a client is being treated for asthma. what would the nurse expect to administer?
Management of Acute Asthma Exacerbations
Am Fam Physician. 2011 Jul 1;84(1):40-47.
Patient information: Run into related handout on how to treat an asthma attack, written by the authors of this article.
Article Sections
- Abstruse
- Diagnosis
- Management
- References
Asthma exacerbations can be classified as balmy, moderate, severe, or life threatening. Criteria for exacerbation severity are based on symptoms and physical examination parameters, also as lung part and oxygen saturation. In patients with a peak expiratory menstruation of l to 79 percent of their personal all-time, upward to two treatments of ii to 6 inhalations of brusque-acting beta2 agonists 20 minutes autonomously followed by a reassessment of peak expiratory period and symptoms may be safely employed at dwelling house. Administration using a manus-held metered-dose inhaler with a spacer device is at least equivalent to nebulized beta2 agonist therapy in children and adults. In the ambulatory and emergency department settings, the goals of handling are correction of severe hypoxemia, rapid reversal of airflow obstruction, and reduction of the gamble of relapse. Multiple doses of inhaled anticholinergic medication combined with beta2 agonists improve lung office and subtract hospitalization in school-age children with severe asthma exacerbations. Intravenous magnesium sulfate has been shown to significantly increase lung function and decrease the necessity of hospitalization in children. The administration of systemic corticosteroids within one hour of emergency section presentation decreases the demand for hospitalization, with the nearly pronounced upshot in patients with severe exacerbations. Airway inflammation can persist for days to weeks after an astute attack; therefore, more intensive treatment should be connected after discharge until symptoms and summit expiratory menstruation return to baseline.
In 2005, the prevalence of asthma in the Usa was near viii percent (close to 9 pct in children younger than xviii years), and approximately four percentage of Americans (5 per centum of children) experienced an asthma attack.ane,2 In that location have been many advances in medical therapy to preclude the worsening of asthma symptoms, including an improved understanding of asthma etiology, identification of risk factors for asthma exacerbations, and show supporting the benefits of written asthma action plans.
One report of children upward to 18 years of historic period presenting to the emergency department with astute asthma symptoms identified multiple take chances factors for a subsequent emergency department visit: age younger than two years, blackness race or Hispanic ethnicity, persistent asthma, public health insurance, lower asthma quality-of-life scores, and increased use of the health care system during the previous 12 months.3 In adults, variables associated with relapse within eight weeks of an asthma exacerbation include iii or more visits for emergent care in the preceding 6 months, difficulty performing daily activities because of physical health in the preceding iv weeks, and patient self-discharge from care within 24 hours of infirmary admission without achieving 50 percent predicted peak expiratory flow (PEF).4 Withal, regular monitoring of PEF does not help predict an asthma exacerbation.5 Other risk factors for developing an asthma exacerbation include allergen triggers (e.g., pets, seasonal allergens, fume exposure) and improper use of medications (e.1000., not using a spacer, improper use of an inhaler or other commitment device).half-dozen
In persons older than 2 years with asthma, neither the injectable nor the intranasal influenza vaccine increases the likelihood of an asthma exacerbation in the period immediately post-obit vaccination. However, one study of infants establish an increase in wheezing and hospital admissions after intranasal influenza vaccination.7 Seasonal influenza vaccine does not reduce the risk of developing an asthma exacerbation. Influenza vaccination appears to improve asthma-related quality-of-life in children during influenza flavour.seven
SORT: KEY RECOMMENDATIONS FOR PRACTICE
| Clinical recommendation | Testify rating | References | Comments |
|---|---|---|---|
| Inhaled short-acting beta2 agonists are the cornerstones of treatment for acute asthma. | C | 14–16 | — |
| An inhaler with a spacer is equivalent to nebulized short-interim beta2 agonist therapy in children and adults. | A | 17, 18 | — |
| Continuous beta2 agonist assistants reduces infirmary admissions in patients with severe acute asthma. | A | 21 | — |
| Inhaled anticholinergic medication improves lung function and decreases hospitalization in school-age children with severe asthma exacerbations. | A | 24, 25 | When multiple doses are used in combination with short-interim beta2 agonists |
| Intravenous magnesium sulfate increases lung role and decreases hospitalizations in children with an acute asthma exacerbation. | A | 29 | — |
| The assistants of systemic corticosteroids within one hour of emergency department presentation decreases the need for hospitalization. | A | 30 | Largest event noted in patients with astringent asthma |
| Oral and parenteral corticosteroids are equally effective in preventing hospital admission in children. | B | 31 | — |
Diagnosis
- Abstract
- Diagnosis
- Management
- References
Asthma exacerbations can be classified as balmy, moderate, severe, or life threatening (Table 1).6 Criteria for severity are based on symptoms and physical examination parameters, every bit well as lung function and oxygen saturation. Although no single parameter has been identified to assess exacerbation severity, lung role is a useful method of assessment, with a PEF of 40 percent or less of predicted part indicating a astringent assail in patients v years or older.half dozen The most useful signs for determining the severity of an asthma exacerbation in children younger than v years, or any kid unable to perform a PEF, include the use of accessory muscles of respiration, chest wall retractions, tachypnea greater than 60 breaths per minute, cyanosis, and the presence of inspiratory and expiratory wheezing.8 For all patients, pulse oximetry on room air is a useful initial assessment. An oxygen saturation of less than 92 to 94 percent i hour later on commencement standard treatment is a strong predictor of the demand for hospitalization.6
Table one.
Classifications of Severity of an Asthma Exacerbation
| Degree of severity | Symptoms and signs | Initial PEF (or FEVane) | Clinical class |
|---|---|---|---|
| Mild | Dyspnea only with activeness (appraise tachypnea in immature children) | PEF ≥ 70 percent of predicted or personal best | Usually treated at habitation |
| Prompt relief with inhaled curt-acting beta2 agonist | |||
| Possible brusque course of oral systemic corticosteroids | |||
| Moderate | Dyspnea interferes with or limits usual activity | PEF 40 to 69 percentage of predicted or personal best | Usually requires office or emergency section visit |
| Relief from frequent inhaled curt-acting beta2 agonist | |||
| Oral systemic corticosteroids; some symptoms last for one to two days after handling begins | |||
| Severe | Dyspnea at residue; interferes with conversation | PEF < twoscore percentage of predicted or personal all-time | Unremarkably requires emergency department visit and likely hospitalization |
| Fractional relief from frequent inhaled brusque-acting beta2 agonist | |||
| Oral systemic corticosteroids; some symptoms final for more than than iii days after treatment begins | |||
| Adjunctive therapies are helpful | |||
| Subset: life threatening | Too dyspneic to speak; perspiration | PEF < 25 percent of predicted or personal best | Requires emergency department visit/hospitalization; possible intensive care unit |
| Minimal or no relief from frequent inhaled short-acting beta2 agonist | |||
| Intravenous corticosteroids | |||
| Adjunctive therapies are helpful |
Laboratory information are not required for most patients with acute exacerbations. Some tests that may be useful include complete blood count, serum theophylline, and bones chemistries. Chest radiography is not routinely recommended considering information technology has not been shown to alter the care of patients with an uncomplicated asthma exacerbation.nine Measurement of arterial blood gases may be considered if hypoventilation is suspected. Electrocardiography is rarely helpful, unless there is a history or suspicion of cardiac disease.6
Management
- Abstract
- Diagnosis
- Management
- References
Home TREATMENT
Early treatment is the most effective strategy for managing asthma exacerbations. It is essential to teach patients how to monitor signs and symptoms, and accept appropriate action. Patients who have a written asthma activeness plan and appropriate medication can oft manage balmy exacerbations at dwelling house (Effigy one half dozen). Key components of an asthma activeness plan that accept reduced emergency section visits and hospitalization include standard written instructions; criteria based on symptoms or PEF (compared with personal all-time) to trigger action; 2 to three action points; and individualized, written instructions on the use of inhaled or oral corticosteroids.ten Patients at risk of asthma-related expiry may need more intensive treatment in a monitored setting at the first sign of an exacerbation (Table 26). These patients should have an asthma action plan that emphasizes early on communication with their doctor.
Management of Asthma Exacerbations: Dwelling Treatment
Figure 1.
Algorithm for home direction of acute asthma exacerbations. (PEF = peak expiratory flow.)
Adapted from the National Heart Lung and Claret Institute. National Asthma Educational activity and Prevention Plan. Adept panel written report 3: Guidelines for the diagnosis and management of asthma; 2007:382. http://world wide web.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm.
Table 2.
Risk Factors for Asthma-Related Death
| Comorbidities (i.e., cardiovascular illness or other chronic lung disease) |
| Difficulty perceiving airway obstacle or severity of exacerbation |
| Illicit drug utilize |
| Low socioeconomic status or inner-metropolis residence |
| Major psychosocial issues or psychiatric disorders |
| Previous severe exacerbation (e.1000., intubation or access to intensive intendance unit for asthma) |
| Two or more than hospitalizations or three or more emergency department visits in the past year |
| 2 or more refills of curt-acting betaii agonists per month |
In children 5 to 12 years of age with frequent acute exacerbations, a brusque course of oral prednisolone at the onset of worsening symptoms produced a modest benefit in terms of decreased symptoms, health resource utilize, and absenteeism from school.11 Patient- or parent-initiated increases in the dosage of inhaled corticosteroids accept been proposed to assist with deteriorating asthma symptoms. The information are insufficient to make a recommendation for children; however, a meta-analysis of data from more than ane,200 adults confirms that increasing the dosage does not reduce the risk of a subsequent asthma exacerbation requiring oral corticosteroids.12
A randomized controlled trial examined the utilize of parent-initiated montelukast (Singulair; four mg for children two to five years of age and 5 mg for children half dozen to 14 years of age) in children with intermittent asthma, defined as three to six episodes of asthma requiring acute hospital- or office-based care with symptom- and medication-free periods between episodes. When given at the onset of asthma or upper respiratory tract infection symptoms, montelukast therapy resulted in a reduction in unscheduled health care visits and fourth dimension lost from work and school or childcare.13
Inhaled short-interim betaii agonists are the cornerstones of treatment for patients with acute asthma.fourteen–sixteen In patients with a PEF of 50 to 79 percentage of their personal best, upwards to two treatments of two to six inhalations of a short-acting beta2 agonist may exist safely employed at home. Treatments should exist twenty minutes apart followed by a reassessment of PEF and symptoms.vi Patients who do not attain a PEF of at to the lowest degree 80 pct of their personal all-time later on 2 treatments should contact their dr. for further instructions. Patients whose PEF declines afterward treatment should contact their physician and seek emergent care.
Multiple studies have shown that administration using a hand-held metered-dose inhaler with a spacer device is at least equivalent to nebulized short-acting betaii agonist therapy in children older than one year (iv puffs per dose) and adults (vi puffs per dose).17 Homemade spacers, such as plastic bottles, foam or paper cups, paper-thin tubes, and paper spacers, can be as constructive as commercial spacers for the treatment of astute asthma exacerbations.18 There is no demonstrable departure in terms of condom or effectiveness between levalbuterol (Xopenex) and albuterol.nineteen
EMERGENCY Section TREATMENT
In the ambulatory and emergency department settings, the goals of treatment are correction of astringent hypoxemia, rapid reversal of airflow obstacle, and reduction of the gamble of relapse by intensifying therapy and carefully monitoring response (Effigy 2).half dozen Correction of hypoxemia and rapid reversal of airflow obstruction are all-time achieved by oxygen assistants and repetitive treatment with short-acting beta2 agonists. Early utilise of systemic corticosteroids can reduce the risk of relapse.
Management of Asthma Exacerbations: Emergency Department and Hospital-Based Treatment
Figure 2.
Algorithm for emergency section and inpatient direction of astute asthma exacerbations. (FEV1 = forced expiratory volume in one second; PEF = acme expiratory flow.)
Adjusted from the National Heart Lung and Blood Institute. National Asthma Education and Prevention Program. Good panel written report 3: Guidelines for thediagnosis and direction of asthma; 2007:388. http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm.
The administration of oxygen to maintain saturation of at to the lowest degree 94 percent is recommended in all patients presenting with a moderate to severe asthma exacerbation. Oxygen should be administered every bit soon as possible, preferably in the prehospital phase in an office setting or in send by emergency medical services.eight It has been proposed that the helium and oxygen mixture (heliox), which has a lower density than oxygen, flows more than easily through constricted airways and, as a consequence, improves outcomes in asthma exacerbations. All the same, there are insufficient data to support the use of heliox in the treatment of acute asthma exacerbations.20
Inhaled brusk-acting beta2 agonist treatment is the mainstay of function or emergency department treatment of moderate to astringent asthma exacerbations. If the patient can tolerate a measurement of PEF or forced expiratory volume in one second (FEVone), an initial value should be obtained and repeated to monitor handling response. In patients with astringent exacerbations, continuous beta2 agonist administration has been shown to improve pulmonary function measurements and reduce hospital access with no notable differences in pulse, blood force per unit area, or tremor.21 The use of loftier-dose albuterol (7.five mg via nebulizer every 20 minutes for three doses)22 and intravenous beta2 agonists does non appear to exist beneficial and is not recommended.23
A meta-analysis of randomized controlled trials compared the combination of inhaled anticholinergics and beta2 agonists with betaii agonists solitary in children i to eighteen years of historic period with balmy, moderate, or astringent exacerbations of asthma. The results showed that calculation multiple doses of inhaled anticholinergic medication improves lung office and decreases hospitalizations in school-aged children with severe asthma exacerbations.24,25 The usefulness of inhaled ipratropium for the treatment of asthma exacerbations in adults is less clear, but information technology does appear to do good those with a astringent exacerbation.26,27
The improver of intravenous magnesium sulfate to standard therapy has been studied in adults and children with divergent results. In adults with severe exacerbations of asthma (PEF of 25 to 30 percent or less of predicted function), intravenous magnesium sulfate therapy resulted in slightly better lung function but no change in rates of hospitalization.28 In children 1 to 18 years of age, intravenous magnesium sulfate (25 to 100 mg per kg) has been demonstrated to significantly increase lung function and to decrease hospitalizations. Nebulized magnesium sulfate has a weak event on respiratory role and infirmary admission rates in adults, and no event on either outcome in children.29
The administration of systemic corticosteroids (500 mg hydrocortisone sodium succinate injection [Solu-Cortef] or 125 mg methylprednisolone sodium succinate injection [Solu-Medrol] in adults, or one to 2 mg per kg of prednisone or prednisolone in children one to 18 years of age) inside 1 hour of emergency department presentation decreases the need for hospitalization. In a Cochrane review, the most pronounced effect occurred in patients with severe exacerbations.30 Oral and parenteral corticosteroids are equally effective in preventing hospital admission in children, but only parenteral corticosteroids have been studied in adults.31 In that location is insufficient show to recommend the use of inhaled corticosteroids in place of or in conjunction with systemic corticosteroids at the fourth dimension of belch from the emergency department. Inhaled corticosteroids exercise not prevent relapse of symptoms requiring access or meliorate quality of life or symptom scores.32
In adults and in hospitalized children ane to 16 years of age, corticosteroid use resulted in earlier discharge and fewer symptomatic relapses.33–35 The optimal dosage in children is unknown,34 merely in adults, lower dosages (80 mg or less per day of methylprednisolone [Depo-Medrol] or 400 mg or less per twenty-four hours of hydrocortisone) are equal to higher dosages in the comeback of lung function, adverse effects, and rates of respiratory failure.35
The improver of intravenous aminophylline to conventional therapy in children and adults has no additional benefit in reducing hospital admissions. It does significantly increase the risk of adverse furnishings, including vomiting, palpitations, and arrhythmias.36,37 There are insufficient data to recommend for or against the apply of antibiotics in the treatment of astute exacerbations.38 In a Cochrane review, one randomized controlled trial of 30 adults examined the use of noninvasive positive force per unit area ventilation in the treatment of severe acute exacerbations of asthma as an adjunct to usual care. The intervention showed promising results in objective measure of lung function and reduced rates of hospitalization, but the data are insufficient to make broad recommendations for the utilize of noninvasive positive pressure ventilation.39 Drinking large amounts of water, high-dose mucolytics, antihistamines, chest physiotherapy, and sedation are all unproven treatments.vi
POSTDISCHARGE CARE
Patients sent domicile from the emergency section with systemic corticosteroids (a v- to x-mean solar day nontapering course of 50- to 100-mg prednisone per 24-hour interval in adults) have decreased relapse of asthma symptoms, future hospitalizations, and employ of curt-interim beta2 agonists.40,41 Although seven to 10 days is the usual treatment duration for oral corticosteroids, three days of therapy (1 mg per kg of prednisone) has been shown to be as effective as v days for the consummate resolution of symptoms within ane calendar week in children two to fifteen years of age.42 There are bereft data to recommend the initiation of montelukast in place of oral corticosteroids or the use of inhaled corticosteroids in combination with oral corticosteroids at the time of discharge to prevent a relapse of asthma symptoms.43,44
Allergen avoidance is routinely recommended after emergency department belch to decrease further acute exacerbations of asthma. Despite multiple trials of allergen command, in that location are no data showing that pet allergen or dust mite allergen avoidance techniques successfully reduce allergens in the home to levels that ameliorate asthma symptoms.45,46
Regardless of the therapy called in the acute intendance setting, step-up therapy should be continued for several days to weeks afterward discharge. Considering exacerbations vary in severity, shut communication betwixt patients and physicians is required. Symptoms may be controlled quickly, merely airway inflammation may persist for 2 to three weeks.47 Scheduled dosing with inhaled beta2 agonists should be connected until symptoms and PEF render to baseline.
Data Sources: The National Guidelines Clearinghouse was searched for guidelines on asthma care. The National Asthma Education and Prevention Plan's "Expert Panel three Written report: Guidelines for the Diagnosis and Management of Asthma" section on direction of asthma exacerbations was reviewed. Ovid Medline was searched for new data related to the major recommendations of both. PubMed was searched using the primal terms asthma + acute + exacerbation. The Cochrane database and Essential Evidence Plus were searched for data pertaining to asthma exacerbations. Search dates: March 2010 and April 2010. Searches on select topics were performed weekly in May and June 2010, with a repeat search in November 2010.
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REFERENCES
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iii. Walsh-Kelly CM, Kelly KJ, Drendel AL, Grabowski L, Kuhn EM. Emergency department revisits for pediatric acute asthma exacerbations: clan of factors identified in an emergency department asthma tracking organization. Pediatr Emerg Care. 2008;24(8):505–510.
4. McCarren Grand, et al. Prediction of relapse within eight weeks after an acute asthma exacerbation in adults. J Clin Epidemiol. 1998;51(2):107–118.
5. Tierney WM, Roesner JF, Seshadri R, Lykens MG, Murray MD, Weinberger M. Assessing symptoms and peak expiratory menstruum rate as predictors of asthma exacerbations [published correction appears in J Gen Intern Med. 2004;19(8):903]. J Gen Intern Med. 2004;nineteen(3):237–242.
6. National Heart Lung and Blood Institute. National Asthma Education and Prevention Program. Expert panel report three: Guidelines for the diagnosis and direction of asthma. 2007. http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm. Accessed December 22, 2010.
7. Cates CJ, Jefferson TO, Rowe BH. Vaccines for preventing influenza in people with asthma. Cochrane Database Syst Rev. 2008;(2):CD000364.
viii. Camargo CA Jr, Rachelefsky G, Schatz M. Managing asthma exacerbations in the emergency department: summary of the National Asthma Educational activity and Prevention Program Skilful Panel Study iii guidelines for the direction of asthma exacerbations. J Allergy Clin Immunol. 2009;124(two suppl):S5–S14.
9. Tsai TW, Gallagher EJ, Lombardi M, Gennis P, Carter West. Guidelines for the selective ordering of admission chest radiography in developed obstructive airway disease. Ann Emerg Med. 1993;22(12):1854–1858.
10. Gibson PG, Powell H. Written action plans for asthma: an testify-based review of the key components. Thorax. 2004;59(2):94–99.
xi. Vuillermin PJ, Robertson CF, Carlin JB, Brennan SL, Biscan MI, Southward M. Parent initiated prednisolone for acute asthma in children of school historic period: randomised controlled crossover trial. BMJ. 2010;(340):c843.
12. Quon BS, Fitzgerald JM, Lemière C, Shahidi N, Ducharme FM. Increased versus stable doses of inhaled corticosteroids for exacerbations of chronic asthma in adults and children. Cochrane Database Syst Rev. 2010;(10):CD007524.
13. Robertson CF, Price D, Henry R, et al. Brusque-course montelukast for intermittent asthma in children: a randomized controlled trial. Am J Respir Crit Intendance Med. 2007;175(4):323–329.
14. Newhouse MT, Dolovich MB. Control of asthma by aerosols. N Engl J Med. 1986;315(fourteen):870–874.
15. Powles AC. The bronchodilator result of fenoterol (Berotec). N Z Med J. 1975;81(535):249–251.
16. Larsson S, Svedmyr North. Bronchodilating effect and side furnishings of beta2-adrenoceptor stimulants by unlike modes of administration (tablets, metered aerosol, and combinations thereof). A written report with salbutamol in asthmatics. Am Rev Respir Dis. 1977;116(5):861–869.
17. Cates CJ, Crilly JA, Rowe BH. Holding chambers (spacers) versus nebulisers for beta-agonist treatment of acute asthma. Cochrane Database Syst Rev. 2006;(2):CD000052.
18. Zar HJ, Chocolate-brown Yard, Donson H, Brathwaite N, Mann MD, Weinberg EG. Home-made spacers for bronchodilator therapy in children with astute asthma: a randomised trial. Lancet. 1999;354(9183):979–982.
19. Qureshi F, Zaritsky A, Welch C, Meadows T, Shush BL. Clinical efficacy of racemic albuterol versus levalbuterol for the treatment of astute pediatric asthma. Ann Emerg Med. 2005;46(one):29–36.
20. Rodrigo Thou, Pollack C, Rodrigo C, Rowe BH. Heliox for nonintubated acute asthma patients. Cochrane Database Syst Rev. 2006;(4):CD002884.
21. Camargo CA Jr, Spooner CH, Rowe BH. Continuous versus intermittent beta-agonists in the handling of astute asthma. Cochrane Database Syst Rev. 2003;(iv):CD001115.
22. Emerman CL, Cydulka RK, McFadden ER. Comparison of two.v vs 7.v mg of inhaled albuterol in the treatment of acute asthma. Chest. 1999;115(1):92–96.
23. Travers A, Jones AP, Kelly One thousand, Barker SJ, Camargo CA, Rowe BH. Intravenous beta2-agonists for acute asthma in the emergency department. Cochrane Database Syst Rev. 2001;(2):CD002988.
24. Plotnick LH, Ducharme FM. Combined inhaled anticholinergics and beta2-agonists for initial treatment of acute asthma in children. Cochrane Database Syst Rev. 2000;(4):CD000060.
25. Qureshi F, Pestian J, Davis P, Zaritsky A. Effect of nebulized ipratropium on the hospitalization rates of children with asthma. N Engl J Med. 1998;339(15):1030–1035.
26. Rodrigo GJ, Rodrigo C. Start-line therapy for adult patients with astute asthma receiving a multiple-dose protocol of ipratropium bromide plus albuterol in the emergency department. Am J Respir Crit Intendance Med. 2000;161(6):1862–1868.
27. Stoodley RG, Aaron SD, Dales RE. The role of ipratropium bromide in the emergency management of astute asthma exacerbation: a metaanalysis of randomized clinical trials. Ann Emerg Med. 1999;34(1):8–18.
28. Silverman RA, Osborn H, Runge J, et al.; Astute Asthma/Magnesium Study Grouping. IV magnesium sulfate in the handling of astute severe asthma: a multicenter randomized controlled trial [published correction appears in Breast. 2002;122(v):1870]. Chest. 2002;122(2):489–497.
29. Mohammed S, Goodacre S. Intravenous and nebulised magnesium sulphate for astute asthma: systematic review and meta-analysis. Emerg Med J. 2007;24(12):823–830.
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31. Barnett PL, Caputo GL, Baskin Thousand, Kuppermann N. Intravenous versus oral corticosteroids in the management of acute asthma in children. Ann Emerg Med. 1997;29(two):212–217.
32. Edmonds ML, Camargo CA, Saunders LD, Brenner BE, Rowe BH. Inhaled steroids in acute asthma following emergency department discharge. Cochrane Database Syst Rev. 2000;(3):CD002316.
33. Smith 1000, Iqbal S, Elliott TM, Everard M, Rowe BH. Corticosteroids for hospitalised children with acute asthma. Cochrane Database Syst Rev. 2003;(two):CD002886.
34. Zhang L, Mendoza RA. Doses of systemic corticosteroids in hospitalised children with acute asthma: A systematic review. J Paediatr Kid Health. 2006;42(4):179–183.
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36. Mitra A, Bassler D, Goodman Thou, Lasserson TJ, Ducharme FM. Intravenous aminophylline for acute astringent asthma in children over two years receiving inhaled bronchodilators. Cochrane Database Syst Rev. 2005;(2):CD001276.
37. Parameswaran Thou, Belda J, Rowe BH. Addition of intravenous aminophylline to betatwo-agonists in adults with astute asthma. Cochrane Database Syst Rev. 2000;(4):CD002742.
38. Graham V, Lasserson T, Rowe BH. Antibiotics for astute asthma Cochrane Database Syst Rev. 2001;(3):CD002741.
39. Ram FS, Wellington South, Rowe B, Wedzicha JA. Not-invasive positive pressure ventilation for handling of respiratory failure due to astringent acute exacerbations of asthma. Cochrane Database Syst Rev. 2005;(three):CD004360.
40. Rowe BH, Spooner CH, Ducharme FM, Bretzlaff JA, Bota GW. Corticosteroids for preventing relapse following astute exacerbations of asthma. Cochrane Database Syst Rev. 2007;(3):CD000195.
41. Krishnan JA, Davis SQ, Naureckas ET, Gibson P, Rowe BH. An umbrella review: corticosteroid therapy for adults with acute asthma. Am J Med. 2009;122(11):977–991.
42. Chang AB, Clark R, Sloots TP, et al. A 5- versus iii-day course of oral corticosteroids for children with asthma exacerbations who are not hospitalised: a randomised controlled trial. Med J Aust. 2008;189(half dozen):306–310.
43. Schuh Southward, Willan AR, Stephens D, Dick PT, Coates A. Can montelukast shorten prednisolone therapy in children with mild to moderate acute asthma? A randomized controlled trial. J Pediatr. 2009;155(6):795–800.
44. Krishnan JA, Nowak R, Davis SQ, Schatz M. Anti-inflammatory handling after belch home from the emergency department in adults with acute asthma. J Allergy Clin Immunol. 2009;124(2 suppl):S29–S34.
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