In 1971 Pierson and colleagues showed that in children with acute asthma, intravenous aminophylline provided additional benefit when added to a regimen of hydrocortisone and sympathomimetic drugs.1 As these drugs are pharmacologically different and each causes bronchodilatation it seemed reasonable that together their effect would be additive. For children with poor pulmonary function (peak flow <25% expected) or with hypercapnoea (arterial carbon dioxide pressure >5 kPa) this combination seemed to work2: less severely ill children recovered when given oral prednisolone and nebulisedsalbutamol and did not need inpatient care.

For nearly 20 years children with acute asthma have been managed along these lines. Recent practice, however, has seen the intravenous treatment of children with severe asthma replaced by the regimen now used to treat …