What is the immediate treatment for a pediatric asthma flare?

Immediate Treatment for Pediatric Asthma Flare

The immediate treatment for a pediatric asthma flare should include high-flow humidified oxygen, nebulized salbutamol (albuterol) 5 mg or terbutaline 10 mg, and oral prednisolone 1-2 mg/kg (maximum 40 mg). 1

Initial Assessment and Management

Assessment of Severity

• Look for features of severe asthma:

  • Too breathless to talk or feed
  • Respiratory rate >50/min
  • Pulse >140/min
  • Use of accessory muscles of breathing
  • PEF <50% predicted (if child able to perform) 2

• Life-threatening features requiring immediate intensive care consideration:

  • Cyanosis, silent chest
  • Poor respiratory effort
  • Fatigue or exhaustion
  • Agitation, reduced consciousness
  • PEF <33% predicted 2

Immediate Treatment Protocol

1. Oxygen: Administer high-flow humidified oxygen via face mask 2, 1

2. Bronchodilator:

   • Nebulized salbutamol 5 mg (0.15 mg/kg) or terbutaline 10 mg (0.3 mg/kg) 2
   • Alternative delivery: If nebulizer not available, use metered-dose inhaler (MDI) with spacer - give one actuation of salbutamol (100 mcg) then inhale, repeat up to 20 times 2

3. Corticosteroids:

   • Oral prednisolone 1-2 mg/kg (maximum 40 mg) as a single dose 2, 3
   • For severe cases: IV hydrocortisone 100 mg six hourly 2

Delivery Method Considerations

MDI with spacer is as effective as nebulization for bronchodilator delivery:

• Recent evidence shows MDI with spacer produces similar or better outcomes than nebulization 4
• MDI with spacer is cheaper and more convenient than nebulizer 2
• For very young children who cannot tolerate face masks and spacers, nebulizers are needed 2
• Even non-valved spacers can be effective in delivering bronchodilators in stable asthmatic children 5

Monitoring and Further Management

Monitoring Response

• Reassess after initial treatment
• Monitor respiratory rate, heart rate, oxygen saturation, and work of breathing
• For children able to perform: measure peak expiratory flow (PEF) 1

Further Management Based on Response

1. If improving: Decrease frequency of bronchodilators as symptoms improve 2

2. If not improving within 15-30 minutes:

   • Add ipratropium bromide 250 mcg six hourly via nebulizer 2, 1
   • Consider continuous nebulization of albuterol (0.3 mg/kg/hr) which has been shown to result in more rapid clinical improvement than intermittent nebulization 6

3. If further deterioration:

   • Start aminophylline infusion (loading dose 5 mg/kg over 20 minutes, then 1 mg/kg/hour) - omit loading dose if already on theophylline 2
   • Consider transfer to intensive care for continuous bronchodilator therapy or mechanical ventilation 2

Discharge Planning

• 24-48 hours before discharge, transition to discharge therapy using appropriate delivery system for the patient's age and technique 2
• Continue oral prednisolone for up to five days 2
• Ensure follow-up within 48 hours for patients treated at home 2
• For hospitalized patients, arrange outpatient appointment within one month 2

Important Considerations

• Avoid sedatives in patients with asthma 1
• Recognize that asthma severity is often underestimated by patients and clinicians 1
• Ensure proper education on inhaler technique before discharge 1
• Consider hypertonic saline as diluent for nebulized albuterol, which may enhance bronchodilator response 7