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VarpuElenius
TuomasJartti
MikaMäkelä

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.

Assessment of asthma exacerbation severity in children

Symptom or findingMildModerateSevere
General conditionNormalNormalImpaired
Skin colourNormalPalePale / cyanotic
Ability to speakNo problemsPartial sentences1-2 words
Respiratory rateNormal>50/min, under 1 year
>40/min, 1-5 years
>30/min, over 5 years
Respiratory distressNone/mildModerateSevere
Intercostal/suprasternal retractionUsually notModerateSevere
Sternocleidomastoid muscle retractionsUsually notModerateSevere
Auscultation findingEnd-expiratory wheezeClear expiratory wheeze, possibly also inspiratoryStrong wheezing, crackles/rales or decreased breath sounds
Inspiratory:expiratory ratio2:1 (normal) or 1:11:21:3
Use of accessory muscles of respirationNone/mildObviousSevere, flaring of the nostrils
Oxygen saturation>95%90-95%<90%
PEF (% of previous personal best)>7040-70Not able to blow

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, and place of further medical care.
      • 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 > 0.3 × 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).
    • 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.

Other treatments

  • In severe exacerbation, racemic adrenaline may also be tried, particularly in young children or if there is also inspiratory difficulty.
  • Antimicrobial drugs as indicated to treat otitis, maxillary sinusitis or pneumonia
  • Intravenous fluids as necessary using reduced dosage; avoid overloading.
  • Theophylline is no longer used in the acute exacerbation of asthma as it offers only minimal additional benefit but has a variety of adverse effects.
  • Adrenaline administered by intramuscular injection is beneficial only in anaphylaxis and laryngeal oedema. It should not be used routinely in the treatment of asthma exacerbation.
  • Mild cases of acute expiratory airflow obstruction or asthma exacerbation should usually be treated within primary health care, and severe cases within specialized health care. Find out about local policies and practices.

Indications for referral to hospital and specialist consultation

Emergency referral

  • Severe attack/exacerbation
  • No improvement in airflow obstruction with bronchodilators, even after repetead administration
  • Airflow obstruction recurs frequently or lasts long and the child starts to become exhausted.
  • Saturation below 94%
  • The younger the child, the lower the threshold for hospital admission.

Routine referral

  • For children under school-age when asthma is suspected
    • Regular maintenance drug therapy for asthma may be started for a child under school-age as a 3-month therapeutic trial and the child can be referred for non-urgent further care provided thatthe child has had 3 episodes of expiratory airflow obstruction during the preceding year and the child has:
      • a significant risk factor of asthma
        • one of the parents has asthma
        • the child has physician-diagnosed atopic eczema
        • the child has become sensitised to an aeroallergen
      • or 2 less significant risk factors:
        • the child has become sensitised to a food allergen
        • expiratory airflow obstruction has occurred at the absence of a respiratory infection
        • blood eosinophils >0.3 × 109 /l.
    • A referreal should be made irrespective of risk factors when
      • symptoms are persistent, i.e. the child benefits from bronchodilating medication and has required it more than twice per week for more than 4 weeks.
      • the child has received 2 oral courses of glucocorticoids at an interval of less than 6 months.
      • severe exacerbations (bronchodilating medication needed 4 or more times daily) have occurred at intervals of less than 6 weeks.
  • Children of school-age with suspected asthma
    • After an evident episode of expiratory airflow obstruction
    • In the case of prolonged sputum production or cough for over 6 weeks, respiratory wheezing, respiratory symptoms provoked by physical exertion or cold weather) or if significantrisk factors of asthma are present.
  • The diagnosis is unclear.

    References

    • [Asthma]. A Current Care Guideline. Working group appointed by the Finnish Medical Society Duodecim, Finnish Respiratory Society, Finnish Paediatric Society and Finnish Society of Clinical Physiology. Helsinki: Finnish Medical Society Duodecim, 2022 (accessed on 4.5.2022). Availabe in Finnish at .
    • Global Initiative for Asthma (GINA). Global Strategy for Asthma Management and Prevention. Updated 2021. http://ginasthma.org/wp-content/uploads/2021/05/GINA-Main-Report-2021-V2-WMS.pdf
    • Gaillard EA, Kuehni CE, Turner S, et al. European Respiratory Society clinical practice guidelines for the diagnosis of asthma in children aged 5-16 years. Eur Respir J 2021;58(5):. [PubMed]
    • Expert Panel Working Group of the National Heart, Lung, and Blood Institute (NHLBI) administered and coordinated National Asthma Education and Prevention Program Coordinating Committee (NAEPPCC)., Cloutier MM, Baptist AP ym. 2020 Focused Updates to the Asthma Management Guidelines: A Report from the National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group. J Allergy Clin Immunol 2020;146(6):1217-1270. [PubMed]
    • Scottish Intercollegiate Guidelines Network (SIGN), British Thoracic Society (BTS). SIGN158: British guideline on the management of asthma, 2019.http://www.sign.ac.uk/media/1773/sign158-updated.pdfhttp://www.sign.ac.uk/our-guidelines/british-guideline-on-the-management-of-asthma/
    • National Heart Lung and Blood Institute. Expert Panel Report 3 (EPR3): Guidelines for the Diagnosis and Management of Asthma. http://www.nhlbi.nih.gov/health-pro/guidelines/current/asthma-guidelines