What is the initial treatment for a child experiencing an asthma exacerbation?

Initial Treatment for Asthma Exacerbation in Children

The initial treatment for a child experiencing an asthma exacerbation should be immediate administration of high-dose inhaled β-agonists (salbutamol/albuterol) via metered-dose inhaler with spacer or nebulizer, along with systemic corticosteroids and oxygen therapy if needed to maintain saturation at 93-95%. 1

First-Line Medications and Dosing

Short-Acting Beta-Agonists (SABA)

• Albuterol/Salbutamol:
  • Dose: 5-10 mg nebulized or equivalent via MDI with spacer
  • Frequency: Every 15-30 minutes as needed during the acute phase 1
  • Mechanism: Preferential effect on beta2-adrenergic receptors causing bronchial smooth muscle relaxation 2
  • Onset of action: Within 5 minutes, with peak effect at approximately 1 hour 2

Corticosteroids

• Should be administered early in the exacerbation
• Oral prednisolone: 1-2 mg/kg (typically 30-60 mg)
• IV hydrocortisone (200 mg) if unable to take oral medications 1

Oxygen Therapy

• Administer to maintain oxygen saturation at 93-95% 1

Delivery Method Considerations

The evidence strongly supports using metered-dose inhalers with spacers (MDI+S) over nebulization for albuterol delivery:

• MDI+S shows significant reduction in pulmonary index scores compared to nebulization 3
• MDI+S results in a smaller increase in heart rate (better cardiovascular profile) 3
• MDI+S with oxygen delivered separately is more effective than nebulization in severe asthma exacerbations, with lower hospitalization rates (5.8% vs 27.5%) 4

Adjunctive Therapy

For severe exacerbations, consider adding ipratropium bromide:

• Dose: 0.5 mg nebulized or equivalent via MDI
• Frequency: Every 6 hours 1
• Evidence shows that adding ipratropium to albuterol and corticosteroid therapy significantly decreases hospitalization rates in children with severe asthma exacerbations (37.5% vs 52.6%) 5

Monitoring and Assessment

Monitor the following during treatment:

• Respiratory rate and work of breathing
• Oxygen saturation
• Heart rate
• Response to bronchodilator therapy
• Peak expiratory flow rate (PEFR) if age-appropriate (may not be reliable in children under 5 years) 1

Treatment Algorithm

1. Assess severity of exacerbation based on:

   • Work of breathing
   • Respiratory rate
   • Oxygen saturation
   • Ability to speak in sentences
   • Use of accessory muscles

2. Administer initial treatment:

   • Albuterol via MDI+S or nebulizer
   • Systemic corticosteroids
   • Oxygen if saturation <93%

3. For moderate-severe exacerbations:

   • Add ipratropium bromide
   • Consider continuous nebulization (0.3 mg/kg/hr) if severe 6

4. Reassess after initial treatment:

   • If improving: Continue treatment and monitor
   • If not improving: Intensify treatment and consider hospital admission

Important Cautions

• Albuterol should be used with caution in patients with cardiovascular disorders, as it can produce significant cardiovascular effects 2
• Monitor for potential hypokalemia with repeated dosing of albuterol 2
• Do not increase dose or frequency without medical consultation 2
• Other sympathomimetic bronchodilators or epinephrine should not be used concomitantly with albuterol 2

Discharge Criteria

Patients can be discharged when:

• They have been on discharge medication for 24 hours
• Inhaler technique has been checked and recorded
• PEF >75% of predicted or best and PEF diurnal variability <25%
• Treatment plan includes:
  • Oral corticosteroids to complete course
  • Inhaled corticosteroids as maintenance therapy
  • Written asthma action plan 1

Indications for Hospital Admission

Consider immediate referral to hospital for:

• Life-threatening features
• Persistent severe attack features after initial treatment
• PEF <33% of predicted or best value 15-30 minutes after treatment 1