Assessment and Management of Pediatric Difficulty Breathing

Initial Assessment and Treatment

The British Thoracic Society recommends immediately assessing for life-threatening features and initiating high-flow oxygen (40-60% via face mask), nebulized salbutamol (5 mg for children, half dose for very young), and intravenous hydrocortisone without delay if severe or life-threatening asthma is suspected 1, 2
Identify acute severe asthma features immediately, including too breathless to talk or feed, respiratory rate >50 breaths/min, heart rate >140 beats/min, and peak expiratory flow (PEF) <50% predicted (if age-appropriate to measure) 1, 2, 3, 4

Recognize life-threatening features that mandate immediate aggressive intervention, including PEF <33% predicted or poor respiratory effort, silent chest, cyanosis, or fatigue/exhaustion, and agitation or reduced level of consciousness 1, 5, 2
The American Academy of Pediatrics recommends that children with severe attacks may not appear distressed, and assessment in very young children is difficult—the presence of ANY life-threatening feature should trigger maximum therapy 1, 5

The British Thoracic Society recommends high-flow oxygen via face mask targeting SpO₂ >92%, nebulized salbutamol 5 mg or terbutaline 10 mg via oxygen-driven nebulizer, and intravenous hydrocortisone immediately for all children with acute severe breathing difficulty (presumed asthma) 1, 2, 6
Add ipratropium 100 mcg nebulized every 6 hours, and consider intravenous aminophylline 5 mg/kg over 20 minutes, followed by 1 mg/kg/hour maintenance infusion if life-threatening features are present 1, 5, 6

Reassess patient at 15-30 minutes, and continue high-flow oxygen, prednisolone 1-2 mg/kg body weight daily, and nebulized β-agonist every 4 hours if patient is improving 1, 5, 6
If patient is NOT improving after 15-30 minutes, increase nebulized β-agonist frequency to every 30 minutes, and add ipratropium to nebulizer and repeat every 6 hours until improvement starts 1, 5

Monitor and document repeat PEF measurement 15-30 minutes after starting treatment, oximetry continuously, maintaining SpO₂ >92%, and chart PEF before and after each β-agonist dose, minimum 4 times daily 1, 5, 2

Before discharge, ensure child has been on discharge medication for 24 hours, inhaler technique checked and documented, PEF >75% of predicted or best with diurnal variability <25% (if measured), and treatment includes oral steroids, inhaled steroids, and bronchodilators 1, 5
Provide written self-management plan or instructions for parents, and arrange GP follow-up within 1 week and respiratory clinic follow-up within 4 weeks 5, 6

Never administer sedatives in acute severe asthma, as they can precipitate respiratory arrest 1
Oxygen does not aggravate CO₂ retention in asthma, and high-flow oxygen should be given without hesitation 1, 2