What is the initial management for a male child with acute exacerbation of asthma?

Initial Management of Acute Asthma Exacerbation in a Male Child

Immediately administer high-flow oxygen via face mask to maintain SpO₂ >92%, nebulized salbutamol 5 mg (or 4-8 puffs via MDI with spacer) every 20 minutes for up to 3 doses in the first hour, oral prednisolone 1-2 mg/kg (maximum 40-60 mg), and add ipratropium bromide 100-250 mcg to each salbutamol dose for the first hour. 1

Severity Assessment

Before initiating treatment, rapidly identify the severity of exacerbation by clinical features:

Severe exacerbation indicators: 2

• Too breathless to talk or feed
• Respiratory rate >50 breaths/minute
• Pulse >140 beats/minute
• Peak expiratory flow <50% predicted

Life-threatening features requiring immediate aggressive intervention: 2, 1

• Peak flow <33% predicted or best
• Silent chest or poor respiratory effort
• Cyanosis, exhaustion, or altered consciousness
• Agitation or reduced level of consciousness

Immediate Treatment Protocol

Oxygen Therapy

• Administer 40-60% oxygen via face mask immediately to maintain SpO₂ >92% 2, 1
• Continue oxygen throughout treatment until SpO₂ remains stable above this threshold 1
• CO₂ retention is not aggravated by oxygen therapy in asthma 2

Bronchodilator Administration

Two equally effective delivery options: 1

Option 1 - Nebulized route:

• Salbutamol 5 mg via oxygen-driven nebulizer every 20 minutes for 3 doses in the first hour 2, 1
• Use half doses (2.5 mg) in very young children 2

Option 2 - MDI with spacer (preferred):

• 4-8 puffs via MDI with large volume spacer every 20 minutes for 3 doses 1
• This method results in lower admission rates and fewer cardiovascular side effects 1

Systemic Corticosteroids

Administer immediately upon recognition - do not delay: 1, 3

• Oral prednisolone 1-2 mg/kg (maximum 40-60 mg) if child can swallow 2, 1
• Intravenous hydrocortisone 200 mg every 6 hours if child is vomiting, seriously ill, or unable to take oral medications 2, 4
• Clinical benefits require 6-12 hours minimum, so early administration is critical 3, 5

Ipratropium Bromide

• Add ipratropium 100-250 mcg to nebulizer every 20 minutes for 3 doses, then every 6 hours 2, 1
• Or 4-8 puffs every 20 minutes for 3 doses via MDI 1
• The combination with beta-agonists reduces hospitalizations, particularly in severe airflow obstruction 1, 3, 6

Monitoring and Reassessment

Repeat assessment 15-30 minutes after starting treatment: 2, 1

• Measure peak expiratory flow before and after each bronchodilator dose 2, 1
• Maintain continuous pulse oximetry with target SpO₂ >92% 2, 1
• Monitor respiratory rate, heart rate, and work of breathing 1
• Chart PEF at least 4 times daily throughout hospital stay 2

Response to initial treatment is a better predictor of hospitalization need than initial severity. 1, 3

Subsequent Management Based on Response

If Patient is Improving:

• Continue high-flow oxygen 2
• Continue prednisolone 1-2 mg/kg daily (maximum 40 mg) 2
• Continue nebulized β-agonist every 4-6 hours 2

If Patient is NOT Improving After 15-30 Minutes:

• Continue oxygen and steroids 2
• Increase nebulized β-agonist frequency to every 15-30 minutes 2
• Continue ipratropium every 6 hours until improvement starts 2
• Consider intravenous magnesium sulfate for life-threatening exacerbations 1, 3, 6

Escalation to Intensive Care

Transfer to ICU accompanied by a doctor prepared to intubate if: 2

• Deteriorating PEF, worsening or persisting hypoxia
• Increased respiratory rate, confusion, or drowsiness
• Exhaustion, coma, or respiratory arrest

For Life-Threatening Features:

• Give intravenous aminophylline 5 mg/kg over 20 minutes followed by maintenance infusion 1 mg/kg/hour 2
• Omit loading dose if child already receiving oral theophyllines 2

Critical Pitfalls to Avoid

Never administer sedatives of any kind - this is absolutely contraindicated in acute asthma 2, 3

Do not delay systemic corticosteroids while giving repeated doses of albuterol alone - underuse of corticosteroids is a leading cause of preventable asthma mortality 3, 4

Do not underestimate severity - patients, families, and clinicians frequently fail to recognize dangerous exacerbations due to inadequate objective measurements 3

Avoid these interventions: 3

• Antibiotics (unless strong evidence of bacterial infection like pneumonia)
• Aggressive hydration in older children
• Methylxanthines as first-line therapy
• Chest physiotherapy
• Mucolytics

Hospital Admission Criteria

Admit to hospital if: 2, 1

• Persistent features of severe asthma after initial treatment
• Peak expiratory flow remains <50% predicted 15-30 minutes after treatment
• SpO₂ <92% despite treatment
• Life-threatening features present
• Presentation in afternoon/evening with recent nocturnal symptoms
• Previous severe attacks or poor social circumstances

Discharge Criteria

Children can be discharged when: 2, 1

• On discharge medication for 24 hours with verified inhaler technique
• Peak flow >75% of predicted or best
• SpO₂ stable >92% on room air
• Treatment includes oral steroids, inhaled steroids, and bronchodilators
• Written self-management plan provided
• GP follow-up arranged within 1 week
• Respiratory clinic follow-up arranged within 4 weeks