What is the emergency room treatment for pediatric asthma (Acute Asthma Exacerbation)?

From the Guidelines

Emergency room treatment of pediatric asthma should prioritize immediate administration of oxygen, inhaled short-acting beta-agonists, and systemic corticosteroids to rapidly relieve respiratory distress and prevent deterioration. The most recent and highest quality study 1 recommends that all patients presenting with an asthma exacerbation should be evaluated and triaged immediately, with treatment instituted promptly based on the severity of the exacerbation. Initial management includes administration of oxygen to maintain oxygen saturation above 92%, inhaled short-acting beta-agonists like albuterol (2.5-5 mg via nebulizer or 4-8 puffs via MDI with spacer) every 20 minutes for the first hour, and systemic corticosteroids such as oral prednisolone (1-2 mg/kg/day, maximum 60 mg) or intravenous methylprednisolone (1-2 mg/kg every 6 hours) if the child cannot take oral medications.

Key considerations in the management of pediatric asthma exacerbations include:

• Frequent monitoring of lung function, oxygen saturation, and response to treatment
• Recognition of signs and symptoms of severe and life-threatening exacerbations
• Familiarity with risk factors for asthma-related death
• Special considerations in the assessment and treatment of infants experiencing asthma exacerbations
• Prescription of 3 to 10 days of corticosteroid therapy to reduce the risk of recurrence before discharge

The goal of emergency room treatment is to stabilize the child, improve oxygenation and ventilation, and reduce airway inflammation. Most children respond well to these interventions and can be discharged after observation with a clear asthma action plan, but those with persistent symptoms may require admission for continued treatment and monitoring 1.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION Adults and Children 2 to 12 Years of Age: The usual dosage for adults and for children weighing at least 15 kg is 2.5 mg of albuterol (one vial) administered three to four times daily by nebulization. The use of albuterol sulfate inhalation solution can be continued as medically indicated to control recurring bouts of bronchospasm Published reports of trials in asthmatic children aged 3 years or older have demonstrated significant improvement in either FEV1 or PEFR within 2 to 20 minutes following a single dose of albuterol inhalation solution

The treatment for pediatric asthma in the emergency room may involve the administration of albuterol via nebulization.

• The dosage for children weighing at least 15 kg is 2.5 mg of albuterol administered three to four times daily by nebulization.
• For children weighing less than 15 kg, albuterol inhalation solution, 0.5% should be used instead of albuterol inhalation solution, 0.083%.
• Improvement in pulmonary function can be expected within 5 minutes and can last for 3 to 4 hours in most patients 2 2.

From the Research

Emergency Room Treatment of Pediatric Asthma

• Asthma is the most common chronic disease of childhood, with many children requiring emergency department care at least once per year 3
• Emergency clinicians must be able to manage patients with acute asthma exacerbations and determine their safe disposition 3
• The use of bronchodilators and systemic corticosteroids is recommended for the management of moderate to severe acute asthma in pediatric patients 3, 4

Treatment Options

• Ipratropium bromide is a quaternary anticholinergic bronchodilator that can be used as adjunctive therapy for the emergency treatment of acute asthma exacerbation 5
• The addition of inhaled ipratropium to inhaled beta2-agonist therapy has been shown to improve lung function and decrease hospitalization rates in pediatric patients with acute asthma exacerbation 5
• High-dose therapy with ipratropium bromide and beta2-agonists has been shown to improve pulmonary function and reduce hospital admission rates in adult patients with acute asthma 6

Standardized Asthma Pathways

• Standardization of asthma management guidelines for patients admitted to the emergency department has been suggested to improve care delivery and patient outcomes 7
• The use of a standardized asthma pathway has been shown to decrease time to corticosteroid administration and improve patient outcomes in pediatric patients with asthma 7
• Current evidence supports the use of inhaled bronchodilators and systemic steroids as first-line agents for the management of acute asthma in pediatric patients 4