From the Guidelines
Persistent desaturations in pediatric asthma exacerbation despite improved clinical picture necessitate a thorough evaluation for potential complications or alternative diagnoses, with a focus on optimizing oxygen supplementation and investigating underlying causes, as recommended by recent guidelines 1. When managing pediatric asthma exacerbations, it is crucial to consider the variability in guideline recommendations and clinical practice, as highlighted in a systematic review of 16 asthma exacerbation clinical practice guidelines for children 1. The primary treatment for asthma exacerbations, as outlined in the National Asthma Education and Prevention Program Expert Panel Report 3 guidelines, consists of administration of oxygen, inhaled β2-agonists, and systemic corticosteroids, with the dose and frequency of administration dependent on the severity of the exacerbation 1.
Key considerations in the management of persistent desaturations include:
- Optimizing oxygen supplementation to ensure adequate oxygenation
- Investigating potential complications, such as pneumonia, atelectasis, pneumothorax, or pulmonary embolism, with a chest X-ray
- Intensifying airway clearance with chest physiotherapy and considering hypertonic saline nebulization (3-7%, 4mL every 6-8 hours) for significant mucus plugging
- Continuing bronchodilator therapy with albuterol (2.5-5mg every 4-6 hours) and considering adding ipratropium bromide (250-500mcg every 6-8 hours) for atelectasis
- Ensuring appropriate anti-inflammatory therapy with systemic corticosteroids (prednisolone/prednisone 1-2mg/kg/day, maximum 60mg daily for 3-5 days)
If hypoxemia persists without explanation, consider high-resolution CT imaging to evaluate for subtle airway or parenchymal abnormalities, as ventilation-perfusion mismatch is common in asthma due to regional differences in airway obstruction, leading to persistent hypoxemia despite clinical improvement in other parameters 1.
From the Research
Persistent Desaturations in Pediatric Asthma Exacerbation
- Persistent desaturations in pediatric asthma exacerbation despite improved clinical picture can be a challenging issue to address, and there are several factors to consider when managing such cases 2, 3.
- According to the study by 2, asthma exacerbations in children can be managed with inhaled corticosteroids, short-acting beta2 agonists, and oral corticosteroids, and the goal is to improve symptoms and lung function to 60-80% of predicted values.
- However, some studies suggest that despite improved clinical picture, persistent desaturations can still occur, and this may be due to various factors such as underlying inflammation, airway obstruction, or other comorbidities 4, 5.
- The use of additional therapies such as magnesium sulfate, heliox, or biologic therapy may be considered in severe or difficult-to-control cases, but the evidence for their use is limited and more research is needed to determine their effectiveness 6, 4, 5.
- Close monitoring and follow-up are crucial in managing pediatric asthma exacerbations, and education on asthma action plans and trigger avoidance can help prevent future exacerbations 2, 3.