Acute asthma exacerbations in children: Inpatient management
- Gregory Sawicki, MD, MPH
Gregory Sawicki, MD, MPH
- Assistant Professor of Pediatrics
- Harvard Medical School
- Kenan Haver, MD
Kenan Haver, MD
- Assistant Professor of Pediatrics
- Harvard Medical School
- Section Editors
- Robert A Wood, MD
Robert A Wood, MD
- Editor-in-Chief — Allergy and Immunology
- Section Editor — Pediatric Allergy
- Professor of Pediatrics
- Johns Hopkins University School of Medicine
- Gregory Redding, MD
Gregory Redding, MD
- Section Editor — Pediatric Pulmonology
- Professor of Pediatrics
- University of Washington School of Medicine
More than 6.1 million children in the United States have asthma, which accounts for approximately 135,000 hospitalizations each year [1-3]. 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 or emergency department (ED), and some will need to be admitted to the hospital for further management.
Inpatient management of acute asthma exacerbation in children is discussed here. Outpatient and intensive care unit (ICU) management are discussed separately. (See "Acute asthma exacerbations in children: Home/office management and severity assessment" and "Acute asthma exacerbations in children: Emergency department management" and "Acute severe asthma exacerbations in children: Intensive care unit management".)
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) . Patients usually have received several albuterol treatments, often combined with ipratropium (children with an asthma exacerbation experience a lower risk of admission to the hospital if they are treated with the combination of inhaled short-acting beta agonists [SABAs] plus anticholinergic versus SABA alone ), systemic glucocorticoids, and supplemental oxygen, when necessary, before arrival to the inpatient unit. The criteria for admission are discussed in detail separately. (See "Acute asthma exacerbations in children: 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.
Inpatient therapy consists of [6,7]:
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- GENERAL APPROACH
- STANDARD THERAPIES
- Inhaled short-acting beta agonists
- - Administration
- - Dose
- - Frequency
- - Continuous therapy
- Adverse effects
- - Systemic
- Dose and duration
- - Inhaled
- Supplemental oxygen
- - Monitoring and management
- THERAPIES RESERVED FOR SPECIAL CIRCUMSTANCES
- Systemic beta agonists
- Magnesium sulfate
- Ipratropium bromide
- Leukotriene receptor antagonists
- Chest physical therapy
- Clinical assessment
- Asthma scores
- Pulmonary function
- FAILURE TO RESPOND
- Asthma specialist
- Social services
- DISCHARGE CRITERIA
- Discharge medications
- Discharge education
- Asthma action plan
- CARE COORDINATION/CASE MANAGEMENT
- SUMMARY AND RECOMMENDATIONS