What is the initial treatment for a child with acute severe asthma?

Initial Treatment for Acute Severe Asthma in Children

Immediately administer high-flow oxygen via face mask, nebulized salbutamol 5 mg (2.5 mg for very young children or those <20 kg), intravenous hydrocortisone, and add ipratropium 100 mcg nebulized every 6 hours. 1, 2

Recognition of Acute Severe Asthma

Identify children requiring immediate aggressive treatment by these clinical features:

• Too breathless to talk or feed 3, 1
• Respiratory rate >50 breaths/minute 3, 1
• Pulse >140 beats/minute 3, 1
• Peak expiratory flow <50% predicted 3, 1
• Use of accessory muscles and difficulty speaking 4

Life-threatening features requiring ICU consideration include:

• PEF <33% predicted or poor respiratory effort 3
• Cyanosis, silent chest, fatigue or exhaustion 3
• Agitation or reduced level of consciousness 3

Immediate Treatment Protocol

First-Line Therapy (Administer Simultaneously)

Oxygen:

• High-flow oxygen via face mask to maintain SaO₂ >92% 3, 1, 5

Bronchodilators:

• Nebulized salbutamol 5 mg via oxygen-driven nebulizer (2.5 mg for very young children or those <20 kg) 3, 1, 2
• Alternative: terbutaline 10 mg (half dose in very young children) 3
• Add ipratropium 100 mcg nebulized every 6 hours immediately 3, 1, 4

Corticosteroids:

• Intravenous hydrocortisone immediately 3, 1
• Oral prednisolone 1-2 mg/kg daily (maximum 40-60 mg) should be started concurrently 1, 5, 2

Life-Threatening Features Protocol

If life-threatening features are present:

• Give intravenous aminophylline 5 mg/kg over 20 minutes followed by maintenance infusion of 1 mg/kg/hour 3
• Omit loading dose if child already receiving oral theophyllines 3

Monitoring Treatment Response

Initial assessment (15-30 minutes after starting treatment):

• Repeat peak expiratory flow measurement if age-appropriate 3, 1
• Maintain continuous oximetry with SaO₂ >92% 3, 1
• Chart PEF before and after β-agonist administration at least 4 times daily 3, 1

Subsequent Management Based on Response

If Patient is Improving:

• Continue high-flow oxygen 3, 1
• Prednisolone 1-2 mg/kg daily (maximum 40 mg) 3, 1
• Nebulized β-agonist every 4-6 hours 3, 1

If Patient is NOT Improving After 15-30 Minutes:

• Continue oxygen and steroids 3, 1
• Increase nebulized β-agonist frequency to every 15-30 minutes 3, 1, 6
• Continue ipratropium 6 hourly until improvement starts 3, 1
• Consider continuous β-agonist nebulization for severe cases 6
• Add intravenous magnesium sulfate for escalating therapy 6

Critical Pitfalls to Avoid

Do not delay corticosteroids: Systemic corticosteroids should be administered as early as possible, ideally within the first hour, as clinical benefits may not occur for a minimum of 6-12 hours 4, 2

Do not underestimate severity in young children: Assessment in the very young may be difficult; the presence of any severe features should alert the physician 3

Do not give sedatives: Sedatives are contraindicated as they can mask deterioration 3

Do not rely on ipratropium alone: Ipratropium provides benefit only when added to β-agonists, not as monotherapy 4, 7

Transfer to Intensive Care Unit

Transfer accompanied by a doctor prepared to intubate if:

• Deteriorating PEF or worsening exhaustion 3, 1
• Feeble respirations, persistent hypoxia or hypercapnia 3, 1
• Coma or respiratory arrest 3, 1

Discharge Criteria

Children should meet all criteria before discharge:

• On discharge medication for 24 hours with verified inhaler technique 3, 1
• PEF >75% of predicted with diurnal variability <25% 3, 1
• Treatment includes soluble steroid tablets and inhaled steroids plus bronchodilators 3, 1
• GP follow-up arranged within 1 week 3, 1
• Respiratory clinic follow-up within 4 weeks 3, 1