Initial Management of Asthma Exacerbation in a 6-Year-Old
The initial management for an asthma exacerbation in a 6-year-old should include immediate administration of a high-dose beta-agonist (salbutamol 5mg or terbutaline 10mg) via nebulizer with oxygen, along with systemic corticosteroids (prednisolone 1-2mg/kg, maximum 40mg). 1, 2
Assessment of Severity
First, quickly assess the severity of the exacerbation:
Severe exacerbation signs:
- Too breathless to talk or feed
- Respiratory rate >50 breaths/min
- Heart rate >140 beats/min
- Peak flow <50% predicted (if measurable in this age)
Life-threatening features:
- Silent chest
- Cyanosis
- Poor respiratory effort
- Fatigue/exhaustion
- Agitation or reduced consciousness
- Peak flow <33% predicted (if measurable)
Step-by-Step Management Algorithm
1. Immediate Treatment
- Oxygen: Administer high-flow oxygen via face mask to maintain SpO₂ >92% 1, 2
- Beta-agonist: Give salbutamol 5mg via oxygen-driven nebulizer (can use half dose in very young children) 1
- Systemic corticosteroids: Administer prednisolone 1-2mg/kg orally (maximum 40mg) or IV hydrocortisone if unable to take oral medication 1, 2
2. Reassessment (after 15-30 minutes)
- Measure peak flow if appropriate for age
- Assess oxygen saturation
- Evaluate clinical response
3. Subsequent Management
If improving:
- Continue oxygen
- Continue prednisolone daily
- Reduce nebulized beta-agonist to every 4 hours 1
If not improving after 15-30 minutes:
Delivery Method Considerations
The British Thoracic Society guidelines note that nebulizers are often overused and may be replaced by metered-dose inhalers (MDIs) with spacers in many cases 1. Research shows that MDIs with spacers can be as effective as nebulizers for delivering beta-agonists in acute asthma 4.
For a 6-year-old:
- Use a large-volume spacer with MDI if nebulizer is not available
- Ensure proper technique: actuate one puff into spacer, have child take 5-6 breaths, then repeat for subsequent puffs
Monitoring During Treatment
- Monitor vital signs, especially respiratory rate and heart rate
- Assess oxygen saturation continuously if possible
- Repeat peak flow measurements (if child is able)
- Observe for signs of improvement or deterioration
Indications for Hospital Admission
Consider hospital admission if:
- Poor response to initial treatment
- Persistent tachypnea or increased work of breathing
- Oxygen requirement to maintain SpO₂ >92%
- Social concerns about home management
- Previous severe exacerbations
Indications for ICU Transfer
Transfer to ICU if there is:
- Deteriorating peak flow
- Persistent hypoxia despite oxygen therapy
- Rising CO₂ levels
- Exhaustion, confusion, or drowsiness 1, 2
Discharge Planning
Before discharge, ensure:
- Child has been on discharge medications for 24 hours
- Inhaler technique has been checked and recorded
- Peak flow >75% of predicted or best (if measurable)
- Treatment plan includes oral steroids and inhaled steroids in addition to bronchodilators
- Follow-up with primary care arranged within 1 week 1
Common Pitfalls to Avoid
- Underestimating severity: Children may appear playful despite significant respiratory compromise
- Delaying corticosteroids: Administer immediately as benefits may take 6-12 hours to appear 5
- Using LABA without ICS: Long-acting beta-agonists should never be prescribed without inhaled corticosteroids due to safety concerns 2
- Inadequate monitoring: Children can deteriorate rapidly; frequent reassessment is essential
- Premature discharge: Ensure stability for at least 24 hours before discharge
By following this structured approach to managing asthma exacerbations in children, you can effectively address the acute episode while minimizing the risk of complications and recurrence.