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]:To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Akinbami LJ, Moorman JE, Garbe PL, Sondik EJ. Status of childhood asthma in the United States, 1980-2007. Pediatrics 2009; 123 Suppl 3:S131.
- Hasegawa K, Tsugawa Y, Brown DF, Camargo CA Jr. Childhood asthma hospitalizations in the United States, 2000-2009. J Pediatr 2013; 163:1127.
- National Center for Environmental Health, Data Resources. http://www.cdc.gov/nceh/data.htm.
- Asthma team CCHMC. Evidence based care guideline for managing an acute exacerbation of asthma. www.cincinnatichildrens.org/svc/alpha/h/health-policy/ev-based/asthma.htm (Accessed on February 08, 2008).
- 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.
- 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 February 08, 2008).
- Nkoy FL, Fassl BA, Simon TD, et al. Quality of care for children hospitalized with asthma. Pediatrics 2008; 122:1055.
- 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).
- Ben-Zvi Z, Lam C, Hoffman J, et al. An evaluation of the initial treatment of acute asthma. Pediatrics 1982; 70:348.
- Mandelberg A, Tsehori S, Houri S, et al. Is nebulized aerosol treatment necessary in the pediatric emergency department? Chest 2000; 117:1309.
- Wildhaber JH, Dore ND, Wilson JM, et al. Inhalation therapy in asthma: nebulizer or pressurized metered-dose inhaler with holding chamber? In vivo comparison of lung deposition in children. J Pediatr 1999; 135:28.
- Portnoy J, Nadel G, Amado M, Willsie-Ediger S. Continuous nebulization for status asthmaticus. Ann Allergy 1992; 69:71.
- Craig VL, Bigos D, Brilli RJ. Efficacy and safety of continuous albuterol nebulization in children with severe status asthmaticus. Pediatr Emerg Care 1996; 12:1.
- Katz RW, Kelly HW, Crowley MR, et al. Safety of continuous nebulized albuterol for bronchospasm in infants and children. Pediatrics 1993; 92:666.
- Papo MC, Frank J, Thompson AE. A prospective, randomized study of continuous versus intermittent nebulized albuterol for severe status asthmaticus in children. Crit Care Med 1993; 21:1479.
- Montgomery VL, Eid NS. Low-dose beta-agonist continuous nebulization therapy for status asthmaticus in children. J Asthma 1994; 31:201.
- Cates CJ, Welsh EJ, Rowe BH. Holding chambers (spacers) versus nebulisers for beta-agonist treatment of acute asthma. Cochrane Database Syst Rev 2013; :CD000052.
- Camargo CA Jr, Spooner CH, Rowe BH. Continuous versus intermittent beta-agonists in the treatment of acute asthma. Cochrane Database Syst Rev 2003; :CD001115.
- Wazeka A, Valacer DJ, Cooper M, et al. Impact of a pediatric asthma clinical pathway on hospital cost and length of stay. Pediatr Pulmonol 2001; 32:211.
- Johnson KB, Blaisdell CJ, Walker A, Eggleston P. Effectiveness of a clinical pathway for inpatient asthma management. Pediatrics 2000; 106:1006.
- 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; 152:476.
- Banasiak NC, Meadows-Oliver M. Inpatient asthma clinical pathways for the pediatric patient: an integrative review of the literature. Pediatr Nurs 2004; 30:447.
- Rodrigo GJ, Rodrigo C. Continuous vs intermittent beta-agonists in the treatment of acute adult asthma: a systematic review with meta-analysis. Chest 2002; 122:160.
- Andrews T, McGintee E, Mittal MK, et al. High-dose continuous nebulized levalbuterol for pediatric status asthmaticus: a randomized trial. J Pediatr 2009; 155:205.
- Kercsmar CM, McDowell KM. Love it or lev it: levalbuterol for severe acute asthma--for now, leave it. J Pediatr 2009; 155:162.
- Phumeetham S, Bahk TJ, Abd-Allah S, Mathur M. Effect of high-dose continuous albuterol nebulization on clinical variables in children with status asthmaticus. Pediatr Crit Care Med 2015; 16:e41.
- Rowe BH, Spooner C, Ducharme FM, et al. Early emergency department treatment of acute asthma with systemic corticosteroids. Cochrane Database Syst Rev 2001; :CD002178.
- Taylor DR, Hancox RJ. Interactions between corticosteroids and beta agonists. Thorax 2000; 55:595.
- Parikh K, Hall M, Mittal V, et al. Comparative Effectiveness of Dexamethasone versus Prednisone in Children Hospitalized with Asthma. J Pediatr 2015; 167:639.
- Becker JM, Arora A, Scarfone RJ, et al. Oral versus intravenous corticosteroids in children hospitalized with asthma. J Allergy Clin Immunol 1999; 103:586.
- 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.
- Schuh S, Reisman J, Alshehri M, et al. A comparison of inhaled fluticasone and oral prednisone for children with severe acute asthma. N Engl J Med 2000; 343:689.
- Quon BS, Fitzgerald JM, Lemière C, et al. Increased versus stable doses of inhaled corticosteroids for exacerbations of chronic asthma in adults and children. Cochrane Database Syst Rev 2010; :CD007524.
- 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.
- Tal A, Pasterkamp H, Leahy F. Arterial oxygen desaturation following salbutamol inhalation in acute asthma. Chest 1984; 86:868.
- Browne GJ, Lam LT. Single-dose intravenous salbutamol bolus for managing children with acute severe asthma in the emergency department:Reanalysis of data. Pediatr Crit Care Med 2002; 3:117.
- Travers A, Jones AP, Kelly K, et al. Intravenous beta2-agonists for acute asthma in the emergency department. Cochrane Database Syst Rev 2001; :CD002988.
- Mitra A, Bassler D, Goodman K, et al. Intravenous aminophylline for acute severe asthma in children over two years receiving inhaled bronchodilators. Cochrane Database Syst Rev 2005; :CD001276.
- Strauss RE, Wertheim DL, Bonagura VR, Valacer DJ. Aminophylline therapy does not improve outcome and increases adverse effects in children hospitalized with acute asthmatic exacerbations. Pediatrics 1994; 93:205.
- Needleman JP, Kaifer MC, Nold JT, et al. Theophylline does not shorten hospital stay for children admitted for asthma. Arch Pediatr Adolesc Med 1995; 149:206.
- Carter E, Cruz M, Chesrown S, et al. Efficacy of intravenously administered theophylline in children hospitalized with severe asthma. J Pediatr 1993; 122:470.
- DiGiulio GA, Kercsmar CM, Krug SE, et al. Hospital treatment of asthma: lack of benefit from theophylline given in addition to nebulized albuterol and intravenously administered corticosteroid. J Pediatr 1993; 122:464.
- Wheeler DS, Jacobs BR, Kenreigh CA, et al. Theophylline versus terbutaline in treating critically ill children with status asthmaticus: a prospective, randomized, controlled trial. Pediatr Crit Care Med 2005; 6:142.
- Alansari K, Ahmed W, Davidson BL, et al. Nebulized magnesium for moderate and severe pediatric asthma: A randomized trial. Pediatr Pulmonol 2015; 50:1191.
- 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.
- 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.
- 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.
- Vézina K, Chauhan BF, Ducharme FM. Inhaled anticholinergics and short-acting beta(2)-agonists versus short-acting beta2-agonists alone for children with acute asthma in hospital. Cochrane Database Syst Rev 2014; :CD010283.
- Graham VA, Milton AF, Knowles GK, Davies RJ. Routine antibiotics in hospital management of acute asthma. Lancet 1982; 1:418.
- 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 February 09, 2008).
- Hondras MA, Linde K, Jones AP. Manual therapy for asthma. Cochrane Database Syst Rev 2002; :CD001002.
- Wallis C, Prasad A. Who needs chest physiotherapy? Moving from anecdote to evidence. Arch Dis Child 1999; 80:393.
- Asher MI, Douglas C, Airy M, et al. Effects of chest physical therapy on lung function in children recovering from acute severe asthma. Pediatr Pulmonol 1990; 9:146.
- Wright RO, Santucci KA, Jay GD, Steele DW. Evaluation of pre- and posttreatment pulse oximetry in acute childhood asthma. Acad Emerg Med 1997; 4:114.
- Solé D, Komatsu MK, Carvalho KV, Naspitz CK. Pulse oximetry in the evaluation of the severity of acute asthma and/or wheezing in children. J Asthma 1999; 36:327.
- Gorelick MH, Stevens MW, Schultz T, Scribano PV. Difficulty in obtaining peak expiratory flow measurements in children with acute asthma. Pediatr Emerg Care 2004; 20:22.
- Smith SR, Baty JD, Hodge D 3rd. Validation of the pulmonary score: an asthma severity score for children. Acad Emerg Med 2002; 9:99.
- Becker AB, Nelson NA, Simons FE. The pulmonary index. Assessment of a clinical score for asthma. Am J Dis Child 1984; 138:574.
- Carroll CL, Sekaran AK, Lerer TJ, Schramm CM. A modified pulmonary index score with predictive value for pediatric asthma exacerbations. Ann Allergy Asthma Immunol 2005; 94:355.
- 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.
- Smith SR, Strunk RC. Acute asthma in the pediatric emergency department. Pediatr Clin North Am 1999; 46:1145.
- Asthma team CCHMC. Evidence based care guideline for managing an acute exacerbation of asthma. www.cincinnatichildrens.org/svc/alpha/h/health-policy/ev-based/asthma.htm (Accessed on February 09, 2008).
- McFadden ER Jr, Lyons HA. Arterial-blood gas tension in asthma. N Engl J Med 1968; 278:1027.
- Khan FI, Reddy RC, Baptist AP. Pediatric Dyspnea Scale for use in hospitalized patients with asthma. J Allergy Clin Immunol 2009; 123:660.
- Bhogal S, Zemek R, Ducharme FM. Written action plans for asthma in children. Cochrane Database Syst Rev 2006; :CD005306.
- 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
- SIGNS OF IMPENDING RESPIRATORY FAILURE
- Asthma specialist
- Social services
- DISCHARGE CRITERIA
- Discharge medications
- Discharge education
- Asthma action plan
- CARE COORDINATION/CASE MANAGEMENT
- SOCIETY GUIDELINE LINKS
- SUMMARY AND RECOMMENDATIONS