Maryam, a 5-year-old girl with a recent asthma diagnosis, presented to the emergency department with worsening respiratory distress following three days of upper respiratory symptoms. Examination revealed signs of moderate asthma exacerbation, including wheezing and agitation, as well as vital signs indicating tachypnea and hypoxia. Treatment began with supplemental oxygen and nebulizations, and in severe cases, further interventions such as IV corticosteroids and magnesium sulfate may be required.

1. Managing an Asthma
Exacerbation in the ED
Emergency Block
Fatima Farid
Ped Resident Year 3

2. Case Study
01
“Wheezy & Breathless”

3. HPI
• Maryam is a 5-year-old girl, known to have asthma, brought to ED by her mother
• Presented with three days’ history of runny nose and cough followed by difficult breathing
today
• Cough has been intermittent throughout the day, worsening at night & preventing her from
sleeping comfortably
• Over the last 3 days, cough has been getting worse & has a whistling sound since yesterday
• Since midnight child has been refusing to lie flat on her back, is unable to speak in sentences
& has been increasingly agitated

4. Can you share some of
your differentials? 

5. 1. Acute asthma exacerbation
2. Viral bronchitis or
pneumonia
3. Foreign body aspiration
4. Allergic reaction
5. Gastro- esophageal reflux/
aspiration pneumonia
DDx

6. Systemic Review
• Temperature was not checked at home, but mother didn’t feel her to be warm
• Maryam has not been sleeping or eating well since yesterday
• No skin rash, ear pain or change in bladder/ bowel habits
• No history of choking, cyanosis or apnea
• No recent weight loss appreciated
• Only a herbal cough syrup was given at home

7. Past Medical Hx
• Diagnosed with asthma last month after she required PICU admission for severe status
asthmaticus
• No intubation/ mechanical ventilation was required
• She was not known to have asthma or any health issues before that
• Since discharge parents were requested to follow in our asthma clinic, but did not attend
because child was “doing fine & the asthma was cured”
• Mother says she never gave Maryam any prophylaxis or her rescue inhaler during current
illness because she believed the herbal syrup was all she needed

8. Other Hx
• No know allergies to food or drugs
• No previous surgeries or regular home medications
• On normal home diet & fully vaccinated
• Developmentally appropriate, bright, friendly & very intelligent girl
• Born at 36 weeks by LSCS in view of fetal distress. Uneventful antenatal and post- natal
period.
• Only child of non- consanguineous parents. Mother has eczema. No other known illnesses in
the family.

9. What will we look for in
our examination? 

10. VS
• Temperature 37.9 C
• Respiratory rate 55 breaths/ min
• Oxygen saturation 94% on room air
• Heart rate 160 beats/ min
• Blood pressure 90/ 65 mmHg

11. General Look
Source: YouTube – Look and listen for wheezing

12. Findings
Positives Negatives
● Agitated but alert
● Audible wheezes
● Pink on room air
● Well- hydrated
● Subcostal and supra- sternal recessions
● Chest with bilateral equal air entry, loud
wheezes & prolonged expiratory phase
● Normal heart sounds, no murmur
● Abdomen soft and non- tender
with no organomegaly
● No skin rash
● CNS grossly intact
● Normal female genitalia
● Femorals palpable bilaterally

13. Do you know how to
determine the severity of
an asthma exacerbation? 

14. Severity Assessment
Symptoms Signs
Functional
Assessment
Alertness HR & RR SpO2 on room air
Level of
breathlessness
Wheezes & use of
accessory muscles
BP
Ability to speak Cyanosis Peak expiratory flow
Pulsus paradoxus PO2 & PCO2

15. Mild
Symptoms Signs
Functional
Assessment
Breathlessness
while walking
Tachypnea PEF > 70%
Child can lie down
Minimal accessory
muscle use
PO2 and PCO2
normal
Speaks in
sentences
Moderate wheeze,
usually only end-
expiratory
SpO2 > 95% on
room air
May be agitated
Pulse less than 100
beats/ min
Normal blood
pressure
No pulses
paradoxus (< 10
mmHg)
Source: YouTube – Look and listen for wheezing

16. Moderate
Symptoms Signs
Functional
Assessment
Breathlessness while
at rest – for infants a
shorter and softer cry
with difficulty in
feeding
Tachypnea
PEF 40- 69% or
response to SABA
lasts less than 2
hours
Child prefers to sit
Presence of
accessory muscle use
PO2 > 60 mmHg
PCO2 < 42 mmHg
Speaks in phrases
Loud wheezes
throughout expiration
SpO2 90- 95% on
room air
Usually agitated
Pulse between 100-
120 beats/ min
Normal blood
pressure
May have pulses
paradoxus (10- 25
mmHg)
Source: rolobotrambles.com- the sounds of winter: an audio-visual review of paediatric respiratory disease

17. Severe
Source: YouTube – Look and listen for wheezing
Symptoms Signs
Functional
Assessment
Breathlessness at
rest and unable to
feed
Tachypnea PEF < 40%
Child only sits
upright
Presence of
accessory muscle
use
PO2 < 60 mmHg
PCO2 > 42 mmHg
Speaks in words
Loud wheezes
present in both
inspiration and
expiration
SpO2 < 90% on
room air
Usually agitated
Pulse between >
120 beats/ min
Normal blood
pressure
Often have pulses
paradoxus (> 20
mmHg)

18. Sub- arrest
Source: teachmepediatrics.com- approach to the seriously unwell child
Symptoms Signs
Functional
Assessment
Drowsy or confused
Poor respiratory
effort
Appears exhausted
PEF < 25%
Cyanosis Hypotension
Paradoxical
thoraco- abdominal
movement
Hypercapnia
Absence of wheeze
(silent chest)
Bradycardia

19. What is our patient’s
severity? 

20. Pulmonary Index Score
Source: UpToDate- Acute asthma exacerbations in children younger than 12 years: Emergency department management
Our patient’s score = 10 (fits 2 for all criteria) = moderate severity

21. How will we start treating
the child? 

22. Principles
Reversal of airway obstruction
Correction of hypoxemia &
hypercarbia
Reduction in rate of
hospitalization and recurrence
1
2
3

23. Initial Mx
1. Give oxygen to keep saturation > 95%
2. Administer salbutamol and ipratropium bromide nebulization
3. In moderate to severe illness, start either oral prednisolone or IV hydrocortisone
4. Re- assess frequently for response & early detection of deterioration

24. Nebulization
Ventolin Atrovent
● Salbutamol: Relaxes bronchial smooth muscle by action on
beta- receptors with little effect on heart rate
● Nebulization: 0.15 mg/kg/dose (minimum 2.5 mg) every 20
minutes for 3 doses, then 0.15- 0.3 mg/kg/dose (not to
exceed 10 mg/dose) every 1- 4 hours
● Inhaler: 4- 8 puffs every 20 minutes for 3 doses then every 1-
4 hours
● Onset within 5 minutes / Time to peak 30 minutes / Duration
3- 6 hours
● Ipratropium bromide: Blocks action of acetylcholine at
parasympathetic sites in bronchial smooth muscle causing
bronchodilation
● Nebulization 250- 500 mcg every 20 minutes for one hour, then
as needed as 250 mcg every 1- 8 hours typically with an
increasing dosing interval as patient improves
● Inhaler 4- 8 puffs every 20 minutes as needed for up to 3 hours
● Onset within 15 minutes / Peak effect in 1- 2 hours / Duration
4- 5 hours (nebulization) & 2- 4 hours (inhaler)

25. Corticosteroid
• Hydrocortisone:
• IV or IM: 0.56- 8 mg/kg/day (or 20- 240 mg/m2/day) in 3 or 4 divided doses
• We use IV 4 mg/kg every 6 hours
• Onset in 1 hour & half- life 2 hours
• Prednisolone:
• Dose is 2 mg/kg/day divided BD
• Max daily dose is 60 mg/ 24 hours (for exacerbations)
• Therapy for moderate cases lasts 5- 7 days & no taper required when stopping

26. Re- assess
in 20 mins
Re- assess
in 20 mins
Mild Cases

27. Moderate Cases
Re- assess
in 20 mins
Re- assess
in 20 mins

28. Severe Cases
Re- assess
in 20 mins
Re- assess
in 20 mins

29. Do you know the next
steps of treating severe
asthma? 

30. Further Care
• High flow oxygen via mask (15 L/ min) + I.V. access + blood gas & chest x- ray
• IV Hydrocortisone 4 mg/kg ASAP
• IV Magnesium sulphate bolus: Use MgSo4 49.3% give 0.1 ml/kg (approximately 40- 50 mg/kg) over
20 minutes (dilute in 20 ml 0.9% saline) maximum dose 5 ml (2- 2.5 gm) then can be given Q6H with
close monitoring of the heart rate, BP, urine output, Mg, Ca & K (hypocalcaemia & hypokalemia,
hypermagnesaemia)

31. Magnesium Sulphate
• IV form improves pulmonary function by causing bronchial smooth muscle relaxation independent of
serum magnesium concentration
• Dosage: 50 mg/kg/dose as a single dose (range 25- 75 mg/kg/dose, max dose 2000 mg/dose)
• Onset is immediate & duration 30 minutes
• Some clinicians recommend a saline bolus prior to administration to prevent hypotension

32. What if the child still
doesn’t improve? 

33. Sub- arrest Mx
• Call PICU immediately
• Continuous nebulized Ventolin if good inspiratory effort
• Switch to Terbutaline or Epinephrine SQ/ IM if child is not breathing well
• If still poor response start IV Terbutaline + continuous Ventolin nebulization
• Consider non- invasive positive pressure ventilation
• Intubation is very risky in asthmatic children & should only be resorted to if absolutely unavoidable

34. Epinephrine & Terbutaline
• Epinephrine 0.01 mg/kg (0.01 ml/kg) of 1:1000 SQ or IM (max dose is 0.5 mg)
• Bronchodilator, vasopressor and inotropic effects
• Short acting (around 15 mins) and should be used as a temporizing rather than definitive therapy
• Terbutaline 0.01 mg/kg SQ (max dose 0.4 mg) every 15 minutes for up to 3 doses
• IV Terbutaline can be considered if there is no response to second dose of SQ
• Limited by cardiac intolerance. Monitor continuous 12 lead ECG, cardiac enzymes, urinalysis and
electrolytes
• Only consider in severely ill patients or in those uncooperative with inhaled beta agonists

35. Intubation
• Potentially dangerous and should be reserved for impending respiratory arrest
• Can increase airway hyper- responsiveness and obstruction
• Indications:
• Deteriorating mental status
• Severe hypoxemia
• Respiratory or cardiac arrest

36. Alternatives
• IV Salbutamol bolus 10- 15 mcg/kg (single dose maximum 500 mcg) over 10 min in a minimum 5 ml 0.9%
saline. Repeat dose at 10 minutes if still not improving.
• Continuous IV salbutamol infusion 1- 5 mcg/kg/minute (200 mcg/ml solution) with close monitoring of the
heart rate.
• IV Aminophylline bolus 5 mg/kg IV loading dose (maximum dose 500 mg) and make up to 100ml with 0.9%
saline over 30 – 60 minutes with close monitoring of HR, RR, SpO2 and BP.
• If inadequate response to bolus therapy, then start further IV therapy in form of Salbutamol +/- aminophylline
infusion 1 mg/kg/hour.

37. References
• Harriet Lane Handbook, 21st edition
• Latifa Hospital Guidelines : Management of Asthma
• UpToDate: Acute asthma exacerbations in children younger than 12 years: Emergency department
management

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