Management of Children with Moderate Asthma (PRAM Score) Requiring 1L O2
Continue high-flow oxygen to maintain SpO2 >92%, administer nebulized salbutamol 5 mg (or terbutaline 10 mg) every 30 minutes, add ipratropium bromide 100 mcg to the nebulizer every 6 hours, and give prednisolone 1-2 mg/kg (maximum 40 mg) orally immediately. 1
Immediate Treatment Algorithm
First-Line Interventions (Start Now)
- Oxygen therapy: High-flow oxygen via face mask to maintain SpO2 >92% 1
- Bronchodilators: Nebulized salbutamol 5 mg or terbutaline 10 mg via oxygen-driven nebulizer (use half doses in very young children) 1
- Systemic corticosteroids: Prednisolone 1-2 mg/kg body weight daily (maximum 40 mg) orally, OR intravenous hydrocortisone if the child cannot tolerate oral medication 1
- Ipratropium bromide: Add 100 mcg nebulized every 6 hours from the start for moderate severity 1
Critical Monitoring Points
Reassess at 15-30 minutes after initial treatment 1:
- Repeat PRAM score or clinical assessment
- Check oxygen saturation continuously
- Chart response before and after each bronchodilator dose
Decision Tree Based on Response
If Improving After 15-30 Minutes:
- Continue high-flow oxygen
- Continue prednisolone 1-2 mg/kg daily (maximum 40 mg)
- Reduce nebulized β-agonist frequency to every 4 hours 1
- Continue ipratropium every 6 hours until clear improvement
If NOT Improving After 15-30 Minutes:
- Continue oxygen and steroids
- Increase nebulized β-agonist frequency to every 30 minutes 1
- Ensure ipratropium is being given every 6 hours
- Consider life-threatening features (see below)
Red Flags Requiring ICU Transfer
Transfer to ICU with a physician prepared to intubate if any of the following develop 1:
- Deteriorating PRAM score or worsening exhaustion
- Feeble respirations
- Persistent hypoxemia despite oxygen
- Hypercapnia on blood gas
- Confusion, drowsiness, or coma
- Respiratory arrest
Life-Threatening Features Requiring IV Aminophylline:
If the child shows poor respiratory effort, silent chest, cyanosis, or severe fatigue 1:
- Give IV aminophylline 5 mg/kg over 20 minutes, followed by maintenance infusion of 1 mg/kg/hour
- Omit loading dose if already receiving oral theophyllines
Important Clinical Caveats
Common pitfalls to avoid:
- Blood gas estimations are rarely helpful in deciding initial management in children 1 - rely on clinical assessment and oximetry
- Children with severe attacks may not appear distressed; assessment in very young children can be difficult 1
- The need for 1L O2 indicates significant hypoxemia and warrants aggressive treatment from the outset
- Do NOT delay systemic corticosteroids - early administration is essential 2, 3
Observation Period
Recent evidence suggests that children with moderate asthma should be observed for 2-3 hours after achieving PRAM <4 to capture the majority (97.7-99.7%) of patients who may deteriorate and require hospitalization 4. A significant proportion (31.7%) of children observed beyond initial improvement criteria experienced subsequent deterioration, with 60.5% worsening within the first additional hour 4.
Monitor hourly:
- PRAM score or clinical severity assessment
- Oxygen saturation
- Response to bronchodilators
- Ability to feed (in younger children)
Disposition Criteria
Safe for Discharge When:
- PRAM <4 maintained for 2-3 hours after last bronchodilator 4
- SpO2 >94% on room air 2
- Minimal or absent symptoms
- Child demonstrates adequate inhaler technique
- Caregiver understands discharge plan
Requires Hospitalization If:
- Persistent hypoxemia
- Poor response to treatment after 2-3 hours
- Feeding difficulties
- Social concerns about home management 2
- PRAM score remains ≥4 despite treatment
Discharge Planning
Before discharge, ensure:
- Prescribed 3-10 days of oral corticosteroids 5
- Inhaler technique checked and recorded 1
- Written asthma action plan provided 5, 2
- GP follow-up arranged within 1 week 1
- Respiratory clinic follow-up within 4 weeks 1
- Consider initiating inhaled corticosteroids if not already prescribed 5
The requirement for supplemental oxygen in a child with moderate PRAM score indicates this is at the upper end of moderate severity, warranting aggressive initial treatment and close monitoring for potential deterioration.