Management of Acute Asthma Exacerbations in Children

Initial Assessment and Treatment

The British Thoracic Society recommends assessing severity by looking for moderate exacerbation signs, including respiratory rate >50/min, pulse >140/min, use of accessory muscles, and PEF 50-70% predicted, in children with acute asthma exacerbations 1, 4
For severe exacerbations, the British Thoracic Society suggests adding ipratropium bromide 250 mcg to the nebulizer, with a frequency of every 6 hours, as needed 1, 2, 6, 4

The British Thoracic Society recommends a standard dose of 5 mg nebulized salbutamol (or 0.15 mg/kg) via oxygen-driven nebulizer, repeated every 15-30 minutes as needed, for children with acute asthma exacerbations 1, 2, 6
For very young children, the American Academy of Pediatrics suggests using half doses of salbutamol 3
The British Thoracic Society recommends using oxygen at 6-8 L/min flow rate whenever possible, as children with acute severe asthma are hypoxic 7, 2, 5

The British Thoracic Society recommends always administering systemic corticosteroids early in moderate to severe exacerbations, with a dose of 2 mg/kg/day for 3 days (maximum 40 mg/day) of prednisolone 1, 2, 6, 3

The British Thoracic Society suggests that nebulizers are preferable when large doses are needed, coordinated breathing is difficult, or the child is acutely ill 7
The American Academy of Pediatrics recommends using a mouthpiece preferred over mask (except in babies/young children who won't tolerate) to maximize drug delivery 7, 8

The British Thoracic Society recommends considering aminophylline infusion for non-responders, with a loading dose of 5 mg/kg IV over 20 minutes (omit if already on theophylline) and maintenance of 1 mg/kg/hour 1, 2, 6, 4

The British Thoracic Society recommends maintaining oxygen saturation >92% in children and monitoring clinical response, including decrease in respiratory rate, accessory muscle use, and improved air entry 5, 1, 4