Initial Treatment for Pediatric Asthma Exacerbation
The initial treatment for pediatric patients experiencing an asthma exacerbation should include high-flow oxygen via face mask, nebulized salbutamol (albuterol) 5 mg (half dose in very young children), intravenous hydrocortisone, and ipratropium bromide 100 mg nebulized every 6 hours. 1
Assessment and Recognition
- Pediatric patients with acute severe asthma may present with symptoms such as being too breathless to talk or feed, respiratory rate >50 breaths/min, pulse >140 beats/min, and peak expiratory flow (PEF) <50% predicted (if measurable) 2, 1
- Life-threatening features include PEF <33% predicted, poor respiratory effort, cyanosis, silent chest, fatigue, exhaustion, agitation, or reduced level of consciousness 2
Immediate Treatment Protocol
Oxygen Therapy
- Provide high-flow oxygen via face mask to maintain oxygen saturation (SaO₂) >92% 1
- Continuous oxygen saturation monitoring is essential for all children with acute asthma exacerbations 2
Bronchodilator Therapy
- Administer salbutamol (albuterol) 5 mg or terbutaline 10 mg via oxygen-driven nebulizer (half doses in very young children) 2, 1
- For patients not improving after 15-30 minutes, give nebulized β-agonist more frequently, up to every 15-30 minutes 2
- Metered-dose inhalers with spacers (MDI+S) are an effective alternative to nebulization for delivering albuterol in mild to moderate exacerbations, with studies showing comparable efficacy for hospital admission rates and potentially better pulmonary index scores 3, 4
Anticholinergic Therapy
- Add ipratropium bromide 100 mg nebulized every 6 hours 2, 1
- For severe asthma exacerbations, adding ipratropium bromide to albuterol and corticosteroid therapy significantly decreases hospitalization rates (37.5% vs 52.6%) 5
Corticosteroid Therapy
- Give intravenous hydrocortisone immediately for severe exacerbations 2, 1
- For improving patients, switch to oral prednisolone 1-2 mg/kg body weight daily (maximum 40 mg) 2, 1
- Oral corticosteroids should be administered early in the treatment of moderate to severe exacerbations 2
Monitoring Treatment
- Repeat PEF measurement 15-30 minutes after starting treatment (if appropriate) 2, 1
- Monitor oxygen saturation continuously to maintain SaO₂ >92% 1
- Chart PEF before and after β-agonist administration and at least 4 times daily 2
- For patients not improving or deteriorating despite initial therapy, consider transfer to intensive care unit 2
Dosing Considerations
- For nebulized salbutamol, the most commonly reported dosage is 2.5-5.0 mg up to three times every 20 minutes over the first hour 2
- For ipratropium bromide, dosages range from 0.25-0.5 mg every 20 minutes for three doses, followed by every 4-6 hours as needed 2
- Higher doses of albuterol (0.30 mg/kg vs standard 0.15 mg/kg) may result in greater improvement in FEV1 for moderate to severe acute asthma, though with potentially higher serum albuterol levels 6
Special Considerations and Pitfalls
- Avoid sedatives in asthmatic children as they may suppress respiratory drive 2
- Be cautious with albuterol in patients with cardiovascular disorders, convulsive disorders, hyperthyroidism, or diabetes mellitus 7
- Large doses of albuterol may produce significant hypokalemia in some patients, which has potential to produce adverse cardiovascular effects 7
- Continuous nebulized albuterol therapy (0.3 mg/kg/hr) may be as effective as intermittent nebulized therapy while requiring less respiratory therapist time 8
- For patients with severe exacerbations not responding to initial therapy, consider intravenous magnesium sulfate 2
Discharge Criteria
- Patient should have been on discharge medication for 24 hours with inhaler technique checked and recorded 2, 1
- If recorded, PEF should be >75% of predicted or best and PEF diurnal variability <25% 2, 1
- Treatment plan should include soluble steroid tablets and inhaled steroids in addition to bronchodilators 2, 1
- Follow-up with primary care provider should be arranged within 1 week 2