How should I manage a 7‑year‑old child with acute heavy breathing (tachypnea)?

Management of a 7-Year-Old with Heavy Breathing

Immediately assess for acute severe asthma and initiate high-flow oxygen (40-60% via face mask), nebulized salbutamol 5 mg via oxygen-driven nebulizer, and intravenous hydrocortisone without delay if any severe features are present. 1

Rapid Initial Assessment

First, determine if this child has acute severe asthma by checking for these features:

• Too breathless to talk or feed 2
• Respiratory rate >50 breaths/min 2
• Heart rate >140 beats/min 2
• Peak expiratory flow <50% predicted (if age-appropriate to measure) 2

Critical pitfall: Children with severe attacks may not appear distressed, and assessment in very young children is difficult—the presence of ANY severe feature should trigger immediate treatment. 1

Identify Life-Threatening Features

Immediately check for these life-threatening signs that mandate maximum therapy:

• PEF <33% predicted or poor/feeble respiratory effort 2
• Silent chest (absent breath sounds despite respiratory distress—this means the child is deteriorating toward respiratory arrest, NOT improving) 2, 3
• Cyanosis 2
• Fatigue or exhaustion 2
• Agitation or reduced level of consciousness 2

Immediate Treatment Protocol

For Acute Severe Asthma (Without Life-Threatening Features):

• High-flow oxygen via face mask targeting SpO₂ >92% 2, 1
• Nebulized salbutamol 5 mg (or terbutaline 10 mg) via oxygen-driven nebulizer 2, 1
• Intravenous hydrocortisone 2, 1
• Add ipratropium 100 mcg nebulized every 6 hours 2, 1

If Life-Threatening Features Are Present:

• All of the above PLUS:
• Intravenous aminophylline 5 mg/kg over 20 minutes, followed by maintenance infusion of 1 mg/kg/hour (omit loading dose if child already receiving oral theophyllines) 2, 1
• Prepare for ICU transfer with a physician ready to intubate 1, 3

Critical safety point: Never administer sedatives in acute severe asthma—they can precipitate respiratory arrest. 1 Oxygen does not aggravate CO₂ retention in asthma, so give high-flow oxygen without hesitation. 1

Reassessment at 15-30 Minutes

If Patient Is Improving:

• Continue high-flow oxygen 2, 1
• Prednisolone 1-2 mg/kg body weight daily (maximum 40 mg) 2, 1
• Nebulized β-agonist every 4 hours 2, 1

If Patient Is NOT Improving:

• Continue oxygen and steroids 2, 1
• Increase nebulized β-agonist frequency to every 30 minutes 2, 1
• Add ipratropium to nebulizer and repeat every 6 hours until improvement starts 2, 1

Continuous Monitoring

• Repeat PEF measurement 15-30 minutes after starting treatment (if age-appropriate) 2, 1
• Continuous oximetry maintaining SpO₂ >92% 2, 1
• Chart PEF before and after each β-agonist dose, minimum 4 times daily 2, 1

Transfer to ICU Criteria

Transfer immediately with a physician prepared to intubate if:

• Deteriorating PEF or worsening exhaustion 2, 1
• Feeble respirations, persistent hypoxia, or hypercapnia 2
• Coma, respiratory arrest, confusion, or drowsiness 2, 1

Differential Diagnosis Considerations

While asthma is the most common cause of acute heavy breathing in a 7-year-old, also consider:

• Foreign body aspiration (sudden onset, unilateral findings, history of choking) 4, 5
• Pneumonia (fever, cough, focal findings) 6, 4
• Upper airway obstruction (stridor, positional changes) 6, 5

However, given the high mortality risk of untreated severe asthma, initiate asthma treatment immediately while assessing for alternative diagnoses. 1

Discharge Criteria (When Stable)

Before discharge, ensure:

• Child has been on discharge medication for 24 hours 2, 1
• Inhaler technique checked and documented 2, 1
• PEF >75% of predicted or best with diurnal variability <25% (if measured) 2, 1
• Treatment includes oral steroids, inhaled steroids, and bronchodilators 2, 1
• Written self-management plan provided to parents 2, 1
• GP follow-up within 1 week and respiratory clinic follow-up within 4 weeks 2, 1