1999;33(4):451\u2013460."},{"issue":"5","key":"i1551-6776-18-2-88-b79","series-title":"Am J Respir Crit Care Med","first-page":"1686","article-title":"Muscle weakness in mechanically ventilated patients with severe asthma","volume":"153","year":"1996","unstructured":"Leatherman\n              JW\n            , FluegelWL, DavidWS, \n          et al. Muscle weakness in mechanically ventilated patients with severe asthma. Am J Respir Crit Care Med. 1996;153(5):1686\u20131690."},{"issue":"5 Pt 3","key":"i1551-6776-18-2-88-b80","series-title":"Am J Respir Crit Care Med","first-page":"S146","article-title":"The beta-adrenoceptor","volume":"158","year":"1998","unstructured":"Johnson\n              M.\n            \n          \n          The beta-adrenoceptor. Am J Respir Crit Care Med. 1998;158(5 Pt 3):S146\u2013S153."},{"issue":"2","key":"i1551-6776-18-2-88-b81","series-title":"Ann Allergy Asthma Immunol","first-page":"177","article-title":"Pharmacology of long-acting beta-agonists","volume":"75","year":"1995","unstructured":"Johnson\n              M.\n            \n          \n          Pharmacology of long-acting beta-agonists. 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Continuous intravenous terbutaline for pediatric status asthmaticus. Crit Care Med. 1998;26(10):1744\u20131748."},{"issue":"8438","key":"i1551-6776-18-2-88-b84","series-title":"Lancet","first-page":"1125","article-title":"Hypokalaemia induced by inhalation of fenoterol","volume":"1","year":"1985","unstructured":"Haalboom\n              JR\n            , DeenstraM, StruyvenbergA.\n          Hypokalaemia induced by inhalation of fenoterol. Lancet. 1985;1(8438):1125\u20131127."},{"issue":"6","key":"i1551-6776-18-2-88-b85","series-title":"Chest","first-page":"1654","article-title":"Potassium and magnesium distribution, ECG changes, and ventricular ectopic beats during beta 2-adrenergic stimulation with terbutaline in healthy subjects","volume":"106","year":"1994","unstructured":"Tveskov\n              C\n            , DjurhuusMS, KlitgaardNA, \n          et al. Potassium and magnesium distribution, ECG changes, and ventricular ectopic beats during beta 2-adrenergic stimulation with terbutaline in healthy subjects. Chest. 1994;106(6):1654\u20131659."},{"issue":"1","key":"i1551-6776-18-2-88-b86","series-title":"Ann Emerg Med","first-page":"29","article-title":"Clinical efficacy of racemic albuterol versus levalbuterol for the treatment of acute pediatric asthma","volume":"46","year":"2005","unstructured":"Qureshi\n              F\n            , ZaritskyA, WelchC, \n          et al. Clinical efficacy of racemic albuterol versus levalbuterol for the treatment of acute pediatric asthma. 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Pediatrics. 1993;92(5):666\u2013669."},{"issue":"10","key":"i1551-6776-18-2-88-b95","series-title":"Crit Care Med","first-page":"1422","article-title":"Continuous nebulization of inhaled beta-agonists for status asthmaticus in children: a cost-effective therapeutic advance?","volume":"21","year":"1993","unstructured":"Ackerman\n              AD.\n            \n          \n          Continuous nebulization of inhaled beta-agonists for status asthmaticus in children: a cost-effective therapeutic advance?\n          Crit Care Med. 1993;21(10):1422\u20131424."},{"issue":"6","key":"i1551-6776-18-2-88-b96","series-title":"Ann Allergy Asthma Immunol","first-page":"499","article-title":"Continuous nebulization therapy for asthma with aerosols of beta2 agonists","volume":"80","year":"1998","unstructured":"Raabe\n              OG\n            , WongTM, WongGB, \n          et al. Continuous nebulization therapy for asthma with aerosols of beta2 agonists. Ann Allergy Asthma Immunol. 1998;80(6):499\u2013508."},{"issue":"6","key":"i1551-6776-18-2-88-b97","series-title":"Chest","first-page":"1913","article-title":"Status asthmaticus in children: a review","volume":"119","year":"2001","unstructured":"Werner\n              HA.\n            \n          \n          Status asthmaticus in children: a review. Chest. 2001;119(6):1913\u20131929."},{"issue":"1","key":"i1551-6776-18-2-88-b98","series-title":"J Pediatr","first-page":"73","article-title":"Cardiac toxicity of intravenous terbutaline for the treatment of severe asthma in children: a prospective assessment","volume":"137","year":"2000","unstructured":"Chiang\n              VW\n            , BurnsJP, RifaiN, \n          et al. Cardiac toxicity of intravenous terbutaline for the treatment of severe asthma in children: a prospective assessment. 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J Pediatr. 1989;114(2):315\u2013320."},{"issue":"8","key":"i1551-6776-18-2-88-b101","series-title":"New Engl J Med","first-page":"486","article-title":"Ipratropium bromide","volume":"319","year":"1988","unstructured":"Gross\n              NJ.\n            \n          \n          Ipratropium bromide. New Engl J Med. 1988;319(8):486\u2013494."},{"issue":"7164","key":"i1551-6776-18-2-88-b102","series-title":"Br Med J","first-page":"971","article-title":"Should inhaled anticholinergics be added to beta2 agonists for treating acute childhood and adolescent asthma: a systematic review","volume":"317","year":"1998","unstructured":"Plotnick\n              LH\n            , DucharmeFM.\n          Should inhaled anticholinergics be added to beta2 agonists for treating acute childhood and adolescent asthma: a systematic review. 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Am J Respir Crit Care Med. 2000;161(6):1862\u20131868."},{"issue":"6","key":"i1551-6776-18-2-88-b110","series-title":"Chest","first-page":"1977","article-title":"The role of anti-cholinergics in acute asthma treatment: an evidence-based evaluation","volume":"121","year":"2002","unstructured":"Rodrigo\n              GJ\n            , RodrigoC.\n          The role of anti-cholinergics in acute asthma treatment: an evidence-based evaluation. Chest. 2002;121(6):1977\u20131987."},{"issue":"9","key":"i1551-6776-18-2-88-b111","series-title":"Am J Health Sys Pharm","first-page":"914","article-title":"Blurred vision from ipratropium bromide inhalation","volume":"56","year":"1999","unstructured":"Kizer\n              KM\n            , BessDT, BedfordNK.\n          Blurred vision from ipratropium bromide inhalation. 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