Initial Treatment for Pediatric Acute Asthma Exacerbation
The initial treatment for pediatric acute asthma exacerbation should include high-flow oxygen via face mask, nebulized beta-agonists (salbutamol 5 mg or terbutaline 10 mg), and systemic corticosteroids (intravenous hydrocortisone or oral prednisolone 1-2 mg/kg). 1
Assessment of Severity
Before initiating treatment, rapidly assess the severity of the exacerbation:
Acute Severe Asthma Features:
- Too breathless to talk or feed
- Respirations >50 breaths/min
- Pulse >140 beats/min
- PEF <50% predicted
Life-Threatening Features:
- PEF <33% predicted or best
- Poor respiratory effort
- Cyanosis, silent chest, fatigue or exhaustion
- Agitation or reduced level of consciousness
Step-by-Step Initial Treatment Algorithm
1. Immediate Treatment for All Acute Exacerbations:
- Administer high-flow oxygen via face mask to maintain SaO₂ >92% 1
- Give nebulized salbutamol 5 mg or terbutaline 10 mg via oxygen-driven nebulizer (half doses for very young children) 1
- Administer systemic corticosteroids:
- Oral prednisolone 1-2 mg/kg (maximum 40 mg) OR
- Intravenous hydrocortisone if unable to take oral medications 1
- Repeat PEF measurement after starting treatment (if appropriate for age)
- Monitor oxygen saturation with pulse oximetry
2. Additional Measures for Severe Exacerbations:
- Add ipratropium bromide 100 μg nebulized 6-hourly 1, 2
- This is particularly beneficial in severe exacerbations, reducing hospitalization rates by 15% compared to beta-agonists alone 2
3. For Life-Threatening Features:
- Give intravenous aminophylline 5 mg/kg over 20 minutes followed by maintenance infusion of 1 mg/kg/h 1
- Omit loading dose if child is already receiving oral theophyllines
- Note: Use with caution as evidence for adding IV theophylline is mixed 3
Monitoring and Subsequent Management
If Patient Is Improving:
- Continue high-flow oxygen
- Continue prednisolone 1-2 mg/kg daily (maximum 40 mg)
- Continue nebulized beta-agonist 4-hourly (maximum 40 mg/day) 1
If Patient Is Not Improving After 15-30 Minutes:
- Continue oxygen and steroids
- Increase frequency of nebulized beta-agonist up to every 30 minutes 1
- Add ipratropium to nebulizer and repeat 6-hourly until improvement starts 1, 2
Important Considerations
Medication Efficacy:
- Short-acting beta-agonists provide rapid, dose-dependent bronchodilation with minimal side effects 1
- High-dose, frequently administered nebulized albuterol (0.15 mg/kg) has been shown to be more effective than low-dose regimens in severe acute asthma, with comparable safety profiles 4
- Adding ipratropium bromide to albuterol significantly decreases hospitalization rates in children with severe asthma exacerbations (37.5% vs 52.6%) 2
Potential Pitfalls:
- Blood gas measurements are rarely helpful in deciding initial management in children 1
- Successful treatment with beta-agonists may cause an initial decrease in oxygen saturation due to ventilation-perfusion mismatch 1
- Do not administer sedatives to asthmatic children 1
- Omit aminophylline loading dose if the child is already receiving oral theophyllines to avoid toxicity 1, 3
Transfer to Intensive Care:
Consider transfer to ICU if there is:
- Deteriorating PEF or worsening exhaustion
- Feeble respirations, persistent hypoxia or hypercapnia
- Coma or respiratory arrest, confusion, or drowsiness 1
By following this algorithmic approach to pediatric acute asthma exacerbation, you can effectively manage symptoms, reduce hospitalization rates, and improve outcomes for these patients.