Acute asthma exacerbation (peds)

This page is for pediatric patients. For adult patients, see: asthma

Background

Comparison of normal airway (B) to airway during asthma symptoms (C).
Features of remodeling in asthma.
  • An estimated 6 million children in the US have asthma
  • In 2007, asthma lead to >700,000 ED visits
  • Asthma is part of the atopy triad (asthma, allergies, eczema)
  • A history of eczema or allergies maybe helpful in making a new diagnosis of asthma
  • Wheezing in an infant is more often bronchiolitis than asthma
  • Viral URI associated with copious rhinorrhea, allergen exposure, and respiratory irritants (i.e. smoke) are common precipitants for pediatric asthma exacerbations

Clinical Features

History

Wheeze, shortness of breath, chest tightness, and/or cough that:[1]

  • Occur variably over time and vary in intensity
  • Are often worse at night or on waking
  • Are often triggered by exercise, laughter, allergens, or cold air
  • Worsen after end-exercise (specific)
  • Often appear or worsen with viral infections

Physical

  • Wheezing
  • Cough
  • Accessory muscle use
  • Dyspnea
  • Prolonged expiration
  • Severity of retractions occurs in caudal to cephalad direction
    • Scalene muscle contractions more severe than subcostal and intercostal retractions

Signs of impending ventilatory failure

  • Paradoxical respiration (chest deflation and abdominal protrusion during inspiration)
  • Altered mental status
  • "Silent chest"

Differential Diagnosis

Pediatric Wheezing

Evaluation

CXR with hyperinflated lungs consistent with broncoconstriction.

Workup

Obtaining a CXR in pediatric patients presenting with their first episode of wheezing was previously common,[2] however is no longer considered standard practice.[3]

  • For uncomplicated exacerbations in patients with known asthma, CXR is not routinely indicated.[4][5]
  • Consider CXR if:
    • Asymmetric lung auscultation findings, after treatment with albuterol
    • Poor response to medications/treatment, if history and exam are not consistent with asthma
    • Worsening symptoms
    • Unexplained fever
    • Chest pain
  • ABG in general unlikely to add to clinical decision making
    • May consider if concerned that the patient is getting tired (fatigue vs elevated CO2?)
    • A CO2 >45 is abnormal and may suggest impending respiratory failure (asthmatics typically hypocapneic during exacerbation)

Diagnosis

<6 Years Old

Diagnosis of asthma can be made at this age, but can be challenging; may treat as "suspected asthma" initially.[6]

  • Definitive diagnosis must exclude other potential conditions (e.g., viral bronchiolitis, tuberculosis, protracted bacterial bronchitis, congenital lung abnormalities)
  • Asthma more likely:[7]
    • Recurrent acute wheezing episodes (at least 2 wheezing episode in past 12 months)
    • No likely alternative cause
    • Timely response to asthma treatment (e.g., improvement of symptoms with SABA)
    • History of allergic disease in child or family
  • Asthma less likely:[8]
    • First wheeze started at <12 months of age (normally bronchiolitis
    • Lack of response to SABA and/or ICS
    • Atypical respiratory signs and symptoms

≥6 Years Old

  • Asthma and asthma exacerbation determination in the ED is a clinical diagnosis, which can be used to guide initial treatment
    • Subsequent outpatient testing/consideration for new onset asthma is recommended to confirm the diagnosis.[9]

Clinical Scores

  • Diagnosis and treatment can be guided by clinical scores
    • Modified Pulmonary Index Score (MPIS - Utilized at CCMC)
    • Pediatric Asthma Score (PAS)
    • Pulmonary Score (PS)
    • Pediatric Respiratory Assessment Measure (PRAM)

Modified Pulmonary Index Score (MPIS)

Age <3 Years
Points SpO2 Acces Musc Use I:E Wheeze HR RR
0 >95% None 2:1 None; Good Aeration ≤120 ≤30
1 93-95% Mild 1:1 End Exp 121-140 31-45
2 90-92% Moderate 1:2 Insp/Exp; Good Aeration 141-160 46-60
3 <90% Severe 1:3 Insp/Exp; Poor Aeration >160 >60
Age 3-6 Years
Points SpO2 Acces Musc Use I:E Wheeze HR RR
0 >95% None 2:1 None; Good Aeration ≤100 ≤30
1 93-95% Mild 1:1 End Exp 101-120 31-45
2 90-92% Moderate 1:2 Insp/Exp; Good Aeration 121-140 46-60
3 <90% Severe 1:3 Insp/Exp; Poor Aeration >140 >60
Age ≥6 Years
Points SpO2 Acces Musc Use I:E Wheeze HR RR
0 >95% None 2:1 None; Good Aeration ≤100 ≤20
1 93-95% Mild 1:1 End Exp 101-120 21-35
2 90-92% Moderate 1:2 Insp/Exp; Good Aeration 121-140 36-50
3 <90% Severe 1:3 Insp/Exp; Poor Aeration >140 >50
  • MPIS <7 - Mild exacerbation
  • MPIS 7-10 - Moderate exacerbation
  • MPIS ≥10 - Severe exacerbation

Acute Management

Albuterol

Favor continuous nebulization to decrease the chance of admission when compared to intermittent dosing[10]

  • Nebulizer
    • Intermittent: 2.5-5mg q20min, three doses are traditionally given back to back, then repeat as needed.
    • Continuous: 0.5mg/kg/hr (max 15mg/hr)[11]
  • MDI
    • 4-8 puffs q20min given in first hour, then q1-4hr as needed

Ipratropium

  • 0.25-0.5mg q20min, given with the first three doses of albuterol, it is shown to reduce admission.

Steroids

Should be given in the first hour with effects to reduce admission[12]

  • Dexamethasone
    • 0.6 mg/kg PO or IV (max 16 mg); consider 2nd dose 24-36hrs later.[13][14][15]
      • PO and IV have equal efficacy. Giving the IV form by mouth is typically better tolerated by young children (same dosing)
    • Both 1 and 2 dose regimens as effective as prednisone or prednisolone in children [16][17]
  • Prednisone
    • 1-2mg/kg/day (60mg max) in one or two divided doses for 3-5 days
  • Methylprednisolone
    • 1mg/kg IV q 4–6hr
    • Only use IV if cannot tolerate PO since equal effectiveness between dosing routes[18]

Magnesium

  • Dose: 50mg/kg IV, max 2-4 g over 20 mins with close blood pressure monitoring
  • Smooth muscle relaxant
  • Duration of action approximately 20 min
  • In patients with moderate to severe asthma there is a decreased rate of admission with an NNT of 2[12]

Beta-agonist

  • Epinephrine
    • 1:1000 0.01mg/kg (max 0.3mg) IM, repeat as needed
  • Terbutaline
    • Given SQ, usual dose 0.01mg/kg up to 0.3mg.
    • Longer-acting beta2-agonist promoting bronchodilation

Assisted Ventilation

  • Non-invasive ventilation
    • Consider as alternative to intubation
    • Alleviates muscle fatigue which leads to larger tidal volumes
    • Maximize inspiratory support
      • Delta pressure 10
      • PEEP >4
    • May benefit from ketamine or dexmedetomidine to mildly sedate and allow the interface

Intubation

  • Push pull (bolus) fluids prior to intubation to maximize the patient's preload and ideally decrease the chance of the patient arresting
  • Consider induction with ketamine
    • Provides bronchodilation and sedation however it does promote secretions
    • Ketamine is the preferred induction agent for intubation in an asthmatic.
    • Dosing 1-2 mg/kg
  • Ventilation of asthmatic patients requires deep sedation
  • Ventilation settings
    • Assist-control ventilation
    • Resp rate
      • Start slow to avoid air-trapping and allow for longer expiration time
      • Consider I:E ratio of 1:2 or 1:3
    • Plateau pressure ideally <30
    • May require "permissive hypoventilation" and permissive hypercarbia and acidosis
      • Low peak pressure/avoidance of breath stacking more important than correcting CO2 [19]
    • Tidal volume 6-8cc/kg ideal wt
    • PEEP >4
    • Flow rate 80-100L/min
    • Keep FiO2 minimum to achieve SpO2 > 90%
  • Use bronchodilators even when intubated
  • Many patients require a continuous paralytic infusion for the first 24+ hrs of intubation

Outpatient Treatment

<6 Years Old

  • Reliever medication (all): SABA
  • Maintenance inhaler (if indicated): ICS
    • Initiate for children with asthma symptoms:
      • >2 times per week, OR
      • ≥1 severe exacerbations required unscheduled medical care in the previous year (i.e., patients seen in the ED)
  • Inhaler of choice is pressurized metered-dose inhaler (pMDI) via spacer
    • Face mask for children <3 years old

≥6 Years Old

Every patient ≥6 years old with asthma should be on an inhaled corticosteroid (ICS) or a combination medication with an inhaled corticosteroid; treatment with a short-acting beta2-agonist (SABA) alone is no longer recommended.[20]

Preferred Approach

  • Single medication: low-dose ICS-formoterol (i.e., Symbicort)[21]
    • Use as both rescue and maintenance inhaler (simplifies and increases compliance)
    • GINA recommends budesonide or beclomethasone as the inhaled corticosteroid, and formoterol as the long-acting beta2-agonist. The only U.S. formulation meeting this recommendation is Symbicort (budesonide-formoterol).

Alternative Approach

Use only if preferred approach above (i.e., LABA) is not available

  • Medications:
    • Maintenance inhaler: ICS
    • Reliever: ICS-SABA or SABA
  • Treatment plan: if reliever is SABA, take ICS whenever SABA is used

Example Asthma Outpatient Medications

Non-Pharmacological Treatment

In addition to, not as a replacement for, medical management.[22]

  • Smoking cessation
  • Physical activity
  • Investigate for occupational asthma
  • Medication reactions (avoid aspirin)

Disposition

Disposition is based on response to treatment (and remaining symptoms after treatment)

Discharge

  • Often, patients will still have mild wheezing, but should have complete resolution of tachypnea, hypoxia, and work of breathing if being discharged
  • A short course of glucocorticoids decreases chance of relapse[23]

Admit

  • If symptoms persist or are severe
  • Peak flow measurements are typically not performed in the ED; however, if performed:
    • Predicted = (30 x age (yrs)) + 30
    • PEF >70% predicted → high likelihood of successful discharge
    • PEF <40% predicted → should be admitted

See Also

External Links

References

  1. ↑ Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention, 2025. Updated 15 November 2025. Available from: www.ginasthma.org
  2. ↑ Patel NH, et al. The Practice of Obtaining a Chest X-Ray in Pediatric Patients Presenting With Their First Episode of Wheezing in the Emergency Department - A Survey of Attending Physicians. Pediatric Emergency Care 36(1):p 16-20, January 2020. | DOI: 10.1097/PEC.0000000000002015
  3. ↑ Ralston SL, et al. Clinical Practice Guideline: The Diagnosis, Management, and Prevention of Bronchiolitis. Pediatrics (2014) 134 (5): e1474–e1502. https://doi.org/10.1542/peds.2014-2742.
  4. ↑ Sakr M, et al. A Quality Improvement Initiative to Minimize Unnecessary Chest X-Ray Utilization in Pediatric Asthma Exacerbations. Pediatr Qual Saf. 2024 Apr 3;9(2):e721. doi: 10.1097/pq9.0000000000000721.
  5. ↑ Sher et al. Int J Crit Care Emerg Med 2022, 8:142
  6. ↑ Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention, 2025. Updated 15 November 2025. Available from: www.ginasthma.org
  7. ↑ Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention, 2025. Updated 15 November 2025. Available from: www.ginasthma.org
  8. ↑ Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention, 2025. Updated 15 November 2025. Available from: www.ginasthma.org
  9. ↑ Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention, 2025. Updated 15 November 2025. Available from: www.ginasthma.org
  10. ↑ Camargo CA et al. Continuous versus intermittent beta- agonists for acute asthma. Cochrane Database Syst Rev. 2003;(4):CD001115. PMID: 14583926.
  11. ↑ National Asthma Education and Prevention Program (NAEPP), “Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma,” Clinical Practice Guidelines, National Institutes of Health, National Heart, Lung, and Blood Institute, NIH Publication No. 08-4051, prepublication 2007; available at http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm.
  12. ↑ 12.0 12.1 Rowe BH et al. Magnesium sulfate for treating exac- erbations of acute asthma in the emergency depart- ment. Cochrane Database Syst Rev. 2000;(2):CD001490. PMID: 10796650.
  13. ↑ Cross KP, et al. Single-dose dexamethasone for mild-to-moderate asthma exacerbations. Can Fam Physician. 2011 Oct; 57(10): 1134–1136.
  14. ↑ Shenoi RP, Timm N; Committee on Drugs; Committee on Pediatric Emergency Medicine. Drugs used to treat pediatric emergencies. Pediatrics. 2020;145(1):e20193450. [PubMed 31871244]
  15. ↑ Dexamethasone versus prednisone for children receiving asthma treatment in the paediatric inpatient population: protocol for a feasibility randomised controlled trial. BMJ Open. http://dx.doi.org/10.1136/bmjopen-2018-025630
  16. ↑ Keeney, et al. Dexamethasone for Acute Asthma Exacerbations in Children: A Meta-analysis. Pediatrics. 2013-2273
  17. ↑ Cronin et al. "A Randomized Trial of Single-Dose Oral Dexamethasone Versus Multidose Prednisolone for Acute Exacerbations of Asthma in Children Who Attend the Emergency Department." Annals of EM. May 2016. 67(5):593-601
  18. ↑ Rowe BH, Keller JL, Oxman AD. Effectiveness of steroid therapy in acute exacerbations of asthma: a meta-analysis. Am J Emerg Med. Jul 1992;10(4):301-10
  19. ↑ Darioli, et al. Mechanical Controlled hypoventilation in status asthmaticus. Am Rev Respir Dis. 1984; 129 (3) 385-7
  20. ↑ Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention, 2025. Updated 15 November 2025. Available from: www.ginasthma.org
  21. ↑ Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention, 2025. Updated 15 November 2025. Available from: www.ginasthma.org
  22. ↑ Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention, 2025. Updated 15 November 2025. Available from: www.ginasthma.org
  23. ↑ Chapman K. Effect of a short course of prednisone in the prevention of early relapse after the emergency room treatment of acute asthma. NEJM. 1991;324(12):788
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