Acute asthma exacerbations in children present with acute or subacute 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, nebulized/intravenous bronchodilators, and intravenous corticosteroids and may require magnesium sulfate infusion, intravenous bronchodilators, and intramuscular epinephrine (if anaphylaxis is present).
Severe and life-threatening exacerbations may require noninvasive 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 the hospital, a clear asthma management plan and asthma education are essential to optimize asthma control and prevent future exacerbations.
An asthma exacerbation is an acute or subacute episode of airflow obstruction occurring on a background of chronic airway inflammation and airway hyperresponsiveness. The exacerbation is initiated by a trigger that produces bronchoconstriction and increased mucus production, thereby worsening asthma symptoms such as wheeze, cough, dyspnea, 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. See Acute asthma exacerbation in adults.
History and exam
Key diagnostic factors
- shortness of breath
- chest tightness
Other diagnostic factors
- exercise limitation
- inability to speak or feed
- intercostal, subcostal, 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 (SABA)
- inadequate use of inhaled corticosteroids (ICS)
- 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 hospitalization for asthma exacerbations
- one or more severe exacerbations in the past 12 months
- low socioeconomic status
- environmental irritants
- African-American ethnicity
- vitamin D deficiency
- younger age
- low parental education
- bacterial infection
- nonsteroidal anti-inflammatory drug (NSAID) use
1st investigations to order
- response to treatment with a short-acting beta-2 agonist (SABA)
- 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
- Inhaled foreign body
- Viral-induced infantile wheezing
- Pocket guide for asthma management and prevention
- Australian asthma handbook
Asthma in children: what is it?
Asthma in children: what treatments work?More Patient leaflets
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