Management of Acute Asthma in Children (Over Two Years)

Some children with bronchial asthma may develop acute exacerbations or attacks. Sometimes, severe acute asthma attacks can be fatal. Therefore, children with severe acute asthma should be offered treatment quickly. It is safer to manage them in a hospital with resuscitation facilities. Children with acute asthma should never be sedated. Physicians in primary care should start treatments as mentioned below and transfer these children to a hospital immediately.

Oxygen therapy

Children with low oxygen saturation in the blood (SpO2<94 %) or life-threatening asthma are offered high-flow oxygen therapy through a close-fitting face mask or a nasal prongs (nasal cannula). Oxygen flow rate is adjusted to keep up a normal oxygen saturation.

β2 agonists

β2 agonists are medications (bronchodilators), which dilate the constricted airways and facilitate the airflow. Salbutamol and Terbutaline belong to short-acting β2 agonists, which have rapid and short-term activity. Formoterol and Salmeterol are long-acting β2 agonists, which act slowly, but have long-lasting effects.

Inhaled short-acting β2 agonists like Salbutamol or Terbutaline are the first-line medication for acute bronchial asthma. A pressurised metered dose inhaler (pMDI) with a spacer is the recommended method to offer a short-acting β2 agonist in mild to moderate acute asthma attacks. The dose is selected based on the initial severity of the condition and is adjusted based on the child’s response.

If the child has got severe asthma and has not responded well to the initial inhaled medications, health-care professionals consider adding a single bolus dose of intravenous (IV) Salbutamol early (according to the body weight 15 µg/kg over ten minutes).

Health-care professionals will discontinue long-acting β2 agonist medications, if the child needs short-acting β2 agonists more frequently than four hourly.

Steroids

Steroids inhibit the inflammation of the airways. Therefore, they dilate the airways as well as decrease the secretions in the lungs. Early treatment with Prednisolone is recommended in acute bronchial asthma attacks.

Recommended Prednisolone dose

Children aged two to five years: 20 mg
Children aged more than five years: 30-40 mg
Children, who are already receiving a maintenance dose of oral steroids: 2 mg/kg (up to 60 mg)

If the child vomits the dose, another dose should be offered, and intravenous (IV) steroids should be considered.

Usually, steroid therapy for approximately three days is given to a child with an acute asthma attack. However, the duration of therapy should be customised to the length of time required to result in recovery. Weaning of the Prednisolone dose is not needed unless the duration of the treatment is greater than 14 days.

Other treatments

Ipratropium Bromide

If symptoms of acute asthma have not responded to initial β2 agonist therapy, physicians add Ipratropium bromide (an antimuscarinic bronchodilator). They will mix 250 µg of Ipratropium with every dose of the nebulised β2 agonist to dilate the airways. Physicians offer repeated doses of Ipratropium early to manage acute asthma, which is poorly responsive to β2 agonists.

Aminophylline

Aminophylline is a bronchodilator medication, which dilate airways. It is not indicated in mild to moderate acute bronchial asthma attacks. If the child has got severe or life-threatening bronchial asthma, which is not responding well to maximum doses of steroids and initial bronchodilators, physicians consider offering Aminophylline for children in a paediatric intensive care unit (PICU) or a high dependency unit (HDU).