696	K. Chugh

•Blood gas analysis and worsening pulsus paradoxus as assessed on the bedside monitors can be additional parameters in making a decision for intubation and ventilation.

Step 8: Initiate ventilation

•Rapid sequence intubation should be done and avoid overventilation with Ambu bag during preoxygenation.

•Ventilation is started in the controlled mode. Both pressureand volumecontrolled modes (or the combined modes like pressure-regulated volume control) can be used initially. As soon as possible, the child is shifted to assist/synchronized intermittent mandatory ventilation modes. Experience with pressure-support mode in the initial stages of ventilation is very limited in pediatrics.

•Standard rules of sedation and muscle relaxation are followed with some preferring to use ketamine.

•Noninvasive ventilation for status asthmaticus in children is not generally recommended, although a few units had encouraging experience with this modality.

•Permissive hypoventilation is an accepted strategy to ventilate asthmatic children.

Suggested Reading

1.Bateman ED, Hurd SS, Barnes PJ, Bousquet J, Drazen JM, FitzGerald M, Gibson P, et al. Global strategy for asthma management and prevention. Eur Respir J. 2008;31(1):143–78.

Guidelines for the management of bronchial asthma.

2.Bogie AL, Towne D, Luckette PM, et al. Comparison of intravenous terbutaline versus normal saline in pediatric patients on continuous high-dose nebulized albuterol for status asthmaticus. Pediatr Emerg Care. 2007;23:355–61.

3.Beers SL, Abramo TJ, Bracken A, et al. Bilevel positive airway pressure in the treatment of status asthmaticus in pediatrics. Am J Emerg Med. 2007;25:6–9.

The study suggests that the addition of BiPAP in treating pediatric status asthmaticus is safe and well tolerated and promises to be a beneficial adjunct.

4.Wheeler DS, Jacobs BR, Kenreigh CA, et al. Theophylline versus terbutaline in treating critically ill children with status asthmaticus: a prospective, randomized controlled trial. Pediatr Crit Care Med. 2005;6:142–7.

Theophylline, when added to continuous nebulized albuterol therapy and intravenous corticosteroids, is as effective as terbutaline in treating critically ill children with status asthmaticus. The addition of theophylline to baseline therapy is more cost-effective when compared with terbutaline alone or terbutaline and theophylline together.