What is the immediate treatment for asthma exacerbation in children?

Immediate Treatment for Asthma Exacerbation in Children

The immediate treatment for asthma exacerbation in children should include high-flow oxygen via face mask, nebulized salbutamol (5 mg) or terbutaline (10 mg), and oral prednisolone at 1-2 mg/kg body weight (maximum 40 mg). 1

Initial Assessment and Treatment

Assessment

• Quickly determine severity based on:
  • Ability to speak in sentences
  • Respiratory rate (>25 breaths/min indicates severe exacerbation)
  • Heart rate (>110 beats/min indicates severe exacerbation)
  • Peak expiratory flow (PEF) (<50% predicted indicates severe exacerbation)
  • Presence of life-threatening features: silent chest, cyanosis, feeble respiratory effort, confusion, exhaustion 1

First-Line Medications

1. Oxygen: High-flow oxygen via face mask 1
2. Short-Acting Beta-Agonists:
   • Salbutamol 5 mg (half dose in very young children) or terbutaline 10 mg via oxygen-driven nebulizer 2, 1
   • Alternative delivery: Metered-dose inhaler with spacer (1 puff every few seconds until improvement, maximum 20 puffs) may be as effective as nebulization 2
   • For children <15 kg who require <2.5 mg/dose, use albuterol inhalation solution 0.5% 3
3. Corticosteroids:
   • Oral prednisolone 1-2 mg/kg body weight (maximum 40 mg) as a single dose 2, 1
   • Continue for up to five days; no tapering needed for short courses 2, 1

Treatment Based on Response

If Improving

• Continue monitoring respiratory status
• Repeat beta-agonist treatments as needed (every 15-30 minutes) 1
• Consider adding ipratropium bromide 0.5 mg nebulized every 6 hours for more severe cases 1

If Not Improving or Worsening

Indicators for hospital admission include:

• Failure to respond to or early deterioration after inhaled bronchodilators
• Inability of the child to take, or the parents to give, appropriate treatment
• Severe breathlessness and increasing tiredness
• Peak expiratory flow <50% of expected value 10 minutes after treatment 2

Age-Specific Considerations

Very Young Children (0-2 years)

• Treatment is more challenging due to variable bronchodilator response
• Diagnosis relies almost entirely on symptoms
• Use age-appropriate inhaler devices with face mask for very young children 2, 1

Children 2-12 Years

• Standard dosing applies as outlined above
• For albuterol via nebulizer: 2.5 mg administered 3-4 times daily 3

Evidence on Corticosteroid Dosing

Research shows that 0.5 mg/kg/day of prednisolone is as effective as higher doses (1.0 mg/kg or 2.0 mg/kg) for treating acute exacerbations, suggesting that lower doses may be sufficient 4. Additionally, oral corticosteroids are as effective as intravenous forms for hospitalized children 5.

Common Pitfalls to Avoid

1. Underestimating severity: Always consider each case as potentially severe until proven otherwise 1
2. Delaying corticosteroid administration: Administer early as benefits may take 6-12 hours to appear 1
3. Overreliance on bronchodilators: Many deaths have been associated with overreliance on bronchodilators without appropriate anti-inflammatory treatment 2
4. Inappropriate discharge: Ensure patients meet all discharge criteria before leaving medical care 1
5. Overuse of oral corticosteroids: Studies suggest substantial overprescribing of oral corticosteroids for children with asthma diagnosis 6

Follow-up Care

• Provide a self-management plan for the family
• Arrange follow-up within 48 hours
• Ensure proper inhaler technique is demonstrated and understood
• Consider underlying triggers and how to avoid them 2, 1

Remember that early and appropriate treatment of asthma exacerbations can prevent progression to severe attacks and reduce the need for hospitalization.