Approach Considerations
Ultimately, the best treatment for reactive airway disease is to prevent an exacerbation from occurring. Knowing the provocative factors, such as infection, exercise, nonadherence to medication, weather, allergens, and irritants, can aid in early treatment intervention.
Phenotyping patients with asthma to allow for better understanding of disease heterogeneity and facilitate individualization of patient management by grouping patients with common clinical features is recommended. [17, 18]
Identification of reliable biomarkers can help in future therapeutic strategies in addition to determining the most effective drug for the right patient phenotype. [19]
A five-fold increase of regularly used inhaled glucocorticoids at the start of worsening symptoms known as the yellow zone has not shown to prevent severe exacerbations. [20] However, quadrupling the dose may be beneficial for adolescents and adults. [21]
Telemedicine, a rapidly growing trend in healthcare, can be used for controlling reactive airway symptoms and reduce the number of emergency room visits by improving adherence to therapy. [22] Symptoms and spirometry readings can be communicated through telephone, web-based systems and phone apps. Novel technologies such as a digital stethoscope and high resolution cameras can be used to gather information.
Prehospital care
Provide oxygen during transport, cardiorespiratory monitoring and pulse oximetry, beta-agonist nebulization, and intravenous access if the patient is in moderate-to-severe respiratory distress. Subcutaneous terbutaline or epinephrine may be considered if severe distress and very poor air movement are present.
Consultations
Consultations with the following specialists may be helpful:
-
Pediatric emergency medicine specialist
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Pediatric critical care specialist
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Pediatric pulmonary specialist
Emergency Department Care
Mild-to-moderate exacerbations (PEF >50% and/or oxygen saturation >92% on room air)
Albuterol is recommended for the initial treatment of mild-to-moderate acute exacerbations of asthma, administered either by a metered-dose inhaler with spacer (with or without mask) or by a hand-held nebulizer.
Two to six puffs of albuterol via metered-dose inhaler with spacer or 0.15 mg/kg (2.5 mg minimum dose, 5 mg maximum dose) via hand-held nebulizer every 20 minutes for up to 3 doses is recommended.
Oral dexamethasone 0.6 mg/kg/dose (first-line treatment) or oral prednisolone 2 mg/kg/dose (second-line treatment).
Severe exacerbations (PEF < 50% and/or oxygen saturation < 92% on room air) or exacerbations refractory to first-line treatment
Nebulized ipratropium bromide and short-acting beta-agonists, every 20 minutes for up to 3 treatments, are recommended for the treatment of children (250 mcg/dose) and adolescents (500 mcg/dose) with severe exacerbations.
Supplemental oxygen (by nasal cannula or mask, whichever is better tolerated) to maintain an oxygen saturation >92% is recommended during the delivery of short-acting beta-agonists and anticholinergics in patients with severe exacerbations.
Oral dexamethasone 0.6 mg/kg/dose (first-line treatment) or oral prednisolone 2 mg/kg/dose (second-line treatment) may be administered if early response to bronchodilators, otherwise parenteral steroids (dexamethasone or methylprednisolone) should be given.
Management of status asthmaticus
Management of status asthmaticus includes continuous inhaled beta-agonist of 0.5 mg/kg/h, nebulized ipratropium, IV dexamethasone 0.6 mg/kg, and intravenous magnesium 25-40 mg/kg (given over 20 min as a single dose up to a maximum of 2 g) concurrently for the child in severe respiratory distress. Consideration for IM or SC epinephrine or terbutaline. IV hydration is recommended in severe asthmatic requiring admission. Patient should be kept NPO in case of respiratory failure and need for intubation.
Frequent evaluation of the patient's cardiorespiratory status is imperative. Pulse oximetry and noninvasive end-tidal CO2 monitoring are ideal. Serial blood gas measurements may be necessary if the patient remains critically ill. If a child fails to improve with these interventions, admission to an ED observation area, inpatient unit, or pediatric critical care unit should be initiated. Continued failure to respond with mental status changes is an ominous finding and suggests rising pCO2. Consider noninvasive positive pressure ventilation (PPV) (eg, continuous positive airway pressure [CPAP] 3-5 cm H2 O, intermittent positive airway pressure [IPAP] 10-18 cm H2 O) prior to rapid sequence intubation. BiPAP utilization in acute pediatric asthma exacerbations for patients 20 kg or less is safe and may improve clinical outcomes. [23] Consider the increased risk of pneumothorax if intubated. Optimize ventilator settings.
-
Avoid intubation if possible.
Consider all other measures first (eg, bilevel positive airway pressure, continuous beta-agonist, helium-oxygen mixture [heliox]).
For rapid sequence intubation, use ketamine for sedation/dissociative state, 1 mg/kg IV (provides 15 min anesthesia and may provide further bronchodilation for up to 30 min) then paralysis with succinylcholine, 2 mg/kg IV preceded by atropine 0.02 mg/kg in the pediatric patient (older adolescent: 1-1.5 mg/kg IV without atropine) may be used. For more information, see Tracheal Intubation, Medications.
Tube size = (age/4) + 4
Avoid nasal intubation. Oral intubation allows for a larger tube size and easier access for suctioning and bronchoscopy.
-
Albuterol
Aerosolized albuterol, a short acting beta2-agonist (SABA), relieves bronchospasm.
Although studies suggest that delivery of albuterol by metered dose inhaler (MDI) with spacer is equally as effective as nebulization in children as young as 2 years, nebulization is recommended for those younger than 6 years or those with severe asthma or poor air movement. Infants and small children need doses of MDI equivalent to those used by adults because of decreased retention time of the drug in the lung, because of their inability to hold their breath, and because the size of the airway limits delivery of medication.
The use of chlorofluorocarbon (CFC) inhalers is being phased out to protect the ozone layer. A decreased ozone layer may lead to health and environmental problems. No difference exists in efficacy between CFC and non-CFC inhalers.
Continuous albuterol nebulization may reduce the need for endotracheal intubation in status asthmaticus.
Levalbuterol, the single isomer, may result in higher patient discharge rates from the ED or hospital and hence may be more cost-effective than the traditional, racemic albuterol given.
-
Ipratropium: The combination of a beta-adrenergic agonist and ipratropium improves FEV1 more effectively than either agent used alone. Other anticholinergics, such as glycopyrrolate, also may be nebulized. Tiotropium bromide, a long-acting muscarinic antagonist, improved lung function, reduced the need for short acting beta-agonist and moderately reduced the risk of a severe exacerbation in severe asthmatics taking high dose inhaled corticosteroids and long acting beta-agonist. [12]
Oral steroids given early during ED treatment reduce hospital admission rates.
Dexamethasone (given as an oral dose or parenteral dose) is the preferred steroid because of longer duration of action and the need for only one additional dose (0.6 mg/kg) to be given 1 or 2 days later.
The dosages for prednisone and prednisolone both are 2 mg/kg/dose. Prednisone, in tablet form, is given to older children or adolescents. Prednisolone can be given orally (Prelone), or methylprednisolone (Solu-Medrol) may be given parenterally.
Nebulized corticosteroids could prove useful in the ED setting. Further studies are pending.
Long-term use of inhaled steroids may have a deleterious effect on lung and organ development during the first 3 years of life.
-
Inhaled albuterol has largely replaced an oral beta2-agonist because of increased effectiveness and safety.
In one study, use of inhaled beta2-agonist was shown to be safe and effective in children younger than 2 years. [24] The patient selection represents the most common acuity of patients younger than age 2 years (with a significant number of subjects younger than age 1). Ninety micrograms of albuterol every 20 minutes (total 4 treatments in 1 h) was successful in restoring normal breathing in most subjects, with a few subjects requiring 1-2 more treatments. Most patients also received corticosteroids per established protocol.
All patients in this study had continuous cardiac monitoring, and no significant cardiac events were reported. Patients ill enough to require more closely spaced "rescue" dosing, or early administration of epinephrine, terbutaline, or intubation, were deleted from this study. [24]
-
Theophylline has no role in the acute setting. It may be considered for outpatient treatment in patients with poor compliance with inhaled beta-agonist and for patients with nocturnal asthma exacerbation.
-
Magnesium at 40 mg/kg IV may provide a "therapeutic bridge." Studies remain in conflict regarding magnesium's effectiveness.
-
European Respiratory Society (ERS) and American Thoracic Society (ATS) 2014 Guidelines recommend against routine use of macrolide therapy. [12]
Asthma management is shown in the illustration below.
Stepwise approach for managing asthma in children 0 to 4 years of age. National Institutes of Health. National Heart, Lung, and Blood Institute. National Asthma Education and Prevention Program. Expert Panel Report 3: Guidelines for the diagnosis and management of asthma. August 2007. NIH publication no. 07-4051. Available at: http://www.nhlbi.nih.gov/guidelines/asthma/index.htm. 3 Accessed December 30, 2007. PRN, As necessary.
One study showed that the rate of return to the emergency department or admission to the hospital was decreased if the patient was discharged home with an inhaled corticosteroid. [25] Another study showed that 2 days of dexamethasone instead of 5 days of prednisone at the time of emergency department visit for asthma leads to a decreased number of emergency department visits and hospital admissions. [26]
Recent experimental biological approaches targeting specific asthmatic inflammatory pathways based on immuno-inflammatory phenotypes. Mepolizumab and reslizumab, anti-IL5 antibodies, used in severe asthmatics with persistent sputum eosinophilia have shown to decrease exacerbations and oral corticosteroid use. [12]
Prevention
The PROSE (Preventative Omalizumab or Step-Up Therapy for Fall Exacerbations) Trial is a 3-arm, randomized, double-blind, double placebo-controlled, multicenter clinical trial that was conducted among inner-city asthmatic children aged 6 to 17 years with 1 or more recent exacerbations. The study compared omalizumab and an inhaled steroid.
The investigators found that asthma exacerbations, which are most frequent during the fall, can be reduced with a preventive strategy of treating high-risk allergic asthma subjects with omalizumab 4 to 6 weeks before the start of school and continuing it for the next 4 months. Omalizumab is thought to increase the release of an antiviral substance called interferon-alpha from certain immune cells, thereby restoring immune protection against common cold viruses. Increasing inhaled steroid treatment levels above those determined to achieve control, offered little to no additional benefit in preventing exacerbations. [27]
Intermittent use of inhaled corticosteroids at the start of asthma exacerbations can decrease the need for future oral corticosteroids. [28]
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Patient peak flow record.
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This nomogram results from tests carried out by S. Godfrey, MD, and his colleagues on a sample of 382 healthy boys and girls aged 5-18 years. Each child blew 5 times into a standard Wright Peak Flow Meter, and the highest reading was accepted in each case. All measurements were completed within a 6-week period. The outer lines of the graph indicated that the results of 95% of the children fell within these boundaries.
-
Stepwise approach for managing asthma in children 0 to 4 years of age. National Institutes of Health. National Heart, Lung, and Blood Institute. National Asthma Education and Prevention Program. Expert Panel Report 3: Guidelines for the diagnosis and management of asthma. August 2007. NIH publication no. 07-4051. Available at: http://www.nhlbi.nih.gov/guidelines/asthma/index.htm. 3 Accessed December 30, 2007. PRN, As necessary.
Tables
Height in Inches |
Average Rate |
Range* |
Height in Inches |
Average Rate |
Range* |
40 |
150 |
110-190 |
56 |
330 |
240-420 |
41 |
160 |
115-205 |
57 |
340 |
240-420 |
42 |
170 |
120-220 |
58 |
360 |
260-460 |
43 |
180 |
130-220 |
59 |
375 |
270-480 |
44 |
190 |
135-245 |
60 |
390 |
280-500 |
45 |
200 |
145-255 |
61 |
400 |
290-510 |
46 |
210 |
150-270 |
62 |
415 |
300-530 |
47 |
220 |
160-280 |
63 |
430 |
310-550 |
48 |
230 |
165-295 |
64 |
445 |
320-570 |
49 |
240 |
175-305 |
65 |
460 |
330-590 |
50 |
250 |
180-320 |
66 |
480 |
345-615 |
51 |
260 |
190-330 |
67 |
500 |
360-640 |
52 |
270 |
195-345 |
68 |
515 |
370-660 |
53 |
280 |
200-360 |
69 |
530 |
380-680 |
54 |
300 |
215-385 |
70 |
550 |
395-705 |
55 |
315 |
225-405 |
71 |
570 |
410-730 |
*Includes 95% of white males aged 7-20 years. Derived and adapted from J Pediatr 1979;95:192-6. |
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