for post graduates pediatrics

1. DIAGNOSIS & MANAGEMENT OF
STATUS ASTHMATICUS
DR I H KASHIF

2. BRONCHIAL ASTHMA
Asthma is a chronic inflammatory disease characterized by
airflow obstruction due to airway hyper-responsiveness
resulting in recurrent episodes of wheezing,
breathlessness, and coughing particularly at night or in
early morning.

3. STATUS ASTHMATICUS
Status Asthmaticus (Acute Severe Asthma) is a condition of
progressively worsening bronchospasm and respiratory
dysfunction which fails to respond to conventional therapy
(inhaled beta2 agonists, oral or IV steroids and O2) and
that which requires hospitalization.

4. ACUTE EXACERBATION OF ASTHMA
 An increase in symptom (cough, wheeze and/or
breathlessness) is termed as Exacerbation of Asthma.
 Severity of exacerbation can be classified into mild/
moderate/ Severe

7. BECKER ASTHMA SCORE
SCORE RESPIRATORY
RATE
WHEEZING I/E RATIO ACCESSORY
MUSCLE USE
0 <30/min None 1:1.5 None
1 30-40/min Terminal
Expiration
1:2 1 site
2 41-50/min Entire
Expiration
1:3 2 site
3 >50/min Inspiration &
entire
Expiration
>1:3 3site or neck
strap muscle
Score >4 : Moderate Asthma exacerbation
Score =>7 : Admit In PICU

10. MANAGEMENT OF ACUTE SEVERE ASTHMA
Aims Of Management-
 Treat to break cycle of bronchoconstriction and impaired
ventilation.
 Reduce inflammation in the airways with steroids
 Offer supportive ventilation as necessary
 Treat precipitating factors.
3 Cornerstones of Severe Asthma Treatment
 Administration Of O2
 Beta Agonists
 Steroids

11. Management of severe exacerbation
General Treatment-
Children with severe asthma admitted in PICU
 Require IV access
 Continuos pulse oxymetry
 Cardiorespiratory monitoring
 Sedation should be strictly avoided (unless intubated)

12. FLUIDS-
Correct shock if present.
Maintain Euvolemia (NS/RL)
Avoid overhydration as there is a risk of SIADH , pulmonary
edema.
Restrict fluid to 2/3rd if Serum Na <138mEq/l
Potassium infusiom may be required if Serum K < 3 mEq/l
ANTIBIOTICS- Not routinely indicated (most cases are triggered by
viral infection)
Cover for Community Acquired Pneumonia if temp>101.5 degree F
OXYGEN- by nasal cannulae (maintain SPO2 93-95%)
Beta agonist may worsen hypoxia by attenuating hypoxic pulmonary
vasoconstriction , hence O2 should always be administered along with
nebulisation.

13. steroids
 IV Hydrocortisone 10mg/kg stat f/b 5 mg/kg QID
 Switch to oral steroids (prednisolone 1-2 mg/kg/day) when stable.
 Gastric acid suppression with H2 blockers/PPI
 Begin effect in 1-3 hrs , reach to maximal effect in 4-8 hrs
 Should be use early in all patients with acute severe asthma
 Oral steroids are as effective as IV (if not vomitting)
 Inhaled steroids- No benefit in acute episode.
 Total duration- 7 days (can be indivisualised based on severity of
attack)

14. HIGH DOSE BETA2 AGONISTS
 When tidal volumes are severely reduced, MDI and spacers are
ineffective and nebulised beta agonists are indicated
 Administer continuous nebulised salbutamol at 0.15-0.5 mg/kg/hr
OR
 3 doses of back to back salbutamol ,each nebulised over 15-20 min
with O2 and ECG monitoring.
 Add Ipratropium to each of the 3 nebulizations
 1ml of 0.5% Salbutamol= 5mg
• Dose- <20 kg- 2.5 mg(0.5 ml) >20 kg- 5 mg (1ml)
• Reassess clinical condition every 20 min.
• If no improvement, consider subcutaneous or intraavenous beta
agonist

15. Subcutaneous beta agonist
 Options are adrenaline and terbutaline
 Adrenaline has superior bronchodialtory property but may cause
more tachycardia.
 Sc dose of terbutaline or adrenaline : 0.01mg/kg/dose (max 0.3mg),
can be repeated every 15-20 min *3 doses
Intravenous beta agonists
 To be use if severe airflow limitataion persists despite continuos
nebulised salbutamol.
 Salbutamol – 5mcg/kg over 1 hr (loading) f/b 1 mcg/kg/hr through IP
OR
 Terbutaline- 5-10 mcg/kg over 10 min f/b 2-10 mcg/kg/hr
 Ecg & serum K monitoring should be there

16.  Total beta agonist dose in an hour (Inhaled +SC +IV)should
not exceed 20mg/hr
 An increase in HR by>20bpm should prompt a decrease in
the dose and re evaluation of the diagnosis (bcz tachycardia
in severe asthma is related to respiratory distress and with
relief of obstruction, tachycardia should be dramatically
resolved)

17. Ipratropium nebulisation
 Add 250mcg of ipratropium to sabutamol in same
nebulizer every 20 min for 3 doses during initial
treatment then every 4 hourly
 Although ipratropium is a long acting drug, it is
synergistic with and and enhances the
performance and efficiency of salbutamoland
hence must be given at a higher frequency during
initial treatment

18. Magnesium sulphate
 Mechanism: smooth muscle relaxation by inhibition
of calcium uptake, resulting in decreased Ach and
Histamine release.
 Side effects: Tachycardia/bradycardia,
hypotension, respiratory muscle weakness at
higher serum levels
 Dose- 20-50 mg/kg over 20 min
 No evidence of benefit from repeat dose., however
toxicity is a concern

19. Aminophylline
 Useful for patients who do not respond well to beta
agonist
 Dose: 5-10mg/kg over 20 min(loading), 0.5-
1mg/kg/hr
 Possible role in improving diaphragmatic
contractility
 s/e- arrhythmias, hypotension, confusion, gi
symptoms
 May break cycle of bronchospasm within 6 -12
hours after which it may be stopped.

20. 1.Oxygen to maintain saturation > 90-95%
2. Nebulisation with Salbutamol: 3 doses at 20 min interval
Salbutamol respule (0.63 mg) OR
Nebulisation solution: <20 kg= 0.5 ml + 3 ml NS
>20kg= 1 ml + 3ml NS
3. Nebulisation with Ipratropium: ( combine with salbutamol 20 minutely, 3
doses)
<1 yr= 0.5 ml
>1yr=1 ml
4 Steroids : Hydrocortisone 10mg/kg stat f/b 5mg/kg QID
switch to oral prednisolone once stable.
5. Treat Shock with 20ml/kg saline bolus.
Hourly nebulisation with salbutamol 3-4 doses
May increase neb. Interval to 2-4 hourly.
Continue steroids.
improved

21. If not Improved
Adrenaline 0.1 ml/kg (1:10000) sc Q20 min – 3 times OR
Terbutaline 0.005 to 0.01 ml/kg sc Q20 min – 3 times
If not Improved
Injection Magnesium Sulfate
50 mg/kg in 10 ml NS over 30 min

22. If not Improved
Terbutaline Infusion 0.05- 0.1 mcg/kg/min infusion,
Reduce dose if HR increases >20/min over baseline or ST changes occur.
Continue nebulisation
If not Improved
Aminophylline infusion (reduce terbutaline infusion by 50%)
May need to consider mechanical Ventilation

23. Mechanical ventilation
 Indication include-
 Cardiopulmonary arrest
 Severe hypoxia
 Rapid deteoration of mental status
 Settings-(to minimise dynamic hyperinflation & air trapping)
 Slow rate with prolonged expiratory phase
 Minimal end expiratory pressure
 Short inspiratory time
 For older children- Volume Control mode using VT of 5-6ml/kg, RR
approximately half for age, I:E ratio 1:3,PEEP 2-3 cm of water
 In infants- Pressure control mode is used

25. Thank you