Verberne AA, Frost C, Duiverman EJ, Grol MH, Kerrebijn KF. Salbutamol is recommended to be delivered by either: MDI with spacer: 4–10 puffs every 20 min for 1 h, then every 1–2 h according to response (Evidence A). Rodrigo G, Rodrigo C. Metered dose inhaler salbutamol treatment of asthma in the ED: Comparison of two doses with plasma levels. Cochrane Database Syst Rev 2000;(4):CD002742. Saji J, Arai M, Yamamoto T, Mineshita M, Miyazawa T. Efficacy of omalizumab in patients with severe asthma using the asthma health questionnaire and asthma control test. Chest 2005;127:509-14. Current thinking on the relationship between rhinosinusitis and asthma. Cochrane Database Syst Rev 2002;(3):CD002314. They are tachypneic and may be using their respiratory accessory muscles. Eur Respir J 2017;50. pii: 1701103. Rowe BH, Spooner C, Ducharme FM, Bretzlaff JA, Bota GW. Respirology 2002;7:141-6. Continuous nebulization may be superior to the MDI/holding chamber method in a patient with severe exacerbations (eg, PEF < 200 L/min). Bronchial thermoplasty: Where there is smoke, there is fire. Levels of acceptance of asthma control test questionnaire among saudi patients attending 5 tertiary care hospitals in Saudi Arabia. Levalbuterol: Pharmacologic properties and use in the treatment of pediatric and adult asthma. Ducharme FM, Ni Chroinin M, Greenstone I, Lasserson TJ. Koczulla AR, Vogelmeier CF, Garn H, Renz H. New concepts in asthma: Clinical phenotypes and pathophysiological mechanisms. However, for patients with early signs of attack at presentation, an initial short course of oral steroids may be required together with the prescription of the maintenance therapy. Knorr B, Franchi LM, Bisgaard H, Vermeulen JH, LeSouef P, Santanello N. Bisgaard H. Leukotriene modifiers in pediatric asthma management. Guilbert TW, Morgan WJ, Zeiger RS, Bacharier LB, Boehmer SJ, Krawiec M. Castro-Rodriguez JA. Ortega HG, Yancey SW, Mayer B, Gunsoy NB, Keene ON, Bleecker ER. The overlap syndrome of asthma and COPD: What are its features and how important is it? Bronchial epithelial cells will subsequently release IL-25, IL-33, and thymic stromal lymphopoietin (TSLP) that will stimulate innate lymphoid cells type 2 to release IL-5 and IL-13. Pediatrics 2006;118:322-9. Ann Pharmacother 2013;47:1175-81. Global Initiative for Asthma. Activation of these receptors causes adenylyl cyclase to convert ATP to cAMP, beginning the signalling cascade that ends with the inhibition of myosin phosphorylation and lowering the intracellular concentration of calcium ions (myosin phosphorylation and calcium ions are necessary for muscle contractions). Relationship between asthma medication and antibiotic use. Monaldi Arch Chest Dis 2002;57:76-83. There is growing evidence to support the use of anti-IgE in children 6–12 years of age who fulfill the following criteria (Evidence A): Severe persistent allergic asthma with frequent daytime symptoms or night-time awakenings and who have multiple documented severe asthma attacks despite daily high-dose ICS plus LABA. Sturdy PM, Victor CR, Anderson HR, Bland JM, Butland BK, Harrison BD. If a formoterol/ICS combination is selected, patient may be advised to use this combination for both maintenance and rescue using extra puffs from the same inhaler (Evidence A). Early consideration may save the patient from frequent or chronic use of oral corticosteroids. Bergeron C, Al-Ramli W, Hamid Q. Remodeling in asthma. Increasing the use of reliever treatment is usually an early sign of worsening of asthma control (Evidence A). Report of a workshop held in Eze, France, October 1992. Miller MK, Lee JH, Miller DP, Wenzel SE; TENOR Study Group. In addition to a low-to-moderate dose of ICS, a short course of oral prednisolone is recommended to be considered for a child aged 5–12 years with early signs of asthma attack at presentation. It was first sold by Allen & Hanburys (UK) under the brand name Ventolin, and has been used for the treatment of asthma ever since. Inhaled salbutamol was banned from those games, but by 1986 was permitted (although oral beta-2 agonists were not). Gibson PG, Powell H. Written action plans for asthma: An evidence-based review of the key components. Hypoxemia apparently disproportionate to the attack severity. Continue systemic steroid: IV hydrocortisone 200 mg daily or IV methylprednisolone 80 mg in divided doses. Taylor DR, Bateman ED, Boulet LP, Boushey HA, Busse WW, Casale TB. Dufour V, Millon L, Faucher JF, Bard E, Robinet E, Piarroux R. Adams NP, Bestall JB, Jones PW. Almakrami IH, Alzahrani EA, Alqarni SA. Assessment of knowledge and adherence of pediatric residents to Saudi initiative asthma (SINA) guidelines in Saudi Arabia. A child is not controlled at step 1: The preferred option is to escalate to step 2 with low-dose ICS (Evidence A). Development of a clinical asthma score for use in hospitalized children between 1 and 5 years of age. Adcock IM, Lane SJ, Brown CR, Peters MJ, Lee TH, Barnes PJ. Chung KF, Wenzel SE, Brozek JL, Bush A, Castro M, Sterk PJ. Prednisolone dose is 1–2 mg/kg up to a maximum dose based on age. Butler C, Heaney LG. Ann Thorac Med 2015;10:143-5. Addition to inhaled corticosteroids of long-acting beta2-agonists versus anti-leukotrienes for chronic asthma. [6] In 2017, it was the tenth most commonly prescribed medication in the United States, with more than 50 million prescriptions. Natarajan S, Subramanian P. Allergic bronchopulmonary aspergillosis: A clinical review of 24 patients: Are we right in frequent serologic monitoring? Saudi Med J 2003;24:1274. Al-Haddad N, Nour A, Koshak E. Asthma care: Structural foundations at primary health care at Al-Qassim region, Saudi Arabia. It is triggered by microbes (bacteria and viruses), pollutants, and irritants. Nat Immunol 2015;16:45-56. Rahimi R, Nikfar S, Abdollahi M. Meta-analysis finds use of inhaled corticosteroids during pregnancy safe: A systematic meta-analysis review. J Allergy Clin Immunol 2003;111:180-6. Hardin M, Silverman EK, Barr RG, Hansel NN, Schroeder JD, Make BJ. This is the fourth version of the updated guidelines for the diagnosis and management of asthma, developed by the Saudi Initiative for Asthma (SINA) group, a subsidiary of the Saudi Thoracic Society. J Pediatr 2011;158:878-840. Kelly HW, Van Natta ML, Covar RA, Tonascia J, Green RP, Strunk RC. Pediatrics 2001;107:381-90. [39], It has also been tested in a trial aimed at treatment of spinal muscular atrophy; it is speculated to modulate the alternative splicing of the SMN2 gene, increasing the amount of the SMN protein whose deficiency is regarded as a cause of the disease. Asthma care pathways in the emergency department. Alanezi M, Al-Jahdali HH, Al-Hajjaj MS, Zeitoni MO, Al-Tasan TH. Just J, Gouvis-Echraghi R, Couderc R, Guillemot-Lambert N, Saint-Pierre P. Novel severe wheezy young children phenotypes: Boys atopic multiple-trigger and girls nonatopic uncontrolled wheeze. Woessner KM, Simon RA, Stevenson DD. Uncontrolled status is determined based on physician assessment complemented by a C-ACT score of ≤19 for a child aged 5–12 years or TRACK score of ≤80 for a child aged <5 years. BMJ 2001;323:1069. ... Finding: Reports recommended dose … Powell H, Gibson PG. Recommended option: Escalation of treatment by combining medium-high-dose ICS with LABA (Evidence A), In addition to the currently available combinations of ICS/LABA mentioned in step 3 section, the once a day combination of fluticasone furoate/vilanterol (Relvar) can be prescribed for adults and children above 12 years at a dose of 200/25 μg dose, If symptom control is not achieved, adding tiotropium to the combination of ICS and LABA is a recommended option as it significantly improves lung function in uncontrolled cases (Evidence A). Chassany O, Fullerton S. Meta-analysis of the effects of ipratropium bromide in adults with acute asthma. Ann Thorac Med 2009;4:115-23. Am J Respir Crit Care Med 2000;162:578-85. Symptoms are usually mild and infrequent with an ACT score of ≥20. Vaquerizo MJ, Casan P, Castillo J, Perpiña M, Sanchis J, Sobradillo V. Joos S, Miksch A, Szecsenyi J, Wieseler B, Grouven U, Kaiser T. Zeiger RS, Szefler SJ, Phillips BR, Schatz M, Martinez FD, Chinchilli VM. Gluck JC, Gluck PA. Differential anti-inflammatory effects of large and small particle size inhaled corticosteroids in asthma. Vous trouverez dans ici le détail sur les médicaments remboursés en France entre 2012 et 2019 (quand des données plus récentes seront publiées, elles … Al-Moamary MS, Alhaider SA, Al-Hajjaj MS, Al-Ghobain MO, Idrees MM, Zeitouni MO. Cochrane Database Syst Rev 2012;4:CD006923. J Allergy Clin Immunol 2007;120:1043-50. J Pediatr 2004;145:172-7. This category is only used in cases where the provision of some guidance was deemed valuable, but the clinical literature addressing the subject was insufficient to justify placement in one of the other categories. The recommended option is to double the dose of ICS (Evidence A). Eur Respir Rev 2012;21:79-81. Failing to respond to therapy, evidenced by: ABG analysis showing respiratory acidosis. A recent study has assessed the benefit of azithromycin at a dose of 250–500 mg 3 days/week as add-on therapy for 48 weeks for patient with persistent symptomatic asthma. It is further subdivided into two types: Early-onset allergic eosinophilic airway inflammation (extrinsic asthma): This type usually starts in childhood and can be triggered by allergen exposure. The maximum dose is 20 mg for children <2 years, 30 mg for children 2–5 years, and 60 mg for children 5–12 years. Allergens are taken up by dendritic cells and presented to naive T-cells that develop into Th2 cells characterized by the secretion of type 2 cytokines: interleukin (IL)-4, IL-5, and IL-13. Papi A, Nicolini G, Baraldi E, Boner AL, Cutrera R, Rossi GA. Fitzpatrick AM, Jackson DJ, Mauger DT, Boehmer SJ, Phipatanakul W, Sheehan WJ. Prevalence of chronic obstructive pulmonary disease among smokers attending primary healthcare clinics in Saudi Arabia. In a randomized crossover study two concentrations of benzalkonium chloride, 0.1% and 0.4%, used as a … Browne GJ, Giles H, McCaskill ME, Fasher BJ, Lam LT. [6] It is a short-acting β2 adrenergic receptor agonist which works by causing relaxation of airway smooth muscle. Deliver continuous nebulized salbutamol at a dose of 10–15 mg with ipratropium bromide at a dose of 1.5 mg over 1 h (Evidence A). Combined inhaled anticholinergics and short-acting beta2-agonists for initial treatment of acute asthma in children. Arch Dis Child 1988;63:900-4. Seear M, Wensley D, West N. How accurate is the diagnosis of exercise induced asthma among vancouver schoolchildren? Dicpinigaitis PV. Adjusted oxygen flow is recommended to keep saturation ≥92% (avoids excess oxygen). Al Moamary MS, Al-Kordi AG, Al Ghobain MO, Tamim HM. Thorax 2000;55:289-94. Eur Respir J 2002;19:846-52. doi: 10.1002/14651858.CD002308. Ann Thorac Med 2016;11:283-8. High doses or prolonged use may cause hypokalemia, which is of concern especially in patients with kidney failure and those on certain diuretics and xanthine derivatives. [6] It may also be used to treat high blood potassium levels. Combined inhaled anticholinergics and short-acting beta2-agonists for initial treatment of acute asthma in children. Step 2: Patients with seasonal asthma who are symptomatic during the season are recommended to start low-dose ICS during the season and to be treated at step 1 for the rest of the year if their ACT score is ≥20 (Evidence D). Ann Saudi Med 2003;23:349-53. Addition of intravenous aminophylline to beta2-agonists in adults with acute asthma. J Allergy Clin Immunol 1984;74:617-22. Proc Am Thorac Soc 2004;1:264-8. Tokuda Y, Miyagi S. Oxygen treatment for acute severe asthma. Egypt J Hosp Med 2018;70:686-91. Kozyrskyj AL, Pawlowski AN. Cochrane Database Syst Rev 2000;(4):CD002738. Hederos CA, Janson S, Andersson H, Hedlin G. Chest X-ray investigation in newly discovered asthma. Chipps BE, Bacharier LB, Harder JM. Pediatr Health 2008;2:631-50. Ignacio-Garcia JM, Gonzalez-Santos P. Asthma self-management education program by home monitoring of peak expiratory flow. Respir Care 2014;59:654-66. Rabe KF, Adachi M, Lai CK, Soriano JB, Vermeire PA, Weiss KB. Frequent clinical evaluation and CXR, electrolytes, glucose, 12-lead ECG, and ABG are recommended. Sullivan SD, Rasouliyan L, Russo PA, Kamath T, Chipps BE; TENOR Study Group. Acad Emerg Med 2014;21:872-8. Blood eosinophils should be >150/μl at the time of treatment initiation or >300/μl within the last 12 months. Price D. Asthma and allergic rhinitis: Linked in treatment and outcomes. Admission is recommended to be considered. Ramnath VR, Clark S, Camargo CA Jr. Multicenter study of clinical features of sudden-onset versus slower-onset asthma exacerbations requiring hospitalization. Cates CJ, Cates MJ. PRAM score is 4–7: It is recommended to continue treatment with salbutamol every 30 min for three doses and to assess PRAM score every 30 min. Future risk of attacks and fixed airflow obstruction. Al Zahrani SS, El Morsy E, Laila S, Dorgham L. The impact of bronchial asthma on quality of life among affected children and adolescents in Taif city, Saudi Arabia. Patients with seasonal asthma who are symptomatic during the season are recommended to be treated with low-dose ICS before the beginning of the season; otherwise, it is recommended to be maintained at step 1 for the rest of the year (Evidence D). Aspirin-exacerbated respiratory disease. Cochrane Database Syst Rev 2006;(3):CD004108. Asthma control assessment using asthma control test among patients attending 5 tertiary care hospitals in Saudi Arabia. Glauber JH, Fuhlbrigge AL, Finkelstein JA, Homer CJ, Weiss ST. The use of leukotriene receptor antagonists (LTRAs) as complementary therapy in asthma. Inhaled anticholinergics and short-acting beta(2)-agonists versus short-acting beta2-agonists alone for children with acute asthma in hospital. Paediatr Child Health 2012;17:251-62. Alternatively, ipratropium bromide can be administered by MDI at a dose of 4–8 puffs every 20 min and then every 4–6 h as needed, Systemic steroid is recommended to be started as soon as possible (Evidence A). Measurement of arterial blood gases (ABGs) are not routinely required in this category; however, if done, it shows widened alveolar–arterial oxygen gradient and low PaCO, Severe acute asthma: Patients are usually agitated and unable to complete full sentences. Am Rev Respir Dis 1986;133:723-4. Koshak EA. Barr RG, Woodruff PG, Clark S, Camargo CA Jr. Sudden-onset asthma exacerbations: Clinical features, response to therapy, and 2-week follow-up. A child with asthma control is not achieved at step 2: It is recommended to escalate treatment to step 3. Asthma GI. LaForce C, Korenblat P, Osborne P, Dong F, Higgins M. 24-hour bronchodilator efficacy of single doses of indacaterol in patients with persistent asthma: Comparison with placebo and formoterol. After a steep rise in the number of athletes taking beta-2 agonists for asthma in the 1990s, Olympic athletes were required to provide proof that they had asthma in order to be allowed to use inhaled beta-2 agonists. [25], The 1972 Munich Olympics were the first Olympics where anti-doping measures were deployed, and at that time beta-2 agonists were considered to be stimulants with high risk of abuse for doping. Low-flow oxygen is recommended to maintain saturation ≥92%. Barnes NC. Ducharme FM, Hicks GC. Request of a patient for second opinion or further advice. Am J Respir Crit Care Med 2000;162:1500-6. Ann Saudi Med 2011;31:129-33. Bentur L, Kerem E, Canny G, Reisman J, Schuh S, Stein R. Wennergren G, Engström I, Bjure J. Transcutaneous oxygen and carbon dioxide levels and a clinical symptom scale for monitoring the acute asthmatic state in infants and young children. Chest 2002;121:329-33. Leynaert B, Bousquet J, Neukirch C, Liard R, Neukirch F. Perennial rhinitis: An independent risk factor for asthma in nonatopic subjects: Results from the European Community Respiratory Health Survey. Unusual cause of respiratory distress misdiagnosed as refractory asthma. The recommended dose is 100 mg subcutaneously every 4 weeks, Benralizumab, an anti-IL-5 receptor that is indicated when blood eosinophil level is ≥300 cells/μl at initiation of treatment. J Allergy Clin Immunol 2009;124:S88-93. Vignola AM, Humbert M, Bousquet J, Boulet LP, Hedgecock S, Blogg M. Wilson AM, Dempsey OJ, Sims EJ, Lipworth BJ. Rodrigo GJ, Castro-Rodríguez JA. Thorax 1999;54:476-81. Obtain vital signs initially and at discharge, Prescribe appropriate oxygen dose to keep saturation ≥92%, Less than 20 kg: 5 puffs by MDI/spacer or 2.5 mg by nebulizer, 20 kg or more: 10 puffs by MDI/spacer or 5 mg by nebulizer-titrate MDI dose based on response). If patient can tolerate oral medications, oral prednisolone 1 mg/kg/day to maximum of 50 mg daily is recommended. Cope SF, Ungar WJ, Glazier RH. The safety of celecoxib in patients with aspirin-sensitive asthma. The recommended dose is 30 mg subcutaneously every 4 weeks for the first 3 months and then every 8 weeks thereafter, There is no available evidence that compares anti-IgE therapy to any of the anti-IL-5 therapies or directly comparing different anti-IL-5 agents. The benefits of using clinical pathways for managing acute paediatric illness in an emergency department. Lancet 1988;1:981-3. Total score of 1–3: Low risk with a chance of <10% for hospital admission, Total score of 4–7: Moderate risk with a chance of 10%–50% for hospital admission. Alzeer AH, Al Otair HA, Khurshid SM, Badrawy SE, Bakir BM. Allergy Asthma Proc 2015;36:251-5. BMC Public Health 2012;12:239. Asma (dalam bahasa Yunani ἅσθμα, ásthma, "terengah") adalah peradangan kronis yang umum terjadi pada bronkus yang ditandai dengan gejala yang bervariasi dan berulang, penyumbatan saluran napas yang bersifat reversibel dan spasme bronkus. Ann Allergy Asthma Immunol 2018;120:504-11. [30] The drug is usually manufactured and distributed as the sulfate salt (salbutamol sulfate). Pauwels RA, Pedersen S, Busse WW, Tan WC, Chen YZ, Ohlsson SV. Addition of long-acting beta-agonists to inhaled corticosteroids for chronic asthma in children. Phenotypic expressions of childhood wheezing and asthma: Implications for therapy. Use of valved-holding spacer, with mouthpiece when possible, is recommended when an MDI is prescribed (Evidence B). Am J Respir Crit Care Med 2000;162:663-9. Park JS, Jang AS, Park SW, Lee YM, Uh ST, Kim YH. Vaessen-Verberne AA, van den Berg NJ, van Nierop JC, Brackel HJ, Gerrits GP, Hop WC. Home oxygenation would be more effective. 49 Likes, 1 Comments - College of Medicine & Science (@mayocliniccollege) on Instagram: “ Our Ph.D. Chest 2001;120:1485-92. [1], As of 2011[update] there was no evidence that an increase in physical performance occurs after inhaling salbutamol, but there are various reports for benefit when delivered orally or intravenously. ABG, CXR, and electrolyte are recommended to be obtained and the pediatrics critical care or equivalent service must be consulted. Controlled trial of oral prednisone in the emergency department treatment of children with acute asthma. Halwani R, Vazquez-Tello A, Horanieh N, Dulgom S, Al-Aseri Z, Al-Khamis N. Shrewsbury S, Pyke S, Britton M. Meta-analysis of increased dose of inhaled steroid or addition of salmeterol in symptomatic asthma (MIASMA). Sears MR, Lötvall J. Levy ML, Nicholson PJ. Vézina K, Chauhan BF, Ducharme FM. If PRAM score after 1 h is 1–3, Observe for another hour. Cowie RL, Underwood MF, Field SK. Step 1: SABA (such as salbutamol) on “as-needed basis” for patients with mild and infrequent symptoms that occurs once or twice a week. N Z Med J 1987;100:309-11. Berlow BA. Respir Med 2007;101:1218-28. Ann Thorac Med 2010;5:65-6. Angiotensin-converting enzyme inhibitor-induced cough: ACCP evidence-based clinical practice guidelines. Diana Shadow: In this assessment, you will become familiarized with the structure and content of a health history exam so that with real-life patients, you can: º ask effective and comprehensive questions º obtain a thorough health history º evaluate the patient's risk of disease, infection, injury, and complications º educate and … Abramson MJ, Bailey MJ, Couper FJ, Driver JS, Drummer OH, Forbes AB. [23] Potential formulation of the R form as an enantiopure drug is complicated by the fact that the stereochemistry is not stable, but rather the compound undergoes racemization within a few days to weeks, depending on pH. Rowe BH, Bretzlaff JA, Bourdon C, Bota GW, Camargo CA Jr. Magnesium sulfate for treating exacerbations of acute asthma in the emergency department. LTRA may be added to this combination if control is not achieved. Zaraket R, Al-Tannir MA, Bin Abdulhak AA, Shatila A, Lababidi H. Parental perceptions and beliefs about childhood asthma: A cross-sectional study. Recommended option: Adding an LABA to a low-medium-dose ICS in a combination device improves asthma control for patient whose asthma is not controlled at step 2 (Evidence A). Beeh KM, Moroni-Zentgraf P, Ablinger O, Hollaenderova Z, Unseld A, Engel M. Tian JW, Chen JW, Chen R, Chen X. Tiotropium versus placebo for inadequately controlled asthma: A meta-analysis. Managing the paediatric patient with an acute asthma exacerbation. Global Strategy for Asthma Management and Prevention: GINA; 2018. Alamoudi O. Abudahish A, Bella H. Primary care physicians perceptions and practices on asthma care in Aseer region, Saudi Arabia. Late-onset nonallergic eosinophilic airway inflammation (intrinsic asthma): This type usually starts during adulthood. Chest 2006;129:75S-9S. Jacobsen L, Niggemann B, Dreborg S, Ferdousi HA, Halken S, Høst A. BMJ 2000;320:1368-73. Maesen FP, Smeets JJ, Sledsens TJ, Wald FD, Cornelissen PJ. Allergy 2007;62:661-7. Cochrane Database Syst Rev 2014;1:CD003137. Chauhan BF, Ducharme FM. Al-Kabbaa AF, Al-Shamrani KM, Salih MA. Hessel PA, Mitchell I, Tough S, Green FH, Cockcroft D, Kepron W. Plaza V, Serrano J, Picado C, Sanchis J; High Risk Asthma Research Group. In addition, IL-13 causes smooth muscle and goblet cell hyperplasia. Salbutamol, also known as albuterol and marketed as Ventolin among other brand names, is a medication that opens up the medium and large airways in the lungs. Fevipiprant is an oral treatment for asthma that is intended for the treatment of uncontrolled severe asthma. Perlow JH, Montgomery D, Morgan MA, Towers CV, Porto M. Severity of asthma and perinatal outcome. Global Initiative for Asthma 2015; 2015. O'Brian AL, Lemanske RF Jr., Evans MD, Gangnon RE, Gern JE, Jackson DJ. Novel long-acting bronchodilators for COPD and asthma. Severe and difficult-to-treat asthma in adults. It is used to treat asthma, including asthma attacks, … Bacharier LB, Phillips BR, Zeiger RS, Szefler SJ, Martinez FD, Lemanske RF Jr.. Reddel HK, Foster JM. Improved asthma control with breath-actuated pressurized metered dose inhaler (pMDI): The SYSTER survey. Prednisolone dose is 1–2 mg/kg up to a maximum dose based on age. Consultation with an asthma specialist is strongly recommended for patients requiring treatment at step 5 (Evidence D), To avoid frequent use of oral steroids, biologic therapy should be considered based on appropriate indications and availability. Tezepelumab is a human monoclonal antibody specific for the epithelial-cell–derived cytokine TSLP that is intended to patients whose asthma remained uncontrolled despite treatment. It is defined by sputum eosinophilia of ≥2% of leukocytes in a sample. Patients should be informed that asthma control may deteriorate if treatment is completely discontinued. Baur X, Aasen TB, Burge PS, Heederik D, Henneberger PK, Maestrelli P. Legiest B, Nemery B. Al-Moamary MS, Al-Hajjaj MS, Idrees MM, Zeitouni MO, Alanezi MO, Al-Jahdali HH. PRAM score is 8–12: Deterioration of clinical status despite adequate treatment in the initial period warrants special care and attention. The effectiveness of IV beta-agonists in treating patients with acute asthma in the emergency department: A meta-analysis. Al-Mobeireek A. Prescribing for asthmatic children in primary care. For patients with evidence of both atopy and high blood eosinophils, to date, there is no available evidence to favor either anti-IgE therapy versus anti-IL-5 agents. Ducharme FM, Ni Chroinin M, Greenstone I, Lasserson TJ. Evid Based Child Health 2014;9:1047-51. Step 2: Low-dose ICS for patients with an ACT score of 16–19 (Evidence B). Addition of long-acting beta2-agonists to inhaled steroids versus higher dose inhaled steroids in adults and children with persistent asthma. Eur Rev Med Pharmacol Sci 2009;13:323-30. LTRA for a child who cannot or will not use ICSs though it is a less-effective option (Evidence B), Low-dose ICS for a child <5 years with a history of asthma attack in the past year or has ever been admitted to ICU (Evidence D). Bousquet J, Rabe K, Humbert M, Chung KF, Berger W, Fox H. Bousquet J, Siergiejko Z, Swiebocka E, Humbert M, Rabe KF, Smith N. Poon AH, Hamid Q. Personalized medicine for asthma: Are we there yet? It can also be nebulized inside an oxygen cage. They can communicate and talk in full sentences. Kerstjens HA, Disse B, Schröder-Babo W, Bantje TA, Gahlemann M, Sigmund R. Kerstjens HA, Engel M, Dahl R, Paggiaro P, Beck E, Vandewalker M. Virchow JC Jr., Prasse A, Naya I, Summerton L, Harris A. Zafirlukast improves asthma control in patients receiving high-dose inhaled corticosteroids. Thorax 2002;57:317-22.