Feature Articles

Endotracheal intubation and pediatric status asthmaticus: Site of

original care affects treatment*
Christopher L. Carroll, MD; Sharon R. Smith, MD; Melanie S. Collins, MD; Anita Bhandari, MD;
Craig M. Schramm, MD; Aaron R. Zucker, MD

Objectives: Status asthmaticus is a common cause of admis-
sion to a pediatric intensive care unit (PICU). Children unrespon-
sive to medical therapies may require endotracheal intubation;
however, this treatment carries significant risk, and thresholds
for intubation vary. Our hypothesis was that children who sought
care at community hospitals received less aggressive treatment
and more frequent intubation than children who sought care at a
children’s hospital.
Design: Retrospective cohort study.
Setting: A university-affiliated children’s hospital PICU.
Patients: We retrospectively examined data from all children
older than 2 yrs admitted to the PICU with status asthmaticus
between April 1997 and July 2005.
Interventions: None.
Measurements and Main Results: Of the 251 children admitted
to the PICU with status asthmaticus, 130 initially presented to the
emergency department of a children’s hospital and 116 presented
to the emergency department of a community hospital. Despite
similar illness severity, children presenting to a community hos-
pital were significantly more likely to be intubated than those
presenting to a children’s hospital (17% vs. 5%; p ⴝ .004). In
addition, those children intubated at community hospitals were
intubated sooner after presentation (2.4 ⴞ 5.2 vs. 7.5 ⴞ 5.8 hrs;
p ⴝ .009), had shorter durations of intubation (71 ⴞ 73 vs. 151 ⴞ
81 hrs; p ⴝ .02), and had shorter PICU length of stays (129 ⴞ 82
vs. 230 ⴞ 84 hrs; p ⴝ .01).
Conclusions: Children with status asthmaticus are more likely
to be intubated, and intubated sooner, at a community hospital.
The shorter duration of intubation suggests that some children
may not have been intubated had they presented to a children’s
hospital or received more aggressive therapy at their community
hospital. (Pediatr Crit Care Med 2007; 8:91–95)
KEY WORDS: pediatrics; status asthmaticus; endotracheal intu-
bation

P ediatric asthma exacerbations
are a frequent cause of emer-
gency department (ED) visits
and one of the most common
causes of hospitalization in the United
States (1–3). Despite considerable ad-
vances in our understanding of its patho-
physiology and an array of treatment op-
tions, asthma remains a potentially fatal
disease with significant morbidity (1, 2).
If a patient does not respond to aggressive
medical therapy, endotracheal intubation
may be required (1–3). Because of the
risk involved with this intervention, ag-
gressive medical therapy is encouraged
before endotracheal intubation.
*See also p. 186.
From Pediatric Critical Care (CLC, ARZ), Pediatric
Emergency Medicine (SRS), and Pediatric Pulmonology
(MSC, AB, CMS), Connecticut Children’s Medical Cen-
ter, Hartford, CT.
The authors have not disclosed any potential con-
flicts of interest related to this manuscript.
Copyright © 2007 by the Society of Critical Care
Medicine and the World Federation of Pediatric Inten-
sive and Critical Care Societies
DOI: 10.1097/01.PCC.0000257115.02573.FC
Nevertheless, identifying which chil-
dren may benefit from mechanical venti-
lation is challenging. Modest degrees of
hypercarbia are generally well tolerated
in nonintubated children with status
asthmaticus (4), and reliable and repro-
ducible measures of pulmonary function
are lacking in ill children (1–3). In addi-
tion, endotracheal intubation and me-
chanical ventilation can have significant
adverse effects in asthmatic patients (5–
12). The presence of an endotracheal tube
can aggravate bronchospasm, and 10 –
26% of children ventilated for status
asthmaticus have been reported to expe-
rience serious complications (8 –11).
Some authors suggest that a subgroup
of pediatric patients with status asthmati-
cus present with acute asphyxial or rapid-
onset near-fatal asthma (13), which is a
recognized phenotype in adult patients
(14). Maffei et al. (13) found that children
intubated in the ED required a shorter
duration of mechanical ventilation than
children intubated in the pediatric inten-
sive care unit (PICU). The authors con-
cluded that the children who were intu-
bated rapidly in the ED may represent a
pediatric version of this phenotype. How-
ever, factors other than a patient’s condi-
tion, such as site of initial presentation,
may be responsible for variations in the
practice of intubation for pediatric pa-
tients with status asthmaticus, many of
whom may not have near-fatal illness.
Based on this impression, we hypoth-
esized that pediatric patients with status
asthmaticus are more likely to be intu-
bated at a community hospital than a
children’s hospital and that the children
intubated at a community hospital are
more likely to receive less aggressive
medical therapy before intubation.
METHODS
This study was approved by the Institu-
tional Review Board at Connecticut Children’s
Medical Center, and the requirement for in-
formed consent was waived due to its retro-
spective nature.
The medical records of all children admit-
ted to the PICU for treatment of status asth-
maticus between April 1997 and July 2005
were retrospectively reviewed. Patients were
identified from a previously existing database
of patients maintained for quality improve-

Pediatr Crit Care Med 2007 Vol. 8, No. 2 91

ment purposes. Children were included in the
study if they were admitted to the intensive
care unit with status asthmaticus and were
between the ages of 2 and 18 yrs. Children
were excluded if they had coexisting chronic
medical conditions other than asthma, such as
chronic aspiration, restrictive lung disease,
and bronchopulmonary dysplasia. One child
died during hospitalization from cerebral
edema and was excluded from further analysis.
Data were collected retrospectively from the
hospital records at Connecticut Children’s
Medical Center, from the referral hospital
records, and from the Emergency Medical Ser-
vices records. Data were extracted using a uni-
form data extraction tool by three of the in-
vestigators (CLC, MSC, and AB). Audits for
uniformity were performed by the principal
investigator (CLC). Data such as symptoms at
presentation and the duration of symptoms
were obtained from the chief complaints, the
history of present illness, and the review of
systems charted.
Location of intubation was classified as a)
at a children’s hospital if the child was intu-
bated at the regional children’s hospital, CT
Children’s Medical Center; b) at a community
hospital if the child was intubated in a non-
children’s hospital facility; or c) out of hospital
if the child was intubated by emergency med-
ical services (EMS) before ED arrival. Location
of original presentation was similarly defined.
Data concerning presenting symptoms, the
history surrounding intubation at a commu-
nity hospital or out of hospital, patient demo-
graphics, and outcomes were obtained retro-
spectively from the medical records of the
involved services. Baseline asthma severity
was determined using the guidelines set by the
National Heart, Lung, and Blood Institute that
classify severity based on frequency of symp-
toms (15). In children who did not have an
asthma classification determined at the time
of admission, a level was assigned retrospec-
tively by one of two investigators (CLC and
AB). There were no other missing data. The
Modified Pulmonary Index Score (MPIS), a
validated asthma severity score in this popu-
lation and in our institution (16), was used to
assess illness severity on admission. The MPIS
was determined prospectively within 1 hr of
PICU admission for intubated and nonintu-
bated patients, by practitioners specifically
trained for use of the score and without ad-
justment for intubation status.
Connecticut Children’s Medical Center is
the only referral center for pediatric patients
in northern Connecticut. In this region, all
children who receive continuous albuterol
nebulizer treatments are transported to the
children’s hospital for further evaluation and
treatment and possible PICU admission. Once
at the children’s hospital, all children with an
MPIS of ⱖ12 or requiring ⬎40% supplemen-
92
tal oxygen to maintain saturations ⱖ94% are
evaluated by the PICU for possible admission.
Although there was no formal treatment
protocol in the study period, there were no
significant changes in practice during the
study period, nor were there significant
changes in physician, nursing, or respiratory
therapist staffing. Four pediatric intensivists
directed the intensive care unit care during
this study period, three of whom were the
same throughout. The criteria for discharge
from the intensive care unit did not change
during the study period. A patient was trans-
ferred from the intensive care unit to the ward
when a) that patient required bronchodilator
therapy of ⱕ20 mg/hr of continuous albuterol
aerosol; b) the patient required supplemental
oxygen ⱕ40%; and c) the MPIS was ⱕ10. At
the study institution, patients may be treated
with continuous albuterol nebulizer treat-
ments on the inpatient ward. Length of stay
was calculated from actual admission and dis-
charge times.
The Modified Pulmonary Index Score.
Asthma scoring systems are often used in pe-
diatric patients to quantify illness severity due
to the difficulty of obtaining reliable and re-
producible measures of air flow obstruction in
critically ill children. The MPIS has been
shown to be highly reproducible between
groups of medical professionals (respiratory
therapists, nurses, and physicians) as well as
among individuals within each group (16). In
the MPIS, six different categories are evalu-
ated: oxygen saturation in room air, accessory
muscle use, inspiratory/expiratory ratio, de-
gree of wheezing, heart rate, and respiratory
rate. For each of these six measurements or
observations, a score of 0 –3 is assigned, re-
sulting in a possible minimum score of 0 and
a maximum score of 18 (16). Although vali-
dated in 2003 and published in 2005, the MPIS
has been a standard part of the initial and
ongoing assessment of a child with status
asthmaticus at our institution since before
this study began.
Statistical Analysis. Descriptive data are
expressed as frequencies (%) or as mean ⫾ SD.
A Student’s t-test was used for comparisons of
continuous variables with normal distribu-
tions, and the Mann-Whitney U test was used
for continuous variables without normal dis-
tributions. The Kruskal-Wallis test was used to
compare continuous variables among more
than two groups. A chi-square test was used
for comparison of categorical variables. A p
value ⬍.05 was considered statistically signif-
icant. Data were analyzed using the JMP sta-
tistical software (version 6.0; Cary, NC) along
with biostatistical consultation from the Office
of Research at Connecticut Children’s Medical
Center.
RESULTS
Site of Original Care Affects Fre-
quency of Intubation. Between April
1997 and July 2005, 251 children meet-
ing the inclusion criteria were admitted
to the PICU. Of these, 130 children (52%)
presented directly to the ED of the chil-
dren’s hospital, 116 children (46%) pre-
sented directly to the ED of an outside
community hospital, and five children
(2%) were intubated by EMS before ED
arrival and then subsequently transferred
to the PICU. Baseline asthma severity,
history of hospitalization for asthma, and
acute asthma severity (admission MPIS)
were similar in children presenting to the
children’s hospital and those presenting
to a community hospital (Table 1). Out-
come data, such as hospital and PICU
length of stay, and duration of therapies
received were also similar between these
two groups (Table 1). However, children
who originally sought medical care at a
community hospital ED were signifi-
cantly more likely (odds ratio 3.7; 95%
confidence interval 1.5, 9.0) to have been
intubated and mechanically ventilated
than those who originally sought care at
a children’s hospital ED.
Characteristics of Mechanically Ven-
tilated Children. Thirty-two of the chil-
dren admitted to the PICU (13%) were
intubated and mechanically ventilated. Of
these children, seven (22%) were intu-
bated at a children’s hospital, 20 (63%) at
community hospitals, and five (16%) by
EMS. Of the 20 children intubated at a
community hospital, 17 (85%) were intu-
bated in the ED and three (15%) were
intubated on the ward. Of the seven chil-
dren intubated at a children’s hospital,
two (29%) were intubated in the ED and
five (71%) in the intensive care unit.
Baseline demographics of these children
were statistically similar (Table 2).
The duration of symptoms and symp-
toms at presentation were similar for all
intubated children (Table 3). However,
compared with those intubated at a chil-
dren’s hospital, children at a community
hospital were intubated sooner. Also, al-
though data were not statistically signif-
icant, children intubated at a community
hospital tended to less frequently receive
albuterol, corticosteroids, and parenteral
␤2-agonists and tended to be more likely
to receive no treatment before intuba-
tion.
Children intubated at community hos-
pitals also had shorter duration of intu-
bation and shorter PICU length of stay
compared with those children intubated
at a children’s hospital (Table 4 & Fig. 1).
Admission severity of illness was similar
between those children intubated at a
Pediatr Crit Care Med 2007 Vol. 8, No. 2
Table 1. Demographic and outcome data of all children admitted to the pediatric intensive care unit The overall rate of significant compli-
(PICU) who presented to an emergency department with an asthma exacerbation (excludes children cations during mechanical ventilation
intubated by emergency medical service and subsequently transferred to the PICU) was high (44%), regardless of location
(43% of children intubated at the chil-
Children Presenting Children Presenting
to a Children’s to a Community
dren’s hospital, 45% of children intu-
Hospital Hospital bated at a community hospital). These
(n ⫽ 130) (n ⫽ 116) p Value complications included ventilator-associ-
ated-pneumonia (16%), pneumomedias-
Age, yrs 8.0 ⫾ 4.5 8.6 ⫾ 4.3 .29 tinum (13%), aspiration pneumonia
Male gender, % 60 53 .31 (9%), pneumothorax (6%), and rhabdo-
Race or ethnicity, % .06
African-American 30 21
myolysis (6%).
Hispanic 45 31 Characteristics of Children Intubated
White 24 47 By EMS. Five children were intubated by
Obese (⬎95% weight-for-age), % 26 22 .55 EMS before transport to an ED. Due to
Previous hospitalization, % 60 59 .89 the small number of children involved
Previous PICU admission, % 23 27 .55
Previous intubation, % 4 9 .18 and the fact that these children were not
NHLBI asthma classification, % .27 evaluated by a physician before intuba-
Mild intermittent 29 37 tion, they were excluded from analysis for
Mild persistent 28 18 the purpose of describing the results. The
Moderate persistent 29 28
Severe persistent 15 16
baseline demographics of these children,
Admission MPIS 13.8 ⫾ 1.8 13.7 ⫾ 2.2 .55 including gender, race/ethnicity, fre-
Intubated, % 5 17 .004 quency of obesity, and frequency of pre-
Hospital length of stay, days 6.6 ⫾ 3.6 6.8 ⫾ 3.9 .65 vious hospitalization for asthma, were
PICU length of stay, hrs 69 ⫾ 59 76 ⫾ 62 .39 statistically similar to those children in-
Duration continuous albuterol, days 4.6 ⫾ 2.7 4.6 ⫾ 2.7 .92
Duration oxygen, days 4.6 ⫾ 2.7 4.7 ⫾ 3.0 .69 tubated at a community hospital and at
Duration of intravenous steroids, days 4.4 ⫾ 2.8 4.5 ⫾ 2.7 .61 the children’s hospital. The duration of
symptoms and types of symptoms at pre-
NHLBI, National Heart, Lung, and Blood Institute; MPIS, Modified Pulmonary Index Score. sentation, duration of hospitalization, du-
ration of mechanical ventilation, and du-
Table 2. Demographic data of intubated children by location of intubation ration of treatments received were also
statistically similar to the other groups of
Intubated at a Intubated at a children.
Children’s Hospital Community Hospital
(n ⫽ 7) (n ⫽ 20) p Value
DISCUSSION
Age, yrs 7.5 ⫾ 5 10.3 ⫾ 4.6 .19
Male gender, % 71 55 .66 In this retrospective review, we found
Race or ethnicity, % .36 that children with status asthmaticus
African-American 14 40 were three times more likely to be intu-
Hispanic 29 25
White 57 35
bated at community hospitals than at a
Obese (⬎95% weight-for-age), % 29 30 1.00 children’s hospital despite similar base-
Previous hospitalization, % 71 90 .29 line illness, acute asthma severity, and
Previous PICU admission, % 29 45 .66 hospital courses. In addition, those chil-
Previous intubation, % 0 25 .28 dren intubated at community hospitals
Asthma classification, % .27
Mild intermittent 0 10 had a shorter duration of observation and
Mild persistent 57 20 treatment before intubation and had a
Moderate persistent 29 35 shorter duration of mechanical ventila-
Severe persistent 14 35 tion. These data suggest that the physi-
cians at community hospitals have a
PICU, pediatric intensive care unit.
lower threshold for endotracheal intuba-
tion and that some of these children may
children’s hospital and those intubated at tained within 1 hr before and after intu- not have been intubated if they had pre-
a community hospital. Children intu- bation. The venous blood gas measure- sented to a children’s hospital or had
bated at a community hospital also re- ments of children intubated at a received more aggressive therapy at their
ceived less therapy during the course of children’s hospital were similar before community hospital.
their hospitalization including a shorter and after intubation: pH (7.27 ⫾ 0.12 vs. Although potentially lifesaving, endo-
duration of continuous albuterol, supple- 7.24 ⫾ 0.21; p ⫽ .57) and PCO2 (59 ⫾ 19 tracheal intubation and mechanical ven-
mental oxygen, and intravenous steroids vs. 68 ⫾ 35; p ⫽ .36). However, the ve- tilation can have significant adverse ef-
(Table 4). nous blood gases of those intubated at a fects in children with asthma (1, 2, 5–12).
Fourteen children (six of those intu- community hospital had a significantly The complication rate is high and in-
bated at a children’s hospital and eight of worse pH (7.29 ⫾ 0.08 vs. 7.16 ⫾ 0.13; cludes pneumothorax (8, 9), barotrauma
those intubated at a community hospital) p ⫽ .01) and PCO2 (49 ⫾ 11 vs. 76 ⫾ 29; (10), and myopathy (10). More than half
had venous blood gas measurements ob- p ⫽ .02) following intubation. of the significant morbidity and mortality

Pediatr Crit Care Med 2007 Vol. 8, No. 2 93

Table 3. Data surrounding intubation by location of intubation a complication during the course of me-
chanical ventilation.
Intubated at a Intubated at a
The results of this study suggest that
Children’s Hospital Community Hospital
treatments received for status asthmati-
(n ⫽ 7) (n ⫽ 20) p Value
cus and respiratory failure may differ for
Duration of symptoms, days 2.6 ⫾ 1.4 1.9 ⫾ 1.7 .37 reasons not related to a patient’s under-
Symptoms at presentation, % lying condition. Previous investigators
Respiratory distress 57 40 .41 have shown that there are also significant
Altered mental status 29 40 .56 variations in the care provided for chil-
Hypoxia 14 20 .73
Seizure 0 10 .48 dren with asthma based on the institu-
Syncope 0 5 .79 tion and on the region of the country
Diminished breath sounds 0 15 .69 where the care is provided (4, 17). In one
Respiratory acidosis 14 0 .43 retrospective study of 1,528 children in
Time to intubation, hrs 7.5 ⫾ 5.2 2.4 ⫾ 5.2 .009
Treatment before intubation, %
11 PICUs, the rate of mechanical ventila-
Albuterol 100 75 .27 tion varied widely from institution to in-
IV/SQ ␤2-agonist 86 40 .08 stitution, ranging from 3% to 47% (17).
Corticosteroid 86 45 .19 In another retrospective study of 7,125
No Tx before intubation 0 20 .28 children admitted for status asthmaticus
IV, intravenous; SQ, subcutaneous; Tx, therapy.
to 41 different PICUs, there was wide
variability in practice across regions of
the United States (4).
Table 4. Outcome and treatment data of intubated children by location of intubation
Acute asphyxial asthma, or rapid-onset
Intubated at a Intubated at a near-fatal asthma, has been described in
Children’s Hospital Community Hospital adults by a brief duration of symptoms
(n ⫽ 7) (n ⫽ 20) p Value and a rapid progression to respiratory
failure (13, 14). Response to therapy
Admission MPIS 15.4 ⫾ 2.0 14.9 ⫾ 2.1 .53 tends to be rapid and duration of me-
Hospital length of stay, days 15.2 ⫾ 7.6 10.1 ⫾ 6.4 .09 chanical ventilation short (13, 14). This
PICU length of stay, hrs 230 ⫾ 84 129 ⫾ 82 .01
Duration intubation, hrs 151 ⫾ 81 71 ⫾ 73 .02 phenotype may exist in pediatric patients,
Intubated ⱕ24 hrs, % 0 30 .15 but the similar duration of illness in chil-
Duration continuous albuterol, days 9.1 ⫾ 3.8 6.2 ⫾ 3.0 .04 dren intubated at community hospitals
Duration oxygen, days 10.9 ⫾ 2.8 6.6 ⫾ 3.7 .01 and the children’s hospital suggests that
Duration IV steroids, days 11.3 ⫾ 4.5 6.8 ⫾ 3.4 .01
other confounders also may significantly
MPIS, Modified Pulmonary Index Score; PICU, pediatric intensive care unit; IV, intravenous. affect the decision to intubate a child
with status asthmaticus.
However, there are several important
reasons that a child with asthma may be
intubated more frequently at a commu-
nity hospital than at a children’s hospital.
Transporting a critically ill child in respi-
ratory distress without a secure airway
may carry significant risk. In addition,
distance to a referral center and the ex-
perience and familiarity of the intubating
physician with pediatric patients may af-
fect the decision to intubate. This study
was conducted in a densely populated
state with relatively short distance to a
referral center, so any influence of these
confounding factors may have an even
greater impact in regions with longer
transport distances.
This study is limited by its small
power and retrospective nature. Deter-
mining presenting symptoms and ration-
Figure 1. Duration of mechanical ventilation by location of intubation (p ⫽ .02 by log-rank test). ales for intubation is difficult retrospec-
tively. The shorter duration of ventilation
in children intubated at community hos-
associated with severe asthma occur dur- exacerbation is associated with an in- pitals could be interpreted as supporting
ing or immediately following endotra- creased risk of death (6, 7, 12). In this a practice of early intubation. However
cheal intubation (1, 2), and the use of study, almost half of the children intu- another explanation, supported by the
mechanical ventilation during an asthma bated for status asthmaticus experienced differences in preintubation medical care

94 Pediatr Crit Care Med 2007 Vol. 8, No. 2

between the two groups, is that some of
the children with short duration of intu-
bation may not have been intubated had
they presented to a children’s hospital.
Although not statistically significant,
children who presented to community
hospitals tended to receive less aggressive
treatment for their acute exacerbation
(Table 3). Along with the higher inci-
dence of endotracheal intubation in chil-
dren presenting to a community hospital
with status asthmaticus (Table 1), these
data support the notion of a lower thresh-
old for intubation at community hospi-
tals. Since complication rates did not
vary with the timing of intubation, early
intubation may expose an increased num-
ber of children to serious complications
that could potentially be avoided with
longer medical treatment.
One child who died during the hospi-
talization from cerebral edema was ex-
cluded from this study. This child was
intubated in the PICU of the children’s
hospital following presentation to the ED
of the children’s hospital. She had no
documented hypoxia before or during her
hospitalization or surrounding her intu-
bation. The etiology of her cerebral
edema, which developed 12–24 hrs fol-
lowing intubation, was undetermined
and no autopsy was obtained. On subse-
quent analysis, inclusion of this patient
did not affect the results of the study.
However, because of the unusual circum-
stances involved, we elected to exclude
her from this study.
Another limitation of this study is a
concern that data may be missing from
other children presenting to community
hospitals for status asthmaticus during
this period. Since our institution is the
only referral center for pediatric patients
in the region, children with more than a
mild or moderate exacerbation (i.e., any
child requiring continuous albuterol neb-
ulizer treatments) are transported to our
children’s hospital for evaluation and
treatment. In addition, all children with
an MPIS ⱖ12 or receiving ⬎40% supple-
mental oxygen are evaluated by the PICU
for possible admission. Given this health-
care environment, we feel that we have
accurately captured all or almost all of
the children in the area with severe status
asthmaticus during this study period.
Although the demographics of chil-
dren intubated at a community hospital
and at the children’s hospital were statis-
Pediatr Crit Care Med 2007 Vol. 8, No. 2
tically similar, there were some notable
trends (Table 2). There were a small
number (n ⫽ 5) of children who were
intubated at community hospitals and
had previous episodes of intubation. Un-
fortunately, we do not have data regard-
ing these children’s previous intubations,
since they occurred before the study pe-
riod. However, compared with the other
children intubated at community hospi-
tals, these five children were significantly
older (13.2 ⫾ 2.8 vs. 8.2 ⫾ 5 yrs; p ⫽
.045). There were no other significant
differences in demographic data or ad-
mission MPIS. On subsequent analysis,
exclusion of these children did not
change the results of the study.
There were no statistically significant
differences in the racial background, his-
tory of previous hospitalization for
asthma, and baseline asthma severity of
the children intubated at a community
hospital and those intubated at the chil-
dren’s hospital (Table 2). Nevertheless, it
should be noted that this relatively small
study was of insufficient power to exclude
differences in any of these variables. In-
deed, it is possible that intubated patients
could have had genetic responsiveness to
␤2-agonist therapy or other differences in
asthma phenotype that need to be ex-
plored in future investigations. Unfortu-
nately, the small number of patients in-
volved in this study precluded further
analysis.
CONCLUSIONS
Children with status asthmaticus and
respiratory failure comprise a small but
significant percentage of children with
asthma. Prospective clinical trials are dif-
ficult due to the relatively small numbers
of children with this condition and the
wide variability in treatment practice be-
tween regions and between institutions.
This study shows that differences in the
care received are also related to the loca-
tion of initial treatment and may not re-
flect the severity of the exacerbation.
Only a well-designed prospective trial in-
volving a variety of types of institutions in
different regions would be able to deter-
mine which children with status asth-
maticus may truly benefit from endotra-
cheal intubation.
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