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Acute Asthma Exacerbations in Children Younger Than 12 Years: Inpatient Manageme
Acute Asthma Exacerbations in Children Younger Than 12 Years: Inpatient Manageme
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All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Jan 2023. | This topic last updated: Jun 29, 2022.
INTRODUCTION
More than 6.2 million children in the United States have asthma [1], which accounts for
nearly 550,000 emergency department (ED) visits, 2,500,000 clinician office visits, and
80,000 hospitalizations each year [2,3]. Although exacerbations are common, most are
mild and can be managed successfully at home. Children with severe exacerbations or
those who fail to improve with outpatient therapy may need to be evaluated and treated in
an urgent care facility or ED, and some will need to be admitted to the hospital for further
management.
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Acute asthma exacerbations in children younger than 12 years: Inpatient management
OVERVIEW
Most children who require admission for asthma are initially treated in the emergency
department (ED), although some are admitted directly from clinicians' offices. Thus,
inpatient treatment is typically a continuation of therapies and monitoring that were
started in the ED ( algorithm 1) [4]. Patients usually have received at least three albuterol
treatments, often combined with ipratropium, systemic glucocorticoids, and supplemental
oxygen, before arrival to the inpatient unit. The criteria for admission are discussed in
detail separately. (See "Acute asthma exacerbations in children younger than 12 years:
Emergency department management", section on 'Hospitalization'.)
Communication among the referring clinicians, providers in the ED, and those caring for
the patient in the hospital is essential to ensure that treatments ordered in the ED are not
missed or duplicated during the transfer of care.
Clinical status and response to therapy must be monitored frequently during treatment for
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Acute asthma exacerbations in children younger than 12 years: Inpatient management
acute asthma exacerbation [5,8-16]. The degree of monitoring depends upon the severity
of the exacerbation and the treatments required. The most important parts of the clinical
evaluation include assessment of respiratory rate, work of breathing (retractions), pulse
oximetry, and the lung exam. Heart rate and rhythm need to be followed given the risk of
cardiac side effects (tachycardia and less common but more severe cardiac side effects
including diastolic hypotension, cardiac dysrhythmias, and myocardial ischemia) with beta
agonists [17-21]. Asthma scores can be used to evaluate response to treatment. Pulmonary
function testing, chest radiographs, and laboratory studies are of limited use in most
children hospitalized for asthma exacerbations. (See "Acute severe asthma exacerbations
in children younger than 12 years: Intensive care unit management", section on 'Severity
assessment' and "Acute asthma exacerbations in children younger than 12 years: Overview
of home/office management and severity assessment", section on 'Assessment of
exacerbation severity'.)
● Cyanosis
poor air movement with a prolonged expiratory phase (respiratory rate may be
inappropriately normal to low and breath sounds reduced or inaudible)
● Carbon dioxide retention (partial pressure of CO2 [PaCO2] >40 mmHg) (see
'Laboratory studies' below)
These patients should be transferred to the pediatric intensive care unit (PICU). (See "Acute
severe asthma exacerbations in children younger than 12 years: Intensive care unit
management".)
Monitoring protocols vary from institution to institution and also depend upon the
patient's clinical status and level of treatment. On an inpatient unit, patients are typically
evaluated before and after treatments when on intermittent therapy or every one to two
hours while receiving continuous inhaled beta agonist therapy (if continuous therapy is
allowed on the regular nursing unit) to determine their response to therapy. Patients
receiving continuous inhaled beta agonist therapy additionally should be on continuous
cardiopulmonary monitoring. Such monitoring should be continued until the patient is
tolerating interval treatments every three hours, at which time the patient can be switched
to intermittent monitoring. The frequency of monitoring vital signs and oxyhemoglobin
saturation are decreased as the patient improves and inhalation treatments are spaced to
every four hours. At minimum, vital signs and oxygen saturation should be assessed every
four hours.
Monitoring and therapy adjustment for inhaled beta agonists and supplemental oxygen is
discussed in greater detail below. (See 'Therapy adjustment' below and 'Management of
hypoxemia' below.)
Asthma scores — Several scoring systems have been developed to standardize and
facilitate assessment of initial severity of an asthma exacerbation in children. These scores
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Acute asthma exacerbations in children younger than 12 years: Inpatient management
also can be used to evaluate the response to treatment and guide changes in the
frequency of bronchodilator (beta agonist) administration. These scores are reviewed in
greater detail separately. (See "Acute asthma exacerbations in children younger than 12
years: Emergency department management", section on 'Assessment of severity' and
"Acute asthma exacerbations in children younger than 12 years: Overview of home/office
management and severity assessment", section on 'Asthma severity scores'.)
Imaging — Chest radiographs are not routinely necessary for children who are admitted
to the hospital with acute asthma exacerbations [16]. However, they may be warranted in
patients with:
● Acute worsening of clinical status (to look for potential complications of asthma:
atelectasis, pneumothorax, pneumomediastinum, and pneumonia). Signs of such
complications include fever ≥38.5ºC, focal examination findings (eg, rales or
decreased aeration), chest pain, unilateral absence of breath sounds, and/or extreme
tachypnea or tachycardia.
● Lack of response to asthma therapy (to look for other processes that can mimic
asthma, such as vascular ring, foreign body aspiration) ( table 3). (See "Vascular
rings and slings" and "Airway foreign bodies in children" and "Evaluation of wheezing
in infants and children".)
Laboratory studies — Routine laboratories are not necessary for children who are
hospitalized for acute asthma exacerbation and receiving intermittent inhalation therapy.
Children receiving continuous albuterol nebulization are at risk of transient hypokalemia,
hypophosphatemia, and hypomagnesemia. Although these decreases are rarely of clinical
importance in children, we typically measure serum electrolytes daily in patients receiving
continuous albuterol, particularly those who have been taking diuretics regularly, have
coexistent cardiovascular disease, and/or have a known predilection to electrolyte
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Acute asthma exacerbations in children younger than 12 years: Inpatient management
Hypocarbia and respiratory alkalosis are frequently seen initially in children with asthma
exacerbations due to an increased respiratory rate. Carbon dioxide (CO2) retention occurs
only at extreme degrees of obstruction and has been found in people with near-fatal
asthma [22]. A venous or capillary blood gas is useful in patients with asthma
exacerbations and may be particularly helpful in patients who also have underlying lung
disease (eg, bronchopulmonary dysplasia, cystic fibrosis, obstructive sleep apnea) and are
on supplemental oxygen since these patients are at higher risk for hypercarbia. An arterial
blood gas is indicated in patients with signs of impending respiratory failure. A normal or
rising CO2 level in a patient with tachypnea and respiratory distress is a concerning finding
that suggests impending respiratory failure. Hypercarbia (PCO2 ≥45 mmHg) despite
maximal medical therapy is an indication for intubation and mechanical ventilation [5].
(See 'Management of bronchospasm' below and 'Signs of impending respiratory failure'
above and "Acute severe asthma exacerbations in children younger than 12 years:
Endotracheal intubation and mechanical ventilation", section on 'Indications'.)
INITIAL THERAPY
We recommend that children who are admitted to the hospital with an acute asthma
exacerbation receive therapy with inhaled short-acting beta-2 agonists (SABAs; eg,
albuterol/salbutamol) [23]. The frequency of dosing depends upon the severity of the
exacerbation and the patient's response to treatment. Children with moderate
exacerbations usually require inhaled SABAs every one to three hours. In addition to the
regularly scheduled beta agonist treatment, "as needed" treatments should be available
for episodes of acute bronchospasm or worsening respiratory distress. Treatments are
typically switched to continuous nebulized therapy if patients require treatment more
often than every two hours. (See 'Clinical assessment' above and "Acute asthma
exacerbations in children younger than 12 years: Overview of home/office management
and severity assessment", section on 'Asthma severity scores'.)
We also recommend systemic glucocorticoids for children with acute asthma exacerbation
who require hospitalization. Oral forms (eg, prednisone/prednisolone or dexamethasone)
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Acute asthma exacerbations in children younger than 12 years: Inpatient management
are preferred over intramuscular or intravenous forms. Most children will have received
their first dose in the acute care setting. (See 'Management of inflammation' below and
"Acute asthma exacerbations in children younger than 12 years: Emergency department
management", section on 'Systemic glucocorticoids'.)
THERAPY ADJUSTMENT
Patients who do not improve or who clinically worsen need more frequent or additional
treatments. Patients who are stable but not significantly improved should continue on the
same frequency of treatments. Patients with clear improvement in clinical parameters
should have the interval between their treatments increased. Titrating supplemental
oxygen delivery is reviewed below. (See 'Clinical assessment' above and 'Management of
hypoxemia' below.)
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Acute asthma exacerbations in children younger than 12 years: Inpatient management
for worsening respiratory status. Delivery systems are discussed separately. (See 'Initial
assessment and ongoing monitoring' above and "Acute severe asthma exacerbations in
children younger than 12 years: Intensive care unit management".)
Indications for PICU/anesthesia consult — A pediatric intensive care unit (PICU) and/or
anesthesia consult should be obtained for children receiving continuous nebulized
albuterol therapy who have increasing fatigue, increasing work of breathing, CO2
retention, or worsening hypoxemia. These children are at risk for further decompensation
and may need noninvasive ventilation or intubation. Most will need to be transferred to
the PICU for closer monitoring and more aggressive treatment. (See 'Signs of impending
respiratory failure' above and "Acute severe asthma exacerbations in children younger
than 12 years: Intensive care unit management".)
ELEMENTS OF TREATMENT
Asthma treatment includes inhaled short-acting beta-2 agonists (SABAs or beta agonists)
( table 6), systemic glucocorticoids (such as prednisone/prednisolone or dexamethasone)
( table 7), and supplemental oxygen when needed. Our approach is consistent with
expert guidelines [5,31,32].
Management of bronchospasm
● Inhaled SABAs – SABAs (eg, albuterol/salbutamol) are one of the primary therapies
for acute asthma exacerbations. (See "Beta agonists in asthma: Acute administration
and prophylactic use".)
SABAs are administered continuously (via nebulizer) or intermittently (via MDI with
valved holding chamber/spacer or nebulizer) [17,33-39]. All nebulized treatments
should be given with oxygen (usually 100 percent fraction of inspired oxygen
[FiO2]) as the driving gas rather than with compressed air since most patients
admitted for an asthma exacerbation will have some degree of hypoxemia. A flow
rate of 6 to 8 L/min produces the optimal particle size for airway deposition.
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Acute asthma exacerbations in children younger than 12 years: Inpatient management
The three most common adverse drug events (ADEs) associated with intermittent
SABAs are anxiety (range 0 to 52 percent, levalbuterol), tachycardia (range 13.6 to
14 percent, salbutamol), and supraventricular ectopy (range 0 to 14 percent,
salbutamol) [48]. With continuous SABAs, 50 percent of ADEs affected the
cardiovascular system, with the three most common ADEs being tachycardia
(range 94 to 95 percent, salbutamol), diastolic hypotension (range 66 to 98
percent, salbutamol), and lactic acidosis (80.6 percent, salbutamol).
Management of inflammation
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Acute asthma exacerbations in children younger than 12 years: Inpatient management
vomiting of doses).
• ≥94 percent – Decrease the flow rate by one-quarter L/minute for children who
weigh <15 kg and by one-half L/minute for children who weigh ≥15 kg.
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Acute asthma exacerbations in children younger than 12 years: Inpatient management
Once patients are no longer receiving supplemental oxygen therapy, oximetry should
be monitored 5 to 10 minutes after discontinuation, just before the next inhaled beta-
agonist treatment, and while the child is sleeping for the first sleep period after
discontinuation [4]. Pulse oximetry can be discontinued if the oxygen saturation
remains ≥92 percent for each of these situations.
ICU care — Inpatient use of systemic beta agonists, methylxanthines, and magnesium
sulfate is reserved for patients with severe exacerbations who are admitted to the
intensive care unit (ICU) since use of these medications requires a higher level of
monitoring than is available on regular nursing units. Other therapies used in the ICU
include noninvasive positive pressure ventilation and high-flow nasal cannula. These
therapies are discussed in greater detail separately. (See "Acute severe asthma
exacerbations in children younger than 12 years: Intensive care unit management".)
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Acute asthma exacerbations in children younger than 12 years: Inpatient management
Therapies not used in the inpatient setting — Inhaled ipratropium bromide and oral
leukotriene receptor antagonists (LTRAs) are not used as adjunctive therapy for
hospitalized patients.
Leukotriene receptor antagonists — There are no data on the use of LTRAs (eg,
montelukast, zafirlukast) for acute asthma exacerbations in children in the hospital setting.
Patients taking an LTRA for long-term asthma control do not need to continue it while
receiving systemic glucocorticoids during hospitalization for an acute asthma
exacerbation. LTRAs should be restarted at the time of discharge if the plan is to continue
them. (See "Antileukotriene agents in the management of asthma", section on 'Future
directions'.)
CONSULTATION
Asthma specialist — Many children with asthma respond quickly to standard care. The
inpatient management of such patients need not involve an asthma specialist (eg,
pediatric pulmonologist or pediatric allergist). However, consultation with an asthma
specialist may be warranted in the following circumstances [5]:
● The diagnosis is in question or the patient fails to improve. (See 'Failure to respond'
above.)
● Repeated hospital admission, history of intensive care unit (ICU) admission, frequent
emergency department (ED) visits, or need for multiple or frequent drug therapies at
home.
● Other conditions complicating asthma (eg, sinusitis, nasal polyps, chronic lung
disease of prematurity, allergic bronchopulmonary aspergillosis, gastroesophageal
reflux, obesity, food allergy, etc).
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Acute asthma exacerbations in children younger than 12 years: Inpatient management
● Patients with asthma and other chronic disease (eg, cystic fibrosis, restrictive lung
disease, neuromuscular weakness).
● The patient requires extensive education about allergen avoidance, problems with
adherence to therapy, or complications of therapy.
Long-term follow-up with an asthma specialist may be warranted for some patients,
particularly those who had near-fatal asthma or required ICU care [5]. (See "An overview of
asthma management", section on 'When to refer'.)
Social services — Consultation with social services may be warranted when caregiver
resources are inadequate to ensure medication availability, adherence, and/or medical
follow-up and to help caregivers connect with asthma programs available in the
community [16]. Social services also may be helpful when environmental triggers related
to housing play a role in the asthma exacerbation (eg, rodents, cockroaches, smoke
exposure). (See "Allergen avoidance in the treatment of asthma and allergic rhinitis".)
DISCHARGE PLANNING
Planning for discharge begins at the time of admission. The patient's and caregiver's
understanding of asthma, including signs and symptoms, triggers, medications, and self-
monitoring, should be assessed so that appropriate education can be provided [5]. For
patients newly diagnosed with asthma, it is important to anticipate the need for
medication equipment, such as a spacer (preferably a valved holding chamber) or a
nebulizer with compressor, so that it can be delivered to the caregiver and they can learn
how to use it before the child is discharged. (See 'Discharge medications' below.)
Discharge criteria — Specific criteria for discharge vary from institution to institution.
General principles to determine appropriate discharge may be used. Patients may be
discharged when:
● Their asthma symptoms and signs (and scores, if available) are considered mild.
Standardized tools, such as the Pediatric Dyspnea Scale (PDS) ( figure 1), may be
useful. In one study, the PDS predicted poor outcomes after discharge, including
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Acute asthma exacerbations in children younger than 12 years: Inpatient management
relapse and activity limitation, and was a better indicator than measures of
pulmonary function [72].
● They are receiving a treatment regimen that can be reasonably duplicated at home
(eg, they are tolerating oral medications, and the frequency and proper technique of
inhalation treatments can be managed by the caregiver, usually every four to six
hours). If possible, patients should be observed in the hospital for at least one
interval while receiving the treatments that will be prescribed after discharge. If
patients have been receiving nebulized medications, they may be changed to
metered-dose inhaler (MDI) spacer after continuous therapy is no longer needed or
any time prior to discharge provided they can demonstrate proper technique.
Discharge medications should include an inhaled short-acting beta-2 agonist (SABA), either
via nebulizer or MDI with a valved holding chamber/spacer, and oral glucocorticoids if the
course was not already completed during the hospitalization [5].
● The beta agonist should be continued roughly every four to six hours until the patient
is seen in follow-up within three to five days. Frequency can then be decreased or
returned to "as needed" depending upon the rate of clinical improvement.
● Oral glucocorticoids are usually continued for a total of five days, although a two-day
course of dexamethasone may be sufficient. Indications for longer courses are
discussed above. (See 'Management of inflammation' above.)
● The need for daily controller therapy should be reviewed prior to discharge. Step-up
therapy is often indicated in patients who were already on controller medication prior
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Acute asthma exacerbations in children younger than 12 years: Inpatient management
to the admission. Daily controller therapy, at least for a few months, is indicated for
almost all children who have been hospitalized with an asthma exacerbation.
Controller medications and preferred regimens are discussed in detail separately.
(See "Asthma in children younger than 12 years: Management of persistent asthma
with controller therapies".)
The patient should have all maintenance medications and the equipment necessary for
their delivery (eg, valved holding chamber/spacer, mask, nebulizer, nebulizer tubing and
mask, etc) prior to discharge. One way of assuring this is to have the caregiver fill the
prescriptions before discharge. An advantage of this approach is that it permits the
inpatient team to review the proper technique for medication administration. If the
caregiver is unable to fill the prescriptions before discharge, patient demonstrator devices
may be used to review technique. (See 'Discharge education' below and "The use of inhaler
devices in children" and "Use of medication nebulizers in children".)
The various aspects of asthma education can be provided by any member of the health
care team with adequate training. Some institutions have dedicated asthma educators that
assist with the education process. (See "An overview of asthma management", section on
'Patient education'.)
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Acute asthma exacerbations in children younger than 12 years: Inpatient management
● Monitoring asthma symptoms and identifying and avoiding triggers when possible,
including avoidance of irritants (eg, tobacco smoke) and allergens (when relevant)
and ensuring that the child receives the yearly influenza vaccine ( table 12). (See
"Asthma education and self-management" and "Seasonal influenza in children:
Prevention with vaccines", section on 'Target groups'.)
Asthma action plan — Patients should be given a written asthma action plan that includes
[5,73]:
● A list of the daily medications and the time(s) of day they are to be taken
● A list of the quick-relief medication(s) and a description of the symptoms for which
they should be taken
● A list of triggers that may exacerbate their asthma (see "Trigger control to enhance
asthma management" and "Allergen avoidance in the treatment of asthma and
allergic rhinitis")
The National Asthma Education and Prevention Program (NAEPP) provides sample asthma
action plans for children aged zero to five years ( form 1), patients older than five years
( form 2), and for use at school (Student Asthma Action Card).
Follow-up — Patients discharged from the hospital should have follow-up in three to five
days with their primary care provider or asthma specialist [5]. At the follow-up visit, the
primary care provider can review the child's severity/control classification, alter controller
therapy as indicated, and taper or discontinue inhaled SABA therapy ( table 10A-B and
table 1A-B and table 11A-B). (See "Asthma in children younger than 12 years:
Management of persistent asthma with controller therapies" and 'Asthma specialist'
above.)
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Acute asthma exacerbations in children younger than 12 years: Inpatient management
The clinician monitoring the child's asthma should ascertain whether the patient's asthma
medications are available and whether they are properly used (including associated
devices). Patients should be reminded to refill their prescriptions as indicated and make
certain the ones they have are not expired or depleted.
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Acute asthma exacerbations in children younger than 12 years: Inpatient management
every 15 minutes to every four hours, depending upon the clinical status. (See 'Initial
assessment and ongoing monitoring' above.)
● When to obtain imaging – Chest radiographs are not routinely necessary for
children who are admitted to the hospital with acute asthma exacerbations. However,
they may be warranted in patients with acute worsening of clinical status or lack of
response to asthma therapy. (See 'Imaging' above.)
● Discharge criteria and follow-up – Discharge criteria include asthma signs and
symptoms that are mild to absent, lack of requirement for supplemental oxygen, a
treatment regimen that is suitable for home administration with availability of all
medications and equipment, completion of asthma education to ensure that patients
and care providers know how to properly administer medications and recognize
symptoms, and a follow-up visit scheduled with the primary care provider or asthma
specialist in three to five days. (See 'Discharge criteria' above and 'Follow-up' above.)
ACKNOWLEDGMENT
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Acute asthma exacerbations in children younger than 12 years: Inpatient management
The UpToDate editorial staff acknowledges Mark Dovey, MD, who contributed to an earlier
version of this topic review.
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