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Management of Asthma in Children: Treatment of Acute Exacerbations

The management of an acute exacerbation should incorporate information about the patient’s precipitating factors; duration of symptoms; prehospital and maintenance medications, including steroid use; previous disease history; previous intensive care unit admission and intubation; other symptoms to rule out infections; child’s speaking ability; and baseline peak expiratory flow rate to determine the severity of the exacerbation. A clinical asthma score based on oxygen saturation, breath sounds, accessory muscle use, expiratory wheezing, and cerebral function can also be used to describe the severity of the exacerbation.Management-of-Asthma-in-Children

Standard treatment with inhaled bronchodilators has replaced systemic beta2-agonists and methylxanthines. However, oral beta2-agonists are an appropriate alternative for managing exacerbations (see TABLE 1). Mild exacerbations can usually be managed successfully at home with one to two treatments of inhaled albuterol or levalbuterol separated by four to six hours. Generally, if the child is not responsive after two treatments, he or she needs medical attention to treat a more severe exacerbation. Initial bronchodilation may involve administration of three back-to-back treatments with albuterol alone or in combination with ipratropium via oxygen-driven nebulization, or a metered dose inhaler (MDI) with a spacer or holding chamber at 20-minute intervals. Lung sounds and vital signs should be assessed between treatments. If the child meets discharge criteria, he or she can be sent home. Of note, the persistence of audible wheezing does not indicate treatment failure. More concerning are distant or absent breath sounds secondary to airflow obstruction.

Table 1. Usual Dosages for Selected Asthma Medications in Acute Exacerbations
Medication Dosage Form Child Dose Adult Dose
Albuterol MDI
90 µg/puff
200 puffs
Inhale 4-8 puffs every 20 minutes for 3 doses, then q1-4h Inhale 4-8 puffs every 20 minutes for 3 doses, then q1-4h
Albuterol Nebulizer solution
5 mg/mL (0.5%)
2.5 mg/3 mL
1.25 mg/3 mL
0.63 mg/3 mL
Inhale 0.15 mg/kg (2.5 mg) every 20 minutes for 3 doses, then 0.15-0.3 mg/kg up to 10 mg q1-4h as needed or 0.5 mg/kg/h by continuous nebulization Inhale 2.5-5 mg every 20 minutes for 3 doses, then 2.5-10 mg q1-4h as needed, or 10-15 mg/hr continuously
Levalbuterol Nebulizer solution
0.31 mg/3 mL
0.63 mg/3 mL
1.25 mg/3 mL
Inhale0.075 mg/kg (max 1.25 mg) every 20 minutes for 3 doses, then0.075-0.15 mg/kg up to 5 mg q1-4h prn, or 0.25 mg/kg/hby continuous nebulization Inhale 1.25-2.5 mg every 20 minutes for 3 doses, then 1.25-5 mg q1-4h prn, or 5-7.5 mg/h continuously
Epinephrine SC injection
1:1,000 (1 mg/mL)
Inject 0.01 mg/kg subcutaneously up to 0.3-0.5 mg every 20 minutes for 3 doses Inject 0.3-0.5 mg every 20 minutes for 3 doses SC
Ipratropium MDI
18 µg/puff; 200 puffs
Inhale 4-8 puffs q1-4h prn Inhale 4-8 puffs q1-4h prn
Ipratropium Nebulizer solution
0.25 mg/mL (0.025%)
Inhale 0.25 mg every 20 minutes for 3 doses, then q2-4h prn Inhale 0.5 mg every 30 minutes for 3 doses, then q2-4h prn
Ipratropium with albuterol MDI
18 µg/puff ipratropium and 90 mg/puff albuterol; 200 puffs
Inhale 4-8 puffs q1-4h prn Inhale 4-8 puffs q1-4h prn
Ipratropium with albuterol Nebulizer solution
0.5 mg/3 mL ipratropium and 2.5 mg/3 mL albuterol
Inhale 1.5 mL every 20 minutes for 3 doses, then q2-4h Inhale 3 mL every 30 minutes for 3 doses, then q2-4h prn
Prednisone, methylprednisolone, prednisolone Various Take 1 mg/kg PO q6h for 48 h, then 1-2 mg/kg/day (max 60 mg) in 2 divided doses until PEF is 70% of predicted or personal best Take 80-120 mg/day PO in 3 or 4 divided doses for 48 hours, then 60-80 mg/day until PEF reaches 70% of predicted or personal best
MDI: metered dose inhaler; SC: subcutaneous; PEF: peak expiratory flow.

Moderate and severe exacerbations may require fluid replacement to treat dehydration and to minimize secretion thickening. Supplemental humidified oxygen may be necessary if the patient is hypoxic, while intubation is indicated for severe respiratory distress or coma. Bronchodilators are continued and systemic corticosteroids are initiated, and although inhaled steroids are not indicated for routine use during an acute exacerbation, they may have a role in mild exacerbation if initiated early at high doses. Antibiotics are not prescribed unless bacterial infections are suspected.

Patients with status asthmaticus, a severe attack that does not respond to normal treatment, should receive supplemental oxygen and systemic steroids with additional back-to-back treatments, continuous beta2-agonist treatments, or, if necessary, subcutaneous (SC) epinephrine and/or intravenous (IV) magnesium. Once stabilized, the patient should be sent to the general ward for further management or to the pediatric intensive care unit for intubation and more aggressive treatment.

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