What is the initial treatment for an asthma exacerbation in pediatric patients?

Initial Treatment for Asthma Exacerbation in Pediatric Patients

The initial treatment for pediatric asthma exacerbation should include high-flow oxygen, inhaled short-acting beta-agonists (salbutamol/albuterol), and systemic corticosteroids. 1

Assessment of Severity

First, rapidly assess the severity of the exacerbation:

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
• Agitation or reduced level of consciousness

Initial Treatment Algorithm

Step 1: Oxygen

• Provide high-flow oxygen via face mask
• Maintain oxygen saturation (SaO₂) >92% 1

Step 2: Short-acting Beta-agonists

• Salbutamol/Albuterol delivery options:
  • Via oxygen-driven nebulizer: 5 mg (2.5 mg for very young children) 1, 2
  • Via MDI with spacer: 4-8 puffs every 20 minutes for first hour 1, 3

Important note: MDI with spacer is equally effective as nebulization for mild to moderate exacerbations and may be preferred due to fewer side effects (smaller increase in heart rate) and equivalent outcomes 3, 4

Step 3: Add Ipratropium Bromide

• Add ipratropium 100 μg nebulized (or 4-8 puffs via MDI with spacer) 1
• Repeat every 20 minutes for first hour, then every 6 hours until improvement 1

Step 4: Systemic Corticosteroids

• Give immediately for all but the mildest exacerbations
• Oral prednisolone: 1-2 mg/kg body weight daily (maximum 60 mg) 1
• If unable to take oral medication: IV hydrocortisone 1

Management Based on Response

If Improving After Initial Treatment:

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

If NOT Improving After 15-30 Minutes:

• Continue oxygen and steroids
• Give nebulized beta-agonist more frequently (up to every 30 minutes)
• Ensure ipratropium is added to nebulizer and repeat every 6 hours 1

For Life-threatening Features:

• Consider IV aminophylline: 5 mg/kg over 20 minutes followed by maintenance infusion (1 mg/kg/h)
  • Omit loading dose if child already receiving oral theophyllines 1
• Consider IV magnesium sulfate 1

Monitoring

• Repeat PEF measurement 15-30 minutes after starting treatment
• Monitor oxygen saturation continuously
• Chart PEF before and after beta-agonist administration 1

Common Pitfalls and Caveats

1. Delayed corticosteroid administration: Systemic corticosteroids should be given early in the treatment of moderate to severe exacerbations to reduce inflammation and prevent deterioration 1

2. Overreliance on beta-agonists: While beta-agonists provide immediate symptom relief, they don't address the underlying inflammation. Always combine with corticosteroids 1

3. Inadequate monitoring: Continuous monitoring of respiratory status, oxygen saturation, and response to treatment is essential 1

4. Underutilization of MDI with spacer: Evidence shows that MDI with spacer is as effective as nebulization for delivering albuterol in mild to moderate exacerbations, with potentially fewer side effects 3, 4

5. Missing life-threatening signs: Be vigilant for signs of deterioration requiring ICU transfer: worsening PEF, persistent hypoxia, exhaustion, confusion, or drowsiness 1

Remember that blood gas measurements are rarely helpful in deciding initial management in children, and no other investigations are needed for immediate management 1.