Treatment for refractory asthma exacerbations is frequently subjective and is generally determined by personal experience, anecdotal evidence, and the results of small clinical studies. First-line care for the treatment of pediatric asthma exacerbations includes oxygen, systemic corticosteroids, and aerosolized β₂-agonists. In children unresponsive to these treatments, PICU admission is necessary for additional therapies and closer monitoring of respiratory status. Several second-line therapies are available, such as intravenous (IV) β₂-adrenergic receptor agonists, magnesium, and heliox. Combinations of these are used in PICUs for the treatment of severe exacerbations. If a child does not respond to this aggressive medical therapy, endotracheal intubation and mechanical ventilation may be required.

Intubation and Mechanical Ventilation
Although potentially life-saving, endotracheal intubation and mechanical ventilation carry significant risks in children with asthma.The presence of an endotracheal tube can aggravate a child’s bronchospasm and is associated with a high incidence of serious complications (25–50%). More than half of the significant morbidity and mortality associated with severe asthma occurs during or immediately following endotracheal intubation. Due to these risks, practitioners must weigh the risks of intubation against the risks of impending respiratory failure. Identifying which children may benefit from intubation and mechanical ventilation is challenging. Modest amounts of hypercapnea and respiratory acidosis are generally well-tolerated in non-intubated children with status asthmaticus. Objective measures of pulmonary function that might give insight into a child’s degree of respiratory distress are difficult to obtain in critically ill children.Variables unrelated to the child’s physiologic condition, such as the presence of pediatric subspecialty back-up and distance to a regional referral center, may also impact the decision to intubate. In general, a strategy of aggressive medical therapy is recommended prior to endotracheal intubation. There are some children in which intubation and mechanical ventilation are necessary and there are some absolute indications for the intubation of a child with status asthmaticus. These include respiratory or cardiac arrest, severe hypoxia, or a rapid deterioration of mental status.

Rapid sequence technique is the preferred method of intubation in children with status asthmaticus. Prior to intubation, the child should be pre-oxygenated with 100% oxygen, placed on respiratory and cardiac monitors, suctioned if necessary, and the stomach decompressed. Ketamine is the preferred induction agent, owing to its bronchodilatory effects. Atropine may also be used as an antisialogogue. Short-acting neuromuscular blocking agents should be considered to reduce some of the large swings in airway pressure following intubation and possibly prevent periintubation barotrauma and its resultant complications. The ‘Sellick’ maneuver (application of cricoid pressure during intubation) should be used to reduce the risk of aspiration. Primary (via visualization and auscultation) and secondary (end-tidal CO₂ monitoring and chest radiography) methods of confirming endotracheal tube placement are essential.