Acute asthma exacerbations in children younger than 12 years: Overview of home/office management and severity assessment

INTRODUCTION — Clinical decision making in the management of the child with an acute asthma exacerbation includes the following questions:

●How sick is the child?

●Which drugs should be used for treatment?

●What are the optimal doses and delivery routes?

●When is additional therapy necessary?

●When is home or office management of an asthma exacerbation appropriate, and when should the child be sent to the emergency department (ED)?

●If the child is sent to the ED, should the child be taken by the parents/caregivers or by ambulance?

This topic addresses home and office management of asthma exacerbations in children, including how to assess the severity of an asthma exacerbation. Additionally, it briefly reviews transfer to the ED and indications for hospitalization.

The approach to the outpatient and inpatient management of the child with an acute asthma exacerbation and chronic management of childhood asthma are discussed in detail separately:

●(See "Acute asthma exacerbations in children younger than 12 years: Emergency department management".)

●(See "Acute asthma exacerbations in children younger than 12 years: Inpatient management".)

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

●(See "Asthma in children younger than 12 years: Quick-relief (rescue) treatment for acute symptoms".)

●(See "Asthma in children younger than 12 years: Overview of initiating therapy and monitoring control".)

●(See "Asthma in children younger than 12 years: Management of persistent asthma with controller therapies".)

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" and "Acute exacerbations of asthma in adults: Emergency department and inpatient management".)

ADVICE RELATED TO COVID-19 PANDEMIC — 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]) [1], although supporting evidence remains mixed, with data largely from studies in adults [2-13]. Several studies that included patients with well-controlled asthma did not indicate increased risk in this population [2-9]. In addition, contrary to that expected for a viral respiratory infection, initial data suggested that COVID-19 did not increase asthma morbidity in children [14-17]. However, other investigations of COVID-19 outcomes have reported increased risk, including a large meta-analysis of over 100,000 patients that reported higher rates of intubation and prolonged mechanical ventilation in adults with asthma [3,10-12]. A comparison of nearly 62,000 children with asthma from 108 health care systems in the United States from March 2020 through February 2021 found that a SARS-CoV-2 polymerase chain reaction (PCR) positive test was associated with increased rates of emergency department (ED) visits, hospitalizations, and use of short-acting beta agonists (SABAs) and oral glucocorticoids in the six months following the positive test compared with those who tested negative [13]. These complications probably occur more frequently in those with poorly controlled asthma at baseline. Thus, patients with asthma should continue all regular medications necessary to maintain optimal asthma control, including inhaled glucocorticoids, oral glucocorticoids, and/or biologic agents (omalizumab, dupilumab, mepolizumab) [18-20]. (See "COVID-19: Clinical manifestations and diagnosis in children" and "COVID-19: Management in children".)

HOME MANAGEMENT

Overview — Instructions regarding at-home monitoring and administration of medications for an acute asthma exacerbation differ depending upon the patient's history (eg, medications currently used to treat asthma, prior history of severe exacerbations, and prior experience with oral glucocorticoids) and the ability of the caregiver(s) to understand and follow the management plan. Patients with an uncomplicated asthma exacerbation often can be managed at home. However, home management is not meant to replace supervised medical care in patients with severe exacerbations. In addition, even children with mild asthma can have severe exacerbations [21]. Suggested treatment regimens are primarily based upon the clinical experience of experts, as well as data extrapolated from studies performed in the emergency department (ED). The caregiver(s) and patient should receive instruction on management of exacerbations, including medications and how and when to contact a clinician. These instructions should be summarized in an asthma action plan. The approach outlined below includes the steps that both the caregiver and clinician should take. (See "Acute asthma exacerbations in children younger than 12 years: Emergency department management".)

Asthma action plan — An individualized written asthma action plan that is based upon symptoms should be provided to patients and their caregiver(s) to provide clear instructions on how to detect and respond to changes in symptoms. The asthma action plan should include clear instructions about how to reach a clinician during exacerbations. Some asthma action plans include peak flow monitoring, which is an optional adjunct to clinical assessment that is most useful when a personal best baseline has recently been established using the same device. Peak flow monitoring is not used universally, because the results are effort dependent and may not accurately reflect the maximal flow. In addition, results from a systematic review suggest that symptom-based asthma action plans are superior to peak flow-based plans in reducing the need for acute care visits in children and adolescents [22]. Patients who use peak flow monitoring regularly are the most likely to gain useful information when using peak flow measurements in the acute setting. (See "Asthma education and self-management", section on 'Asthma action plans'.)

Detecting the onset of an exacerbation — Some patients or their caregivers are very sensitive to increased asthma symptoms (eg, cough, breathlessness), while others notice or perceive reduced airflow only when it becomes marked. Parents/caregivers should be taught to monitor for manifestations of an exacerbation, such as a persistent cough, increased respiratory rate, retractions, wheezing, or inability to speak in full sentences, particularly in the setting of an upper respiratory infection or exposure to a known asthma trigger for the child.

Need for urgent medical attention — Patients with an acute asthma exacerbation who are at high risk for a life-threatening or fatal attack based upon history (table 1) and/or who have acute signs and symptoms indicative of a severe exacerbation (eg, marked breathlessness, inability to speak more than short phrases, use of accessory muscles, and drowsiness) require immediate medical attention in the ED (algorithm 1). It is helpful to identify high-risk patients and to educate their caregiver(s) about identifying early warning signs of deterioration, following an oral glucocorticoid-based action plan, and calling emergency services promptly for ambulance transport to the ED while initiating treatment. (See 'Patients with severe symptoms or at high risk for fatal asthma' below and 'Criteria for referral to the emergency department' below.)

Initial treatment

All patients — When patients/caregivers recognize the onset of an exacerbation, they should administer the patient's quick-relief medication (algorithm 1). This is typically an inhaled short-acting beta agonist (SABA; eg, albuterol [salbutamol], levalbuterol [levosalbutamol]) via metered dose inhaler with spacer (MDI-S; a valved holding chamber [VHC] is preferred) or nebulizer. The usual home dose is 2 to 4 puffs of albuterol (salbutamol) or nebulization solution dose of 1.25 to 2.5 mg for children <4 years old and 2.5 to 5 mg if 4 to 11 years old if a SABA is used, or 1 puff of budesonide-formoterol (maximum dose 8 puffs/day) if that treatment is used (table 2). The higher dose of SABA typically is used in children showing obvious signs of respiratory distress (table 3). Beta agonists are the standard emergency treatment for acute asthma exacerbations in all patients based upon adult data, a few early trials in the ED setting in children, and many ensuing years of clinical use. Use of beta agonists for acute symptoms and exacerbations is discussed in detail separately. (See "Asthma in children younger than 12 years: Quick-relief (rescue) treatment for acute symptoms" and "Acute asthma exacerbations in children younger than 12 years: Emergency department management", section on 'Inhaled short-acting beta-2 agonists'.)

Prior to use, the caregiver should confirm that the medication is not expired and, if using an MDI, confirm that the inhaler is not empty. If the medication is expired or the inhaler is empty, the caregiver should contact the child's clinician immediately to determine whether the child should be seen in the office or ED. The MDI should be primed before use, if necessary, based upon the manufacturer's recommendations in the package insert; these instructions vary from inhaler to inhaler. Each puff should be administered separately. Actuating the inhaler into the spacer more than once before inhaling does not work as well, because the medication is more likely to stick to the walls of the chamber, resulting in less medication available for inhalation. (See "Delivery of inhaled medication in children" and "The use of inhaler devices in children" and "Use of medication nebulizers in children".)

Patients with severe symptoms or at high risk for fatal asthma — Patients with severe symptoms (eg, marked breathlessness, inability to speak more than short phrases, use of accessory muscles, and agitation or drowsiness) (table 3) require immediate treatment and medical attention (algorithm 1). The caregiver should be instructed to call for ambulance transport to the ED while initiating the patient's quick-relief medication. For these patients, we also recommend initiating oral glucocorticoids as soon as possible, preferably in consultation with the patient's clinician. We also suggest administering oral glucocorticoids after initial beta agonist treatment for patients who have mild-to-moderate symptoms but are at high risk for fatal asthma (table 1). These patients also require medical attention in the ED after initial treatment. Use of oral glucocorticoids for acute exacerbations is discussed in detail separately. (See "Acute asthma exacerbations in children younger than 12 years: Emergency department management", section on 'Systemic glucocorticoids' and 'Incomplete response' below.)

Reassessment — The child's symptoms should then be reassessed by the caregiver in 10 to 20 minutes. The dose of inhaled beta agonist can be repeated 20 minutes after initiation of the first dose, if needed. Based upon the initial response to the inhaled beta agonist, the patient should either continue self-care or seek medical attention, as described below and in the algorithm (algorithm 1). (See "Asthma in children younger than 12 years: Quick-relief (rescue) treatment for acute symptoms".)

Triage based upon response to initial home treatment

Good response — If symptoms such as wheezing and dyspnea resolve and peak flow measurements improve, if following, after one to two beta agonist treatments and do not return within four hours, then the patient may safely continue at-home treatment with a SABA given every four to six hours as needed (algorithm 1). Oral glucocorticoids are not routinely given to patients who respond to beta agonist treatment at home. Another important early intervention is removal of or from the offending stimulus (eg, animal dander, tobacco smoke), if known and possible. The caregiver should initiate contact with the child's clinician for instructions about how to continue care.

Incomplete response — Patients with an incomplete response with mild symptoms after two beta agonist treatments given 20 minutes apart (particularly if the higher dose of 4 puffs of an MDI or 2.5 or 5 mg via nebulizer was given) should contact their clinician urgently for advice regarding further treatment and whether they should be seen in the office or ED. A third dose of beta agonist can be given while the clinician is determining disposition. For patients who have oral glucocorticoids available at home as part of their asthma action plan, we suggest initiating oral glucocorticoids at home rather than waiting for administration in the office or ED (algorithm 1). Timely administration of oral glucocorticoids for serious asthma exacerbations is probably the single most effective strategy for reducing hospitalizations for acute asthma exacerbations and relapses after ED visits [23-27]. Oral glucocorticoids are also routinely used in the home setting for asthma exacerbations that do not respond quickly to beta agonist treatment even though the efficacy data are primarily derived from ED studies and patient- or caregiver-initiated use has not been studied in randomized trials [28]. Use of oral glucocorticoids for acute exacerbations is discussed in detail separately. (See "Acute asthma exacerbations in children younger than 12 years: Emergency department management", section on 'Systemic glucocorticoids'.)

Other early interventions include removal of or from the offending stimulus (if known) and continued administration of inhaled beta agonists (up to every two hours for six to eight hours after giving oral glucocorticoids).

Several additional interventions have been studied but typically are not used. The available evidence, largely from ED management of asthma, indicates that inhaled glucocorticoids are not as effective as systemic glucocorticoid therapy for reducing the severity or preventing the progression of exacerbations in children [29]. Increasing the dose of inhaled glucocorticoids in patients already on this therapy daily is also not as effective as systemic glucocorticoids [26,30-33]. The addition of a leukotriene receptor antagonist (LTRA) to standard therapy for acute asthma in children also does not appear to provide additional benefit [34]. These treatments are reviewed in detail separately. (See "Acute asthma exacerbations in children younger than 12 years: Emergency department management", section on 'Inhaled glucocorticoids' and "Acute asthma exacerbations in children younger than 12 years: Emergency department management", section on 'Systemic glucocorticoids' and "Acute asthma exacerbations in children younger than 12 years: Emergency department management", section on 'Leukotriene receptor antagonists'.)

Poor response — Patients should seek immediate medical attention in the ED (algorithm 1) if they have a poor response to two beta agonist treatments (continued moderate-to-severe or worsening symptoms or recurrence of symptoms less than two hours after last treatment). While awaiting transport to the ED, we recommend giving a third dose of inhaled beta agonists and initiating oral glucocorticoids. (See "Identifying patients at risk for fatal asthma".)

Factors to consider when deciding whether to advise that the patient be seen in the office or ED and whether to have the parent/caregiver bring the child or come by ambulance include:

●Severity of the exacerbation (see 'Assessment of exacerbation severity' below)

●Whether or not oral glucocorticoids have been given (see 'Incomplete response' above)

●Distance to the health care provider's office or the ED

●The patient's prior asthma history, including hospitalizations or need for intensive care

●The caregiver's reliability and proficiency in asthma management

OUTPATIENT MANAGEMENT

Factors that affect treatment approach — The level of treatment given in the office, outpatient clinic, or urgent care center for an acute asthma exacerbation depends upon a number of factors, including the experience of the treating clinician, the resources available in that setting (eg, does the office have pulse oximetry, supplemental oxygen, and medications such as oral glucocorticoids and ipratropium? How far is the nearest hospital/emergency department [ED]?), and the severity of the exacerbation.

Assessment of exacerbation severity — The severity of an asthma exacerbation is primarily determined by assessment of clinical findings, occasionally supplemented by objective tests (table 3 and table 4) [25,35,36]. A focused history and physical examination should be performed promptly and nearly concurrently with initiation of treatment.

Clinical findings — A brief focused history and examination should be obtained before therapy is initiated [37].

The history should include [25,37-40]:

●Suspected cause of the exacerbation (eg, viral infection, environmental or food allergen exposure)

●The time of onset of exacerbation

●Current medications

●Recent use of beta agonists (dose and frequency) and/or systemic glucocorticoids

●Risk factors for severe, uncontrolled disease, such as ED visits, hospital and intensive care unit admissions, repeated courses of oral glucocorticoids, and history of intubation, rapidly progressive episodes, or food allergy

The focused examination should include [25,37]:

●Vital signs and pulse oximetry

●Assessment of level of consciousness, anxiety, and agitation

●Assessment of breathlessness, wheezing, air entry, accessory muscle use, and retractions

Asthma severity scores — Several clinical asthma severity scores have been designed for use in the acute care setting to evaluate initial exacerbation severity, assess response to treatment, and help determine if hospitalization is necessary [41-52]. However, there is limited evidence regarding their use in the home or office setting.

●Pediatric Respiratory Assessment Measure (PRAM) – The PRAM (originally Preschool Respiratory Assessment Measure) uses five variables: wheezing, air entry, contraction of scalenes, suprasternal retraction, and oxygen saturation (table 4).

The PRAM was initially validated against respiratory resistance measured by forced oscillation in children three to six years of age [41]. It was found to have moderate discrimination for assessing asthma severity during an acute exacerbation. In a subsequent study of children aged 2 to 17 years with acute asthma, the PRAM score at triage and after treatment with an inhaled beta agonist was strongly associated with hospitalization [42]. Another study found a moderate level of discrimination between PRAM and length of stay more than six hours and/or hospitalization in children 18 months to seven years [43]. However, it was not better than clinician assessment in predicting severity in another study [44].

●Pulmonary Index Score (PIS) – The PIS is an asthma score based on five clinical variables: respiratory rate, degree of wheezing, inspiratory to expiratory ratio, accessory muscle use, and oxygen saturation [45]. Each variable is assigned a score from 0 to 3 (table 5). Total scores range from 0 to 15.

As a general rule, a score of 7 to 11 indicates an exacerbation of moderate severity, and a score ≥12 indicates a severe attack. However, the PIS may underestimate the degree of illness in an older child. Bradypnea, caused by a prolonged expiratory phase, will result in fewer points for the respiratory rate component.

The PIS has been validated and used as an outcome measure in several clinical trials [45-47]. It can be used to assess initial severity, judge response to treatment, and facilitate admission and discharge planning [48].

●Pediatric Asthma Severity Score (PASS) – The PASS, which includes three clinical findings (wheezing, prolonged expiration, and work of breathing), was validated in a study of children aged 1 to 18 years [49]. It was able to discriminate between those patients who did and did not require hospital admission. The addition of number of inhaled short-acting beta agonist (SABA) treatments in the ED further improved the ability of this tool to predict successful discharge from the ED [50].

●RAD – The Respiratory rate, Accessory muscle use, and Decreased breath sounds (RAD) score, which uses three clinical measures (respiratory rate, accessory muscle use, and decreased breath sounds), has similar performance in assessing severity of an acute asthma exacerbation in children aged 5 to 17 years as the PASS and PRAM [51].

Peak flow rate — A peak flow meter may be used to assess airflow obstruction, providing an objective assessment of disease severity. However, we rarely use a peak flow meter in the acute setting to assess lung function in children during an exacerbation because it has several limitations related to effort and technique. Peak flow measurements require maximal effort, which is difficult to assess. Poor technique can also lead to erroneous data. In addition, children younger than six years may not be able to cooperate with peak expiratory flow rate (PEFR) assessments, and severely ill children may not be able to stand and provide three consecutive recordings as is recommended. Furthermore, the reading is most helpful when the child's personal best PEFR measurement is known. (See "Peak expiratory flow monitoring in asthma" and "Overview of pulmonary function testing in children", section on 'Peak expiratory flow rate'.)

Spirometry — Forced expiratory volume in one second (FEV₁) and FEV₁/forced vital capacity (FVC) can be used to assess airflow obstruction, providing an objective assessment of disease severity. However, spirometry is very rarely in the acute setting to assess lung function in children during an exacerbation because, similar to peak flow measurement, it is often very difficult to perform maximal, reproducible efforts.

Chest radiograph — Chest radiographs (CXRs) rarely provide information that alters the management of children with acute asthma. Indications for obtaining CXRs in children with asthma exacerbations are discussed in greater detail separately. (See "Acute asthma exacerbations in children younger than 12 years: Emergency department management", section on 'Indications for chest radiograph'.)

Overview of treatment in the office/urgent care setting — Most mild-to-moderate exacerbations (table 3 and table 5) can be managed in the outpatient setting. The approach is similar to that used in the ED (algorithm 2), with a few exceptions that are noted below. Treatment should be initiated in patients with severe exacerbations while arranging for transfer to the ED. Suggested treatment regimens are primarily based upon the clinical experience of experts, as well as data extrapolated from studies performed in the ED. (See 'Criteria for referral to the emergency department' below and "Acute asthma exacerbations in children younger than 12 years: Emergency department management".)

SABAs are the primary initial treatment, as they are in at-home and ED exacerbations. Higher doses of SABAs (eg, albuterol 4 to 8 puffs of a metered-dose inhaler [MDI] or 2.5 mg to 5 mg via nebulizer) are often given in the outpatient setting compared with the doses used for home management. However, continuous beta agonist nebulization is usually not administered in the office setting. Patients are typically given up to three doses of inhaled beta agonist over one hour and are reassessed after each dose. (See 'Initial treatment' above and "Acute asthma exacerbations in children younger than 12 years: Emergency department management", section on 'Inhaled short-acting beta-2 agonists'.)

Inhaled ipratropium (table 6), if available, can be administered to patients with moderate-to-severe symptoms in addition to beta agonists. Oral glucocorticoids (table 6) typically are only started in patients with mild symptoms if they have not responded to the first two doses of beta agonist, whereas they are started shortly after initiation of beta agonist therapy in patients with moderate-to-severe symptoms. Magnesium sulfate is usually not given in the office setting. Use of these medications is discussed in greater detail separately. (See "Acute asthma exacerbations in children younger than 12 years: Emergency department management", section on 'Ipratropium bromide' and "Acute asthma exacerbations in children younger than 12 years: Emergency department management", section on 'Systemic glucocorticoids'.)

Disposition — Patients who present with mild-to-moderate symptoms and who have a good response to therapy may be discharged home. Discharge medications are reviewed separately. Those who have a severe exacerbation or who have an inadequate response to therapy should be transferred to an ED for further management and possible hospital admission. (See 'Good response' above and 'Criteria for referral to the emergency department' below and "Acute asthma exacerbations in children younger than 12 years: Emergency department management" and "Acute asthma exacerbations in children younger than 12 years: Emergency department management", section on 'Discharge to home'.)

Criteria for referral to the emergency department — Patients with an acute asthma exacerbation who are at high risk for a life-threatening or fatal attack based upon history (table 1) and/or who have acute signs and symptoms indicative of a more serious exacerbation (table 3 and table 5) require immediate medical attention in the ED. The other primary criterion for referral to the ED is lack of (or incomplete) response to inhaled SABAs and oral glucocorticoids. This includes an inadequate response to three beta agonist treatments given in the first hour of care, although patients initially treated at home may respond to bronchodilators in the office (or ED) due to issues with administration technique or, less commonly, an empty or expired MDI at home. Lack of response also includes recurrence of symptoms within four hours after the first one to two beta agonist treatments. Any patient who has a supplemental oxygen requirement after the first dose or two of inhaled beta agonist should also be transferred to the ED. Assessing response to medications should take into account how much home management a patient received prior to treatment in the office. As an example, a patient who has received no home treatment may gain more from office intervention than one who has already received aggressive treatment, including oral glucocorticoids, at home. (See 'Home management' above.)

Criteria for admission — Children are usually evaluated in the ED before being admitted to the hospital. Clinical evaluation should be repeated frequently during the management of an acute asthma exacerbation to assess response to therapy and need for admission [25]. The decision regarding the need for hospitalization is a complex one that is based upon clinical and social factors. Patients who were moderately to severely ill on arrival and who have little improvement after initial therapy with beta agonists and systemic glucocorticoids require hospitalization. This includes patients who continue to have significant wheezing and retracting, poor aeration, or altered mental status, such as drowsiness or agitation. It also includes patients who require supplemental oxygen. Additional factors that may be used in making decisions regarding disposition include severity of previous exacerbations, adherence to medication regimen, access to care, and social support. The criteria for admission are discussed in greater detail separately. (See "Acute asthma exacerbations in children younger than 12 years: Emergency department management", section on 'Hospitalization'.)

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 5^th to 6^th 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 10^th to 12^th 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

●General principles – The general principles of management of asthma exacerbations include early recognition, assessment of attack severity, timely intervention, and reassessment. The treatment depends upon several factors including the setting, medications and equipment available, and clinical expertise of the person administering care. (See 'Home management' above and 'Assessment of exacerbation severity' above and 'Outpatient management' above.)

●Education and asthma action plan – An individualized written asthma action plan that provides clear instructions on how to detect and respond to changes in symptoms should be given to patients and their caregiver(s). Education of patients and their caregiver(s) should include the appropriate steps to take upon recognition of increased asthma symptoms. (See 'Asthma action plan' above and 'Detecting the onset of an exacerbation' above and 'Need for urgent medical attention' above.)

●Assessment – In the office or urgent care setting, the severity of an asthma exacerbation is assessed based upon symptoms, physical findings, and pulse oximetry (table 3 and table 4 and table 5). These same measures can also be used to judge the response to therapy and determine disposition. (See 'Outpatient management' above and 'Assessment of exacerbation severity' above.)

●Treatment approach – The typical approach to home management is reviewed in the algorithm (algorithm 1). Office/outpatient management for mild-to-moderate exacerbations is similar to the approach used in the emergency department (ED) (algorithm 2), although certain approaches may not be available depending upon the office resources. Most mild-to-moderate exacerbations can be managed in the office setting. In either setting, treatment should be initiated in patients with severe exacerbations while arranging for transfer to the ED. Evidence for these therapies is primarily based upon adult data, a few early trials in the ED setting in children, and many ensuing years of clinical use. (See 'Home management' above and 'Outpatient management' above and "Acute asthma exacerbations in children younger than 12 years: Emergency department management".)

•Initial therapy – All patients require treatment with a rapid-onset beta agonist. Up to three doses may be given in one hour (20 minutes apart), with reassessment after each dose. For most patients, we suggest a short-acting inhaled beta agonist (SABA; albuterol [salbutamol], levalbuterol [levosalbutamol]) (Grade 2C). Higher doses of SABAs (eg, albuterol 4 to 8 puffs of a metered-dose inhaler [MDI] or 2.5 to 5 mg via nebulizer) are often given in the outpatient setting compared with the doses used for home management (eg, albuterol 2 to 4 puffs of an MDI or nebulization solution dose of 1.25 to 2.5 mg for children <4 years old and 2.5 to 5 mg if 4 to 11 years old). Ipratropium bromide, if available, can be administered to patients with moderate-to-severe symptoms in addition to beta agonists. These treatments are discussed in detail separately. (See 'Initial treatment' above and 'Overview of treatment in the office/urgent care setting' above and "Asthma in children younger than 12 years: Quick-relief (rescue) treatment for acute symptoms" and "Acute asthma exacerbations in children younger than 12 years: Emergency department management", section on 'Inhaled short-acting beta-2 agonists' and "Acute asthma exacerbations in children younger than 12 years: Emergency department management", section on 'Ipratropium bromide'.)

For patients with severe symptoms (eg, marked breathlessness, inability to speak more than short phrases, use of accessory muscles, and drowsiness) (table 3 and table 4 and table 5), we recommend initiating systemic glucocorticoids (Grade 1B). Systemic glucocorticoids should be given as soon as possible while awaiting transport to the ED. We also suggest initiating systemic glucocorticoids as part of initial therapy for patients who have less severe symptoms but have risk factors for fatal asthma (table 1), rather than waiting to assess response to initial beta agonist therapy (Grade 2C). This treatment is discussed in detail separately. (See 'Patients with severe symptoms or at high risk for fatal asthma' above and 'Overview of treatment in the office/urgent care setting' above and "Acute asthma exacerbations in children younger than 12 years: Emergency department management", section on 'Systemic glucocorticoids'.)

•Subsequent therapy and disposition – Clinical evaluation should be repeated frequently during the management of an acute asthma exacerbation to assess response to therapy and need for transfer to the ED or admission. Patients who were moderately to severely ill on arrival and who have little improvement after initial therapy with inhaled beta agonists and systemic glucocorticoids require transfer to the ED. (See 'Reassessment' above and 'Assessment of exacerbation severity' above and 'Disposition' above.)

-Good response – If signs and symptoms improve after one to two beta agonist treatments and do not return within four hours, then the patient may continue at-home treatment with a rapid-onset beta agonist given every four to six hours as needed. Follow-up should be arranged with the child's primary care clinician or asthma specialist. (See 'Good response' above and 'Overview of treatment in the office/urgent care setting' above.)

-Incomplete response – If the child has an incomplete response with mild symptoms after two beta agonist treatments, we suggest initiation of systemic glucocorticoids (Grade 2C). Oral agents (eg, dexamethasone, prednisolone, prednisone) are typically used in the home and office setting. An additional dose of beta agonist also should be given. The patient and caregivers should be provided appropriate instructions regarding further treatment and whether the child should be seen in the office or ED. Systemic glucocorticoid treatment is discussed separately. (See 'Incomplete response' above and 'Overview of treatment in the office/urgent care setting' above and "Acute asthma exacerbations in children younger than 12 years: Emergency department management", section on 'Systemic glucocorticoids' and 'Criteria for referral to the emergency department' above.)

-Poor response – If the child has a poor response to two beta agonist treatments (continued moderate-to-severe or worsening symptoms or recurrence of symptoms less than two hours after last treatment), we recommend initiation of systemic glucocorticoids (Grade 1B). An additional dose of beta agonist also should be given and arrangements made for transport to the ED. Systemic glucocorticoid treatment is discussed separately. (See 'Poor response' above and 'Overview of treatment in the office/urgent care setting' above and "Acute asthma exacerbations in children younger than 12 years: Emergency department management", section on 'Systemic glucocorticoids' and 'Criteria for referral to the emergency department' above.)