Acta Pædiatrica ISSN 0803-5253

REGULAR ARTICLE

Randomised comparison of intravenous magnesium sulphate, terbutaline

and aminophylline for children with acute severe asthma
Sunit Singhi (sunit.singhi@gmail.com), Sudhanshu Grover, Arun Bansal, Kapil Chopra
Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Keywords
Acute asthma, Aminophylline, Children, Magnesium
sulphate, Terbutaline
Correspondence
Prof. Sunit C. Singhi, MBBS, MD, FIAP, FAMS,
FISCCM, FICCM, FCCM, Head, Department of
Pediatrics and Pediatric Emergency and Intensive
care, Post graduate Institute of Medical Education
And Research, Chandigarh 160012, India.
Tel: +91 172 2755301 and 2755302 |
Fax: +91 172 2747099 and 2744401 |
Email: sunit.singhi@gmail.com
Received
27 January 2014; revised 16 July 2014;
accepted 18 August 2014.
DOI:10.1111/apa.12780
ABSTRACT
Aim: This study compared the efficacy of intravenous magnesium sulphate, terbutaline and
aminophylline for children with acute, severe asthma poorly responsive to standard initial
treatment.
Methods: We enrolled 100 children, aged one to 12 years, who had failed to respond to
initial standard treatment for acute, severe asthma, in this randomised controlled trial. They
received either intravenous magnesium sulphate, terbutaline or aminophylline. Responses
were monitored using a modified Clinical Asthma Severity (CAS) score. The primary
outcome was treatment success, defined as a reduction in the CAS of four points or more
1 h after starting the intervention.
Results: The magnesium sulphate group had higher treatment success (33/34, 97%)
than the terbutaline and aminophylline groups (both 23/33, 70%) (p = 0.006) and faster
resolution of retractions, wheeze and dyspnoea (p < 0.001). No adverse events occurred
among patients receiving magnesium sulphate, but two patients receiving terbutaline had
hypokalemia and nine patients receiving aminophylline had nausea and, or, vomiting.
Conclusion: Adding a single dose of Intravenous magnesium sulphate to inhaled beta2-
agonists and corticosteroids was more effective, and safer, than using terbutaline or
aminophylline when treating a child with acute severe asthma poorly responsive to initial
treatment.

INTRODUCTION oxygen, inhaled short acting beta2-agonists and ipratropi-

Asthma is one of the most common chronic diseases in
children. Estimates suggest that the prevalence of childhood
asthma varies from 10 to 30% in various geographical
regions and that it is increasing globally by 50% every
decade (1,2). Poorly controlled asthma is associated with
significant morbidity and socio-economic consequences
(3). Intermittent acute exacerbations are common and are
characterised by episodes of coughing, respiratory distress,
dyspnoea, wheezing, low arterial oxygen saturation and a
widespread reduction in airflow (4). Acute severe exacer-
bations are potentially life-threatening and often need
hospitalisation. In our hospital, acute asthma is the third
most common paediatric emergency (5).
The emergency management of acute exacerbations
includes rapidly assessing the severity, correcting hypoxa-
emia, relieving breathing difficulties using therapies to
reverse bronchospasms and inflammation of the airways,
monitoring responses and stepping up therapy if the patient
remains unresponsiveness (6,7). Initial treatment includes
Abbreviations
CAS, Clinical Asthma Severity; SpO2, Oxygen saturation.
um, and oral or parenteral corticosteroids (6,8). In acute
severe exacerbations that show incomplete or poor
response to initial treatment, additional interventions that
are commonly considered are intravenous administration of
magnesium sulphate, beta2-agonists – in the form of
terbutaline or salbutamol – or aminophylline (6–8). There
is no clear evidence to support which of these options is
most effective. Therefore, the aim of this study was to
compare the efficacy and safety of intravenous magnesium
Key notes
 This study compared the efficacy of intravenous mag-
nesium sulphate, terbutaline and aminophylline for
children with acute, severe asthma who did not
respond well to standard treatment.
 We enrolled 100 children, from one to 12 years of age
and the primary outcome, treatment success, was
measured using the Clinical Asthma Severity score.
 Adding a single dose of Intravenous magnesium
sulphate to inhaled beta2-agonists and corticosteroids
was more effective, and safer, than terbutaline or
aminophylline.

©2014 Foundation Acta Pædiatrica. Published by John Wiley & Sons Ltd 2014 103, pp. 1301–1306 1301
Drugs for acute severe asthma
sulphate, terbutaline and aminophylline in reversing symp-
toms of acute severe asthma in children who responded
poorly to standard initial treatment.
MATERIAL AND METHODS
We enrolled 100 children aged from one to 12 years of age,
with acute severe asthma poorly responsive to standard
initial treatment, in a randomised open label controlled
trial. The study was conducted in paediatric emergency unit
of a teaching hospital in north India from 1 January 2008 to
30 November, 2009. Other inclusion criteria were at least
three previous episodes of physician-diagnosed asthma
treated with beta2-agonists and written informed consent
from the parents. We excluded patients with an axillary
temperature of more than 38°C, significant acute or chronic
pulmonary diseases other than asthma, congenital or
acquired heart disease, renal disease or hypotension. The
study was approved by the ethics committee of the institute.
The patients were assessed and monitored using a
Clinical Asthma Severity (CAS) score, which is a modified
version of a pulmonary index (9) and includes respiratory
rate, wheeze, retractions, dyspnoea and oxygen saturation
(SpO2) measured by pulse oximetry (Novametrixâ,
Wallingford, Connecticut, USA). Each parameter was
scored from zero to three with a maximum total score of
15 (Table S1).
Enrolment and randomisation
All patients who presented to the paediatric emergency
department with acute severe asthma were initially treated
with oxygen inhalation (6 L/min), three nebuliser doses of
salbutamol (0.15 mg/kg/dose), budesonide (800 lg/dose)
and ipratropium bromide (250 lg/dose) every 20 min for
1 h and one dose of hydrocortisone (10 mg/kg) after the
first nebulisation. The nebuliser doses were delivered using
a Micromistâ nebulisation chamber (Hudson RCIâ,
Research Triangle Park (Durham), NC, USA). Changes in
the CAS score was recorded at the end of 1 h and the
patients who showed a poor response, defined as the CAS
score improving by <4 points after the first hour of
treatment, were consecutively enrolled.
Patients were randomly allocated to three groups, A, B
and C, by block randomisation. The blocks were permuted,
randomly varied in size and were in multiples of three. A
computer generated randomisation list was generated by a
person not directly involved with the data collection,
analysis or interpretation. The individual assignments were
placed in opaque, serially numbered, sealed envelopes and
were only opened after the parents had provided written
consent. The intervention arms were not masked because of
the nature of the study, but the statistician was blinded to
the treatment assignment until the initial analysis.
Intervention and data recording
Group A received magnesium sulphate (50% solution of
50 mg/kg in 30 ml 0.18% saline in D5W) as an intravenous
infusion over 20 min. Group B received intravenous
1302 ©2014 Foundation Acta Pædiatrica. Published by John Wiley & Sons Ltd 2014 103, pp. 1301–1306
Singhi et al.
terbutaline (0.05% solution in 0.9% saline, 10 lg/kg as a
bolus, followed by 0.1 lg/kg/min given as an intravenous
infusion, which was stepped up by 0.1 lg/kg/min to a
maximum dose of 1 lg/kg/min) until they responded.
Group C received intravenous aminophylline (5 mg/kg
bolus, followed by 0.9 mg/kg/h) until their symptoms
resolved. All subjects continued to receive oxygen and
continuous nebulised salbutamol (0.3 mg/kg/h) in line with
our standard protocol (6).
The individual elements of the CAS score were recorded by
specially trained paediatric residents, at baseline, one, two,
four, eight and 12 h after the infusion started, and this
training continued after the study. The patients were also
carefully assessed and monitored for skin flushing, warmth or
burning at the intravenous site, hypotension, hypertension,
respiratory failure, hypo-active tendon reflexes, tachycardia
(a heart rate of 10% above the baseline) and electrocardio-
graphic changes (prolonged PR, QRS and QT, heart block,
arrhythmia). Blood sugar and serum electrolytes were mea-
sured at baseline, and at six and 12 h after enrolment, to
check for hyperglycaemia, and hypokalemia.
Outcome measures
The primary outcome was treatment success, defined as an
improvement of four or more points in the CAS 1 h after
starting the interventional drug. Secondary outcomes were
trends in the CAS score over 12 h, the number of hours
from enrolment to resolution of wheeze, retractions and
dyspnoea and the frequency of adverse events.
Statistical analysis
Data entry and statistical analysis were performed using
Microsoft Excelâ and SPSSâ software version 15, respec-
tively. Normally distributed continuous variables were
summarised as means and standard deviations and ordinal
variables (CAS scores) as medians and interquartile ranges
(IQR). The proportions were compared using the chi-square
test. The change in CAS scores over time across three groups
was compared with repeated measures analysis using mixed
linear models. The dependent variable was the CAS score.
The fixed effects included the intercept, the group to which
the patient belonged, and the interaction between each
group and time. The random effect was intercept and time.
An autoregressive covariance structure was used and the
model converged. A two-way RM-ANOVA was performed
to analyse the interaction between the groups and the
overall change in respiratory rate and oxygen saturation
over time, after testing for normality of distribution and
equality of variances using Levene’s test. Kaplan–Meier
analysis was used to estimate the time since enrolment to
resolution of wheeze, retraction and dyspnoea. All tests were
two-tailed, and a p value of <0.05 was considered significant.
OBSERVATIONS AND RESULTS
Of the 358 patients who were treated for acute severe
exacerbation of asthma during the study period, 104
responded poorly to initial treatment (Figure S1) and 100
Singhi et al. Drugs for acute severe asthma

were enrolled. They were split into three groups, with 34 in
the magnesium sulphate group and 33 each in terbutaline
and aminophylline groups. The study groups were similar
with respect to demographic and baseline clinical charac-
teristics. All the patients had wheeze, retractions and
dyspnoea, but the respiratory rates were somewhat lower
in the magnesium sulphate group (Table 1).
The proportion of patients with treatment success,
defined as an improvement in the CAS score of four or
more points after 1 h, was significantly higher in the
magnesium sulphate group (33 of 34, 97%), than the
terbutaline (23 of 33, 70%) and aminophylline groups (23
of 33, 70%) (p = 0.006). The magnesium sulphate group
performed better than the terbutaline and aminophylline
groups on all of the components of the CAS score at the end
of the first hour (Table 2).
Analysis of trends in the CAS scores over times showed
that the overall CAS scores were significantly different in
the three groups (Figure 1). They declined significantly over
time and the rate of that decline differed in the three
groups.(Table S2). The decline in CAS scores over time in
the magnesium sulphate group was significantly greater
than the other groups (Figure 1, Table S2).
The improvement in respiratory rate and oxygen satura-
tion over time was also significantly greater in the magne-
sium sulphate group (Figure S2). Using the Kaplan–Meier
analysis, we found that the resolution of wheeze, retractions
and dyspnoea occurred significantly earlier in the magne-
sium sulphate group than the other two groups (Table 2).
There were no adverse events in the magnesium sulphate
group, but two patients in the terbutaline group had
hypokalemia and nine patients in the aminophylline group
had nausea and, or, vomiting. The blood pressure levels in
the magnesium sulphate group were similar to the other two
groups, but the heart rates were consistently higher in the
terbutaline group (Figure S3).
DISCUSSION
We found that a single dose of intravenous magnesium
sulphate resulted in a significant improvement in the CAS
scores and other monitored parameters at the end of the
first hour of treatment, when compared to treatment with
terbutaline or aminophylline. We used a clinical scoring
system that included a combination of symptoms, signs and
an objective measure of oxygenation to evaluate the efficacy
of the three drugs (9). We did not correlate the CAS scores
with parameters such as forced expiratory volume in 1-sec
or peak expiratory flow rate. Nonetheless, such clinical
scores have been used as objective and reproducible
measures of the severity of acute asthma exacerbations in
previous studies (10), are simple to apply and provide
clinically relevant measures of the severity of the condition
and the patient’s response to treatment.
Our finding is consistent with findings of a meta-analysis
of five randomised controlled trials in children from one to
18 years of age, which showed that intravenous magnesium
sulphate decreased hospitalisations and improved pulmo-
nary function and symptom scores (11). The doses of
magnesium sulphate that we used reached levels that have
bronchodilator and anti-inflammatory effects (12). These
effects are mediated through inhibition of the release of

Table 1 Demographic and baseline clinical characteristics of the three study groups at the time of randomisation
Magnesium sulphate Terbutaline Aminophylline
(n = 34) (n = 33) (n = 33) p-Value

Age, years* 5.0 (3.0–8.5) 4.0 (2.5–8.0) 4.0 (3.0–8.0) 0.115

Sex, boys:girls 18:16 23:10 24:9 0.186
Number (percentage) of patients 16 (47%) 14 (42%) 14 (42%) ns
hospitalised in the past
Number of patients on inhaled 27 (79%) 24 (73%) 22 (67%) ns
beta2-agonists and, or, inhaled steroids‡
CAS Scores 10 (9–11) 10 (9.5–12) 11 (9.5–12) 0.061
Respiratory rate/min† 52 (6) 57 (8) 59 (8) 0.001
SpO2, %† 94.2 (1.3) 94.8 (1.8) 95 (1.8) 0.107
Heart rate per min† 132 (10) 136 (11) 136 (11) 0.814
Systolic BP, mm Hg* 102 (100–110) 102 (98–110) 104 (97–106) 0.927
Diastolic BP, mm Hg* 68 (64–70) 66 (62–70) 66 (62–70) 0.573
PulsusParadoxus, mm Hg* 24 (22–26) 22 (22–24) 22 (22–24) 0.200
Blood gas
pH* 7.37 (7.34–7.39) 7.34 (7.32–7.38) 7.35 (7.34–7.38) ns
pCO2* 35 (30.3–39.0) 37 (30.4–38.8) 35 (29.0–38.6) ns
Number of patients 30 16 31

CAS = Clinical Asthma Severity; SpO2 = Oxygen saturation by pulse oximetry.

*Median (95% CI).
†
Mean (SD).
‡
Includes those on regular inhaled salbutamol and or budesonide by metered dose inhalers.

©2014 Foundation Acta Pædiatrica. Published by John Wiley & Sons Ltd 2014 103, pp. 1301–1306 1303
Drugs for acute severe asthma Singhi et al.

Table 2 Secondary outcomes in three treatment groups

Magnesium Sulphate Terbutaline Aminophylline
(n = 34) (n = 33) (n = 33) p-Value

At the end of 1 h
Improvement in CAS scores, median (IQR) 7 (5–8) 5 (3–7) 5 (3–7) 0.002
Fall in respiratory rate (breaths/min) 16 (4)* 10 (7) 11 (10) 0.003
Increase in SpO2 percentage 3.4 (1.6)* 1.8 (1.6) 1.5 (2.1) 0.001
Number of patients at the end of 1h having
Wheeze 19 (57%) 31 (91.2%) 30 (88.2%) 0.001
Retraction 15 (45.5%) 25 (73.5%) 24 (70.6%) 0.038
Dyspnoea 11 (33%) 23 (67.6%) 24 (70.6%) 0.002
Length of time in hours from enrolment to resolution of
Wheeze 2 (1.2–2.7)† 8.0 (1.6–14.4) 8.0 (3.9–12.2) 0.001
Retraction 1.1 (0.4–1.1)† 4.0 (2.5–5.5) 8.0 (4.9–11.1) 0.001
Dyspnoea 1.0 (0.35–1.65)† 4.0 (2.6–5.3) 4.0 (2.7–5.3) 0.001
To reach CAS Score <4 1.65 (1.05–2.4)† 4.0 (1.9–6.1) 4.0 (2.4–5.6) 0.001

*Mean (SD).
†
Median (95% CI).

evidence to support the use of intravenous beta2-agonists in

Figure 1 Trend of Clinical Asthma Severity (CAS) Scores over 12 h in the three
study groups (■ Terbutaline group, ▲ Aminophylline group and ♦ Magnesium
sulphate group).
calcium from vesicles in the sarcoplasmic reticulum, which
relaxes the bronchial smooth muscle (13), reduction in the
neutrophilic respiratory burst associated with inflammation
(14) and inhibition of the release of histamine from mast
cells (15).
The use of intravenous beta2-agonists, such as terbuta-
line, for treating severe asthma has been controversial.
Studies have shown that terbutaline significantly shortened
the length of stay in an intensive care unit and reduced
hospital charges (16) and a single dose of intravenous
salbutamol over 10 min resulted in faster relief of symptoms
and early discharge than a placebo (17). However, other
studies and a systematic review have concluded that the
acute severe asthma is inadequate (18,19). Very limited
evidence supports the theory that adding intravenous beta2-
agonists to inhaled beta2-agonists shortens the recovery
time and improves pulmonary index scores (20). Higher
doses of terbutaline may lead to better efficacy, but this has
been associated with higher incidence of adverse cardiac
events (20).
We found that intravenous aminophylline and beta2-
agonists had similar efficacy with respect to recovering CAS
scores and oxygen saturation. This is in line with the
conclusion of a recent systematic review, which stated that
there was no consistent evidence favouring either intrave-
nous beta2-agonists or aminophylline for acute asthma
(21). The use of aminophylline may be appropriate in
children with severe acute exacerbations that have not
responded to maximal inhaled bronchodilators and sys-
temic steroids (22).
A survey among emergency physicians in the USA and
Canada revealed that even though they were aware of
evidence supporting the use of intravenous magnesium
sulphate in severe acute asthma in children, they were
reluctant to use it because they were concerned about the
risk of hypotension (23). Our finding that a single dose of
magnesium sulphate was safe and did not cause hypoten-
sion, or any other significant adverse event, together with
the results of previous studies (12,24), should help allay
these concerns. On the other hand, terbutaline can cause
hypokalemia and tachycardia, and aminophylline can cause
nausea and vomiting in a significant number of patients
(21,22).
There are some limitations to our study. Firstly, no formal
attempt was made to determine the inter-rater or intrarater
agreement for the CAS scores recorded by the paediatric
residents. We regarded the CAS scores as an objective and
reproducible measure and regularly trained, and retrained,
the paediatric residents involved in the data collection on

1304 ©2014 Foundation Acta Pædiatrica. Published by John Wiley & Sons Ltd 2014 103, pp. 1301–1306
Singhi et al.
how to apply the CAS score. Secondly, the study was not
double blind. However, it was not feasible to use two
placebo infusions, or prepare similar looking dosage forms,
because the composition and rates of infusion of the study
drugs were too heterogeneous. Thirdly, we did not formally
look for infections caused by respiratory syncytial virus.
However, we excluded patients under 1 year of age, febrile
patients with wheeze and patients having their first or
second episode of wheezing. The major strength of the
study was the use of clinical assessments for therapeutic
decisions in a paediatric emergency setting, as this enhances
the general applicability of our results to similar settings
elsewhere. The sample size seemed to be adequate, as a post
hoc calculation for 80% power and a 5% alpha error
showed that the required sample size for the observed effect
size was 26 patients per group.
In conclusion, the addition of a single dose of intravenous
magnesium sulphate to inhaled beta2-agonists and corti-
costeroids led to faster resolution of acute severe asthma in
patients who responded poorly to standard initial treat-
ment, compared to intravenous boluses and infusions of
terbutaline and aminophylline. The efficacy of aminophyl-
line and terbutaline was similar. There is a need to compare
these three drugs using multicentre studies in different
geographical regions, to draw clear guidelines on the best
therapy for children who respond poorly to standard initial
treatment for acute severe asthma.
ACKNOWLEDGEMENTS
We are grateful to Mr Rakesh Mohindra, Statistician, and
Dr Saurabh Dutta, Additional Professor of Pediatrics, for
the data analysis and to Dr Joseph Mathew, Associate
Professor, and Professor Pratibha Singhi for critical review
of the manuscript.
FUNDING
No specific funding was received.
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Drugs for acute severe asthma
SUPPORTING INFORMATION
Additional Supporting Information may be found in the
online version of this article:
Table S1 Clinical Asthma Severity (CAS) scoring system.
Table S2 Results of mixed linear model analysis of changes
in the CAS scores over time in the three study groups.
1306 ©2014 Foundation Acta Pædiatrica. Published by John Wiley & Sons Ltd 2014 103, pp. 1301–1306
Singhi et al.
Figure S1 Flowchart showing enrolment and allocation of
patients to the three study groups.
Figure S2 Trends of oxygen saturations and respiratory
rates in the three study groups over 12 h.
Figure S3 Trends of heart rates and blood pressures over
12 h in the three study groups.
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