What are the guidelines for nebulisation in pediatric patients with acute asthma exacerbations in the Emergency Room (ER)?

Nebulization Guidelines for Pediatric Patients with Acute Asthma in the ER

For pediatric patients with acute asthma exacerbations in the Emergency Room, immediate treatment should include high-flow oxygen, nebulized salbutamol (5 mg or half dose in very young children), intravenous hydrocortisone, and addition of ipratropium (100 mg) nebulized every 6 hours. 1

Recognition of Acute Severe Asthma in Children

• Too breathless to talk or feed 1
• Respiratory rate >50 breaths/min 1
• Pulse >140 beats/min 1
• Peak expiratory flow (PEF) <50% predicted (if measurable) 1

Life-threatening Features

• PEF <33% predicted or best 1
• Poor respiratory effort 1
• Cyanosis, silent chest, fatigue or exhaustion 1
• Agitation or reduced level of consciousness 1

Immediate Treatment Protocol

1. Oxygen Therapy

   • Provide high-flow oxygen via face mask 1
   • Maintain SaO₂ >92% 1

2. Bronchodilator Therapy

   • Administer salbutamol 5 mg or terbutaline 10 mg via oxygen-driven nebulizer 1
   • Use half doses in very young children 1
   • Nebulization technique: Remove vial, squeeze contents into nebulizer reservoir, connect to mouthpiece or mask, and have patient breathe calmly for 5-15 minutes 2

3. Anti-inflammatory Therapy

   • Give intravenous hydrocortisone immediately 1
   • For improving patients, switch to oral prednisolone 1-2 mg/kg daily (maximum 40 mg) 1

4. Anticholinergic Therapy

   • Add ipratropium 100 mg nebulized every 6 hours 1
   • Can be mixed with albuterol in the nebulizer if used within one hour 3

5. For Life-threatening Features

   • Administer intravenous aminophylline 5 mg/kg over 20 minutes followed by maintenance infusion of 1 mg/kg/h 1
   • Omit loading dose if child is already receiving oral theophyllines 1

Subsequent Management

If Patient is Improving:

• Continue high-flow oxygen 1
• Continue prednisolone 1-2 mg/kg daily (maximum 40 mg) 1
• Continue nebulized β-agonist every 4 hours (maximum 40 mg/day) 1

If Patient is Not Improving After 15-30 Minutes:

• Continue oxygen and steroids 1
• Increase frequency of nebulized β-agonist up to every 30 minutes 1
• Add ipratropium to nebulizer and repeat every 6 hours until improvement starts 1
• Consider continuous nebulization of albuterol (0.3 mg/kg/hr) as it results in more rapid clinical improvement than intermittent nebulization in severe cases 4

Monitoring Treatment

• Repeat PEF measurement 15-30 minutes after starting treatment (if appropriate) 1
• Monitor oxygen saturation continuously to maintain SaO₂ >92% 1
• Chart PEF before and after β-agonist administration and at least 4 times daily 1

Indications for ICU Transfer

• Deteriorating PEF or worsening exhaustion 1
• Feeble respirations, persistent hypoxia or hypercapnia 1
• Coma or respiratory arrest, confusion, or drowsiness 1

Special Considerations

Delivery Method Options

• Metered-dose inhalers with spacers (MDI+S) may be as effective as nebulizers for delivering albuterol, with significant reduction in pulmonary index scores and smaller increases in heart rate 5
• For children under 2 years with recurrent wheezing, nebulized albuterol (0.15 mg/kg per dose) has been shown to improve clinical status without significant oxygen desaturation 6

Combination Therapy

• Combined nebulization of salbutamol and ipratropium bromide provides better improvement in PEFR than salbutamol alone in moderate asthma 7
• For severe asthma (PEF <50% predicted), adding ipratropium to albuterol and corticosteroid therapy significantly decreases hospitalization rates (37.5% vs 52.6%) 8

Discharge Criteria

• Patient has been on discharge medication for 24 hours with inhaler technique checked and recorded 1
• If recorded, PEF >75% of predicted or best and PEF diurnal variability <25% 1
• Treatment plan includes soluble steroid tablets and inhaled steroids in addition to bronchodilators 1
• Patient has own PEF meter (if appropriate) and written management plan or instructions for parents 1
• Follow-up with GP arranged within 1 week 1
• Follow-up appointment in clinic within 4 weeks 1