What is the management of an acute asthma exacerbation in pediatric patients?

From the Guidelines

Managing an asthmatic crisis in children requires prompt recognition and treatment, with the administration of a short-acting beta-agonist like albuterol (salbutamol) via a metered-dose inhaler with spacer or nebulizer, and supplemental oxygen if oxygen saturation falls below 92%. The initial treatment should include 2-4 puffs of albuterol every 20 minutes for the first hour, or 2.5-5mg via nebulizer if symptoms are severe, as recommended by the National Asthma Education and Prevention Program Expert Panel report 3 guidelines for the management of asthma exacerbations 1. For moderate to severe attacks, oral prednisolone (1-2mg/kg, maximum 60mg) should be added immediately, and albuterol continued every 1-4 hours as needed based on response.

Some key points to consider in the management of an asthmatic crisis in children include:

• The use of inhaled short-acting beta2-agonists (SABA) such as albuterol, with dosages of 0.15 mg/kg (minimum dose 2.5 mg) every 20 minutes for 3 doses then 0.15–0.3 mg/kg up to 10 mg every 1–4 hours as needed, or 0.5 mg/kg/hour by continuous nebulization 1.
• The addition of anticholinergics such as ipratropium bromide, with dosages of 0.25–0.5 mg every 20 minutes for 3 doses, then as needed, for severe exacerbations 1.
• The importance of monitoring response to therapy closely, and adjusting treatment as needed to maintain control and prevent exacerbations 1.
• The consideration of long-term control medications, such as inhaled corticosteroids (ICS), for children with recurrent asthma attacks or persistent symptoms, with the goal of reducing impairment and risk of exacerbations 1.

It is also important to note that the management of an asthmatic crisis in children should be individualized, taking into account the child's age, severity of symptoms, and response to treatment. After the crisis resolves, it is essential to review the child's asthma action plan, ensure proper inhaler technique, identify triggers, and consider preventive medications if attacks are recurrent, as recommended by the expert panel report 3 guidelines for the diagnosis and management of asthma-summary report 2007 1.

From the FDA Drug Label

In repetitive dose studies, continued effectiveness was demonstrated throughout the three-month period of treatment in some patients. 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 An increase of 15% or more in baseline FEV1 has been observed in children aged 5 to 11 years up to 6 hours after treatment with doses of 0. 10 mg/kg or higher of albuterol inhalation solution. The National Heart, Lung, and Blood Institute (NHLBI) recommended dosing for systemic prednisone, prednisolone or methylprednisolone in children whose asthma is uncontrolled by inhaled corticosteroids and long-acting bronchodilators is 1–2 mg/kg/day in single or divided doses

To manage an asthmatic crisis in children, albuterol inhalation solution can be used, with doses of 0.10 mg/kg or higher resulting in significant improvement in FEV1 or PEFR within 2 to 20 minutes 2. For children with uncontrolled asthma, systemic prednisolone can be used at a dose of 1-2 mg/kg/day in single or divided doses, as recommended by the NHLBI 3. Key points to consider when managing an asthmatic crisis in children include:

• Using albuterol inhalation solution as a bronchodilator to relieve acute symptoms
• Administering systemic prednisolone to reduce inflammation in uncontrolled asthma
• Monitoring the child's response to treatment and adjusting the dose as needed
• Considering the potential for cardiovascular effects with albuterol use, particularly at higher doses 2.

From the Research

Management of Asthmatic Crisis in Children

• The management of asthmatic crisis in children typically involves the use of inhaled bronchodilators and systemic steroids as first-line agents 4.
• According to a study published in 2020, intravenous magnesium sulfate was the only intervention shown to reduce hospital length of stay, and the addition of inhaled anticholinergic agents to inhaled beta2-agonists reduced the risk of hospital admission 5.
• A 2016 review of available modalities for assessing and managing acute asthma exacerbations in pediatric patients emphasized the importance of optimal assessment and management of exacerbations, including appropriate escalation of interventions 6.
• The use of metered-dose inhalers (MDIs) with spacers has been shown to be effective in reducing follow-up visits to the clinic and emergency department visits within 30 days, compared to nebulized albuterol 7.
• A study published in 2001 found that the routine addition of repeated doses of nebulized ipratropium bromide to a standardized regimen of systemic corticosteroids and frequently administered beta-2 agonists did not significantly enhance clinical outcome for the treatment of hospitalized children with status asthmaticus 8.

Treatment Options

• Inhaled bronchodilators, such as albuterol, are commonly used as first-line agents for the treatment of acute asthma exacerbations in children 4, 6.
• Systemic corticosteroids are also used as first-line agents, and are often administered in conjunction with inhaled bronchodilators 4, 6.
• Intravenous magnesium sulfate has been shown to reduce hospital length of stay and the risk of hospital admission in children with acute asthma exacerbations 5.
• Inhaled anticholinergic agents, such as ipratropium bromide, may be added to inhaled beta2-agonists to reduce the risk of hospital admission 5.
• Metered-dose inhalers (MDIs) with spacers may be used as an alternative to nebulized albuterol for the treatment of acute asthma exacerbations in children 7.