Asthma Exacerbations For Children Aged ≥ 12 months

Approximately one-third of children with asthma presenting to the emergency department (ED) have moderate respiratory distress, and less than 5% will have a severe exacerbation. Refer to TREKK’s Severe Asthma Exacerbation Algorithm for emergent management. There are some differences between provincial asthma pathways with regards to PRAM scores and treatment. Pathways are hyperlinked below and provide additional management information:

• Alberta
• British Columbia
• Ontario
• Quebec (Sainte-Justine)

• Use of the Pediatric Respiratory Assessment Measure (PRAM) to classify severity of respiratory distress in children with asthma exacerbations improves use of evidence-based medications and lowers hospitalization rates.¹
• Regardless of their PRAM score, children with lethargy, cyanosis, decreasing respiratory effort and/or rising pCO₂ should be considered to have impending respiratory failure. Consult Pediatric Referral Centre.

Summary of Evidence-based Management of Acute Asthma Exacerbations

• Giving oral corticosteroids and repeated doses of bronchodilators in the first 60 minutes of care reduces hospitalization rates substantially.³
• MDI/spacer versus nebulization: Beta-agonist treatment with MDI/spacer is clinically equivalent with fewer side-effects and shorter ED length of stay as compared with nebulization.² Patients with severe respiratory distress improve more quickly with bronchodilators nebulized continuously vs intermittent treatment every 20 minutes.⁴ Use a large-volume nebulizer for continuous therapy or a small-volume nebulizer with repeat doses given “back-to-back”.⁴
• Ipratropium: 2-3 doses in the first hour of treatment yields greater improvement and decreases hospitalization.⁵ Benefits appear to be greatest in severe respiratory distress but may also aid patients in moderate distress.⁵
• Corticosteroids: Early administration of steroids with initial beta-agonists shortens respiratory distress and decreases hospitalization.³ Oral dexamethasone or prednisone/prednisolone are comparably effective;⁶ Dexamethasone is the preferred due to less vomiting and better tolerance.⁶ A one or two-day course of dexamethasone appears to be as effective as a five-day course of oral prednisone/prednisolone.⁶
• Magnesium sulfate: Give to children in impending respiratory failure as part of initial management OR to those who remain in moderate to severe respiratory distress after the first hour of bronchodilator treatment in addition to continuous bronchodilator therapy.⁷

• Consider admission to hospital if persistent PRAM score greater than or equal to 4 more than 4-6 hours after corticosteroid given.
• Consult Pediatric Referral Centre/Transport Team if persistent PRAM score greater than or equal to 8 after initial 1-2 hours of treatment.

• PRAM score less than or equal to 3 at least 1-2 hours after last bronchodilator treatment.
  • No significant intercostal and/or suprasternal indrawing.
  • Good air entry on auscultation with at most mild expiratory wheeze.
  • Oxygen saturation greater or equal to 92% in room air (>90% for higher altitude).
• Provide all children being discharged home with:
• Prescription for age-appropriate reliever medication, controller medication (if required), and spacer for use with all MDIs.
  • All children presenting with a PRAM ≥4 should go home on controller medication (i.e., daily inhaled corticosteroid) until follow up.
• Asthma Teaching and Action Plan for:
  1. when and how to use discharge medications
  2. when to seek further care
  3. steps to reduce asthma triggers and/or allergens
• Instructions to follow up with primary care provider or alternative (ideally within 7 days)

Suggested Discharge Medications

*Symbicort: ICS budesonide 100 mcg or 200 mcg/inhalation + long-acting beta-agonist with fast onset formoterol 6 mcg/inhalation

§Higher risk for severe exacerbations includes ANY of: 1) history of severe exacerbation requiring systemic steroids, ED visit or hospitalization; 2) asthma not well-controlled#; 3) overuse of reliever medication (> 2 inhalers/year); or 4) current smoker.

#Well-controlled asthma defined as ALL of the following: 1) daytime symptoms < 2 days/week; 2) nighttime symptoms < 1 night/week; 3) normal physical activity; 4) mild (no ED visit/hospitalization) and infrequent (frequency does not impair quality of life) exacerbations; 5) no school absence due to asthma; and 6) < 2 reliever doses/week.

Thank you to the following content experts who led the development of the Asthma Exacerbations Bottom Line Recommendations:

David W Johnson, MD, Professor of Pediatrics and Physiology and Pharmacology; University of Calgary, Faculty of Medicine; Senior Medical Director, AHS Maternal Newborn Child and Youth Strategic Clinical Network

Jennifer Turnbull, MD, FRCPC, Assistant Professor, Division of Pediatric Emergency Medicine, McGill University Health Centre; Co-Director, McGill Global Child Health Program; Montreal Children’s Hospital

Thank you to the TREKK Editorial Committee, and Editor Dr. Sarah Reid (CHEO), who provided editorial support and expertise in the development of this resource.

Thank you to the TREKK Editorial Committee and the following people who supported the development of these resources:

• Pharmacy review: Danica Irwin (CHEO, Ottawa) & Tracy Furst (HSC, Winnipeg)
• Pediatric Respirology review: Dhenuka Radhakrishnan (CHEO, Ottawa)
• Pediatric Critical Care review: Anna-Theresa Lobos (CHEO, Ottawa)
• Pediatric Emergency Medicine review: Gina Neto (CHEO, Ottawa)
• TREKK Project Coordinator: Chelsea Bowkett (University of Manitoba)
• TREKK Editorial Lead: Sarah Reid (CHEO, University of Ottawa)

To see our resource development process please visit our website here.

1. Ducharme FM, Chalut D, Plotnick L, et al. The Pediatric Respiratory Assessment Measure: a valid clinical score for assessing acute asthma severity from toddlers to teenagers. J Pediatr. 2008;152(4):476-80.
2. Cates CJ, Crilly JA, Rowe BH. Holding chambers (spacers) versus nebulisers for beta-agonist treatment of acute asthma. Cochrane Database Syst Rev. 2013;(9).
3. Rowe BH, Spooner C, Ducharme F, Bretzlaff J, Bota G. Early emergency department treatment of acute asthma with systemic corticosteroids. Cochrane Database Syst Rev. 2001.
4. Camargo CA Jr, Spooner CH, Rowe BH. Continuous versus intermittent beta-agonists in the treatment of acute asthma. Cochrane Database Syst Rev. 2003;(4)
5. Griffiths B, Ducharme FM. Combined inhaled anticholinergics and short-acting beta2-agonists for initial treatment of acute asthma in children. Cochrane Database Syst Rev. 2013;(8).
6. Keeney GE, Gray MP, Morrison AK, et al. Dexamethasone for acute asthma exacerbations in children: a meta- analysis. Pediatrics. 2014;133(3):493-9.
7. Griffiths B, Kew KM. Intravenous magnesium sulfate for treating children with acute asthma in the emergency department. Cochrane Database Syst Rev. 2016;4(4).

For a complete list of the evidence that informed the creation of the Asthma Bottom Line Recommendations see the Evidence Repository here.

The purpose of this document is to provide healthcare professionals with key facts and recommendations for the diagnosis and treatment of asthma in children in the emergency department. The TREKK Network is not liable for any damages, claims, liabilities, costs or obligations arising from the use of this document including loss or damages arising from any claims made by a third party. THIS DOCUMENT IS SUBJECT TO FULL DISCLAIMER HERE: trekk.ca/terms-of-use/