What is the treatment for acute asthma exacerbation in pediatric patients?

From the Guidelines

The treatment of asthma exacerbations in children should start with inhaled short-acting beta-agonists (SABA) like albuterol, administered via metered-dose inhaler with spacer (4-8 puffs every 20 minutes for 3 doses) or nebulizer (0.15 mg/kg, minimum dose 2.5 mg, every 20 minutes for 3 doses) as recommended by the National Asthma Education and Prevention Program Expert Panel Report 3 guidelines for the management of asthma exacerbations 1.

Key Considerations

• For moderate to severe exacerbations, oral corticosteroids such as prednisolone or prednisone should be added, with a dose of 1-2 mg/kg/day, maximum 60 mg, for 3-5 days without tapering.
• Oxygen should be provided to maintain saturation above 92%.
• For severe exacerbations, consider adding ipratropium bromide (0.25-0.5 mg every 20 minutes for 3 doses via nebulizer) as it may be beneficial in severe cases, although its addition has not been shown to provide further benefit once the patient is hospitalized 1.

Monitoring and Follow-Up

• Continuous monitoring of respiratory rate, oxygen saturation, and work of breathing is essential.
• After the acute phase, ensure the child has a written asthma action plan, proper inhaler technique, and appropriate controller medications like inhaled corticosteroids.

Rationale

These interventions work by relaxing airway smooth muscle, reducing inflammation, and improving airflow, addressing the bronchoconstriction and inflammation that characterize asthma exacerbations, as outlined in the guidelines for managing asthma exacerbations in the emergency department 1.

From the FDA Drug Label

The usual dosage for adults and for children weighing at least 15 kg is 2.5 mg of albuterol (one vial) administered three to four times daily by nebulization. Children weighing < 15 kg who require < 2.5 mg/dose (i.e., less than a full vial) should use albuterol inhalation solution, 0.5% instead of albuterol inhalation solution, 0. 083%. Published reports of trials in asthmatic children aged 3 years or older have demonstrated significant improvement in either FEV1 or PEFR within 2 to 20 minutes following a single dose of albuterol inhalation solution

The treatment for asthma exacerbation in kids involves the administration of albuterol via nebulization. The recommended dosage is:

• For children weighing at least 15 kg: 2.5 mg of albuterol three to four times daily
• For children weighing less than 15 kg: use albuterol inhalation solution, 0.5% instead of 0.083% Key points:
• The medication should be administered as needed to control recurring bouts of bronchospasm
• If a previously effective dosage regimen fails to provide relief, medical advice should be sought immediately 2
• Significant improvement in pulmonary function can be expected within 2 to 20 minutes following a single dose of albuterol inhalation solution 2

From the Research

Treatment Options for Asthma Exacerbation in Kids

• The goal of treatment is to minimize morbidity and prevent mortality, with inhaled albuterol and systemic corticosteroids being the mainstay of exacerbation management 3.
• A score-based, respiratory therapist-driven pathway for initiation and discontinuation of continuous albuterol has been shown to be safe and effective in the treatment of pediatric asthma exacerbation 4.
• The use of ipratropium bromide as an adjunctive therapy to beta2-agonists has been found to improve lung function and decrease hospitalization rates in children with acute asthma exacerbation 5, 6.

Medication Management

• Inhaled corticosteroids (ICS) are recommended as the preferred drug for infants and preschoolers with recurrent wheezing, especially in asthmatics 7.
• The combination of ipratropium bromide and salbutamol has been found to be more effective than salbutamol alone in reducing the risk of hospital admission in children and adolescents with severe and moderate to severe asthma exacerbation 6.
• Daily ICS has been shown to be superior to daily or intermittent leukotriene receptor antagonist (LTRA) in reducing symptoms, preventing exacerbations, and improving lung function in preschoolers with asthma 7.

Safety and Efficacy

• The use of ipratropium bromide in conjunction with beta2-agonists has been found to be safe and effective in the treatment of acute asthma exacerbation in children and adults, with no severe adverse effects reported 5.
• The safety and efficacy of combination therapy with ICS and long-acting beta2-agonists (LABA) or LTRA in infant/preschoolers has not been established, with no randomized controlled trials (RCTs) published on this topic 7.