What is the management for a 10-year-old with an asthma exacerbation?

Management of Asthma Exacerbation in a 10-Year-Old Child

For a 10-year-old child with an asthma exacerbation, immediate treatment should include high-flow oxygen, nebulized salbutamol (5 mg), intravenous hydrocortisone, and ipratropium (100 mg) nebulized every 6 hours. 1

Assessment of Severity

• Recognize acute severe asthma if the child is too breathless to talk or feed, has respiratory rate >50 breaths/min, pulse >140 beats/min, or peak expiratory flow (PEF) <50% predicted 2, 1
• Life-threatening features include PEF <33% predicted, poor respiratory effort, cyanosis, silent chest, fatigue, exhaustion, agitation, or reduced level of consciousness 2
• Continuous oxygen saturation monitoring is essential to maintain SaO₂ >92% 1

Immediate Treatment Protocol

• Administer high-flow oxygen via face mask 2, 1
• Give salbutamol 5 mg via oxygen-driven nebulizer (half doses in very young children) 2, 1
• Administer intravenous hydrocortisone immediately 2, 1
• Add ipratropium 100 mg nebulized every 6 hours 2, 1
• Measure PEF after starting treatment if appropriate for age 2
• Chart PEF before and after β-agonist administration and at least 4 times daily throughout hospital stay 2, 1

If Patient Is Improving

• Continue high-flow oxygen 2
• Switch to oral prednisolone 1-2 mg/kg body weight daily (maximum 40 mg) 2, 1
• Continue nebulized β-agonist every 4 hours 2

If Patient Is Not Improving After 15-30 Minutes

• Continue oxygen and steroids 2
• Increase frequency of nebulized β-agonist up to every 30 minutes 2
• Continue ipratropium nebulization every 6 hours until improvement starts 2
• Consider intravenous aminophylline 5 mg/kg over 20 minutes followed by maintenance infusion of 1 mg/kg/h if life-threatening features are present (omit loading dose if child is already receiving oral theophyllines) 2

Transfer to Intensive Care Unit

• Transfer to ICU accompanied by a doctor prepared to intubate if there is deteriorating PEF, worsening exhaustion, feeble respirations, persistent hypoxia, coma, respiratory arrest, confusion, or drowsiness 2

Alternative Delivery Methods

• Metered-dose inhalers with spacers (MDI+S) can be as effective as nebulizers for delivering albuterol in children with asthma exacerbations 3, 4
• For severe exacerbations, MDI with valved-holding chamber and mask along with oxygen by a separate cannula has shown lower hospitalization rates compared to nebulization (5.8% vs 27.5%) 4
• Standard albuterol dosing for children weighing at least 15 kg is 2.5 mg administered three to four times daily by nebulization 5

Discharge Criteria and Follow-up

• Patient should have been on discharge medication for 24 hours 2, 1
• Inhaler technique should be checked and recorded 2, 1
• If PEF is recorded, it should be >75% of predicted or best with diurnal variability <25% 2, 1
• Treatment plan should include oral steroids, inhaled steroids, and bronchodilators 2, 1
• Provide the child with a peak flow meter and written asthma action plan or instructions for parents 2, 1, 6
• Arrange follow-up with primary care provider within 1 week 2, 1
• Schedule follow-up appointment in respiratory clinic within 4 weeks 2, 1

Common Pitfalls to Avoid

• Underestimating the severity of the exacerbation 2
• Underuse of corticosteroids 2, 6
• Overreliance on short-acting beta-agonists without adequate controller medications 6
• Failure to step up therapy when asthma is not well-controlled 6
• Inadequate assessment of inhaler technique 6
• Insufficient follow-up after medication changes 6