EMS calls to let you know that they have a 7 year old male with an acute asthma exacerbation. They report that the child has increased work of breathing and is currently receiving a duoneb treatment. Five minutes later they arrive. The child appears uncomfortable, grey and tired on arrival. He has a respiratory rate of 46 with visible subcostal and intercostal retractions. On lung auscultation, the child is moving air but has diffuse wheezing. He has good perfusion to the extremities. He is immediately placed on the oxygen and his SpO2 reaches 99% on a nonrebreather with a heart rate of 165. Respiratory therapy is called for high flow nasal cannula and a repeat duoneb. 

In speaking with the parents to get a further history, the child has a history of asthma and was admitted to the hospital several years prior for observation for an asthma exacerbation. He has never been intubated or had an exacerbation this bad. He has a history of ADHD but does not take medications. He had a mild nonproductive cough last evening without nasal congestion or fever. He was not exposed to any smoke or irritants. This morning he woke up mildly short of breath, used 2 puffs of his inhaler and went back to sleep. The dyspnea slowly progressed this morning.  

Respiratory arrives at bedside. The child is given a third duoneb treatment, decadron, magnesium 50mg/kg IV, and placed on high flow nasal cannula at 50% O2 at 10 LPM. His oxygen saturation drops to 91%, but his heart rate decreases to 150s, and his work of breathing decreases. On repeat exam, the patient has diffuse wheezing and is able to put together 4-5 word sentences. His respiratory rate decreases to 31. Overall he is showing moderate improvement, but will need PICU care. URMC is called, and the pediatric support team is sent to have the patient transferred to the PICU.  The child is then placed on continuous albuterol with further improvement.  Retractions are now minimal with work of breathing mild to moderate.   

The Pediatric support team transfers the patient via ambulance. Ten minutes after departure, they call back to state that the patient is decompensating and that they are returning to the ED. Intubation equipment is placed back outside the room. Flight team is contacted to assess whether flying the child is an option. Upon arrival back to the ED, the patient again has increased work of breathing with subcostal and intercostal retractions. He is put on BIPAP, given solumedrol, and started on a terbutaline drip with improvement. He is subsequently able to be transferred.

What are the treatment options for pediatric asthma exacerbation?

Initial Treatments:

• Beta 2 agonist: Albuterol
• Anticholinergic agent: Ipatroprium, usually combined with albuterol for the first 3 doses as duoneb
• Steroids: Decadron 0.3-0.6 mg/kg

2^nd line therapy:

• Magnesium Sulfate 50 mg/kg given over 20 minutes to avoid hypotension
• Continuous Albuterol

3^rd line therapy:

• Terbutaline 2-10 mcg/kg as a loading dose then 0.1-0.4 mcg/kg/min infusion
• Epinephrine (1:1000) 0.01mg/kg IM (max 0.5mg) every 5-15 minutes
• BIPAP or Heated High Flow Nasal Cannula (limited data)
• Heliox
• Ketamine 1mg/kg IV

Be scared about intubating any asthmatic. These patients can tire out quickly, but if you take away their ability to move air, they can decompensate quickly. Have airway equipment outside the room.  Calculate your doses of RSI medications, endotracheal tube size, and vent settings before the patient arrives if possible. Ketamine at 1-2 mg/kg IV is a strong option for sedation for its hemodynamic stability and theoretical bronchodilatory effects.

Additionally, consider other diagnoses. These include foreign body aspiration, bronchiolitis, croup, pneumonia, anaphylaxis, and congenital heart disease. Consider a chest x-ray, especially in those with no prior history of asthma or shortness of breath without wheezing.  

Authors:
Timothy LaFrance, DO
Peer reviewed and edited by:
James Bohan, MD