Asthma in children younger than 12 years: Rescue treatment for acute symptoms
- 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
Rescue medications are primarily taken to relieve the bronchoconstriction that occurs with acute asthma symptoms, although some agents may have additional effects. Quick-relief agents include short-acting beta agonists (SABAs), anticholinergic bronchodilators (eg, ipratropium bromide), and short-term systemic glucocorticoids.
Medications used for the quick relief of asthma symptoms in children younger than 12 years of age are reviewed here. The recommendations below are based upon National Asthma Education and Prevention Program (NAEPP) expert panel guidelines published in 2007 , which are similar to other major published asthma guidelines [2,3].
The management of acute asthma exacerbations in children is discussed in detail separately. (See "Acute asthma exacerbations in children: Emergency department management" and "Acute asthma exacerbations in children: Inpatient management".)
Prophylactic use of quick-relief agents, such as SABAs prior to anticipated triggers (eg, exercise, allergen exposure), is discussed in detail separately. (See "Beta agonists in asthma: Acute administration and prophylactic use", section on 'Use in exercise-induced asthma' and "Exercise-induced bronchoconstriction" and "Beta agonists in asthma: Acute administration and prophylactic use", section on 'Prophylaxis in allergen-induced asthma'.)
SHORT-ACTING BETA AGONISTS
Short-acting beta agonists (SABAs), such as albuterol (salbutamol) and levalbuterol, remain a cornerstone of the treatment of childhood asthma . SABAs relax airway smooth muscle, leading to a prompt increase in airflow. These drugs generally provide rapid relief of acute asthma symptoms (eg, coughing, wheezing, chest tightness, and shortness of breath), with a time to onset of action of approximately 5 to 10 minutes, peak effect beginning within approximately 50 minutes, and duration of action of approximately three to six hours. Thus, as-needed use of these drugs is the primary therapy for acute symptoms in patients with intermittent asthma (figure 1A and figure 1B) and also is first-line therapy in patients with acute exacerbations. (See "Beta agonists in asthma: Acute administration and prophylactic use" and "Acute asthma exacerbations in children: Emergency department management" and "Acute asthma exacerbations in children: Inpatient management".)
- National Asthma Education and Prevention Program: Expert Panel Report III: Guidelines for the diagnosis and management of asthma. Bethesda, MD. National Heart, Lung, and Blood Institute, 2007. (NIH publication no. 08-4051) www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm (Accessed on March 17, 2016).
- Lougheed MD, Lemiere C, Ducharme FM, et al. Canadian Thoracic Society 2012 guideline update: diagnosis and management of asthma in preschoolers, children and adults. Can Respir J 2012; 19:127.
- The Global Initiative for Asthma (GINA). Resources include Pocket Guide for Asthma Management and Prevention, and GINA Report, Global Strategy for Asthma Management and Prevention. www.ginasthma.org (Accessed on July 13, 2015).
- Camargo CA Jr, Spooner CH, Rowe BH. Continuous versus intermittent beta-agonists in the treatment of acute asthma. Cochrane Database Syst Rev 2003; :CD001115.
- Karpel JP, Aldrich TK, Prezant DJ, et al. Emergency treatment of acute asthma with albuterol metered-dose inhaler plus holding chamber: how often should treatments be administered? Chest 1997; 112:348.
- Rudnitsky GS, Eberlein RS, Schoffstall JM, et al. Comparison of intermittent and continuously nebulized albuterol for treatment of asthma in an urban emergency department. Ann Emerg Med 1993; 22:1842.
- Lin RY, Sauter D, Newman T, et al. Continuous versus intermittent albuterol nebulization in the treatment of acute asthma. Ann Emerg Med 1993; 22:1847.
- Ben-Zvi Z, Lam C, Hoffman J, et al. An evaluation of the initial treatment of acute asthma. Pediatrics 1982; 70:348.
- Rossing TH, Fanta CH, Goldstein DH, et al. Emergency therapy of asthma: comparison of the acute effects of parenteral and inhaled sympathomimetics and infused aminophylline. Am Rev Respir Dis 1980; 122:365.
- Israel E, Chinchilli VM, Ford JG, et al. Use of regularly scheduled albuterol treatment in asthma: genotype-stratified, randomised, placebo-controlled cross-over trial. Lancet 2004; 364:1505.
- Ortega VE, Meyers DA, Bleecker ER. Asthma pharmacogenetics and the development of genetic profiles for personalized medicine. Pharmgenomics Pers Med 2015; 8:9.
- McGarry ME, Castellanos E, Thakur N, et al. Obesity and bronchodilator response in black and Hispanic children and adolescents with asthma. Chest 2015; 147:1591.
- Brehm JM, Ramratnam SK, Tse SM, et al. Stress and Bronchodilator Response in Children with Asthma. Am J Respir Crit Care Med 2015; 192:47.
- Gawchik SM, Saccar CL, Noonan M, et al. The safety and efficacy of nebulized levalbuterol compared with racemic albuterol and placebo in the treatment of asthma in pediatric patients. J Allergy Clin Immunol 1999; 103:615.
- Handley DA, Tinkelman D, Noonan M, et al. Dose-response evaluation of levalbuterol versus racemic albuterol in patients with asthma. J Asthma 2000; 37:319.
- Nelson HS, Bensch G, Pleskow WW, et al. Improved bronchodilation with levalbuterol compared with racemic albuterol in patients with asthma. J Allergy Clin Immunol 1998; 102:943.
- Carl JC, Myers TR, Kirchner HL, Kercsmar CM. Comparison of racemic albuterol and levalbuterol for treatment of acute asthma. J Pediatr 2003; 143:731.
- Lötvall J, Palmqvist M, Arvidsson P, et al. The therapeutic ratio of R-albuterol is comparable with that of RS-albuterol in asthmatic patients. J Allergy Clin Immunol 2001; 108:726.
- Hardasmalani MD, DeBari V, Bithoney WG, Gold N. Levalbuterol versus racemic albuterol in the treatment of acute exacerbation of asthma in children. Pediatr Emerg Care 2005; 21:415.
- Qureshi F, Zaritsky A, Welch C, et al. Clinical efficacy of racemic albuterol versus levalbuterol for the treatment of acute pediatric asthma. Ann Emerg Med 2005; 46:29.
- Ameredes BT, Calhoun WJ. Levalbuterol versus albuterol. Curr Allergy Asthma Rep 2009; 9:401.
- Larson S, Svedmyr N. Bronchodilating effects and side effects of beta-2-adrenostimulants by different routes of administration. Am Rev Respir Dis 1972; 116:861.
- Conner WT, Dolovich MB, Frame RA, Newhouse MT. Reliable salbutamol administration in 6- to 36-month-old children by means of a metered dose inhaler and Aerochamber with mask. Pediatr Pulmonol 1989; 6:263.
- Whelan AM, Hahn NW. Optimizing drug delivery from metered-dose inhalers. DICP 1991; 25:638.
- Cates CJ, Welsh EJ, Rowe BH. Holding chambers (spacers) versus nebulisers for beta-agonist treatment of acute asthma. Cochrane Database Syst Rev 2013; :CD000052.
- Albuterol dry powder inhaler FDA approval for children ages 4 to 11 years. http://www.accessdata.fda.gov/drugsatfda_docs/appletter/2016/205636Orig1s004ltr.pdf.
- Jones CA, Madison JM, Tom-Moy M, Brown JK. Muscarinic cholinergic inhibition of adenylate cyclase in airway smooth muscle. Am J Physiol 1987; 253:C97.
- Teoh L, Cates CJ, Hurwitz M, et al. Anticholinergic therapy for acute asthma in children. Cochrane Database Syst Rev 2012; :CD003797.
- Zorc JJ, Pusic MV, Ogborn CJ, et al. Ipratropium bromide added to asthma treatment in the pediatric emergency department. Pediatrics 1999; 103:748.
- Qureshi F, Pestian J, Davis P, Zaritsky A. Effect of nebulized ipratropium on the hospitalization rates of children with asthma. N Engl J Med 1998; 339:1030.
- Schuh S, Johnson DW, Callahan S, et al. Efficacy of frequent nebulized ipratropium bromide added to frequent high-dose albuterol therapy in severe childhood asthma. J Pediatr 1995; 126:639.
- Rodrigo GJ, Castro-Rodriguez JA. Anticholinergics in the treatment of children and adults with acute asthma: a systematic review with meta-analysis. Thorax 2005; 60:740.
- 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; :CD000060.
- Rachelefsky G. Treating exacerbations of asthma in children: the role of systemic corticosteroids. Pediatrics 2003; 112:382.
- Rowe BH, Spooner C, Ducharme FM, et al. Early emergency department treatment of acute asthma with systemic corticosteroids. Cochrane Database Syst Rev 2001; :CD002178.
- FitzGerald JM, Becker A, Sears MR, et al. Doubling the dose of budesonide versus maintenance treatment in asthma exacerbations. Thorax 2004; 59:550.
- Garrett J, Williams S, Wong C, Holdaway D. Treatment of acute asthmatic exacerbations with an increased dose of inhaled steroid. Arch Dis Child 1998; 79:12.
- Harrison TW, Oborne J, Newton S, Tattersfield AE. Doubling the dose of inhaled corticosteroid to prevent asthma exacerbations: randomised controlled trial. Lancet 2004; 363:271.
- Rice-McDonald G, Bowler S, Staines G, Mitchell C. Doubling daily inhaled corticosteroid dose is ineffective in mild to moderately severe attacks of asthma in adults. Intern Med J 2005; 35:693.
- Schuh S, Dick PT, Stephens D, et al. High-dose inhaled fluticasone does not replace oral prednisolone in children with mild to moderate acute asthma. Pediatrics 2006; 118:644.
- Kew KM, Quinn M, Quon BS, Ducharme FM. Increased versus stable doses of inhaled corticosteroids for exacerbations of chronic asthma in adults and children. Cochrane Database Syst Rev 2016; :CD007524.
- Edmonds ML, Milan SJ, Camargo CA Jr, et al. Early use of inhaled corticosteroids in the emergency department treatment of acute asthma. Cochrane Database Syst Rev 2012; 12:CD002308.
- Robertson CF, Price D, Henry R, et al. Short-course montelukast for intermittent asthma in children: a randomized controlled trial. Am J Respir Crit Care Med 2007; 175:323.
- Over-the-Counter Asthma Products Labeled as Homeopathic: FDA Statement - Consumer Warning About Potential Health Risks. http://www.fda.gov/safety/medwatch/safetyinformation/safetyalertsforhumanmedicalproducts/ucm439014.htm.
- Safety Concerns with Asthmanefrin and the EZ Breathe Atomizer. http://www.fda.gov/Drugs/DrugSafety/ucm370483.htm.
- Canadian Society of Allergy and Clinical Immunology: Non-prescription availability of theophylline, epinephrine and ephedrine for asthma. http://csaci.ca/index.php?page=359.
- Mondal P, Kandala B, Ahrens R, et al. Nonprescription racemic epinephrine for asthma. J Allergy Clin Immunol Pract 2014; 2:575.
- SHORT-ACTING BETA AGONISTS
- - Racemic albuterol
- - Levalbuterol
- - Other SABAs
- Route of delivery
- - Inhaled
- - Oral
- IPRATROPIUM BROMIDE
- SYSTEMIC GLUCOCORTICOIDS
- INHALED GLUCOCORTICOIDS
- LEUKOTRIENE RECEPTOR ANTAGONISTS
- NONSTANDARD THERAPIES
- SOCIETY GUIDELINE LINKS
- INFORMATION FOR PATIENTS