What is the initial management for an asthma exacerbation in a 7-year-old child?

Initial Management of Asthma Exacerbation in a 7-Year-Old Child

Immediately administer high-flow oxygen via face mask, nebulized salbutamol 5 mg (or via MDI with spacer), oral prednisolone 1-2 mg/kg (maximum 40 mg), and add ipratropium 100 mcg to the nebulizer—all without delay for any investigations. 1, 2, 3

Immediate Recognition and Treatment

First-Line Medications (Give Simultaneously)

• High-flow oxygen via face mask to maintain oxygen saturation >92% 1, 2, 3
• Salbutamol 5 mg via oxygen-driven nebulizer (or 5 mg via MDI with large volume spacer—one puff every few seconds up to 20 puffs) 1, 3, 4
• Oral prednisolone 1-2 mg/kg (maximum 40 mg) as a single dose 1, 3
• Ipratropium 100 mcg added to the nebulizer immediately, repeated every 6 hours 1, 2, 3

Critical Point on Delivery Method

MDI with large volume spacer is equally effective to nebulization and may result in lower admission rates, particularly in more severe exacerbations, with fewer cardiovascular side effects. 3, 4 The spacer device should use a face mask if the child cannot coordinate with a mouthpiece, and each puff should be actuated separately with individual breaths 1

Assessment of Severity

Features Indicating Severe Exacerbation (Any One Present)

• Too breathless to talk or feed 1, 3
• Respiratory rate >50 breaths/minute 1, 3
• Pulse >140 beats/minute 1, 3
• Peak expiratory flow <50% predicted (if child can perform) 1, 3

Life-Threatening Features (Require Immediate ICU Consideration)

• Peak flow <33% predicted or poor respiratory effort 1
• Silent chest, cyanosis, or exhaustion 1
• Altered level of consciousness or agitation 1

Monitoring and Reassessment

Timing of Reassessment

• Repeat assessment 15-30 minutes after starting treatment 1, 2, 3
• Measure peak expiratory flow before and after each bronchodilator dose (if age-appropriate) 1, 3
• Maintain continuous pulse oximetry with target >92% 1, 2, 3

If Patient is Improving After 15-30 Minutes

• Continue high-flow oxygen 1, 3
• Continue prednisolone 1-2 mg/kg daily (maximum 40 mg) for up to 5 days 1, 3
• Reduce nebulized β-agonist frequency to every 4 hours 1, 3

If Patient is NOT Improving After 15-30 Minutes

• Continue oxygen and steroids 1, 3
• Increase nebulized β-agonist frequency to every 30 minutes 1, 3
• Continue ipratropium every 6 hours until improvement starts 1, 3
• Consider intravenous hydrocortisone if unable to tolerate oral medication 1, 2

Critical Pitfalls to Avoid

Do NOT Delay Treatment

• No investigations are needed for immediate management—do not delay treatment for chest X-ray or blood gases 1, 2
• Blood gas estimations are rarely helpful in deciding initial management in children 1
• Do not withhold corticosteroids, as this is a major factor in preventable asthma deaths 2

Do NOT Underestimate Severity

• Children with severe attacks may appear distressed, and assessment in the very young may be difficult 1
• Regard each emergency presentation as potentially severe until proven otherwise 1, 2
• Afternoon or evening presentations carry higher risk and lower threshold for admission 3

Common Technical Errors

• Most children cannot use an unmodified MDI without a spacer—always use a large volume spacer device 1, 3
• Shake the MDI before each actuation 1, 5
• Actuate one puff at a time into the spacer, then have the child take one breath before the next puff 1

Hospital Admission Criteria

Admit if ANY of the Following Present

• Failure to respond to initial treatment or early deterioration after inhaled bronchodilators 1, 3
• Peak expiratory flow remains <50% predicted 15-30 minutes after treatment 1, 3
• Persistent features of severe asthma (respiratory rate >50, pulse >140, too breathless to talk) 1, 3
• Inability of parents to give appropriate treatment at home 1
• Request for admission from the general practitioner 1

Discharge Criteria (All Must Be Met)

• On discharge medication for 24 hours with confirmed proper inhaler technique 1, 3
• Peak flow >75% of predicted with diurnal variability <25% 1, 3
• Treatment includes oral steroids (continue for 3-5 days total) and inhaled steroids in addition to bronchodilators 1, 3
• Parents have written action plan detailing when to increase bronchodilators and when to seek immediate care 3
• GP follow-up arranged within 1 week 1, 3
• Respiratory clinic follow-up within 4 weeks 1, 3