What is the appropriate management for a child with acute severe asthma?

Management of Acute Severe Asthma in a 5-Year-Old Child

Immediately administer high-flow oxygen via face mask, nebulized salbutamol 5 mg (or terbutaline 10 mg), intravenous hydrocortisone, and add ipratropium 100 mcg nebulized every 6 hours—this is the standard immediate treatment protocol for acute severe asthma in children. 1

Initial Recognition and Assessment

Recognize acute severe asthma in this 5-year-old by identifying these clinical features:

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

Life-threatening features requiring even more aggressive management include:

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

Important caveat: Children with severe attacks may not appear distressed and may not have all these abnormalities—the presence of any should alert you. 1 Assessment in very young children may be difficult. 1

Immediate Treatment Protocol (First 15-30 Minutes)

Step 1: Administer simultaneously:

• Intravenous hydrocortisone immediately 1, 2, 3
• High-flow oxygen via face mask to maintain SaO₂ >92% 1, 2, 3
• Nebulized salbutamol 5 mg (or terbutaline 10 mg) via oxygen-driven nebulizer 1, 2, 3
• Add ipratropium 100 mcg nebulized every 6 hours 1, 2, 3

Note: The British Thoracic Society guidelines specify half doses in very young children, but at age 5, use the full pediatric dose of salbutamol 5 mg. 1

Step 2: If life-threatening features are present:

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

Step 3: Monitoring during initial treatment:

• Repeat PEF measurement 15-30 minutes after starting treatment (if appropriate for age) 1, 3
• Maintain oximetry SaO₂ >92% 1, 3
• Chart PEF before and after β-agonist administration at least 4 times daily 1, 3

Important: No other investigations are needed for immediate management. 1 Blood gas estimations are rarely helpful in deciding initial management in children. 1

Subsequent Management Based on Response

If Patient is Improving After 15-30 Minutes:

Continue:

• High-flow oxygen 1, 3
• Prednisolone 1-2 mg/kg body weight daily (maximum 40 mg) 1, 2, 3, 4
• Nebulized β-agonist 4 hourly 1, 3

If Patient is NOT Improving After 15-30 Minutes:

Escalate treatment:

• Continue oxygen and steroids 1, 3
• Give nebulized β-agonist more frequently, up to every 30 minutes 1, 3
• Add ipratropium to nebulizer and repeat 6 hourly until improvement starts (if not already added) 1, 3

Critical point: The addition of ipratropium to beta-agonist therapy is specifically indicated when initial beta-agonist treatment fails, providing additional bronchodilation through a different mechanism. 3

Transfer to Intensive Care Unit

Transfer the patient to ICU accompanied by a doctor prepared to intubate if there is:

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

Systemic Corticosteroid Dosing Details

Oral prednisolone is the preferred route:

• Dose: 1-2 mg/kg/day (maximum 40-60 mg/day) 1, 2, 4
• Administer as soon as possible, ideally within the first hour 2
• Continue until PEF reaches 70% of predicted or personal best, or for 3-10 days for outpatient treatment 2
• The National Heart, Lung, and Blood Institute recommends 1-2 mg/kg/day in single or divided doses for children whose asthma is uncontrolled 4

Common pitfall to avoid: Do not delay systemic corticosteroids while continuing to give repeated doses of albuterol alone—if the patient has failed initial beta-agonist treatment, escalation with steroids is mandatory. 3

Discharge Criteria

Children should meet ALL of the following before discharge:

• Been on discharge medication for 24 hours with inhaler technique checked and recorded 1, 3
• PEF >75% of predicted or best and PEF diurnal variability <25% (if recorded) 1, 3
• Treatment with soluble steroid tablets and inhaled steroids in addition to bronchodilators 1, 3
• Own PEF meter and self-management plan or written instructions for parents 1, 3
• GP follow-up arranged within 1 week 1, 3
• Follow-up appointment in respiratory clinic within 4 weeks 1, 3

Alternative Treatment Considerations

If nebulizer is unavailable:

• Administer 10-20 puffs of salbutamol via metered-dose inhaler with large volume spacer, which is equivalent to one 5 mg nebulization treatment 5
• Each puff delivers approximately 100 mcg of salbutamol, so 10-20 puffs provides 1-2 mg total dose 5

Recent evidence on inhaled corticosteroids:

• High-dose inhaled corticosteroids are at least as effective as oral corticosteroids in controlling moderate to severe asthma attacks in children and should be considered an alternative 6
• However, oral prednisolone remains the treatment of choice for the most severe exacerbations when airways are extremely contracted and filled with secretions 6

Key Points on Adjunctive Therapies

Ipratropium bromide:

• Should only be given in addition to β₂-agonists, not as monotherapy 6
• Particularly beneficial when initial beta-agonist treatment fails 3

Theophylline:

• Has no additional benefit beyond standard therapy 6

Magnesium sulfate:

• Has no clear advantage in routine management 6