Management of severe acute asthma attacks in pediatric patients.

Severe acute asthma involves complex pathophysiological mechanisms. Oxygen therapy, bronchodilators, and corticosteroids remain the mainstays of thera py, although changes in their dosages and methods of administration have oc curred over recent years. Use of spacers to administer drugs in metered-dos e inhalers is being increasingly advocated. When this treatment is inadequa tely effective, ipratropium bromide provides additional bronchodilation. Ip ratropium bromide should be used immediately in severe cases. Theophylline is rarely indicated in acute asthma. Antimicrobials should be given only to those patients with a patent focus of infection (e.g., sinusitis, pneumoni a, or otitis). Magnesium sulfate and helium-oxygen mixtures may be useful i n patients who fail to respond to other treatments. Tracheal intubation and mechanical ventilation are associated with a high risk of adverse events. The concept of permissive hypercapnia with or without artificial ventilatio n is useful for minimizing barotrauma. In doubtful cases, overtreatment is better than undertreatment. Even when highly experienced health care provid ers are involved, a few patients fail to receive aggressive therapy. This i ndicates a need for emphasizing the importance of maintenance therapy and o f providing simple, clear instructions to follow in the event of an exacerb ation. This approach has been shown to reduce the number of hospital admiss ions.