Peds Pulm

Pediatric Asthma: Acute Treatment

Acute Evaluation
Chronic Management
Disposition

Treatment

1. ABCs, immediate critical care if resp failure
2. Supplemental O2: keep pulse ox > 92%
   • Mask for infants
   • Nasal cannula for older children
3. Continuous pulse oximeter and cardiac monitor
4. Obtain peak flow before and 10 min post nebulizer treatments
5. Power nebulizers with 6-8 L/min of O₂
6. Intital treatments is based on asthma severity scores
   • Pediatric Respiratory Assessment Measure
   • Pulmonary Index Score
   • Pediatric Asthma Severity Score
   • Respiratory rate, Accessory muscle use, and Decreased breath sound score (RAD score)

Medications

1. Inhaled (short-acting beta 2-agonists)
   • Albuterol
     • MDI can be used
       • 6 puffs 1 min apart q 20 min
     • Intermittent nebulizer (q 20 min. up to 3 doses)
       • (< 50 kg) 2.5 mg (3 mL)/dose (1 plastic bullet)
       • (> 50 kg); 5 mg (6 mL)/dose (2 plastic bullets)
     • Continuous nebulizer (moderate/severe exacerbations)
       • (< 50 kg) 7.5 mg (9 mL)/dose (3 plastic bullets)
       • (> 50 kg); 15 mg (18 mL)/dose (6 plastic bullets)
   • Levalbuterol (R isomer of albuterol)
     • No clear advantage over racemic albuterol
     • May be better for first nebulizer treatment
       • More expensive
     • Nebulized dose
       • 6-11 yo: 0.31 mg x 1
       • > 12 yo: 0.63 mg x 1
2. Inhaled anticholinergics
   • Ipratropium bromide
     • Use with albuterol for moderate/severe exacerbations
     • Intermittent nebulizer (add to 2nd/3rd treatments)
       • 0.25 mg (1.251 mL)/dose (1/2 plastic bullet)
     • Continuous nebulizer
       • 1 mg (5 mL) / dose (2 plastic bullets)
3. Steroids
   • For moderate/severe exacerbations
   • Prednisone: 2 mg/kg (max: 60 mg) PO
     • If emesis within 30 min, repeat
     • If unable to take PO, IV/IM equivalent dose of methylprednisolone
   • Low -dose inhaled corticosteroids are the preferred treatment for children with mild persistent asthma
   • Contraindications for steroid administration
     • Active varicella or herpes infection, or
     • History of exposure to varicella in past 3 wk
     • Appropriate dose of oral steroids already given in last 6 hr
     • Parents decline steroids (document)
4. Magnesium
   • Generally reserved for severe exacerbations
   • 25-40 mg/kg (2G max.) over 10-20 min
   • Still controversial
   • * In this authors experience, rapid administration has prevented intubation on numerous occasions
   • Side effect (rapid administration): flushing, vomiting
5. Systemic beta-agonists
   • Should be reserved for severe/impending intubation cases
   • Terbutaline
     • IV: 2-10 mcg/kg bolus, then 0.4 mcg/kg/min infusion (max 6 mcg/kg/min)
     • SC (? effectiveness): 0.01 mg/kg, max 0.3 mg
   • Epinephrine
     • SC (1:1,000): 0.01 mL/kg max 0.5 mg
     • IV (1:10,000): 50-1,000 mcg load, then 3-20 mcg/kg/min drip
       • IV use controversial, still being explored
   • Theophylline: minimal or no value in acute ED Rx
6. Heliox
   • No real current role in treatment of lower airway disease
   • Not well studied in pediatric asthma
   • Use very limited by needing 70-80% helium to be effective
     • Inadequate O2 for severely hypoxic patients
   • May be more useful in intubated patients
7. Inhaled nitric oxide
   • Potent selective pulmonary vasodilator/bronchodilator
   • Very limited experience in non-neonates
   • Used with ventilator at 20-40 ppm
   • Further studies pending

Follow-Up

1. Management plan: stepwise treatment
2. Exercise-induced bronchoconstriction best prevented by
   • Baseline asthma control
   • Avoidance of allergens
   • Choosing appropriate sports with short bursts of activity
   • Warm, humid environment

Acute Evaluation
Chronic Management
Disposition

Clinical Inquiries

1. What is the preferred treatment for a child with mild persistent asthma?
2. What best prevents exercise-induced bronchoconstriction for a child with asthma?

Evidence-Based Inquiries

1. How effective are leukotriene inhibitors in children with asthma?
2. Is levalbuterol superior to racemic albuterol for treating acute childhood asthma?
3. What is the best treatment for exercise-induced asthma?

References

1. Arnold DH, Gebretsadik T, Abramo TJ, et al. The RAD score: a simple acute asthma severity score compares favorably to more complex scores [published correction appears in Ann Allergy Asthma Immunol. 2014 Mar;112(3):273]. Ann Allergy Asthma Immunol. 2011;107(1):22-28. doi:10.1016/j.anai.2011.03.011
2. Gorelick MH, Stevens MW, Schultz TR, Scribano PV. Performance of a novel clinical score, the Pediatric Asthma Severity Score (PASS), in the evaluation of acute asthma. Acad Emerg Med. 2004;11(1):10-18. doi:10.1197/j.aem.2003.07.015
3. Hsu P, Lam LT, Browne G. The pulmonary index score as a clinical assessment tool for acute childhood asthma. Ann Allergy Asthma Immunol. 2010;105(6):425-429. doi:10.1016/j.anai.2010.10.009
4. Chalut DS, Ducharme FM, Davis GM. The Preschool Respiratory Assessment Measure (PRAM): a responsive index of acute asthma severity. J Pediatr. 2000;137(6):762-768. doi:10.1067/mpd.2000.110121
5. Emergency Medicine Clinics of North America. 2002;20(1).
6. Clinical Pediatric Emergency Medicine. 2004;5(4).
7. Marx: Rosen's Emergency Medicine: Concepts and Clinical Practice, 5th ed., Mosby, Inc.: 2002.
8. Murray & Nadel: Textbook of Respiratory Medicine, 3rd ed., W. B. Saunders Company: 2000.
9. Behrman: Nelson Textbook of Pediatrics, 17th ed., Elsevier: 2004.

Contributor(s)

1. Ausi, Michael, MD, MPH

Updated/Reviewed: July 2023