INTRODUCTION — More than 6.5 million children in the United States have asthma , which accounts for nearly 550,000 emergency department (ED) visits, 2,500,000 clinician office visits, and 80,000 hospitalizations each year [2,3]. Although exacerbations are common, most are mild and can be managed successfully at home. Children with severe exacerbations or those who fail to improve with outpatient therapy may need to be evaluated and treated in an urgent care facility or ED, and some will need to be admitted to the hospital for further management.
Inpatient management of acute asthma exacerbations in children is discussed here. Outpatient and intensive care unit (ICU) management are discussed separately:
OVERVIEW — Most children who require admission for asthma are initially treated in the emergency department (ED), although some are admitted directly from clinicians' offices. Thus, inpatient treatment is typically a continuation of therapies and monitoring that were started in the ED (algorithm 1) . Patients usually have received at least three albuterol treatments, often combined with ipratropium, systemic glucocorticoids, and supplemental oxygen, before arrival to the inpatient unit. The criteria for admission are discussed in detail separately. (See "Acute asthma exacerbations in children younger than 12 years: Emergency department management", section on 'Hospitalization'.)
Communication among the referring clinicians, providers in the ED, and those caring for the patient in the hospital is essential to ensure that treatments ordered in the ED are not missed or duplicated during the transfer of care.
Inpatient management consists of [5-8]:
●Initial clinical assessment followed by ongoing monitoring for change in clinical status (see 'Initial assessment and ongoing monitoring' below)
●Management of bronchospasm, inflammation, and hypoxemia with inhaled short-acting beta agonists (SABAs; such as albuterol/salbutamol) and ipratropium, systemic glucocorticoids, and supplemental oxygen, respectively (see 'Management of bronchospasm' below and 'Management of inflammation' below and 'Management of hypoxemia' below)
●Discharge planning, including asthma education, assessment for medication equipment need, and initiation or adjustment of controller agents, based upon classification of severity and/or control prior to discharge (table 1A-B) (see 'Discharge criteria' below and "Asthma in children younger than 12 years: Management of persistent asthma with controller therapies" and "Asthma in children younger than 12 years: Overview of initiating therapy and monitoring control")
INITIAL ASSESSMENT AND ONGOING MONITORING — Clinical status and response to therapy must be monitored frequently during treatment for acute asthma exacerbation [5,9-17]. The degree of monitoring depends upon the severity of the exacerbation and the treatments required. The most important parts of the clinical evaluation include assessment of respiratory rate, work of breathing (retractions), pulse oximetry, and the lung exam. Heart rate and rhythm need to be followed given the risk of cardiac side effects (tachycardia and less common but more severe cardiac side effects including diastolic hypotension, cardiac dysrhythmias, and myocardial ischemia) with beta agonists [18-22]. Asthma scores can be used to evaluate response to treatment. Pulmonary function testing, chest radiographs, and laboratory studies are of limited use in most children hospitalized for asthma exacerbations. (See "Acute severe asthma exacerbations in children younger than 12 years: Intensive care unit management", section on 'Severity assessment' and "Acute asthma exacerbations in children younger than 12 years: Overview of home/office management and severity assessment", section on 'Assessment of exacerbation severity'.)
Administration of supplemental oxygen (100 percent fraction of inspired oxygen [FiO2], given either separately or with nebulized medications) may mask worsening asthma and delay recognition until the episode is more severe and potentially life threatening. Thus, parameters other than pulse oximetry should be relied upon to assess deterioration in patients on supplemental oxygen.
Clinical assessment — The clinical evaluation includes assessment of:
●Vital signs, particularly the respiratory rate
●Accessory muscle use
●Ability to complete full sentences
●Level of consciousness
Signs of impending respiratory failure — Signs of impending respiratory failure include (table 2):
●Marked tachypnea or inability to maintain respiratory effort due to fatigue and/or poor air movement with a prolonged expiratory phase (respiratory rate may be inappropriately normal to low and breath sounds reduced or inaudible)
●Change in mental status (eg, lethargy, agitation)
●Worsening hypoxemia (peripheral arterial oxygen saturation [SpO2] <90 percent)
●Carbon dioxide retention (partial pressure of CO2 [PaCO2] >40 mmHg) (see 'Laboratory studies' below)
These patients should be transferred to the pediatric intensive care unit (PICU). (See "Acute severe asthma exacerbations in children younger than 12 years: Intensive care unit management".)
Frequency and extent of evaluation — Patients should be assessed immediately upon arrival to the inpatient unit. Clinical findings should be compared with those obtained in the emergency department (ED) to determine whether the patient is improving or worsening.
Monitoring protocols vary from institution to institution and also depend upon the patient's clinical status and level of treatment. On an inpatient unit, patients are typically evaluated before and after treatments when on intermittent therapy or every one to two hours while receiving continuous inhaled beta agonist therapy to determine their response to therapy. Patients receiving continuous inhaled beta agonist therapy additionally should be on continuous cardiopulmonary monitoring. Such monitoring should be continued until the patient is tolerating interval treatments every three hours, at which time the patient can be switched to intermittent monitoring. The frequency of monitoring vital signs and oxyhemoglobin saturation are decreased as the patient improves and inhalation treatments are spaced to every four hours. At minimum, vital signs and oxygen saturation should be assessed every four hours.
Asthma scores — Several scoring systems have been developed to standardize and facilitate assessment of initial severity of an asthma exacerbation in children. These scores also can be used to evaluate the response to treatment and guide changes in the frequency of bronchodilator (beta agonist) administration. These scores are reviewed in greater detail separately. (See "Acute asthma exacerbations in children younger than 12 years: Emergency department management", section on 'Assessment of severity' and "Acute asthma exacerbations in children younger than 12 years: Overview of home/office management and severity assessment", section on 'Asthma severity scores'.)
Studies reserved for select patients
Pulmonary function testing — We generally do not use pulmonary function measurements to monitor children with acute exacerbations. Pulmonary function testing may be useful in the cooperative child, once stabilized, whose asthma diagnosis or level of control is in doubt. (See "Overview of pulmonary function testing in children", section on 'Spirometry'.)
Imaging — Chest radiographs are not routinely necessary for children who are admitted to the hospital with acute asthma exacerbations . However, they may be warranted in patients with:
●Acute worsening of clinical status (to look for potential complications of asthma: pneumothorax, pneumomediastinum, and pneumonia). Signs of such complications include fever ≥38.5ºC, focal examination findings (eg, crackles or decreased aeration), chest pain, unilateral absence of breath sounds, and/or extreme tachypnea or tachycardia.
●Lack of response to asthma therapy (to look for other processes that can mimic asthma, such as vascular ring, inducible laryngeal obstruction , foreign body aspiration) (table 3). (See "Vascular rings and slings" and "Airway foreign bodies in children" and "Evaluation of wheezing in infants and children" and "Inducible laryngeal obstruction (paradoxical vocal fold motion)".)
Laboratory studies — Routine laboratories are not necessary for children who are hospitalized for acute asthma exacerbation and receiving intermittent inhalation therapy. Children receiving continuous albuterol nebulization are at risk of transient hypokalemia, hypophosphatemia, and hypomagnesemia. Although these decreases are rarely of clinical importance in children, we typically measure serum electrolytes daily in patients receiving continuous albuterol, particularly those who have been taking diuretics regularly, have coexistent cardiovascular disease, and/or have a known predilection to electrolyte disturbances. (See "Causes of hypokalemia in adults", section on 'Elevated beta-adrenergic activity' and "Acute severe asthma exacerbations in children younger than 12 years: Intensive care unit management".)
Hypocarbia and respiratory alkalosis are frequently seen initially in children with asthma exacerbations due to an increased respiratory rate. Carbon dioxide (CO2) retention occurs only at extreme degrees of obstruction and has been found in people with near-fatal asthma . A venous or capillary blood gas is useful in patients with asthma exacerbations and may be particularly helpful in patients who also have underlying lung disease (eg, bronchopulmonary dysplasia, cystic fibrosis, obstructive sleep apnea) and are on supplemental oxygen since these patients are at higher risk for hypercarbia. An arterial blood gas is indicated in patients with signs of impending respiratory failure. A normal or rising CO2 level in a patient with tachypnea and respiratory distress is a concerning finding that suggests impending respiratory failure. Hypercarbia (PCO2 ≥45 mmHg) despite maximal medical therapy is an indication for intubation and mechanical ventilation . (See 'Management of bronchospasm' below and 'Signs of impending respiratory failure' above and "Acute severe asthma exacerbations in children younger than 12 years: Endotracheal intubation and mechanical ventilation", section on 'Indications'.)
INITIAL THERAPY — We recommend that children who are admitted to the hospital with an acute asthma exacerbation receive therapy with inhaled short-acting beta agonists (SABAs; eg, albuterol/salbutamol) . The frequency of dosing depends upon the severity of the exacerbation and the patient's response to treatment. Children with moderate exacerbations usually require inhaled SABAs every one to three hours. In addition to the regularly scheduled beta agonist treatment, "as needed" treatments should be available for episodes of acute bronchospasm or worsening respiratory distress. Treatments are typically switched to continuous nebulized therapy if patients require treatment more often than every two hours. (See 'Clinical assessment' above and "Acute asthma exacerbations in children younger than 12 years: Overview of home/office management and severity assessment", section on 'Asthma severity scores'.)
We also recommend systemic glucocorticoids for children with acute asthma exacerbation who require hospitalization. Oral forms (eg, prednisone/prednisolone or dexamethasone) are preferred over intramuscular or intravenous forms. Most children will have received their first dose in the acute care setting. (See 'Management of inflammation' below and "Acute asthma exacerbations in children younger than 12 years: Emergency department management", section on 'Systemic glucocorticoids'.)
Humidified oxygen should be provided as needed to maintain an oxygen saturation of ≥92 percent. (See 'Management of hypoxemia' below.)
THERAPY ADJUSTMENT — Patients who do not improve or who clinically worsen need more frequent or additional treatments. Patients who are stable but not significantly improved should continue on the same frequency of treatments. Patients with clear improvement in clinical parameters should have the interval between their treatments increased. Titrating supplemental oxygen delivery is reviewed below. (See 'Clinical assessment' above and 'Management of hypoxemia' below.)
Some institutions have established multidisciplinary protocols (clinical pathways or care paths) for increasing or decreasing the frequency of inhaled short-acting beta agonist (SABA) treatments based upon asthma scores or other methods of assessment performed largely by respiratory therapists and/or nurses [4,26,27]. One example of a protocol that uses an asthma score is the modified Pediatric Respiratory Assessment Measure (PRAM) (table 4) . Another score used is the Pulmonary Index Score (PIS) (table 5) . The effect of such protocols was evaluated in a systematic review, which found that the use of clinical pathways appeared to be effective in reducing length of stay and hospital costs associated with pediatric asthma [5,30]. However, they were less effective in reducing readmission rates or affecting clinical outcomes, such as increasing asthma education and the use of controller medications or spacers .
Escalation of therapy — In children admitted to the hospital with an asthma exacerbation, we switch from intermittent inhaled beta agonist treatments to continuous nebulized therapy if there is minimal to no improvement after several intermittent treatments and/or treatments are required more frequently than every two hours. Some hospitals only permit continuous administration in the intensive care unit (ICU). Patients treated with continuous therapy who do not improve rapidly should be monitored closely for worsening respiratory status. Delivery systems are discussed separately. (See 'Initial assessment and ongoing monitoring' above and "Acute severe asthma exacerbations in children younger than 12 years: Intensive care unit management".)
Failure to respond — Some patients fail to improve or worsen despite frequent or continuous administration of inhaled SABAs and systemic glucocorticoids. Reasons for worsening or failure to improve include severe asthma, development of a complication (eg, atelectasis, pneumothorax, pneumomediastinum, pneumonia), or incorrect diagnosis (ie, the patient's symptoms are caused by a process other than asthma) (table 3). Obtaining a chest radiograph is warranted in these patients. Findings on chest radiographs and/or on lung examination (eg, crackles or localized decreased breath sounds with pneumonia or diminished breath sounds, hyperresonant percussion, and decreased vocal fremitus on the affected side in the case of a pneumothorax) can help to distinguish among these possibilities. Consultation with an asthma specialist may also help determine the underlying cause of the patient's worsening status or lack of improvement. (See "Spontaneous pneumothorax in children", section on 'Physical examination' and 'Imaging' above and "Evaluation of wheezing in infants and children" and "Community-acquired pneumonia in children: Clinical features and diagnosis", section on 'History and examination' and 'Asthma specialist' below.)
Indications for PICU/anesthesia consult — A pediatric intensive care unit (PICU) and/or anesthesia consult should be obtained for children receiving continuous nebulized albuterol therapy who have increasing fatigue, increasing work of breathing, CO2 retention, or worsening hypoxemia. These children are at risk for further decompensation and may need noninvasive ventilation or intubation. Most will need to be transferred to the PICU for closer monitoring and more aggressive treatment. (See 'Signs of impending respiratory failure' above and "Acute severe asthma exacerbations in children younger than 12 years: Intensive care unit management".)
Weaning of therapy — Children receiving continuous nebulized albuterol are switched to intermittent therapy given every two to three hours when they have improving asthma parameters or score. Weaning or spacing out therapies is performed when indications of clinical improvement are present based upon close monitoring of symptoms and vital signs. Standardized Clinical Assessment and Management Plans (SCAMPs) and other such pathways have been used to more quickly wean patients off of continuous nebulized therapy [31,32]. (See 'Clinical assessment' 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' and "Acute asthma exacerbations in children younger than 12 years: Overview of home/office management and severity assessment", section on 'Asthma severity scores'.)
ELEMENTS OF TREATMENT — Asthma treatment includes inhaled short-acting beta agonists (SABAs or beta agonists) (table 6), systemic glucocorticoids (such as prednisone/prednisolone or dexamethasone) (table 7), and supplemental oxygen when needed. Our approach is consistent with expert guidelines [5,33,34].
Management of bronchospasm
●Inhaled SABAs – SABAs (eg, albuterol/salbutamol) are one of the primary therapies for acute asthma exacerbations. (See "Beta agonists in asthma: Acute administration and prophylactic use".)
•Dosing and administration – The National Asthma Education and Prevention Program (NAEPP) has published doses for common medications used during asthma exacerbation . However, weight-based dosing of inhaled SABAs may not be appropriate for young children, because of the low deposition of medication in the lungs [4,35]. Standard doses, such as 2.5 mg of nebulized albuterol for children who weigh less than 30 kg and 5 mg for children who weigh more than 30 kg, may be used . Common metered-dose inhaler (MDI) doses for albuterol in children range from four to eight puffs, although typically the dose does not exceed six puffs.
SABAs are administered continuously (via nebulizer) or intermittently (via MDI with valved holding chamber/spacer or nebulizer) [18,35-41]. All nebulized treatments should be given with oxygen (usually 100 percent fraction of inspired oxygen [FiO2]) as the driving gas rather than with compressed air since most patients admitted for an asthma exacerbation will have some degree of hypoxemia. A flow rate of 6 to 8 L/min produces the optimal particle size for airway deposition.
•Efficacy – Data in adults indicate that continuous nebulized albuterol is as efficacious as intermittent nebulization [41,42]. Continuous nebulized albuterol also appears to be safe and effective in children [18,37-40,43,44]. In one small, randomized trial, children with severe status asthmaticus on continuous albuterol improved more rapidly and no longer had impending respiratory failure within a median of 12 hours (range 4 to 24) compared with 18 hours (range 12 to 24) in the intermittent albuterol group . Results from another small, randomized trial suggest that continuous nebulization of levalbuterol (levosalbutamol), which consists of only the R-enantiomer of albuterol [45,46], is no more effective than albuterol, which is a racemic mixture of the R- and S-enantiomers [47,48]. (See "Beta agonists in asthma: Acute administration and prophylactic use", section on 'Levalbuterol'.)
•Adverse effects – Potential adverse effects of beta-agonist therapy include transient decreases in serum potassium, magnesium, and phosphate . These decreases are rarely of clinical importance in children. Other adverse effects include an increased heart rate and decreased diastolic blood pressure and mean arterial pressure, which were seen during nebulization compared with measurements at initiation of therapy or at hospital discharge in one study . (See 'Laboratory studies' above and "Causes of hypokalemia in adults", section on 'Elevated beta-adrenergic activity' and "Clinical manifestations and treatment of hypokalemia in adults".)
The three most common adverse drug events (ADEs) associated with intermittent SABAs are anxiety (range 0 to 52 percent, levalbuterol), tachycardia (range 13.6 to 14 percent, salbutamol), and supraventricular ectopy (range 0 to 14 percent, salbutamol) . With continuous SABAs, 50 percent of ADEs affected the cardiovascular system, with the three most common ADEs being tachycardia (range 94 to 95 percent, salbutamol), diastolic hypotension (range 66 to 98 percent, salbutamol), and lactic acidosis (80.6 percent, salbutamol).
●Other bronchodilators – Other bronchodilators (eg, ipratropium bromide, magnesium sulfate, terbutaline, epinephrine) are used in the emergency department (ED) or intensive care unit (ICU) settings, but not routinely in the regular inpatient unit, and are discussed separately. (See "Acute asthma exacerbations in children younger than 12 years: Emergency department management", section on 'Management of bronchospasm' and "Acute severe asthma exacerbations in children younger than 12 years: Intensive care unit management", section on 'Bronchodilators'.)
Management of inflammation
●Systemic glucocorticoids – Systemic glucocorticoids are an important component of the management of asthma exacerbations due to their ability to decrease airway inflammation and secretions by reducing the production of inflammatory mediators, capillary permeability, and the activity of lymphocytes . In acute severe asthma, the administration of glucocorticoids also enhances the bronchodilator response to beta agonists by reversing desensitization and downregulation of beta receptors . In the rare cases in which glucocorticoids are contraindicated (eg, hypersensitivity reaction, varicella infection, herpes simplex keratitis), the severity of bronchospasm must be weighed against the reason for the contraindication.
•Dosing and administration – Glucocorticoids may be given as prednisone, prednisolone, methylprednisolone, or dexamethasone, all of which have been shown to decrease inflammation in asthma . They are similar in how well and how quickly (one to two hours after an enteral dose) they decrease asthma symptoms. The plasma half-life, which correlates with the antiinflammatory potency of glucocorticoids, is longer for dexamethasone than either prednisone or prednisolone (table 8). Dosing varies from institution to institution but is typically 2 mg/kg/day of prednisone, prednisolone, or methylprednisolone orally in divided doses given twice daily for a total of five days (with a maximum dose of 60 mg per day) . An alternative is to administer as a single dose given once daily. Dexamethasone dosing is typically 0.3 to 0.6 mg/kg (maximum daily dose of 8 to 16 mg), given as a single daily oral dose, a twice-daily split oral dose, or a single daily intramuscular dose for a total of two days. (See "Acute asthma exacerbations in children younger than 12 years: Emergency department management", section on 'Systemic glucocorticoids' and "Pharmacologic use of glucocorticoids".)
Oral administration is preferred to intravenous administration since it is less invasive and equally efficacious [5,54]. Glucocorticoids can be given intravenously, or intramuscularly in the case of dexamethasone, if the patient cannot tolerate oral administration (eg, due to gastrointestinal impairment or repeated spitting or vomiting of doses).
Clinical experience suggests a longer course (eg, 7 to 10 days) may be beneficial for patients who have a severe exacerbation that is slow to respond to treatment or patients who have had more than one exacerbation requiring oral glucocorticoids in the previous two months. In addition, patients whose control regimen includes oral glucocorticoids may benefit from a >10 day course.
We taper systemic glucocorticoid therapy in patients who require a course longer than 14 to 21 days . Glucocorticoid therapy may be tapered in a number of ways. We typically decrease the dose by 50 percent every two to three days (ie, 2 mg/kg/day for days 1 to 10, 1 mg/kg/day for days 11 to 12, 0.5 mg/kg/day for days 13 to 14, and 0.25 mg/kg/day for days 15 to 16). A more gradual taper may be indicated for patients receiving chronic oral glucocorticoid therapy. (See "Glucocorticoid withdrawal".)
•Efficacy – Studies of ED management of acute asthma exacerbations in children suggest that a two-day course of oral dexamethasone is as effective as a five-day course of oral prednisone with regard to return visits to the ED, hospital admission or readmission, and persistence of symptoms and has fewer side effects [55,56]. There are no studies that have examined the use of dexamethasone in the inpatient setting, although it is used in some centers [53,57]. A systematic review of oral glucocorticoids for acute asthma exacerbations in adults and children found no difference in outcomes between prednisolone and dexamethasone , nor between shorter and longer courses or lower or higher doses of systemic glucocorticoids. However, meta-analyses were limited by the heterogeneity among interventions and outcomes.
•Adverse effects – Glucocorticoids have adverse effects on many organ systems (table 9) . Even short-term use of oral glucocorticoids can result in transient adrenal suppression, an effect that appears to be dose related. Adrenal suppression following treatment with dexamethasone has not been well studied. The adverse effects of glucocorticoids are dose and duration dependent and are reviewed in greater detail separately. (See "Major adverse effects of systemic glucocorticoids".)
●Inhaled glucocorticoids – Inhaled glucocorticoids are not as effective as systemic glucocorticoids for severe asthma exacerbations and should not be used as a substitute for systemic glucocorticoids [5,59-61]. However, previous home treatment with inhaled glucocorticoids is typically continued during an admission while the patient is on systemic glucocorticoids. It is also not necessary to wait until a patient has completed a course of systemic glucocorticoids before starting inhaled glucocorticoids. The additional effects of inhaled glucocorticoids while on systemic glucocorticoids are insignificant, but the hope is that use during the admission will promote adherence to outpatient therapy after discharge. This also allows for review of administration technique and correction of any errors. (See 'Discharge medications' below.)
Management of hypoxemia — Patients with acute asthma have ventilation-perfusion (V/Q) mismatch, which may lead to hypoxemia. Beta agonists may worsen this mismatch by causing increased blood flow in areas of the lung that are poorly ventilated. Oxyhemoglobin saturation may decrease by ≥5 percent in the first 30 minutes after an albuterol treatment .
Supplemental oxygen (humidified) should be provided by nasal cannula or facemask as needed to maintain an oxygen saturation of ≥92 percent . All nebulized medications should be delivered with oxygen, generally at a flow rate of 6 to 8 L/min. Small children should be placed on infant flow meters to allow accurate weaning below 1 L/min of flow. (See "Continuous oxygen delivery systems for the acute care of infants, children, and adults".)
●Titration of supplemental oxygen – We typically adjust the oxygen flow rate as follows, depending upon the oxygen saturation :
•≥94 percent – Decrease the flow rate by one-quarter L/minute for children who weigh <15 kg and by one-half L/minute for children who weigh ≥15 kg.
•91 to 94 percent – Continue the same flow rate.
•≤90 percent – Increase the flow rate to achieve a saturation of 91 to 94 percent.
●Monitoring – Patients receiving supplemental oxygen therapy should be monitored with continuous pulse oximetry . Oxygen saturation should be noted at the time of each patient assessment by the nurse, respiratory therapist, or clinician. Oxygen saturation should be rechecked 5 to 10 minutes after changes to the oxygen flow rate. The oxygen flow rate can continue to be decreased further if the patient's oxygen saturation remains ≥94 percent each time it is rechecked. Changes to the oxygen flow rate should be documented appropriately. (See 'Initial assessment and ongoing monitoring' above.)
Once patients are no longer receiving supplemental oxygen therapy, oximetry should be monitored 5 to 10 minutes after discontinuation, just before the next inhaled beta-agonist treatment, and while the child is sleeping for the first sleep period after discontinuation . Pulse oximetry can be discontinued if the oxygen saturation remains ≥92 percent for each of these situations.
Children with underlying lung disease (eg, bronchopulmonary dysplasia, cystic fibrosis, obstructive sleep apnea) should also be monitored closely for hypercarbia while receiving supplemental oxygen. (See 'Laboratory studies' above.)
Therapies reserved for special circumstances
ICU care — Inpatient use of systemic beta agonists, methylxanthines, and magnesium sulfate is reserved for patients with severe exacerbations who are admitted to the intensive care unit (ICU) since use of these medications requires a higher level of monitoring than is available on regular nursing units. Other therapies used in the ICU include noninvasive positive pressure ventilation and high-flow nasal cannula. These therapies are discussed in greater detail separately. (See "Acute severe asthma exacerbations in children younger than 12 years: Intensive care unit management".)
Comorbid infection — Routine antibiotic administration has no benefit in acute asthma exacerbations [64,65]. However, antibiotics may be indicated to treat comorbid infections (eg, bacterial pneumonia, bacterial sinusitis) . (See "Pneumonia in children: Inpatient treatment", section on 'Empiric therapy' and "Acute bacterial rhinosinusitis in children: Microbiology and management", section on 'Empiric antibiotics'.)
Atelectasis — Chest physiotherapy is not recommended for routine inpatient treatment of asthma exacerbations. It is not beneficial and may subject the patient to unnecessary stress [5,67-69]. An exception may be made for children with asthma exacerbation complicated by atelectasis. (See "Atelectasis in children".)
Therapies not used in the inpatient setting — Inhaled ipratropium bromide and oral leukotriene receptor antagonists (LTRAs) are not used as adjunctive therapy for hospitalized patients.
Ipratropium bromide — Although the addition of inhaled ipratropium bromide to inhaled beta-agonist therapy has proven effective in the ED setting, studies of its use during hospital admissions have not revealed added benefit [70-73]. Thus, ipratropium bromide is not used as standard therapy during hospitalizations for asthma exacerbations.
Leukotriene receptor antagonists — There are no data on the use of LTRAs (eg, montelukast, zafirlukast) for acute asthma exacerbations in children in the hospital setting. Patients taking an LTRA for long-term asthma control do not need to continue it while receiving systemic glucocorticoids during hospitalization for an acute asthma exacerbation. LTRAs should be restarted at the time of discharge if the plan is to continue them. (See "Antileukotriene agents in the management of asthma", section on 'Clinical use of leukotriene-modifying drugs in asthma' and "Antileukotriene agents in the management of asthma", section on 'Adverse effects'.)
Asthma specialist — Many children with asthma respond quickly to standard care. The inpatient management of such patients need not involve an asthma specialist (eg, pediatric pulmonologist or pediatric allergist). However, consultation with an asthma specialist may be warranted in the following circumstances :
●The diagnosis is in question or the patient fails to improve. (See 'Failure to respond' above.)
●Life-threatening asthma exacerbation, including any patient requiring intensive care management.
●Repeated hospital admission, history of intensive care unit (ICU) admission, frequent emergency department (ED) visits, or need for multiple or frequent drug therapies at home.
●Other conditions complicating asthma (eg, sinusitis, nasal polyps, chronic lung disease of prematurity, allergic bronchopulmonary aspergillosis, gastroesophageal reflux, obesity, food allergy, etc).
●Patients with asthma and other chronic disease (eg, cystic fibrosis, restrictive lung disease, neuromuscular weakness).
●The patient requires extensive education about allergen avoidance, problems with adherence to therapy, or complications of therapy.
●The patient is receiving or would benefit from establishing ongoing care by an asthma specialist (ie, those with severe or difficult-to-treat asthma).
Long-term follow-up with an asthma specialist may be warranted for some patients, particularly those who had near-fatal asthma or required ICU care . (See "An overview of asthma management", section on 'When to refer'.)
Social services — Consultation with social services may be warranted when caregiver resources are inadequate to ensure medication availability, adherence, and/or medical follow-up and to help caregivers connect with asthma programs available in the community . Social services also may be helpful when environmental triggers related to housing play a role in the asthma exacerbation (eg, rodents, cockroaches, smoke exposure). (See "Allergen avoidance in the treatment of asthma and allergic rhinitis".)
DISCHARGE PLANNING — Planning for discharge begins at the time of admission. The patient's and caregiver's understanding of asthma, including signs and symptoms, triggers, medications, and self-monitoring, should be assessed so that appropriate education can be provided . For patients newly diagnosed with asthma, it is important to anticipate the need for medication equipment, such as a spacer (preferably a valved holding chamber) or a nebulizer with compressor, so that it can be delivered to the caregiver and they can learn how to use it before the child is discharged. (See 'Discharge medications' below.)
Discharge criteria — Specific criteria for discharge vary from institution to institution. General principles to determine appropriate discharge may be used. Patients may be discharged when:
●Their asthma symptoms and signs (and scores, if available) are considered mild. Standardized tools, such as the Pediatric Dyspnea Scale (PDS) (figure 1), may be useful. In one study, the PDS predicted poor outcomes after discharge, including relapse and activity limitation, and was a better indicator than measures of pulmonary function .
●They no longer require supplemental oxygen (peripheral arterial oxygen saturation [SpO2] ≥94 percent without supplemental oxygen).
●They are receiving a treatment regimen that can be reasonably duplicated at home (eg, they are tolerating oral medications, and the frequency and proper technique of inhalation treatments can be managed by the caregiver, usually every four to six hours). If possible, patients should be observed in the hospital for at least one interval while receiving the treatments that will be prescribed after discharge. If patients have been receiving nebulized medications, they may be changed to metered-dose inhaler (MDI) spacer after continuous therapy is no longer needed or any time prior to discharge provided they can demonstrate proper technique.
●Access to medications and appropriate follow-up have been confirmed.
●Asthma education is complete. (See 'Discharge education' below.)
Discharge medications — Hospitalization for an asthma exacerbation signifies a break in control. The patient's preadmission medication regimen, asthma severity classification, and asthma control should be reviewed and controller medications adjusted as indicated (table 10A-B and table 1A-B and table 11A-B).
Discharge medications should include an inhaled short-acting beta agonist (SABA), either via nebulizer or MDI with a valved holding chamber/spacer, and oral glucocorticoids if the course was not already completed during the hospitalization .
●The beta agonist should be continued roughly every four to six hours until the patient is seen in follow-up within three to five days. Frequency can then be decreased or returned to "as needed" depending upon the rate of clinical improvement.
●Oral glucocorticoids are usually continued for a total of five days, although a two-day course of dexamethasone may be sufficient. Indications for longer courses are discussed above. (See 'Management of inflammation' above.)
●The need for daily controller therapy should be reviewed prior to discharge. Step-up therapy is often indicated in patients who were already on controller medication prior to the admission. Daily controller therapy, at least for a few months, is indicated for almost all children who have been hospitalized with an asthma exacerbation. Controller medications and preferred regimens are discussed in detail separately. (See "Asthma in children younger than 12 years: Management of persistent asthma with controller therapies".)
The patient should have all maintenance medications and the equipment necessary for their delivery (eg, valved holding chamber/spacer, mask, nebulizer, nebulizer tubing and mask, etc) prior to discharge. One way of assuring this is to have the caregiver fill the prescriptions before discharge. An advantage of this approach is that it permits the inpatient team to review the proper technique for medication administration. If the caregiver is unable to fill the prescriptions before discharge, patient demonstrator devices may be used to review technique. (See 'Discharge education' below and "The use of inhaler devices in children" and "Use of medication nebulizers in children".)
Discharge education — The inpatient hospitalization is an excellent time to provide education about asthma. Every interaction should be viewed as an opportunity to educate the patient and caregiver(s).
The various aspects of asthma education can be provided by any member of the health care team with adequate training. Some institutions have dedicated asthma educators that assist with the education process. (See "An overview of asthma management", section on 'Patient education'.)
Areas of asthma education that should be covered include:
●The importance of taking medications properly and consistently. How each medication works should also be discussed, including the difference between daily long-term controller medications and quick-relief rescue medications. (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".)
●The proper technique of medication administration, which can be demonstrated throughout the hospitalization. (See "Use of medication nebulizers in children" and "The use of inhaler devices in children", section on 'pMDI technique'.)
●Monitoring asthma symptoms and identifying and avoiding triggers when possible, including avoidance of irritants (eg, tobacco smoke) and allergens (when relevant) and ensuring that the child receives the yearly influenza vaccine (table 12). (See "Asthma education and self-management" and "Seasonal influenza in children: Prevention with vaccines", section on 'Target groups'.)
Asthma action plan — Patients should be given a written asthma action plan that includes [5,75]:
●A list of the daily medications and the time(s) of day they are to be taken
●A list of the quick-relief medication(s) and a description of the symptoms for which they should be taken
●The phone number they should call if they have questions
●A list of triggers that may exacerbate their asthma (see "Trigger control to enhance asthma management" and "Allergen avoidance in the treatment of asthma and allergic rhinitis")
The National Asthma Education and Prevention Program (NAEPP) provides sample asthma action plans for children aged zero to five years (form 1), patients older than five years (form 2), and for use at school (Student Asthma Action Card).
Care coordination/case management — Care coordination and case management, both during the hospitalization and after discharge, are particularly important in patients who have had repeated admissions for asthma exacerbations. Maintaining the continuity of care is important, as is reinforcing the asthma education received during the hospitalization. (See 'Discharge education' above.)
Follow-up — Patients discharged from the hospital should have follow-up in three to five days with their primary care provider or asthma specialist . At the follow-up visit, the primary care provider can review the child's severity/control classification, alter controller therapy as indicated, and taper or discontinue inhaled SABA therapy (table 10A-B and table 1A-B and table 11A-B). (See "Asthma in children younger than 12 years: Management of persistent asthma with controller therapies" and 'Asthma specialist' above.)
The clinician monitoring the child's asthma should ascertain whether the patient's asthma medications are available and whether they are properly used (including associated devices). Patients should be reminded to refill their prescriptions as indicated and make certain the ones they have are not expired or depleted.
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".)
SUMMARY AND RECOMMENDATIONS
•Management of bronchospasm – All children who are admitted to the hospital with an acute asthma exacerbation require treatment with an inhaled short-acting beta agonist (SABA or beta agonist), such as albuterol (salbutamol) or an equivalent. The frequency of administration ranges anywhere from continuously to every four hours, depending upon the severity of the exacerbation and the patient's response to treatment. (See 'Management of bronchospasm' above.)
•Management of inflammation – We recommend that children who are admitted to the hospital with an acute asthma exacerbation be treated with systemic glucocorticoids (Grade 1B). (See 'Management of inflammation' above.)
•Management of hypoxemia – Humidified oxygen should be provided as needed to maintain an oxygen saturation of ≥92 percent. (See 'Management of hypoxemia' above.)
●Clinical assessment and frequency of monitoring – Clinical status and response to therapy must be monitored frequently during treatment for acute asthma exacerbation (table 2 and table 4 and table 5). Patients are typically assessed every 15 minutes to every four hours, depending upon the clinical status. (See 'Initial assessment and ongoing monitoring' above.)
●When to obtain imaging – Chest radiographs are not routinely necessary for children who are admitted to the hospital with acute asthma exacerbations. However, they may be warranted in patients with acute worsening of clinical status or lack of response to asthma therapy. (See 'Imaging' above.)
●Escalation of therapy – Failure to respond to standard asthma therapy may indicate impending respiratory failure, development of a complication, or a disease process other than asthma (table 3). Such patients may require transfer to the intensive care unit (ICU). Signs of impending respiratory failure include (see 'Failure to respond' above and 'Signs of impending respiratory failure' above):
•Reduced or inaudible breath sounds
•Change in mental status
●Weaning of therapy – Children receiving continuous nebulized albuterol are switched to intermittent therapy given every two to three hours when they have improving asthma parameters or score. Weaning or spacing out therapies is performed when indications of clinical improvement are present based upon close monitoring of symptoms and vital signs. (See 'Weaning of therapy' above.)
●Discharge criteria and follow-up – Discharge criteria include asthma signs and symptoms that are mild to absent, lack of requirement for supplemental oxygen, a treatment regimen that is suitable for home administration with availability of all medications and equipment, completion of asthma education to ensure that patients and care providers know how to properly administer medications and recognize symptoms, and a follow-up visit scheduled with the primary care provider or asthma specialist in three to five days. (See 'Discharge criteria' above and 'Follow-up' above.)
ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Mark Dovey, MD, who contributed to earlier versions of this topic review.
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