 Step 1, 2, and 3 preferred therapies are  based on Evidence A; Step 3 alternative  therapy is based on Evidence A for LTRA,  Evidence B for Theophylline, and Evidence  D for Zileuton. Step 4 preferred therapy is  based on Evidence B, and alternative  therapy is based on Evidence B for LTRA  and Theophylline and Evidence D Zileuton.  Step 5 preferred therapy is based on  Evidence B. Step 6 preferred therapy is based on (EPR–2 1997) and Evidence B for Omalizumab.
 Immunotherapy for Steps 2–4 is based on  Evidence B for house-dust mites, animal  danders, and pollens; evidence is weak or  lacking for molds and cockroaches.  Evidence is strongest for immunotherapy  with single allergens. The role of allergy in  asthma is greater in children than in adults.
 Clinicians who administer immunotherapy or Omalizumab should be prepared and  equipped to identify and treat anaphylaxis  that may occur.
http://www.nhlbi.nih.gov/guidelines/asthma/asthsumm.pdf
Most asthma exacerbations can be successfully managed at home. Status asthmaticus is an acute exacerbation of asthma that does not respond adequately to therapeutic measures and may require hospitalization. Exacerbations may progress over several days or occur suddenly and can range in severity from mild to life threatening. Significant respiratory distress, dyspnea, wheezing, cough, and a decrease in peak expiratory flow rate (PEFR) characterize deterioration in asthma control. During severe episodes of wheezing, pulse oximetry is helpful in monitoring oxygenation. In status asthmaticus, arterial blood gases may be necessary for measurement of ventilation. As airway obstruction worsens and chest compliance decreases, carbon dioxide retention can occur. In the face of tachypnea, a normal pCO2 (40 mm Hg) indicates impending respiratory arrest.
First-line management of asthma exacerbations includes supplemental oxygen, repetitive, or continuous administration of short-acting bronchodilators. Early administration of oral or intravenous corticosteroids (Fig. 78-4) is important in treating the underlying inflammation. Administration of anticholinergic agents (ipratropium) with bronchodilators decreases rates of hospitalization and duration of time in the emergency department. Intravenous magnesium sulfate is given in the emergency department if there is clinical deterioration, despite treatment with β2-agonists, ipratropium, and systemic glucocorticoids. The typical dose is 25 to 75 mg/kg (maximum 2.0 g) intravenously administered over 20 minutes. Epinephrine (intramuscular) or terbutaline (subcutaneous) is rarely used except when severe asthma is associated with anaphylaxis or unresponsive to continuous administration of short-acting bronchodilators.
For some children, symptoms of wheezing with respiratoryinfections subside in the preschool years, whereas othershave more persistent asthma symptoms. Prognostic indicators for children younger than 3 years of age who are at riskfor asthma include eczema, parental asthma, or two of the 90, 180, or 200 µg/inhalation
Fluticasone HFA/MDI: 44, 110, or 220 µg/puff DPI: 50, 100, or 250 µg/inhalation
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