Basics of pediatric asthma exacerbation management, case presentation and clinical assessment points.

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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