Current therapies for severe asthma exacerbations in children

This article reviews the epidemiology, pathophysiology, and current treatment strategies for severe asthma exacerbations in children. The prevalence of asthma is increasing, as are the markers of this severe disease such as tracheal intubation and death. Inflammation is now recognized as central to the pathophysiology of asthma, and inflammation control is the cornerstone of therapy. Therapies for severe asthma continue to evolve. Parenteral corticosteroids are standard therapy for acute exacerbations and inhaled corticosteroids are the mainstay of chronic care. Inhaled β₂- adrenergic agents dosed to effect are the first-line treatment for bronchospasm; however, intravenous β₂-adrenergic agents can be used in patients who do not improve with continuous inhaled therapy. Inhaled anticholinergics are effective bronchodilators when used in addition to inhaled β₂-adrenergic agents. Aminophylline, magnesium sulfate, ketamine, and nebulized furosemide are also used to treat severe asthma exacerbations; however, their efficacy as additional therapy to β₂-adrenergic agents is not well established. Use of helium oxygen blends have been used to treat severe exacerbations both to improve particle deposition of inhaled medications and to decrease work of breathing. Strategies to prevent barotrauma are central to mechanical ventilation. Brief reports and recent clinical experience suggest that support modes of ventilation may be useful to avoid use of neuromuscular blocking agents and to allow active exhalation. Inhalational anesthetic gases and extracorporeal life support have also been used to treat asthma exacerbations that did not improve with conventional care.