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									                          ED Management of Asthma
                            in Infants and Children

RESPIRATORY FAILURE1?                100% O2,2 CR monitoring, IV, ABG, CXR,
                                   Continuous Levalbuterol/Albuterol,3Atrovent,4
                                   Steroids,5 Consider: Terbutaline IV6/Magnesium IV7/
                                   Heliox8/Ketamine IV9/Theophylline IV10/RSI11-14/ PICU
RESPIRATORY DISTRESS                              100% O2 if SaO2 < 94% (RA), monitors,
SEVERE (PS >6,15 PEFR/FEV1 < 50%) or             PEFR16 as tolerated, Albuterol17/Atrovent4
MODERATE (PS 4-6, PEFR/FEV1 50-80%)?             Steroids,5 Consider: IV/CXR18/ABG

                                                       Albuterol17 Q15-20 min, Atrovent,4
                                                       Consider continuous Albuterol,3
              No                                       VS + PEFR Q15-20 min
                                                       Consider IV/CXR18/ABG

                                                            Yes               No
                            Meets D/C criteria ?                  Improved?         Admit20

                            D/C home,
                            Asthma Action Plan,21
                            Peds Asthma Clinic Consult22

RESPIRATORY DISTRESS                 Yes      Albuterol17
MILD (PS < 3, PEFR/FEV1 > 80%)?               PEFR,                           Yes
                                              Consider Steroids5

                                  Repeat Albuterol17                 Improved?

Guideline for ED Management of Asthma in Children

1 Clinical Asthma Score: > 7 respiratory failure; > 5 impending respiratory failure
VARIABLE                   SCORE = 0             SCORE = 1             SCORE = 2
Cyanosis or                No cyanosis       Cyanosis in 21% O2 Cyanosis in 40% O2
PaO2 (mm Hg)             or PaO2 70-100         or PaO2 < 70          or PaO2 < 70
                            in 21% O2             in 21% O2             in 40% O2
Inspiratory                   Normal         Unequal or Absent          Decreased
Breath Sounds
Accessory                      None                Moderate              Maximal
Muscles Used
Expiratory                     None                Moderate              Marked
Cerebral                      Normal            Depressed or              Coma
Function                                           Agitated
2 100% O2 via: non-rebreather mask + 3 way tee adaptor + small volume hand-
   held nebulizer (intermittent nebs at 15 L/min); Hope Nebulizer (continuous nebs
   at 13 L/min)
3 Levalbuterol continuous neb 3.75-7.0 mg/hr or racemic albuterol continuous neb
   at 40-80 mg/hr for status asthmaticus (via Hope Nebulizer); notify RT
4 Atrovent (ipratropium bromide) neb 250 mcg Q 20 min X 3 doses then Q4-6H for
   status asthmaticus; otherwise MDI 6 puffs with spacer Q 20 min 3 doses
5 Steroids: methylprednisolone 2 mg/kg (max 125 mg) IV followed by 1 mg/kg/
   dose (max 80 mg) IV Q4-6H for status asthmaticus; otherwise prednisolone (15
   mg/5 mL) 2 mg/kg PO or prednisone 2 mg/kg PO (max 80 mg)
6 Terbutaline IV load 10 mcg/kg over 10 min followed by 3-6 mcg/kg/min (max 10
   mcg/kg/min); may use salbutamol IV 0.5-5 mcg/kg/min if available
7 Magnesium sulfate IV 50 mg/kg (max 2 g) over 20 min
8 Heliox (80:20 or 70:30 mixtures) can be given via tight-fitting non-rebreather
   mask or through ventilator; notify RT; may need to provide supplemental O2 via
   nasal cannula; should not be used in patients with high O2 requirement
9 Ketamine IV load 1-2 mg/kg followed by 0.5-2 mg/kg/hr infusion
10 Theophylline IV 6 mg/kg load followed by 1 mg/kg/hr infusion (0.1 mg/kg/hr for
   neonates & infants)
11 Indications for intubation in severe status asthmaticus: respiratory or cardiac
   arrest (absolute); severe hypoxia (absolute); rapidly deteriorating mental status
   or coma (absolute); progressive exhaustion despite maximal treatment (relative)
12 Asthma RSI protocol: 100% O2; atropine 0.02 mg/kg IV (max 0.5 mg child/1 mg
   adolescent); lidocaine 1 mg/kg IV; ketamine 2 mg/kg IV; rocuronium 1 mg/kg
   OR vecuronium 0.1 mg/kg IV
13 Consider using cuffed ETT (1/2 size smaller than size predicted by traditional
   formula, i.e. age (yr) + 16/4) since high airway pressures may be needed to
   counter high airflow resistance
14 Initial ventilator settings: tidal volume 6 mL/kg; rate well below normal for
   patient age; inspiratory time 0.5 - 1.0 sec (pressure-regulated volume control)

Guideline for ED Management of Asthma in Children
15 Pulmonary Score (PS) = add RR + SaO2 + Wheezing + Accessory Muscle Use
    PS: > 6 (severe resp distress); 4-6 (mod resp distress); < 3 (mild resp distress)
  Points      Respiratory Rate          SaO2           Wheezing             Accessory
              < 6 yr      > 6 yr                                           Muscle Use
     0          < 30      < 20       99-100%              none                 none
     1         31-45     21-35        96-98%      terminal expiration            +
     2         46-60     36-50        93-95%        entire expiration           ++
     3          > 61      > 51         < 92%     inspiration/expiration        +++
16 Predicted Average PEFR (Peak Expiratory Flow Rate) for Normal Children:
 HT     PEFR    PEFR    PEFR     HT    PEFR    PEFR    PEFR     HT    PEFR    PEFR    PEFR
(cm)    100%     80%     50%    (cm)   100%     80%     50%    (cm)   100%     80%     50%
        L/min   L/min   L/min          L/min   L/min   L/min          L/min   L/min   L/min
 100      99      80      50    129     251     201     126    158     403     322     202
 101     104      83      52    130     256     205     128    159     408     326     204
 102     107      86      54    131     261     209     131    160     413     330     207
 103     114      91      57    132     266     213     133    161     419     335     210
 104     120      96      60    133     272     218     136    162     424     340     212
 105     125     100      63    134     277     222     139    163     429     343     215
 106     130     104      65    135     282     226     141    164     434     347     217
 107     136     109      68    136     287     230     144    165     439     351     220
 108     141     113      71    137     293     234     147    166     445     356     223
 109     146     117      73    138     298     238     149    167     450     360     225
 110     151     121      76    139     303     242     152    168     455     364     228
 111     156     125      78    140     308     246     154    169     460     368     230
 112     162     130      81    141     314     251     157    170     466     373     233
 113     167     134      84    142     319     255     160    171     471     377     236
 114     171     137      86    143     324     262     162    172     476     381     238
 115     177     142      89    144     329     263     165    173     481     385     241
 116     183     146      92    145     335     268     168    174     487     390     244
 117     188     150      94    146     340     272     170    175     492     394     246
 118     191     153      96    147     345     276     173    176     497     398     249
 119     198     158      99    148     350     280     175    177     502     402     251
 120     204     163     102    149     356     285     178    178     508     406     254
 121     207     166     104    150     361     289     181    179     513     410     257
 122     214     171     107    151     366     293     183    180     518     414     259
 123     219     175     110    152     371     297     186    181     523     418     262
 124     225     180     113    153     377     302     189    182     529     423     265
 125     230     184     115    154     382     306     191    183     534     427     267
 126     235     189     118    155     387     310     194    184     539     431     270
 127     240     192     120    156     392     314     196    185     544     435     272
 128     246     197     123    157     398     318     199
17 Racemic albuterol: neb 0.15 mg/kg/dose (2.5 mg if < 25 kg; 5.0 mg if > 25 kg) via
   Aerosol Mask/Misty-Neb Nebulizer/Tee adaptor or MDI 6 puffs with spacer
18 Indications for CXR in asthmatics: suspected pneumonia or barotrauma
19 Discharge criteria: PS 2 30-60 min after last neb; SaO2 > 94% (RA)
20 Admission criteria: persistent respiratory distress; SaO2 < 94% (RA); PEFR <
   50% predicted; inability to tolerate PO meds; previous EMD visit for asthma in
   past 24 hrs; air leak; underlying high-risk factors (congenital heart disease, BPD,
   cystic fibrosis, neuromuscular disease)
21 Asthma Action Plan: start in yellow zone (PEFR/FEV1 50-80%); continue daily
   controller meds; albuterol MDI/neb PRN; use spacer for MDI as indicated;
   steroids (prednisolone or prednisone) 1 mg/kg X 5 days as indicated; double

Guideline for ED Management of Asthma in Children
   steroid MDI until back in green zone (PEFR/FEV1 > 80%); peak flow meter if
   able to use; follow-up plan with primary care physician
22 All asthmatics should be referred to Pediatric Pulmonology via a routine consult.


Davis A, Vickerson F, Worsley G, et al. Determination of dose-response
relationship for nebulized ipratropium in asthmatic children. J Pediatr 1984;
[In asthmatic children aged 9-17 years, IB produced dose-dependent bronchodilation that
became significant at doses > 75 mug, and no further increase in bronchodilation was
seen beyond 250 mug.]

Bohn D, Kalloghlian A, Jenkins J, et al. Intravenous salbutamol in the treatment of
status asthmaticus in children. Crit Care Med 1984;12:892-6
[Salbutamol IV (loading dose 1 mcg/kg/min over 10 min followed by infusion 0.2
mcg/kg/min increased in 0.1 mcg/kg/min increments to maximum of 4 mcg/kg/min) is a
safe and effective bronchodilator capable of reversing severe bronchospasm.]

Rock MJ, Reyes de la Rocha SR, L'Hommedieu CS, et al. Use of ketamine in
asthmatic children to treat respiratory failure refractory to conventional therapy.
Crit Care Med 1986;14:514-516
[Continuous infusion of ketamine (1.0 to 2.5 mg/kg/hr) immediately improved airway
obstruction in 2 pediatric patients suffering respiratory failure associated with status
asthmaticus refractory to maximal bronchodilatory therapy and mechanical ventilation.
Ketamine appears to increase catecholamine levels and directly relax bronchial smooth

Johnston RG, Noseworthy TW, Friesen EG, et al. Isoflurane therapy for status
asthmaticus in children and adults. Chest 1990;97:698-701
[Two children with life-threatening asthma refractory to maximal standard therapy were
treated effectively with the inhalational anesthetic agent isoflurane. Rapid therapeutic
benefit, minimal side effects, absence of cumulative toxicity, and ease of administration
are factors supporting the use of isoflurane for patients with severe asthma.]

 Rudinsky G, Eberlain R, Schoffstall J, et al. Comparison of intermittent and
continuously nebulized albuterol for treatment of asthma in an urban emergency
department. Ann Emerg Med 1993;22:1842-6
[Patients with a PEFR 200 L/min gained a small benefit with continuous nebulization as
compared to intermittent nebulization treatment.]

Papo MC, Frank J, Thompson AE. A prospective, randomized study of continuous
versus intermittent nebulized albuterol for severe status asthmaticus in children.
Crit Care Med 1993;21: 1479-86
[Continuous albuterol nebulization appears to be superior to intermittent nebulization in
Guideline for ED Management of Asthma in Children
severe status asthmaticus.]

Katz R, Kelly W, Crowley M, et al. Safety of continuous nebulized albuterol for
bronchospasm in infants and children. Pediatrics 1993;92:666-9
[Continuous albuterol therapy does not cause significant cardiotoxicity in infants or

Lin R, Sauter D, Newman T, et al. Continuous versus intermittent albuterol
nebulization in the treatment of acute asthma. Ann Emerg Med 1993;22:1847-53
[Administration of albuterol by either intermittent or continuous nebulization showed
equal improvement in pulmonary function; however, a possible benefit for the continuous
nebulization was seen in patients with FEV  50%.]

Wolthers OD, Riis BJ, Pedersen S. Bone turnover in asthmatic children treated
with oral prednisolone or inhaled budesonide. Pediatr Pulmonol 1993;16:341-6
[Short-term treatment with low daily doses of prednisolone may cause a suppression of
bone turnover in children with asthma. To reduce the risk of adverse effects on bone
turnover, doses of inhaled budesonide up to 800 micrograms daily may be preferable to
low doses of prednisolone. Bone turnover remains to be evaluated during long-term

Tveskov C, Djurhuus MS, Klitgaard NA, et al. Potassium and magnesium
distribution, ECG changes, and ventricular ectopic beats during beta 2-adrenergic
stimulation with terbutaline in healthy subjects. Chest 1994;106:1654-9
[Short-term IV administration of terbutaline in healthy subjects produced hypokalemia,
partly due to an increase in the number of sodium-potassium pumps, and induced ECG
changes with a highly significant lengthening of the QTc interval but with an unchanged
number of ventricular ectopic beats.]

Geelhoed GC, Landau LI, Le Souef PN. Evaluation of SaO2 as a predictor of
outcome in 280 children presenting with acute asthma. Ann Emerg Med 1994;23:
[In acute childhood asthma, the proportion of children at each percent SaO2 who had a
poor outcome increased with decreasing SaO2 (r = .97). A SaO2 of < 91% predicted
with a sensitivity of 100% and a specificity of 84% those children with a worst outcome
who required IV therapy.]

Schuh S, Johnson DW, Callahan S, et al. Efficacy of frequent nebulized
ipratropium bromide added to frequent high-dose albuterol therapy in severe
childhood asthma. J Pediatr 1995;126:639-45
[Repeated doses of IB (250 mcg administered three times within an hour) was superior to
single dose IB (250 mcg) and placebo in terms of pulmonary function, and when added to
frequent high-dose albuterol therapy was both safe and more effective than albuterol

Guideline for ED Management of Asthma in Children
Chou KJ, Cunningham SJ, Crain EF. Metered-dose inhalers with spacers vs
nebulizers for pediatric asthma. Arch Pediatr Adolesc Med 1995;149:201-5
[MDIs with spacers may be an effective alternative to nebulizers for the treatment of
children with acute asthma exacerbations in the ED.]

Osmond MH, Klassen TP. Efficacy of ipratropium bromide in acute childhood
asthma: a meta-analysis. Acad Emerg Med 1995;2:651-6
[The existing evidence reveals that the addition of IB to a beta 2-agonist offers a
statistically significant improvement in percentage predicted FEV1 but no clinical
improvement. As it may cause deterioration in PEFR in severely asthmatic children, IB
should not be used universally for acute childhood asthma until further research
determines the clinical significance of these spirometric changes.]

Scarfone RJ, Loiselle JM, Wiley JF II et al. Nebulized dexamethasone versus oral
prednisone in the emergency treatment of asthmatic children. Ann Emerg Med
[Nebulized dexamethasone 1.5 mg/kg was as effective as oral prednisone 2 mg/kg in the
ED treatment of moderately ill children with acute asthma and was associated with more
rapid clinical improvement, more reliable drug delivery, and fewer relapses.]

Nehama J, Pass R, Bechtler-Karsch A, et al. Continuous ketamine infusion for the
treatment of refractory asthma in a mechanically ventilated infant: case report and
review of the pediatric literature. Pediatr Emerg Care 1996;12:294-297

Ciarallo L, Sauer AH, Shannon MW. Intravenous magnesium therapy for
moderate to severe pediatric asthma: Results of a randomized, placebo-controlled
trial. J Pediatr 1996;129:809-14
[Magnesium 25 mg/kg IV improved FEV, PEFR, and FVC compared to placebo in 15
children with moderate to severe asthma.]

Wetzel RC. Pressure-support ventilation in children with severe asthma. Crit Care
Med 1996;24:1603-5
[Pressure-support ventilation permits children with severe asthma to determine their own
respiratory pattern and to maintain forced exhalation.]

Khine H, Fuchs SM, Saville AL. Continuous vs. intermittent albuterol for
emergency management of asthma. Acad Emerg Med 1996;3:1019-24
[No difference was demonstrated in efficacy or safety between intermittent and
continuous nebulized albuterol in the ED management of children with moderate to
severe asthma exacerbations. Continuous nebulized therapy, however, provides
significant time savings in the delivery of asthma therapy to patients in a busy ED.]

Youssef-Ahmed MZ, Silver P, Nimkoff L, el al. Continuous infusion of ketamine in
mechanically ventilated children with refractory bronchospasm. Intensive Care Med
[Ketamine 2 mg/kg IV bolus followed by a continuous infusion of 0.5-2 mg/kg/hr is

Guideline for ED Management of Asthma in Children
useful in the treatment of mechanically-ventilated children with refractory status

Carter ER, Webb CR, Moffitt DR. Evaluation of heliox in children hospitalized
with acute severe asthma: a randomized crossover trial. Chest 1996;109:1256-61
[Use of heliox in 11 nonintubated children with severe asthma failed to produce an effect
on respiratory mechanics or dyspnea scores.]

Tobias JD, Garrett JS. Therapeutic options for severe, refractory status
asthmaticus: inhalational anesthetic agents, extracorporeal membrane oxygenation
and helium/oxygen ventilation. Paediatr Anaesth 1997;7:47-57
[Improved respiratory mechanics were observed with use of heliox in spontaneously
breathing children with asthma.]

Miyagi T, Gushima Y, Matsumoto T, et al. Prolonged isoflurane anesthesia in a
case of catastrophic asthma. Acta Paediatr Jpn 1997;39:375-8
[A 13-year-old female patient with life-threatening, refractory status asthmaticus was
effectively treated with the inhalational anesthetic agent, 1% isoflurane, for 202 h (140
minimum alveolar concentration (MAC) hours).]

Kudukis TM, Manthous CA, Schmidt GA, et al. Inhaled helium-oxygen revisited:
effect of inhaled helium-oxygen during the treatment of status asthmaticus in
children. J Pediatr 1997;130:217-24
[Heliox significantly lowered pulsus paradoxus, increased PEFR, and lessened dyspnea
index in children during status asthmaticus.]

Qureshi F, Zaritsky A, Lakkis H. Efficacy of nebulized ipratropium in severely
asthmatic children. Ann Emerg Med 1997;29:205-11
[Significant improvement in PEFR and FEV1 was demonstrated in children with severe
asthma who were trreated with nebulized albuterol 0.15 mg/kg/dose Q30 min combined
with nebulized IB 500 mcg X 2 doses (given with 1st & 3rd doses of albuterol) compared
to nebulized albuterol therapy alone.]

Rice M, Hatherill M, Murdoch IA. Rapid response to isoflurane in refractory status
asthmaticus. Arch Dis Child 1998;78:395-6

Yung M, South M. Randomised controlled trial of aminophylline for severe acute
asthma. Arch Dis Child 1998;79:405-10
[Aminophylline treatment resulted in greater improvement in SaO2 and pulmonary
function testing compared to placebo in 163 children with severe status asthmaticus
refractory to frequent nebulized albuterol, IB, and IV steroid treatment.]

National Asthma Education and Prevention Program. Expert Panel Report 2:
Guidelines for the diagnosis and management of asthma. Bethedsa (MD): United
States Department of Health and Human Services, Public Health Service, National
Institutes of Health (National Heart, Lung, and Blood Institute): 1997

Guideline for ED Management of Asthma in Children
[Statement of standard of care for diagnosis and treatment of asthma in children.]

Simons FE. A comparison of beclomethasone, salmeterol, and placebo in children
with asthma. Canadian Beclomethasone Dipropionate-Salmeterol Xinafoate Study
Group. N Engl J Med 1997;337:1659-65
[Long-term (1 year) treatment with beclomethasone was effective in reducing airway
hyperresponsiveness and in controlling symptoms of asthma, but it was associated with
decreased linear growth. Long-term treatment with salmeterol was not as effective as
beclomethasone in reducing airway hyperresponsiveness or in controlling symptoms;
however, it was an effective bronchodilator and was not associated with rebound airway
hyperresponsiveness, masking of symptoms, or adverse effects.]

Qureshi F, Pestian J, Davis P, Zaritsky A. Effect of nebulized ipratropium bromide
on the hospitalization rates of children with asthma. N Engl J Med 1998;339:1030-5
[IB in addition to albuterol and corticosteroid therapy can decrease the hospitalization
rate in children with severe asthma exacerbation.]

Stephanopoulos DE, Monge R, Schell KH, et al. Continuous intravenous terbutaline
for pediatric status asthmaticus. Crit Care Med 1998;26:1744-8
[IV terbutaline is well tolerated in children with status asthmaticus at varying doses up to
a maximum of 10 mcg/kg/min.]

Zorc JJ, Pusic MV, Ogborn CJ, et al. Ipratropium bromide added to asthma
treatment in the pediatric emergency department. Pediatrics 1999;103:748-52
[The addition of 3 doses of IB 250 mcg to an ED treatment protocol for acute pediatric
asthma was associated with reductions in duration and amount of treatment before

Smith SR, Strunk RC. Acute asthma in the pediatric emergency department.
Pediatr Clin North Am 1999;46:1145-65
[Summary of current ED management of acute asthma in children.]

Matthews EE, Curtis PD, McLain BI, et al. Nebulized budesonide versus oral
steroid in severe exacerbations of childhood asthma. Acta Paediatr 1999;88:841-3
[Nebulized budesonide is as effective as oral steroid in improving lung function and
symptom severity in severe exacerbations of childhood asthma.]

Manjra AI, Price J, Lenney W, et al. Efficacy of nebulized fluticasone propionate
compared with oral prednisolone in children with an acute exacerbation of asthma.
Respir Med 2000;94:1206-14
[Nebulized FP is at least as effective as oral prednisolone in the treatment of children
presenting with an acute exacerbation of asthma.]

The Childhood Asthma Management Program Research Group. Long-term effects
of budesonide or nedocromil in children with asthma. N Engl J Med 2000;343:

Guideline for ED Management of Asthma in Children
[The side effects of budesonide are limited to a small, transient reduction in growth

Agertoft L, Pedersen S. Effect of long-term treatment with inhaled budesonide on
adult height in children with asthma. N Engl J Med 2000;343:1064-9
[Children with asthma who have received long-term treatment with budesonide attain
normal adult height.]

Scarfone RJ, Loiselle JM, Joffe MD, et al. A randomized trial of magnesium in the
emergency department treatment of children with asthma. Ann Emerg Med 2000;
[Routine administration of high-dose magnesium to moderate to severely ill children with
asthma, as a adjunct to initial treatment with albuterol and corticosteroids, is not

Ciarallo L, Brousseau D, Reinert S. Higher-dose intravenous magnesium therapy
for children with moderate to severe acute asthma. Arch Ped Adolesc Med 2000;
[In children with refractory moderate to severe acute asthma, magnesium sulfate 40
mg/kg IV produced a marked improvement in % PEFR & FEV1.]

Chiang VW, Burns JP, Rifai N, et al. Cardiac toxicity of intravenous terbutaline for
the treatment of severe asthma in children: a prospective assessment. J Pediatr
[No clinically significant cardiac toxicity was found in children receiving IV terbutaline
for severe asthma.]

Plotnick LH, Ducharme FM. Combined inhaled anticholinergic agents and beta-2-
agonists for initial treatment of acute asthma in children (Cochrane Review). In:
The Cochrane Library, issue 1, 2001. Osford, UK: Update Software, 2001

Qureshi F, Zaritsky A, Poirier MP. Comparative efficacy of oral dexamethasone
versus oral prednisone in acute pediatric asthma. J Pediatr 2001;139:20-6
[Two doses of dexamethasone 0.6 mg/kg/day PO provides similar efficacy with improved
compliance and fewer side effects than 5 doses of prednisone (2 mg/kg first dose, then 1
mg/kg/day X 4 doses) in children with acute asthma]

Ream RS. Efficacy of IV theophylline in children with severe status asthmaticus.
Chest 2001;119:1480-8
[Theophylline IV safely hastened the recovery of children in severe status asthmaticus
who were also receiving albuterol, IB, and solumedrol.]

Werner HA. Status asthmaticus in children: a review. Chest 2001;119:1913-29
[A thorough review of the topic.]

Rodrigo GJ, Rodrigo C. The role of anticholinergics in acute asthma treatment: an

Guideline for ED Management of Asthma in Children
evidence-based evaluation. Chest 2002;121:1977-87
[A review of current evidence regarding the role of anticholinergics in combination with
beta(2)-agonists in acute asthma yielded the following conclusions: (1) the addition of
multiple-dose IB to a beta(2)-agonist therapy is indicated in the ED treatment of children
with severe acute asthma and is associated with a substantial reduction in hospital
admissions and a significant difference in lung function; (2) the use of single-dose
protocols of IB with beta(2)-agonist treatment produced, particularly in children with
more severe acute asthma, a modest improvement in pulmonary function without
reduction in hospital admissions.]

Rodrigo GJ, Rodrigo C, Pollack CV, et al. Use of helium-oxygen mixtures in the
treatment of acute asthma: a systematic review. Chest 2003;123:891-6
[Existing evidence does not provide support the administration of helium-oxygen
mixtures to ED patients with moderate-to-severe acute asthma.]

Carl JC, Myers TR, Kirchner HL, et al. Comparison of racemic albuterol and
levalbuterol for treatment of acute asthma. J Pediatr 2003;143:731-6
[In patients aged 1-18 years with acute asthma, hospitalization rate was significantly
lower in patients treated with levalbuterol 1.25 mg (36%) than in patients treated with
racemic albuterol 2.5 mg (45 %, p=0.02).]

Guideline for ED Management of Asthma in Children

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