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 , Ipratropium Bromide Added to Beta2-Agonists in Acute Childhood Asthma, 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 consultation