What is the recommended nebulization treatment for acute asthma exacerbations in children?

Nebulization Treatment for Acute Asthma Exacerbations in Children

For acute asthma exacerbations in children, administer nebulized salbutamol 5 mg (or 0.15 mg/kg) via oxygen-driven nebulizer, with half doses for very young children, repeated every 15-30 minutes as needed, and add ipratropium bromide 250 mcg for severe exacerbations. 1, 2

Initial Assessment and Severity Classification

Before initiating nebulization, assess severity by looking for:

• Moderate exacerbation: Respiratory rate >50/min, pulse >140/min, use of accessory muscles, PEF 50-70% predicted (if child can perform), too breathless to talk or feed 1, 3
• Severe exacerbation: Poor respiratory effort, fatigue/exhaustion, agitation or reduced consciousness, PEF <50% predicted 1, 3
• Life-threatening: PEF <33% predicted, silent chest, cyanosis, poor respiratory effort 1

Primary Bronchodilator Therapy

Salbutamol Dosing

• Standard dose: 5 mg nebulized OR 0.15 mg/kg 1, 2
• Very young children: Use half doses 2
• Frequency: Repeat every 15-30 minutes if not improving 2
• Driving gas: Use oxygen at 6-8 L/min flow rate whenever possible, as children with acute severe asthma are hypoxic 1, 3
• Duration: 10 minutes is sufficient for bronchodilator nebulization 1

Alternative: Terbutaline

• Dose: 10 mg nebulized OR 0.3 mg/kg 1
• Same frequency and delivery parameters as salbutamol 1

Adding Ipratropium Bromide

Add ipratropium bromide 250 mcg to the nebulizer for severe exacerbations or if the child is not improving after initial salbutamol. 1

• Frequency: Every 6 hours (can be given with second and third doses of albuterol in emergency settings) 1, 4
• Evidence: In children with severe asthma, adding ipratropium to albuterol and corticosteroids significantly reduces hospitalization rates (37.5% vs 52.6%, p=0.02) 4
• Note: No additional benefit in bronchiolitis, so reserve for confirmed asthma exacerbations 5

Concurrent Systemic Corticosteroids

Always administer systemic corticosteroids early in moderate to severe exacerbations: 1, 2

• Prednisolone: 2 mg/kg/day for 3 days (maximum 40 mg/day) 1, 2
• Alternative: Hydrocortisone 100 mg IV every 6 hours 1
• Give with the second dose of bronchodilator 4

Delivery System Selection

Nebulizer vs MDI with Spacer

• Nebulizers are preferable when: Large doses needed, coordinated breathing difficult, child acutely ill 1
• MDI with spacer alternative: 100 mcg salbutamol, one actuation then inhale, repeat up to 20 times (may be as effective and cheaper, but not yet widely used in acute settings) 1

Equipment Specifications

• Mouthpiece preferred over mask (except in babies/young children who won't tolerate) to maximize drug delivery 1
• Masks with straps better for acutely ill patients when holding nebulizer is tiring 1
• Gas flow rate: 6-8 L/min to nebulize 50% of particles to 2-5 µm diameter 1
• Volume: 2.0-4.5 mL in nebulizer chamber; bronchodilators can be mixed together 1

Escalation for Non-Responders

If inadequate response after 3 doses of bronchodilators with corticosteroids:

1. Aminophylline infusion: 1

   • Loading dose: 5 mg/kg IV over 20 minutes (omit if already on theophylline)
   • Maintenance: 1 mg/kg/hour

2. Consider high-dose continuous nebulization: 6

   • Doses up to 3.7 mg/kg/hr have been used safely in PICU settings
   • Associated with low mechanical ventilation rates and short PICU stays
   • Monitor for tachycardia, hypotension, and hypokalemia

3. Transfer to intensive care for continuous bronchodilator therapy ± mechanical ventilation 1

Monitoring During Treatment

• Oxygen saturation: Maintain >92% in children 3
• Clinical response: Decrease in respiratory rate, accessory muscle use, improved air entry 1
• Heart rate: Expect mild increases (6-11 bpm increase is typical) 5
• Decrease frequency of bronchodilators as symptoms improve 1

Common Pitfalls to Avoid

• Do not use water for nebulization—it causes bronchoconstriction; use normal saline 1
• Do not routinely use oxygen as driving gas in COPD patients (not applicable to children with asthma) 1
• Do not delay corticosteroids—give early with second bronchodilator dose 4
• Do not use ipratropium in bronchiolitis—no proven benefit 5
• Avoid ultrasonic nebulizers—jet nebulizers produce superior bronchodilation in acute asthma 7

Emerging Evidence

Recent research suggests nebulizing albuterol with 3% hypertonic saline (rather than normal saline) produces significantly greater bronchodilator response in children with mild-moderate obstruction (41.2% vs 17.3% FEV1 improvement, p<0.0001), though this is not yet standard practice 8

Discharge Planning

24-48 hours before discharge, transition to appropriate delivery system (MDI with spacer or dry powder inhaler) based on child's age, understanding, and technique, with proper education 1