Pediatric asthma severity scores distinguish suitable inpatient level of care for children admitted for status asthmaticus.

Objective: To determine if the Pediatric Asthma Severity Score (PASS) can distinguish "late-rescues" (transfer to the pediatric intensive care unit [PICU] within 24-hours of general pediatric floor admission), "PICU readmissions" (readmission within 24-h after transfer to a lower inpatient level of care), and unplanned 30-day hospital readmission in children admitted with status asthmaticus.Methods: We performed a single center, retrospective cohort study in 328 children admitted for asthma exacerbation aged 5-18 years from May 2015 to October 2017. We sought to determine if PASS values preceding admission from the emergency department or transfer to the general pediatric unit will be greater in children with late rescues and PICU readmissions and if a cutoff PASS values exist to discriminate these events prior to intrafacility transfer.Results: Nine (5%) late-rescues and 5 (3%) PICU readmissions accounted for 14/328 (4%) composite outcomes. PASS values were greater in children with these events (8 [IQR:5-8] vs. 5 [IQR:3-6], p < .01). Logistic regression of PASS on composite outcome yielded an odds ratio of 1.4 (1.1-1.8, p < .01) and ROC curve of PASS on a composite outcome yielded an AUC of 0.74 (0.61-0.87) with a threshold of ≥ 9. Nine (3%) children experienced unplanned 30-day hospital readmissions but PASS preceding hospital discharge was neither discriminative nor associated with hospital readmission.Conclusions: PASS values ≥ 9 identify children at increased risk for late-rescue and PICU readmission. Applied with traditionally criteria for selection of inpatient level of care, PASS may assist providers in reducing acute inpatient disposition errors.

Extracorporeal Carbon Dioxide Removal in the Treatment of Status Asthmaticus.

OBJECTIVES: Venovenous extracorporeal carbon dioxide removal may be lifesaving in the setting of status asthmaticus. DESIGN: Retrospective review. SETTING: Medical ICU. PATIENTS: Twenty-six adult patients with status asthmaticus treated with venovenous extracorporeal carbon dioxide removal. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Demographic data and characteristics of current and prior asthma treatments were obtained from the electronic medical record. Mechanical ventilator settings, arterial blood gases, vital signs, and use of vasopressors were collected from the closest time prior to cannulation and 24 hours after initiation of extracorporeal carbon dioxide removal. Extracorporeal carbon dioxide removal settings, including blood flow and sweep gas flow, were collected at 24 hours after initiation of extracorporeal carbon dioxide removal. Outcome measures included rates of survival to hospital discharge, ICU and hospital lengths of stay, duration of invasive mechanical ventilation and extracorporeal carbon dioxide removal support, and complications during extracorporeal carbon dioxide removal. Following the initiation of extracorporeal carbon dioxide removal, blood gas values were significantly improved at 24 hours, as were peak airway pressures, intrinsic positive end-expiratory pressure, and use of vasopressors. Survival to hospital discharge was 100%. Twenty patients (76.9%) were successfully extubated while receiving extracorporeal carbon dioxide removal support; none required reintubation. The most common complication was cannula-associated deep venous thrombosis (six patients, 23.1%). Four patients (15.4%) experienced bleeding that required a transfusion of packed RBCs. CONCLUSIONS: In the largest series to date, use of venovenous extracorporeal carbon dioxide removal in patients with status asthmaticus can provide a lifesaving means of support until the resolution of the exacerbation, with an acceptably low rate of complications. Early extubation in select patients receiving extracorporeal carbon dioxide removal is safe and feasible and avoids the deleterious effects of positive-pressure mechanical ventilation in this patient population.

Noninvasive Ventilation Use in Critically Ill Patients with Acute Asthma Exacerbations.

Rationale: Noninvasive ventilation decreases the need for invasive mechanical ventilation and mortality among patients with chronic obstructive pulmonary disease but has not been well studied in asthma.Objectives: To assess the association between noninvasive ventilation and subsequent need for invasive mechanical ventilation and in-hospital mortality among patients admitted with asthma exacerbation to the ICU.Methods: We performed a retrospective cohort study using administrative data collected during 2010-2017 from 682 hospitals in the United States. Outcomes included receipt of invasive mechanical ventilation and in-hospital mortality. Generalized estimating equations, propensity-matched models, and marginal structural models were used to assess the association between noninvasive ventilation and outcomes.Measurements and Main Results: The study population included 53,654 participants with asthma exacerbation. During the study period, 13,540 patients received noninvasive ventilation (25.2%; 95% confidence interval [CI], 24.9-25.6%), 14,498 underwent invasive mechanical ventilation (27.0%; 95% CI, 26.7-27.4%), and 1,291 died (2.4%; 95% CI, 2.3-2.5%). Among those receiving noninvasive ventilation, 3,013 patients (22.3%; 95% CI, 21.6-23.0%) required invasive mechanical ventilation after first receiving noninvasive ventilation, 136 of whom died (4.5%; 95% CI, 3.8-5.3%). Across all models, the use of noninvasive ventilation was associated with a lower odds of receiving invasive mechanical ventilation (adjusted generalized estimating equation odds ratio, 0.36; 95% CI, 0.32-0.40) and in-hospital mortality (odds ratio, 0.48; 95% CI 0.40-0.58). Those who received noninvasive ventilation before invasive mechanical ventilation were more likely to have comorbid pneumonia and severe sepsis.Conclusions: Noninvasive ventilation use during asthma exacerbation was associated with improved outcomes but should be used cautiously with acute comorbid conditions.

Synchronized abdominal compression as a novel treatment of life-threatening preschool asthma.

Introduction: In severe asthma, management of life-threatening air trapping that persists despite initiation of standard asthma treatment is difficult in the absence of extracorporeal membranous oxygenation.Case study: Three children with life-threatening asthma could not be adequately ventilated despite maximum conventional treatment because of severe air trapping. A novel method of active expiration by abdominal compression with a standard ventilator was adopted with immediate effect with significant improvement in ventilation.Conclusion: Synchronized abdominal compression is a novel and simple method that allows an effective treatment of severe air trapping in an intubated paralyzed asthma child.

Inflammatory and Comorbid Features of Children Admitted to a PICU for Status Asthmaticus.

OBJECTIVES: To determine risk factors associated with admission to a PICU with or without endotracheal intubation for an asthma exacerbation. We hypothesized that children with critical and near-fatal asthma would have distinguishing clinical features but varying degrees of asthma severity and measures of type 2 inflammation. DESIGN: Retrospective analysis of prospectively collected data of children with asthma recruited into outpatient asthma clinical research studies at Emory University between 2004 and 2015. SETTING: Large, free-standing academic quaternary care children's hospital in Atlanta, GA. PATIENTS: Children 6-18 years old with physician-diagnosed and confirmed asthma. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 579 children were analyzed with 170 children (29.4%) being admitted to the PICU for an asthma exacerbation in their lifetime. Of these 170 children with a history of critical asthma, 24.1% were classified as having mild-to-moderate asthma, and 83 of 170 children (48.8%) had been intubated and experienced near-fatal asthma. Multiple logistic regression was used to identify risk factors associated with increased odds of PICU admission with or without endotracheal intubation. Hospitalization within the prior 12 months of survey (odds ratio, 8.19; 95% CI, 4.83-13.89), a history of pneumonia (odds ratio, 2.56; 95% CI, 1.52-4.29), having a designation of increased chronic asthma severity on high-dose inhaled corticosteroids (odds ratio, 2.76; 95% CI, 1.62-4.70), having a father with asthma (odds ratio, 2.15; 95% CI, 1.23-3.76), living in a region with a higher burden of poverty (odds ratio, 1.28; 95% CI, 1.02-1.61), and being of black race (odds ratio, 2.01; 95% CI, 1.05-3.84) were all associated with increased odds of PICU admission with or without intubation. CONCLUSIONS: Our findings suggest that there are factors associated with critical and near-fatal asthma, distinct from the chronic asthma severity designations, that should be the focus of future investigation.

At-risk registers integrated into primary care to stop asthma crises in the UK (ARRISA-UK): study protocol for a pragmatic, cluster randomised trial with nested health economic and process evaluations.

BACKGROUND: Despite effective treatments and long-standing management guidelines, there are approximately 1400 hospital admissions for asthma weekly in the United Kingdom (UK), many of which could be avoided. In our previous research, a secondary analysis of the intervention (ARRISA) suggested an improvement in the management of at-risk asthma patients in primary care. ARRISA involved identifying individuals at risk of adverse asthma events, flagging their electronic health records, training practice staff to develop and implement practice-wide processes of care when alerted by the flag, plus motivational reminders. We now seek to determine the effectiveness and cost-effectiveness of ARRISA in reducing asthma-related crisis events. METHODS: We are undertaking a pragmatic, two-arm, multicentre, cluster randomised controlled trial, plus health economic and process evaluation. We will randomise 270 primary care practices from throughout the UK covering over 10,000 registered patients with 'at-risk asthma' identified according to a validated algorithm. Staff in practices randomised to the intervention will complete two 45-min eLearning modules (an individually completed module giving background to ARRISA and a group-completed module to develop practice-wide pathways of care) plus a 30-min webinar with other practices. On completion of training at-risk patients' records will be coded so that a flag appears whenever their record is accessed. Practices will receive a phone call at 4 weeks and a reminder video at 6 weeks and 6 months. Control practices will continue to provide usual care. We will extract anonymised routine patient data from primary care records (with linkage to secondary care data) to determine the percentage of at-risk patients with an asthma-related crisis event (accident and emergency attendances, hospitalisations and deaths) after 12 months (primary outcome). We will also capture the time to crisis event, all-cause hospitalisations, asthma control and any changes in practice asthma management for at-risk and all patients with asthma. Cost-effectiveness analysis and mixed-methods process evaluations will also be conducted. DISCUSSION: This study is novel in terms of using a practice-wide intervention to target and engage with patients at risk from their asthma and is innovative in the use of routinely captured data with record linkage to obtain trial outcomes. TRIAL REGISTRATION: ISRCTN95472706 . Registered on 5 December 2014.

Adjunctive extracorporeal carbon dioxide removal in refractory status asthmaticus.

Status asthmaticus (SA) is a life-threatening disorder. Severe respiratory failure may require extracorporeal membrane oxygenation (ECMO). Previous reports have demonstrated utility of ECMO in SA in various patients with varying success. A 25-year-old man was admitted with status asthmatics and severe hypercapnic respiratory failure. Despite tailored ventilator therapies, such as pressure control ventilation and maximal pharmacological therapy, including general anaesthesia, the patient’s condition deteriorated rapidly. Veno-venous ECMO (VV-ECMO) was provided for respiratory support. The patient’s clinical condition improved over the following 72 hours and was discharged from the intensive care unit on day 3. This case report demonstrates the successful use of VV-ECMO in a patient with severe respiratory failure due to SA, who failed to respond to maximal therapy. This case adds support to a growing body of literature that shows that ECMO can be used with success for refractory status asthmaticus.

Manifestaciones clínicas en pacientes con asma persistente / Clinical manifestations in patients with persistent asthma

Se efectuó un estudio descriptivo y transversal, de casos y controles no pareado, de 120 pacientes con asma persistente, atendidos en la consulta de Alergología del Policlínico de Especialidades, perteneciente al Hospital Provincial Docente Clinicoquirúrgico Saturnino Lora Torres de Santiago de Cuba, desde enero de 2014 hasta igual periodo de 2015, con vistas a describir las características clínicas y causas de esta enfermedad. Los pacientes fueron seleccionados mediante muestreo aleatorio simple y se distribuyeron en 2 grupos: uno de 60 integrantes con asma severa (de estudio) y el otro de igual cantidad con asma ligera (control). En la casuística predominaron los afectados con asma persistente moderada-severa del sexo femenino y el grupo etario de 40 años y más, mientras que los irritantes inespecíficos y las infecciones respiratorias resultaron ser los factores predisponentes de mayor ocurrencia. Sobresalieron la asociación con nasosinopatías y los cambios bruscos de temperatura

A descriptive and cross-sectional, cases and controls non paired study of 120 patients with persistent asthma was carried out. They were assisted in the Allergology Service of the Specialties Polyclinic, belonging to Saturnino Lora Torres Teaching Clinical Surgical Provincial Hospital in Santiago de Cuba, from January, 2014 to the same period in 2015, aimed at describing the clinical characteristics and causes of this disease. The patients were selected by means of simple random sampling and they were distributed into 2 groups: one of 60 members with severe asthma (study group) and the other with the same number with light asthma (control group). In the case material there was a prevalence of those affected with moderate-severe persistent asthma from the female sex and the 40 years age group and over, while the unspecific irritant and the respiratory infections were the predisposing factors that occurred with more frequency. The association with nasosinopathies and the abrupt changes of temperature were notable

Status Asthmaticus and Central Herniation: A Case for Multidisciplinary Critical Care.

A 24-year-old woman with history of asthma was intubated emergently for acute status asthmaticus triggered by acute respiratory syncytial virus infection and treated with permissive hypercapnia. Her ventilation was complicated by auto-positive end-expiratory pressure and elevated peak airway, plateau, and central venous pressures. On hospital day 2, she was noted to have anisocoria. Imaging showed diffuse cerebral edema with central herniation. Difficult ventilation and hypercapnia directly contributed to her severe cerebral edema. Comanagement between neurologic and medical/pulmonary intensivists enabled the management of the competing treatment requirements for status asthmaticus and cerebral edema. This case highlights the importance of balancing conflicting physiologic needs and collaboration between teams.

Medications and Recent Patents for Status Asthmaticus in Children.

BACKGROUND: Status asthmaticus is an acute exacerbation of asthma that is persistent and intractable and remains unresponsive to initial treatment with bronchodilators and systemic corticosteroids and that the condition can result in hypoxemia, hypercarbia, and secondary respiratory failure. OBJECTIVE: To review treatment and recent patents on management of status asthmaticus. METHOD: A PubMed search was completed in Clinical Queries using the key term "status asthmaticus". The search included meta-analyses, randomized controlled trials, clinical trials, reviews and pertinent references. Patents were searched using the key term status "asthmaticus" from www.google.com/patents, www.uspto.gov, and www.freepatentsonline.com. RESULTS: Supplemental oxygen should be given to maintain an oxygen saturation of ≥ 92% in room air. Mainstay of pharmacologic treatment of status asthmaticus includes short-acting, ß2 agonists such as salbutamol (albuterol) administered by metered-dose inhaler with spacer or, preferably, by nebulizer and oral corticosteroids. There is no advantage to intravenous corticosteroids unless the child cannot tolerate oral corticosteroids (e.g., protracted vomiting), or unable to take oral corticosteroid (e.g., intubated or unconscious). Inhaled ipratropium bromide and intravenous magnesium sulfate should be considered in children with severe asthma exacerbations not responsive to conventional therapy. Subcutaneous and intramuscular ß2 agonists such as terbutaline and epinephrine may be considered for children with severe asthma exacerbation who have poor air entry, are uncooperative with nebulized therapy, or have poor response to nebulized therapy. Monoclonal anti-IgE antibody (omalizumab) and humanized monoclonal antibodies targeting interleukin pathway have shown great promise in severe refractory eosinophilic asthma. Failing therapeutic interventions necessitate non-invasive or invasive ventilation support. Severe exhaustion, deteriorating consciousness, poor air entry, worsening hypoxemia, hypercapnia, and cardiopulmonary arrest are indications for mechanical ventilation and intubation. For chronic treatment of asthma, inhaled corticosteroids, bronchodilator, and oral montelukasts are the mainstay. Some formulations of herbal medicine are efficacious but evidence of other modalities of complementary and alternative medicine are generally lacking. This review also discusses recent patents related to the management of asthma. These recent patents describe a few immunomodulating medications useful for the treatment of chronic severe asthma. There have been no recent patents for the management of status asthmaticus. CONCLUSION: Inhaled bronchodilators and systematic corticosteroids are the mainstay of therapy in the management of severe and status asthmaticus.

Estado asmático en pediatría / Pediatric status asthmaticus

The status asmathicus is an important cause of morbidity in children, due to the increasing incidence of asthma in the pediatric population. Its mortality is relatively low, and it concentrates in patients with acute asfictic asthma and during the period of endotracheal peri-intubation in patients who require it. The treatment consists on oxygen therapy, bronchodilators and systemic corticosteroids, with other pharmacological alternatives in children who do not respond to the former treatments. Non-invasive ventilatory support improves gas exchange and reduces the work of breathing. Invasive mechanical ventilation is thus only used in children with severe refractory respiratory failure to the former measures, considering its associated morbidity and mortality.

El estado asmático es una causa importante de morbilidad en Pediatría, debido al aumento de la incidencia de asma en la población infantil. Su mortalidad es relativamente baja, y se concentra principalmente en aquellos pacientes con asma aguda asfíctica y en el período peri-intubación endotraqueal en aquellos pacientes que lo requieren. El tratamiento tiene como pilares el uso de oxígeno, broncodilatadores y corticoides sistémicos, existiendo otras alternativas farmacológicas para niños que no responden a las medidas anteriores. El soporte ventilatorio no-invasivo permite mejorar el intercambio gaseoso y disminuir el trabajo respiratorio, reservando la ventilación mecánica invasiva solamente para niños en falla respiratoria grave refractaria a medidas anteriores, considerando la morbimortalidad asociada a ésta.

Albuterol via metered-dose inhaler in children: Lower doses are effective, and higher doses are safe.

BACKGROUND: The ideal dosing of albuterol via metered-dose inhalers for acute childhood asthma is not well established. We hypothesized that greater doses of albuterol would result in less time in the hospital and lower admission rates. METHODS: This was a randomized controlled double-blind multicenter study, conducted in emergency rooms (ER). We included patients with 2-17 years old with moderate to severe acute asthma (Pediatric Respiratory Assessment Measure, PRAM, score ≥5). Dosages administered during the first hour included: 6 (up to 25 kg) or 12 puffs (>25 kg) in the control group and 9 (up to 15 kg), 12 (>15-20 kg), 15 (>20-25 kg), or 18 puffs (>25 kg) in the study group. Several efficacy (changes in PRAM score, pulse oximetry, and FEV1 , length of stay, and admission rates) and safety (albuterol plasma levels, heart rate, serum potassium, glucose and bicarbonate levels, EKG, and tremor rates) outcome measures were assessed. RESULTS: We included 119 patients with similar baseline conditions, and no significant differences were observed between groups in the length of stay (P = 0.48) or admission rate (P = 0.55). No significant differences were observed in FEV1 , PRAM score, and pulse oximetry changes after 1 hr and at discharge or admission. No significant differences were observed in safety outcomes between groups. CONCLUSIONS: Higher albuterol dosage regimens did not result in lower admission rate or shorter length of stay in the ER, but showed similar safety profile for children with moderate to severe acute asthma. Pediatr Pulmonol. 2016;51:1122-1130. © 2016 Wiley Periodicals, Inc.

Impairment of Venous Drainage on Extracorporeal Membrane Oxygenation Secondary to Air Trapping in Acute Asphyxial Asthma.

The inability to adequately support a patient on extracorporeal membrane oxygenation (ECMO) due to impaired drainage is not an uncommon occurrence during support. Typically, the causes include hypovolemia, kinks in the circuit, cannula malposition, or inadequate cannula size. In this report we present an uncommon etiology of this problem. A 3-year-old female presented to our hospital in status asthmaticus and pulseless electrical activity (PEA). This was a result of dynamic hyperinflation of the lungs causing physical obstruction of venous return to the heart. Upon initiating venoarterial (VA) ECMO, we experienced inadequate drainage that did not improve despite multiple interventions. This resolved with the addition of an inhaled anesthetic gas to treat this patient's severe bronchospasm. This case illustrates the importance of considering a patient's physiology or disease state and how that may affect the mechanics of ECMO support.

Volatile anesthetics for status asthmaticus in pediatric patients: a comprehensive review and case series.

Status asthmaticus is an acute, intractable asthma attack refractory to standard interventions that can lead to progressive respiratory failure. Successful management requires a fundamental understanding of the disease process, its clinical presentation, and proper evaluation. Treatment must be instituted early and is aimed at reversing the airway inflammation, bronchoconstriction, and hyper-reactivity that often lead to lower airway obstruction, impaired ventilation, and oxygenation. Most patients are effectively treated with standard therapy including beta2-adrenergic agonists and corticosteroids. Others necessitate adjunctive therapies and escalation to noninvasive ventilation or intubation. We will review the pathophysiology, evaluation, and treatment options for pediatric patients presenting with status asthmaticus with a particular focus on refractory status asthmaticus treated with volatile anesthetics. In addition, we include a proven approach to the management of these patients in the critical care setting, which requires close coordination between critical care and anesthesia providers. We present a case series of three patients, two of which have the longest reported cases of continuous isoflurane use in status asthmaticus. This series was obtained from a retrospective chart review and highlights the efficacy of the volatile anesthetic, isoflurane, in three pediatric patients with refractory life-threatening status asthmaticus.

Extracorporeal membrane modality conversions.

We report the case of a patient with cardiovascular and respiratory failure due to severe anaphylaxis requiring multiple extracorporeal membrane oxygenation (ECMO) cannulation strategies to provide adequate oxygen delivery and ventilatory support during a period of rapid physiological change. ECMO provides partial or complete support of oxygenation-ventilation and circulation. The choice of which ECMO modality to use is governed by anatomical (vessel size, cardiovascular anatomy and previous surgeries) and physiological (respiratory and/or cardiac failure) factors. The urgency with which ECMO needs to be implemented (emergency cardiopulmonary resuscitation (eCPR), urgent, elective) and the institutional experience will also influence the type of ECMO provided. Here we describe a 12-year-old schoolgirl who, having been resuscitated with peripheral veno-venous (VV) ECMO for severe hypoxemia due to status asthmaticus in the setting of acute anaphylaxis, required escalation to peripheral veno-arterial (VA) ECMO for precipitous cardiovascular deterioration. Insufficient oxygen delivery for adequate cellular metabolic function and possible cerebral hypoxia due to significant differential hypoxia necessitated ECMO modification. After six days of central (transthoracic) VA ECMO support and 21 days of intensive care unit (ICU) care, she made a complete recovery with no neurological sequelae. The use of ECMO support warrants careful consideration of the interplay of a patient's pathophysiology and extracorporeal circuit dynamics. Particular emphasis should be placed on the potential for mismatch between cardiovascular and respiratory support as well as the need to meet metabolic demands through adequate cerebral, coronary and systemic oxygenation. Cannulation strategies occasionally require alteration to meet and anticipate the patient's evolving needs.

Efficacy of nebulised budesonide versus oral prednisolone in acute severe asthma.

OBJECTIVE: To compare the efficacy of nebulised budesonide with that of oral prednisone in the treatment of acute severe asthma in children. METHODS: Children aged 5-12 y with acute exacerbation of bronchial asthma were included. The study (budesonide) group received budesonide respirator solution (800 µg) at intervals of 20 min and a single dose of placebo tablets. The control (prednisolone) group received placebo solution at intervals of 20 min and a single dose of oral prednisolone (2 mg/kg). Both groups received three doses of nebulised salbutamol (0.15 mg/kg). Heart rate, respiratory rate, oxygen saturation, PEFR (Peak Expiratory Flow Rate) and fitness for discharge were assessed. RESULTS: Both groups showed a progressive decrease in tachycardia with treatment, but it was significantly greater in study group (p = 0.0002). There was significant decrease in tachypnea and improvement in oxygen saturation in both groups, but the difference between the groups (p = 0.334 and p = 0.814 respectively) was not significant. There was significant improvement in PEFR values in budesonide group (p = 0.024). Both groups showed significant improvement in clinical severity scores at the end of 2 h (p < 0.0001). Budesonide group had significantly higher proportion of patients fit for discharge at 2 h (based on clinical severity scores) (p = 0.0278). CONCLUSIONS: Nebulised budesonide significantly improves PEFR levels and fitness for discharge at 2 h when compared to oral prednisolone in children between 5 and 12 y with acute severe asthma.

Aminophylline infusion for status asthmaticus in the pediatric critical care unit setting is independently associated with increased length of stay and time for symptom improvement.

INTRODUCTION: The role of aminophylline in the treatment of severe acute asthma in the pediatric critical care unit (PCCU) is not clear. We sought to examine the association of aminophylline treatment with PCCU length of stay and time to symptom improvement. MATERIAL AND METHODS: Patients with severe acute asthma who were admitted to our PCCU and received aminophylline infusion were retrospectively compared with similar patients who did not receive aminophylline. The primary outcome measure was functional length of stay (i.e. time to which patients could be transferred to a general pediatric ward bed). A secondary outcome was time to symptom improvement. RESULTS: Adjusted functional length of stay was longer for subjects who received aminophylline (n = 49) than for the patients who did not (n = 47) (hazard ratio 0.396, p < 0.001), as well as the time for symptom improvement (hazard ratio 0.359, p < 0.001). In the group of subjects receiving aminophylline, those with a serum theophylline level ≥ 10 mcg/ml (therapeutic) (n = 31) had longer functional length of stay (hazard ratio 0.457, p = 0.0225) and time to symptom improvement (hazard ratio 0.403, p = 0.0085) than those with levels < 10 mcg/ml (sub-therapeutic) (n = 18). CONCLUSIONS: The addition of aminophylline to therapy with corticosteroids and inhaled ß-agonists was associated with statistically and clinically significant increases in functional length of stay and time to symptom improvement in the PCCU. This potential morbidity supports the National Asthma Education and Prevention Program guideline proscribing aminophylline use in acute asthma.