How to manage acute asthma in a child in the emergency department?

Emergency Management of Acute Asthma in a 6-Year-Old Child

Immediately administer high-flow oxygen via face mask, nebulized salbutamol 5 mg (or 2.5 mg for very young children) via oxygen-driven nebulizer, and oral prednisolone 1-2 mg/kg (maximum 40 mg) without delay. 1, 2

Immediate Assessment and Recognition

Rapidly assess severity using objective criteria:

• Acute severe asthma features in children include being too breathless to talk or feed, respiratory rate >50 breaths/min, pulse >140 beats/min, or peak expiratory flow (PEF) <50% predicted if measurable 1, 2
• Life-threatening features include PEF <33% predicted, poor respiratory effort, cyanosis, silent chest, fatigue/exhaustion, agitation, or reduced level of consciousness 1
• Do not wait for investigations—begin treatment immediately based on clinical assessment 1

First-Line Treatment Protocol (Start Within Minutes)

Oxygen Therapy

• Administer high-flow oxygen via face mask to maintain oxygen saturation >92% 1, 3, 2
• This is essential—nasal cannula is inadequate for acute severe asthma 1

Bronchodilator Therapy

• Give salbutamol 5 mg via oxygen-driven nebulizer (use 2.5 mg or half dose in very young children under 5 years) 4, 1, 2
• Alternative: terbutaline 10 mg nebulized (5 mg in very young children) 4
• Alternative delivery method: If nebulizer unavailable, give 1 puff of albuterol MDI with spacer every few seconds until improvement occurs (maximum 20 puffs), using a face mask in very young children 4, 5

Corticosteroid Therapy

• Administer oral prednisolone 1-2 mg/kg body weight (maximum 40 mg) immediately 4, 1, 2
• If the child cannot take oral medication or has life-threatening features, give intravenous hydrocortisone 200 mg instead 4, 1, 3
• Critical pitfall: Underuse of corticosteroids is a major factor in preventable asthma deaths—give steroids early 1

Monitoring at 15-30 Minutes After Initial Treatment

• Repeat assessment of respiratory rate, heart rate, oxygen saturation, and ability to speak/feed 4, 1
• Measure PEF if child is old enough and able to cooperate 4, 1
• Maintain continuous pulse oximetry with target SaO₂ >92% 1, 2

If Patient Is Improving After 15-30 Minutes

• Continue high-flow oxygen to maintain SaO₂ >92% 4, 1
• Continue prednisolone 1-2 mg/kg daily (maximum 40 mg) 4, 1
• Give nebulized β-agonist every 4-6 hours 4, 1
• Monitor closely for deterioration 4

If Patient Is NOT Improving After 15-30 Minutes

• Continue oxygen and steroids 4, 1
• Increase nebulized β-agonist frequency to every 30 minutes 4, 1
• Add ipratropium bromide 100-250 mcg to nebulizer and repeat every 6 hours until improvement starts 4, 1, 6

Life-Threatening Features: Escalate Treatment

If the child shows life-threatening features (PEF <33%, silent chest, cyanosis, poor respiratory effort, altered consciousness):

• Add intravenous aminophylline: 5 mg/kg loading dose 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
• Prepare for possible ICU transfer with a physician ready to intubate 1

Transfer to Intensive Care Unit

Arrange immediate ICU transfer with a physician prepared to intubate if:

• Deteriorating PEF or worsening exhaustion 4, 1
• Feeble respirations, persistent hypoxia, or hypercapnia 4, 1
• Coma, respiratory arrest, confusion, or drowsiness 4, 1

Discharge Criteria (When Stabilized)

The child must meet ALL of the following before discharge:

• Been on discharge medication for 24 hours with inhaler technique checked and recorded 4, 1
• PEF >75% of predicted or best with diurnal variability <25% (if measurable) 4, 1
• Treatment includes oral steroid tablets and inhaled steroids in addition to bronchodilators 4, 1
• Family has own PEF meter with self-management plan or written instructions 4, 1
• GP follow-up arranged within 1 week 4, 1

Critical Pitfalls to Avoid

• Never delay corticosteroids—this is the most common preventable factor in asthma deaths 1
• Never underestimate severity—regard each emergency consultation as potentially severe until proven otherwise 4, 1
• Never give sedatives of any kind—they can precipitate respiratory failure 3
• Never use inadequate oxygen delivery—high-flow via face mask is essential, not nasal cannula 1, 3
• Never delay treatment for investigations—chest X-ray and blood tests are not needed for immediate management unless considering pneumothorax 3