What is the first line of treatment for a child with hyperactive airway disease?

First-Line Treatment for Hyperactive Airway Disease in Children

The first-line treatment for a child with hyperactive airway disease (asthma) is a short-acting inhaled beta-2 agonist (albuterol/salbutamol) for acute symptom relief, combined with inhaled corticosteroids for ongoing control of persistent disease. 1

Acute Symptom Management (First-Line Bronchodilator)

For immediate relief of bronchospasm, nebulized albuterol 5 mg (or terbutaline 10 mg) via oxygen-driven nebulizer is the cornerstone of acute treatment. 1, 2

• In very young children, use half the standard dose of bronchodilator 1
• Albuterol demonstrates onset of improvement within 5 minutes, with maximum effect at approximately 1 hour, and duration of 3-6 hours in most patients 3
• The medication can be delivered via nebulizer or 4-12 puffs via MDI with valved holding chamber, repeated every 20-30 minutes for three doses initially 4
• Approximately 60-70% of patients respond sufficiently to these initial three doses 4

Long-Term Control (First-Line Anti-Inflammatory)

Inhaled corticosteroids are the most effective first-line therapy for persistent asthma, as they are the only treatment that suppresses airway inflammation and prevents disease progression. 5, 6, 7

• Inhaled corticosteroids reduce asthma symptoms, improve lung function, reduce airway inflammation and bronchial hyperreactivity more effectively than any other treatment 5, 7
• Early introduction of inhaled steroids appears to result in better improvement in lung function compared with delayed use, and may prevent irreversible airway remodeling 5, 8
• For children, doses ≤400 micrograms daily, individually tailored, do not cause growth retardation concerns 5
• Budesonide inhalation suspension can be given to children with persistent asthma from 12 months of age via nebulizer 6

Assessment-Based Treatment Algorithm

For Mild Exacerbation (PEF >50% predicted, normal speech, pulse <110, respirations <25):

• Nebulized albuterol 5 mg or terbutaline 10 mg 1
• Monitor response at 15-30 minutes 1
• If PEF improves to >75%, step up usual maintenance treatment 1
• If PEF 50-75%, add prednisolone 30-60 mg (or 1-2 mg/kg in children, maximum 40 mg) 1

For Moderate-to-Severe Exacerbation (PEF <50% predicted, too breathless to talk/feed, respirations >50, pulse >140):

• Immediately administer all three components simultaneously: 2, 4
  • High-flow oxygen via face mask to maintain SaO₂ >92% 1, 2
  • Nebulized albuterol 5 mg via oxygen-driven nebulizer 1, 2
  • Add ipratropium 100 mcg nebulized every 6 hours 1, 2
• Give systemic corticosteroids immediately: prednisolone 1-2 mg/kg body weight daily (maximum 40 mg) 1, 2

For Life-Threatening Features (PEF <33%, silent chest, cyanosis, exhaustion, altered consciousness):

• All of the above PLUS intravenous aminophylline 5 mg/kg over 20 minutes, followed by maintenance infusion 1 mg/kg/hour 1, 2
• Omit aminophylline loading dose if child already receiving oral theophyllines 1
• Prepare for ICU transfer with physician ready to intubate 1, 2

Critical Monitoring Points

• Reassess at 15-30 minutes after initial treatment to determine response 1, 2
• If not improving, increase nebulized β-agonist frequency to every 30 minutes 1, 2
• Maintain continuous pulse oximetry with target SaO₂ >92% 1, 2
• Chart PEF before and after β-agonist administration at least 4 times daily 1

Common Pitfalls to Avoid

Underuse of corticosteroids is a major factor in preventable asthma deaths—systemic steroids must be given early in moderate-to-severe exacerbations. 1, 2

• Do not delay treatment waiting for investigations; no other tests are needed for immediate management 1
• Do not use inadequate oxygen delivery; high-flow oxygen via face mask is essential, not just nasal cannula 1, 2
• Do not fail to appreciate severity; regard each emergency consultation as potentially severe until proven otherwise 1
• Do not use other sympathomimetic bronchodilators or epinephrine concomitantly with albuterol 3
• Do not delay introduction of inhaled corticosteroids for persistent asthma, as delayed treatment results in reduced lung function improvement and may allow irreversible airway remodeling 5, 8

Hospital Admission Criteria

Admit if any of the following are present after initial treatment: 1

• Any life-threatening features persist
• PEF remains <50% predicted (especially <33%)
• SpO₂ <92% after 1 hour of treatment
• Attack occurs in afternoon/evening with recent nocturnal symptoms
• Recent hospital admission or previous severe attacks