What is the treatment for asthma exacerbation in children?

Treatment of Asthma Exacerbation in Children

The immediate treatment for asthma exacerbation in children consists of high-flow oxygen via face mask, nebulized salbutamol (5 mg for older children, 2.5 mg for very young children), and oral prednisolone 1-2 mg/kg (maximum 40 mg). 1, 2

Initial Assessment and Management

• Assess severity of exacerbation based on symptoms such as breathlessness, ability to talk/feed, respiratory rate (>50 breaths/min indicates severe), pulse (>140 beats/min indicates severe), and peak expiratory flow (<50% predicted if measurable) 3, 1
• Provide high-flow oxygen via face mask to maintain oxygen saturation >92% 1, 3
• Administer salbutamol 5 mg or terbutaline 10 mg via oxygen-driven nebulizer (half doses in very young children) 3, 2
• Give prednisolone tablets 1-2 mg/kg body weight orally (maximum 40 mg) immediately 3, 4
• Monitor oxygen saturation continuously during treatment 2, 1

Medication Administration

Short-Acting Beta-Agonists (SABA)

• Nebulized salbutamol is the standard treatment for acute asthma exacerbation 5
• Dosage: 5 mg for children >20 kg; 2.5 mg for children <20 kg 2
• For severe symptoms, repeat every 20-30 minutes for the first hour, then as needed 1
• Alternative delivery methods:
  • Metered-dose inhaler (MDI) with spacer can be as effective as nebulization (6-20 puffs given one puff every few seconds) 3, 6
  • Dry powder inhalers like Easyhaler have shown similar efficacy to nebulization in children 5-18 years old 6, 7

Corticosteroids

• Oral prednisolone should be given immediately at 1-2 mg/kg/day (maximum 40 mg) 3, 4
• Continue for 3-10 days or until peak expiratory flow reaches 80% of personal best 4
• No evidence that tapering the dose after improvement prevents relapse 4
• For severe exacerbations, consider IV hydrocortisone initially, then switch to oral prednisolone 1

Additional Medications

• Consider adding ipratropium bromide (100 mg nebulized every 6 hours) for moderate to severe symptoms 2, 1
• In cases where salbutamol is nebulized, using 3% hypertonic saline as the diluent instead of normal saline may enhance bronchodilator response 8

Monitoring and Follow-up

• Measure peak expiratory flow 15-30 minutes after starting treatment if age-appropriate 2, 1
• Chart peak expiratory flow before and after β-agonist administration 2
• Continue monitoring oxygen saturation to maintain SaO₂ >92% 2, 1
• For patients not responding adequately to initial treatment, consider:
  • Ensuring at least 3 doses of nebulized salbutamol in the emergency room 5
  • Being particularly vigilant with patients who have a previous history of intubation 5
  • Checking for pneumonia as a trigger, which is associated with treatment failure 5

Hospital Admission Criteria

• Failure to respond to or early deterioration after inhaled bronchodilators 3
• Inability of the child to take, or the parents to give, appropriate treatment 3
• Severe breathlessness and increasing tiredness 3
• Peak expiratory flow <50% of expected value 10 minutes after treatment 3
• Oxygen saturation <92% at presentation 5

Discharge Considerations

• Patient should have been on discharge medication for 24 hours 1
• Peak expiratory flow >75% of predicted or best 1
• Treatment plan should include oral steroids and inhaled steroids in addition to bronchodilators 1
• Schedule follow-up appointment within one month with a respiratory physician 3

Common Pitfalls to Avoid

• Delaying administration of corticosteroids in acute exacerbations; they should be given concurrently with salbutamol 2
• Inadequate assessment of inhaler technique, leading to suboptimal medication delivery 2, 9
• Overreliance on short-acting beta-agonists without adequate controller medications in children with persistent asthma 9
• Insufficient number of nebulized treatments in the emergency room (at least 3 doses should be given before determining treatment failure) 5