Initial Treatment for Pediatric Asthma Exacerbation
The initial treatment for pediatric patients experiencing an asthma exacerbation should include high-flow oxygen, nebulized salbutamol (5 mg or half dose in very young children), intravenous hydrocortisone, and ipratropium bromide (100 mg nebulized every 6 hours). 1, 2
Recognition of Acute Severe Asthma in Children
- 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 and Bronchodilators
- Provide high-flow oxygen via face mask and maintain SaO₂ >92% 1, 2
- Administer salbutamol 5 mg or terbutaline 10 mg via oxygen-driven nebulizer (half doses in very young children) 2, 3
- For children weighing less than 20 kg, use nebulized salbutamol at a dose of 2.5 mg; for children weighing over 20 kg, use 5 mg 3
- Add ipratropium bromide 100 mg nebulized every 6 hours 2, 1
Corticosteroids
- Give intravenous hydrocortisone immediately 2, 1
- For improving patients, switch to oral prednisolone 1-2 mg/kg daily (maximum 40 mg) 2, 4
For Life-Threatening Features
- Consider intravenous aminophylline 5 mg/kg over 20 minutes followed by maintenance infusion of 1 mg/kg/h (omit loading dose if child already receiving oral theophyllines) 2
Delivery Method Considerations
- Metered-dose inhalers with spacer (MDI+S) have been shown to be as effective or superior to nebulization for delivering albuterol in pediatric asthma exacerbations 5, 6
- MDI+S has been associated with significant reduction in pulmonary index scores and a smaller increase in heart rate compared to nebulization 6
- For severe asthma exacerbations, MDI with valved-holding chamber and mask along with oxygen by a cannula separately has shown lower hospitalization rates (5.8% vs 27.5%) compared to nebulization 5
Monitoring Treatment Response
- Repeat PEF measurement 15-30 minutes after starting treatment (if age-appropriate) 1, 2
- Monitor oxygen saturation continuously to maintain SaO₂ >92% 1, 3
- Chart PEF before and after β-agonist administration and at least 4 times daily throughout hospital stay 2
Subsequent Management
If the patient is improving:
- Continue high-flow oxygen 2
- Continue prednisolone 1-2 mg/kg body weight daily (maximum 40 mg) 2
- Continue nebulized β-agonist 4 hourly 2
If the patient is not improving after 15-30 minutes:
- Continue oxygen and steroids 2
- Give nebulized β-agonist more frequently, up to every 30 minutes 2
- Add ipratropium to nebulizer and repeat 6 hourly until improvement starts 2, 7
Transfer to Intensive Care Unit
Consider transfer to ICU if there is:
- Deteriorating PEF, worsening or persisting hypoxia, feeble respirations, confusion, or drowsiness 2, 1
- Exhaustion, coma, or respiratory arrest 2
Discharge Criteria
Patients should have:
- Been on discharge medication for 24 hours and had inhaler technique checked and recorded 2, 1
- PEF >75% of predicted or best and PEF diurnal variability <25% 2
- Treatment plan including soluble steroid tablets and inhaled steroids in addition to bronchodilators 2, 1
- Own PEF meter and self-management plan or written instructions for parents 2
- GP follow-up arranged within 1 week 2
- Follow-up appointment in respiratory clinic within 4 weeks 2
Common Pitfalls to Avoid
- Delaying administration of corticosteroids in acute exacerbations; they should be given concurrently with salbutamol 3
- Inadequate assessment of inhaler technique, which can lead to suboptimal medication delivery 3, 4
- Overreliance on short-acting beta-agonists without adequate controller medications in children with persistent asthma 4
- Underestimating the severity of the exacerbation, which can lead to delayed appropriate treatment 2