Initial Treatment Protocol for Asthma in Children
The initial treatment protocol for asthma in children 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 Asthma in Children
Assessment of severity is critical for appropriate management:
Children with acute severe asthma may present with symptoms such as:
Life-threatening features include:
Immediate Treatment Protocol
For Acute Severe Asthma:
- Administer high-flow oxygen via face mask to maintain SaO₂ >92% 2, 1
- Give salbutamol 5 mg or terbutaline 10 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
- Repeat PEF measurement after starting treatment (if appropriate) 2
- Monitor oxygen saturation continuously 1
- Chart PEF before and after β-agonist administration and at least 4 times daily 2
For Life-Threatening Features:
- Continue all treatments for acute severe asthma 2
- Give intravenous aminophylline 5 mg/kg over 20 minutes followed by maintenance infusion of 1 mg/kg/h 2
- Omit the loading dose if child is already receiving oral theophyllines 2
Subsequent Management
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 4 hourly (maximum 40 mg/day) 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
- Add ipratropium to nebulizer and repeat every 6 hours until improvement starts 2, 3
Pharmacological Considerations
- Albuterol (salbutamol) has a preferential effect on beta2-adrenergic receptors in bronchial smooth muscle, providing effective bronchodilation 4
- In children, most of the absorbed dose is recovered in the urine 24 hours after administration 4
- The combination of inhaled anticholinergics with short-acting beta2-agonists provides enhanced bronchodilation and significantly reduces the risk of hospital admission (RR 0.73; 95% CI 0.63 to 0.85) 3
- Children treated with anticholinergics plus SABA experience greater improvement in lung function 3
Monitoring Treatment
- Repeat PEF measurement 15-30 minutes after starting treatment 2, 1
- Maintain oxygen saturation >92% 2, 1
- Chart PEF before and after β-agonist administration 2
- Consider transfer to intensive care unit if there is:
Discharge Criteria
- Patient has been on discharge medication for 24 hours 2
- Inhaler technique has been checked and recorded 2
- If recorded, PEF >75% of predicted or best and PEF diurnal variability <25% 2
- Treatment plan includes steroid tablets, inhaled steroids, and bronchodilators 2
- Patient has own PEF meter and appropriate self-management plan or written instructions for parents 2
- Follow-up with GP arranged within 1 week 2
- Follow-up appointment in clinic within 4 weeks 2
Common Pitfalls to Avoid
- Underestimating severity of asthma exacerbation in children 2
- Delaying corticosteroid administration 2
- Failing to recognize life-threatening features requiring intensive care 2
- Blood gas estimations are rarely helpful in deciding initial management in children and should not delay treatment 2
- Assessment in very young children may be difficult; presence of any concerning features should prompt aggressive management 2