Pediatric Asthma Treatment Approach
For chronic asthma management in children, inhaled corticosteroids are the preferred first-line controller therapy for persistent asthma across all pediatric age groups, while acute exacerbations require immediate administration of high-flow oxygen, nebulized salbutamol, and systemic corticosteroids simultaneously. 1, 2
Chronic Asthma Management
Controller Therapy Selection
- Low-dose inhaled corticosteroids (ICS) are the cornerstone of treatment for children with persistent asthma, using the lowest dose that provides acceptable symptom control 1, 3
- For children ≥5 years with mild persistent asthma, start with low-dose ICS such as fluticasone 100 mcg or budesonide equivalent 3
- Alternative therapies include leukotriene receptor antagonists, cromolyn, nedocromil, or sustained-release theophylline, though these are less preferred 3
- Combination ICS/LABA should be reserved for children inadequately controlled on ICS monotherapy 3
Treatment Goals
The outcome of successful management should include: 4, 1
- Minimal daytime symptoms and no nocturnal awakening
- Full participation in activities and sports without limitation
- No missed school days
- Infrequent need for relief medications (not requiring daily use)
- Peak flow >75% predicted with diurnal variability <25%
Growth Monitoring Considerations
- Short-term reductions in growth rate can occur at ICS doses above 400 µg/day, though long-term effects remain unclear 1
- Height and weight velocities should be documented at each visit 4
- The benefits of asthma control far outweigh potential growth concerns, as uncontrolled asthma itself delays growth and puberty 4
Acute Asthma Exacerbation Management
Severity Assessment
Recognize severe exacerbation by these features: 4, 2, 3
- Too breathless to talk or feed
- Respiratory rate >50 breaths/minute
- Pulse >140 beats/minute
- Peak expiratory flow <50% predicted
- Use of accessory muscles
Life-threatening features requiring immediate escalation: 4, 2, 3
- Peak flow <33% predicted or poor respiratory effort
- Silent chest, cyanosis, or exhaustion
- Altered level of consciousness or agitation
- Oxygen saturation <92% despite supplemental oxygen
Immediate Treatment Protocol
Three simultaneous interventions must be initiated immediately: 1, 2, 3
Salbutamol (albuterol) 5 mg via oxygen-driven nebulizer OR 4-8 puffs via MDI with large volume spacer, repeated every 20 minutes for up to 3 doses in the first hour 2, 5
Systemic corticosteroids immediately - either oral prednisolone 1-2 mg/kg (maximum 40 mg) OR intravenous hydrocortisone 4, 2, 3
Add ipratropium bromide 100 mcg to nebulizer immediately for moderate to severe exacerbations, repeated every 6 hours until improvement starts 4, 1, 2
Critical Pitfall to Avoid
Do NOT delay systemic corticosteroids while giving repeated albuterol doses alone - this is a common cause of treatment failure and preventable mortality 2
Monitoring and Reassessment
- Repeat peak expiratory flow measurement 15-30 minutes after starting treatment 4, 2
- Maintain continuous pulse oximetry with target >92% 1, 2
- Chart PEF before and after β-agonist administration at least 4 times daily throughout hospital stay 4, 2
- Response to treatment is a better predictor of hospitalization need than initial severity 1
Escalation for Non-Responders (15-30 minutes after initial treatment)
If the patient is NOT improving: 4, 2
- Continue high-flow oxygen and systemic steroids
- Increase nebulized β-agonist frequency up to every 30 minutes
- Ensure ipratropium is added if not already given
- Consider intravenous magnesium sulfate 6, 7
- For life-threatening features: give intravenous aminophylline 5 mg/kg over 20 minutes followed by 1 mg/kg/h maintenance infusion (omit loading dose if already on oral theophyllines) 4
Hospital Admission Criteria
- Persistent features of severe asthma after initial treatment
- Peak expiratory flow remains <50% predicted 15-30 minutes after treatment
- Life-threatening features present
- Parents unable to provide appropriate treatment at home
ICU Transfer Criteria
Transfer to intensive care unit accompanied by a physician prepared to intubate if: 4, 2
- Deteriorating peak flow despite treatment
- Worsening exhaustion or feeble respirations
- Persistent hypoxemia or hypercapnia
- Altered consciousness, confusion, or drowsiness
- Coma or respiratory arrest
Discharge Planning
Children may be discharged when ALL of the following are met: 4, 1, 3
- On discharge medications for 24 hours with proper inhaler technique verified and documented
- Peak flow >75% of predicted or best with diurnal variability <25%
- Prescribed oral steroids, inhaled steroids, and bronchodilators
- Own peak flow meter provided (for children ≥5 years)
- Written self-management plan or instructions for parents provided
- GP follow-up arranged within 1 week
- Respiratory clinic follow-up scheduled within 4 weeks
Essential Discharge Education
Families must understand: 4, 3
- Proper inhaler technique and peak flow meter use (for children ≥5 years)
- Difference between reliever and preventer medications
- How and when to vary medications according to symptoms or peak flow
- Recognition of worsening asthma signs
- When to call for help or seek urgent care
Device Selection by Age
Proper device selection is critical for treatment success: 4
- Most children cannot achieve coordination for unmodified MDI - this should not be used unless technique is verified 4
- Large volume spacers should be used with MDI for all children receiving inhaled steroids to enhance lung deposition 4
- Some children under 5 years can use powdered drugs, especially with Turbohaler or Diskhaler 4
- Nebulizers are overused and often can be replaced by MDI with large volume spacer, which is more efficient and less time-consuming 4
What NOT to Do
Avoid these interventions in pediatric asthma exacerbations: 1
- Antibiotics (unless bacterial infection confirmed)
- Aggressive hydration
- Chest physiotherapy
- Mucolytics
- Sedatives of any kind - they can depress respiratory function 2