What is the management of bronchial asthma in children in an Emergency Room (ER) setting according to Global Initiative for Asthma (GINA) guidelines?

Emergency Management of Pediatric Asthma Exacerbations

Immediately administer high-flow oxygen, nebulized salbutamol 5 mg (or 2.5 mg in very young children), intravenous or oral corticosteroids, and add ipratropium 100-250 mcg for severe exacerbations, with reassessment every 15-30 minutes to guide escalation. 1, 2, 3

Initial Assessment and Severity Classification

Rapidly categorize the child's exacerbation severity using objective criteria:

Acute Severe Asthma:

• Too breathless to talk or feed 1
• Respiratory rate >50 breaths/minute 1
• Heart rate >140 beats/minute 1
• Peak expiratory flow (PEF) <50% predicted or personal best 1
• Oxygen saturation <92% 1, 2

Life-Threatening Features:

• PEF <33% predicted or poor respiratory effort 1
• Silent chest, cyanosis, or fatigue/exhaustion 1
• Agitation or reduced level of consciousness 1

Critical Pitfall: Children with severe attacks may not appear distressed, and assessment in very young children can be difficult—the presence of any single severe feature should trigger aggressive management. 1

Immediate Treatment Protocol

Oxygen Therapy

• Administer high-flow oxygen (40-60%) via face mask immediately 1
• Maintain oxygen saturation >92% throughout treatment 1, 2, 3
• CO2 retention is NOT aggravated by oxygen therapy in asthma 1

Bronchodilator Therapy

First-Line Beta-2 Agonist:

• Nebulized salbutamol 5 mg (or terbutaline 10 mg) via oxygen-driven nebulizer 1, 3
• Use half doses (2.5 mg salbutamol) in very young children 1
• Repeat every 20 minutes for 3 doses initially 2, 3

Alternative if nebulizer unavailable:

• Metered-dose inhaler with large volume spacer: 10-20 puffs (equivalent to one 5 mg nebulization) 4, 5, 6
• Each puff delivers 100 mcg, so 10-20 puffs provides 1-2 mg total dose 4

Add Ipratropium Bromide:

• Ipratropium 100-250 mcg nebulized immediately for severe exacerbations 1, 2
• Repeat every 6 hours until improvement begins 1
• Adding ipratropium to beta-2 agonists reduces hospital admission risk by 25% in severe exacerbations 7
• Do NOT add ipratropium for mild exacerbations—it provides no benefit 7

Systemic Corticosteroids

Administer within the first hour:

• Oral prednisolone 1-2 mg/kg/day (maximum 40-60 mg) 1, 2, 8
• OR intravenous hydrocortisone 200 mg if unable to take oral medication 1
• Do NOT delay corticosteroids while giving repeated bronchodilators alone 3

Life-Threatening Features: Additional Interventions

If life-threatening features are present:

• Intravenous aminophylline 5 mg/kg over 20 minutes, followed by 1 mg/kg/hour maintenance infusion 1
• Omit loading dose if child already receiving oral theophyllines 1
• Consider chest radiograph to exclude pneumothorax 1
• Never give sedatives 1

Monitoring and Reassessment

Timing of Reassessment

• Repeat PEF measurement 15-30 minutes after starting treatment 1
• Continuous pulse oximetry to maintain SaO2 >92% 1, 2
• Chart PEF before and after each bronchodilator dose, minimum 4 times daily 1, 3

Important Note: Blood gas estimations are rarely helpful in deciding initial management in children 1

Subsequent Management Based on Response

If Patient is Improving (15-30 minutes post-treatment):

• Continue high-flow oxygen 1
• Continue prednisolone 1-2 mg/kg daily (maximum 40 mg) 1, 8
• Reduce nebulized beta-agonist frequency to every 4-6 hours 1

If Patient is NOT Improving (15-30 minutes post-treatment):

• Continue oxygen and steroids 1
• Increase nebulized beta-agonist frequency to every 15-30 minutes 1, 3
• Add or continue ipratropium 100-250 mcg every 6 hours 1, 7

Prognostic Factors for Treatment Failure:

• Previous history of intubation (6.5-fold increased risk) 9
• Receiving <3 doses of nebulized salbutamol in ER (3.2-fold increased risk) 9
• SpO2 <92% on arrival (3-fold increased risk) 9
• Exacerbation triggered by pneumonia (2.7-fold increased risk) 9

ICU Transfer Criteria

Transfer to intensive care unit immediately if:

• Deteriorating PEF despite treatment 1
• Worsening or persisting hypoxia 1
• Exhaustion, feeble respirations, or confusion 1
• Coma or respiratory arrest 1

The child must be accompanied by a physician prepared to intubate. 1

Discharge Criteria

Children may be discharged when ALL of the following are met:

• On discharge medication for 24 hours with verified inhaler technique 1, 3
• PEF >75% of predicted or personal best 1, 3
• PEF diurnal variability <25% 1
• Treatment includes oral corticosteroids, inhaled corticosteroids, and bronchodilators 1
• Written asthma action plan provided 2, 3
• GP follow-up arranged within 1 week 1
• Respiratory clinic follow-up within 4 weeks 1

Common Pitfalls to Avoid

• Do not delay systemic corticosteroids while continuing repeated albuterol alone—this is the most common error 3
• Do not use antibiotics unless bacterial infection is confirmed; viral triggers are most common and do not require antibiotics 3
• Do not add ipratropium for mild exacerbations—it only benefits severe cases 7
• Do not rely on single-dose ipratropium—repeated doses every 6 hours are required for benefit 7
• Verify inhaler technique at every visit—inadequate technique is a common cause of treatment failure 4, 3
• Do not discharge before 24 hours on discharge medications—premature discharge increases relapse risk 1

Age-Specific Considerations

Children <2 years:

• Beta-2 agonists are beneficial and safe in the majority of children under 2 years 10
• Use half doses of nebulized medications (2.5 mg salbutamol) 1
• Clinical score combined with oxygen saturation provides simple noninvasive monitoring 10
• Assessment may be particularly difficult—maintain high index of suspicion 1