If our management of children with asthma was optimal, there would be no need for this article as we would be able to prevent the development and progression of any asthma exacerbation. In reality, we are quite a long way from optimal care of childhood asthma in the UK and although hospital admissions for acute asthma are at last beginning to decline, having reached their peak in the late 1980s, acute asthma remains the most common reason for emergency admission to hospital.¹ The vast majority of children respond well to treatment with oral steroids and inhaled bronchodilators, with deaths from childhood asthma remaining low: approximately 25 UK children die each year.² However, identifiable causes of death include suboptimal routine and emergency care in a third to half of all children.^3,4 The initial management of children with acute asthma has changed little over the last 20 years.^5–7 However, data continue to emerge on how best to manage the small number of children who respond poorly to first-line treatment. This article aims to review the recent evidence (or highlight the lack of it) and gives suggestions for treatment strategies when faced with a child who is failing to respond.

As background to this article, we interrogated the MEDLINE database for articles concerning “acute asthma” AND “treatment” OR “therapeutics”. By limiting the search to articles about children and excluding reviews, we initially retrieved 494 abstracts. For the sake of clarity we have attempted to exclude opinions and keep the evidence separate whenever possible. At the end of each section of the review we offer a brief description of our own views and experience in managing children with acute severe asthma with particular reference to the clinical cases described.

CASE 1

A 4 year old child was admitted to the …