A review of the use of adjunctive therapies in severe acute asthma exacerbation in critically ill children

Abstract

Asthma is a common and potentially life threatening childhood condition. Asthma involves not only chronic airway remodeling, but may also include frequent exacerbations resulting from bronchospasm, edema, and mucus production. In children with severe exacerbations, standard therapy with β₂-agonists, anti-cholinergic agents, oxygen, and systemic steroids may fail to reverse the severe airflow obstruction and necessitate use of adjunctive therapies. These therapies include intravenous or inhaled magnesium, inhaled helium-oxygen mixtures, intravenous methylxanthines, intravenous β₂-agonists, and intravenous ketamine. Rarely, these measures are not successful and following the initiation of invasive mechanical ventilation, inhaled anesthetics or extracorporeal life support may be required. In this review, we discuss the mechanisms and evidence for adjunctive therapies in the setting of severe acute asthma exacerbations in children.

Keywords::

• β₂-agonist
• children
• critical asthma
• extracorporeal life support
• heliox
• inhaled anesthetics
• ketamine
• magnesium
• methylxanthine
• pediatric
• status asthmaticus

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending or royalties.

No writing assistance was utilized in the production of this manuscript.

Key issues

• All children with acute asthma exacerbation should receive first-line treatment as per published guidelines. Those who do not respond sufficiently to these measures should be admitted and adjunctive therapies considered, in addition to (not to replace) first-line treatment strategies.

• Intravenous (iv.) magnesium use in the emergency department reduces hospital admission rate, LOS and intubation rate, but there is little evidence for its continued use in the PICU. There are limited data to support the use of nebulized magnesium in the emergency department.

• Iv. β-agonists and iv. methylxanthines may be used as second-tier therapies, but these agents are associated with significant side effects.

• Inhaled heliox can be safely administered and may improve pulmonary function in severe asthma exacerbations.

• Inhaled anesthetics and iv. ketamine have bronchodilatory and anesthetic/sedative effects. These agents may be considered in children with severe asthma who require mechanical ventilation.

• The use of extracorporeal membrane oxygenation in refractory severe asthma has been increasing over the past two decades and despite disease severity, survival in this group remains high.

Notes