ACUTE ASTHMA EXACERBATIONS IN CHILDREN - Emergency department management

Acute asthma exacerbations in children: Emergency department management

Author:Richard J Scarfone, MD, FAAPSection Editors:Gregory Redding, MDStephen J Teach, MD, MPHDeputy Editor:Elizabeth TePas, MD, MS

Contributor Disclosures

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Sep 2016. | This topic last updated: Jun 22, 2016.

INTRODUCTION — Clinical decision making in the management of the child with an acute asthma exacerbation includes the following questions:

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How sick is the child?

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Which drugs should be used for treatment?

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What are the optimal doses and delivery routes?

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When is more aggressive management necessary?

The approach to emergency department (ED) management of the child with an acute asthma exacerbation is presented below. Management of acute asthma exacerbations in the home, office/outpatient clinic, and inpatient settings are discussed in detail separately. Rescue medications for acute symptoms are also reviewed elsewhere. (See "Acute asthma exacerbations in children: Home/office management and severity assessment" and "Acute asthma exacerbations in children: Inpatient management" and "Acute severe asthma exacerbations in children: Intensive care unit management" and "Asthma in children younger than 12 years: Rescue treatment for acute symptoms".)

The management of acute asthma exacerbations in adults is also discussed separately. (See "Treatment of acute exacerbations of asthma in adults".)

OVERVIEW OF TREATMENT — The approach to the management of acute asthma exacerbations described below is geared toward management in the emergency department (ED). Initial treatment (beta-agonist therapy and oral glucocorticoids) is sometimes provided in the primary care setting or even at home [1]. However, children with moderate to severe exacerbations require close observation for clinical deterioration, frequent treatments, and repeated evaluation. Thus, most children with moderate or severe asthma exacerbations should be managed in an ED setting. (See "Acute asthma exacerbations in children: Home/office management and severity assessment".)

Initial assessment of severity — We use the Pulmonary Index Score (PIS) (table 1), one of several ordinal scales for the assessment of the initial severity of the exacerbation and level of treatment needed (ie, mild, moderate, or severe) [2]. Assessment of the severity of an acute asthma exacerbation, including review of other available scores, is discussed in detail separately. (See "Acute asthma exacerbations in children: Home/office management and severity assessment", section on 'Assessment of exacerbation severity'.)

Goals — The goals of therapy for an acute asthma exacerbation include [1]:

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Rapid reversal of airflow obstruction by administration of inhaled bronchodilators and early institution of systemic glucocorticoids. (See 'Pharmacotherapy' below.)

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Correction of hypoxemia and/or severe hypercapnia, if present; hypoxemia is alleviated by administration of supplemental oxygen as necessary; hypercapnia usually improves with reversal of airflow obstruction. (See 'Oxygen therapy' below and 'Pharmacotherapy' below.)

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Reduction of likelihood of recurrence by ensuring adequate baseline controller therapy when indicated. (See 'Discharge medications' below.)

General approach — The general approach to treatment of an acute asthma exacerbation includes administration of inhaled bronchodilators (eg, albuterol), as well as anti-inflammatory agents (ie, systemic glucocorticoids) in most patients (algorithm 1 and algorithm 2). Supportive care for children with acute asthma exacerbations includes administration of supplemental oxygen and fluids as necessary and frequent monitoring of response to therapy.

Medications — Inhaled, short-acting, selective beta-2-adrenergic agonists (beta-agonists or SABAs) are the mainstay of emergent treatment of acute asthma exacerbations. For children with mild exacerbations, systemic glucocorticoids are usually added if the symptoms and signs of airway obstruction fail to resolve after the first treatment with inhaled beta-agonists. Children with moderate or severe exacerbations should receive systemic glucocorticoids as soon as possible. Additional pharmacotherapeutic agents that may be indicated in children with moderate or severe asthma include nebulized ipratropium bromide, intravenous magnesium sulfate, and parenteral beta-agonists. (See 'Pharmacotherapy' below.)

Oxygen therapy — Many patients with moderate to severe acute asthma exacerbations have hypoxemia as a result of ventilation-perfusion (V/Q) mismatch, although, in most patients, the hypoxemia is mild and does not require treatment with supplemental oxygen. Beta-agonists may worsen this mismatch by causing pulmonary vasodilation in areas of the lung that are poorly ventilated. Humidified oxygen should be provided as needed to maintain an oxygen saturation of ≥92 percent [3]. All nebulized medications should also be delivered with oxygen, generally at a flow rate of 6 to 8 L/min. (See "Continuous oxygen delivery systems for infants, children, and adults".)

Monitoring — Ongoing monitoring of respiratory rate, heart rate, oxygen saturation, degree of alertness, accessory muscle use, and retractions is crucial to decisions regarding treatment and disposition [4].The frequency of monitoring varies depending upon the severity of illness and response to initial therapy, but for most patients is typically every 20 to 30 minutes for the first hour of therapy. Patients who require continuous nebulizer therapy continue to be monitored every 20 to 30 minutes. Clinicians may also find it helpful to measure peak expiratory flow rate (PEFR). However, assessment of PEFR may have limited utility in the assessment of sicker or younger children. It is optimal if the child can make three attempts while standing (the best score is used), and it is most useful when it can be compared with the child's known personal best score. (See "Overview of pulmonary function testing in children", section on 'Peak expiratory flow rate (PEFR)'.)

Arterial blood gas — It is rarely necessary to obtain arterial blood gas (ABG) samples in children with acute asthma. Oxyhemoglobin saturation can be assessed with pulse oximetry.

Many severely ill children have hypercapnia on arrival to the ED, but this usually improves after therapy. In children who require admission to the intensive care unit (ICU), measurement of PaCO2 via ABG after a clinical plateau has been reached provides an objective measure of disease severity. Alternatively, end tidal CO2 may be measured noninvasively via capnometry. In moderately or severely ill children, ABGs obtained before aggressive intervention often are abnormal, but rarely affect management. (See "Acute severe asthma exacerbations in children: Intensive care unit management".)

Chest radiograph — Chest radiographs (CXRs) rarely provide information that alters the management of children with acute asthma exacerbation [5,6]. Viral upper respiratory tract infections are the most common trigger for wheezing in children, and the presence of low-grade fever in children with acute asthma exacerbation often prompts clinicians to obtain CXRs to exclude pneumonia. However, the rate of specific CXR findings in this setting is extremely low, except in the presence of focal examination findings (eg, crackles or decreased breath sounds), fever (>39ºC), or severe disease [5,7]. Consider obtaining CXRs to rule out pneumonia, atelectasis, and air leak if there are focal examination findings (eg, crackles or decreased breath sounds), fever (>39ºC), severe disease, uncertainty about the diagnosis, or tachypnea, hypoxemia, or chest pain that are present after initial therapy has been given.

Mild exacerbation — For children with mild asthma exacerbation (PIS <7 (table 1)), we suggest the following:

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Albuterol inhalation therapy administered via small volume nebulizer (SVN) at a dose of 0.15 mg/kg (minimum 2.5 mg and maximum 5 mg per dose) or metered-dose inhaler with spacer (MDI-S) at a dose of one-quarter to one-third puff/kg (minimum two puffs and maximum eight puffs per dose). If repeated doses are needed, they should be given every 20 to 30 minutes for three doses [1]. (See 'Dosing and administration' below.)

Patients who do not respond after three doses should be reassessed and treated accordingly (algorithm 1). Discharge criteria for patients who do respond to therapy are reviewed below. (See 'Moderate exacerbation' below and 'Severe exacerbation' below and 'Discharge to home' below.)

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Administration of systemic glucocorticoids to those who fail to show any improvement or worsen after one inhalation therapy (table 2) or who have a history of severe or recurrent exacerbations in the past. (See 'Systemic glucocorticoids' below.)

Moderate exacerbation — For children with moderate asthma exacerbation (PIS 7 to 11 (table 1)), we suggest the following approach (algorithm 1):

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Administration of supplemental oxygen if oxygen saturation ≤92 percent in room air. (See 'Oxygen therapy' above.)

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Albuterol nebulization (0.15 mg/kg, maximum 5 mg) combined with ipratropium bromide (250 microgram/dose if <20 kg; 500 microgram/dose if >20 kg) every 20 to 30 minutes for three doses or continuously. (See 'Inhaled short-acting beta-agonists' below and 'Ipratropium bromide' below.)

Many studies show comparable outcomes for patients who receive albuterol via SVN or MDI-S. However, continuous delivery of the first three doses of albuterol via SVN in the first hour after ED arrival helps to ensure compliance with national treatment guidelines. In addition, delivery via SVN facilitates simultaneous administration of albuterol and ipratropium. Thus, many ED clinicians choose to treat moderately to severely ill patients with albuterol delivered via SVN. (See 'Nebulizer versus inhaler' below and 'Continuous delivery' below.)

Patients who have received three doses of intermittent therapy and require additional albuterol therapy may be treated intermittently every 30 to 45 minutes or may be switched to continuous therapy. (See 'Inhaled short-acting beta-agonists' below.)

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Administration of systemic glucocorticoids soon after arrival in the ED or after the first inhalation therapy is initiated (table 2). (See 'Systemic glucocorticoids' below.)

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Administration of intravenous magnesium sulfate (75 mg/kg, maximum 2.5 g administered over 20 minutes) if there is lack of clinical improvement or clinical deterioration despite treatment with beta-agonists, ipratropium bromide, and systemic glucocorticoids. (See 'Magnesium sulfate' below.)

Severe exacerbation — For children with severe asthma exacerbation (PIS ≥12 (table 1)), we suggest the following approach (algorithm 2):

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Administration of supplemental oxygen if oxygen saturation is ≤92 percent in room air. (See 'Oxygen therapy' above.)

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Albuterol nebulization (0.15 mg/kg, maximum 5 mg) combined with ipratropium bromide (250 microgram/dose if <20 kg; 500 microgram/dose if >20 kg), every 20 to 30 minutes for three doses or continuously.

Patients who have received three doses of albuterol in the first hour after ED arrival and require additional albuterol therapy may be treated intermittently every 30 to 45 minutes or may be switched to continuous therapy.

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Children with poor inspiratory flow or children who cannot cooperate with nebulized therapy can be treated with epinephrine or terbutaline (dose for both mediations is 0.01 mL/kg of a 1 mg/mL solution; maximum dose of 0.4 mg or 0.4 mL) administered intramuscularly or subcutaneously instead of inhaled albuterol and ipratropium. (See 'Inhaled short-acting beta-agonists' below and 'Ipratropium bromide' below and 'Parenteral beta-agonists' below.)

Subsequent management depends upon response to initial therapy:

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For patients who improve after the initial treatment, the approach is as described above for moderate exacerbations. (See 'Moderate exacerbation' above.)

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For patients with a poor response to initial treatment, we recommend:

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Administration of intravenous methylprednisolone (1 to 2 mg/kg, maximum 125 mg), which can be started as soon as intravenous access is obtained. (See 'Systemic glucocorticoids' below.)

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Continuously nebulized albuterol (alternatively, can be administered intermittently every 30 to 45 minutes). (See 'Inhaled short-acting beta-agonists' below.)

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Administration of intravenous magnesium sulfate (75 mg/kg, maximum 2.5 g administered over 20 minutes). (See 'Magnesium sulfate' below.)

For patients who do not respond to these interventions, administration of intravenous terbutaline after completion of the magnesium sulfate infusion may be indicated: bolus with 10 microgram/kg over 10 minutes, then 0.3 to 0.5 microgram/kg/minute; infusion may be increased by 0.5 microgram/kg/minute every 30 minutes to a maximum of 5 microgram/kg/minute. (See 'Parenteral beta-agonists' below.)

Endotracheal intubation — Intubation should be approached cautiously in patients with status asthmaticus because manipulation of the airway can cause increased airflow obstruction due to exaggerated bronchial responsiveness. Clinicians must be prepared to manage acute deterioration after intubation. Adequate venous access, noninvasive monitoring, and sedation should be optimized before intubation. The clinician most experienced with airway management should perform the intubation. The indications for endotracheal intubation in children with asthma and the performance of the procedure are reviewed in detail separately. (See "Emergency endotracheal intubation in children" and "Rapid sequence intubation (RSI) in children" and "Acute severe asthma exacerbations in children: Endotracheal intubation and mechanical ventilation", section on 'Endotracheal intubation and mechanical ventilation'.)

PHARMACOTHERAPY — The two primary agents used in the treatment of acute asthma exacerbations are inhaled beta-agonists and systemic glucocorticoids. Additional agents are used as needed, depending upon the severity of the exacerbation.

Inhaled short-acting beta-agonists — Inhaled, short-acting, selective beta-2-adrenergic agonists (beta-agonists or SABAs) are the mainstay of emergent treatment of acute asthma exacerbations [8-11]. Albuterol is the most widely used SABA in the acute setting.

Inhaled beta-agonists are administered by intermittent nebulization, continuous nebulization, or metered-dose inhaler with a spacer (MDI-S, preferably a valved holding chamber [VHC]). These delivery systems are discussed in detail separately. (See "Use of medication nebulizers in children" and "The use of inhaler devices in children".)

Nebulizer versus inhaler — Clinicians may use either small volume nebulizers (SVNs) or MDI-S when administering inhaled beta-agonists intermittently. These methods appear to be equally effective for children of all ages and with a wide range of illness severity. Thus, the choice of one over the other mainly depends upon the frequency of dosing required. (See 'Moderate exacerbation' above and 'Continuous delivery' below.)

Clinical trials and meta-analyses indicate that the administration of beta-agonists via MDI-S (4 to 12 puffs) is at least as effective and possibly superior to delivery of medication by SVN in reversing bronchospasm in infants and children [1,12-14]. (See "The use of inhaler devices in children", section on 'Pressurized MDI or nebulizer?'.)

Advantages of SVN delivery compared with MDI-S include the ability to simultaneously deliver humidified oxygen and ipratropium bromide and to passively administer drug therapy to a child in respiratory distress. However, when using SVNs, up to 90 percent of drug remains in the machine or is lost to the atmosphere [15]. In addition, the portability of SVNs is limited by the need for an external power source. (See "The use of inhaler devices in children", section on 'Spacers and holding chambers'.)

Continuous delivery — Studies comparing continuous versus intermittent nebulized delivery of beta-agonists have found similar outcomes and side effect profiles with both methods [8,9,16-18]. We suggest continuous therapy over intermittently nebulized or MDI-S therapy for children with moderate to severe exacerbations. (See "Use of medication nebulizers in children", section on 'Continuous nebulization'.)

Continuous nebulizer therapy is less labor intensive than intermittent nebulizer therapy, resulting in reduced respiratory therapy costs. In addition, it ensures that the goal of three treatments within the first hour of care for moderately ill children is met. However, young children may not tolerate wearing a facemask for long periods of time. (See 'Moderate exacerbation' above and "Delivery of inhaled medication in children", section on 'Patient technique, acceptance, and preference'.)

Levalbuterol — Racemic albuterol (RA) is an equal mixture of two mirror-imaged enantiomers: the active R-albuterol and S-albuterol. Levalbuterol (LA), on the other hand, is pure R-albuterol. Data from animal studies and in vitro studies with human cells suggest that S-albuterol may be a weak bronchoconstrictor [19-26]. Thus, in theory, pure active R-albuterol could be more effective than RA because there is no bronchoconstricting effect from the S-isomer. However, studies of LA for acute asthma in children have had conflicting results. In addition to its lack of proven superiority, LA is substantially more expensive than RA. Thus, we suggest RA rather than LA as the drug of choice for children with acute asthma exacerbations, except in patients with a known history of adverse effects from albuterol. Use of LA is discussed in greater detail separately. (See "Beta agonists in asthma: Acute administration and prophylactic use", section on 'Levalbuterol'.)

In the earliest trial, 547 children with acute asthma who were treated in the emergency department (ED) were randomly assigned to treatment with 1.25 mg LA or 2.5 mg RA every 20 minutes for a maximum of six doses [27]. The hospitalization rate was higher among children who received RA (45 versus 36 percent). Three subsequent studies comparing RA with LA in the emergency department (ED) treatment of children with acute asthma found no differences in outcome measures (changes from baseline clinical asthma score, changes in forced expiratory volume in one second [FEV1], number of treatments, length of ED care, rate of hospitalization) [28-30]. It is worth noting that the baseline admission rates in these three studies [28-30] were substantially lower than in the first study [27].

Dosing and administration — The doses of medications commonly used in the management of acute asthma exacerbations in children are listed in the table (table 2).

Albuterol via MDI-S — Optimal dosing for albuterol administered by metered-dose inhaler with spacer (MDI-S) is not well established. The 2007 National Asthma Education and Prevention Program (NAEPP) guidelines state that "equivalent bronchodilation can be achieved either by high doses (4 to 12 puffs) of a short-acting beta-agonist by MDI-S with a VHC or by nebulizer"; they suggest a dose of four to eight puffs [1].

One strategy is to administer one-quarter to one-third puff/kg (22.5 to 30 microgram/kg) with a maximum of eight puffs (720 microgram). Thus, proportionately greater doses are provided for young children weighing less than 20 to 30 kg (44 to 66 pounds), who are the least efficient users.

Another strategy is to use a dosing schedule, stratified by weight, as with continuous albuterol nebulization:

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For children who weigh 5 to 10 kg, the dose is four puffs

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For children who weigh 10 to 20 kg, the dose is six puffs

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For children who weigh >20 kg, the dose is eight puffs

The dose can be repeated every 20 to 30 minutes for three doses, then every one to four hours as needed.

To maximize drug delivery, a spacer (preferably a VHC) should be employed by all patients, and infants and young children should use a spacer with a facemask, low dead space, and a low resistance valve (picture 1). Mouthpieces are preferable to facemasks for older children to avoid nasal filtering of drug, which may reduce lung deposition. (See "The use of inhaler devices in children", section on 'Spacer devices'.)

Intermittent albuterol nebulization — The standard dose for nebulized albuterol is 0.15 mg/kg (minimum 2.5 mg; maximum 5 mg) (table 2) [1,31]. Nebulized albuterol can be administered every 20 to 30 minutes for three doses [1]. Beyond that, frequency of therapy may be limited by side effects, such as tachycardia, hypertension, or tremors. Patients who have shown little or no improvement after three doses and who are not experiencing significant adverse effects may be treated every 30 to 45 minutes or switched to continuous therapy.

Drug delivery is maximized by having a total solution volume of 3 to 4 mL and an oxygen flow rate of 6 to 8 L/min [32-35], tapping the sides of the reservoir to renebulize droplets, and having older children use a mouthpiece to avoid nasal deposition of drug (picture 1).

Continuous albuterol nebulization — The optimal dose for continuous albuterol nebulization therapy has not been determined. One dosing schedule, stratified by weight, is as follows:

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For children who weigh 5 to 10 kg, the dose is 7.5 mg/hour

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For children who weigh 10 to 20 kg, the dose is 11.25 mg/hour

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For children who weigh >20 kg, the dose is 15 mg/hour

Glucocorticoids — The anti-inflammatory action of glucocorticoids effectively reduces the airway edema and secretions associated with acute asthma exacerbations.

Systemic glucocorticoids — Systemic glucocorticoids are indicated for most children who present to the ED with an acute asthma exacerbation, and their effects may be noted within two to four hours of administration [2,36]. Systemic glucocorticoids are not indicated in children with mild exacerbations who have not received beta-agonist therapy within a few hours of presenting for medical care and who respond promptly to a single albuterol treatment. When indicated, we recommend administering systemic glucocorticoids as soon as possible after arrival in the ED. Oral administration is suitable for most patients. The dosing of systemic glucocorticoids is reviewed in the table (table 2).

A study examined outcomes before and after initiation of a medical directive that allowed triage nurse-initiated glucocorticoids before clinician assessment in 644 consecutive children presenting with a moderate to severe asthma exacerbation [37]. Nursing initiation of glucocorticoids was associated with a reduced likelihood of admission (odds ratio [OR] 0.56, 95% CI 0.36-0.87), as well as significantly decreased times to clinical improvement and discharge.

The NAEPP guidelines suggest that oral administration of glucocorticoids is preferred to intravenous administration because oral administration is less invasive and the effects are equivalent [1]. Intramuscular administration of glucocorticoids (eg, dexamethasone) may be warranted in patients who vomit orally administered glucocorticoids, yet do not require an intravenous line for other purposes [38-40].

Orally administered prednisone/prednisolone or dexamethasone are each a reasonable choice for ED therapy [41]. A meta-analysis comparing a three- to five-day course of oral prednisolone or prednisone (2 mg/kg/day for the first day and then 1 to 2 mg/kg/day for the subsequent two to four days) with dexamethasone given as a single intramuscular dose (0.3 to 1.7 mg/kg) or one to two daily oral doses (0.6 mg/kg) for asthma exacerbations managed in the ED found that the treatments were equivalent with regard to rate of relapse, defined as an unplanned clinic visit, return ED visit, or unplanned hospitalization related to the initial asthma exacerbation [42]. Similar results were seen in a subsequent randomized, open-label trial comparing a single oral dose of dexamethasone (0.3 mg/kg) to a three-day course of prednisolone (1 mg/kg/day), with equivalent Pediatric Respiratory Assessment Measure (PRAM) scores at day 4 after the ED visit [43]. In this study and in the meta-analysis, lower rates of vomiting, both in the ED and at home, were seen in the groups treated with dexamethasone via either route of administration compared with prednisone/prednisolone [42,43]. However, newer and more palatable prednisone/prednisolone liquid formulations and oral dissolving tablets are far better tolerated with less frequent episodes of emesis compared with older prednisone formulations.

It is not necessary to deliver glucocorticoids via the intravenous route, even among the subset of patients being hospitalized. However, for severely ill patients, intravenous access should be established and intravenous methylprednisolone may be administered (table 2).

The benefit of early administration (within one hour) of systemic glucocorticoids versus placebo in patients presenting to the ED with acute asthma exacerbation was evaluated in a meta-analysis of 12 trials involving 863 patients [44]. The following results were reported:

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Early administration of systemic glucocorticoids reduced admission rates (pooled OR 0.40, 95% CI 0.21-0.78); eight patients (95% CI 5-21) would need to be treated to prevent one admission.

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The benefit was more pronounced in those not receiving systemic glucocorticoids before ED presentation (OR 0.37, 95% CI 0.19-0.7) and in those with more severe asthma (OR 0.35, 95% CI 0.21-0.59).

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Oral glucocorticoids were effective in reducing hospital admission (OR 0.24, 95% CI 0.11-0.53) compared with placebo in the three trials included in the meta-analysis that evaluated oral glucocorticoids in children with an acute asthma exacerbation.

Inhaled glucocorticoids — The use of inhaled glucocorticoids to treat children with acute asthma is an area of ongoing clinical research. Studies comparing the use of oral with inhaled glucocorticoids in the ED management of children with acute asthma have thus far had mixed results. Until more conclusive data are available, we do not suggest the routine use of inhaled glucocorticoids in addition to, or instead of, systemic glucocorticoids in the management of acute asthma exacerbation in children.

The following studies are illustrative:

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Some studies have found benefits of inhaled glucocorticoids compared with oral glucocorticoids (eg, earlier discharge from the ED, less vomiting, decreased relapse rate, improved clinical parameters, improved pulmonary function) [45,46].

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Other studies have found oral glucocorticoids and inhaled glucocorticoids to have similar outcomes [47-49].

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One study found improved pulmonary function and a lower relapse rate with oral prednisone compared with inhaled fluticasone [50].

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Two randomized trials found no additional benefit to adding nebulized budesonide to standard therapy (systemic glucocorticoids, and inhaled albuterol and ipratropium) early in the course of treatment [51,52].

Ipratropium bromide — Ipratropium bromide is an anticholinergic agent that provides bronchodilation through smooth muscle relaxation [53]. It is inexpensive and safe.

We recommend that children with moderate to severe asthma exacerbations be treated with ipratropium bromide. We prefer the nebulized form (250 micrograms per dose for children who weigh <20 kg; 500 micrograms per dose for children who weigh >20 kg). We administer ipratropium bromide with each of the first three albuterol treatments [54]. Alternatively, ipratropium may be administered with the second and third treatments [55].

In randomized trials, systematic reviews, and meta-analyses [54-58], multiple doses of inhaled ipratropium combined with inhaled beta-agonists have been shown to reduce hospital admissions and improve lung function in children with severe asthma exacerbations. In contrast, ipratropium has not been shown to reduce the length of hospital stay or to prevent admission to the intensive care unit (ICU) [59,60].

A systematic review of 20 randomized trials comparing combined inhaled beta-2-agonists and anticholinergic agents (atropine sulfate and ipratropium bromide) with inhaled beta-agonists alone found the following results [58]:

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Combination therapy reduced the risk of hospitalization (relative risk [RR] 0.73, 95% CI 0.63-0.85, 15 studies, 2497 children); 16 children (95% CI 12-29) with an asthma exacerbation of any severity would need to be treated with combination therapy rather than inhaled beta-agonists alone to avoid one hospital admission.

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The incidence of nausea and tremor was lower in the combination therapy group, but there was no significant difference in the rate of vomiting.

Ipratropium can be administered via SVN or MDI-S. If administered by MDI-S, the NAEPP guidelines recommend a dose of four to eight puffs (each puff is 18 micrograms) [1]. The NAEPP guidelines also comment that the MDI dose is low and has not been studied in asthma exacerbations. The MDI formulation that contains both ipratropium and albuterol should not be administered to highly sensitive patients with allergy to peanut or soy, because it contains soy lecithin, which may precipitate an allergic reaction (the MDI that contains ipratropium alone no longer contains soy lecithin). (See "Management of food allergy: Avoidance", section on 'Soy lecithin'.)

Magnesium sulfate — There is accumulating evidence that intravenous magnesium sulfate benefits adults and children with severe asthma [61-66]. Magnesium is inexpensive, has minimal adverse effects at the doses indicated, and is widely available. The NAEPP guidelines suggest 25 to 75 mg/kg (maximum 2 grams) for severe exacerbations unresponsive to initial treatments after one hour and as add-on for life-threatening exacerbations [1]. We suggest using magnesium sulfate in children with severe asthma exacerbations and in children with moderate asthma exacerbations who have clinical deterioration despite treatment with beta-agonists, ipratropium bromide, and systemic glucocorticoids. Given its relative safety and the critical importance of early effective treatment, in our practice, we use a dose of 50 mg/kg (maximum 2 grams), given intravenously and administered over 20 minutes. A fluid bolus may be administered to prevent clinically significant hypotension, a rare side effect of magnesium infusion. Magnesium infusion is relatively contraindicated in renal failure.

The use of magnesium sulfate in the ED setting for treatment of children with asthma has been evaluated in several small studies. Four of the five prospective, randomized, controlled trials of intravenous magnesium sulfate (25 to 40 mg/kg) in children demonstrated benefit (improved pulmonary function or clinical asthma scores) in children who had failed to respond to conventional therapy with albuterol and glucocorticoids [64,65,67,68]. A fifth study found no significant effect of magnesium sulfate (75 mg/kg) on Pulmonary Index Score (PIS), admission rate, or time to discharge when administered as a component of initial therapy [69]. Serious adverse effects (eg, hypotension) were not noted in any of the studies.

A meta-analysis of these studies found that magnesium sulfate was effective in preventing hospitalization in children with moderate to severe acute asthma when added to bronchodilators and glucocorticoids (absolute risk reduction 0.26, 95% CI 0.12-0.39) [70]. Four children would need to be treated to avoid one hospitalization (95% CI 3-8). Two other systematic reviews and meta-analyses assessed the use of magnesium among 182 children unresponsive to beta-agonists in five separate studies [71,72]. The use of magnesium was associated with significant benefits in respiratory function tests and resulted in fewer hospitalizations.

Parenteral beta-agonists — Subcutaneous and intramuscular beta-agonists (eg, epinephrine, terbutaline) are reserved for children with a severe asthma exacerbation who have poor inspiratory flow or who cannot cooperate with nebulized therapy. Additionally, intravenous terbutaline can be used in children with a severe asthma exacerbation who have not responded to initial therapy.

Subcutaneous or intramuscular epinephrine or terbutaline — The rapid subcutaneous or intramuscular administration of beta-agonists may be superior to inhaled beta-agonists for children with severe exacerbations and poor inspiratory flow or anxious, young children who are uncooperative with or have suboptimal response to initial aerosolized therapy. The intramuscular route may provide for more rapid drug absorption, although direct comparisons are lacking. Typically, subcutaneous or intramuscular therapy is given within minutes of arrival to a severely ill patient who is aerating poorly, concurrent with starting albuterol therapy and obtaining intravenous access.

The dose of subcutaneous or intramuscular terbutaline for bronchodilation is 0.01 mg/kg/dose (0.01 mL/kg of a 1 mg/mL solution), with a maximum dose of 0.4 mg (0.4 mL). The dose of subcutaneous or intramuscular epinephrine for bronchodilation is 0.01 mg/kg (0.01 mL/kg of 1:1000 solution [1 mg/mL]), with a maximum dose of 0.4 mL (0.4 mg). The dose may be repeated every 20 minutes for three doses unless significant side effects (eg, extreme hypertension, persistent emesis) develop, although most patients are switched to an intravenous medication (eg, magnesium sulfate, terbutaline) if they do not respond after the second dose of subcutaneous or intramuscular terbutaline or epinephrine. The dosing interval may be decreased to 5 to 10 minutes for children who continue with severe respiratory distress; autoinjectable epinephrine may be used for this purpose to avoid a delay in drawing up the medication. (See 'Magnesium sulfate' above and 'Intravenous terbutaline' below.)

Intravenous terbutaline — Severely ill patients who are poorly responsive to conventional therapy may be treated with a combination of intravenous beta-agonists and inhaled beta-agonists, although additional studies are needed to clarify the role of intravenous beta-agonists. The possible benefit needs to be weighed against increased side effects associated with this therapy, including dysrhythmias, hypertension, and myocardial ischemia. There is no role for using intravenous beta-agonists as initial therapy, even for severely ill children.

A systematic review of studies published through September 2012 found only two randomized trials that met inclusion criteria [73-75]. Limited evidence from these two trials suggests that there is shorter recovery time and improved PISs with the addition of intravenous beta-agonists in children poorly responsive to conventional interventions (including inhaled beta-agonists and ipratropium, systemic glucocorticoids, and magnesium sulfate).

Dosing for intravenous terbutaline in the ED setting is as follows: 10 microgram/kg bolus over 10 minutes, followed by 0.3 to 0.5 microgram/kg/minute; every 30 minutes the infusion may be increased by 0.5 microgram/kg/minute to a maximum of 3 microgram/kg/minute (higher doses are sometimes used in the ICU setting). (See "Acute severe asthma exacerbations in children: Intensive care unit management", section on 'Pharmacotherapy'.)

Nonstandard therapies — There are insufficient data to support the routine administration of heliox, ketamine, or leukotriene receptor antagonists (LTRAs) in the treatment of children with acute asthma.

Heliox — In theory, a mixture of helium and oxygen may enhance beta-agonist delivery because the lower gas density should result in decreased flow resistance. The 2007 NAEPP guidelines suggest administration of beta-agonists with heliox in patients with life-threatening exacerbations or who are not responding to conventional therapy [1]. However, the use of heliox should not delay intubation once it is considered necessary. (See "Physiology and clinical use of heliox", section on 'Use in children' and 'Endotracheal intubation' above.)

The benefits of continuous beta-agonist administration delivery by heliox compared with oxygen were evaluated in a controlled trial in 30 children (2 to 18 years) with moderate to severe asthma (PIS ≥8) (table 1) [76]. After initial treatment with albuterol inhalation and prednisone or prednisolone, the patients were randomly assigned to receive continuous albuterol nebulization delivered by heliox or oxygen. At 240 minutes, patients in the heliox group had greater decrease in PIS score from baseline (decrease of 7 versus 3 points). In addition, more patients in the heliox group were discharged from the hospital in less than 12 hours (73 versus 33 percent).

Ketamine — Due to its bronchodilating properties, the dissociative agent ketamine is the drug of choice to provide sedation and analgesia before intubating a child with asthma. Although several small case series of nonintubated children treated with ketamine suggest that ketamine improves acute asthma [77,78], the one randomized trial found that ketamine was no better than standard therapy in nonintubated children with severe acute asthma [79,80]. (See "Acute severe asthma exacerbations in children: Endotracheal intubation and mechanical ventilation", section on 'Sedation and paralysis'.)

Leukotriene-receptor antagonists — The data do not support the routine use of LTRA therapy to treat children with acute asthma exacerbations requiring urgent or emergent care [81]. LTRA add-on therapy in acute asthma has shown promise in adults [82,83]. However, it does not appear to provide additional benefit in children when added to standard therapy for acute asthma [84]. (See "Treatment of acute exacerbations of asthma in adults", section on 'Leukotriene receptor antagonists'.)

A randomized trial of 117 children aged 5 to 15 years treated in the ED found no difference in the Modified Pulmonary Index Score (MPIS) between those treated with a single age-appropriate dose of montelukast versus placebo [84]. Intravenous montelukast was not effective in improving FEV1 in a randomized trial of children with acute asthma [85].

DISPOSITION — The decision regarding disposition (eg, discharge to home, continued observation, or hospitalization) is based upon both clinical and social factors.

Discharge to home — Children who have marked improvement in clinical parameters within the first one to two hours of therapy may be discharged home [1]. Marked improvement is manifested by diminished or absent wheezing and retracting and increased aeration that is sustained at least 60 minutes after the most recent albuterol dose.

Discharge medications — All patients seen for an acute asthma exacerbation should have an inhaled short-acting beta-agonist (SABA) available for treatment of symptoms [1]. We suggest treatment with a SABA every four hours during waking hours and up to every four hours as needed during sleep for the first three days after an emergency department (ED) visit for an asthma exacerbation. After that, albuterol dosing should be weaned as tolerated, with the goal of discontinuing by day 5 to 7. (See "Asthma in children younger than 12 years: Rescue treatment for acute symptoms", section on 'Short-acting beta agonists'.)

We treat children with a short course of oral glucocorticoids if they received a dose of systemic glucocorticoids in the ED. A three- to five-day course of prednisone or prednisolone (or a two day course of dexamethasone) is sufficient for most children, although a course up to 10 days may be indicated in some children (eg, those who have had more than one exacerbation requiring oral glucocorticoids in the previous two months or those who are still symptomatic after a five-day course). Greater than 10 days may be necessary for patients whose control regimen includes oral glucocorticoids. Glucocorticoids that are administered for less than 10 days do not require a taper at discontinuation [86].

Whether inhaled glucocorticoids offer any short-term benefits in addition to inhaled albuterol and oral glucocorticoids when started in the ED or at the time of discharge from the ED in patients who were not already receiving inhaled glucocorticoids as controller therapy is a question that remains unanswered [87,88]. However, patients may be started on an inhaled glucocorticoid in the ED, if controller therapy is indicated, to ensure that institution of this therapy is not delayed or forgotten [89]. Alternatively, the treating clinician in the ED can advise the family to address this issue during the follow-up visit with the child's primary care provider. (See "Asthma in children younger than 12 years: Treatment of persistent asthma with controller medications".)

Benefits were not seen with leukotriene receptor antagonists (LTRAs) as monotherapy in children discharged from the ED after treatment for acute asthma was successful. A five-day course of montelukast was not as effective as a similar course of prednisolone in a randomized trial of 130 children with mild to moderate acute asthma exacerbations who were stabilized with prednisolone in the ED [90]. Treatment failure occurred in 8 percent of children treated with prednisolone compared with 22 percent treated with montelukast.

Discharge education — Prior to discharge from the ED, it is recommended that the following are reviewed with patients and their parents/caregivers [1]:

●

Signs and symptoms necessitating a return visit to the ED including worsening shortness of breath, difficulty speaking a complete sentence, or increased work of breathing.

●

The need to follow-up with their primary care provider or asthma specialist within one week of the ED visit.

●

Discharge medications, with respect to purpose, side effects, and proper technique for administration. (See "Asthma in children younger than 12 years: Treatment of persistent asthma with controller medications" and "Asthma in children younger than 12 years: Rescue treatment for acute symptoms" and "The use of inhaler devices in children", section on 'Spacer devices' and "The use of inhaler devices in children", section on 'Valved-holding chambers'.)

●

A written asthma action plan (form 1A-B). (See "What do patients need to know about their asthma?".)

●

Risk factors for asthma. (See "Risk factors for asthma".)

●

Prevention of acute exacerbations. (See "Trigger control to enhance asthma management" and "Allergen avoidance in the treatment of asthma and allergic rhinitis".)

Continued treatment and observation — Children with some, but incomplete, improvement within the first two hours of therapy require continued observation. Incomplete response is manifest by modest, but insufficient, benefits in degree of wheezing, retracting, and aeration.

During continued observation, patients with partial improvement should continue to receive albuterol nebulizations every 30 to 45 minutes (or continuously) for another one to two hours, after which a decision regarding hospitalization or discharge home is made.

Hospitalization — Patients who were moderately to severely ill on arrival and who have little improvement after initial therapy with beta-agonists and systemic glucocorticoids require hospitalization. This includes patients who continue to have significant wheezing and retracting, poor aeration, or altered mental status, such as drowsiness or agitation.

Additional factors that suggest a need for hospitalization include [1]:

●

Beta-agonist therapy more often than four hours; patients who require treatment more often than every two hours may need to be admitted to an intensive care unit (ICU)

●

Requirement for supplemental oxygen/low oxygen saturation on pulse oximetry an hour or more after commencement of initial therapy

●

A history of rapid progression of severity in past exacerbations

●

Poor adherence with outpatient medication regimen

●

Recent treatment with systemic glucocorticoids (includes current treatment with oral glucocorticoids at the time of presentation) or beta-agonist overuse

●

Inadequate access to medical care, including lack of transportation back to the hospital if deterioration occurs

●

Poor social support system at home, with inability of the caregiver(s) to provide medical care and supervision at home

A history of severe exacerbations, including a prior need for ICU management with or without invasive or noninvasive ventilation, even in the setting of mild baseline asthma, suggests the patient may require a greater level of care in the hospital (ie, admission to the ICU) [91]. (See "Acute severe asthma exacerbations in children: Intensive care unit management", section on 'Risk factors'.)

Inpatient therapy for acute asthma exacerbations is discussed separately. (See "Acute asthma exacerbations in children: Inpatient management" and "Acute severe asthma exacerbations in children: Intensive care unit management".)

Follow-up — Patients discharged from the ED should follow-up with their primary care provider or asthma specialist within one week of the ED visit [1]. At the follow-up visit, the primary care provider can review the child's asthma control, asthma care plan, and initiate or alter controller therapy as indicated. (See "Asthma in children younger than 12 years: Treatment of persistent asthma with controller medications".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●

Basics topics (see "Patient education: How to use your child’s dry powder inhaler (The Basics)" and "Patient education: Asthma in children (The Basics)" and "Patient education: How to use your child’s metered dose inhaler (The Basics)")

●

Beyond the Basics topics (see "Patient education: Asthma inhaler techniques in children (Beyond the Basics)" and "Patient education: Asthma treatment in children (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

●

The initial severity of the exacerbation and level of treatment needed (ie, mild, moderate, or severe) can be determined using an asthma exacerbation severity score such as the Pulmonary Index Score (PIS) (table 1). (See 'Initial assessment of severity' above and "Acute asthma exacerbations in children: Home/office management and severity assessment", section on 'Assessment of exacerbation severity'.)

●

The immediate goals of treatment of an acute asthma exacerbation include rapid reversal of airflow obstruction and correction of severe hypercapnia or hypoxemia, if present. (See 'Goals' above.)

●

Inhaled, short-acting, selective beta-2-adrenergic agonists (beta-agonists or SABAs) are the mainstay of management of acute asthma exacerbations (table 2). Systemic glucocorticoids are added if the signs and symptoms of airway obstruction are moderate to severe or fail to improve after the first treatment with inhaled beta-agonists. (See 'General approach' above and "Asthma in children younger than 12 years: Rescue treatment for acute symptoms", section on 'Short-acting beta agonists'.)

●

The approach to the child with a mild asthma exacerbation (Pulmonary Index Score [PIS] <7 (table 1)) is as follows (see 'Mild exacerbation' above):

•

We recommend administration of a SABA (Grade 1A). Beta-agonists may be administered by nebulizer (0.15 mg/kg; minimum 2.5 mg and maximum 5 mg per dose) or metered-dose inhaler with spacer (MDI-S; one-quarter to one-third puff/kg; minimum two puffs and maximum eight puffs per dose). SABAs are administered every 20 to 30 minutes for one to three doses. (See 'Inhaled short-acting beta-agonists' above.)

•

For patients who do not improve after one inhalation therapy, we recommend the administration of systemic glucocorticoids (Grade 1A). Oral agents (eg, dexamethasone, prednisolone, or prednisone) are preferred. (See 'Systemic glucocorticoids' above.)

●

The approach to management of a moderate asthma exacerbation (PIS 7 to 11 (table 1)) is summarized in the algorithm (algorithm 1) and below (see 'Moderate exacerbation' above):

•

Administration of supplemental oxygen is indicated if oxygen saturation is ≤92 percent in room air. (See 'Oxygen therapy' above.)

•

We recommend inhalation therapy with a SABA (Grade 1A). (See 'Inhaled short-acting beta-agonists' above.)

•

We recommend that children with asthma exacerbations of moderate severity also receive ipratropium bromide (Grade 1A). We administer ipratropium bromide with each of the first three beta-agonist nebulizer treatments or continuously; alternatively it may be administered with the second and third treatments. (See 'Ipratropium bromide' above.)

•

We recommend administration of systemic glucocorticoids soon after arrival in the emergency department (ED) or after the first inhalation therapy is initiated (Grade 1A). Oral agents (eg, dexamethasone, prednisolone, or prednisone) are preferred. (See 'Systemic glucocorticoids' above.)

•

We suggest the administration of intravenous magnesium sulfate for patients with moderate asthma exacerbations who have clinical deterioration despite treatment with beta-agonist, ipratropium, and systemic glucocorticoids (Grade 2A). (See 'Magnesium sulfate' above.)

●

The approach to management of a severe asthma exacerbation (PIS ≥12 (table 1)) is summarized in the algorithm (algorithm 2) and below (see 'Severe exacerbation' above):

•

Administration of supplemental oxygen is indicated if oxygen saturation is ≤92 percent in room air. (See 'Oxygen therapy' above.)

•

We recommend nebulized therapy with a SABA for children with a severe asthma exacerbation (Grade 1A). Subcutaneous or intramuscular administration of a beta-agonist (eg, terbutaline, epinephrine) is an alternative for children with poor inspiratory flow, those who are uncooperative with inhalation therapy, and/or those who have suboptimal response to initial inhalation therapy. (See 'Inhaled short-acting beta-agonists' above and 'Parenteral beta-agonists' above.)

•

We recommend that children with severe asthma exacerbations also receive ipratropium bromide (Grade 1A). We administer ipratropium bromide with each of the first three beta-agonist nebulizer treatments or continuously; alternatively it may be administered with the second and third treatments. (See 'Ipratropium bromide' above.)

•

We recommend administration of systemic glucocorticoids after the first inhalation therapy (Grade 1A). We administer systemic glucocorticoids intravenously in most patients since patients with severe exacerbations are likely to require additional intravenous medications. (See 'Systemic glucocorticoids' above.)

•

Management after the first dose of SABA depends upon the response to initial therapy. Patients who improve after the initial inhalation treatment proceed with treatment as for patients with moderate exacerbations (algorithm 1).

•

For patients who have a poor response to initial treatment:

-

We suggest administration of intravenous magnesium sulfate (Grade 2A). (See 'Magnesium sulfate' above.)

-

We suggest administration of intravenous terbutaline if there is no response to intravenous magnesium sulfate (Grade 2B). A bolus of 10 microgram/kg is administered over 10 minutes; this is followed by continuous infusion of 0.3 to 0.5 microgram/kg/minute; the infusion may be increased by 0.5 microgram/kg/minute every 30 minutes to a maximum of 5 microgram/kg/minute. (See 'Parenteral beta-agonists' above.)

●

The disposition of children with acute asthma exacerbation depends upon the response during the first one to two hours of therapy:

•

Children who have marked improvement in clinical parameters may be discharged home. All patients seen for an acute asthma exacerbation should have an inhaled SABA available for treatment of symptoms. We typically advise treating with a SABA every four hours during waking hours and up to every four hours during sleep for the first three days after discharge from the ED. We treat children with a short course of oral glucocorticoids if they received a dose of systemic glucocorticoids in the ED. (See 'Discharge to home' above.)

•

Children with some, but incomplete, improvement within the first two hours of therapy require continued observation and treatment. (See 'Continued treatment and observation' above.)

•

Patients who have little improvement and/or continued need for supplemental oxygen after initial therapy with beta-agonists and systemic glucocorticoids require hospitalization. (See 'Hospitalization' above and "Acute asthma exacerbations in children: Inpatient management".)

●

Patients discharged from the ED should follow-up with their primary care provider or asthma specialist within one week after the ED visit. (See 'Follow-up' above.)

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