57 A Cochrane review showed that nebulized magnesium sulfate provided significant improvement in pulmonary function tests and a nonsignificant trend to decreased hospital admission rates in severe asthma exacerbations, but no statistically significant difference when included in all severities of asthma attacks. 58 Inhaled magnesium sulfate is given as the diluent in place of normal saline (usually 2.5 mL of a 250 mmol/L solution) combined with salbutamol and ipratropium bromide in the same nebulized mask.
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There are small studies analyzing the ability of NPPV to avoid intubation and improve outcomes in children with status asthmaticus, 70 , 71 , 72 , 73 , 74 , 75 and a Cochrane review showed a trend toward benefit. 76 If the patient is unable to tolerate NPPV and continues to deteriorate, endotracheal intubation with mechanical ventilation is necessary. 3 , 9 Once the decision has been made, the most experienced physician should make the attempt, as asthmatic patients are often difficult to intubate and desaturate quickly.