Acute asthma exacerbations in children present with acute or sub-acute onset of wheeze and respiratory distress, the symptoms and signs of which vary depending on the developmental and maturational age of the child.
Triggers include viral or bacterial infection, inhaled allergens, environmental irritants, emotion, medications, and poor adherence with preventive therapy.
The majority of children will respond to initial bronchodilator therapy; oral corticosteroids should be initiated early in those who do not respond to regular bronchodilator therapy.
Patients with severe exacerbations require oxygen, nebulised/intravenous bronchodilators, and intravenous corticosteroids and may require magnesium sulfate infusion, intravenous bronchodilators, and intramuscular adrenaline (if anaphylaxis is present).
Severe and life-threatening exacerbations may require non-invasive ventilation or intubation, and the intensive care team should be involved as early as possible.
In children not responding to standard treatment for asthma, other differential diagnoses should be considered.
On discharge from hospital, a clear asthma management plan and asthma education are essential to optimise asthma control and prevent future exacerbations.
An asthma exacerbation is an acute or sub-acute episode of airflow obstruction occurring on a background of chronic airway inflammation and airway hyper-responsiveness. The exacerbation is initiated by a trigger that produces bronchoconstriction and increased mucus production, thereby worsening asthma symptoms such as wheeze, cough, dyspnoea, and respiratory distress. This topic covers the treatment of children up to 11 years of age. Children 12 years and older are treated the same as adults. Please see our Acute asthma exacerbation in adults topic for more information.
History and exam
Key diagnostic factors
- presence of risk factors
- shortness of breath
- chest tightness
Other diagnostic factors
- exercise limitation
- inability to speak or feed
- intercostal, sub-costal, or sternal retraction
- accessory muscle use
- pulsus paradoxus
- sleep disturbance
- decreased consciousness level
- viral infection
- uncontrolled asthma symptoms
- high use of short-acting beta-2 agonists
- inadequate use of inhaled corticosteroids
- incorrect inhaler technique
- low forced expiratory volume in 1 second (FEV₁)
- high bronchodilator reversibility
- inhaled allergens
- poor adherence with regular asthma medication
- history of asthma
- history of other atopic disease
- family history of atopic disease
- history of hospitalisation for asthma exacerbations
- one or more severe exacerbations in the past 12 months
- low socio-economic status
- environmental irritants
- African-American ethnicity
- vitamin D deficiency
- younger age
- low parental education
- bacterial infection
- non-steroidal anti-inflammatory drug (NSAID) use
1st investigations to order
- response to treatment with a short-acting beta-2 agonist
- peak expiratory flow rate or FEV₁
- oxygen saturation
Investigations to consider
- arterial or venous blood gases
- chest x-ray
life-threatening exacerbation or impending respiratory failure
mild to moderate exacerbation
Paul D. Robinson, MBChB, MRCPCH, FRACP, PhD
Respiratory and Sleep Physician
The Children's Hospital at Westmead
Clinical Associate Professor
Discipline of Paediatrics and Child Health
Sydney Medical School
University of Sydney
New South Wales
PDR declares that he has no competing interests.
Anne Chang, MBBS, FRACP, MPHTM, PhD
Menzies School of Health Research
Charles Darwin University
Respiratory and Sleep Physician
Queensland Children's Hospital
Queensland University of Technology
AC's institution has received fees from her work on the independent data monitoring committee board for an unlicensed vaccine (GSK) and as an advisory member of study design for an unlicensed molecule for chronic cough (Merck), outside the work for this topic. AC also received fees from UpToDate for writing topics on cough in children. AC is an author of references cited in this topic.
Lucille A. Lester, MD
Professor of Pediatrics
University of Chicago Comer Children's Hospital
LAL declares that she has no competing interests.
Caro Minasian, BSc (Hons), MB, BS, FCPCH, MD (Res)
Consultant in Paediatrics
Adolescent Medicine & Paediatric Respiratory Medicine
University College London Hospitals NHS Foundation Trust
CM declares that he has no competing interests.
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