What is the immediate treatment for status asthmaticus in a pediatric patient?

Status Asthmaticus Treatment in a 10-Year-Old Boy

Immediately administer intravenous hydrocortisone, high-flow oxygen via face mask to maintain oxygen saturation >92%, nebulized salbutamol 5 mg via oxygen-driven nebulizer, and add ipratropium 100 mcg nebulized every 6 hours. 1, 2

Immediate Recognition and Assessment

First, rapidly identify if this child has life-threatening features that require even more aggressive intervention:

• Life-threatening features include PEF <33% predicted, poor respiratory effort, cyanosis, silent chest, fatigue/exhaustion, agitation, or reduced level of consciousness 1
• Acute severe asthma features in this age group include being too breathless to talk or feed, respirations >50 breaths/min, pulse >140 beats/min, or PEF <50% predicted 1, 2

Critical pitfall: Do not wait for blood gas results to initiate treatment—blood gas estimations are rarely helpful in deciding initial management in children and delay can be fatal 1

First-Line Immediate Treatment Protocol

Core Medications (Start Simultaneously)

• Intravenous hydrocortisone - give immediately without delay 1, 2
• High-flow oxygen via face mask to maintain SaO₂ >92% 1, 3, 2
• Nebulized salbutamol 5 mg (or terbutaline 10 mg) via oxygen-driven nebulizer 1, 2
  • Note: For a 10-year-old, use the full 5 mg dose (half doses are only for very young children) 1
• Ipratropium 100 mcg nebulized, repeat every 6 hours 1, 2

Monitoring During Initial Treatment

• Repeat PEF measurement 15-30 minutes after starting treatment 1, 2
• Maintain continuous pulse oximetry with target SaO₂ >92% 1, 3, 2
• Chart PEF before and after β-agonist administration at least 4 times daily 1, 2

Life-Threatening Features: Add Aminophylline

If life-threatening features are present (as defined above), immediately add:

• Intravenous aminophylline 5 mg/kg over 20 minutes, followed by maintenance infusion of 1 mg/kg/hour 1
• Omit the loading dose if the child is already receiving oral theophyllines 1

Subsequent Management at 15-30 Minutes

If Patient is Improving:

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

If Patient is NOT Improving After 15-30 Minutes:

• Continue oxygen and steroids 1
• Increase nebulized β-agonist frequency to every 30 minutes 1
• Add ipratropium to nebulizer if not already done, repeat every 6 hours until improvement starts 1
• Consider continuous nebulization of albuterol (0.3 mg/kg/hr), which has been shown to result in more rapid clinical improvement than intermittent dosing in children with impending respiratory failure 4

Important consideration: Continuous nebulization of albuterol results in patients being out of impending respiratory failure in a median of 12 hours versus 18 hours with intermittent dosing, with shorter hospital stays and less respiratory therapy time required 4

Transfer to Intensive Care Unit

Prepare for ICU transfer with a physician ready to intubate if:

• Deteriorating PEF or worsening exhaustion 1, 2
• Feeble respirations, persistent hypoxia, or hypercapnia 1, 2
• Coma, respiratory arrest, confusion, or drowsiness 1, 2

Discharge Criteria (When Stabilized)

The child should meet all of the following before discharge:

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

Critical Pitfalls to Avoid

• Underuse of corticosteroids is a major factor in preventable asthma deaths—give steroids early 1
• Doctors and families failing to appreciate severity—regard each emergency consultation as potentially severe until proven otherwise 1
• Delaying treatment for investigations—no other investigations are needed for immediate management 1
• Using inadequate oxygen—high-flow oxygen is essential, not just nasal cannula 1, 3, 2