Management of Acute Asthma in a 7-Year-Old Boy
For acute asthma in a 7-year-old boy, immediate treatment should include high-flow oxygen, nebulized salbutamol (5 mg) or terbutaline (10 mg), oral prednisolone (1-2 mg/kg, maximum 40 mg), and consideration of ipratropium bromide if there is no improvement within 15-30 minutes. 1, 2
Initial Assessment
Assess severity based on:
- Respiratory rate (>50 breaths/min indicates severe asthma)
- Heart rate (>140 beats/min indicates severe asthma)
- Ability to speak or feed (too breathless to talk/feed indicates severe asthma)
- Peak expiratory flow (PEF) if appropriate for age (<50% predicted indicates severe asthma)
- Oxygen saturation via pulse oximetry (maintain >92%)
Life-threatening features to watch for:
- PEF <33% of predicted or best
- Poor respiratory effort
- Cyanosis
- Silent chest
- Fatigue or exhaustion
- Agitation or reduced level of consciousness
Step-by-Step Management Algorithm
1. Immediate Treatment
- Administer high-flow oxygen via face mask 1
- Give nebulized salbutamol 5 mg or terbutaline 10 mg via oxygen-driven nebulizer (half doses may be appropriate in very young children) 1, 2
- Administer prednisolone 1-2 mg/kg body weight orally (maximum 40 mg) 1
- Consider intravenous hydrocortisone if unable to take oral medication 1
2. Reassessment after 15-30 minutes
If improving:
- Continue high-flow oxygen
- Continue prednisolone 1-2 mg/kg daily
- Continue nebulized β-agonist 4 hourly (maximum 40 mg/day) 1
If not improving after 15-30 minutes:
- Continue oxygen and steroids
- Increase frequency of nebulized β-agonist (up to every 30 minutes) 1
- Add ipratropium bromide (100 μg) to nebulizer and repeat 6 hourly 1, 2
If life-threatening features present:
- Give intravenous aminophylline 5 mg/kg over 20 minutes followed by maintenance infusion of 1 mg/kg/h 1
- Note: Omit the loading dose if the child is already receiving oral theophyllines 1
- Be cautious with aminophylline in patients with decreased renal function, hepatic insufficiency, or congestive heart failure 3
Monitoring Treatment
- Repeat PEF measurement 15-30 minutes after starting treatment (if age-appropriate) 1
- Use pulse oximetry to maintain SpO2 >92% 1, 2
- Chart PEF before and after β-agonist administration and at least 4 times daily throughout hospital stay 1
- Monitor for signs of fatigue, which may precede respiratory failure 2
Criteria for Hospital Admission
Consider hospital admission if:
- Life-threatening features are present
- Features of acute severe asthma persist after initial treatment
- PEF <33% of predicted/best 2
- Unable to maintain adequate oxygenation
- Decreased activity level or inability to speak in sentences 2
Transfer to Intensive Care
Transfer to ICU accompanied by a doctor prepared to intubate if:
- Deteriorating PEF
- Worsening or persistent hypoxia or hypercapnia
- Exhaustion, feeble respirations, confusion, or drowsiness 1
- Requiring FiO2 ≥0.50 to maintain adequate oxygenation 2
- Altered mental status 2
Discharge Criteria
Before discharge, ensure the patient:
- Has been on discharge medication for 24 hours
- Has had inhaler technique checked and recorded
- If PEF was recorded, it should be >75% of predicted or best, with diurnal variability <25% 1
- Has a follow-up appointment arranged within 1 week 1
Common Pitfalls to Avoid
- Underestimating severity: Children with severe attacks may not appear distressed 1
- Delaying corticosteroid administration: Administer as early as possible as clinical benefits may take 6-12 hours to appear 4
- Inadequate monitoring: Children can maintain normal oxygen saturation until late in disease progression 2
- Sedation: Avoid sedatives of any kind in acute asthma 1
- Underuse of corticosteroids: This is a common factor in preventable asthma deaths 1
Remember that approximately 50% of acute asthma episodes are attributable to upper respiratory infections 4, and getting the basics of management right is the foundation for successful treatment 5.