Escolar Documentos
Profissional Documentos
Cultura Documentos
EDUCATIONAL AIMS
A R T I C L E I N F O S U M M A R Y
Keywords: Recent literature on paediatric status asthmaticus (PSA) confirms an increasing percentage of admissions
Paediatric status asthmaticus
to paediatric intensive care units. PSA is a medical emergency that can be fatal and needs careful and
Pathophysiology
prompt intervention. The severity of PSA is mainly determined by clinical judgement of signs and
Assessment
Treatment symptoms. Peak flow measurements and serial lung function measurements are not reliable in PSA.
Validated clinically useful instruments are lacking. The three main factors that are involved in the
pathophysiology of PSA, bronchoconstriction, mucus plugging and airway inflammation need to be
addressed to optimise treatment. Initial therapies include supplementation of oxygen, repetitive
administration of rapid acting b2-agonists, inhaled anticholinergics in combination with systemic
glucocorticosteroids and intravenous magnesium sulphate. Additional treatment modalities may include
methylxanthines, DNase, ketamine, sodium bicarbonate, heliox, epinephrine, non-invasive respiratory
support, mechanical ventilation and inhalational anaesthetics.
! 2013 Elsevier Ltd. All rights reserved.
1526-0542/$ see front matter ! 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.prrv.2013.03.003
M. Koninckx et al. / Paediatric Respiratory Reviews 14 (2013) 7885 79
Table 1
Clinical judgement
Use of auxiliary muscles; Most often not Often Usually Paradoxal thoracoabdominal
Sternal retractions movements
Wheeze Moderate, most often Loud, whole expiration Mostly loud in- Absent
end-exiratory and expiratory
Pulse rate/minute < 100 100-120 > 120 Bradycardia
Normal pulse rate in children
Age Normal pulse:
212 months 80180
13 years 75150
412 years 60120
Table 2
Asthma score
2. Werner HA. Status asthmaticus in children: a review. Chest 2001;119: 35. Browne GJ, Penna AS, Phung X, Soo M. Randomised trial of intravenous
191329. salbutamol in early management of acute severe asthma in children. Lancet
3. Papiris S, Kotanidou A, Malagari K, Roussos C. Clinical review: severe asthma. 1997;349:3015.
Crit Care 2002;6:3044. 36. Shann F. Dose of intravenous infusions of terbutaline and salbutamol. Critical
4. Carroll CL, Zucker AR. The increased cost of complications in children with Care Medicine 2000;28:217980.
status asthmaticus. Pediatric pulmonology 2007;42:9149. 37. Sellers WF, Messahel B. Rapidly repeated intravenous boluses of salbutamol for
5. CDC Vital Signs: Asthma prevalence, disease characteristics and self-manage- acute severe asthma. Anaesthesia 2003;58:6803.
ment education. United States 20012009 MMWR. 2011; 60:54752. 38. Bogie AL, Towne D, Luckett PM, Abramo TJ, Wiebe RA. Comparison of intrave-
6. Hartert TV, Peebles Jr RS. Epidemiology of asthma: the year in review. Curr Opin nous terbutaline versus normal saline in pediatric patients on continuous high-
Pulm Med 2000;6:49. dose nebulized albuterol for status asthmaticus. Pediatric Emergency Care
7. Hartman ME, Linde-Zwirble WT, Angus DC, Watson RS. Trends in admissions for 2007;23:35561.
pediatric status asthmaticus in New Jersey over a 15-year period. Pediatrics 39. Stephanopoulos DE, Monge R, Schell KH, Wyckoff P, Peterson BM. Continuous
2010;126:e90411. intravenous terbutaline for pediatric status asthmaticus. Critical Care Medicine
8. Triasih R, Duke T, Robertson CF. Outcomes following admission to intensive care 1998;26:17448.
for asthma. Arch Dis Child 2011;96:72934. 40. Carroll CL, Schramm CM. Protocol-based titration of intravenous terbutaline
9. Malmstrom K, Kaila M, Korhonen K, Dunder T, Nermes M, Klaukka T, et al. decreases length of stay in pediatric status asthmaticus. Pediatric Pulmonology
Mechanical ventilation in children with severe asthma. Pediatric pulmonology 2006;41:3506.
2001;31:40511. 41. Carroll CL, Sala KA, Zucker AR, Schramm CM. Beta-adrenergic receptor poly-
10. Peebles Jr RS, Hartert TV. Respiratory viruses and asthma. Curr Opin Pulm Med morphisms associated with length of ICU stay in pediatric status asthmaticus.
2000;6:104. Pediatric Pulmonology 2012;47:2339.
11. Kikuchi Y, Okabe S, Tamura G, Hida W, Homma M, Shirato K, et al. Chemo- 42. Plotnick LH, Ducharme FM. Should inhaled anticholinergics be added to beta2
sensitivity and perception of dyspnea in patients with a history of near-fatal agonists for treating acute childhood and adolescent asthma? A systematic
asthma. N Engl J Med 1994;330:132934. review. BMJ 1998;317:9717.
12. Verbruggen SC, Corel LJ, Tiddens HA, Joosten KF, de Hoog M. [Fatal asthma in 43. Health NIo. 3rd expert panel summary report from the national asthma
childhood preventable by recognizing risk factors and presenting features] education and prevention programm 2007.
Fataal astma op de kinderleeftijd te voorkomen door herkenning van risico- 44. Browne GJ, Trieu L, Van Asperen P. Randomized, double-blind, placebo-con-
factoren en presentatiewijze. Ned Tijdschr Geneeskd 2006;150:2259. trolled trial of intravenous salbutamol and nebulized ipratropium bromide in
13. Picado C. Classification of severe asthma exacerbations: a proposal. Eur Respir J early management of severe acute asthma in children presenting to an emer-
1996;9:17758. gency department. Critical Care Medicine 2002;30:44853.
14. Sur S, Crotty TB, Kephart GM, Hyma BA, Colby TV, Reed CE, et al. Sudden-onset 45. Rodrigo GJ, Castro-Rodriguez JA. Anticholinergics in the treatment of children
fatal asthma. A distinct entity with few eosinophils and relatively more and adults with acute asthma: a systematic review with meta-analysis. Thorax
neutrophils in the airway submucosa? Am Rev Respir Dis 1993;148:7139. 2005;60:7406.
15. Plaza V, Serrano J, Picado C, Sanchis J. High Risk Asthma Research G. Frequency 46. Rafferty P, Beasley R, Howarth PH, Mann JS, Holgate ST. Bronchoconstriction
and clinical characteristics of rapid-onset fatal and near-fatal asthma. Eur Respir induced by nebulised ipratropium bromide: relation to the bromide ion. Br Med
J 2002;19:84652. J (Clin Res Ed) 1986;293:15389.
16. Shugg AW, Kerr S, Butt WW. Mechanical ventilation of paediatric patients with 47. Barnes NC. Effects of corticosteroids in acute severe asthma. Thorax 1992;
asthma: short and long term outcome. J Paediatr Child Health 1990;26:3436. 47:5823.
17. Corbridge TC, Hall JB. The assessment and management of adults with status 48. Boschetto P, Rogers DF, Fabbri LM, Barnes PJ. Corticosteroid inhibition of airway
asthmaticus. Am J Respir Crit Care Med 1995;151:1296316. microvascular leakage. Am Rev Respir Dis 1991;143:6059.
18. Gorelick MH, Stevens MW, Schultz T, Scribano PV. Difficulty in obtaining peak 49. Smith M, Iqbal S, Elliott TM, Everard M, Rowe BH. Corticosteroids for hospi-
expiratory flow measurements in children with acute asthma. Pediatric Emer- talised children with acute asthma. Cochrane Database Syst Rev 2003;
gency Care 2004;20:226. CD002886.
19. Saetta M, Thiene G, Crescioli S, Fabbri LM. Fatal asthma in a young patient with 50. Chipps BE, Murphy KR. Assessment and treatment of acute asthma in children. J
severe bronchial hyperresponsiveness but stable peak flow records. Eur Respir J Pediatr 2005;147:28894.
1989;2:100812. 51. Gries DM, Moffitt DR, Pulos E, Carter ER. A single dose of intramuscularly
20. Geelhoed GC, Landau LI, Le Souef PN. Evaluation of SaO2 as a predictor of administered dexamethasone acetate is as effective as oral prednisone to treat
outcome in 280 children presenting with acute asthma. Ann Emerg Med asthma exacerbations in young children. J Pediatr 2000;136:298303.
1994;23:123641. 52. Schuh S, Reisman J, Alshehri M, Dupuis A, Corey M, Arseneault R, et al. A
21. Keahey L, Bulloch B, Becker AB, Pollack Jr CV, Clark S, Camargo Jr CA, et al. Initial comparison of inhaled fluticasone and oral prednisone for children with severe
oxygen saturation as a predictor of admission in children presenting to the acute asthma. N Engl J Med 2000;343:68994.
emergency department with acute asthma. Ann Emerg Med 2002;40:3007. 53. Schramm CM, Carroll CL. Advances in treating acute asthma exacerbations in
22. Qureshi F, Pestian J, Davis P, Zaritsky A. Effect of nebulized ipratropium on the children. Curr Opin Pediatr 2009;21:32632.
hospitalization rates of children with asthma. N Engl J Med 1998;339:10305. 54. Upham BD, Mollen CJ, Scarfone RJ, Seiden J, Chew A, Zorc JJ. Nebulized
23. Gorelick MH, Stevens MW, Schultz TR, Scribano PV. Performance of a novel budesonide added to standard pediatric emergency department treatment of
clinical score, the Pediatric Asthma Severity Score (PASS), in the evaluation of acute asthma: a randomized, double-blind trial. Acad Emerg Med 2011;18:
acute asthma. Acad Emerg Med 2004;11:108. 66573.
24. Belessis Y, Dixon S, Thomsen A, Duffy B, Rawlinson W, Henry R, et al. Risk factors 55. Skobeloff EM. An ion for the lungs. Acad Emerg Med 1996 Dec;3:10824.
for an intensive care unit admission in children with asthma. Pediatric pulmo- 56. Rowe B, Bretzlaff J, Bourdon C, Bota G, Camargo C. Magnesium sulfate is
nology 2004;37:2019. effective for severe acute asthma treated in the emergency department. West
25. van den Bosch GE, Merkus P, Buysse C, Boehmer A, Vaessen-Verberne A, van J Med 2000;172:96.
Veen LN, et al. Risk Factors for Pediatric Intensive Care Admission in Children 57. Cheuk DK, Chau TC, Lee SL. A meta-analysis on intravenous magnesium
With Acute. Asthma Respir Care 2012;57:13917. sulphate for treating acute asthma. Arch Dis Child 2005;90:747.
26. Molfino NA, Nannini LJ, Martelli AN, Slutsky AS. Respiratory arrest in near-fatal 58. Ciarallo L, Sauer AH, Shannon MW. Intravenous magnesium therapy for mod-
asthma. N Engl J Med 1991;324:2858. erate to severe pediatric asthma: results of a randomized, placebo-controlled
27. Inwald D, Roland M, Kuitert L, McKenzie SA, Petros A. Oxygen treatment for trial. J Pediatr 1996;129:80914.
acute severe asthma. BMJ 2001;323:98100. 59. Devi RR KL, Singhi SC, Prasad R, Singh M. Intravenous magnesium sulfate in
28. Morgan DJ. Clinical pharmacokinetics of beta-agonists. Clin Pharmacokinet acute severe asthma not responding to conventional therapy. Indian Pediatr.
1990;18:27094. 1997; 34:38997.
29. Wang XF, Hong JG. Management of severe asthma exacerbation in children. 60. Mitra A, Bassler D, Goodman K, Lasserson TJ, Ducharme FM. Intravenous
World J Pediatr 2011;7:293301. aminophylline for acute severe asthma in children over two years receiving
30. Papo MC, Frank J, Thompson AE. A prospective, randomized study of continuous inhaled bronchodilators. Cochrane Database Syst Rev 2005. CD001276.
versus intermittent nebulized albuterol for severe status asthmaticus in chil- 61. Wheeler DS, Jacobs BR, Kenreigh CA, Bean JA, Hutson TK, Brilli RJ. Theophylline
dren. Critical Care Medicine 1993;21:147986. versus terbutaline in treating critically ill children with status asthmaticus: a
31. Leversha AM, Campanella SG, Aickin RP, Asher MI. Costs and effectiveness of prospective, randomized, controlled trial. Pediatr Crit Care Med 2005;6:1427.
spacer versus nebulizer in young children with moderate and severe acute 62. Rodrigo C, Rodrigo G. Treatment of acute asthma. Lack of therapeutic benefit
asthma. J Pediatr 2000;136:497502. and increase of the toxicity from aminophylline given in addition to high doses
32. Cates CJ, Crilly JA, Rowe BH. Holding chambers (spacers) versus nebulisers for of salbutamol delivered by metered-dose inhaler with a spacer. Chest
beta-agonist treatment of acute asthma. Cochrane Database Syst Rev 2006. 1994;106:10716.
CD000052. 63. Durward A, Forte V, Shemie SD. Resolution of mucus plugging and atelectasis
33. Castro-Rodriguez JA, Rodrigo GJ. beta-agonists through metered-dose inhaler after intratracheal rhDNase therapy in a mechanically ventilated child with
with valved holding chamber versus nebulizer for acute exacerbation of refractory status asthmaticus. Critical Care Medicine 2000;28:5602.
wheezing or asthma in children under 5 years of age: a systematic review 64. Greally P. Human recombinant DNase for mucus plugging in status asthma-
with meta-analysis. J Pediatr 2004;145:1727. ticus. Lancet 1995;346:14234.
34. Bohn D, Kalloghlian A, Jenkins J, Edmonds J, Barker G. Intravenous salbutamol in 65. Boogaard R, Smit F, Schornagel R, Vaessen-Verberne AA, Kouwenberg JM,
the treatment of status asthmaticus in children. Critical Care Medicine Hekkelaan M, et al. Recombinant human deoxyribonuclease for the treatment
1984;12:8926. of acute asthma in children. Thorax 2008;63:1416.
M. Koninckx et al. / Paediatric Respiratory Reviews 14 (2013) 7885 85
66. Denmark TK, Crane HA, Brown L. Ketamine to avoid mechanical ventilation in 76. Thill PJ, McGuire JK, Baden HP, Green TP, Checchia PA. Noninvasive positive-
severe pediatric asthma. J Emerg Med 2006;30:1636. pressure ventilation in children with lower airway obstruction. Pediatr Crit Care
67. Allen JY, Macias CG. The efficacy of ketamine in pediatric emergency depart- Med 2004;5:33742.
ment patients who present with acute severe asthma. Ann Emerg Med 77. Basnet S, Mander G, Andoh J, Klaska H, Verhulst S, Koirala J. Safety, efficacy, and
2005;46:4350. tolerability of early initiation of noninvasive positive pressure ventilation in
68. Buysse CM, de Jongste JC, de Hoog M. Life-threatening asthma in children: pediatric patients admitted with status asthmaticus: A pilot study. Pediatr Crit
treatment with sodium bicarbonate reduces PCO2. Chest 2005;127:86670. Care Med 2012;13:3938.
69. Caroll. Heliox for children with acute asthma: Has the sun set on this therapy? 78. Tobias JD. Inhalational anesthesia: basic pharmacology, end organ effects, and
Pediatr Crit Care Med 2010;11:4289. applications in the treatment of status asthmaticus. J Intensive Care Med
70. Kim IK, Phrampus E, Venkataraman S, Pitetti R, Saville A, Corcoran T, et al. 2009;24:36171.
Helium/oxygen-driven albuterol nebulization in the treatment of children with 79. Wheeler DS, Clapp CR, Ponaman ML, Bsn HM, Poss WB. Isoflurane therapy for
moderate to severe asthma exacerbations: a randomized, controlled trial. status asthmaticus in children: A case series and protocol. Pediatr Crit Care Med
Pediatrics 2005;116:112733. 2000;1:559.
71. Rodrigo G, Pollack C, Rodrigo C, Rowe BH. Heliox for nonintubated acute asthma 80. Shankar V, Churchwell KB, Deshpande JK. Isoflurane therapy for severe refrac-
patients. Cochrane Database Syst Rev 2006. CD002884. tory status asthmaticus in children. Intensive Care Med 2006;32:92733.
72. Walker DM. Update on epinephrine (adrenaline) for pediatric emergencies. Curr 81. Mikkelsen ME WY, Sager JS, Fuchs BD, Christie JD. Outcomes using extracor-
Opin Pediatr 2009;21:3139. poreal life support for adult respiratory failure due to status asthmaticus. ASAIO
73. Wiebe K, Rowe BH. Nebulized racemic epinephrine used in the treatment of Journal 2009;55:4752.
severe asthmatic exacerbation: a case report and literature review. CJEM 82. Hebbar KB, Petrillo-Albarano T, Coto-Puckett W, Heard M, Rycus PT, Forten-
2007;9:3048. berry JD. Experience with use of extracorporeal life support for severe refrac-
74. Asthma: follow-up statement from an international paediatric asthma con- tory status asthmaticus in children. Crit Care 2009;13:R29.
sensus group. Arch Dis Child 1992; 67:2468. 83. Camargo CA, Rachelefsky G, Schatz M. Managing asthma exacerbations in the
75. Mayordomo-Colunga J, Medina A, Rey C, Concha A, Menendez S, Arcos ML, et al. emergency department. Summary of the national asthma education and pre-
Non-invasive ventilation in pediatric status asthmaticus: a prospective obser- vention program expert panel report 3 guidelines for the management of
vational study. Pediatric Pulmonology 2011;46:94955. asthma exacerbations. Proc Am Thoracic Society 2009;6:35766.