A 5‑year‑old child is waking up at night gasping for air; how should this be managed acutely and what are the likely causes?

A 5-Year-Old Gasping for Air at Night

This child requires immediate assessment for acute severe asthma, which is the most likely cause of nocturnal gasping in this age group, and should receive high-flow oxygen to maintain SpO₂ >92%, nebulized salbutamol 5 mg (or 4-8 puffs via MDI with spacer), and oral prednisolone 1-2 mg/kg (maximum 40 mg) immediately. 1, 2

Immediate Assessment and Recognition

Assess for features of acute severe asthma, which in a 5-year-old include: 3

• Too breathless to talk or feed
• Respiratory rate >50 breaths/minute
• Pulse >140 beats/minute
• Use of accessory muscles, intercostal or subcostal recession
• Oxygen saturation <92%

Identify life-threatening features immediately, as these require aggressive intervention: 3, 1

• Silent chest or poor respiratory effort
• Cyanosis
• Exhaustion or fatigue
• Agitation or reduced level of consciousness

Acute Management Protocol

First-Line Treatment (Administer Simultaneously)

Oxygen therapy: Deliver high-flow oxygen (40-60%) via face mask immediately to maintain SpO₂ >92% and continue throughout treatment. 3, 2

Bronchodilator: Administer salbutamol 5 mg via oxygen-driven nebulizer OR 4-8 puffs via MDI with spacer, repeated every 20 minutes for up to 3 doses in the first hour. 3, 1

Systemic corticosteroid: Give oral prednisolone 1-2 mg/kg (maximum 40 mg) immediately upon recognition—do not delay while giving repeated bronchodilator doses alone, as this is a leading cause of preventable asthma mortality. 1, 2, 4

Ipratropium bromide: Add ipratropium 100 mcg to each nebulizer dose (or 4-8 puffs via MDI) every 20 minutes for the first hour if severe features are present. 3, 2

Critical Pitfall to Avoid

Never postpone systemic corticosteroid administration while giving repeated bronchodilator doses alone—immediate anti-inflammatory treatment is essential because clinical benefit takes 6-12 hours to manifest, and underuse of corticosteroids is specifically identified as a leading cause of preventable asthma mortality. 1, 2, 4

Reassessment at 15-30 Minutes

Repeat clinical assessment including: 2, 4

• Respiratory rate, heart rate, work of breathing
• Oxygen saturation (maintain continuous pulse oximetry)
• Peak expiratory flow if child can cooperate (though often difficult at age 5)

If improving: Continue high-flow oxygen, prednisolone 1-2 mg/kg daily, and nebulized salbutamol every 4 hours. 3

If NOT improving after 15-30 minutes: 3

• Continue oxygen and steroids
• Increase nebulized salbutamol frequency to every 15-30 minutes
• Continue ipratropium 6-hourly until improvement starts
• Consider intravenous magnesium sulfate for life-threatening features

Hospital Admission Criteria

Admit to hospital if: 2, 4

• Persistent severe features after initial treatment
• SpO₂ <92% despite treatment
• Life-threatening features present
• Parents unable to provide appropriate home treatment

Transfer to intensive care if deteriorating despite treatment, with exhaustion, confusion, or respiratory arrest. 3

Alternative Diagnoses to Consider

While asthma is most likely, also consider: 5, 6, 7

Upper airway obstruction (croup, foreign body): Characterized by inspiratory stridor, barking cough, and positional changes in symptoms. Requires different management with nebulized epinephrine and dexamethasone. 6, 8

Obstructive sleep apnea: Presents with chronic nocturnal gasping, snoring, and witnessed apneas rather than acute distress—requires polysomnography and ENT evaluation, not emergency bronchodilators. 5

Anaphylaxis: Would present with acute onset, associated urticaria, angioedema, or gastrointestinal symptoms—requires intramuscular epinephrine. 7

Discharge Planning (Once Stabilized)

Discharge criteria: 1, 2

• On discharge medication for 24 hours
• SpO₂ stable >92% on room air
• Peak flow >75% predicted (if measurable)

Prescribe at discharge: 1, 2

• Oral prednisolone 1-2 mg/kg daily for 3-10 days to prevent relapse
• Inhaled corticosteroid controller therapy (not just rescue bronchodilator)
• Written asthma action plan with clear instructions

Arrange follow-up within 48 hours to 1 week to reassess control and address underlying poor adherence, which is the most common contributor to nocturnal symptoms and emergency presentations. 1, 2