What is the appropriate management for a pediatric patient with status asthmaticus?

Management of Pediatric Status Asthmaticus

Immediately administer high-flow oxygen via face mask to maintain oxygen saturation >92%, nebulized salbutamol 5 mg (or 2.5 mg if age ≤2 years) every 20 minutes for up to 3 doses, systemic corticosteroids (oral prednisolone 1-2 mg/kg or IV hydrocortisone if unable to take oral), and add ipratropium 100 mcg to the nebulizer for moderate to severe exacerbations. 1, 2

Recognition of Severity

Identify children requiring immediate aggressive intervention by assessing for:

Severe exacerbation features: 1, 2

• 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 escalation: 3, 1

• 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

First-Line Therapy (Administer Simultaneously)

Oxygen: 1, 2

• High-flow oxygen via face mask immediately
• Maintain oxygen saturation >92% throughout treatment
• Continue pulse oximetry monitoring

Beta-Agonist Bronchodilator: 1, 4

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

Systemic Corticosteroids (Do NOT Delay): 1, 2

• Oral route preferred: Prednisolone 1-2 mg/kg daily (maximum 60 mg) if child can swallow and is not vomiting 1, 4
• IV route: Hydrocortisone 200 mg every 6 hours (or 4 mg/kg/dose every 6 hours) if vomiting, seriously ill, or unable to take oral medications 2
• Administer within the first hour—underuse of corticosteroids is a leading cause of preventable asthma mortality 2

Ipratropium Bromide: 1, 2

• Add ipratropium 100 mcg to nebulizer immediately for moderate to severe exacerbations
• Repeat every 6 hours until improvement starts
• Particularly indicated when initial beta-agonist treatment fails 2

Life-Threatening Features Present

If life-threatening features are identified: 3, 2

• Give IV aminophylline 5 mg/kg over 20 minutes followed by maintenance infusion 1 mg/kg/hour
• Omit loading dose if child already receiving oral theophyllines
• Consider IV magnesium sulfate for life-threatening exacerbations or those remaining severe after 1 hour of intensive conventional treatment 2

Reassessment and Monitoring

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

• Measure peak expiratory flow before and after each bronchodilator dose
• Chart PEF at least 4 times daily throughout hospital stay
• Maintain continuous pulse oximetry with target >92%
• Response to treatment in the ED is a better predictor of hospitalization need than initial severity 2

Subsequent Management Based on Response

If Patient is Improving: 3, 1

• Continue high-flow oxygen
• Continue prednisolone 1-2 mg/kg daily (maximum 40-60 mg)
• Continue nebulized β-agonist 4 hourly

If Patient is NOT Improving After 15-30 Minutes: 3, 1

• Continue oxygen and steroids
• Increase nebulized β-agonist frequency up to every 30 minutes
• Ensure ipratropium is added to nebulizer and repeat 6 hourly
• Consider escalation to second-line therapies

Critical Pitfalls to Avoid

Do NOT delay systemic corticosteroids while giving repeated albuterol doses alone—this is a common cause of treatment failure and preventable mortality. 1, 2

Do NOT use sedatives of any kind in acute severe asthma, as they can depress respiratory function. 1, 2

Do NOT use antibiotics routinely unless bacterial infection is confirmed—viral respiratory infections are the most common trigger in this age group. 2

Do NOT delay intubation once deemed necessary—signs of impending respiratory failure include inability to speak, altered mental status, worsening fatigue, and PaCO₂ ≥42 mm Hg. 2, 5

Hospital Admission Criteria

Admit to hospital if: 1, 2

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

Transfer to Intensive Care Unit

Transfer to ICU accompanied by a doctor prepared to intubate if: 3, 1

• Deteriorating peak flow or worsening exhaustion
• Persistent hypoxemia or hypercapnia despite treatment
• Feeble respirations or poor respiratory effort
• Altered consciousness, confusion, or drowsiness
• Coma or respiratory arrest

Discharge Criteria

Children can be discharged when: 3, 1

• On discharge medication for 24 hours with inhaler technique checked and recorded
• PEF >75% of predicted or best with diurnal variability <25%
• Treatment includes oral steroids (continue for 3-5 days) and inhaled steroids in addition to bronchodilators 2, 4
• Written asthma action plan provided to parents 4
• GP follow-up arranged within 1 week
• Respiratory clinic follow-up within 4 weeks