This leads to increased trans- pulmonary pressure, which may close the small bronchioli. With labored breathing there is a rise in oxygen consumption and pro.
Paediatrica Indonesiana 15 : 269 — 272. Sept. — Oct. 1975.
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From the Department of Child Health, Medical School, University of Airlangga, Surabaya.
Status Asthmaticus •j
J.S. PARTANA Abstract The therapy of status asthmaticus must be rational. Thus it is important to evaluate: 1. the severity and d/uratiem of an asthmatic attack. 2. the degree of dehydration. 3. whether infecti on plays a role. 4> all medication previously administered. 5. any possible complication. Treatment is as follows : Ï.
2. 3. 4.
5. 6. 7. 8.
Fluid and electrolyte therapy is important not only for the correc tion of dehydration and electrolyte disturbances but also for pre venting inspissation of mucus in the bronchi. The best route of fluid administration is intravenous. Potassium iodide- orally administered may be helpful as an expec torant. After hydration and normal acid-base balance have been esta blished, epinephrine may be of benefit. Aminophyllme is effective when administered intravenously. It should be used with extreme caution: the dose should not exceed 8 mg per kg of body weight, it should be given slowly and should not be given more frequently than every 8 hours. Corticosteroids should be administered, especially in oases who have received suppressive doses previously. Humidified oxygen administration is of the utmost importance. Antibiotics are recommended when infection is suspected. Management of complications.
■Received 2nd July, 1975.
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J .S . FA R T A N A
In, Surabaya status asthmaticus among children does not seem to be a gneat problem. Between August 1973 and January 1974, 14 children w ere admitted to Dr. Soetomo Hos pital With the diagnosis of status asthmaticus. This is about 1 percent of tbe total admission of 1420 chil dren during the same period. All 14 cases recovered. Nevertheless, we have to be aware of the potential dangers of status asthmaticus. Etiology Status asthmaticus is a severe asthmatic attack, which does not res pond to conventional treatment, es pecially to epinephrine injections. One possibility for this poor res ponse to epinephrine is infection, which is not seldom encountered in patients with status asthmaticus. Another important factor is dehy dration, which leads to the formation of mucus plugs. In other countries excessive use of inhalers, sedatives and narcotics are mentioned as pos sible causes of status, asthmaticus. Acidosis and hypoxaemia are also considered as causative factorsPathology Gross: Obstruction of the bronchi and bronchioli is caused by contrac tion of smooth muscles, mucosal ede ma and excessive secretion of mucus. Microscopy: The bronchial muco sa shows eosinophilic, or plasma cell infiltrations. There is hypertrophy and hyper plasia of the mucus glands in the
bronchial wall. In the mucus eosino phils, epithelial cells and CharcotLeyden crystals may be found. The basement membrane is thickenedHypertrophy of the bronchiolar mus culature may also be seen. Pathophysiology Increase in airway resistance is the basic problem in asthma, which is caused by 3 factors: bronchospasm, edema of the mucosa and excessive mucus production. Other factors contributing to the increase in air way resistance are thickening of the bronchial wall caused b y inflamma tion and hyperplasia o f the mucus glands, obstruction of the airways by exudate, by external compression or internal cohesion. Since the tracheobronchial tree shortens, and narrows during expi ration, airway resistance is more pro nounced in this phase of respiration and this leads to hyperinflation. This is followed by an increase in residual volume, total lung volume and func tional dead space and a decrease in pulmonary compliance and alveolar ventilation. With the increase in airway resis-. tance, the use of the accessory mus cles of respiration becomes manda tory. This leads to increased transpulmonary pressure, which may close the small bronchioli. With labored breathing there is a rise in oxygen consumption and pro duction of carbondioxide and oxida tive metabolic products. This results
STA T U S A STH M A T IC U S
in hypoxemia and hypercapnia, cau sing central nervous system, cardio vascular and metabolic disturbances.
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Treatment Hydration An often neglected but very im portant aspect in the treatment of status asthmaticus is correction of the dehydration ('and electrolyte im balance) to prevent inspissation of mucus in the bronchi. The same types and amounts of fluid and elec trolytes can be used as in other pedi atric problems.
Examination History It is important not only to eva luate the duration and severity of the asthmatic attack, but also the severity and course of previous at tacks. The degree of dehydration can be estimated from the intake, vomiting, fever, bodyweight and Iodides urine production. Although low In some patients Iodide is worth grade fever can be found in asthma, trying as an expectorant, but in together with purulent secretion it iodide-sensitive patients it is contramust be considered as suggestive of indicated. Most often it is given as Infection. All ¡previous medication a watery solution of the potassium must be listed regarding the dose salt. and the time given. This is especially Epinephrine important with aminophyllin so as to Epinephrine must not be given in prevent overdosage. With previous status asthmaticus. But after hy use of corticosteroid it may be life dration and acid-base balance have saving to give corticosteroid treat been restored, epinephrine may be ment in high dosage. beneficial. Physical Examination Signs of infection, the degree of AminophyTlme Aminophylline is usually very ef dehydration, respiratory and cardio fective when given intravenously vascular function and the sensorium over a 15-minute period. The recom must be evaluated. mended dose is 3 mg per kg bodyLaboratory Examination weight diluted in a 5% dextrose so Investigations needed are blood, lution. It may be dangerous if re urine and stool examinations, tuber peated before 8 hours. Signs of ami culin skin testing, electrolyte and nophylline intoxication include vo blood gases determination and an miting, hematemesis, convulsions, E.C.G. coma and death. An X-Ray picture is essential to detect complications as pneumonia, Corticosteroids atelectasis, pneumothorax and pneu Corticosteroids may be life-saving momediastinum. in status asthmaticus, especially in
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J . S. PA R T A N A
patients who had previously received suppcressive doses. It should be given immediately in an adequate dose. A dose of 100 mg of a water so luble hydrocortison preparation given every 6 hours usually suffices. A short term corticosteroid the rapy has almost no side effects and it is not necessary to lower the dose gradually. Oxygen Oxygen treatment is indicated in status asthmaticus- The most conve nient method its by nasal catheter. Drying of the mucus membranes
should be prevented by giving hu midified oxygen. Alkalization Sodium lactate may be used al though there is a risk of causing lactic acidosis. Sodium bicarbonate is usually more effective. Antibiotics Antibiotics should be given if in fection is suspected. With respira tory depression and with serious complications like pneumothorax and pneumomediastinum, the anesthesio logist and pulmonologist must be consulted.
REFERENCES 1. BARR, L.W. and LOGAN, G.B.: P ro g (1974). nosis of children h aving asthm a. P e 8. REISM AN , R .E.; F R IE D M A N , I. and d ia trics 43 : 856 (1964). ARBESM AN, C.E. : S evere sta tu s as2. B A R TER , B. an d RO BERTS, R .J.: th m aticu s: Prolonged tr e a tm e n t w ith U nusual case of am inophylline intoxi assisted ventilation. J. A llerg y 43 : 37 (1968). cation. P ed ia trics 52 : 608 (1973). S. BIERM A N , C.W .: Pneum om ediastinum 9. RICHARDS, W. and P A T R IC K , J .: a n d pneum othorax com plicating a s D eath from a sth m a in children. Am. th m a in children. Am. J . Dis. Child. J. Dis. Child. 110: 4 (1965)._ 114 : 42 (1967). 10. SHAPIRO, G.G.; EG G LESTO N P.A.; 4 . D EES, S.C.: A sth m a tic Child: Deve PIE R SO N , W .E .; RA Y , C.G. and lopm ent and course of a sth m a in chil BIERM AN, C .W .: D ouble blind stu d y dren. Am. J. Dis. Child. 93 : 228 of th e effectiveness of a broadspec(1957). tru m an tib io tic in s ta tu s asthm aticus. 5. DWORETZKY, M. and PH ELSO N , P ed iatr. 53 : 867 (1974). A.D. : Review of a sth m a tic p atien ts 11. SIEG EL, S.C.: A CTH an d th e c o rti hospitalized in th e pavilion service of costeroids in th e m an ag em en t of al th e N ew Y ork H ospital from 1948 to lergic disorders in children. J. P ed iatr. 1963 w ith em phasis on m o rta lity rate . 66 : 927 (1965). J . A llergy 41 : 181 (1968). 12. TSUCHIYA, Y. an d BUKANTZ, S.C.: 6. PIE R SO N . W .E .; B IERM A N , C.W.; S tudies on s ta tu s asth m a ticu s in chil STAMM, S.J. and VAN A RSD EL, P .P. dren. J. A llergy 36 : 514 (1965). J r .: Double blind tria l of am inophyl line in s ta tu s asth m aticu s. P ed ia trics 13. WOOD, D.W.; DOW NS, J.J. and LECKS, H I .: T he m an ag em en t of 48 : 642 (1971). 7. PIE R SO N , W .E.; B IERM A N , C.W. resp ira to ry failu re in childhood sta tu s asth m a ticu s: E xperience w ith 30 epi and K ELLEY , V.C.: A double-blind tria l of corticosteroid th e ra p y in s ta sodes and evolution of a technique. J. A llergy 42 : 261 (1968). tus asth m aticu s. P ed ia trics 54 : 282
