Acute Management of Asthma Exacerbation in Children

Initial Assessment and Severity Classification

The presence of wheeze with exertional dyspnoea indicates active bronchospasm that requires immediate treatment. 1
Acute severe asthma in children is defined by any of the following: inability to talk or feed due to breathlessness, respiratory rate > 50 breaths/min, heart rate > 140 beats/min, or peak expiratory flow < 50 % of predicted. [4][1]5
Normal respiratory rate and oxygen saturation around 98 % suggest a non‑life‑threatening presentation, but wheeze confirms reversible airway obstruction. 6

Administer nebulized salbutamol 5 mg (or a half‑dose of 2.5 mg for a stable presentation) via an oxygen‑driven nebuliser. [1][2]4
If a nebuliser is unavailable, give salbutamol via metered‑dose inhaler (MDI) with a large‑volume spacer: 100 µg per actuation, repeat up to 20 actuations. [1][4]
The British Thoracic Society (BTS) recommends that MDI + spacer can replace nebulisers for most acute episodes and is more convenient. [7][4]

Give oral prednisolone 1–2 mg/kg body weight once daily, not exceeding a maximum dose of 40 mg. [1][2]5
The maximum 40 mg dose applies to children at the upper end of typical weight ranges. 3

Re‑evaluate the child 15–30 minutes after the initial bronchodilator dose, checking respiratory rate, heart rate, work of breathing, and auscultating for wheeze. [1][8]2
Measure peak expiratory flow (PEF) if the child can perform the maneuver reliably (appropriate for children ≥ 10 years). [1][2]

Continue supplemental oxygen and systemic steroids. [1][2]
Increase nebulised β‑agonist frequency to every 30 minutes. [1][2]
Add ipratropium bromide 250 µg to the nebuliser, repeating every 6 hours. [1][2]4
Consider hospital admission for further observation and treatment. [8][5]

Do not rely solely on symptoms for an asthma diagnosis; objective assessment with PEF and bronchodilator response is required. 6
Recognise that viral upper‑respiratory infections are frequent triggers of paediatric asthma exacerbations. [7][9]
Avoid routine use of nebulisers for chronic maintenance; prefer MDI with spacer for long‑term therapy as advised by the BTS. [7][4]

Ensure the child has at least 24 hours of prescribed medication and demonstrate correct inhaler technique before discharge. 8
Provide a written personalised self‑management plan. [7][10]
Prescribe a short course of oral prednisolone (typically 3–5 days). [1][2]
Arrange follow‑up with the primary‑care physician within one week. [1][8]2
Consider stepping up maintenance therapy with inhaled corticosteroids if baseline control is inadequate. [7][10]
Supply a peak flow meter for home monitoring of lung function. [1][8]

Children presenting with exertional dyspnoea during an exacerbation should receive both acute treatment and an evaluation of long‑term asthma control, as this symptom suggests sub‑optimal baseline management. [7][10]9