What is the immediate management for an 8-year-old with status asthmaticus and a history of wheezing?

Assessment and Management of an 8-Year-Old with Status Asthmaticus

Critical History Questions to Ask

Immediately assess severity markers and risk factors for fatal asthma:

• Current symptoms severity: Can the child complete sentences in one breath? (inability indicates severe asthma) 1
• Respiratory rate: Is it >50 breaths/min? (threshold for severe asthma in children) 2
• Heart rate: Is it >140 beats/min? (indicates severe exacerbation) 2
• Level of consciousness: Any confusion, drowsiness, or exhaustion? (life-threatening features) 1, 2
• Response to initial treatment: How many albuterol treatments has the child received in the past 24 hours, and what was the response? (lack of response to 2 doses signals treatment failure) 3

Identify triggers and risk factors:

• Recent viral illness: Any fever, rhinorrhea, or upper respiratory symptoms in the past week? (viral infections are the most common trigger in this age group) 3
• Medication adherence: Has the child been using any controller medications (inhaled corticosteroids)? When was the last dose? 4
• Previous severe episodes: Any prior ICU admissions, intubations, or hospitalizations for asthma? (predicts risk of fatal asthma) 5, 4
• Allergen or irritant exposure: Recent exposure to pets, smoke, or other known triggers? 4

Physical Examination Findings to Document

Life-threatening features (require immediate ICU consideration):

• Silent chest on auscultation despite respiratory distress (indicates minimal air movement) 1, 2
• Cyanosis (severe hypoxia) 1, 2
• Poor respiratory effort or feeble respirations (impending respiratory failure) 1, 2
• Altered mental status: confusion, drowsiness, agitation, or reduced consciousness 2
• Bradycardia or hypotension (ominous signs) 1

Severe asthma features:

• Accessory muscle use: suprasternal, intercostal, or subcostal retractions 4
• Inability to speak in full sentences or feed (too breathless) 2, 3
• Respiratory rate >50 breaths/min 2
• Heart rate >140 beats/min 2
• Pulsus paradoxus (>10 mmHg drop in systolic BP with inspiration) 4
• Refusal to recline below 30 degrees (indicates severe distress) 4

Objective measurements (essential, not optional):

• Oxygen saturation: Measure before oxygen administration; <92% requires immediate high-flow oxygen 6, 2
• Peak expiratory flow (PEF): <50% predicted indicates severe asthma; <33% predicted is life-threatening 1, 2

Immediate Management Protocol

The British Thoracic Society guidelines mandate starting all of the following AT ONCE for status asthmaticus in children:

First-Line Treatment (Start Simultaneously)

• High-flow oxygen via face mask to maintain SaO₂ >92% (not nasal cannula—this is inadequate) 6, 2
• Nebulized salbutamol 5 mg via oxygen-driven nebulizer (or terbutaline 10 mg) 2, 7
• Intravenous hydrocortisone 200 mg immediately without delay (or oral prednisolone 1-2 mg/kg, maximum 40 mg) 2, 3
• Ipratropium 100 mcg nebulized added to beta-agonist, repeat every 6 hours 2, 3

Monitoring at 15-30 Minutes

• Repeat PEF measurement to assess response 6, 2
• Continuous pulse oximetry with target SaO₂ >92% 6, 2
• Arterial blood gas if PaO₂ <8 kPa (60 mmHg), normal or elevated PaCO₂, or clinical deterioration (normal or high CO₂ in a breathless child is life-threatening) 1

If Not Improving After Initial Treatment

• Increase nebulized beta-agonist frequency to every 30 minutes 2, 3
• Continue oxygen and corticosteroids 2
• Consider intravenous aminophylline 5 mg/kg over 20 minutes if life-threatening features present (omit loading dose if already on oral theophyllines) 2

ICU Transfer Criteria

Transfer immediately if any of the following develop:

• Deteriorating PEF despite treatment 6, 2
• Worsening or persistent hypoxia 6
• Exhaustion, confusion, drowsiness, or coma 6, 2
• Feeble respirations or respiratory arrest 2
• Normal or rising PaCO₂ (indicates impending respiratory failure) 1

Critical Pitfalls to Avoid

• Do not delay systemic corticosteroids while giving repeated albuterol alone—underuse of corticosteroids is a major factor in preventable asthma deaths 2, 3
• Do not underestimate severity—regard each emergency consultation as potentially severe until proven otherwise; doctors and families frequently fail to appreciate severity 2
• Do not use inadequate oxygen delivery—high-flow face mask is essential, not nasal cannula 2
• Do not delay treatment for investigations—no other investigations are needed for immediate management 2
• Do not use paralytic agents unless absolutely necessary for intubation (increased risk of ICU myopathy) 5

Discharge Planning (When Stabilized)

The child must meet ALL of the following criteria before discharge:

• Been on discharge medication for 24 hours with inhaler technique checked 2
• PEF >75% of predicted or best with diurnal variability <25% 6, 2
• Treatment includes oral corticosteroids AND inhaled corticosteroids in addition to bronchodilators 2
• Own PEF meter with written self-management plan for parents 2
• GP follow-up arranged within 1 week 6, 2
• Respiratory clinic follow-up within 4 weeks 3

Given this child's history of status asthmaticus requiring overnight admission, this represents high-risk asthma with 14% mortality at 3 years—very close medical follow-up is mandatory 5.