Status Asthmaticus Treatment & Management: Approach Considerations, Beta2-Agonists, Anticholinergics

After confirming the diagnosis and assessing the severity of an asthma attack, direct treatment toward controlling bronchoconstriction and inflammation. Beta-agonists, corticosteroids, and theophylline are mainstays in the treatment of status asthmaticus. Sevoflurane, a potent inhalation agent, was successful in a single case report in which it was used when conventional treatment failed in a woman aged 26 years.

Fluid replacement

Hydration, with intravenous normal saline at a reasonable rate, is essential. Special attention to the patient’s electrolyte status is important.

Hypokalemia may result from either corticosteroid use or beta-agonist use. Correcting hypokalemia may help to wean an intubated patient with asthma from mechanical ventilation. Hypophosphatemia may result from poor oral intake and is also an important consideration when weaning such patients.


The routine administration of antibiotics is discouraged. Patients are administered antibiotics only when they show evidence of infection (eg, pneumonia, sinusitis). In some situations, sinus imaging using computed tomography (CT) scanning or plain radiography
[16, 17] may be essential to rule out chronic sinusitis.

Oxygen monitoring and therapy

Monitoring the patient’s oxygen saturation is essential during the initial treatment of status asthmaticus. Arterial blood gas (ABG) values are usually used to assess hypercapnia during the patient’s initial assessment. Oxygen saturation is then monitored via pulse oximetry throughout the treatment protocol. Oxygen saturation may increase following the use of bronchodilators secondary to an increase in V/Q mismatch.

Oxygen therapy is essential, with hypoxia being the leading cause of death in children with asthma. Oxygen therapy can be administered via a nasal canula or mask, although patients with dyspnea often do not like masks. With the advent of pulse oximetry, oxygen therapy can be easily titrated to maintain the patient’s oxygen saturation above 92% (>95% in pregnant patients or those with cardiac disease).

In the event of significant hypoxemia, non-rebreathing masks may be used to deliver as much as 98% oxygen. Tracheal intubation and mechanical ventilation are indicated for respiratory failure.

Chest tube placement

Chest tube placement may be necessary in the management of pneumothorax.

Nitrate oxide

Nitrate oxide has been employed in a child with refractory asthma. The future role of this therapy remains to be determined.

Leukotriene modifiers

Leukotriene modifiers are useful for treating chronic asthma but not acute asthma. This treatment may be beneficial if used via a nebulizer, but it remains experimental. Most studies have examined intravenous use.
[19, 20]  Montelukast can be used as an add-on treatment for asthma in general. It is mostly used for improving the quality of life as an add-on therapy to inhaled corticosteroids and not necessarily just for status asthmaticus. There has been one study that showed minimal to no effect of using montelukast in the emergency department setting for patients with status asthmaticus.
[21, 22] In general, it did not show any significant benefit. It is not used specifically for status asthmaticus prevention.


ICU admission criteria

Indications for ICU admission include the following:

  • Altered sensorium

  • Use of continuous inhaled beta-agonist therapy

  • Exhaustion

  • Markedly decreased air entry

  • Rising PCO2 despite treatment

  • Presence of high-risk factors for a severe attack

  • Failure to improve despite adequate therapy


Status asthmaticus is generally managed by means of medical therapy, with some exceptions. For example, thoracostomy is indicated in pneumothoraces.

Some children may have asthma that is primarily exacerbated by gastroesophageal reflux disease. Some patients can be treated with a combination of antireflux (eg, proton pump inhibitors) and histamine 2 (H2)–receptor antagonist agents. However, surgery, such as Nissen fundoplication, is occasionally required.

Anesthesia support is needed if inhaled anesthetic agents are considered for refractory severe intubated status asthmaticus.

If all other support modalities fail and extracorporeal membrane oxygenation (ECMO) is required, surgical support for cannula placement should take place at an established pediatric ECMO center.


Some children with asthma may have episodes triggered by food allergies. Consultation with a nutritionist may be necessary to provide appropriate dietary management.

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