Management of asthma exacerbations in children <12 years old in the emergency department

PIS: pulmonary index score; SpO₂: pulse oxygen saturation; ICU: intensive care unit; SVN: small-volume nebulizer; MDI: metered-dose inhaler; pCO₂: partial pressure of carbon dioxide.
* A severe exacerbation is characterized by 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%.
¶ 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), SpO₂ <90%, and respiratory acidosis (elevated pCO₂ noted on venous, arterial, or capillary blood gas sample).
Δ A moderate exacerbation is characterized by 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%.
◊ A mild exacerbation in characterized by normal alertness, slight tachypnea, expiratory wheezing only, a mildly prolonged expiratory phase, minimal accessory muscle use, and an oxygen saturation of >95%.
§ An alternative in children with poor inspiratory flow or who cannot cooperate with nebulized therapy is intramuscular or subcutaneous epinephrine or terbutaline.
¥ Patient may need to be transported to a hospital with the appropriate pediatric resources.
‡​ Alternative diagnoses or comorbidities include, but are not limited to, upper airway obstruction, pneumothorax, cardiac tamponade, sepsis, pneumonia, heart failure, and mediastinal mass. Refer to UpToDate topics on these disorders and on acute respiratory distress in children.
† Refer to UpToDate topics on inpatient and ICU management of severe asthma exacerbations in children.
** Good response includes resolution of symptoms or marked improvement in a patient/family with good adherence and understanding of asthma management. Marked improvement is manifested by diminished or absent wheezing and retractions and increased aeration that is sustained for at least 60 minutes after the most recent albuterol dose. Children who were moderately to severely ill on arrival should demonstrate a more sustained period of improvement before discharge to home. Patients with incomplete response have continued mild-to-moderate symptoms and do not meet criteria for discharge.
¶¶ Discharge medications include an inhaled albuterol (every 4 to 6 hours for 3 days and then weaned as tolerated), oral glucocorticoids if given with initial treatment (3- to 5-day course for most children), and resumption or initiation of inhaled glucocorticoids if controller therapy is indicated. Patients should also receive discharge education of medications (purpose, side effects, proper administration technique), a written asthma action plan, prevention of exacerbations, and follow-up instructions.