How to manage pediatric asthma in the emergency department (ED)?

Management of Pediatric Asthma in the Emergency Department

The immediate management of pediatric asthma in the ED should include high-flow oxygen via face mask, nebulized salbutamol (5 mg) or terbutaline (10 mg) via oxygen-driven nebulizer (half doses for very young children), and oral prednisolone 1-2 mg/kg (maximum 40 mg). 1

Initial Assessment and Treatment

Assessment

• Evaluate severity based on:
  • Respiratory rate (compared to age-appropriate norms)
  • Work of breathing (retractions, accessory muscle use)
  • Oxygen saturation
  • Peak flow measurement (in children over 5 years)
  • Mental status
  • Ability to speak in complete sentences

Immediate Treatment

1. Oxygen: High-flow oxygen via face mask to maintain O₂ saturation >92%
2. Bronchodilators:
   • First-line: Salbutamol 5 mg (2.5 mg for children under 2 years) or terbutaline 10 mg (5 mg for children under 2 years) via oxygen-driven nebulizer 1
   • Alternative delivery method: Metered-dose inhaler (MDI) with spacer can be as effective as nebulization for mild exacerbations 2, 3
     • Give one puff every few seconds until improvement occurs (maximum 20 puffs)
     • Use face mask attachment for very young children
3. Corticosteroids:
   • Oral prednisolone 1-2 mg/kg (maximum 40 mg) 1, 4
   • For severe exacerbations, may need to continue for up to five days

Management Algorithm Based on Severity

Mild Exacerbation

• Albuterol via MDI with spacer (more cost-effective than nebulization) 2
• Reassess after 10 minutes
• If improved: Consider discharge with appropriate follow-up
• If not improved: Escalate to moderate exacerbation protocol

Moderate to Severe Exacerbation

• High-flow oxygen
• Nebulized salbutamol/albuterol or MDI with spacer (multiple doses)
• Oral prednisolone/prednisone
• Consider adding inhaled corticosteroids at discharge 5
• Reassess after treatment
• If peak flow <50% of predicted or personal best after treatment, manage as severe attack 1

Life-Threatening Exacerbation

• Immediate high-flow oxygen
• Continuous nebulized salbutamol/albuterol
• IV corticosteroids if unable to take oral medication
• Consider IV magnesium sulfate
• Call for specialist assistance (pediatric intensivist/anesthesiologist)
• Do not attempt intubation until the most expert available doctor is present 1

Discharge Planning

1. Medication:

   • Albuterol via MDI with spacer (overwhelming majority of children should receive this) 6
   • Oral corticosteroids to complete 3-5 day course
   • Consider new or continued inhaled corticosteroids 6, 5

2. Education:

   • Proper inhaler technique
   • Recognition of worsening symptoms
   • Written asthma action plan

3. Follow-up:

   • Arrange follow-up within 48 hours
   • Contact primary care provider before discharge if possible 1

Special Considerations

Very Young Children (0-2 years)

• Diagnosis relies almost entirely on symptoms
• Bronchodilator response may be variable but should still be tried
• Consider alternative diagnoses (gastroesophageal reflux, cystic fibrosis, etc.) 1

Catastrophic/Brittle Asthma

• Identify patients with history of sudden severe attacks
• These patients may require direct admission to intensive care
• Consider early involvement of pediatric intensivist 1

Common Pitfalls to Avoid

1. Underutilization of spacer devices: MDI with spacer is as effective as nebulization for many patients 2, 3

2. Delaying corticosteroid administration: Early administration improves outcomes 1

3. Overuse of antibiotics: Only 2.6% of asthma exacerbations should require antibiotics; avoid unless clear evidence of bacterial infection 6

4. Aminophylline use: Should no longer be used in children at home 1

5. Inadequate discharge planning: Failure to provide comprehensive therapy (albuterol MDI, oral steroids, and inhaled corticosteroids) 6

6. Cardiovascular effects: Monitor for potential cardiovascular effects of albuterol, especially with repeated dosing 7

7. Hypokalemia: Repeated dosing with albuterol can cause transient hypokalemia 7

By following this structured approach to pediatric asthma management in the ED, you can optimize outcomes while minimizing risks and unnecessary treatments.