Management of Acute Expiratory Airflow Obstruction and Exacerbation of Asthma in Children

Essentials

• Management of an acute phase: good general treatment, rest, half-sitting position, antipyretics as needed, and optimal oxygenation (target saturation > 95%).
• The onset of asthma must be recognised promptly and children below school-age should be referred to specialized care for starting pharmacotherapy.
• The aim of clear, written instructions is to reduce the number of emergency visits and the need for hospitalization.
• In this article, school-age children denote children of about 7 years of age and older. Consult also local policies and practices concerning the age of children in different clinical situations.

Symptoms and examinations

• Expiratory difficulty and wheezing
• Symptoms develop rapidly, or slowly over days. The severity of symptoms is often underestimated.
• Visually observe the work of breathing, auscultate, check possible sites of infection and skin.
• In school-aged children the peak expiratory flow (PEF)
  • >80% of personal best → intensify home medication
  • <80% of personal best → physician's assessment of need for hospital care
  • >70% of personal best → discharge
• Evaluation of the severity of asthma exacerbation, see table T1.

Medication , Short Acting Beta Agonists for Recurrent Wheeze in Children Under 2 Years of Age, Ipratropium Bromide Added to Beta2-Agonists in Acute Childhood Asthma, Leukotriene Receptor Antagonists for Acute Asthma in Adults and Children, Anticholinergic Drugs for Wheeze in Children Under the Age of Two Years, Holding Chambers (Spacers) Versus Nebulisers for Beta-Agonist Treatment of Acute Asthma in Children, Inhaled Ipratropium Bromide Added to Beta2-Agonists for Hospitalized Children with Acute Asthma

• Treatment instructions for mild expiratory airflow obstruction
  • Salbutamol 0.1 mg/metered dose (puff) primarily via a spacer (holding chamber) Holding Chambers (Spacers) Versus Nebulisers for Beta-Agonist Treatment of Acute Asthma in Children: initially 0.2-0.4 mg repeated 3 times every 20 minutes, followed by 0.2-0.4 mg puffs every 1-4 hours as needed.
  • Asthma home management check
    • If the child has a history of more than one acute exacerbations, the following should be checked: correct inhalation technique, treatment compliance, whether known environmental allergens have been removed, and place of further medical care.
    • If the child is taking regular asthma medication, review the written asthma action plan and increase the regular medication for at least a fortnight. Check that a follow-up appointment is organized.
    • Provide written instructions (asthma action plan) for home management.
• Treatment of moderate/severe expiratory airflow obstruction
  • Salbutamol (0.1 mg/metered dose [puff]) primarily via a spacer (holding chamber):
    • Weight of child < 25 kg: 0.6-0.8 mg
    • Weight of child > 25 kg: 0.9-1.2 mg
    • Repeat, as necessary, every 20-30 minutes until symptoms alleviate.
  • Alternatively, salbutamol 0.15 mg/kg (at maximum 5 mg) by a nebulizer with supplemental O₂ if saturation is < 92%.
  • An oral glucocorticoid (prednisolone by mouth)
    • Started if symptoms persist despite repeated administration of salbutamol.
    • Glucocorticoids are usually not useful in the treatment of bronchiolitis in small infants.
    • Also in the treatment of obstructive bronchitis in children less than 5 years of age, the greatest benefit from glucocorticoids is achieved in children with a high risk of asthma (1 primary risk factor: parental history of asthma, the child has atopic eczema or is sensitised to an aeroallergen, or 2 secondary risk factors: child sensitised to a food allergen, symptoms of expiratory airflow obstruction have occurred earlier apart from colds, or increased blood eosinophils > 4% or > 0.4 × 10⁹ /l).
    • Glucocorticoids are usually administered to children admitted to hospital, to children suffering from prolonged or severe dyspnoea, to children with known asthma and to children with at least a moderate exacerbation and a significant asthma risk.
    • Dosage: prednisolone 1-2 mg/kg/day (maximum 40 mg/day) orally divided into 2 doses; treatment duration is 3 days in children under 3 years of age, 3-5 days in children over 3 years of age.
    • If oral administration is not successful, the same dose of methylprednisolone can be given intramuscularly or intravenously.
  • If salbutamol and glucocorticoid do not provide sufficient therapeutic response, ipratropium bromide can be added to the treatment Ipratropium Bromide Added to Beta2-Agonists in Acute Childhood Asthma by a nebulizer (nebulizer solution 0.25 mg/ml).
    • Age < 2 years: 0.25 mg 4 times/day
    • Age > 2 years: 0.5 mg 4 times/day
    • Since there is no evidence on the additional benefit of this medication after the acute phase Inhaled Ipratropium Bromide Added to Beta2-Agonists for Hospitalized Children with Acute Asthma, its administration may be discontinued once the symptoms alleviate.
  • Asthma home management check, as above.
  • If the child has taken 2 courses of oral glucocorticoids at an interval less than 6 months, refer the child for a thorough assessment by a physician with expertise in children's asthma.

Indications for referral to hospital and specialist consultationInterventions for Educating Children Who are at Risk of Asthma-Related Emergency Department Attendance