Acute asthma exacerbation (peds): Difference between revisions
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''For adult patients see [[Asthma]]'' | |||
==Background== | ==Background== | ||
* | *An estimated 6 million children in the US have asthma | ||
* | *In 2007, asthma lead to >700,000 ED visits | ||
* | *Asthma is part of the atopy triad (asthma, allergies, eczema) | ||
* | *A history of eczema or allergies maybe helpful in making a new diagnosis of asthma | ||
*Wheezing in an infant is more often [[bronchiolitis]] than asthma | |||
*Viral [[URI]] associated with copious rhinorrea, allergen exposure, and respiratory irritants (i.e. smoke) are common precipitants for pediatric asthma exacerbations | |||
==Clinical Features== | ==Clinical Features== | ||
*Dyspnea | *[[Wheezing]] | ||
*[[Cough]] | |||
*Accessory muscle use | |||
*[[Dyspnea]] | |||
*Prolonged expiration | *Prolonged expiration | ||
* | *Severity of retractions occurs in caudal to cephalad direction | ||
**Scalene muscle contractions more severe than subcostal and intercostal retractions | |||
*Sign of impending ventilatory failure | *Sign of impending ventilatory failure | ||
**Paradoxical respiration | **Paradoxical respiration | ||
***Chest deflation and abdominal protrusion during | ***Chest deflation and abdominal protrusion during inspiration | ||
**Altered mental status | **[[Altered mental status]] | ||
**"Silent chest" | **"Silent chest" | ||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
{{ | {{Pediatric wheezing DDX}} | ||
== | ==Evaluation== | ||
*Clinical diagnosis | *Clinical diagnosis | ||
*Can consider a blood gas if there are fears that the patient is getting tired (sleepy baby vs [[hypercapnia|elevated CO2]]?) | |||
**A CO2 >45 is abnormal in a patient hyperventilating and warrants close monitoring | |||
===Consider [[CXR]]=== | |||
*1st wheezing episode | |||
*Asymmetric lung auscultation findings, after treatment with albuterol | |||
*Poor response to medications/treatment, if history and exam are not consistent with [[bronchiolitis]] | |||
*Worsening symptoms | |||
*Fever not explained by apparent viral illness | |||
===Clinical Scores=== | |||
*Diagnosis and treatment can be guided by clinical scores | *Diagnosis and treatment can be guided by clinical scores | ||
**Modified Pulmonary Index Score (MPIS - Utilized at CCMC) | **Modified Pulmonary Index Score (MPIS - Utilized at CCMC) | ||
Line 25: | Line 43: | ||
**Pulmonary Score (PS) | **Pulmonary Score (PS) | ||
**Pediatric Respiratory Assessment Measure (PRAM) | **Pediatric Respiratory Assessment Measure (PRAM) | ||
{{Modified Pulmonary Index Score}} | {{Modified Pulmonary Index Score}} | ||
Line 39: | Line 50: | ||
''Favor continuous nebulization to decrease the chance of admission when compared to intermittent dosing''<ref>Camargo CA et al. Continuous versus intermittent beta- agonists for acute asthma. Cochrane Database Syst Rev. 2003;(4):CD001115. PMID: 14583926.</ref> | ''Favor continuous nebulization to decrease the chance of admission when compared to intermittent dosing''<ref>Camargo CA et al. Continuous versus intermittent beta- agonists for acute asthma. Cochrane Database Syst Rev. 2003;(4):CD001115. PMID: 14583926.</ref> | ||
*Nebulizer | *Nebulizer | ||
** | **Intermittent: 2.5-5mg q20min, three doses are traditionally given back to back, then repeat as needed. | ||
**Continuous: 0. | **Continuous: 0.5mg/kg/hr (max 15mg/hr)<ref>National Asthma Education and Prevention Program (NAEPP), “Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma,” Clinical Practice Guidelines, National Institutes of Health, National Heart, Lung, and Blood Institute, NIH Publication No. 08-4051, prepublication 2007; available at http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm.</ref> | ||
*MDI | *MDI | ||
**4-8 puffs q20min | **4-8 puffs q20min given in first hour, then q1-4hr as needed | ||
===[[Ipratropium]]=== | ===[[Ipratropium]]=== | ||
*0.5mg q20min | *0.25-0.5mg q20min, given with the first three doses of albuterol, it is shown to reduce admission. | ||
===[[Steroids]]=== | ===[[Steroids]]=== | ||
Should be given in the first hour with effects to reduce admission<ref name="Rowe">Rowe BH et al. Magnesium sulfate for treating exac- erbations of acute asthma in the emergency depart- ment. Cochrane Database Syst Rev. 2000;(2):CD001490. PMID: 10796650.</ref> | ''Should be given in the first hour with effects to reduce admission<ref name="Rowe">Rowe BH et al. Magnesium sulfate for treating exac- erbations of acute asthma in the emergency depart- ment. Cochrane Database Syst Rev. 2000;(2):CD001490. PMID: 10796650.</ref>'' | ||
*[[Dexamethasone]] | *[[Dexamethasone]] | ||
** | **0.6mg/kg PO or IV (max 16mg); consider 2nd dose 24-36hrs later. | ||
***PO and IV have equal efficacy. Giving the IV form by mouth is typically better tolerated by young children (same dosing) | |||
**Both 1 and 2 dose regimens as effective as [[prednisone]] or [[prednisolone]] in children <ref>Keeney, et al. Dexamethasone for Acute Asthma Exacerbations in Children: A Meta-analysis. Pediatrics. 2013-2273</ref><ref>Cronin et al. "A Randomized Trial of Single-Dose Oral Dexamethasone Versus Multidose Prednisolone for Acute Exacerbations of Asthma in Children Who Attend the Emergency Department." Annals of EM. May 2016. 67(5):593-601</ref> | |||
*[[Prednisone]] | *[[Prednisone]] | ||
** | **1-2mg/kg/day (60mg max) in one or two divided doses for 3-5 days | ||
*[[Methylprednisolone]] | *[[Methylprednisolone]] | ||
**1mg/kg IV q 4–6hr | **1mg/kg IV q 4–6hr | ||
**Only use IV if cannot tolerate PO since equal effectiveness between dosing routes<ref>Rowe BH, Keller JL, Oxman AD. Effectiveness of steroid therapy in acute exacerbations of asthma: a meta-analysis. Am J Emerg Med. Jul 1992;10(4):301-10</ref> | **Only use IV if cannot tolerate PO since equal effectiveness between dosing routes<ref>Rowe BH, Keller JL, Oxman AD. Effectiveness of steroid therapy in acute exacerbations of asthma: a meta-analysis. Am J Emerg Med. Jul 1992;10(4):301-10</ref> | ||
===[[Magnesium]]=== | ===[[Magnesium]]=== | ||
*Dose: 50mg/kg IV, max 2-4 g over 20 mins with close blood pressure monitoring | |||
*Dose: | *Smooth muscle relaxant | ||
*Duration of action | *Duration of action approximately 20 min | ||
*In patients with moderate to severe asthma there is a decreased rate of admission with an NNT of 2<ref name="Rowe"></ref> | *In patients with moderate to severe asthma there is a decreased rate of admission with an NNT of 2<ref name="Rowe"></ref> | ||
=== | ===Beta-agonist=== | ||
*[[Epinephrine]] | |||
*1:1000 0.01mg/kg (max 0.3mg) IM | **1:1000 0.01mg/kg (max 0.3mg) IM, repeat as needed | ||
*[[Terbutaline]] | |||
**Given SQ, usual dose 0.01mg/kg up to 0.3mg. | |||
* | **Longer-acting beta2-agonist promoting bronchodilation | ||
*Given SQ, usual dose 0. | |||
===[[Non-invasive ventilation]] | ===Assisted Ventilation=== | ||
*Consider as alternative to intubation | *[[Non-invasive ventilation]] | ||
*Alleviates muscle fatigue which leads to larger tidal volumes | **Consider as alternative to intubation | ||
*Maximize inspiratory support | **Alleviates muscle fatigue which leads to larger tidal volumes | ||
** | **Maximize inspiratory support | ||
**PEEP | ***Delta pressure 10 | ||
***PEEP >4 | |||
**May benefit from [[ketamine]] or [[dexmedetomidine]] to mildly sedate and allow the interface | |||
* | |||
===[[Intubation]]=== | ===[[Intubation]]=== | ||
*Consider induction with [[ | *Push pull (bolus) [[IVF|fluids]] prior to intubation to maximize the patient's preload and ideally decrease the chance of the patient arresting | ||
*Consider induction with [[ketamine]] | |||
**Provides bronchodilation and sedation however it does promote secretions | **Provides bronchodilation and sedation however it does promote secretions | ||
**Ketamine is the preferred induction agent for intubation in an asthmatic. | **Ketamine is the preferred induction agent for intubation in an asthmatic. | ||
**Dosing 1- | **Dosing 1-2 mg/kg | ||
*Ventilation of asthmatic | *Ventilation of asthmatic patients requires deep sedation | ||
**[[Benzos]], | **[[Benzos]], [[ketamine]] (1 mg/kg/hr) | ||
*[[Ventilation settings]] | *[[Ventilation settings]] | ||
**Assist-control ventilation | **Assist-control ventilation | ||
**Resp rate | **Resp rate | ||
***Start slow to avoid air-trapping and allow for longer expiration time | ***Start slow to avoid air-trapping and allow for longer expiration time | ||
*** Consider I:E ratio of 1:2 or 1:3 | ***Consider I:E ratio of 1:2 or 1:3 | ||
** | **Plateau pressure ideally <30 | ||
**May require "permissive hypoventilation" and permissive hypercarbia and acidosis | **May require "permissive hypoventilation" and permissive hypercarbia and acidosis | ||
***Low peak pressure/avoidance of breath stacking more important than correcting CO2 <ref> Darioli, et al. Mechanical Controlled hypoventilation in status asthmaticus. Am Rev Respir Dis. 1984; 129 (3) 385-7 </ref> | ***Low peak pressure/avoidance of breath stacking more important than correcting CO2 <ref> Darioli, et al. Mechanical Controlled hypoventilation in status asthmaticus. Am Rev Respir Dis. 1984; 129 (3) 385-7 </ref> | ||
**Tidal volume 6-8cc/kg ideal wt | **Tidal volume 6-8cc/kg ideal wt | ||
**PEEP | **PEEP >4 | ||
**Flow rate 80-100L/min | **Flow rate 80-100L/min | ||
**Keep FiO2 minimum to achieve SpO2 > 90% | **Keep FiO2 minimum to achieve SpO2 > 90% | ||
*Use bronchodilators even when intubated | *Use bronchodilators even when intubated | ||
*Many patients require a continuous [[neuromuscular blocking agents|paralytic]] infusion for the first 24+ hrs of intubation | |||
==Outpatient Treatment== | ==Outpatient Treatment== | ||
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| align="center" style="background:*f0f0f0;"|'''Treatment (WHO 2008 Formulary)<ref>Stuart MC et al. WHO Model Formulary 2008. http://www.who.int/selection_medicines/list/WMF2008.pdf.</ref>''' | | align="center" style="background:*f0f0f0;"|'''Treatment (WHO 2008 Formulary)<ref>Stuart MC et al. WHO Model Formulary 2008. http://www.who.int/selection_medicines/list/WMF2008.pdf.</ref>''' | ||
|- | |- | ||
| Mild intermittent, > 80% peak flow||< 2/wk||< 2/mo||[[Albuterol]] MDI 100-200 mcg | | Mild intermittent, > 80% peak flow||< 2/wk||< 2/mo||[[Albuterol]] MDI 100-200 mcg PRN QID | ||
|- | |- | ||
| Mild persistent, > 80% peak flow||>2/wk||>2/mo||[[Albuterol]] MDI 100-200 mcg | | Mild persistent, > 80% peak flow||>2/wk||>2/mo||[[Albuterol]] MDI 100-200 mcg PRN QID '''AND''' | ||
[[Beclometasone]] 100-250 mcg BID | |||
[[Beclometasone]] 100-250 mcg | |||
|- | |- | ||
| Moderate persistent, 60-80% peak flow||Daily with exacerbations weekly||> 1/wk||[[Albuterol]] MDI 100-200 mcg | | Moderate persistent, 60-80% peak flow||Daily with exacerbations weekly||> 1/wk||[[Albuterol]] MDI 100-200 mcg PRN QID '''AND''' | ||
[[Beclometasone]] 100-500 mcg BID '''AND''' | |||
[[Beclometasone]] 100-500 mcg | |||
[[Salmeterol]] inhaled 50 mcg BID | |||
[[Salmeterol]] inhaled 50 mcg | |||
|- | |- | ||
| Severe persistent, < 60% peak flow||Continuous daily||Frequent||[[Albuterol]] MDI 100-200 mcg | | Severe persistent, < 60% peak flow||Continuous daily||Frequent||[[Albuterol]] MDI 100-200 mcg PRN QID '''AND''' | ||
[[Beclometasone]] 1mg BID (high dose) '''AND''' | |||
[[Beclometasone]] | |||
[[Salmeterol]] inhaled 50 mcg BID '''AND''' | |||
[[Salmeterol]] inhaled 50 mcg | |||
[[theophylline]], leukotriene antagonist, or PO [[prednisolone]] with taper | |||
|} | |} | ||
==Disposition== | ==Disposition== | ||
*'''Discharge''' | *'''Discharge''' | ||
**Often, | **Often, patients will still have mild wheezing, but should have complete resolution of tachypnea, hypoxia, and improved work of breathing | ||
**A short course of glucocorticoids decreases chance of relapse <ref>Chapman K. Effect of a short course of [[prednisone]] in the prevention of early relapse after the emergency room treatment of acute asthma. NEJM. 1991;324(12):788</ref>) | |||
**A short course of glucocorticoids | **Patient should generally continue albuterol at home q6hrs for at least the first 24hrs after discharge | ||
*'''Admit''' | **A spacer should be prescribed to be used with the MDI to improve medication delivery to the lungs | ||
* | *'''Admit''' | ||
**If symptoms do not significantly improve or for severe exacerbations | |||
*Peak flow measurements maybe helpful when deciding disposition | |||
**Predicted = (30 x age (yrs)) + 30 | **Predicted = (30 x age (yrs)) + 30 | ||
**PEF >70% predicted → high likelihood of successful discharge | **PEF >70% predicted → high likelihood of successful discharge | ||
Line 146: | Line 154: | ||
==See Also== | ==See Also== | ||
*[[Asthma]] | |||
*[[Modified pulmonary index score]] | |||
*[[Ventilation settings]] | *[[Ventilation settings]] | ||
*[[Deterioration after intubation]] | *[[Deterioration after intubation]] | ||
*[[Shortness of breath]] | *[[Shortness of breath]] | ||
==External Links== | ==External Links== |
Revision as of 15:22, 11 October 2019
For adult patients see Asthma
Background
- An estimated 6 million children in the US have asthma
- In 2007, asthma lead to >700,000 ED visits
- Asthma is part of the atopy triad (asthma, allergies, eczema)
- A history of eczema or allergies maybe helpful in making a new diagnosis of asthma
- Wheezing in an infant is more often bronchiolitis than asthma
- Viral URI associated with copious rhinorrea, allergen exposure, and respiratory irritants (i.e. smoke) are common precipitants for pediatric asthma exacerbations
Clinical Features
- Wheezing
- Cough
- Accessory muscle use
- Dyspnea
- Prolonged expiration
- Severity of retractions occurs in caudal to cephalad direction
- Scalene muscle contractions more severe than subcostal and intercostal retractions
- Sign of impending ventilatory failure
- Paradoxical respiration
- Chest deflation and abdominal protrusion during inspiration
- Altered mental status
- "Silent chest"
- Paradoxical respiration
Differential Diagnosis
Pediatric Wheezing
- Upper Airway diseases
- Large Airway Obstruction
- Foreign body aspiration
- Vascular ring or laryngeal webs
- Laryngotracheomalacia
- Enlarged lymph node or tumor
- Vocal cord dysfunction
- Small Airway Obstruction
- Asthma
- Viral bronchiolitis
- Cystic Fibrosis
- Bronchopulmonary dysplasia
- Congenital heart disease or other cardiac disease
- Other causes
Evaluation
- Clinical diagnosis
- Can consider a blood gas if there are fears that the patient is getting tired (sleepy baby vs elevated CO2?)
- A CO2 >45 is abnormal in a patient hyperventilating and warrants close monitoring
Consider CXR
- 1st wheezing episode
- Asymmetric lung auscultation findings, after treatment with albuterol
- Poor response to medications/treatment, if history and exam are not consistent with bronchiolitis
- Worsening symptoms
- Fever not explained by apparent viral illness
Clinical Scores
- Diagnosis and treatment can be guided by clinical scores
- Modified Pulmonary Index Score (MPIS - Utilized at CCMC)
- Pediatric Asthma Score (PAS)
- Pulmonary Score (PS)
- Pediatric Respiratory Assessment Measure (PRAM)
Modified Pulmonary Index Score (MPIS)
Age <3 Years | ||||||
---|---|---|---|---|---|---|
Points | SpO2 | Acces Musc Use | I:E | Wheeze | HR | RR |
0 | >95% | None | 2:1 | None; Good Aeration | ≤120 | ≤30 |
1 | 93-95% | Mild | 1:1 | End Exp | 121-140 | 31-45 |
2 | 90-92% | Moderate | 1:2 | Insp/Exp; Good Aeration | 141-160 | 46-60 |
3 | <90% | Severe | 1:3 | Insp/Exp; Poor Aeration | >160 | >60 |
Age 3-6 Years | ||||||
---|---|---|---|---|---|---|
Points | SpO2 | Acces Musc Use | I:E | Wheeze | HR | RR |
0 | >95% | None | 2:1 | None; Good Aeration | ≤100 | ≤30 |
1 | 93-95% | Mild | 1:1 | End Exp | 101-120 | 31-45 |
2 | 90-92% | Moderate | 1:2 | Insp/Exp; Good Aeration | 121-140 | 46-60 |
3 | <90% | Severe | 1:3 | Insp/Exp; Poor Aeration | >140 | >60 |
Age ≥6 Years | ||||||
---|---|---|---|---|---|---|
Points | SpO2 | Acces Musc Use | I:E | Wheeze | HR | RR |
0 | >95% | None | 2:1 | None; Good Aeration | ≤100 | ≤20 |
1 | 93-95% | Mild | 1:1 | End Exp | 101-120 | 21-35 |
2 | 90-92% | Moderate | 1:2 | Insp/Exp; Good Aeration | 121-140 | 36-50 |
3 | <90% | Severe | 1:3 | Insp/Exp; Poor Aeration | >140 | >50 |
- MPIS <7 - Mild exacerbation
- MPIS 7-10 - Moderate exacerbation
- MPIS ≥10 - Severe exacerbation
Management
Albuterol
Favor continuous nebulization to decrease the chance of admission when compared to intermittent dosing[1]
- Nebulizer
- Intermittent: 2.5-5mg q20min, three doses are traditionally given back to back, then repeat as needed.
- Continuous: 0.5mg/kg/hr (max 15mg/hr)[2]
- MDI
- 4-8 puffs q20min given in first hour, then q1-4hr as needed
Ipratropium
- 0.25-0.5mg q20min, given with the first three doses of albuterol, it is shown to reduce admission.
Steroids
Should be given in the first hour with effects to reduce admission[3]
- Dexamethasone
- 0.6mg/kg PO or IV (max 16mg); consider 2nd dose 24-36hrs later.
- PO and IV have equal efficacy. Giving the IV form by mouth is typically better tolerated by young children (same dosing)
- Both 1 and 2 dose regimens as effective as prednisone or prednisolone in children [4][5]
- 0.6mg/kg PO or IV (max 16mg); consider 2nd dose 24-36hrs later.
- Prednisone
- 1-2mg/kg/day (60mg max) in one or two divided doses for 3-5 days
- Methylprednisolone
- 1mg/kg IV q 4–6hr
- Only use IV if cannot tolerate PO since equal effectiveness between dosing routes[6]
Magnesium
- Dose: 50mg/kg IV, max 2-4 g over 20 mins with close blood pressure monitoring
- Smooth muscle relaxant
- Duration of action approximately 20 min
- In patients with moderate to severe asthma there is a decreased rate of admission with an NNT of 2[3]
Beta-agonist
- Epinephrine
- 1:1000 0.01mg/kg (max 0.3mg) IM, repeat as needed
- Terbutaline
- Given SQ, usual dose 0.01mg/kg up to 0.3mg.
- Longer-acting beta2-agonist promoting bronchodilation
Assisted Ventilation
- Non-invasive ventilation
- Consider as alternative to intubation
- Alleviates muscle fatigue which leads to larger tidal volumes
- Maximize inspiratory support
- Delta pressure 10
- PEEP >4
- May benefit from ketamine or dexmedetomidine to mildly sedate and allow the interface
Intubation
- Push pull (bolus) fluids prior to intubation to maximize the patient's preload and ideally decrease the chance of the patient arresting
- Consider induction with ketamine
- Provides bronchodilation and sedation however it does promote secretions
- Ketamine is the preferred induction agent for intubation in an asthmatic.
- Dosing 1-2 mg/kg
- Ventilation of asthmatic patients requires deep sedation
- Ventilation settings
- Assist-control ventilation
- Resp rate
- Start slow to avoid air-trapping and allow for longer expiration time
- Consider I:E ratio of 1:2 or 1:3
- Plateau pressure ideally <30
- May require "permissive hypoventilation" and permissive hypercarbia and acidosis
- Low peak pressure/avoidance of breath stacking more important than correcting CO2 [7]
- Tidal volume 6-8cc/kg ideal wt
- PEEP >4
- Flow rate 80-100L/min
- Keep FiO2 minimum to achieve SpO2 > 90%
- Use bronchodilators even when intubated
- Many patients require a continuous paralytic infusion for the first 24+ hrs of intubation
Outpatient Treatment
Severity | Day Sx | Night Sx | Treatment (WHO 2008 Formulary)[8] |
Mild intermittent, > 80% peak flow | < 2/wk | < 2/mo | Albuterol MDI 100-200 mcg PRN QID |
Mild persistent, > 80% peak flow | >2/wk | >2/mo | Albuterol MDI 100-200 mcg PRN QID AND
Beclometasone 100-250 mcg BID |
Moderate persistent, 60-80% peak flow | Daily with exacerbations weekly | > 1/wk | Albuterol MDI 100-200 mcg PRN QID AND
Beclometasone 100-500 mcg BID AND Salmeterol inhaled 50 mcg BID |
Severe persistent, < 60% peak flow | Continuous daily | Frequent | Albuterol MDI 100-200 mcg PRN QID AND
Beclometasone 1mg BID (high dose) AND Salmeterol inhaled 50 mcg BID AND theophylline, leukotriene antagonist, or PO prednisolone with taper |
Disposition
- Discharge
- Often, patients will still have mild wheezing, but should have complete resolution of tachypnea, hypoxia, and improved work of breathing
- A short course of glucocorticoids decreases chance of relapse [9])
- Patient should generally continue albuterol at home q6hrs for at least the first 24hrs after discharge
- A spacer should be prescribed to be used with the MDI to improve medication delivery to the lungs
- Admit
- If symptoms do not significantly improve or for severe exacerbations
- Peak flow measurements maybe helpful when deciding disposition
- Predicted = (30 x age (yrs)) + 30
- PEF >70% predicted → high likelihood of successful discharge
- PEF <40% predicted → should be admitted
See Also
- Asthma
- Modified pulmonary index score
- Ventilation settings
- Deterioration after intubation
- Shortness of breath
External Links
References
- ↑ Camargo CA et al. Continuous versus intermittent beta- agonists for acute asthma. Cochrane Database Syst Rev. 2003;(4):CD001115. PMID: 14583926.
- ↑ National Asthma Education and Prevention Program (NAEPP), “Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma,” Clinical Practice Guidelines, National Institutes of Health, National Heart, Lung, and Blood Institute, NIH Publication No. 08-4051, prepublication 2007; available at http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm.
- ↑ 3.0 3.1 Rowe BH et al. Magnesium sulfate for treating exac- erbations of acute asthma in the emergency depart- ment. Cochrane Database Syst Rev. 2000;(2):CD001490. PMID: 10796650.
- ↑ Keeney, et al. Dexamethasone for Acute Asthma Exacerbations in Children: A Meta-analysis. Pediatrics. 2013-2273
- ↑ Cronin et al. "A Randomized Trial of Single-Dose Oral Dexamethasone Versus Multidose Prednisolone for Acute Exacerbations of Asthma in Children Who Attend the Emergency Department." Annals of EM. May 2016. 67(5):593-601
- ↑ Rowe BH, Keller JL, Oxman AD. Effectiveness of steroid therapy in acute exacerbations of asthma: a meta-analysis. Am J Emerg Med. Jul 1992;10(4):301-10
- ↑ Darioli, et al. Mechanical Controlled hypoventilation in status asthmaticus. Am Rev Respir Dis. 1984; 129 (3) 385-7
- ↑ Stuart MC et al. WHO Model Formulary 2008. http://www.who.int/selection_medicines/list/WMF2008.pdf.
- ↑ Chapman K. Effect of a short course of prednisone in the prevention of early relapse after the emergency room treatment of acute asthma. NEJM. 1991;324(12):788