What is the appropriate assessment and management for a pediatric patient with difficulty breathing and potential history of respiratory conditions such as asthma?

Assessment and Management of Pediatric Difficulty Breathing

Immediately assess for life-threatening features and initiate high-flow oxygen (40-60% via face mask), nebulized salbutamol (5 mg for children, half dose for very young), and intravenous hydrocortisone without delay if severe or life-threatening asthma is suspected. 1, 2

Rapid Initial Assessment

Identify acute severe asthma features immediately:

• Too breathless to talk or feed 1
• Respiratory rate >50 breaths/min 1, 2
• Heart rate >140 beats/min 1, 2
• Peak expiratory flow (PEF) <50% predicted (if age-appropriate to measure) 1, 2

Recognize life-threatening features that mandate immediate aggressive intervention:

• PEF <33% predicted or poor respiratory effort 1, 2
• Silent chest, cyanosis, or fatigue/exhaustion 1, 2
• Agitation or reduced level of consciousness 1

Critical pitfall: Children with severe attacks may not appear distressed, and assessment in very young children is difficult—the presence of ANY life-threatening feature should trigger maximum therapy. 1

Immediate Treatment Protocol

For all children with acute severe breathing difficulty (presumed asthma):

• High-flow oxygen via face mask targeting SpO₂ >92% 1, 2, 3
• Nebulized salbutamol 5 mg or terbutaline 10 mg via oxygen-driven nebulizer (use half doses in very young children) 1, 2, 3
• Intravenous hydrocortisone immediately 1, 3
• Add ipratropium 100 mcg nebulized every 6 hours 1, 3

If life-threatening features are present, also give:

• Intravenous aminophylline 5 mg/kg over 20 minutes, followed by 1 mg/kg/hour maintenance infusion (omit loading dose if child already on oral theophyllines) 1

Critical caveat: Blood gas estimations are rarely helpful in deciding initial management in children—do not delay treatment to obtain them. 1

Reassessment at 15-30 Minutes

If patient is improving:

• Continue high-flow oxygen 1, 3
• Prednisolone 1-2 mg/kg body weight daily (maximum 40 mg) 1, 3
• Nebulized β-agonist every 4 hours 1, 3

If patient is NOT improving after 15-30 minutes:

• Continue oxygen and steroids 1
• Increase nebulized β-agonist frequency to every 30 minutes 1
• Add ipratropium to nebulizer and repeat every 6 hours until improvement starts 1

Continuous Monitoring Requirements

Monitor and document:

• Repeat PEF measurement 15-30 minutes after starting treatment (if age-appropriate) 1
• Oximetry continuously, maintaining SpO₂ >92% 1, 2
• Chart PEF before and after each β-agonist dose, minimum 4 times daily 1

ICU Transfer Criteria

Transfer to intensive care unit accompanied by a doctor prepared to intubate if:

• Deteriorating PEF or worsening exhaustion 1
• Feeble respirations, persistent hypoxia, or hypercapnia 1
• Coma, respiratory arrest, confusion, or drowsiness 1

Differential Considerations Beyond Asthma

While asthma is common, rapidly assess for alternative causes requiring different management:

• Upper airway obstruction (stridor, positional changes in breathing, drooling)—may require endotracheal intubation or emergency tracheostomy 4
• Pneumothorax—obtain chest radiograph if suspected, perform needle thoracotomy if tension physiology present 1, 4
• Pneumonia with sepsis—administer first dose of antibiotic for febrile children with focal findings 4
• Foreign body aspiration—history of choking, unilateral wheeze, sudden onset 4

Important: Paradoxical bronchospasm can occur with nebulized albuterol—if breathing worsens immediately after treatment, discontinue and use alternative therapy. 5

Discharge Criteria (When Applicable)

Before discharge, ensure:

• Child has been on discharge medication for 24 hours 1
• Inhaler technique checked and documented 1
• PEF >75% of predicted or best with diurnal variability <25% (if measured) 1
• Treatment includes oral steroids, inhaled steroids, and bronchodilators 1
• Written self-management plan or instructions for parents provided 1, 3
• GP follow-up arranged within 1 week 1
• Respiratory clinic follow-up within 4 weeks 1

Critical Safety Points

Never administer sedatives in acute severe asthma—they can precipitate respiratory arrest. 1

Oxygen does not aggravate CO₂ retention in asthma—always give high-flow oxygen without hesitation. 1, 2

Many deaths from acute severe asthma are preventable—factors include doctors failing to assess severity objectively, patients/families failing to appreciate severity, and underuse of corticosteroids. 1