What is the initial management for a 16-month-old patient with reactive airway disease in the emergency department?

Reactive Airway Management in the Emergency Department for a 16-Month-Old

Immediately administer high-flow oxygen via face mask, nebulized albuterol 2.5 mg (half the standard 5 mg dose for very young children), oral prednisolone 1-2 mg/kg (maximum 40 mg), and add ipratropium 100 mcg to the nebulizer. 1, 2, 3

Immediate Assessment

Rapidly identify severity by looking for these specific features in your 16-month-old patient:

Acute severe features:

• Too breathless to feed (the infant equivalent of "too breathless to talk") 1, 2
• Respiratory rate >50 breaths/minute 1, 2
• Pulse >140 beats/minute 1, 2
• Oxygen saturation <92% 1, 3

Life-threatening features (require ICU preparation):

• Poor respiratory effort, silent chest, or cyanosis 1, 3
• Exhaustion, agitation, or reduced level of consciousness 1, 3

First-Line Treatment Protocol

Oxygen Therapy

• Deliver high-flow oxygen via face mask (not nasal cannula) to maintain SaO₂ >92% 1, 2, 3
• Continue oxygen throughout the entire treatment period 1

Bronchodilator Administration

Two equally effective delivery options exist:

Option 1: Nebulized albuterol (traditional approach)

• Give 2.5 mg albuterol via oxygen-driven nebulizer (half the standard 5 mg dose for very young children) 1, 2

Option 2: MDI with spacer (preferred by recent guidelines)

• Administer 4-8 puffs of albuterol via MDI with large volume spacer and face mask 2
• Give one puff every few seconds until improvement occurs 1
• This method may result in lower admission rates and fewer cardiovascular side effects 2, 3

Systemic Corticosteroids (Critical - Do Not Delay)

• Give oral prednisolone 1-2 mg/kg as a single dose (maximum 40 mg) immediately 1, 2
• Common pitfall: Do not delay steroids while giving repeated albuterol doses alone—this is a major factor in preventable asthma deaths 1, 3
• Use IV hydrocortisone only if the child is vomiting, seriously ill, or unable to swallow 2, 3

Ipratropium Bromide

• Add ipratropium 100 mcg to the nebulizer immediately 1, 2, 3
• Repeat every 6 hours until improvement starts 1, 3
• This provides additional bronchodilation through a different mechanism when initial beta-agonist treatment is insufficient 2

Reassessment at 15-30 Minutes

If improving:

• Continue high-flow oxygen 1
• Continue prednisolone 1-2 mg/kg daily (maximum 40 mg) 1
• Continue nebulized albuterol every 4 hours 1

If NOT improving:

• Continue oxygen and steroids 1
• Increase nebulized albuterol frequency to every 30 minutes 1
• Continue ipratropium every 6 hours 1

If life-threatening features present:

• Add IV aminophylline 5 mg/kg over 20 minutes, followed by 1 mg/kg/hour maintenance infusion 1, 3
• Omit loading dose if already receiving oral theophyllines 1, 3
• Prepare for ICU transfer with physician ready to intubate 1, 3

Hospital Admission Criteria

Admit if any of the following:

• Persistent features of severe asthma after initial treatment 1, 2
• Failure to respond to initial bronchodilator therapy 1, 2
• Afternoon or evening presentation (lower threshold for admission) 1
• Parents unable to provide appropriate treatment at home 2

Discharge Criteria (When Stabilized)

The child must meet ALL of the following before discharge:

• On discharge medication for 24 hours with proper inhaler technique verified 1, 2, 3
• Oxygen saturation stable on room air 1
• Treatment includes oral steroids and inhaled steroids plus bronchodilators 1, 2, 3
• Written action plan provided to parents 2, 3
• GP follow-up arranged within 1 week 1, 2, 3
• Respiratory clinic follow-up within 4 weeks 1, 3

Critical Pitfalls to Avoid

• Never delay systemic corticosteroids—underuse of steroids is a major factor in preventable asthma deaths 1, 3
• Do not use inadequate oxygen delivery—high-flow via face mask is essential, not just nasal cannula 3
• Avoid delaying treatment for investigations—blood gases are rarely helpful in initial management of children and should not delay therapy 1, 3
• Do not prescribe antibiotics unless bacterial infection is confirmed—viral triggers are most common in this age group and do not require antibiotics 2
• Regard each emergency consultation as potentially severe until proven otherwise—doctors and families often fail to appreciate severity 1, 3