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Acute asthma exacerbations in children: Emergency department management

Richard J Scarfone, MD, FAAP
Section Editors
Gregory Redding, MD
Stephen J Teach, MD, MPH
Deputy Editor
Elizabeth TePas, MD, MS


Clinical decision making in the management of the child with an acute asthma exacerbation includes the following questions:

How sick is the child?

Which drugs should be used for treatment?

What are the optimal doses and delivery routes?

When is more aggressive management necessary?

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Literature review current through: Nov 2017. | This topic last updated: Dec 12, 2017.
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  1. National Asthma Education and Prevention Program: Expert panel report III: Guidelines for the diagnosis and management of asthma.(NIH publication no. 08-4051). Bethesda, MD: National Heart, Lung, and Blood Institute, 2007. www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm (Accessed on September 01, 2007).
  2. Scarfone RJ, Fuchs SM, Nager AL, Shane SA. Controlled trial of oral prednisone in the emergency department treatment of children with acute asthma. Pediatrics 1993; 92:513.
  3. Rodrigo GJ, Rodriquez Verde M, Peregalli V, Rodrigo C. Effects of short-term 28% and 100% oxygen on PaCO2 and peak expiratory flow rate in acute asthma: a randomized trial. Chest 2003; 124:1312.
  4. Canny GJ, Reisman J, Healy R, et al. Acute asthma: observations regarding the management of a pediatric emergency room. Pediatrics 1989; 83:507.
  5. Gershel JC, Goldman HS, Stein RE, et al. The usefulness of chest radiographs in first asthma attacks. N Engl J Med 1983; 309:336.
  6. Quinonez RA, Garber MD, Schroeder AR, et al. Choosing wisely in pediatric hospital medicine: five opportunities for improved healthcare value. J Hosp Med 2013; 8:479.
  7. Rushton AR. The role of the chest radiograph in the management of childhood asthma. Clin Pediatr (Phila) 1982; 21:325.
  8. 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.
  9. 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.
  10. Ben-Zvi Z, Lam C, Hoffman J, et al. An evaluation of the initial treatment of acute asthma. Pediatrics 1982; 70:348.
  11. 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.
  12. Castro-Rodriguez JA, Rodrigo GJ. beta-agonists through metered-dose inhaler with valved holding chamber versus nebulizer for acute exacerbation of wheezing or asthma in children under 5 years of age: a systematic review with meta-analysis. J Pediatr 2004; 145:172.
  13. Ploin D, Chapuis FR, Stamm D, et al. High-dose albuterol by metered-dose inhaler plus a spacer device versus nebulization in preschool children with recurrent wheezing: A double-blind, randomized equivalence trial. Pediatrics 2000; 106:311.
  14. Cates CJ, Welsh EJ, Rowe BH. Holding chambers (spacers) versus nebulisers for beta-agonist treatment of acute asthma. Cochrane Database Syst Rev 2013; :CD000052.
  15. Rubilar L, Castro-Rodriguez JA, Girardi G. Randomized trial of salbutamol via metered-dose inhaler with spacer versus nebulizer for acute wheezing in children less than 2 years of age. Pediatr Pulmonol 2000; 29:264.
  16. Khine H, Fuchs SM, Saville AL. Continuous vs intermittent nebulized albuterol for emergency management of asthma. Acad Emerg Med 1996; 3:1019.
  17. Besbes-Ouanes L, Nouira S, Elatrous S, et al. Continuous versus intermittent nebulization of salbutamol in acute severe asthma: a randomized, controlled trial. Ann Emerg Med 2000; 36:198.
  18. Camargo CA Jr, Spooner CH, Rowe BH. Continuous versus intermittent beta-agonists in the treatment of acute asthma. Cochrane Database Syst Rev 2003; :CD001115.
  19. Mazzoni L, Naef R, Chapman ID, Morley J. Hyperresponsiveness of the airways following exposure of guinea-pigs to racemic mixtures and distomers of beta 2-selective sympathomimetics. Pulm Pharmacol 1994; 7:367.
  20. Johansson F, Rydberg I, Aberg G, Andersson RG. Effects of albuterol enantiomers on in vitro bronchial reactivity. Clin Rev Allergy Immunol 1996; 14:57.
  21. Templeton AG, Chapman ID, Chilvers ER, et al. Effects of S-salbutamol on human isolated bronchus. Pulm Pharmacol Ther 1998; 11:1.
  22. Volcheck GW, Kelkar P, Bartemes KR, et al. Effects of (R)- and (S)-isomers of beta-adrenergic agonists on eosinophil response to interleukin-5. Clin Exp Allergy 2005; 35:1341.
  23. Leff AR, Herrnreiter A, Naclerio RM, et al. Effect of enantiomeric forms of albuterol on stimulated secretion of granular protein from human eosinophils. Pulm Pharmacol Ther 1997; 10:97.
  24. Yamaguchi H, McCullough JR. S-albuterol exacerbates calcium responses to carbachol in airway smooth muscle cells. Clin Rev Allergy Immunol 1996; 14:47.
  25. Mitra S, Ugur M, Ugur O, et al. (S)-Albuterol increases intracellular free calcium by muscarinic receptor activation and a phospholipase C-dependent mechanism in airway smooth muscle. Mol Pharmacol 1998; 53:347.
  26. Agrawal DK, Ariyarathna K, Kelbe PW. (S)-Albuterol activates pro-constrictory and pro-inflammatory pathways in human bronchial smooth muscle cells. J Allergy Clin Immunol 2004; 113:503.
  27. Carl JC, Myers TR, Kirchner HL, Kercsmar CM. Comparison of racemic albuterol and levalbuterol for treatment of acute asthma. J Pediatr 2003; 143:731.
  28. 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.
  29. 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.
  30. Ralston ME, Euwema MS, Knecht KR, et al. Comparison of levalbuterol and racemic albuterol combined with ipratropium bromide in acute pediatric asthma: a randomized controlled trial. J Emerg Med 2005; 29:29.
  31. Schuh S, Parkin P, Rajan A, et al. High-versus low-dose, frequently administered, nebulized albuterol in children with severe, acute asthma. Pediatrics 1989; 83:513.
  32. Clay MM, Pavia D, Newman SP, et al. Assessment of jet nebulisers for lung aerosol therapy. Lancet 1983; 2:592.
  33. Wood JA, Wilson RS, Bray C. Changes in salbutamol concentration in the reservoir solution of a jet nebulizer. Br J Dis Chest 1986; 80:164.
  34. Clay MM, Pavia D, Newman SP, Clarke SW. Factors influencing the size distribution of aerosols from jet nebulisers. Thorax 1983; 38:755.
  35. Douglas JG, Leslie MJ, Crompton GK, Grant IW. Is the flow rate used to drive a jet nebuliser clinically important? Br Med J (Clin Res Ed) 1985; 290:29.
  36. Tal A, Levy N, Bearman JE. Methylprednisolone therapy for acute asthma in infants and toddlers: a controlled clinical trial. Pediatrics 1990; 86:350.
  37. Rowe BH, Spooner C, Ducharme FM, et al. Early emergency department treatment of acute asthma with systemic corticosteroids. Cochrane Database Syst Rev 2001; :CD002178.
  38. Zemek R, Plint A, Osmond MH, et al. Triage nurse initiation of corticosteroids in pediatric asthma is associated with improved emergency department efficiency. Pediatrics 2012; 129:671.
  39. Gordon S, Tompkins T, Dayan PS. Randomized trial of single-dose intramuscular dexamethasone compared with prednisolone for children with acute asthma. Pediatr Emerg Care 2007; 23:521.
  40. Klig JE, Hodge D 3rd, Rutherford MW. Symptomatic improvement following emergency department management of asthma: a pilot study of intramuscular dexamethasone versus oral prednisone. J Asthma 1997; 34:419.
  41. Gries DM, Moffitt DR, Pulos E, Carter ER. A single dose of intramuscularly administered dexamethasone acetate is as effective as oral prednisone to treat asthma exacerbations in young children. J Pediatr 2000; 136:298.
  42. Normansell R, Kew KM, Mansour G. Different oral corticosteroid regimens for acute asthma. Cochrane Database Syst Rev 2016; :CD011801.
  43. Keeney GE, Gray MP, Morrison AK, et al. Dexamethasone for acute asthma exacerbations in children: a meta-analysis. Pediatrics 2014; 133:493.
  44. Cronin JJ, McCoy S, Kennedy U, et al. A Randomized Trial of Single-Dose Oral Dexamethasone Versus Multidose Prednisolone for Acute Exacerbations of Asthma in Children Who Attend the Emergency Department. Ann Emerg Med 2016; 67:593.
  45. Scarfone RJ, Loiselle JM, Wiley JF 2nd, et al. Nebulized dexamethasone versus oral prednisone in the emergency treatment of asthmatic children. Ann Emerg Med 1995; 26:480.
  46. Devidayal, Singhi S, Kumar L, Jayshree M. Efficacy of nebulized budesonide compared to oral prednisolone in acute bronchial asthma. Acta Paediatr 1999; 88:835.
  47. Manjra AI, Price J, Lenney W, et al. Efficacy of nebulized fluticasone propionate compared with oral prednisolone in children with an acute exacerbation of asthma. Respir Med 2000; 94:1206.
  48. Matthews EE, Curtis PD, McLain BI, et al. Nebulized budesonide versus oral steroid in severe exacerbations of childhood asthma. Acta Paediatr 1999; 88:841.
  49. Volovitz B, Bentur L, Finkelstein Y, et al. Effectiveness and safety of inhaled corticosteroids in controlling acute asthma attacks in children who were treated in the emergency department: a controlled comparative study with oral prednisolone. J Allergy Clin Immunol 1998; 102:605.
  50. 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.
  51. Upham BD, Mollen CJ, Scarfone RJ, et al. Nebulized budesonide added to standard pediatric emergency department treatment of acute asthma: a randomized, double-blind trial. Acad Emerg Med 2011; 18:665.
  52. Alangari AA, Malhis N, Mubasher M, et al. Budesonide nebulization added to systemic prednisolone in the treatment of acute asthma in children: a double-blind, randomized, controlled trial. Chest 2014; 145:772.
  53. 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.
  54. Zorc JJ, Pusic MV, Ogborn CJ, et al. Ipratropium bromide added to asthma treatment in the pediatric emergency department. Pediatrics 1999; 103:748.
  55. 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.
  56. 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.
  57. 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.
  58. 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.
  59. Craven D, Kercsmar CM, Myers TR, et al. Ipratropium bromide plus nebulized albuterol for the treatment of hospitalized children with acute asthma. J Pediatr 2001; 138:51.
  60. Goggin N, Macarthur C, Parkin PC. Randomized trial of the addition of ipratropium bromide to albuterol and corticosteroid therapy in children hospitalized because of an acute asthma exacerbation. Arch Pediatr Adolesc Med 2001; 155:1329.
  61. Skobeloff EM, Spivey WH, McNamara RM, Greenspon L. Intravenous magnesium sulfate for the treatment of acute asthma in the emergency department. JAMA 1989; 262:1210.
  62. Bloch H, Silverman R, Mancherje N, et al. Intravenous magnesium sulfate as an adjunct in the treatment of acute asthma. Chest 1995; 107:1576.
  63. Rowe BH, Bretzlaff JA, Bourdon C, et al. Intravenous magnesium sulfate treatment for acute asthma in the emergency department: a systematic review of the literature. Ann Emerg Med 2000; 36:181.
  64. Ciarallo L, Sauer AH, Shannon MW. Intravenous magnesium therapy for moderate to severe pediatric asthma: results of a randomized, placebo-controlled trial. J Pediatr 1996; 129:809.
  65. Ciarallo L, Brousseau D, Reinert S. Higher-dose intravenous magnesium therapy for children with moderate to severe acute asthma. Arch Pediatr Adolesc Med 2000; 154:979.
  66. Rowe BH, Bretzlaff JA, Bourdon C, et al. Magnesium sulfate for treating exacerbations of acute asthma in the emergency department. Cochrane Database Syst Rev 2000; :CD001490.
  67. Devi PR, Kumar L, Singhi SC, et al. Intravenous magnesium sulfate in acute severe asthma not responding to conventional therapy. Indian Pediatr 1997; 34:389.
  68. Gürkan F, Haspolat K, Boşnak M, et al. Intravenous magnesium sulphate in the management of moderate to severe acute asthmatic children nonresponding to conventional therapy. Eur J Emerg Med 1999; 6:201.
  69. Scarfone RJ, Loiselle JM, Joffe MD, et al. A randomized trial of magnesium in the emergency department treatment of children with asthma. Ann Emerg Med 2000; 36:572.
  70. Cheuk DK, Chau TC, Lee SL. A meta-analysis on intravenous magnesium sulphate for treating acute asthma. Arch Dis Child 2005; 90:74.
  71. Shan Z, Rong Y, Yang W, et al. Intravenous and nebulized magnesium sulfate for treating acute asthma in adults and children: a systematic review and meta-analysis. Respir Med 2013; 107:321.
  72. Griffiths B, Kew KM. Intravenous magnesium sulfate for treating children with acute asthma in the emergency department. Cochrane Database Syst Rev 2016; 4:CD011050.
  73. Browne GJ, Penna AS, Phung X, Soo M. Randomised trial of intravenous salbutamol in early management of acute severe asthma in children. Lancet 1997; 349:301.
  74. Travers AH, Milan SJ, Jones AP, et al. Addition of intravenous beta(2)-agonists to inhaled beta(2)-agonists for acute asthma. Cochrane Database Syst Rev 2012; 12:CD010179.
  75. Bogie AL, Towne D, Luckett PM, et al. Comparison of intravenous terbutaline versus normal saline in pediatric patients on continuous high-dose nebulized albuterol for status asthmaticus. Pediatr Emerg Care 2007; 23:355.
  76. Kim IK, Phrampus E, Venkataraman S, et al. Helium/oxygen-driven albuterol nebulization in the treatment of children with moderate to severe asthma exacerbations: a randomized, controlled trial. Pediatrics 2005; 116:1127.
  77. Denmark TK, Crane HA, Brown L. Ketamine to avoid mechanical ventilation in severe pediatric asthma. J Emerg Med 2006; 30:163.
  78. Petrillo TM, Fortenberry JD, Linzer JF, Simon HK. Emergency department use of ketamine in pediatric status asthmaticus. J Asthma 2001; 38:657.
  79. Allen JY, Macias CG. The efficacy of ketamine in pediatric emergency department patients who present with acute severe asthma. Ann Emerg Med 2005; 46:43.
  80. Jat KR, Chawla D. Ketamine for management of acute exacerbations of asthma in children. Cochrane Database Syst Rev 2012; 11:CD009293.
  81. Watts K, Chavasse RJ. Leukotriene receptor antagonists in addition to usual care for acute asthma in adults and children. Cochrane Database Syst Rev 2012; :CD006100.
  82. Camargo CA Jr, Smithline HA, Malice MP, et al. A randomized controlled trial of intravenous montelukast in acute asthma. Am J Respir Crit Care Med 2003; 167:528.
  83. Silverman RA, Nowak RM, Korenblat PE, et al. Zafirlukast treatment for acute asthma: evaluation in a randomized, double-blind, multicenter trial. Chest 2004; 126:1480.
  84. Todi VK, Lodha R, Kabra SK. Effect of addition of single dose of oral montelukast to standard treatment in acute moderate to severe asthma in children between 5 and 15 years of age: a randomised, double-blind, placebo controlled trial. Arch Dis Child 2010; 95:540.
  85. Morris CR, Becker AB, Piñieiro A, et al. A randomized, placebo-controlled study of intravenous montelukast in children with acute asthma. Ann Allergy Asthma Immunol 2010; 104:161.
  86. O'Driscoll BR, Kalra S, Wilson M, et al. Double-blind trial of steroid tapering in acute asthma. Lancet 1993; 341:324.
  87. Edmonds ML, Camargo CA, Pollack CV, Rowe BH. Early use of inhaled corticosteroids in the emergency department treatment of acute asthma. Cochrane Database Syst Rev 2000; :CD002308.
  88. Edmonds ML, Camargo CA, Saunders LD, et al. Inhaled steroids in acute asthma following emergency department discharge. Cochrane Database Syst Rev 2000; :CD002316.
  89. Scarfone RJ, Zorc JJ, Angsuco CJ. Emergency physicians' prescribing of asthma controller medications. Pediatrics 2006; 117:821.
  90. Schuh S, Willan AR, Stephens D, et al. Can montelukast shorten prednisolone therapy in children with mild to moderate acute asthma? A randomized controlled trial. J Pediatr 2009; 155:795.
  91. Carroll CL, Schramm CM, Zucker AR. Severe exacerbations in children with mild asthma: characterizing a pediatric phenotype. J Asthma 2008; 45:513.