Status Asthmaticus Management in Children

Immediate Recognition and Assessment

The British Thoracic Society recommends immediate administration of intravenous hydrocortisone, high-flow oxygen via face mask to maintain oxygen saturation >92%, nebulized salbutamol 5 mg via oxygen-driven nebulizer, and add ipratropium 100 mcg nebulized every 6 hours in children with status asthmaticus 1, 2, 3
Life-threatening features include PEF <33% predicted, poor respiratory effort, cyanosis, silent chest, fatigue/exhaustion, agitation, or reduced level of consciousness in children with acute asthma 1, 2
Acute severe asthma features in children include being too breathless to talk or feed, respirations >50 breaths/min, pulse >140 beats/min, or PEF <50% predicted 1, 2, 3

The American Academy of Pediatrics recommends intravenous hydrocortisone immediately without delay in children with status asthmaticus 1, 2, 3
High-flow oxygen via face mask should be used to maintain SaO₂ >92% in children with acute asthma 1, 2, 4, 3
Nebulized salbutamol 5 mg (or terbutaline 10 mg) via oxygen-driven nebulizer should be administered in children with status asthmaticus 1, 2, 3
Ipratropium 100 mcg nebulized should be repeated every 6 hours in children with acute asthma 1, 2, 3

Repeat PEF measurement should be done 15-30 minutes after starting treatment in children with acute asthma 1, 2, 3
Continuous pulse oximetry with target SaO₂ >92% should be maintained in children with status asthmaticus 1, 2, 4, 3
PEF should be charted before and after β-agonist administration at least 4 times daily in children with acute asthma 1, 2, 3

Intravenous aminophylline 5 mg/kg over 20 minutes, followed by maintenance infusion of 1 mg/kg/hour should be administered in children with life-threatening features of asthma 1, 2
The loading dose of aminophylline should be omitted if the child is already receiving oral theophyllines 1, 2

If the patient is improving, high-flow oxygen should be continued, and prednisolone 1-2 mg/kg body weight daily (maximum 40 mg) should be administered in children with acute asthma 1, 2, 3
If the patient is not improving, oxygen and steroids should be continued, and nebulized β-agonist frequency should be increased to every 30 minutes in children with status asthmaticus 1, 2

Preparation for ICU transfer with a physician ready to intubate should be done if the patient has deteriorating PEF or worsening exhaustion, feeble respirations, persistent hypoxia, or hypercapnia, coma, respiratory arrest, confusion, or drowsiness 1, 2, 3

The child should meet all of the following criteria before discharge: been on discharge medication for 24 hours with inhaler technique checked and recorded, PEF >75% of predicted or best with diurnal variability <25%, treatment includes soluble steroid tablets and inhaled steroids in addition to bronchodilators, own PEF meter with self-management plan or written instructions for parents, and GP follow-up arranged within 1 week 1, 2, 3

Underuse of corticosteroids is a major factor in preventable asthma deaths—give steroids early in children with acute asthma 1, 2
Doctors and families failing to appreciate severity—regard each emergency consultation as potentially severe until proven otherwise in children with asthma 1, 2
Delaying treatment for investigations—no other investigations are needed for immediate management of acute asthma 1, 2
Using inadequate oxygen—high-flow oxygen is essential, not just nasal cannula in children with status asthmaticus 1, 2, 4, 3