acute asthma exacerbation in children

1. ACUTE ASTHMA
EXACERBATIONS IN
CHILDREN.
DR.ODONG RICHARD JUSTIN.
PAEDIATRICIAN.
KAMPALA INTERNATIONAL UNIVERSITY.

2. INTRODUCTION.
• Clinical decision making in the management of
acute asthma exacerbation includes:
• How sick is the child?
• Which drugs should be used for treatment?
• What are the optimal doses and delivery routes?
• When is more aggressive management necessary?

3. ASSESSMENT OF SEVERITY.
• A brief focused history and examination should be
obtained before therapy is initiated:
• The time of onset of exacerbation
• Current medications and allergies
• Recent use of beta 2-agonists
• Risk factors for severe, uncontrolled disease.

4. • Focused examination should include:
• Vital signs and pulse oximetry.
• Assessment of level of consciousness, anxiety, and
agitation.
• Assessment of breathlessness, wheezing, air entry,
accessory muscle use, and retractions.

5. PULMONARY INDEX.
• Pulmonary Index Score (PIS) is an asthma score
based on five clinical variables:
• Respiratory rate.
• Degree of wheezing.
• Inspiratory to expiratory ratio.
• Accessory muscle use.
• Oxygen saturation.

6. • Each variable is assigned a score from 0 to 3.
• Total scores range from 0 to 15.
• A score of 7 to 11 indicates an exacerbation of
moderate severity.
• A score of ≥12 indicates a severe attack.

7. • A peak flow meter may be used to assess airflow
obstruction.
• Chest radiographs (CXRs) rarely provide
information that alters the management.
• Arterial blood gas is rarely necessary to since
oxygen saturation can be assessed with pulse
oximetry.

8. OVERVIEW OF TREATMENT.
• Goals of therapy for acute severe asthma include:
• Rapid reversal of airflow obstruction: By repeated
administration of inhaled bronchodilators and early
institution of systemic glucocorticoids.
• Correction of hypoxemia and/or severe
hypercapnia: Hypoxemia supplemental oxygen;
hypercapnia by reversal of airflow obstruction.
• Reduction of likelihood of recurrence: By
intensifying baseline therapy.

9. GENERAL APPROACH.
• Moderate or severe asthma exacerbations should
be managed in an emergency.
• Inhaled short-acting beta 2-agonists are the
mainstay of emergent treatment.

10. • Moderate or severe exacerbations should receive
systemic glucocorticoids.
• Additional agents moderate or severe asthma
include nebulized ipratropium bromide, magnesium
sulfate , and parenteral beta 2-agonists.

12. MILD EXACERBATION.
• PIS <7.
• Albuterol inhalation therapy administered via small
volume nebulizer (SVN) at a dose of 0.15 mg/kg
(maximum 5 mg) or metered dose inhaler (MDI-S) at
a dose of one-quarter to one-third puff/kg
(maximum eight puffs).
• Given every 20 to 30 minutes for three doses.

13. MODERATE EXACERBATION.
• PIS 7 to 11.
• Supplemental oxygen if oxygen saturation ≤92 percent
in room air.
• Albuterol nebulization (0.15 mg/kg, maximum 5 mg)
combined with ipratropium bromide (250
microgram/dose if <20 kg; 500 microgram/dose if >20
kg).
• Every 20 to 30 minutes for three doses or continuously.

14. • Patients who have received three doses of
intermittent therapy and require additional
albuterol therapy may be treated intermittently
every 30 to 45 minutes.
• Administration of systemic glucocorticoids.

15. • IV magnesium sulfate (75 mg/kg, maximum 2.5 g
administered over 20 minutes) if there is clinical
deterioration despite treatment with beta 2-
agonists, ipratropium bromide, and systemic
glucocorticoids.

16. SEVERE EXACERBATION.
• PIS ≥12.
• Supplemental oxygen if oxygen saturation is ≤92
percent in room air.
• Albuterol nebulization (0.15 mg/kg, maximum 5 mg)
combined with ipratropium bromide (250
microgram/dose if <20 kg; 500 microgram/dose if
>20 kg).
• Every 20 to 30 minutes for three doses or
continuously.

17. • Alternatively, epinephrine or terbutaline (0.01
mL/kg of a 1 mg/mL solution) intramuscularly or
subcutaneously for children with poor inspiratory
flow or children who cannot cooperate with
nebulized therapy.

18. • For patients with a poor response to initial
treatment, we recommend:
• IV methylprednisolone (1 to 2 mg/kg, maximum 125
mg).
• IV magnesium sulfate (75 mg/kg, maximum 2.5 g
administered over 20 minutes).

19. • For patients who do not respond to these
interventions, administration of IV terbutaline may
be indicated.
• Bolus with 10 microgram/kg over ten minutes, then
0.3 to 0.5 microgram/kg per minute.
• Infusion may be increased by 0.5 microgram/kg per
minute every 30 minutes to a maximum of 5
microgram/kg minute.

20. PHARMACOTHERAPY.
• Inhaled short-acting beta 2-agonists are the
mainstay of emergent treatment of acute asthma
exacerbations.
• Albuterol is the most widely used short-acting beta
2-agonist in the acute setting.

21. NEBULIZER VERSUS MDI-S.
• Clinicians may use either small volume nebulizers
(SVNs) or MDI-S.
• Advantages of SVN delivery compared to MDI-S
include the ability to simultaneously deliver
humidified oxygen and ipratropium bromide.
• However, when using SVNs, up to 90 percent of
drug remains in the machine or is lost.

22. • Portability of SVNs is limited by the need for an
external power source.
• Clinical trials and meta-analyses indicate that the
administration of beta 2-agonists via MDI-S (4 to 12
puffs) is at least as effective, and possibly superior
to delivery of medication by SVN.

23. LEVALBUTEROL.
• Racemic albuterol (RA) is an equal mixture of two
mirror-imaged enantiomers: the active R-albuterol
and S-albuterol.
• Levalbuterol (LA), on the other hand, is pure R-
albuterol.
• Data from animal studies suggest that S-albuterol,
thought to be inert, may in fact be a weak
bronchoconstrictor.
• We suggest racemic albuterol rather than
levalbuterol as the drug of choice for children with
acute asthma exacerbations.

24. SYSTEMIC GLUCOCORTICOIDS.
• Indicated for most children who present to the ED
with acute asthma exacerbation.
• Early administration of systemic glucocorticoids
reduced admission rates.
• Oral administration of glucocorticoids is preferred
to intravenous administration because oral
administration is less invasive and the effects are
equivalent.

25. DOSE.
• Prednisone is 2 mg/kg (maximum 60 mg).
• Dexamethasone phosphate is 0.6 mg/kg (maximum
dose 16 mg).
• Methylprednisolone usual doses of intravenous
methylprednisolone for acute asthma
exacerbations is 1 to 2 mg/kg (maximum 60 mg).

26. MAGNESIUM SULFATE.
• Intravenous magnesium sulfate benefits adults and
children with severe asthma.
• We suggest that magnesium sulfate be used in
children with severe asthma exacerbations and in
children with moderate asthma exacerbations who
have clinical deterioration despite treatment with
beta 2-agonists, ipratropium bromide, and systemic
glucocorticoids.
• We use a dose of 75 mg/kg (maximum 2.5 g) IV
administered over 20 minutes.

27. PARENTERAL BETA 2-AGONISTS.
• Parenteral beta 2-agonists include epinephrine and
terbutaline.
• These drugs may be administered subcutaneously,
intramuscularly, or intravenously
• The rapid subcutaneous or intramuscular
administration of beta 2-agonists may be superior
to inhaled beta 2-agonists for children with severe
exacerbations and poor inspiratory flow or anxious
young.

28. • Terbutaline for bronchodilation is 0.01 mg/kg per
dose.
• Every 20 minutes for three doses.
• Dosing interval may be decreased.

29. • Dose of subcutaneous or intramuscular epinephrine
for bronchodilation is 0.01 mg/kg.
• Every 20 minutes for three doses, then every two to
six hours as needed.
• Dosing interval may be decreased.

30. • Heliox mixture of helium and oxygen theoretically
may enhance beta 2-agonist delivery because the
lower gas density would result in decreased flow
resistance.
• Ketamine due to its bronchodilating properties.

31. • Patients discharged from the ED should have
follow-up in one to four weeks.
• Primary care provider can review the child's
asthma control and alter controller therapy as
indicated.

32. REFERENCE.
• UPTODATE PAEDIATRICS 2018.

33. THANKS.