What is the recommended treatment approach for asthma in children?

Treatment of Asthma in Children

For acute severe asthma exacerbations in children, immediately administer high-flow oxygen, nebulized salbutamol 5 mg (or 2.5 mg for very young children), intravenous hydrocortisone, and add ipratropium 100 mcg nebulized every 6 hours, with prednisolone 1-2 mg/kg daily (maximum 40 mg) for ongoing management. 1

Recognition of Acute Severe Asthma

Identify children requiring immediate aggressive treatment by these clinical features:

• Too breathless to talk or feed 1
• Respiratory rate >50 breaths/minute 1
• Pulse >140 beats/minute 1
• Peak expiratory flow <50% predicted (if measurable) 1

Life-Threatening Features Requiring ICU Consideration

• PEF <33% predicted or poor respiratory effort 1
• Cyanosis, silent chest, fatigue or exhaustion 1
• Agitation or reduced level of consciousness 1

Important caveat: Assessment in very young children may be difficult, and children with severe attacks may appear distressed—the presence of any of these features should alert you immediately. 1

Immediate Treatment Protocol

First-Line Acute Management

• Administer intravenous hydrocortisone immediately 1, 2
• High-flow oxygen via face mask to maintain SaO₂ >92% 1, 2
• Nebulized salbutamol 5 mg or terbutaline 10 mg via oxygen-driven nebulizer (use half doses in very young children) 1, 2
• Add ipratropium 100 mcg nebulized every 6 hours 1, 2

Critical timing: Administer salbutamol 2.5 mg by nebulization every 20 minutes for 3 doses initially, or use metered-dose inhaler with spacer: 4-8 puffs every 20 minutes as needed. 2

For Life-Threatening Features

Give intravenous aminophylline 5 mg/kg over 20 minutes followed by maintenance infusion of 1 mg/kg/hour—omit the loading dose if the child is already receiving oral theophyllines. 1

Common pitfall: Blood gas estimations are rarely helpful in deciding initial management in children and should not delay treatment. 1

Subsequent Management Based on Response

If Patient Is Improving (15-30 Minutes After Initial Treatment)

• Continue high-flow oxygen 1
• Prednisolone 1-2 mg/kg body weight daily (maximum 40 mg) 1, 2
• Nebulized β-agonist 4 hourly (maximum 40 mg/day) 1

If Patient Is NOT Improving After 15-30 Minutes

• Continue oxygen and steroids 1
• Give nebulized β-agonist more frequently, up to every 30 minutes 1, 2
• Add ipratropium to nebulizer and repeat 6 hourly until improvement starts 1

Evidence note: The combination of salbutamol with ipratropium bromide provides significant additional bronchodilation beyond salbutamol alone, indicating a substantial cholinergic element to acute pediatric asthma exacerbations. 3

Monitoring During Treatment

• Repeat peak expiratory flow measurement 15-30 minutes after starting treatment (if appropriate for age) 1, 2
• Maintain oximetry SaO₂ >92% 1, 2
• Chart PEF before and after β-agonist administration at least 4 times daily throughout hospital stay 1

ICU Transfer Criteria

Transfer to intensive care unit accompanied by a doctor prepared to intubate if:

• Deteriorating PEF or worsening exhaustion 1
• Feeble respirations, persistent hypoxia or hypercapnia 1
• Coma, respiratory arrest, confusion, or drowsiness 1

Discharge Criteria and Follow-Up

Children should meet ALL of the following before discharge:

• Been on discharge medication for 24 hours with inhaler technique checked and recorded 1
• PEF >75% of predicted or best and PEF diurnal variability <25% (if recorded) 1
• Treatment with soluble steroid tablets and inhaled steroids in addition to bronchodilators 1
• Own PEF meter and written self-management plan or instructions for parents 1
• GP follow-up arranged within 1 week 1, 2
• Follow-up appointment in respiratory clinic within 4 weeks 1, 2

Chronic Asthma Management

Stepwise Approach to Long-Term Control

The treatment approach should start with aggressive therapy to achieve control, followed by a "step down" to minimal therapy that maintains control. 4

Controller Medications for Persistent Symptoms

• Inhaled corticosteroids are the most potent long-term anti-inflammatory medications and should be considered first-line for persistent asthma 4
• Long-acting beta₂ agonists (such as salmeterol) can be added to inhaled corticosteroids for patients ≥4 years with inadequate control 5
• Montelukast (leukotriene receptor antagonist): 5 mg chewable tablet for ages 6-14 years, 4 mg chewable for ages 2-5 years 6

Important limitation: Long-acting beta-agonists should NEVER be used as monotherapy—they must be combined with inhaled corticosteroids, as LABA monotherapy increases the risk of serious asthma-related events. 5

Verification Before Treatment Escalation

Before intensifying therapy, always verify:

• Inhalation technique is correct 2, 7
• Adherence to current therapy 2

Common pitfall: Inadequate inhaler technique is a frequent cause of treatment failure and must be assessed at every visit. 7

Home Management of Yellow Zone Symptoms

Aggressive Upfront Protocol for Parents

• Administer 4-8 puffs of salbutamol via MDI with spacer every 20 minutes for up to 3 doses (total 12-24 puffs over one hour) 7
• Start oral prednisone 1-2 mg/kg (maximum 60 mg) immediately when yellow zone symptoms appear—do not wait to see if bronchodilators work 7
• Reassess the child 15-30 minutes after each bronchodilator dose 7

Critical teaching point: Yellow zone is a short-term intervention (1-2 hours maximum at home before seeking help if not improving). 7

Red Flags Requiring Immediate Medical Attention

Parents must seek immediate medical care if:

• Child cannot complete sentences in one breath 7
• Pulse >110 bpm or respiratory rate >25/minute persists after first treatment round 7
• Child appears exhausted, drowsy, or confused 7

Special Considerations

Alternative Formulations

When nebulizer is unavailable: 10-20 puffs of salbutamol via metered-dose inhaler with large volume spacer is equivalent to one 5 mg nebulization treatment. 7

Levosalbutamol vs Racemic Salbutamol

While levosalbutamol (containing only the R-isomer) shows superior efficacy with less tachycardia and fewer electrolyte disturbances compared to racemic salbutamol 8, 9, the standard guidelines recommend racemic salbutamol as first-line therapy due to widespread availability and established protocols. 1, 2

Intravenous Salbutamol for Severe Cases

For children with acute severe asthma not responding to nebulized therapy, a 10-minute infusion of intravenous salbutamol (15 mcg/kg) can curtail clinical progression and reduce recovery time from 11.5 hours to 4 hours. 10