European Review for Medical and Pharmacological Sciences
Acute asthma in children: treatment in emergency
P. PAVONE, M.R. LONGO, R. TAIBI, G. NUNNARI*, C. ROMANO,
E. PASSANITI, R. FALSAPERLA
Department of Pediatrics and Pediatric Emergency, University Hospital “Policlinico-Vittorio Emanuele”,
Catania (Italy)
*Department of Infectious Diseases, University Hospital “Garibaldi”, Catania (Italy)
Abstract. – Background and Objective:
Asthma is one of the most common chronic dis-
eases, leading to an increased rate of hospital-
ization.
Material and Methods: The aim of this re-
port is to review the current concepts and treat-
ment of asthmatic children, focusing our atten-
tion on the treatment of children in a Department
of Pediatric Emergency.
Discussion: Frequent respiratory infections,
personal or familial allergy, disease severity and
young age are important factors leading to hos-
pitalization. However, regular clinical follow-up
and use of inhaled corticosteroids, the IgE lev-
els and O2 saturation may reduce the probability
of hospitalization during asthma attacks. The di-
agnosis of asthma in children is based on rec-
ognizing a characteristic pattern of episodic res-
piratory symptoms and signs, in the absence of
an alternative explanation for them. The pres-
ence of these factors increases the probability
that a child with respiratory symptoms will have
asthma. These factors include age at presenta-
tion; sex; severity and frequency of previous
wheezing episodes; coexistence of atopic dis-
ease; family history of atopy; and abnormal lung
function.
Conclusion: Asthma is a chronic condition
that often remains uncontrolled for reasons that
may be related to the disease process itself, the
management decisions of clinicians, the patien-
t’s perceptions of disease control or self-man-
agement behaviors, the cost of medications, or
a combination of all of these factors. To this end,
patients with asthma should be educated not to
accept a certain level of symptoms or activity
limitations as an inevitable consequence of
asthma. Both the levels of current impairment
and the future risks (of asthma exacerbations or
adverse medication effects) should be used to
inform decisions about appropriate levels of
asthma therapy, and physicians should be aware
of the new medication recommendations.
Key Words:
Asthma, Childhood, Emergency, Treatment.
Corresponding Author: Piero Pavone, MD; e-mail: ppavone@unict.it
2011; 15: 711-716
Introduction
Asthma is one of the most common chronic
diseases, leading to an increased rate of hospital-
ization. Frequent respiratory infections, personal
or familial allergy, disease severity and young
age are important factors leading to hospitaliza-
tion. However, regular clinical follow-up and use
of inhaled corticosteroids, the IgE levels and O2
saturation may reduce the probability of hospital-
ization during asthma attacks. The aim of this re-
port is to review the current concepts and treat-
ment of asthmatic children, focusing our atten-
tion on the treatment of children in a Department
of Pediatric Emergency.
A correct diagnosis of asthma is the first step
toward attaining disease control. In general, a di-
agnosis of asthma is established if episodic
symptoms of airflow obstruction or airway hy-
per-responsiveness are present, airflow obstruc-
tion is at least partially reversible, and alternative
diagnoses are excluded. The guidelines recom-
mend the use of a detailed medical history, the
results of a physical examination (focusing on
the upper respiratory tract, chest, and skin), and
the results of spirometry (for patients aged 5
years or older) in making the diagnosis. Particu-
larly important factors that should be addressed
as part of the medical history include the fre-
quency of symptoms (eg, perennial, seasonal, or
both; continual, episodic, or both; diurnal varia-
tions), precipitating factors (such as the presence
of allergic triggers), and a family history of asth-
ma, allergy, or other atopic disorders. Although
recurrent cough and wheezing often result from
asthma, other causes of airway obstruction
should be considered in the initial diagnosis, or if
the patient does not respond to initial therapy.
Several other conditions may coexist, or compli-
cate the diagnosis or management of asthma. The
diagnosis of asthma is confirmed by a positive
711
 P. Pavone, M.R. Longo, R. Taibi, G. Nunnari, C. Romano, E. Passaniti, R. Falsaperla

response to asthma medication, and treatment
should follow the usual stepwise approach to
asthma management1-6,9,10.
The diagnosis of asthma in children is based
on recognizing a characteristic pattern of episod-
ic respiratory symptoms and signs (Table I) in
the absence of an alternative explanation for
them (Tables II and III).
The presence of these factors increases the
probability that a child with respiratory symp-
toms will have asthma. These factors include age
at presentation; sex; severity and frequency of
previous wheezing episodes; coexistence of
atopic disease; family history of atopy; and ab-
normal lung function.
Once the diagnosis has been established, the
focus is on classifying to the severity of asthma
so that therapy can be initiated, and on monitor-
ing control over time so that therapy can be ad-
justed. According to the new guidelines, severity
and control should be assessed separately, but
both are classified on the basis of the domains of
current impairment and future risk. Impairment is
defined as “the frequency and intensity of symp-
toms and functional limitations the patient is ex-
periencing currently or has recently experienced,”
whereas risk is defined as “the likelihood of ei-
ther asthma exacerbations, progressive decline in
lung function (or, for children, lung growth), or
Table I. Clinical features that increase the probability of
asthma.
More than one of the following symptoms: wheezing,
cough, difficulty breathing, chest tightness, particularly
if these symptoms:
• Are frequent and recurrent
• Are worse at night and in the early morning
• Occur in response to exercise or other triggers or
emotions
• Occur apart from colds
Personal history of atopic disorder
Family history of atopic disorder and/or asthma
History of improvement in symptoms or lung function
in response to adequate therapy
Table II. Clinical features that lower the probability of asthma.
• Symptoms with colds only, with no interval symptoms
• Isolated cough in the absence of wheezing or difficulty
breathing
• History of moist cough
• Prominent dizziness, light-headedness, peripheral
tingling
• No response to a trial of asthma therapy
risk of adverse effects from medication”1-15. In as-
sessing impairment, asthma severity should be
evaluated using the following categories:
• Intermittent asthma severity
• Persistent asthma severity (mild, moderate, se-
vere).
Clinical Assessment
Before starting treatment for acute asthma in
any setting, it is essential to assess accurately the
severity of their symptoms. The following clini-
cal signs should be recorded:
• Pulse rate
• Respiratory rate and degree of breathlessness
• Use of accessory muscles of respiration
• Amount of wheezing
• Degree of agitation and conscious level
Clinical signs do not always correlate with the
severity of airways obstruction. Some children
with acute severe asthma do not appear dis-
tressed.
Pulse oximetry: accurate measurements of oxy-
gen saturation are essential in the assessment
of all children with acute wheezing.
Consider intensive inpatient treatment for chil-
dren with SpO2 <92% in air after initial bron-
chodilator treatment.

Table III. Value of respiratory and cardiac rate in acute asthma.

Light Moderate Severe

AGE R.R. C.R. R.R. C.R. R.R. C.R.

< 12 months < 50-60 < 160 > 50-60 > 160
1-5 years < 40 < 120 > 40 > 120 > 50 > 140
> 6 years < 30 < 110 > 30 > 110 > 40 > 120

712
 Acute asthma in children: treatment in emergency
PEF: a measurement of <50% predicted PEF or
forced expiratory volume (FEV), with poor
improvement after initial bronchodilator treat-
ment is predictive of a more prolonged asthma
attack.
Chest X-ray: A chest X-ray should be performed
if there is subcutaneous emphysema, persisting
unilateral signs suggesting pneumothorax, lobar
collapse or consolidation and/or life threatening
asthma not responding to treatment.
Blood gases: Blood gas measurements should be
considered if there are threatening features not
responding to treatment. Normal or raised
pCO2 levels are indicative of worsening asth-
ma. A more easily obtained free-flowing ve-
nous blood pCO2 measurement <45 mmHg ex-
cludes hypercapnia.
Treatment of Acute Asthma in Children
Aged Over 2 years
There is good evidence supporting recommen-
dations for the initial treatment of acute asthma
presenting to primary and secondary healthcare
resources. There is less evidence to guide the use
of second line therapies to treat the small number
of severe cases poorly responsive to first line
measures. Despite this, the risk of death and oth-
er adverse outcomes after admission to hospital
are extremely small irrespective of the treatment
options chosen.
Children with severe or life threatening asth-
ma should be transferred to Hospital urgently1-20.
Oxygen
Children with life threatening asthma or SpO2
<94% should receive high flow oxygen via a
tight fitting face mask or nasal cannula at suffi-
cient flow rates to achieve normal saturations.
Inhaled β2-Agonists
(Salbutamol/Terbutaline)
Inhaled β2-agonists are the first line treatment
for acute asthma. Children receiving a β2-agonist
via pressurized metered dose inhaled (pMDI) +
spacer are less likely to have tachycardia and hy-
poxia than the same drug given via a nebulizer.
Children with severe or life threatening asth-
ma (SpO2 <92%) should receive frequent doses
of nebulised bronchodilators driven by oxygen
(2.5-5 mg salbutamol or 5-10 mg terbutaline), al-
though children with mild symptoms can benefit
from lower doses.
Doses can be repeated every 20-30 min. Con-
tinuous nebulised β2-agonists are of no greater
benefit than the use of frequent intermittent dos-
es at the same total hourly dosage. If there is
poor response to the initial dose of β2-agonists,
subsequent doses should be given in combination
with nebulised ipratropium bromide.
Ipratropium Bromide
There is good evidence for the safety and effi-
cacy of frequent doses of ipratropium bromide
(every 20-30 min) used in addition to β2-agonists
for the first 2 hours of a severe asthma attack.
Benefits are more apparent in the most severe pa-
tients. Frequent doses up to every 20-30 minutes
(250 μg/dose mixed with 5 mg of salbutamol so-
lution in the same nebulizer) should be used for
the first few hours of admission. The salbutamol
dose should be reduced to one to two hourly
thereafter, according to the clinical response. The
ipratropium dose should be reduced to four to six
hourly or discontinued.
Steroid Therapy
Steroid Tables
The early use of steroids in Emergency De-
partments and assessment units reduce the need
for Hospital admission and prevent relapse in
symptoms after initial presentation. Benefits can
be apparent within 3 or 4 hours.
Give prednisone early in the treatment of acute
asthma attacks. Use a dose of 1-2 mg/kg/day
(max 40 mg/dose) 2 to 3 times. Betamethasone
0.1-0.2 mg/kg/day (max 4 mg/dose), in 2 to 3 ad-
ministrations. Intravenous administration of 1-2
mg/kg/6-8 hours (max 40 mg dose).
Oral and intravenous steroids are of similar ef-
ficacy 21 . Intravenous hydrocortisone (5-10
mg/kg/6-8 h; 4 mg/kg repeated every 4 hours
should be reserved for severely affected children
who are unable to retain oral medication.
Treatment for up to 3 days is usually suffi-
cient, but the length of course should be tailored
to the number of days necessary to bring about
recovery. Weaning is unnecessary unless the
course of steroids exceeds 14 days.
Formulations such as hydrocortisone and
methylprednisolone can be given parenterally.
Studies have found these routes to be equally ef-
fective, with the oral route being less painful and
invasive21,23. Prednisone is given for 5 days at a
dose of 1 to 2 mg/kg daily (maximum 50
713
 P. Pavone, M.R. Longo, R. Taibi, G. Nunnari, C. Romano, E. Passaniti, R. Falsaperla
mg/dose). Dexamethasone can be given for 1 to
5 days at a dose ranging from 0.3 to 0.6 mg/kg
daily. Dexamethasone is a long-acting glucocor-
ticoid with a half-life of 36 to 72 hours, and is 6
times more potent than prednisone. Prednisone is
shorter acting, with a half-life of 18 to 36
hours22.
In our practice in the Department of Pediatric
Emergency we are accustomed to seeing 18% to
20% of our patients with different degrees of
asthmatic attack. After therapy almost 90-95% of
them return home and 5% of the patients need
hospitalization.
Leukotriene Receptor Antagonists
There is no clear evidence to support the use
of leukotriene receptor antagonists for moderate
to severe acute asthma in the Emergency Depart-
ment. Leukotriene receptor antagonists is impor-
tant as a chronic support therapy, but not in an
acute attack. At the moment we do not have suf-
ficient data to determine if this drug could be
used during the acute follow-up phase with some
dosing modifications. The use of these treat-
ments is beyond the scope of our review.
Second Line Treatment of Acute Asthma
in Children Aged Over 2 Years
Children with continuing severe asthma de-
spite frequent nebulised β2-agonists and iprat-
ropium bromide plus oral steroids, and those
with life threatening features, need urgent review
by a specialist with a view to transfer to a high
dependency unit or paediatric Intensive Care
Unit (ICU) to receive second line intravenous
therapies. There are three options to consider:
salbutamol, aminophylline and magnesium sul-
phate.
The early addition of a single bolus of intra-
venous salbutamol (5 μg/kg over 10 min) should
be considered in severe cases where the patient
has not responded to initial inhaled therapy.
Aminophylline is not recommended in chil-
dren with mild to moderate acute asthma.
Aminophylline should be considered for children
with severe or life threatening bronchospasm un-
responsive to maximal doses of bronchodilators
plus steroids.
A 5 mg/kg loading dose should be given over
20 minutes with ECG monitoring, followed by a
continuous infusion at 1 mg/kg/hour. Serum
theophylline should be measured in patients al-
714
ready receiving oral treatment and in those re-
ceiving prolonged treatment.
Intravenous magnesium sulphate is a safe
treatment for acute asthma, but its place in
management is not yet established. Doses of up
to 40 mg//kg/day (maximum 2 g) by slow infu-
sion have been used. Studies of efficacy for se-
vere childhood asthma unresponsive to more
conventional therapies have been inconsistent.
Children can be discharged when stable on 3-4
hourly inhaled bronchodilators. This treatment
can be continued at home. PEF and/or FEV
should be >75% of best of predicted, and SpO2
>94%.
Assessment of Acute Asthma in Children
aged Less Than 2 Years
The assessment of acute asthma in early child-
hood can be difficult. Intermittent wheezing at-
tacks are usually due to viral infection and re-
sponse to asthma medication is inconsistent. Pre-
maturity and low birth weight are risk factors for
recurrent wheezing. The differential diagnosis of
symptoms includes aspiration pneumonitis,
pneumonia, bronchiolitis, tracheomalacia, and
complications of underlying conditions, such as
congenital anomalies and cystic fibrosis.
Treatment of Acute Asthma in Children
Aged Less Than 2 Years
β2-Agonist Bronchodilators
Inhaled β2-agonists are the initial treatment of
choice for acute asthma. Close fitting face masks
are essential for optimal drug delivery. The dose
received is increased if the child is breathing ap-
propriately, and not taking large gasps because of
distress and screaming.
There is good evidence that pMDI + spacer is
as effective as, if not better than, nebulisers for
treating mild to moderate asthma in children
aged <2 years.
Oral β 2-agonists are not recommended for
acute asthma in infants.
Steroid Therapy
Consider steroid tablets as early treatment of
severe episodes of acute asthma in the hospital
setting. Steroid tablet therapy (1-2 mg/kg of solu-
ble prednisolone for up to 3 days) is the preferred
steroid preparation for use in this age group.
 Acute asthma in children: treatment in emergency

ACUTE ASTHMA ATTACKS

Light Moderate Severe

Salbutamol spray Salbutamol spray Salbutamol spray

(200 mcg) or via a (200-400 mcg) or via a (200-400 mcg)
Incomplete Over 20 minutes; plus
nebulizer (0,1 mg/kg) in response nebulizer (0.1 mg/kg) in 3 Worsening
3 administration or ipratropium bromide
somministration or in case
250 mcg/dose
in case of need of need; plus ipratropium every 20-30 min
bromide 250 mcg/dose +
every 20-30 min Prednisolone 1-2 mg/kg/die
If there is a good response (max 40-50 mg/dose)

Incomplete response
Good or incomplete
response
Good response Worsening
Continue salbutamol Salbutamol spray
(200-400 mcg) or via a
nebulizer (0.1 mg/kg) in 3
somministrations or
Resolution in case of need Hospitalization
+ Incomplete
Prednisolone 1-2 mg/kg/day response or
(max 40-50 mg/dose) worsening

Figure 1.

Ipratropium Bromide ––––––––––––––––––––

Acknowledgements
Inhaled ipratropium bromide should be con-
sidered in combination with inhaled β2-agonist
for more severe symptoms.
Many children with recurrent episodes of vi-
ral-induced wheezing in infancy do not go on to
have chronic atopic asthma. The majority do not
require treatment with regular inhaled steroids.
Parents should be advised about the relationship
between cigarette smoke exposure and wheezy
illnesses.
Parents of wheezy infants should receive ap-
propriate discharge plans, along similar lines to
those given for older children.
Figure 1 summarizes the therapy in an asthma
attack. The use of other new medicaments like
omalizumab monoclonal antibody seems to re-
duce the asthmatic attack in 50% of patients in
the first year with a good tolerability in children
6-11 years old, but is still controversial, and
more studies are needed to better clarify the safe-
ty of this therapy. The use of these treatments is
beyond the scope of our review.
We are grateful to Prof. Lorenzo Pavone (Catania) for
the helpful suggestions and the critical review of the
manuscript. We also wish to thank International Sci-
ence Editing Co, Shannon Ireland, for editing the man-
uscript.
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