What is the management approach for an asthma exacerbation in pediatric patients?

Management of Asthma Exacerbation in Pediatric Patients

The management of pediatric asthma exacerbation requires immediate administration of oxygen, inhaled short-acting β2-agonists, and systemic corticosteroids, with severity assessment determining treatment intensity and monitoring frequency. 1

Recognition and Assessment of Severity

Signs of Acute Severe Asthma in Children:

• Too breathless to talk or feed
• Respiratory rate >50 breaths/min
• Pulse >140 beats/min
• PEF <50% predicted 2

Life-Threatening Features:

• PEF <33% predicted or best
• Poor respiratory effort
• Cyanosis
• Silent chest
• Fatigue or exhaustion
• Agitation or reduced level of consciousness 2

Immediate Treatment Algorithm

Step 1: Initial Management for All Exacerbations

• High-flow oxygen via face mask to maintain SaO2 >92% 2, 1
• Salbutamol 5 mg (2.5 mg for very young children) or terbutaline 10 mg via oxygen-driven nebulizer 2
• Systemic corticosteroids:
  • Oral prednisolone 1-2 mg/kg body weight daily (maximum 40 mg) 2
  • OR intravenous hydrocortisone if unable to take oral medication 2
• Add ipratropium 100 μg nebulized every 6 hours 2

Step 2: For Life-Threatening Features

• Continue oxygen and steroids
• Give intravenous aminophylline 5 mg/kg over 20 minutes followed by maintenance infusion of 1 mg/kg/h
  • Omit loading dose if child already receiving oral theophyllines 2
• Consider IV magnesium sulfate for severe exacerbations not responding to initial therapy 2, 1

Step 3: Monitoring Response (15-30 minutes after starting treatment)

• If improving:

  • Continue high-flow oxygen
  • Continue prednisolone 1-2 mg/kg daily
  • Continue nebulized β-agonist every 4 hours (maximum 40 mg/day) 2

• If not improving after 15-30 minutes:

  • Continue oxygen and steroids
  • Give nebulized β-agonist more frequently (up to every 30 minutes)
  • Add ipratropium to nebulizer and repeat every 6 hours until improvement starts 2

Ongoing Monitoring

• Repeat PEF measurement after starting treatment (if age-appropriate)
• Maintain oxygen saturation >92% using pulse oximetry
• Chart PEF before and after β-agonist treatments and at least 4 times daily throughout hospital stay 2

Transfer to Intensive Care Criteria

Transfer to ICU accompanied by a doctor prepared to intubate if:

• Deteriorating PEF
• Worsening exhaustion
• Feeble respirations
• Persistent hypoxia or hypercapnia
• Coma, respiratory arrest, confusion, or drowsiness 2

Discharge Criteria

Patients should have:

• Been on discharge medication for 24 hours with inhaler technique checked and recorded
• PEF >75% of predicted or best and PEF diurnal variability <25%
• Treatment with oral steroids and inhaled steroids in addition to bronchodilators
• Own PEF meter (if appropriate) and self-management plan or written instructions for parents
• Follow-up with primary care provider within 1 week
• Follow-up in respiratory clinic within 4 weeks 2

Important Considerations

Medication Delivery Methods

• Albuterol via metered-dose inhaler with spacer can be as effective as nebulized treatment for mild to moderate exacerbations 2, 1
• Albuterol produces a greater bronchodilator response when nebulized with 3% hypertonic saline compared to normal saline in children with mild or moderate bronchial obstruction 3

Treatment Pitfalls to Avoid

• Delaying corticosteroid administration (reduces hospitalization rates) 1
• Routine use of antibiotics (not recommended without clear evidence of bacterial infection) 2, 1
• Overhydration in older children 1
• Using non-selective β-agonists (cardiotoxic) 1, 4
• Delaying treatment while obtaining laboratory studies 1

Evidence-Based Considerations

• Blood gas estimations are rarely helpful in deciding initial management in children 2
• Continuous nebulized albuterol therapy is as effective as intermittent nebulization and may save healthcare provider time in emergency settings 5
• Adding theophylline to the combination of systemic corticosteroids and inhaled albuterol does not provide additional benefit in children hospitalized with mild to moderate asthma 6

By following this structured approach to managing pediatric asthma exacerbations, clinicians can effectively reduce morbidity and mortality while improving quality of life outcomes for children experiencing asthma attacks.