Initial Treatment for Acute Bronchospasm or Asthma Exacerbations in Pediatric Patients
Administer salbutamol 2.5 mg (age ≤2 years) or 5.0 mg (age >2 years) via nebulizer every 20 minutes for 3 doses in the first hour, or alternatively 4-8 puffs via metered-dose inhaler (MDI) with spacer every 20 minutes for 3 doses, and immediately start oral prednisone 1-2 mg/kg/day (maximum 60 mg/day). 1, 2
Bronchodilator Administration
Delivery Method Selection
- MDI with large volume spacer is the preferred delivery device and is equally effective to nebulization, may result in lower admission rates particularly in severe exacerbations, and causes fewer cardiovascular side effects. 1, 2
- For nebulization: administer salbutamol 2.5 mg for children ≤2 years or 5.0 mg for children >2 years every 20 minutes for up to 3 doses in the first hour. 2
- For MDI with spacer: administer 4-8 puffs every 20 minutes for 3 doses (each puff delivers 100 mcg of salbutamol). 3, 1
Dosing Equivalence
- 10-20 puffs of salbutamol via MDI with spacer (1-2 mg total) approximates one 2.5-5 mg nebulized dose. 4
- Each actuation delivers 90 mcg of albuterol base from the mouthpiece. 5
Systemic Corticosteroids (Essential Concurrent Therapy)
- Administer oral prednisone 1-2 mg/kg/day (maximum 60 mg/day) immediately upon recognition of the exacerbation, ideally within the first hour. 1, 2
- Oral corticosteroids are preferred when the child can swallow and has no vomiting, as there is no advantage to intravenous administration when gastrointestinal transit is normal. 2
- For children who are vomiting, seriously ill, or unable to take oral medications, give intravenous hydrocortisone 200 mg every 6 hours (or 4 mg/kg/dose every 6 hours). 2
- Continue corticosteroids for 3-10 days for outpatient treatment or until peak expiratory flow reaches 70% of predicted or personal best. 1
Adjunctive Therapy for Severe Exacerbations
- Add ipratropium bromide 0.25-0.5 mg via nebulizer every 20 minutes for 3 doses if the exacerbation is severe or if response to salbutamol alone is insufficient. 3, 1
- Ipratropium provides additive benefit to short-acting beta-agonists in moderate or severe exacerbations in the emergency care setting. 3
- The addition of ipratropium has not been shown to provide further benefit once the patient is hospitalized. 3
Oxygen Therapy
Reassessment and Monitoring
- Reassess the child 15-30 minutes after starting treatment by evaluating respiratory rate, use of accessory muscles, oxygen saturation, and ability to speak in complete sentences. 1, 2
- Measure peak expiratory flow rate before and after each bronchodilator dose if the child can cooperate. 1, 2
- Continue monitoring with pulse oximetry targeting SaO₂ >92%. 2
Common Pitfalls to Avoid
- Do not delay systemic corticosteroids while continuing repeated doses of salbutamol alone—corticosteroids address the underlying airway inflammation and should be given immediately. 2
- Do not use regularly scheduled, daily, chronic use of short-acting beta-agonists, as this is not recommended. 3
- Ensure proper inhaler technique and age-appropriate device before escalating therapy, as inadequate technique is a common cause of treatment failure. 2, 4
- Increasing use of short-acting beta-agonist treatment or use >2 days a week for symptom relief (not prevention of exercise-induced bronchospasm) indicates inadequate asthma control and the need for initiating or intensifying anti-inflammatory therapy. 3
Criteria for Hospital Admission
- Admit if the child fails to respond to initial treatment, has peak expiratory flow <50% predicted after 15-30 minutes, or has persistent features of severe asthma. 2
- Life-threatening features requiring immediate intensive care include peak flow <33% predicted, poor respiratory effort, silent chest, cyanosis, exhaustion, altered level of consciousness, or agitation. 2