Management of Severe Asthma in Children

Assessment and Initial Management

The British Thoracic Society recommends checking for life-threatening features such as poor respiratory effort, cyanosis, silent chest, fatigue/exhaustion, agitation, or reduced level of consciousness in children with severe asthma exacerbations 1
The British Thoracic Society suggests monitoring vital signs, including respiratory rate and pulse, to assess the severity of asthma exacerbations in children, with rates >50/min and >140/min indicating severe asthma 1
The American Academy of Allergy, Asthma, and Immunology recommends evaluating the ability to speak or feed, as inability indicates severe exacerbation 1
The British Thoracic Society recommends maintaining oxygen saturation (SaO2) >92% in children with severe asthma exacerbations 1

The British Thoracic Society recommends administering high-flow oxygen via face mask to maintain SaO2 >92% in children with severe asthma exacerbations 1, 2
The British Thoracic Society suggests giving oral prednisolone 1-2 mg/kg body weight (maximum 40 mg) to children with severe asthma exacerbations 1
The American Academy of Allergy, Asthma, and Immunology recommends that corticosteroids speed resolution of airflow obstruction and reduce relapse rates in children with severe asthma exacerbations 2
The British Thoracic Society recommends increasing the frequency of nebulized albuterol (salbutamol) up to every 15-30 minutes in children with severe asthma exacerbations who are not improving 1, 2

The British Thoracic Society recommends repeating peak flow measurement 15-30 minutes after each treatment to monitor response in children with severe asthma exacerbations 1
The American Academy of Allergy, Asthma, and Immunology suggests monitoring for clinical improvement, including decreased work of breathing, improved air entry, and decreased wheezing 2
The British Thoracic Society recommends transferring children with severe asthma exacerbations to the ICU if they have deteriorating PEF despite treatment, worsening exhaustion, feeble respirations, persistent hypoxia despite oxygen therapy, development of confusion or drowsiness, or respiratory arrest or coma 1

The British Thoracic Society recommends planning for at least 24 hours of observation before considering discharge for children with severe asthma exacerbations who have improved with treatment 1
The British Thoracic Society suggests ensuring that children with severe asthma exacerbations meet discharge criteria, including being on discharge medications for 24 hours with proper inhaler technique, having a PEF >75% of predicted with diurnal variability <25%, and having a treatment plan including oral steroids, inhaled steroids, and bronchodilators, before sending them home 1