What is the appropriate treatment protocol for a pediatric patient with a respiratory condition, such as a respiratory infection or asthma?

Pediatric Acute Asthma Exacerbation Treatment Protocol

For a pediatric patient presenting with acute asthma exacerbation, immediately administer high-flow oxygen via face mask to maintain SaO₂ >92%, nebulized salbutamol 5 mg (or 2.5 mg if age ≤2 years), oral prednisolone 1-2 mg/kg (maximum 60 mg), and add ipratropium 100 mcg to the nebulizer if the exacerbation is severe or fails to respond to initial beta-agonist therapy. 1, 2

Initial Severity Assessment

Rapidly determine severity using objective clinical criteria:

Severe Asthma Features in Children:

• Too breathless to talk or feed 3
• Respiratory rate >50 breaths/minute 3
• Pulse >140 beats/minute 3
• Peak expiratory flow <50% predicted 3
• Use of accessory muscles 1
• Oxygen saturation <92% 1

Life-Threatening Features:

• Peak flow <33% predicted 3
• Poor respiratory effort or silent chest 3
• Cyanosis, exhaustion, or fatigue 3
• Altered level of consciousness or agitation 3

Immediate Treatment Protocol

First-Line Therapy (Administer Simultaneously)

Oxygen:

• High-flow oxygen via face mask immediately 1
• Target SaO₂ >92% with continuous pulse oximetry 3

Bronchodilator:

• Salbutamol 5 mg via oxygen-driven nebulizer (2.5 mg if age ≤2 years) 1, 2
• Alternative: 4-8 puffs via MDI with large volume spacer every 20 minutes 1, 2
• Repeat every 20 minutes for up to 3 doses in the first hour 1
• MDI with spacer is equally effective to nebulization and may result in lower admission rates with fewer cardiovascular side effects 1

Systemic Corticosteroids:

• Oral prednisolone 1-2 mg/kg (maximum 60 mg) immediately if child can swallow 1, 2
• If vomiting or unable to take oral medications: IV hydrocortisone 200 mg every 6 hours (or 4 mg/kg/dose every 6 hours) 1
• Do not delay corticosteroids—underuse is a leading cause of preventable asthma mortality 1

Ipratropium:

• Add ipratropium 100 mcg to nebulizer immediately if severe exacerbation or failure of initial beta-agonist therapy 1, 2
• Repeat every 6 hours 3
• Combination of beta-agonist plus ipratropium reduces hospitalizations, particularly in severe airflow obstruction 1

Reassessment at 15-30 Minutes

Measure response to treatment:

• Repeat peak expiratory flow measurement 3
• Reassess respiratory rate, oxygen saturation, and clinical appearance 1
• Response to treatment in the ED is a better predictor of hospitalization need than initial severity 1

If Patient Is Improving:

• Continue high-flow oxygen 3
• Continue prednisolone 1-2 mg/kg daily (maximum 40 mg) 3
• Nebulized beta-agonist every 4 hours 3

If Patient Is NOT Improving:

• Continue oxygen and steroids 3
• Increase nebulized beta-agonist frequency to every 30 minutes 3
• Continue ipratropium every 6 hours 3
• Consider IV aminophylline 5 mg/kg over 20 minutes followed by 1 mg/kg/hour infusion (omit loading dose if already on oral theophyllines) 3

Critical Pitfalls to Avoid

• Never delay systemic corticosteroids while giving repeated albuterol doses alone—this is a leading cause of preventable mortality 1
• Never use sedatives of any kind in acute severe asthma as they depress respiratory function 1
• Do not use antibiotics unless bacterial infection is confirmed—viral infections are the most common trigger for asthma exacerbations in children 1, 4, 5
• Do not use aggressive hydration, methylxanthines, chest physiotherapy, or mucolytics as routine therapy 1

Hospital Admission Criteria

Admit if any of the following:

• Persistent features of severe asthma after initial treatment 1
• Peak expiratory flow remains <50% predicted 15-30 minutes after nebulization 1
• Life-threatening features present 3
• Parents unable to give appropriate treatment at home 1

ICU Transfer Criteria

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

• Deteriorating peak flow or worsening exhaustion 3
• Persistent hypoxia or hypercapnia (PaCO₂ ≥42 mm Hg) 1
• Altered mental status, confusion, or drowsiness 3
• Inability to speak 1
• Consider IV magnesium sulfate for life-threatening exacerbations remaining severe after 1 hour of intensive treatment 1

Discharge Criteria

Patient must meet ALL criteria before discharge:

• On discharge medication for 24 hours with verified inhaler technique 3
• Peak flow >75% of predicted or best 3
• Peak flow diurnal variability <25% 3
• Treatment includes oral steroids and inhaled steroids plus bronchodilators 3
• Own peak flow meter provided 3
• Written asthma action plan given to parents 3, 2
• GP follow-up arranged within 1 week 3
• Respiratory clinic follow-up within 4 weeks 3

Post-Discharge Management

• Continue oral prednisolone until peak flow reaches 70% of predicted or for 3-10 days 2
• Verify inhalation technique and adherence before making chronic therapy changes 2
• Intensify controller therapy if asthma was not well-controlled prior to exacerbation 6, 2
• Schedule follow-up within 1-4 weeks after treatment modification 6, 2