1. The Pharmacologic Management of Status Asthmaticus in Children
C. Warren Bierman and William E. Pierson
Pediatrics 1974;54;245-247
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2. PHARMACOLOGY FOR THE PEDIATRICIAN
The Pharmacologic Management of Status Asthmaticus
in Children
C. Warren Bierman, M.D., and William E. Pierson, M.D.
From the Department ofPediatrics, University of Washington SchoolofMedicine, and the Division of Allergy,
Children’s Orthopedic Hoital and Medical Center, Seattle
Status asthmaticus, or asthma unresponsive to rax (25% of pediatric patients will have such
epinephrine injections, is an acute medical emer- abnormalities). 11
gency in children. ‘ In the 1960s status asthmaticus 5. Laboratory Studies: Arterial’2 or arterial-
mortality in children increased abruptly in widely ized” (histamine iontophoresis of sampling
separated areas of the world.2 Because of these site) blood gases (Pao2, Paco2, pH, and base
deaths, a treatment protocol was devised for the excess), serum electrolytes, CBC, urinalysis,
pediatric house staff in Children’s Orthopedic and bacterial or viral cultures if indicated by
Hospital and Medical Center, Seattle. This proto- clinical or x-ray evidence of infection.
cot has been used in treating over 500 children. 6. Pulmonary Function Studies: Forced vital
There have been no fatalities. It has permitted the capacity (FVC), forced expiratory volume 1
evaluation of aminophy1line, adrenocortico- second (FEy,),’4 and forced expiratory
steroids,6 antibiotics,7 and respiratory therapy flow2575% (FEF2575%) in children old enough
techniques, and it has taught a succession of medi- to cooperate (a skilled respiratory therapist
cal students, interns and residents how to treat often can conduct this study in children as
status asthmaticus. It is presented here as an effec- young as 5 years of age).5
tive approach to the pharmacologic management
of status asthmaticus.
II. INITIAL THERAPY
1 . Admit to Intensive Care Unit r other
o special
I. INITIAL EVALUATION area for acutely ill patients.
The initial evaluation should establish as many 2. Intravenous Therapy:
objective measurements as possible, both as a basis a. Intravenous fluids (guidelines only):
for initial therapy and for following the patient’s 1. Hydrating (initial)-12 mt/kg or 360
clinical course. Of particular relevance are the mt/sq m for first hour’5 (5% glucose in
following:
1. History: Duration of illness, evidence of in-
Score Reap. Wheezing Inapir./ Accessary
fection, fluid balance (intake, vomiting, un- Rate Score Expir. Reap. Muec.
nation), medications administered, dosage Ratio Utilization
and time (particularly methyixanthines and 0 <30 None 5/2 0
catecholamines).
1 31-45 Terminal 5/3-5/4 +
2. Physical Examination: General status of pa- Expir. or -
E Steth.
tient (anxiety, obtundation, respiratory ef- only
fort), vital signs including respiratory rate,
2 46-60 Entire 1/1
pulse, pulsus paradoxus,8 blood pressure, Expir. or
Steth.
A/P chest diameter, weight and height,
quality and symmetry of breath sounds, and 3 >60 Inspir. <1/1 ++++
a Expir.
presence of papilledema which indicates a Steth.
Paco2 of greater than 75 mm Hg.9
3. Pulmonary Index: A systemized clinical
scoring system’#{176}shown in Figure 1. If no wheezing is audible due to minimal
air exchange, score 3
4. Admission Chest X-ray for pneumonia, ate-
lectasis, pneumomediastinum, pneumotho- Fic. 1. Pulmonary index.
PEDIATRICS Vol. 54 No. 2 August 1974 245
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3. normal saline). bronchoconstriction and/or pneumo-
2. Maintenance-50 to 60 ml/kg/24 hr or mediastinum or pneumothorax.19bO
1,500 mi/sq m/24 hr (5% glucose in
water).
3. Depletion Repair: III. FOLLOW-UP EVALUATION AND
a. Saline (5% glucose in normal saline) TREATMENT
10 to 15 ml/kg/24 hr or 300 to 500 1. Clinical Evaluation:
mt/sq m. a. Pulmonary Index: Repeat scoring at #{189},1,
b. Water (5% glucose/water) 10 to 15 3, 6, 12 and 24 hours after admission (Fig.
ml/kg/24 hr or 300 to 500 ml/sq 1). If score increases, repeat arterial blood
m/24 hr. gases.
b. Electrolytes: b. Pulmonary Function: Repeat FVC, FEy1,
1. Potassium (2 mEq/100 ml of mainte- and FEF2575% at 1, 3, 6, 12, and 24 hours,
nance intravenous fluids). then every 12 hours for duration of hospi-
2. Sodium (3 mEq/ 100 ml of mainte- talization.
nance intravenous fluids). c. Arterial Blood Gases: Repeat at one and
C. Buffers: If pH is below 7.35 and base def- three hours or more frequently, if mdi-
icit greater than 5 mEq/liter, correct to cated by clinical course. If Paco2 goes
normal range with IV sodium bicarbonate above 60 mm Hg, anticipate assisted yen-
as clinically 16 tilation. A falling pH in the face of a rising
d. Aminophylline: 7 mg/kg diluted by 3 Paco2 warns of impending respiratory
volumes of saline and given in 15 minutes failure.
by IV infusion asloading dose, followed d. Repeat Chest X-ray: Do if sudden worsen-
by 15 mg/kg/24 hr, by continuous IV in- ing of clinical or laboratory course. A sud-
fusion.5 If possible, theophylline serum den increase in respiratory rate or fall in
levels should be monitored during early blood pressure may indicate pneumo-
therapy. 17 mediastinum or pneumothorax.
e. Adrenocorticosteroid.s: 2. Therapy:
1. Betamethasone 0.3 mg/kg/STAT,
- a. In Hospital: At 24 hours, theophyitine,
followed by 0.3 mg/kg/24 hr IV, or corticosteroids and antibiotics may be
2. Hydrocortisone-7 mg/kg/STAT fol- administered orally if the patient is im-
towed by 7 mg/kg/24 hr
IV.6 proving. An overlap of six to eight hours
1. Antibiotics: (ONLY if indicated by clini- in oral and intravenous therapy provides
cat or x-ray evidence of infection) ampi- for a smooth transition. Nebulized bron-
ciilin, 100 mg/kg/24 hr.7 Adjust on identi- chodilators may be administered as need-
fication of bacterial pathogen. ed.
3. Respiratory Therapy: b. Outpatient Treatment: Status asthmati-
a. Oxygen: Initial therapy with humidified cus in most children can be controlled in
oxygen is desirable,’2 preferably by Ven- 24 to 48 hours with an average hospital
turi mask. Adjustments in oxygen therapy stay of 2.5 J: 0.5 days.7 The patient should
can be made on receipt of blood arterial be discharged on theophylline or a the-
oxygen determination. phyllmne-ephednmne combination, admin-
b. Aerosolized Sympathicomimetic Agents: istered every six hours, a tapering steroid
Either 0.05% isoproterenol or a combina- dosage which may be discontinued after
tion of 0.04% isoproterenol and 0.06% a seven- to ten-day course (administered
phenylephrine’8; solution should be ad- once daily in the early morning) and com-
ministered for five to ten minutes every pletion of the antibiotic course if mdi-
half hour for the first two hours of therapy cated.
by an ultrasonic or Puritan wall nebulizer
with oxygen, and less frequently thereaf-
ter depending on clinical course. The IV. ASSISTED VENTILATION
child’s pulse rate should be monitored The patient with any of the following should be
during administration. If the rate exceeds considered for assisted ventilation2l:
180 to 200 beats/mm, the treatment 1. A Paco2 above 65 mm.
should be temporarily discontinued. 2. A Pao2 of less than 60 mm on 100% oxygen.
Avoid positive pressure ventilators (IPPB) 3. A steadily rising Paco2 in an exhausted pa-
because of the danger of inducing further tient.
246 ASTHMA IN CHILDHOOD
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4. Comment: The specific management of pa- 3. Shapiro, J. B., and Tate, C. F. Deaths
: in status asthmati-
cus. Dis. Chest, 48:484, 1965.
tients by assisted ventilation is beyond the scope of
4. Richards, W., and Siegel, S. C.: Status asthmaticus.
this paper. Respiratory failure demands a team Pediat. Clin. N. Amer., 16:9, 1969.
approach. If assisted ventilation appears likely, 5. Pierson, W. E., Bierman, C. W., Stamm, J., S. and Van
obtain early consultation with the anesthesiologist Arsdel, P. P., Jr.: Double blind trial of aminophyl-
so that he or she may be acquainted with the pa- line in status asthmaticus. Pediatrics, 48:642, 1971.
6. Pierson, W. E., Bierman, C. XV., and Kelley, V. C.: A
tient and may participate in the decision mi- to
double-blind trial of corticosteroid therapy in
tiate assisted ventilation. status asthmaticus. Pediatrics, 54:282, 1974.
7. Shapiro, C. C., Eggleston, P. A., Pierson, W. E., Ray,
C. C., and Bierman, C. W.: Double-blind study of
V. PITFALLS IN CARE the effectiveness of a broad-spectrum antibiotic in
status asthinaticus. Pediatrics, 53:867, 1974.
1 . Attempting to treat the patient with intrave- 8. Knowles, G. K., and Clark, J.P.H.: Pulsus paradoxus as a
nous fluids and ammnophylline in the Emer- valuable sign indicating severity of asthma. Lan-
gency Room. A pediatric patient, sick cet, 11:1356, 1973.
enough to require these measures, is unlikely 9. Papilledema in chest disease (editorial). Brit. J.,
Med.
2:1486, 1963.
to recover sufficiently in a few hours to be
10. Dabbous, I. A., Tkachyk, J. S., and Stamm, J.:
S. A double
sent home safely. blind study on the effects of corticosteroids in the
2. Administering ammnophyllmne in suppository treatment of bronchiolitis. Pediatrics, 37:477, 1966.
form. Suppositories not only do not provide 11. Eggleston, P. A., Ward, B. H., Pierson, W. E., and Bier-
dependable serum levels, but frequently are man, C. W.: Radiographic abnormalities in acute
asthma in children. Pediatrics, to be published.
responsible for toxic overdoses.
12. McFadden, E. R., Jr., and Lyons, H. A.: Arterial blood
3. Delaying administration of therapeutic gas tension in asthma. New J.
Eng. Med., 278:1027,
doses of adrenocorticosteroids on admission. 1968.
The complications of hypoxemia5 may be in- 13. Stamm, S.J.: Reliability of capillary blood for the mea-
surement of Pao2 and oxygen saturation. Dis.
creased.
Chest, 52:191, 1967.
4. Writing orders illegibly. For example, the 14. McFadden, E. R., Jr., Kiser, R., and De Groot, J.: W.
nurse may confuse aminophyllmne (15 Acute bronchial asthma: Relations between clini-
mg/kg/24 hr) for ampicillin (100 mg/kg/24 cal and physiological manifestations. New J.
Eng.
hr),22 with serious consequences. Med., 288:221, 1973.
15. Straub, P. V., Buhlmann, A. A., and Rossier, P. H.: Hy-
5. Sedating the hypoxemic patient. The likeli-
povolemia in status asthmaticus. Lancet, 11:923,
hood of respiratory failure increases propor-
1969.
tionately with such medication. 16. Bodes, J. S.: Status asthmaticus. Med. Clin. N. Amer.,
6. Admission to a regular hospital ward rather 54:493, 1970.
than the intensive care unit. The early recog- 17. Intravenous aminophylline (editorial). Lancet, 11:950,
1973.
nition of serious complications may be criti-
18. Freedman, B. ., and
J Hill, C. B.: Comparative study of
cally delayed. duration of action and cardiovascular effects of
7. The use of antihistamines or cromolyn sodi- bronchodilator aerosols. Thorax, 26:46, 1971.
um in status asthmaticus. Neither agent has 19. Bierman, C. W. : Pneumomediastinum and pneumotho-
bronchodilator properties and both may ad- rax complicating asthma in children. J.
Amer. Dis.
Child., 114:42, 1967.
versely affect therapy.
20. Moore, R. B., Cotton, E. K., and Pinney, M. A.: The ef-
fect of IPPB on airway resistance in normal and
asthmatic children. J. All. Clin. Immun., 49:137,
CONCLUSIONS 1972.
21. Wood, D. W., Downs, J. J., and Lecks, H. I.: The man-
This treatment protocol has been employed ef- agement of respiratory failure in childhood status
fectively as a specific guide. It also can be adapted asthmaticus: Experience with 30 episodes and evo-
to changing or unique clinical situations and aids lution of a technique. J. Allerg., 42:261, 1968.
in bringing optimum treatment to the child or ad- 22. Barter, B., and Roberts, J. : Unusual
R. case of amino-
phylline intoxication. Pediatrics, 52:608, 1973.
olescent with status asthmaticus.
REFERENCES ACETAMINOPHEN POISONING-A
1. American Thoracic Society: Management of status asth- CRITICAL COMMENT
maticus: A statenient of the Committee on Thera-
py. Amer. Rev. Resp. Dis., 97:735, 1968.
2. Speizer, F. E., Doll, R., and Heaf, P.: Observations on re- EDITOR, Pharmacology for the Pediatrician:
cent increase in mortality from asthma. Brit. Med. In the December 1973 issue of
Pediatrics there
J., 1:335, 1968. appeared an article attempting to summarize the
PHARMACOLOGY FOR THE PEDIATRICIAN 247
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5. The Pharmacologic Management of Status Asthmaticus in Children
C. Warren Bierman and William E. Pierson
Pediatrics 1974;54;245-247
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