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 Departmentof Pediatric Emergency.

Discussion: Frequent respiratory infections,personal or familial allergy, disease severity andyoung age are important factors leading to hos-pitalization. However, regular clinical follow-upand use of inhaled corticosteroids, the IgE lev-els and O2 saturation may reduce the probabilityof 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 ofan alternative explanation for them. The pres-ence of these factors increases the probabilitythat a child with respiratory symptoms will haveasthma. These factors include age at presenta-tion; sex; severity and frequency of previouswheezing episodes; coexistence of atopic dis-ease; family history of atopy; and abnormal lungfunction.

Conclusion: Asthma is a chronic conditionthat often remains uncontrolled for reasons thatmay be related to the disease process itself, themanagement decisions of clinicians, the patien-t’s perceptions of disease control or self-man-agement behaviors, the cost of medications, ora combination of all of these factors. To this end,patients with asthma should be educated not toaccept a certain level of symptoms or activitylimitations as an inevitable consequence ofasthma. Both the levels of current impairmentand the future risks (of asthma exacerbations oradverse medication effects) should be used toinform decisions about appropriate levels ofasthma therapy, and physicians should be awareof the new medication recommendations.

Key Words:

Asthma, Childhood, Emergency, Treatment.

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)

Corresponding Author: Piero Pavone, MD; e-mail: ppavone@unict.it 711

Introduction

Asthma is one of the most common chronicdiseases, leading to an increased rate of hospital-ization. Frequent respiratory infections, personalor familial allergy, disease severity and youngage are important factors leading to hospitaliza-tion. However, regular clinical follow-up and useof 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 Departmentof Pediatric Emergency.

A correct diagnosis of asthma is the first steptoward attaining disease control. In general, a di-agnosis of asthma is established if episodicsymptoms of airflow obstruction or airway hy-per-responsiveness are present, airflow obstruc-tion is at least partially reversible, and alternativediagnoses are excluded. The guidelines recom-mend the use of a detailed medical history, theresults of a physical examination (focusing onthe upper respiratory tract, chest, and skin), andthe results of spirometry (for patients aged 5years or older) in making the diagnosis. Particu-larly important factors that should be addressedas part of the medical history include the fre-quency of symptoms (eg, perennial, seasonal, orboth; continual, episodic, or both; diurnal varia-tions), precipitating factors (such as the presenceof allergic triggers), and a family history of asth-ma, allergy, or other atopic disorders. Althoughrecurrent cough and wheezing often result fromasthma, other causes of airway obstructionshould be considered in the initial diagnosis, or ifthe patient does not respond to initial therapy.Several other conditions may coexist, or compli-cate the diagnosis or management of asthma. Thediagnosis of asthma is confirmed by a positive

2011; 15: 711-716

response to asthma medication, and treatmentshould follow the usual stepwise approach toasthma management1-6,9,10.

The diagnosis of asthma in children is basedon recognizing a characteristic pattern of episod-ic respiratory symptoms and signs (Table I) inthe absence of an alternative explanation forthem (Tables II and III).

The presence of these factors increases theprobability that a child with respiratory symp-toms will have asthma. These factors include ageat presentation; sex; severity and frequency ofprevious wheezing episodes; coexistence ofatopic disease; family history of atopy; and ab-normal lung function.

Once the diagnosis has been established, thefocus is on classifying to the severity of asthmaso that therapy can be initiated, and on monitor-ing control over time so that therapy can be ad-justed. According to the new guidelines, severityand control should be assessed separately, butboth are classified on the basis of the domains ofcurrent impairment and future risk. Impairment isdefined 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 inlung function (or, for children, lung growth), or

risk of adverse effects from medication”1-15. In as-sessing impairment, asthma severity should beevaluated using the following categories:

• Intermittent asthma severity• Persistent asthma severity (mild, moderate, se-

vere).

Clinical Assessment

Before starting treatment for acute asthma inany setting, it is essential to assess accurately theseverity 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 theseverity of airways obstruction. Some childrenwith acute severe asthma do not appear dis-tressed.

Pulse oximetry: accurate measurements of oxy-gen saturation are essential in the assessmentof all children with acute wheezing.

Consider intensive inpatient treatment for chil-dren with SpO2 <92% in air after initial bron-chodilator treatment.

P. Pavone, M.R. Longo, R. Taibi, G. Nunnari, C. Romano, E. Passaniti, R. Falsaperla

712

More than one of the following symptoms: wheezing,cough, difficulty breathing, chest tightness, particularlyif 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 coldsPersonal history of atopic disorderFamily history of atopic disorder and/or asthmaHistory of improvement in symptoms or lung function in response to adequate therapy

Table I. Clinical features that increase the probability ofasthma.

• 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

Table II. Clinical features that lower the probability of asthma.

Light Moderate SevereAGE R.R. C.R. R.R. C.R. R.R. C.R.

< 12 months < 50-60 < 160 > 50-60 > 1601-5 years < 40 < 120 > 40 > 120 > 50 > 140> 6 years < 30 < 110 > 30 > 110 > 40 > 120

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

Acute asthma in children: treatment in emergency

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Doses can be repeated every 20-30 min. Con-tinuous nebulised β2-agonists are of no greaterbenefit than the use of frequent intermittent dos-es at the same total hourly dosage. If there ispoor response to the initial dose of β2-agonists,subsequent doses should be given in combinationwith nebulised ipratropium bromide.

Ipratropium BromideThere is good evidence for the safety and effi-

cacy of frequent doses of ipratropium bromide(every 20-30 min) used in addition to β2-agonistsfor 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 forthe first few hours of admission. The salbutamoldose should be reduced to one to two hourlythereafter, according to the clinical response. Theipratropium dose should be reduced to four to sixhourly or discontinued.

Steroid Therapy

Steroid TablesThe early use of steroids in Emergency De-

partments and assessment units reduce the needfor Hospital admission and prevent relapse insymptoms after initial presentation. Benefits canbe apparent within 3 or 4 hours.

Give prednisone early in the treatment of acuteasthma attacks. Use a dose of 1-2 mg/kg/day(max 40 mg/dose) 2 to 3 times. Betamethasone0.1-0.2 mg/kg/day (max 4 mg/dose), in 2 to 3 ad-ministrations. Intravenous administration of 1-2mg/kg/6-8 hours (max 40 mg dose).

Oral and intravenous steroids are of similar ef-ficacy21. Intravenous hydrocortisone (5-10mg/kg/6-8 h; 4 mg/kg repeated every 4 hoursshould be reserved for severely affected childrenwho are unable to retain oral medication.

Treatment for up to 3 days is usually suffi-cient, but the length of course should be tailoredto the number of days necessary to bring aboutrecovery. Weaning is unnecessary unless thecourse of steroids exceeds 14 days.

Formulations such as hydrocortisone andmethylprednisolone can be given parenterally.Studies have found these routes to be equally ef-fective, with the oral route being less painful andinvasive21,23. Prednisone is given for 5 days at adose of 1 to 2 mg/kg daily (maximum 50

PEF: a measurement of <50% predicted PEF orforced expiratory volume (FEV), with poorimprovement after initial bronchodilator treat-ment is predictive of a more prolonged asthmaattack.

Chest X-ray: A chest X-ray should be performedif there is subcutaneous emphysema, persistingunilateral signs suggesting pneumothorax, lobarcollapse or consolidation and/or life threateningasthma not responding to treatment.

Blood gases: Blood gas measurements should beconsidered if there are threatening features notresponding to treatment. Normal or raisedpCO2 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 ChildrenAged Over 2 years

There is good evidence supporting recommen-dations for the initial treatment of acute asthmapresenting to primary and secondary healthcareresources. There is less evidence to guide the useof second line therapies to treat the small numberof severe cases poorly responsive to first linemeasures. Despite this, the risk of death and oth-er adverse outcomes after admission to hospitalare extremely small irrespective of the treatmentoptions chosen.

Children with severe or life threatening asth-ma should be transferred to Hospital urgently1-20.

OxygenChildren with life threatening asthma or SpO2

<94% should receive high flow oxygen via atight 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 treatmentfor acute asthma. Children receiving a β2-agonistvia 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 dosesof nebulised bronchodilators driven by oxygen(2.5-5 mg salbutamol or 5-10 mg terbutaline), al-though children with mild symptoms can benefitfrom lower doses.

714

mg/dose). Dexamethasone can be given for 1 to5 days at a dose ranging from 0.3 to 0.6 mg/kgdaily. Dexamethasone is a long-acting glucocor-ticoid with a half-life of 36 to 72 hours, and is 6times more potent than prednisone. Prednisone isshorter acting, with a half-life of 18 to 36hours22.

In our practice in the Department of PediatricEmergency we are accustomed to seeing 18% to20% of our patients with different degrees ofasthmatic attack. After therapy almost 90-95% ofthem return home and 5% of the patients needhospitalization.

Leukotriene Receptor AntagonistsThere is no clear evidence to support the use

of leukotriene receptor antagonists for moderateto severe acute asthma in the Emergency Depart-ment. Leukotriene receptor antagonists is impor-tant as a chronic support therapy, but not in anacute attack. At the moment we do not have suf-ficient data to determine if this drug could beused during the acute follow-up phase with somedosing modifications. The use of these treat-ments is beyond the scope of our review.

Second Line Treatment of Acute Asthmain Children Aged Over 2 Years

Children with continuing severe asthma de-spite frequent nebulised β2-agonists and iprat-ropium bromide plus oral steroids, and thosewith life threatening features, need urgent reviewby a specialist with a view to transfer to a highdependency unit or paediatric Intensive CareUnit (ICU) to receive second line intravenoustherapies. 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) shouldbe considered in severe cases where the patienthas not responded to initial inhaled therapy.

Aminophylline is not recommended in chil-dren with mild to moderate acute asthma.Aminophylline should be considered for childrenwith severe or life threatening bronchospasm un-responsive to maximal doses of bronchodilatorsplus steroids.

A 5 mg/kg loading dose should be given over20 minutes with ECG monitoring, followed by acontinuous infusion at 1 mg/kg/hour. Serumtheophylline should be measured in patients al-

ready receiving oral treatment and in those re-ceiving prolonged treatment.

Intravenous magnesium sulphate is a safetreatment for acute asthma, but its place inmanagement is not yet established. Doses of upto 40 mg//kg/day (maximum 2 g) by slow infu-sion have been used. Studies of efficacy for se-vere childhood asthma unresponsive to moreconventional therapies have been inconsistent.Children can be discharged when stable on 3-4hourly inhaled bronchodilators. This treatmentcan be continued at home. PEF and/or FEVshould be >75% of best of predicted, and SpO2

>94%.

Assessment of Acute Asthma in Childrenaged 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 forrecurrent wheezing. The differential diagnosis ofsymptoms includes aspiration pneumonitis,pneumonia, bronchiolitis, tracheomalacia, andcomplications of underlying conditions, such ascongenital anomalies and cystic fibrosis.

Treatment of Acute Asthma in ChildrenAged Less Than 2 Years

β2-Agonist BronchodilatorsInhaled β2-agonists are the initial treatment of

choice for acute asthma. Close fitting face masksare essential for optimal drug delivery. The dosereceived is increased if the child is breathing ap-propriately, and not taking large gasps because ofdistress and screaming.

There is good evidence that pMDI + spacer isas effective as, if not better than, nebulisers fortreating mild to moderate asthma in childrenaged <2 years.

Oral β2-agonists are not recommended foracute asthma in infants.

Steroid TherapyConsider steroid tablets as early treatment of

severe episodes of acute asthma in the hospitalsetting. Steroid tablet therapy (1-2 mg/kg of solu-ble prednisolone for up to 3 days) is the preferredsteroid preparation for use in this age group.

P. Pavone, M.R. Longo, R. Taibi, G. Nunnari, C. Romano, E. Passaniti, R. Falsaperla

Ipratropium BromideInhaled ipratropium bromide should be con-

sidered in combination with inhaled β2-agonistfor more severe symptoms.

Many children with recurrent episodes of vi-ral-induced wheezing in infancy do not go on tohave chronic atopic asthma. The majority do notrequire treatment with regular inhaled steroids.Parents should be advised about the relationshipbetween cigarette smoke exposure and wheezyillnesses.

Parents of wheezy infants should receive ap-propriate discharge plans, along similar lines tothose given for older children.

Figure 1 summarizes the therapy in an asthmaattack. The use of other new medicaments likeomalizumab monoclonal antibody seems to re-duce the asthmatic attack in 50% of patients inthe first year with a good tolerability in children6-11 years old, but is still controversial, andmore studies are needed to better clarify the safe-ty of this therapy. The use of these treatments isbeyond the scope of our review.

––––––––––––––––––––Acknowledgements

We are grateful to Prof. Lorenzo Pavone (Catania) forthe helpful suggestions and the critical review of themanuscript. We also wish to thank International Sci-ence Editing Co, Shannon Ireland, for editing the man-uscript.

References

1) BRITISH THORACIC SOCIETY; SCOTTISH INTERCOLLEGIATE

GUIDELINES NETWORK. British guidelines on the man-agement of asthma. Thorax 2003; 58(Suppl 1):S1-94.

2) KROEGEL C. Global initiative for asthma (GINA)guidelines: 15 years of application. Expert RevClin Immunol 2009; 5: 239-249.

3) NORTH OF ENGLAND EVIDENCE BASED GUIDELINES DEVEL-OPMENT PROJECT: SUMMARY VERSION OF EVIDENCE BASED

GUIDELINE FOR THE PRIMARY CARE MANAGEMENT IN ADULTS.North of England Asthma Guidelines Develop-ment Group. Br Med J 1996; 312: 762-766.

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Acute asthma in children: treatment in emergency

Figure 1.

ACUTE ASTHMA ATTACKS

Continue salbutamol

Worsening

Good or incompleteresponseGood response

Incompleteresponse orworsening

Incompleteresponse

Incomplete response

Salbutamol spray(200-400 mcg) or via a

nebulizer (0.1 mg/kg) in 3somministrations or

in case of need+

Prednisolone 1-2 mg/kg/day(max 40-50 mg/dose)

Resolution Hospitalization

Light Severe

Salbutamol spray(200 mcg) or via a

nebulizer (0,1 mg/kg) in3 administration or

in case of need

Salbutamol spray(200-400 mcg)

Over 20 minutes; plusipratropium bromide

250 mcg/doseevery 20-30 min

+Prednisolone 1-2 mg/kg/die

(max 40-50 mg/dose)If there is a good response

Worsening

Moderate

Salbutamol spray(200-400 mcg) or via a

nebulizer (0.1 mg/kg) in 3somministration or in caseof need; plus ipratropium

bromide 250 mcg/doseevery 20-30 min

716

4) CANE RS, RANGANATHAN SC, MCKENZIE SA. What doparents of wheezy children understand bywheeze? Arch Dis Child 2000; 82: 327-332.

5) DODGE R, MARTINEZ FD, CLINE MG. Early childhoodrespiratory symptoms and the subsequent diag-nosis of asthma. J Allergy Clin Immun 1996; 98:48-54.

6) MARTINEZ FD, WRIGHT AL, TAUSSIG LM, HOLBERG CJ,HALONEN M, MORGAN WJ. Asthma and wheezing inthe first years of life. The group Health MedicalAssociates. N Engl J Med 1995; 322: 133-138.

7) CASTRO-RODRIGUEZ JA, HOLBERG CJ, WRIGHT AL, MAR-TINEZ AD. A clinical index to define risk of asthmain young children with recurrent wheezing. Am JRespir Crit Care Med 2000; 162: 1403-1406.

8) SCHONBERGER H, VAN SCHAYCK O, MURIS J, BOR H,VAN DEN HOOGEN H, KNOTTNERUS A, VAN WEEL C. To-wards improving the accuracy of diagnosing asth-ma in early childhood. Eur J Gen Pract 2004; 10:138-145.

9) CHILDHOOD ASTHMA MANAGEMENT PROGRAM RESEARCH

GROUP. The management of the childhood asth-ma. Grants for clinical trials. www. ClinicalTri-als.gov. Accessed April 30, 2008.

10) NATIONAL ASTHMA EDUCATION AND PREVENTION PRO-GRAM. Expert Panel Report 3: Guidelines for theDiagnosis and Management of Asthma (EPR-3).www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf Accessed March 30, 2010.

11) CHAPMAN KR, BOULET LP, REA RM, FRANSSEN E. Sub-optimal asthma control: prevalence, detectionand consequences in general practice. EurRespir J 2008; 31: 320-325.

12) RABE KF, ADACHI M, LAI CK, SORIANO JB, VERMEIRE PA,WEISS KB, WEISS ST. Worldwide severity and controlof asthma in children and adults: the global asth-ma insights and reality surveys. J Allergy Clin Im-munol 2004; 114: 40-47.

13) STEMPEL DA, MCLAUGHIN TP, STANFORD RH,FUHLBRIGGE AL. Patterns of asthma control: a 3-year analysis of patient claims. J Allergy Clin Im-munol 2005; 115: 935-939.

14) SAPRA SJ, BRODER MS, CHANG E. Alignement withthe revised NHLBI 2007 asthma guidelines, Ex-

pert Panel Report 3 (EPR 3) in a large payerdatabase. J Allergy Clin Immunol 2009; 123(Sup-pl 1): S117.

15) HOLGATE ST, PRICE D, VALOVIRTA E. Asthma out ofcontrol? A structured review of recent patient sur-veys. BMC Pulm Med 2006; 6(Suppl 1): S2-S5.

16) HORNE R, PRICE D, CLELAND J, COSTA R, COVEY D,GRUFFYDD-JONES K, HAUGHNEY J, HENRICHSEN SH, KA-PLAN A, LANGHAMMER A, ØSTREM A, THOMAS M, VAN

DER MOLEN T, VIRCHOW JC, WILLIAMS S. Can asthmacontrol be improved by understanding the patien-t’s perspective? BMC Pulm Med 2007; 7: 8.

17) BARNES PJ. The size of the problem of managingasthma. Respir Med 2004; 98(suppl 2): S4-S8.

18) OHAR JA, DONOHUE JF. Mono- and combinationtherapy of long-acting bronchodilators and in-haled corticosteroids in advanced COPD. SeminRespir Crit Care Med 2010; 31: 321-333.

19) US DEPARTMENT OF HEALTH AND HUMAN SERVICES, NA-TIONAL 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 ofAsthma. NIH Publication No. 07-40511-440.Bethesda, MD: US Dept of Health and HumanServices, National Institutes of Health, NationalHeart, Lung, and Blood Institute; 2007.www.gov/guidelines/asthma/asthgdln.pdf. Ac-cessed May 15, 2009.

20) LONG AA. Addressing unmet needs in asthmacare. P&T Digest 2005; 2: 16-22.

21) SHEFRIN AE, AND GOLDMAN RD. Use of dexametha-sone and prednisone in acute asthma exacerba-tions in pediatric patients. Can Fam Phys 2009;55: 704-706.

22) BARNETT PL, CAPUTO GL, BASKIN M, KUPPERMAN N. In-travenous versus oral corticosteroids in the man-agement of acute asthma in children. Ann EmergMed 1997; 29: 212-217.

23) BECKER JM, ARORA A, SCARFONE RJ, SPECTOR ND,FONTANA-PENN ME, GRACELY E, JOFFE MD, GOLDSMITH

DP, MALATACK JJ. Oral versus intravenous corticos-teroids in children hospitalized with asthma. J Al-lergy Clin Immunol 1999; 103: 586-590.

P. Pavone, M.R. Longo, R. Taibi, G. Nunnari, C. Romano, E. Passaniti, R. Falsaperla

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