What is the management of acute asthma exacerbation in a pediatric patient?

From the Guidelines

Acute asthma exacerbations in pediatric patients require prompt assessment and treatment with albuterol (salbutamol) via metered-dose inhaler with spacer or nebulizer, and oral prednisolone, as recommended by the most recent guidelines 1. For mild to moderate exacerbations, administer albuterol (salbutamol) via metered-dose inhaler with spacer, 4-8 puffs every 20 minutes for three doses, or via nebulizer at 0.15 mg/kg (minimum 2.5 mg, maximum 5 mg) every 20 minutes for three doses. Add oral prednisolone at 1-2 mg/kg/day (maximum 60 mg) for 3-5 days. For severe exacerbations, give high-dose albuterol nebulization continuously or every 20 minutes, add ipratropium bromide 250-500 mcg via nebulizer every 20 minutes for 1-2 hours, and administer systemic corticosteroids (oral prednisolone or IV methylprednisolone 1-2 mg/kg/day). Oxygen should be provided to maintain saturation above 92%. For life-threatening exacerbations, consider IV magnesium sulfate (25-75 mg/kg, maximum 2 g) and prepare for possible intubation. After stabilization, create an asthma action plan, ensure proper inhaler technique, review trigger avoidance, and schedule follow-up within 1-2 weeks. Beta-agonists work by relaxing bronchial smooth muscle, corticosteroids reduce airway inflammation, and anticholinergics provide additional bronchodilation by blocking parasympathetic bronchoconstriction. Early intervention with appropriate medications can prevent progression to respiratory failure and hospitalization, as supported by recent studies 1.

Some key considerations in the management of acute asthma exacerbations in pediatric patients include:

• The importance of prompt assessment and treatment to prevent progression to severe exacerbations 1
• The use of albuterol (salbutamol) via metered-dose inhaler with spacer or nebulizer as the first-line treatment for mild to moderate exacerbations 1
• The addition of oral prednisolone for 3-5 days to reduce airway inflammation and prevent relapse 1
• The consideration of IV magnesium sulfate for life-threatening exacerbations, as it may help to reduce the severity of the exacerbation and prevent intubation 1
• The importance of creating an asthma action plan and ensuring proper inhaler technique to prevent future exacerbations and improve quality of life 1.

Overall, the management of acute asthma exacerbations in pediatric patients requires a comprehensive approach that includes prompt assessment and treatment, the use of evidence-based medications, and the creation of an asthma action plan to prevent future exacerbations and improve quality of life.

From the FDA Drug Label

The National Heart, Lung, and Blood Institute (NHLBI) recommended dosing for systemic prednisone, prednisolone or methylprednisolone in children whose asthma is uncontrolled by inhaled corticosteroids and long-acting bronchodilators is 1–2 mg/kg/day in single or divided doses It is further recommended that short course, or "burst" therapy, be continued until a child achieves a peak expiratory flow rate of 80% of his or her personal best or symptoms resolve. This usually requires 3 to 10 days of treatment, although it can take longer.

For the treatment of acute asthma exacerbation in pediatric patients, the recommended dose of prednisolone is 1-2 mg/kg/day in single or divided doses, as recommended by the National Heart, Lung, and Blood Institute (NHLBI) 2. This short course, or "burst" therapy, should be continued until the child achieves a peak expiratory flow rate of 80% of his or her personal best or symptoms resolve, which usually requires 3 to 10 days of treatment.

• The dose may vary depending on the specific disease entity being treated and the response of the patient.
• It is essential to monitor the patient's condition and adjust the dosage as needed.
• Albuterol can be used as an adjunct therapy to help manage symptoms, but the provided drug label does not specify the exact dosage for acute asthma exacerbation in pediatric patients 3.

From the Research

Assessment and Management of Acute Asthma Exacerbation in Pediatric Patients

• The goal of managing acute asthma exacerbations in pediatric patients is to minimize morbidity and prevent mortality, with optimal assessment and management of exacerbations being essential 4.
• Effective treatment depends on the accurate and rapid assessment of disease severity at presentation, with guidance including the assessment of asthma severity, treatment considerations, proper discharge planning, follow-up, and prescription for inhaled corticosteroids to prevent exacerbation and decrease chronic morbidity 5.

Treatment Options for Acute Asthma Exacerbation

• Inhaled albuterol and systemic corticosteroids are the mainstay of exacerbation management, with escalation including interventions such as metered-dose inhalers with a spacer (MDI+S) or nebulization (NEB) for albuterol delivery 4, 6.
• The use of MDI+S has been shown to be effective in reducing the pulmonary index score and heart rate compared to NEB, with no significant difference in hospital admission rates 6.
• The addition of ipratropium bromide to albuterol has been shown to improve pulmonary function and reduce hospital admission rates in adult patients with acute asthma, although the evidence for pediatric patients is limited 7.

Evidence-Based Review of Acute Asthma Management

• Current evidence supports the use of inhaled bronchodilators and systemic steroids as first-line agents for acute asthma management in pediatric patients 8.
• Adjunct therapies and interventions are available for patients who fail to respond to initial therapies, although the evidence for their use varies 8.
• A thorough understanding of acute asthma management is vital for emergency clinicians, given the high prevalence of asthma and its potential to progress from mild to life-threatening 8.