What is the management of acute asthma in pediatrics?

Management of Acute Asthma in Pediatrics

Immediately administer high-flow oxygen via face mask, nebulized salbutamol 5 mg (or 2.5 mg in very young children), and oral prednisolone 1-2 mg/kg (maximum 40 mg) within the first few minutes of presentation for any child with acute severe asthma. 1, 2

Initial Assessment and Recognition

Recognize acute severe asthma in children by the following clinical features:

• 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 (if measurable in children ≥5 years) 1

Life-threatening features requiring immediate aggressive intervention include:

• 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 may be difficult—the presence of any single feature should alert you to severity. 1

Immediate Treatment Protocol (First 15-30 Minutes)

Oxygen Therapy

• Administer high-flow oxygen (40-60%) via face mask immediately 1, 2, 3
• Maintain oxygen saturation >92% with continuous pulse oximetry 1, 2
• CO2 retention is not aggravated by oxygen therapy in asthma 1

Bronchodilator Therapy

Nebulized beta-agonist is the primary bronchodilator:

• Salbutamol 5 mg via oxygen-driven nebulizer (use 2.5 mg in very young children) 1, 2, 3
• Alternative: Terbutaline 10 mg via nebulizer (5 mg in very young children) 1, 3

Alternative delivery method with equivalent efficacy:

• Metered-dose inhaler (MDI) with large volume spacer: 1 puff every few seconds up to 10-20 puffs maximum 1, 2
• Use a face mask with the spacer in very young children 1
• This method is supported by high-quality evidence showing comparable efficacy to nebulization with shorter treatment times and fewer adverse effects 4, 5

Systemic Corticosteroids

Administer corticosteroids immediately—do not delay:

• Oral prednisolone 1-2 mg/kg body weight (maximum 40 mg) 1, 2, 3
• If child is vomiting or severely ill: Intravenous hydrocortisone 200 mg 1, 2

Anticholinergic Therapy

• Add ipratropium 100 mcg (0.1 mg) to nebulizer, repeat every 6 hours 1, 3
• Can be mixed in the same nebulizer with salbutamol 2

Reassessment at 15-30 Minutes

Measure and document the following:

• Peak expiratory flow rate (if appropriate for age) 1, 2
• Oxygen saturation 1, 2
• Respiratory rate and heart rate 2
• Clinical appearance and work of breathing 2

If Patient is Improving:

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

If Patient is NOT Improving:

• Continue oxygen and steroids 1
• Increase nebulized beta-agonist frequency to every 15-30 minutes 1, 2
• Continue ipratropium every 6 hours until improvement begins 1
• Consider continuous nebulization 2

Life-Threatening Features: Additional Management

If life-threatening features are present, add:

• Intravenous aminophylline: 5 mg/kg loading dose over 20 minutes, followed by 1 mg/kg/hour maintenance infusion 1
• Critical caveat: Omit the loading dose if the child is already receiving oral theophyllines 1

Monitoring Throughout Treatment

Continuous monitoring includes:

• Pulse oximetry to maintain SaO2 >92% 1, 2, 3
• Chart PEF before and after each beta-agonist administration and at least 4 times daily 1, 3
• Respiratory rate and heart rate 2
• Clinical assessment of work of breathing and mental status 2

Blood gas measurements are rarely helpful in deciding initial management in children. 1

Critical Pitfalls to Avoid

• Never give sedatives of any kind—they can precipitate respiratory failure 1, 2
• Do not delay systemic corticosteroids—they should be given immediately 2
• Do not underestimate severity—children may not appear distressed despite severe obstruction 1
• Avoid inadequate oxygen delivery—use high-flow systems 2

Criteria for ICU Transfer

Transfer to intensive care unit if:

• Deteriorating PEF despite treatment 1, 2
• Worsening or persistent hypoxia 1, 2
• Exhaustion, feeble respirations, confusion, or drowsiness 1, 2
• Coma or respiratory arrest 1

The patient should be accompanied by a physician prepared to intubate. 1

Discharge Criteria

Before discharge, ensure:

• Patient has been on discharge medication for 24 hours 1, 3
• Inhaler technique has been checked and recorded 1, 3
• PEF >75% of predicted or best (if measurable) 1, 3
• PEF diurnal variability <25% 1, 3
• Treatment plan includes oral corticosteroids (continue for 3-5 days), inhaled corticosteroids, and bronchodilators 1, 3
• Written self-management plan provided 1
• GP follow-up arranged within 1 week 1
• Respiratory clinic follow-up within 4 weeks 1

Evidence Considerations

The British Thoracic Society guidelines provide the foundational framework for pediatric acute asthma management. 1 Recent meta-analyses demonstrate that MDI with spacer is equally effective as nebulization, with advantages including shorter treatment times (66 vs 103 minutes), fewer episodes of vomiting (9% vs 20%), and smaller increases in heart rate. 4, 5 However, nebulizers remain the standard in most emergency settings and are explicitly recommended in the guidelines. 1, 3