Acute asthma exacerbations in children younger than 12 years: Emergency department management

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Acute asthma exacerbations in children younger than

12 years: Emergency department management
Author: Richard J Scarfone, MD, FAAP
Section Editors: Gregory Redding, MD, Stephen J Teach, MD, MPH
Deputy Editor: Elizabeth TePas, MD, MS

Contributor Disclosures

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Aug 2024. | This topic last updated: Sep 04, 2024.

INTRODUCTION

Initial treatment (beta-agonist therapy and oral glucocorticoids) of acute asthma

exacerbations is sometimes provided in the primary care setting or even at home [1].
However, children with moderate-to-severe exacerbations require close observation for
clinical deterioration, frequent bronchodilator treatments, and repeated evaluation. Thus,
most children with moderate or severe asthma exacerbations should be managed in an
emergency department (ED) setting. The general approach to treatment of an acute asthma
exacerbation includes administration of inhaled bronchodilators (eg, albuterol), as well as
systemic glucocorticoids for most patients.

The approach to ED management of the child with an acute asthma exacerbation is presented
here. Management of acute asthma exacerbations in the home, office/outpatient clinic, and
inpatient/intensive care unit (ICU) settings are discussed in detail separately:
● (See "Acute asthma exacerbations in children younger than 12 years: Overview of
home/office management and severity assessment".)
● (See "Acute asthma exacerbations in children younger than 12 years: Inpatient
management".)
● (See "Acute severe asthma exacerbations in children younger than 12 years: Intensive
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Acute asthma exacerbations in children younger than 12 years: Emergency department management

care unit management".)

Rescue medications for acute symptoms are also reviewed elsewhere. (See "Asthma in
children younger than 12 years: Quick-relief (rescue) treatment for acute symptoms".)

The management of acute asthma exacerbations in adolescents and adults is also discussed
separately. (See "Acute exacerbations of asthma in adults: Home and office management".)

TREATMENT GOALS

The goals of therapy for an acute asthma exacerbation include [1]:

● Rapid reversal of airflow obstruction (see 'Initial treatment' below and 'Management of
bronchospasm' below)
● Correction of hypoxemia and/or severe hypercapnia, if present (see 'Management of
hypoxemia and hypercapnia' below)
● Reduction of the likelihood of hospitalization and recurrence after discharge (see
'Management of inflammation' below and 'Discharge medications' below and 'Discharge
education' below)

ASSESSMENT OF SEVERITY

The severity of an asthma exacerbation is primarily determined by assessment of clinical

findings, occasionally supplemented by objective tests ( table 1):
● Mild – A mild exacerbation is characterized by normal alertness, slight tachypnea,
expiratory wheezing only, a mildly prolonged expiratory phase (inspiratory-to-expiratory
ratio of 1:1 rather than the normal 2:1), minimal accessory muscle use, and an oxygen
saturation of >95 percent.
● Moderate – A moderate exacerbation is characterized by normal alertness, tachypnea,
wheezing throughout expiration with or without inspiratory wheezing, an inspiratory-to-
expiratory ratio of approximately 1:2, significant use of accessory muscles, and an
oxygen saturation that is typically 92 to 95 percent.

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Acute asthma exacerbations in children younger than 12 years: Emergency department management
● Severe – A severe exacerbation is characterized by inability to repeat a short phrase,
extreme tachypnea, inspiratory and expiratory wheezing, an inspiratory-to-expiratory
ratio exceeding 1:2, very poor aeration, significant use of accessory muscles, and an
oxygen saturation that is typically <92 percent. Signs of impending respiratory failure
include cyanosis, inability to maintain respiratory effort (respiratory rate may be
inappropriately normal to low), depressed mental status (lethargy or agitation), pulse
oxygen saturation (SpO2) <90 percent, and respiratory acidosis (elevated partial pressure
of carbon dioxide [pCO2] noted on venous, arterial, or capillary blood gas sample).

There are also several ordinal scales available for the assessment of the initial severity of the
exacerbation and level of treatment needed. One such scale is the Pulmonary Index Score
(PIS) ( table 2), with a PIS 1 to 6 = mild, PIS 7 to 11 = moderate, or PIS ≥12 = severe [2]. An
alternative scale is the Pediatric Respiratory Assessment Measure (PRAM) ( table 3).
Assessment of the severity of an acute asthma exacerbation, including review of other
available scores, is discussed in detail separately. (See "Acute asthma exacerbations in
children younger than 12 years: Overview of home/office management and severity
assessment", section on 'Assessment of exacerbation severity'.)

ELEMENTS OF TREATMENT

The treatment of an acute asthma exacerbation in the ED includes both bronchodilators to

address acute bronchospasm ( table 4) and, in most patients, systemic glucocorticoids to
address underlying airway inflammation ( table 5). Supportive care for children with acute
asthma exacerbations may include administration of supplemental oxygen if needed and
fluids (oral preferred) to make up for evaporative losses.

Management of hypoxemia and hypercapnia — Many patients with moderate-to-severe

acute asthma exacerbations have hypoxemia as a result of ventilation-perfusion (V/Q)
mismatch, although, in most patients, the hypoxemia is mild and does not require treatment
with supplemental oxygen. Beta-agonists may worsen this mismatch by causing pulmonary
vasodilation in areas of the lung that are poorly ventilated, especially among this sickest
subset of children. Hypoxemia is alleviated by administration of supplemental humidified
oxygen as needed to maintain an oxygen saturation of ≥92 percent [3]. All nebulized

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medications should also be delivered with oxygen, generally at a flow rate of 6 to 8 L/min.
Hypercapnia usually improves with reversal of airflow obstruction. (See "Continuous oxygen
delivery systems for the acute care of infants, children, and adults".)

Management of bronchospasm — Additional bronchodilators used in children with

moderate or severe asthma may include intravenous magnesium sulfate and parenteral beta-
agonists such as terbutaline or epinephrine.

Inhaled short-acting beta-2 agonists — Inhaled short-acting beta-2 agonists (beta-

agonists or SABAs), particularly albuterol (salbutamol), are the standard emergent treatment
for acute asthma exacerbations in all patients based upon adult data, a few early trials in
children, and many ensuing years of clinical use [1,4-6]. Subsequent studies have focused on
the optimal dosing and route of administration for SABAs. Albuterol has never been
compared with placebo. (See "Acute exacerbations of asthma in adults: Emergency
department and inpatient management", section on 'Inhaled beta-agonists' and "Beta
agonists in asthma: Acute administration and prophylactic use", section on 'Use in acute
exacerbations of asthma'.)

SABAs are administered by intermittent nebulization, continuous nebulization, or metered-

dose inhaler with a valved holding chamber (MDI-VHC) or spacer (MDI-S) ( table 4).
Albuterol (salbutamol) is the SABA used for most patients. The choice of drug and delivery
systems are discussed in detail separately and are reviewed briefly here (see "Beta agonists in
asthma: Acute administration and prophylactic use" and "Delivery of inhaled medication in
children" and "Use of medication nebulizers in children" and "The use of inhaler devices in
children"):
● Racemic albuterol versus levalbuterol – Racemic albuterol is an equal mixture of two
mirror-imaged enantiomers: R-albuterol, the active bronchodilator, and S-albuterol, a
possible weak bronchoconstrictor. Levalbuterol is pure R-albuterol. In theory, pure active
R-albuterol would be more effective than racemic albuterol because there is no
bronchoconstricting effect from the S-isomer. However, studies of levalbuterol for acute
asthma in children have had conflicting results, and, overall, levalbuterol appears to
have no clinically significant advantage over racemic albuterol [7-10]. Thus, we
recommend racemic albuterol rather than the more costly levalbuterol for children with
acute asthma exacerbations, unless the patient has a known history of adverse effects
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from albuterol. Use of levalbuterol is discussed in greater detail separately. (See "Beta
agonists in asthma: Acute administration and prophylactic use", section on
'Levalbuterol'.)
● Nebulizer versus inhaler – Clinical trials and meta-analyses indicate that the
administration of SABAs via MDI-VHC/S (eg, 4 to 12 puffs of albuterol) is at least as
effective and possibly superior to delivery of medication by small-volume nebulizer
(SVN) in reversing bronchospasm in children of all ages and with a wide range of illness
severity [1,11-13]. Thus, the choice of one over the other for intermittent administration
of SABAs mainly depends upon the frequency of dosing required. Continuous delivery of
the first three doses of albuterol via SVN in the first hour after ED arrival helps to ensure
compliance with national treatment guidelines. Additional advantages of SVN delivery
compared with MDI-VHC/S include the ability to simultaneously deliver humidified
oxygen and ipratropium bromide and to passively administer drug therapy to a child in
respiratory distress. Thus, many ED clinicians choose to treat moderately to severely ill
patients with albuterol delivered via SVN. However, when using SVNs, up to 90 percent
of drug remains in the machine or is lost to the atmosphere [14]. (See "The use of
inhaler devices in children", section on 'pMDI or nebulizer?' and "The use of inhaler
devices in children", section on 'Spacers and holding chambers'.)
● Intermittent versus short-term continuous delivery – Studies comparing intermittent
versus continuously nebulized delivery of beta-agonists have found similar outcomes
and side effect profiles with both methods [15-20]. For short-term continuous therapy
within the first hour of ED care, we provide three doses of albuterol and one dose of
ipratropium for children with moderate-to-severe exacerbations. Continuous nebulizer
therapy is less labor intensive than intermittent nebulizer therapy, resulting in reduced
respiratory therapy time and costs. In addition, it helps to ensure that the goal of three
albuterol treatments within the first hour of care for moderately to severely ill children is
met. However, young children may not tolerate wearing a facemask for long periods of
time. (See "Use of medication nebulizers in children", section on 'Continuous
nebulization' and "Delivery of inhaled medication in children", section on 'Patient
technique, acceptance, and preference'.)

Dosing of albuterol depends upon route of administration and the severity of the asthma

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exacerbation ( table 4) (see 'Mild exacerbation' below and 'Moderate exacerbation' below
and 'Severe exacerbation' below):
● Albuterol via MDI-VHC/S – Albuterol delivery via MDI-VHC/S is typically the method of
choice for the treatment of mildly to moderately ill children. As described above, this is
not because nebulized delivery is superior to this delivery method. Rather, nebulized
therapy is chosen for the sicker subset of patients because it helps ensure that they
receive three albuterol treatments within one hour.

Optimal dosing for albuterol administered by MDI-VHC/S for acutely ill children is not
well established, and protocols used vary by institution. The 2007 National Asthma
Education and Prevention Program (NAEPP) guidelines state that "equivalent
bronchodilation can be achieved either by high doses (4 to 12 puffs) of a SABA by MDI
with a VHC or by nebulizer"; they suggest a dose of 4 to 8 puffs [1].

One strategy is to administer one-quarter to one-third puff/kg (22.5 to 30 microgram/kg)

with a minimum of 4 puffs (360 micrograms) and a maximum of 8 puffs (720
microgram). Thus, proportionately greater doses are provided for young children
weighing less than 20 to 30 kg (44 to 66 pounds), who are the least efficient users.

Another strategy is to use a dosing schedule, stratified by weight, as with continuous

albuterol nebulization:

• For children who weigh 5 to 10 kg, the dose is 4 puffs.

• For children who weigh 10 to 20 kg, the dose is 6 puffs.
• For children who weigh >20 kg, the dose is 8 puffs.
The dose can be repeated up to every 20 minutes for up to three doses, then every one
to four hours as needed.

To maximize drug delivery, a VHC (preferred) or a spacer should be employed by all

patients, and infants and young children should use such a device with a facemask, low
dead space, and a low-resistance valve. Mouthpieces are preferable to facemasks for
older children to avoid nasal filtering of drug, which may reduce lung deposition.
Children should take a slow and deep breath at the same time that the MDI canister is
depressed. The breath should be held for a count of five. For young children who are

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unable to breath-hold, the facemask should be held in place for five to six breaths for
inhalation of all of the medication. (See "The use of inhaler devices in children", section
on 'Spacer devices'.)
● Intermittent albuterol nebulization – Some medical centers may opt to use
intermittently nebulized albuterol therapy instead of short-term continuous therapy. The
standard dose for one nebulized albuterol treatment is 0.15 mg/kg (minimum 2.5 mg;
maximum 5 mg) [1,21]. Nebulized albuterol can be administered every 20 minutes for
up to three doses [1]. Beyond that, frequency of therapy may be limited by side effects,
such as tachycardia, hypertension, or tremors. Patients who have shown little or no
improvement after three doses and who are not experiencing significant adverse effects
may be treated every 30 to 45 minutes or switched to continuous therapy. Blow-by
techniques for aerosol delivery, rather than using a mask or mouthpiece, should be
avoided because they significantly decrease the inspired dose, limiting treatment
efficacy. (See "Delivery of inhaled medication in children", section on 'Special
considerations in infants and young children'.)

Drug delivery is maximized by having a total solution volume of 3 to 4 mL and an oxygen

flow rate of 6 to 8 L/min [22-25], tapping the sides of the reservoir to renebulize
droplets, and having older children use a mouthpiece to avoid nasal deposition of drug (
picture 1).
● Continuous albuterol nebulization – The sickest subset of patients will likely require
longer-term continuously nebulized albuterol that begins in the ED and continues
during the initial phases of hospitalization. The optimal dose for continuous albuterol
nebulization therapy has not been determined, and protocols used vary by institution.
One dosing schedule, stratified by weight, is as follows:

• For children who weigh 5 to 10 kg, the dose is 5 to 7.5 mg/hour.

• For children who weigh 10 to 20 kg, the dose is 10 to 12.5 mg/hour.
• For children who weigh >20 kg, the dose is 15 to 20 mg/hour.
Ipratropium bromide — Ipratropium bromide is an inexpensive and safe anticholinergic
agent that provides bronchodilation through smooth muscle relaxation [26]. We recommend
treating children with a moderate-to-severe asthma exacerbation with ipratropium bromide
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in addition to a beta-agonist. In randomized trials, systematic reviews, and meta-analyses [27-

31], treatment with two to three doses of inhaled ipratropium combined with an inhaled beta-
agonist was shown to reduce hospital admissions and improve lung function in children (most
with moderate-to-severe asthma exacerbations) compared with an inhaled beta-agonist
alone. In a 2013 systematic review, combination therapy was found to reduce the risk of
hospitalization (relative risk [RR] 0.73, 95% CI 0.63-0.85, 15 studies, 2497 children), with 23 out
of 100 children who received only beta-agonists hospitalized compared with 17 out of 100
who were treated with combination therapy [30]. Thus, 16 children (95% CI 12-29) with an
asthma exacerbation of any severity would need to be treated with combination therapy
rather than inhaled beta-agonists alone to avoid one hospital admission. The incidence of
nausea and tremor was lower in the combination therapy group, but no difference was seen
in the rate of vomiting.

Ipratropium can be administered via SVN or MDI-VHC/S ( table 5). We prefer the nebulized
form (250 micrograms per dose for children who weigh <20 kg; 500 micrograms per dose for
children who weigh ≥20 kg). We administer ipratropium bromide with each of the first three
albuterol treatments [27]. Alternatively, ipratropium may be administered with the second
and third treatments [28]. If administered by MDI-VHC/S, the NAEPP guidelines recommend a
dose of 4 to 8 puffs (each puff is 18 micrograms) [1]. The NAEPP guidelines also comment that
the MDI dose is low and has not been studied in asthma exacerbations.

Magnesium sulfate — Magnesium is inexpensive, has minimal adverse effects at the doses
indicated, and is widely available. We suggest using intravenous magnesium sulfate in
children with severe asthma exacerbations and in children with moderate to severe asthma
exacerbations who have not responded to initial treatment with beta-agonists, ipratropium
bromide, and systemic glucocorticoids. Magnesium sulfate administered intravenously
causes relaxation of bronchial smooth muscle, and there is accumulating evidence of its
benefits in adults and children with severe asthma [32,33]. A meta-analysis of five studies (182
children) found that magnesium sulfate was effective in preventing hospitalization in children
with moderate-to-severe acute asthma when added to bronchodilators and glucocorticoids
(absolute risk reduction 0.26, 95% CI 0.12-0.39) [34]. Four children would need to be treated to
avoid one hospitalization (95% CI 3-8). Two other systematic reviews and meta-analyses
assessed the same five studies and found that the use of magnesium was also associated
with significant improvements in pulmonary function tests [33,35]. A subsequent meta-
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analysis that included six trials was consistent with previous findings [36]. However, a
randomized trial of intravenous magnesium sulfate (40 mg/kg) or placebo in 61 children aged
six months to four years with acute, severe virus-induced wheezing unresponsive to initial
treatment with short-acting bronchodilators in the ED found no difference between the two
groups in the change in respiratory distress scores from baseline to six hours after treatment
[37].

The NAEPP guidelines suggest 25 to 75 mg/kg (maximum 2 grams) intravenously for severe
exacerbations unresponsive to initial treatments after one hour and as add-on therapy for
life-threatening exacerbations ( table 5) [1]. Given its relative safety and the critical
importance of early effective treatment, in our practice, we use a dose of 50 mg/kg
(maximum 2 grams), given intravenously and administered over 20 minutes. A fluid bolus
may be administered to prevent clinically significant hypotension, an uncommon side effect
of magnesium when infused slowly over 20 minutes. Magnesium infusion is relatively
contraindicated in kidney failure. We do not advocate the use of nebulized magnesium
sulfate, due to lack of demonstrated clinically important benefits in randomized trials [38].

Parenteral beta-agonists — Subcutaneous and intramuscular beta-agonists (eg,

epinephrine, terbutaline) are reserved for children with a severe asthma exacerbation with
poor inspiratory flow (eg, markedly decreased breath sounds) and/or who cannot cooperate
with nebulized therapy due to agitation. Additionally, intravenous terbutaline may be used in
children with a severe asthma exacerbation who have not responded to initial therapy.
● Subcutaneous or intramuscular epinephrine or terbutaline – Typically, subcutaneous
or intramuscular therapy is given within minutes of arrival to a severely ill patient who is
aerating poorly, concurrent with starting albuterol therapy and obtaining intravenous
access. While terbutaline is more beta-2-selective at lower doses than epinephrine, it
may result in mild hypotension, whereas epinephrine can increase cardiac output and
raise blood pressure. In addition, epinephrine is also suitable for anaphylaxis, which can
have a similar presentation to a severe asthma attack. In a sick patient, the preferred
medication is the one most readily available, which is epinephrine (in the form of
autoinjectable epinephrine devices for intramuscular administration) in most cases.

Early studies showed that inhaled beta-agonists were as efficacious as subcutaneous or

intramuscular epinephrine [5,6]. However, inhaled beta-agonists are poorly delivered in
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severely ill children with markedly diminished aeration. Theoretically then, in this
setting, the rapid subcutaneous or intramuscular administration of epinephrine or
terbutaline may be superior to inhaled beta-agonists. The intramuscular route may
provide for more rapid drug absorption compared with the subcutaneous route,
although direct comparisons are lacking.

The dose of intramuscular or subcutaneous epinephrine for bronchodilation is 0.01

mg/kg (0.01 mL/kg a 1 mg/mL solution), with a maximum dose of 0.5 mL (0.5 mg) (
table 5). The dose of subcutaneous or intramuscular terbutaline for bronchodilation
is 0.01 mg/kg/dose (0.01 mL/kg of a 1 mg/mL solution), with a maximum dose of 0.4 mg
(0.4 mL). The dose may be repeated every 20 minutes for three doses unless significant
side effects (eg, extreme hypertension, persistent emesis) develop, although most
patients are switched to an intravenous medication (eg, magnesium sulfate, terbutaline)
if they do not respond after the second dose of subcutaneous or intramuscular
terbutaline or epinephrine. The dosing interval may be decreased to 5 to 10 minutes for
children who continue with severe respiratory distress; autoinjectable epinephrine may
be used for this purpose to avoid a delay in drawing up the medication.
● Intravenous terbutaline – Severely ill patients who are poorly responsive to
conventional therapy may be treated with a combination of intravenous beta-agonists
and inhaled beta-agonists, although additional studies are needed to clarify the role of
intravenous beta-agonists. A systematic review of studies published through September
2012 [39] found only two randomized trials that met inclusion criteria [40,41]. Limited
evidence from these two trials suggests that there is shorter recovery time and
improved pulmonary index scores (PIS) with the addition of intravenous beta-agonists in
children poorly responsive to conventional interventions (including inhaled beta-
agonists and ipratropium, systemic glucocorticoids, and magnesium sulfate). Although
at least one pediatrics study found no significant adverse effects with continuous
intravenous terbutaline, the possible benefit needs to be weighed against increased side
effects associated with this therapy, including dysrhythmias, hypertension, and
myocardial ischemia [42,43]. Thus, there is no role for using intravenous beta-agonists
as initial therapy, even for severely ill children. Alternative treatment options include
noninvasive positive pressure ventilation (NPPV) and high-flow nasal cannula. (See
"Acute severe asthma exacerbations in children younger than 12 years: Intensive care
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unit management", section on 'Preintubation therapies'.)

Dosing for intravenous terbutaline in the ED setting is as follows: 10 micrograms/kg

bolus over 10 minutes, followed by 0.3 to 0.5 micrograms/kg/minute; every 30 minutes,
the infusion may be increased by 0.1 to 0.5 micrograms/kg/minute to a maximum of 3
micrograms/kg/minute. Use of higher doses in the intensive care unit (ICU) setting have
been described (up to 6 to 10 micrograms/kg/minute). However, in clinical practice, the
maximum dose is often limited to 2 to 3 micrograms/kg/minute because of drug
toxicities (eg, troponin leak, electrocardiogram changes). (See "Acute severe asthma
exacerbations in children younger than 12 years: Intensive care unit management",
section on 'Pharmacotherapy'.)

Management of inflammation — The other primary treatment for acute asthma

exacerbations in the ED is systemic glucocorticoids.

Systemic glucocorticoids — Systemic glucocorticoids are a well-established asthma therapy

and are indicated for all children who present to the ED with a moderate-to-severe acute
asthma exacerbation. Most children with mild exacerbations are also treated with systemic
glucocorticoids, although it is reasonable to omit this treatment in children who have not
received beta-agonist therapy within a few hours of presenting for medical care and who
respond promptly to a single albuterol treatment in the ED. Systemic glucocorticoids have
been used for the treatment of acute asthma exacerbations for over 60 years [44]. The
antiinflammatory action of glucocorticoids effectively reduces the airway edema and
secretions associated with acute asthma exacerbations, and their effects may be noted within
two to four hours of administration [2,45]. Treatment of moderate-to-severe exacerbations
with systemic glucocorticoids in the ED is associated with a decreased rate of hospitalization
in placebo-controlled trials (RR 0.58 [95% CI 0.37-0.92] in an analysis of two trials in preschool
children, for example) [2,46], and admission rates are similar in children whether they are
given oral or intravenous glucocorticoids [47].

When indicated, we recommend administering systemic glucocorticoids as soon as possible

after arrival in the ED. Oral administration is suitable and preferred for most patients.
Dexamethasone has become the oral glucocorticoid of choice to treat children with acute
asthma because of its prolonged half-life and similar efficacy compared with prednisone
[48,49]. The dosing of systemic glucocorticoids is reviewed in the table ( table 5). The NAEPP
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guidelines suggest that oral administration of glucocorticoids is preferred to intravenous

administration because oral administration is less invasive and the effects are equivalent [1].
Intramuscular administration of glucocorticoids (eg, dexamethasone) may be warranted in
patients who vomit orally administered glucocorticoids yet do not require an intravenous line
for other purposes [50-52].

The benefit of early administration (within one hour) of systemic glucocorticoids versus
placebo in patients presenting to the ED with acute asthma exacerbation was evaluated in a
meta-analysis of 12 trials involving 863 patients [53]. The following results were reported:
● Early administration of systemic glucocorticoids reduced admission rates (pooled odds
ratio [OR] 0.40, 95% CI 0.21-0.78); eight patients (95% CI 5-21) would need to be treated
to prevent one admission.
● The benefit was more pronounced in those not receiving systemic glucocorticoids
before ED presentation (OR 0.37, 95% CI 0.19-0.7) and in those with more severe asthma
(OR 0.35, 95% CI 0.21-0.59).
● Oral glucocorticoids were effective in reducing hospital admission (OR 0.24, 95% CI 0.11-
0.53) compared with placebo in the three trials included in the meta-analysis that
evaluated oral glucocorticoids in children with an acute asthma exacerbation.

Another study examined outcomes before and after initiation of a medical directive that
allowed triage nurse-initiated glucocorticoids before clinician assessment in 644 consecutive
children presenting with a moderate-to-severe asthma exacerbation [54]. Nursing initiation of
glucocorticoids was associated with a reduced likelihood of admission (OR 0.56, 95% CI 0.36-
0.87), as well as significantly decreased times to clinical improvement and discharge.

A meta-analysis comparing a three- to five-day course of oral prednisolone or prednisone (2

mg/kg/day for the first day and then 1 to 2 mg/kg/day for the subsequent two to four days)
with dexamethasone given as a single intramuscular dose (0.3 to 1.7 mg/kg) or one to two
daily oral doses (0.6 mg/kg) for asthma exacerbations managed in the ED found that the
treatments were equivalent with regard to rate of relapse, defined as an unplanned clinic
visit, return ED visit, or unplanned hospitalization related to the initial asthma exacerbation
[55]. Similar results were seen in two subsequent randomized, open-label trials. The first of
these compared a single oral dose of dexamethasone 0.3 mg/kg to a three-day course of

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prednisolone 1 mg/kg/day, with equivalent Pediatric Respiratory Assessment Measure (PRAM)

scores at day 4 after the ED visit [56]. The second compared two daily oral doses of
dexamethasone 0.6 mg/kg/dose (maximum dose 12 mg) to a five-day course of
prednisone/prednisolone 1.5 mg/kg/day (maximum 60 mg) on day 1 and 1 mg/kg/day
(maximum 60 mg) on days 2 through 5, with no difference seen in asthma symptoms and
quality of life at day 7, admission rate, or unscheduled return visits to the ED [57]. In the first
trial and in the meta-analysis, lower rates of vomiting, both in the ED and at home, were seen
in the groups treated with dexamethasone via either route of administration compared with
prednisone/prednisolone [55,56]. However, newer and more palatable
prednisone/prednisolone liquid formulations and oral dissolving tablets are far better
tolerated with less frequent episodes of emesis compared with older prednisone
formulations.

Most patients do not require delivery glucocorticoids via the intravenous route, even among
those being hospitalized. However, for severely ill patients, intravenous access should be
established, and intravenous methylprednisolone may be administered ( table 5).

Inhaled glucocorticoids — The use of inhaled glucocorticoids to treat children with acute
asthma is an area of ongoing clinical research. Studies comparing the use of oral with inhaled
glucocorticoids in the ED management of children with acute asthma have thus far had mixed
results, although one systematic review found no differences between inhaled and systemic
glucocorticoids [58]. Until more conclusive data are available, we do not suggest the routine
use of inhaled glucocorticoids in addition to, or instead of, systemic glucocorticoids in the
management of acute asthma exacerbation in children.

The following studies are illustrative:

● Some studies have found benefits of inhaled glucocorticoids compared with oral
glucocorticoids (eg, earlier discharge from the ED, less vomiting, decreased relapse rate,
improved clinical parameters, improved pulmonary function) [59,60].
● Other studies have found oral glucocorticoids and inhaled glucocorticoids to have
similar outcomes [61-63].
● One study found improved pulmonary function and a lower relapse rate with oral
prednisone compared with inhaled fluticasone [64].

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● Two randomized trials found no additional benefit to adding nebulized budesonide to
standard therapy (systemic glucocorticoids and inhaled albuterol and ipratropium) early
in the course of treatment [65,66].

Nonstandard therapies — There are insufficient data to support the routine administration
of heliox, ketamine, or leukotriene receptor antagonists (LTRAs) in the treatment of
bronchospasm in children with acute asthma exacerbations.

Heliox — In theory, a mixture of helium and oxygen may enhance beta-agonist delivery
because the lower gas density should result in decreased flow resistance. The 2007 NAEPP
guidelines suggest administration of beta-agonists with heliox in patients with life-
threatening exacerbations or who are not responding to conventional therapy [1]. However,
the use of heliox should not delay intubation once it is considered necessary. Heliox is not
used if the patient requires greater than 40 percent oxygen, because the beneficial effect of
using a low-density gas is diminished as the oxygen fraction increases. (See "Physiology and
clinical use of heliox", section on 'Use in children' and 'Endotracheal intubation' below.)

The benefits of continuous beta-agonist administration delivery by heliox compared with

oxygen were evaluated in a pilot study of 30 children (2 to 18 years) with moderate-to-severe
asthma (PIS ≥8) ( table 2) [67]. After initial treatment with albuterol inhalation and
prednisone or prednisolone, the patients were randomly assigned to receive continuous
albuterol nebulization delivered by heliox or oxygen. At 240 minutes, patients in the heliox
group had greater decrease in PIS from baseline (decrease of 7 versus 3 points). In addition,
more patients in the heliox group were discharged from the hospital in less than 12 hours (73
versus 33 percent).

Ketamine — Due to its bronchodilating properties, the dissociative agent ketamine is the
drug of choice to provide sedation and analgesia before intubating a child with asthma (see
'Endotracheal intubation' below). Although several small case series of nonintubated children
treated with ketamine suggest that ketamine improves acute asthma [68,69], the one
randomized trial found that ketamine was no better than standard therapy in nonintubated
children with severe acute asthma [70,71]. (See "Acute severe asthma exacerbations in
children and adolescents: Endotracheal intubation and mechanical ventilation", section on
'Sedation and paralysis'.)

Leukotriene receptor antagonists — The data do not support the routine use of LTRA
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therapy to treat children with acute asthma exacerbations requiring urgent or emergent care
[72]. LTRA add-on therapy in acute asthma has shown promise in adults [73,74]. However, it
does not appear to provide additional benefit in children when added to standard therapy for
acute asthma [75]. (See "Acute exacerbations of asthma in adults: Emergency department and
inpatient management", section on 'Ineffective therapies'.)

A randomized trial of 117 children aged 5 to 15 years treated in the ED found no difference in
the Modified Pulmonary Index Score (MPIS) between those treated with a single age-
appropriate dose of montelukast versus placebo [75]. Intravenous montelukast was not
effective in improving forced expiratory volume in the first second (FEV1) in a randomized trial
of children with acute asthma [76].

ADVICE RELATED TO COVID-19

The United States Centers for Disease Control and Prevention (CDC) have identified asthma as
a risk factor for severe coronavirus disease 2019 (COVID-19; severe acute respiratory
syndrome coronavirus 2 [SARS-CoV-2]) [77]. Expert groups have advised continuing usual ED
management in patients with asthma [78-81]. This includes following the usual guidelines for
prompt initiation of systemic glucocorticoids for asthma exacerbations since delaying therapy
is known to increase the risk of a life-threatening exacerbation. In addition, clinicians should
have a low threshold for testing for COVID-19 in all children with an acute asthma
exacerbation; any such child with fever should be tested. (See "An overview of asthma
management in children and adults", section on 'Immunizations and antiviral strategies'.)

At the outset of the COVID-19 pandemic, the CDC and the World Health Organization both
classified nebulizer therapy as an aerosol-generating procedure (AGP). As such, their
recommendations to clinicians were to use metered-dose inhalers (MDIs) instead of
nebulizers to deliver beta-agonists when possible and for clinicians to wear full personal
protective equipment including an N95 mask or respirator, eye protection, gloves, and a gown
when in close proximity to a patient receiving nebulized medications. Subsequently, these
organizations consider the evidence insufficient to classify nebulizer therapy as an AGP that is
associated with COVID-19 transmission. (See "COVID-19: Clinical manifestations and diagnosis
in children".)

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Acute asthma exacerbations in children younger than 12 years: Emergency department management

INITIAL TREATMENT

Treatment is based upon the initial assessment of severity ( table 2) followed by ongoing
monitoring of response to therapy ( algorithm 1). All drug doses and routes are shown in
the tables ( table 4 and table 5). (See 'Assessment of severity' above and 'Monitoring'
below.)

Mild exacerbation — For children with a mild asthma exacerbation (see 'Assessment of
severity' above), the approach is as follows ( algorithm 1):
● Administer albuterol inhalation therapy via small-volume nebulizer (SVN) or metered-
dose inhaler with spacer (MDI-S). If repeated doses are needed, they should be given up
to every 20 minutes for three doses [1]. (See 'Inhaled short-acting beta-2 agonists'
above.)
● Give systemic glucocorticoids (eg, oral prednisolone/prednisone or dexamethasone) to
those who fail to show sustained improvement or worsen after one inhalation therapy
or who have a history of severe or recurrent exacerbations in the past. (See 'Systemic
glucocorticoids' above.)

Moderate exacerbation — For children with a moderate asthma exacerbation (see

'Assessment of severity' above), the following therapies are administered ( algorithm 1):
● Nebulized albuterol combined with ipratropium bromide up to every 20 minutes for
three doses or continuously for one hour. (See 'Inhaled short-acting beta-2 agonists'
above and 'Ipratropium bromide' above.)
● Systemic glucocorticoids (oral administration of dexamethasone [preferred] or
prednisolone/prednisone is suitable for most patients) within 30 to 60 minutes after
arrival in the ED in a manner that does not delay the initiation of beta-agonist therapy.
(See 'Systemic glucocorticoids' above.)

Severe exacerbation — For children with a severe asthma exacerbation (see 'Assessment of
severity' above), the approach is as follows ( algorithm 1):
● Continuous nebulized albuterol combined with ipratropium, as noted above for
moderate exacerbation, for the first hour. Most children with a severe exacerbation will

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need ongoing administration of continuous rather than intermittent nebulized albuterol,

unless they experience dramatic improvement after their first hour of albuterol therapy.
(See 'Moderate exacerbation' above.)

Children with very poor inspiratory flow or severely ill children who cannot cooperate
with nebulized therapy can be treated with terbutaline or epinephrine administered
intramuscularly or subcutaneously instead of inhaled albuterol and ipratropium. The
intramuscular route has the theoretical advantage of more rapid distribution, and,
unlike epinephrine, terbutaline is a beta-selective agent. (See 'Inhaled short-acting beta-
2 agonists' above and 'Ipratropium bromide' above and 'Parenteral beta-agonists'
above.)
● Intravenous methylprednisolone, which can be started as soon as intravenous access is
obtained. (See 'Systemic glucocorticoids' above.)
● Intravenous magnesium sulfate. (See 'Magnesium sulfate' above.)

Impending respiratory failure — The pediatric intensive care unit (PICU) and/or anesthesia
should be consulted when a patient has signs of impending respiratory failure (
algorithm 1), including cyanosis, inability to maintain respiratory effort (respiratory rate
may be inappropriately normal to low), depressed mental status (lethargy or agitation), pulse
oxygen saturation (SpO2) <90 percent, and/or respiratory acidosis (elevated partial pressure
of carbon dioxide [pCO2] noted on venous, arterial, or capillary blood gas sample).
Intravenous terbutaline in addition to inhaled short-acting beta-2 agonists (SABAs) and
noninvasive positive pressure ventilation (NPPV) or endotracheal intubation may be indicated
for these children. (See "Acute severe asthma exacerbations in children younger than 12
years: Intensive care unit management" and 'Noninvasive positive pressure ventilation' below
and 'Endotracheal intubation' below.)

Intravenous terbutaline — For the child with impending respiratory failure, the risk-
benefit ratio favors the use of intravenous terbutaline in addition to continuously nebulized
albuterol ( table 5). (See 'Parenteral beta-agonists' above.)

Noninvasive positive pressure ventilation — NPPV (continuous positive airway

pressure [CPAP] or bilevel positive airway support [BPAP]) is sometimes used to treat severely
ill children with asthma who are responding poorly to other interventions, although there are

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little data proving the efficacy of this approach [82]. This strategy of employing positive
pressure has the theoretical benefit of decreasing the workload of fatigued muscles by
decreasing the pressure needed to initiate a breath and helping to prevent airway collapse on
exhalation. Subsets of patients, as yet hard to define, do have demonstrable benefit from the
use of NPPV. As such, it is reasonable for clinicians to employ this option in children with
severe exacerbations refractory to other interventions, with the caveat that NPPV should be
discontinued if there is clinical deterioration. NPPV is discussed in greater detail separately.
(See "Noninvasive ventilation for acute and impending respiratory failure in children" and
"Noninvasive ventilation in adults with acute respiratory failure: Practical aspects of
initiation".)

Endotracheal intubation — Intubation should be approached cautiously in patients

with status asthmaticus because manipulation of the airway can cause increased airflow
obstruction due to exaggerated bronchial responsiveness. Clinicians must be prepared to
manage acute deterioration after intubation. Adequate venous access, noninvasive
monitoring, and sedation should be optimized before intubation. The clinician most
experienced with airway management should perform the intubation. The indications for
endotracheal intubation in children with asthma and the performance of the procedure are
reviewed in detail separately. (See "Technique of emergency endotracheal intubation in
children" and "Rapid sequence intubation (RSI) in children for emergency medicine:
Approach" and "Acute severe asthma exacerbations in children and adolescents: Endotracheal
intubation and mechanical ventilation", section on 'Endotracheal intubation and mechanical
ventilation'.)

FURTHER EVALUATION

Indications for chest radiograph — Most children with asthma exacerbations do not require
chest radiographs (CXRs), since they rarely provide information that alters the management
of children with acute asthma exacerbation [83,84]. Indications for CXR to rule out
pneumonia, atelectasis, and air leak include some combination of fever (>39ºC); presence of
focal examination findings (eg, persistent crackles or decreased breath sounds, crepitus);
persistent tachypnea, hypoxemia, or chest pain; severe disease; or uncertainty about the
diagnosis [83]. (See "Evaluation of wheezing in infants and children", section on
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'Radiography'.)

Alternative diagnoses and comorbidities — Patients who present with acute onset of
wheezing and do not respond to the usual asthma therapies should be evaluated for
alternative diagnoses and comorbidities ( table 6 and table 7). In addition to asthma,
acute onset of wheezing in a child is most often caused by an infectious process (particularly
viral bronchiolitis in infants less than two years of age and atypical pneumonia in older
children) or foreign body aspiration (FBA). Environmental allergies and obesity are among the
more common comorbidities. Common triggers and comorbidities are reviewed in greater
detail separately. (See "Evaluation of wheezing in infants and children", section on 'Acute
wheezing (hours to days)' and "An overview of asthma management in children and adults",
section on 'Controlling asthma triggers'.)

MONITORING

Ongoing monitoring of respiratory rate, heart rate, oxygen saturation, degree of alertness,
accessory muscle use, and retractions is crucial to decisions regarding treatment and
disposition [85]. The frequency of monitoring varies depending upon the severity of illness
and response to initial therapy but for most patients is typically every 20 to 30 minutes for the
first hour of therapy. Patients who require continuous nebulizer therapy continue to be
monitored every 20 to 30 minutes. Clinicians may also find it helpful to measure peak
expiratory flow rate (PEFR) in select patients (eg, a person with obesity, in whom assessment
of aeration is more difficult). However, assessment of PEFR may have limited utility in the
assessment of sicker or younger children. It is optimal if the child can make three attempts
while standing (the best score is used), and it is most useful when it can be compared with the
child's known personal best score. (See "Overview of pulmonary function testing in children",
section on 'Peak expiratory flow rate'.)

Management decisions can be based upon the physical exam findings, along with
oxyhemoglobin saturation assessed with pulse oximetry. In addition, an elevated end tidal
CO2 measurement assessed noninvasively via capnometry may indicate impending
respiratory failure. It is rarely necessary to obtain arterial blood gas (ABG) samples in children
with acute asthma. ABGs obtained before aggressive intervention are often abnormal

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(hypercapnia) in moderately or severely ill children but rarely affect management and usually
improve after therapy. In children who require admission to the intensive care unit (ICU),
measurement of partial pressure of carbon dioxide (pCO2) via ABG after a clinical plateau has
been reached provides an objective measure of disease severity. Data suggest that capillary
blood is an acceptable sample alternative to arterial blood if only acid-base parameters (pH
and pCO2) are of clinical interest [86]. (See "Acute severe asthma exacerbations in children
younger than 12 years: Intensive care unit management".)

SUBSEQUENT MANAGEMENT

Subsequent management depends upon response to initial therapy ( algorithm 1). All drug
doses and routes are shown in the tables ( table 4 and table 5). Discharge criteria for
patients who do respond to therapy are reviewed below. (See 'Assessment of severity' above
and 'Discharge to home' below.)

Poor response and severely ill — For patients with a poor response to initial treatment and
severe signs and/or symptoms (see 'Assessment of severity' above), the following additional
steps are taken while awaiting admission to the hospital (see 'Hospitalization' below):
● Consult the pediatric intensive care unit (PICU) and/or anesthesia. (See "Acute severe
asthma exacerbations in children younger than 12 years: Intensive care unit
management".)
● Give continuously nebulized albuterol (or give intermittently every 30 to 45 minutes)
without ipratropium ( table 4). (See 'Inhaled short-acting beta-2 agonists' above.)
● Administer intravenous magnesium sulfate if not already given and there is lack of
clinical improvement or clinical deterioration despite treatment with albuterol,
ipratropium bromide, and systemic glucocorticoids. (See 'Magnesium sulfate' above.)
● For patients who do not respond to these interventions and have signs and/or
symptoms of impending respiratory failure, administer intravenous terbutaline after
completion of the magnesium sulfate infusion. Dosing for intravenous terbutaline in the
ED setting is as follows: 10 microgram/kg bolus over 10 minutes, followed by 0.3 to 0.5
microgram/kg/minute; every 30 minutes, the infusion may be increased by 0.1 to 0.5

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microgram/kg/minute to a maximum of 3 microgram/kg/minute. (Higher doses are

sometimes used in the ICU setting.) (See 'Parenteral beta-agonists' above and
'Impending respiratory failure' above.)
● Assess for alternative diagnoses or comorbidities. (See 'Alternative diagnoses and
comorbidities' above.)
● Additional management may include noninvasive positive pressure ventilation (NPPV) or
endotracheal intubation. (See 'Noninvasive positive pressure ventilation' above and
'Endotracheal intubation' above.)

Incomplete response and moderately ill — For patients with an incomplete response to
initial treatment and continued moderate signs and/or symptoms (see 'Assessment of
severity' above), the approach is as follows ( algorithm 1):
● Give albuterol MDI therapy continuously (or every 30 to 45 minutes).
● Administer intravenous magnesium sulfate if it was not already given and symptoms are
moderate.
● Reassess response to therapy in one to three hours to determine whether to admit or
discharge to home. (See 'Disposition' below.)

Incomplete response and mildly ill — For patients with an incomplete response to initial
treatment and continued mild signs and/or symptoms (see 'Assessment of severity' above),
the approach is as follows ( algorithm 1):
● Give nebulized albuterol every 30 to 45 minutes.
● Reassess response to therapy in one to three hours to determine whether to admit or
discharge to home. (See 'Disposition' below.)

Good response and minimal to no symptoms — Patients who have resolution of symptoms
or marked improvement and the patient and parents/caregivers have a good understanding
of asthma management and are able to adhere to therapy can be discharged to home (
algorithm 1). (See 'Discharge to home' below.)

DISPOSITION

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The decision regarding disposition (eg, discharge to home, continued observation, or

hospitalization) is based upon both clinical and social factors.

Hospitalization — Patients who were moderately to severely ill on arrival and who have little
improvement or worsen after initial therapy with beta-agonists and systemic glucocorticoids
require hospitalization. This includes patients who continue to have significant wheezing and
retracting and poor aeration.

Additional factors that suggest a need for hospitalization include [1]:

● Need for beta-agonist therapy more often than every four hours; patients who require
treatment more often than every two hours may need to be admitted to an intensive
care unit (ICU; this varies from institution to institution and is dependent upon the level
of care that can be administered in the regular inpatient unit)
● Requirement for supplemental oxygen/low oxygen saturation on pulse oximetry an hour
or more after commencement of initial therapy
● Inability to self-hydrate
● A history of rapid progression of severity in past exacerbations
● Poor adherence with outpatient medication regimen
● Recent treatment with systemic glucocorticoids (includes current treatment with oral
glucocorticoids at the time of presentation) or beta-agonist overuse
● Inadequate access to medical care, including lack of transportation back to the hospital
if deterioration occurs
● Poor social support system at home, with inability of the caregiver(s) to provide medical
care and supervision at home

Severely ill children with a poor response to ED interventions will require admission to a
pediatric intensive care unit (PICU). Clinicians should have a low threshold to admit a child
with altered mental status (may present as drowsiness or agitation) to an ICU. Other factors
that may influence this decision include a history of severe exacerbations and/or a prior need
for ICU management [87].

Inpatient and ICU therapy for acute asthma exacerbations in children are discussed
separately. (See "Acute asthma exacerbations in children younger than 12 years: Inpatient
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Acute asthma exacerbations in children younger than 12 years: Emergency department management

management" and "Acute severe asthma exacerbations in children younger than 12 years:
Intensive care unit management".)

Discharge to home — Children who have marked improvement in clinical parameters within
the first one to two hours of therapy may be discharged home [1]. Marked improvement is
manifested by diminished or absent wheezing and retracting and increased aeration that is
sustained at least 60 minutes after the most recent albuterol dose.

Discharge medications — All patients seen for an acute asthma exacerbation should have
an inhaled short-acting beta-2 agonist (SABA; eg, albuterol) available for treatment of
symptoms [1]. We suggest treatment with a SABA (eg, albuterol) every four hours during
waking hours and up to every four hours as needed during sleep for the first three days after
an ED visit for an asthma exacerbation. After that, albuterol dosing should be weaned as
tolerated, with the goal of discontinuing by day 5 to 7. (See "Asthma in children younger than
12 years: Quick-relief (rescue) treatment for acute symptoms", section on 'Short-acting beta
agonists (SABAs)'.)

We treat children with a short course of oral glucocorticoids if they received a dose of
systemic glucocorticoids in the ED. A meta-analysis of combined adult and pediatric data
found that this treatment was associated with fewer relapses to additional care, a decreased
number of subsequent hospitalizations, and less albuterol use [88]. As few as 10 patients
need to be treated with systemic glucocorticoids to prevent relapse. A one- to two day course
of dexamethasone given once per day has become the glucocorticoid of choice for post-ED
asthma management [55]. It is well tolerated and has the same efficacy as a five-day course
of prednisone given twice each day. More prolonged glucocorticoid regimens may be
indicated for those with persistent symptoms or those whose control regimen includes oral
glucocorticoids. Glucocorticoids that are administered for less than 10 days do not require a
taper at discontinuation [89].

Whether inhaled glucocorticoids offer any short-term benefits in addition to inhaled albuterol
and oral glucocorticoids when started in the ED or at the time of discharge from the ED in
patients who were not already receiving inhaled glucocorticoids as controller therapy is a
question that remains unanswered [90,91]. However, patients may be started on an inhaled
glucocorticoid in the ED, if controller therapy is indicated, to ensure that institution of this
therapy is not delayed or forgotten [92]. Alternatively, the treating clinician in the ED can
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advise the parents/caregivers to address this issue during the follow-up visit with the child's
primary care provider. (See "Asthma in children younger than 12 years: Management of
persistent asthma with controller therapies".)

Benefits were not seen with leukotriene receptor antagonists (LTRAs) as monotherapy in
children discharged from the ED after treatment for acute asthma was successful. A five-day
course of montelukast was not as effective as a similar course of prednisolone in a
randomized trial of 130 children with mild-to-moderate acute asthma exacerbations who
were stabilized with prednisolone in the ED [93]. Treatment failure occurred in 8 percent of
children treated with prednisolone compared with 22 percent treated with montelukast.

Discharge education — Prior to discharge from the ED, it is recommended that the
following are reviewed with patients and their parents/caregivers [1]:
● Signs and symptoms necessitating a return visit to the ED including worsening
shortness of breath, difficulty speaking a complete sentence, or increased work of
breathing
● The need to follow-up with their primary care provider or asthma specialist within one
week of the ED visit
● Discharge medications, with respect to purpose, side effects, and proper technique for
administration (see "Asthma in children younger than 12 years: Management of
persistent asthma with controller therapies" and "Asthma in children younger than 12
years: Quick-relief (rescue) treatment for acute symptoms" and "The use of inhaler
devices in children", section on 'Spacer devices' and "The use of inhaler devices in
children", section on 'Valved-holding chambers')
● A written asthma action plan ( form 1A-B) (see "Asthma education and self-
management")
● Risk factors for asthma (see "Risk factors for asthma")
● Prevention of acute exacerbations (see "Trigger control to enhance asthma
management" and "Allergen avoidance in the treatment of asthma and allergic rhinitis")

Follow-up — Patients discharged from the ED should follow up with their primary care
provider or asthma specialist within one week of the ED visit [1]. At the follow-up visit, the

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Acute asthma exacerbations in children younger than 12 years: Emergency department management

primary care provider can review the child's asthma control, asthma care plan, and initiate or
alter controller therapy as indicated. (See "Asthma in children younger than 12 years:
Management of persistent asthma with controller therapies".)

SOCIETY GUIDELINE LINKS

Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: Asthma in children".)

INFORMATION FOR PATIENTS

UpToDate offers two types of patient education materials, "The Basics" and "Beyond the
Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th
grade reading level, and they answer the four or five key questions a patient might have
about a given condition. These articles are best for patients who want a general overview and
who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are
longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th
grade reading level and are best for patients who want in-depth information and are
comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to
print or e-mail these topics to your patients. (You can also locate patient education articles on
a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
● Basics topics (see "Patient education: How to use your child's dry powder inhaler (The
Basics)" and "Patient education: Asthma in children (The Basics)" and "Patient education:
How to use your child's metered dose inhaler (The Basics)")
● Beyond the Basics topics (see "Patient education: Asthma inhaler techniques in children
(Beyond the Basics)" and "Patient education: Asthma treatment in children (Beyond the
Basics)")

SUMMARY AND RECOMMENDATIONS

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Acute asthma exacerbations in children younger than 12 years: Emergency department management
● Determining exacerbation severity – The severity of an asthma exacerbation is
primarily determined by assessment of clinical findings, occasionally supplemented by
objective tests ( table 1). The initial severity of the exacerbation and level of treatment
needed can also be determined using an asthma exacerbation severity score such as the
pulmonary index score (PIS) ( table 2) or the Pediatric Respiratory Assessment
Measure (PRAM) ( table 3). (See 'Assessment of severity' above and "Acute asthma
exacerbations in children younger than 12 years: Overview of home/office management
and severity assessment", section on 'Assessment of exacerbation severity'.)

• Mild – A mild exacerbation is characterized by normal alertness, slight tachypnea,

expiratory wheezing only, a mildly prolonged expiratory phase, minimal accessory
muscle use, and an oxygen saturation of >95 percent.

• Moderate – A moderate exacerbation is defined as normal alertness, tachypnea,

wheezing throughout expiration with or without inspiratory wheezing, an inspiratory-
expiratory ratio of approximately 1:2, significant use of accessory muscles, and an
oxygen saturation that is typically 92 to 95 percent.

• Severe – A severe exacerbation is defined as lethargy or agitation, inability to repeat

a short phrase, extreme tachypnea, inspiratory and expiratory wheezing, an
inspiratory-expiratory ratio exceeding 1:2, very poor aeration, significant use of
accessory muscles, and an oxygen saturation that is typically <92 percent.
● Initial management – The approach to the initial management of the child who
presents to the emergency department (ED) with an asthma exacerbation is
summarized in the algorithm ( algorithm 1) and as follows, with dosing and route of
administration summarized in the tables ( table 4 and table 5) (see 'Initial
treatment' above):

• Patients with hypoxemia – Administration of supplemental oxygen is indicated if

oxygen saturation is ≤92 percent in room air. (See 'Management of hypoxemia and
hypercapnia' above.)

• All patients – All patients seen in the ED for an acute asthma exacerbation require
treatment with an inhaled short-acting beta-2 agonist (SABA or beta-agonist), such as
albuterol (salbutamol) or an equivalent. Albuterol is administered by nebulizer or

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metered-dose inhaler with a valved holding chamber (preferred) or spacer (MDI-

VHC/S) up to every 20 minutes for one to three doses or continuously via nebulizer.
The delivery method and dose vary with the severity of the attack, and studies show
similar outcomes with each mode of delivery. Subcutaneous or intramuscular
administration of a beta-agonist (eg, terbutaline, epinephrine) is an alternative for
children with poor inspiratory flow and/or who have moderate-to-severe symptoms
and are uncooperative with inhalation therapy. (See 'Inhaled short-acting beta-2
agonists' above and 'Parenteral beta-agonists' above.)

• Patients with mild exacerbations – We suggest oral glucocorticoids for children

who present to the ED with a mild asthma exacerbation (Grade 2B), although it is
reasonable to omit this therapy in children who have not received beta-agonist
therapy within a few hours of presenting for medical care and who respond promptly
to a single albuterol treatment in the ED. (See 'Systemic glucocorticoids' above.)

• Patients with moderate-to-severe exacerbations – For patients who present to the

ED with a moderate-to-severe asthma exacerbation:
- We recommend systemic glucocorticoids (Grade 1B). Systemic glucocorticoids
should be administered within 30 to 60 minutes after arrival in the ED. Oral
agents (eg, dexamethasone, prednisolone, or prednisone) are preferred in those
with moderate exacerbations. Dexamethasone is preferred because of its
prolonged half-life, which allows for shorter dosing, and similar efficacy
compared with prednisone and prednisolone. We administer systemic
glucocorticoids intravenously in most patients with severe exacerbations since
they are likely to require additional intravenous medications. (See 'Systemic
glucocorticoids' above.)
- We recommend inhaled ipratropium bromide (Grade 1A). We administer
ipratropium bromide combined with initial beta-agonist therapy (given as
nebulizer treatments up to every 20 minutes for three doses or continuously);
alternatively, it may be administered with the second and third treatments. (See
'Ipratropium bromide' above.)
- We suggest intravenous magnesium sulfate as part of the initial therapy only in
patients with a severe exacerbation (Grade 2A).
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● Patients with impending respiratory failure – The pediatric intensive care unit (PICU)
and/or anesthesia should be consulted when a patient has signs and/or symptoms of
impending respiratory failure. (See 'Impending respiratory failure' above.)
● Further evaluation in patients who are not responding to usual therapy – Most
children with asthma exacerbations do not require chest radiographs (CXRs) as part of
their evaluation. Patients who present with acute onset of wheezing and do not respond
to the usual asthma therapies should be evaluated for alternative diagnoses and
comorbidities ( table 6 and table 7). (See 'Further evaluation' above.)
● Subsequent management and disposition – The disposition of children with acute
asthma exacerbation depends upon the response during the first one to two hours of
therapy and subsequent severity of symptoms ( algorithm 1) (see 'Subsequent
management' above and 'Disposition' above):

• Marked improvement – Children who have marked improvement in clinical

parameters may be discharged home. All patients seen for an acute asthma
exacerbation should have an inhaled SABA (eg, albuterol) available for treatment of
symptoms. We typically advise treating with albuterol every four hours for the first
three days after discharge from the ED; albuterol frequency may be weaned for the
next two to three days following that, as tolerated. We treat children with a short
course of oral glucocorticoids if they received a dose of systemic glucocorticoids in
the ED. Patients discharged from the ED should follow-up with their primary care
provider or asthma specialist within one week after the ED visit. (See 'Good response
and minimal to no symptoms' above and 'Discharge to home' above.)

• Poor or incomplete response – Children with no or incomplete improvement within

the first two hours of therapy require continued observation and treatment (
algorithm 1). (See 'Incomplete response and mildly ill' above and 'Incomplete
response and moderately ill' above and 'Poor response and severely ill' above.)
- Inhaled SABA is continued in all patients.
- We suggest the administration of intravenous magnesium sulfate for patients
who have a poor response to initial treatment with beta-agonist, ipratropium,
and systemic glucocorticoids and have moderate-to-severe symptoms (Grade

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2A). (See 'Magnesium sulfate' above.)

- We suggest administration of intravenous terbutaline if there is no response to
intravenous magnesium sulfate and the patient has signs and/or symptoms of
impending respiratory failure (Grade 2B). (See 'Parenteral beta-agonists' above.)
- Patients who continue to have symptoms and/or continued need for
supplemental oxygen after treatment with bronchodilators and systemic
glucocorticoids require hospitalization. Severely ill children with a poor response
to ED interventions require admission to a PICU. (See 'Hospitalization' above and
"Acute asthma exacerbations in children younger than 12 years: Inpatient
management" and "Acute severe asthma exacerbations in children younger than
12 years: Intensive care unit management" and "Acute severe asthma
exacerbations in children and adolescents: Endotracheal intubation and
mechanical ventilation".)

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