Pediatric Asthma Exacerbation

Key considerations: Status asthmaticus, Foreign body aspiration mimicking wheeze, Anaphylaxis

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history: Current medications and adherence; Frequency of exacerbations and ED visits; Previous ICU admissions or intubations; Trigger identification: URI, allergens, exercise, cold air; Home peak flow readings; Steroid courses in past year; exam: Respiratory rate, SpO2, work of breathing; Wheeze: expiratory (mild), inspiratory+expiratory (moderate), absent (severe — no air movement); Accessory muscle use, retractions; Air entry assessment bilaterally; Ability to speak: full sentences (mild), phrases (moderate), words only (severe); Pulsus paradoxus >10mmHg (moderate-severe); labs: VBG if severe: CO2 rising = impending failure; No routine labs needed for typical exacerbation; imaging: CXR NOT routinely needed unless: first episode of wheeze, fever with consolidation suspected, subcutaneous emphysema, or not responding to treatment; bedside: Continuous SpO2 monitoring; Peak flow if >6 years and able to perform

immediate: Albuterol 2.5mg nebulized q20min x3 (or MDI 4-8 puffs with spacer); Ipratropium 250-500mcg nebulized with first 3 albuterol doses; Dexamethasone 0.6mg/kg PO (max 16mg) — single dose; general: Reassess after each albuterol treatment; Transition to q1-2h albuterol if improving; Space to q4h before considering discharge; specific: diagnosis: Moderate exacerbation; steps: Albuterol + ipratropium q20min x3; Dexamethasone 0.6mg/kg PO x1; Reassess after 1 hour of treatment; If improving, continue albuterol q1-2h, space to q4h before discharge; diagnosis: Severe exacerbation; steps: Continuous albuterol nebulization 10-20mg/hr; Ipratropium 500mcg q20min x3; Magnesium sulfate 50mg/kg IV over 20 min (max 2g); IV methylprednisolone 2mg/kg if unable to take PO; Prepare for BiPAP or intubation if worsening; diagnosis: Status asthmaticus / impending respiratory failure; steps: Continuous albuterol + IV magnesium; Terbutaline 10mcg/kg IV loading dose then 0.1-10mcg/kg/min drip; Ketamine 1-2mg/kg IV as bronchodilator for RSI; Intubation: use ketamine for induction (bronchodilator properties); PICU admission

admit: Persistent respiratory distress after 3 rounds of treatment; SpO2 <92% after treatment; Previous near-fatal asthma or frequent admissions; Poor social situation or medication access concerns; Rising CO2 on VBG; discharge: Good response to treatment (speaking full sentences, no retractions); SpO2 ≥94% on room air for >60 minutes; Can space albuterol to q4h; Asthma action plan reviewed with family; Follow-up within 1-2 weeks; consults: PICU for status asthmaticus; Pulmonology/allergy for poorly controlled asthma

Single dose dexamethasone 0.6mg/kg PO is non-inferior to 5-day prednisone — better compliance, less vomiting
A normal or rising CO2 in an asthmatic child is OMINOUS — they should be hyperventilating (low CO2). Normal CO2 = tiring out
MDI with spacer is as effective as nebulizer for mild-moderate asthma — and faster to administer
Magnesium sulfate IV is most effective in severe exacerbations — give it early, not as a last resort

GINA Pediatric Asthma Guidelines 2024, NAEPP EPR-3, AAP Clinical Practice Guidelines. Last reviewed: 2024-11-01