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

From the Guidelines

Emergency room treatment of pediatric asthma should prioritize the administration of oxygen to maintain saturation above 92%, along with the use of short-acting beta-agonists (SABA) like albuterol, and oral corticosteroids for moderate to severe exacerbations, as recommended by the most recent guidelines 1. The initial assessment of pediatric asthma in the emergency room should include vital signs, oxygen saturation, and asthma severity scoring.

• Oxygen therapy should be provided to maintain saturation above 92% to prevent hypoxia and its consequences.
• First-line treatment involves short-acting beta-agonists (SABA) like albuterol, typically administered via metered-dose inhaler with spacer (4-8 puffs) or nebulizer (2.5-5 mg) every 20 minutes for the first hour, as supported by the guidelines 1.
• For moderate to severe exacerbations, oral corticosteroids should be given early (prednisolone/prednisone 1-2 mg/kg/day, maximum 60 mg daily for 3-5 days) to reduce inflammation and prevent recurrence, as recommended by the guidelines 1.
• In severe cases, ipratropium bromide can be added to nebulized treatments (250-500 mcg every 20 minutes for 1-2 hours) to enhance bronchodilation.
• Reassessment should occur after each treatment to determine response and adjust the treatment plan accordingly.
• Discharge criteria include good response to treatment, oxygen saturation >94% on room air, and minimal respiratory distress, with discharge planning involving a written asthma action plan, inhaler technique review, prescription for continued medications, and follow-up appointment within 1-2 weeks, as emphasized by the guidelines 1. The management of pediatric asthma exacerbations has evolved, with recent systematic reviews highlighting the importance of updated and comprehensive guidelines to improve clinical practice quality and promote evidence-based recommendations 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 emergency room treatment of pediatric asthma with albuterol (INH) involves administering 2.5 mg of albuterol by nebulization, as indicated by the dosage and administration guidelines for children 2 to 12 years of age.

• The treatment can be repeated as medically indicated to control recurring bouts of bronchospasm.
• Significant improvement in pulmonary function can be expected within 2 to 20 minutes following a single dose of albuterol inhalation solution in asthmatic children aged 3 years or older 2 2.

From the Research

Emergency Room Treatment of Pediatric Asthma

• Asthma is the most common chronic disease of childhood, with asthma exacerbations and wheezing resulting in more than 2 million emergency department visits per year 3.
• Current evidence clearly supports the use of inhaled bronchodilators and systemic steroids as first-line agents for the treatment of acute asthma in pediatric patients 3.
• The use of ipratropium bromide as an adjunctive therapy to beta2-agonists has been shown to improve lung function and decrease hospitalization rates in pediatric patients with acute asthma exacerbations 4.

Treatment Protocols

• A standardized asthma pathway in the emergency room has been shown to improve patient outcomes by reducing wait times for administration of steroids 5.
• The use of a protocol-driven approach to implementation of care for patients with asthma can improve patient outcomes by decreasing time to treatment 5.
• Combination therapy with ipratropium bromide and beta2-agonists has been shown to be effective in the treatment of acute asthma exacerbations in pediatric patients 4, 6.

Key Findings

• The addition of ipratropium bromide to beta2-agonist therapy has been shown to improve pulmonary function and reduce hospital admission rates in patients with acute asthma exacerbations 4, 6.
• The use of high doses of ipratropium bromide has been shown to reduce the risk of hospital admission by 49% in patients with acute asthma exacerbations 6.
• Patients with more severe obstruction (FEV1 ≤ 30% of predicted) and long duration of symptoms before emergency department presentation (≥ 24 h) are most likely to benefit from the addition of high doses of ipratropium bromide 6.