Treatment algorithm
Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer
nebulized anticholinergic
Treatment recommended for SOME patients in selected patient group
Children ages 6-11 years are routinely given a nebulized anticholinergic. Children ages 5 years and younger only receive a nebulized anticholinergic if there is poor response to initial treatment with beta-2 agonists, corticosteroids, and oxygen. The benefits and risks in children <2 years are unclear and anticholinergics are not recommended, except for children with bronchiolitis and chronic lung disease of prematurity.[7][57][89]
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]
Anticholinergics are given by oxygen-driven nebulizer every 20 minutes for the first hour and then reassessed.[7][57] Nebulized anticholinergics produce a weaker bronchodilation response with a slower onset of action (30-90 minutes) than beta-2 agonists (5-15 minutes).[88] Their addition can improve both cholinergic bronchomotor tone and secretions.
Cardiac stimulation occurs but is less marked than that produced by beta-2 agonists.
Primary options
ipratropium bromide inhaled: children ≤5 years of age: 250 micrograms nebulized every 20 minutes for 3 doses; children 6-11 years of age: 250-500 micrograms nebulized every 20 minutes for 3 doses
intravenous bronchodilator or nebulized magnesium sulfate
Treatment recommended for SOME patients in selected patient group
Consider intravenous bronchodilator therapy if there is poor response to inhaled bronchodilators and corticosteroids.[7][57][59] Criteria for starting include no response to initial therapies, persistent hypoxemia, and an FEV₁ <60% predicted at 1 hour.[7]
Intravenous magnesium sulfate is preferred by GINA (children 6-11 years old) and BTS/NICE/SIGN (children 2-11 years old) for exacerbations unresponsive to first-line therapy.[7][57][59][78][79]
[ ]
Its use can reduce the length of hospital stay.[87] However, it does not have an established role in children 5 years and younger due to a lack of evidence.[7] Nebulized magnesium sulfate can be considered if there is no intravenous access, but this offers only modest benefit in severe exacerbations.[7][57][81][82][83]
[ ]
Nebulized magnesium sulfate can be added to a nebulized short-acting beta-2 agonist and anticholinergic in the first hour of treatment for children 2-5 years with severe asthma (e.g., oxygen saturation <92%), particularly if symptoms have lasted <6 hours.[7][57] However, this may not be as effective as intravenous therapy.[7][76][77]
[ ]
Intravenous SABA (albuterol or subcutaneous terbutaline where intravenous albuterol is not available) or a methylxanthine (aminophylline or theophylline) are listed as second-line intravenous bronchodilators by the BTS/NICE/SIGN guideline for use in children 2-11 years old, but only under expert supervision and with extreme caution.[57][59] Neither approach is recommended by GINA.[7]
Treatment with intravenous magnesium sulfate requires close monitoring for respiratory depression. During intravenous treatment with beta-2 agonists, monitor and replace potassium levels as required.[57] If patients receive intravenous aminophylline, adverse effects are more likely in those taking sustained-release theophylline as part of their chronic management.[7] Serum theophylline levels should be checked regularly and the dose adjusted accordingly if patients receive continuous therapy.
Primary options
magnesium sulfate: children ≥2 years of age: 40-50 mg/kg intravenously by slow infusion over 20-60 minutes, maximum 2000 mg/dose
Secondary options
terbutaline: consult specialist for guidance on dose
OR
magnesium sulfate: children ≥2 years of age: 150 mg nebulized every 20 minutes for 3 doses
MoreTertiary options
aminophylline: consult specialist for guidance on dose
nebulized anticholinergic
Treatment recommended for SOME patients in selected patient group
Children ages 6-11 years are routinely given a nebulized anticholinergic. Children ages 5 years and younger only receive a nebulized anticholinergic if there is poor response to initial treatment with beta-2 agonists, corticosteroids, and oxygen. The benefits and risks in children <2 years are unclear and anticholinergics are not recommended, except for children with bronchiolitis and chronic lung disease of prematurity.[7][57][89]
[ ]
Anticholinergics are given by oxygen-driven nebulizer every 20 minutes for the first hour and then reassessed.[7][57] Nebulized anticholinergics produce a weaker bronchodilation response with a slower onset of action (30-90 minutes) than beta-2 agonists (5-15 minutes).[88] Their addition can improve both cholinergic bronchomotor tone and secretions.
Cardiac stimulation occurs but is less marked than that produced by beta-2 agonists.
Primary options
ipratropium bromide inhaled: children ≤5 years of age: 250 micrograms nebulized every 20 minutes for 3 doses; children 6-11 years of age: 250-500 micrograms nebulized every 20 minutes for 3 doses
intravenous bronchodilator or nebulized magnesium sulfate
Treatment recommended for SOME patients in selected patient group
Consider intravenous bronchodilator therapy if there is poor response to inhaled bronchodilators and corticosteroids.[7][57][59] Criteria for starting include no response to initial therapies, persistent hypoxemia, and an FEV₁ <60% predicted at 1 hour.[7]
Intravenous magnesium sulfate is preferred by GINA (children 6-11 years old) and BTS/NICE/SIGN (children 2-11 years old) for exacerbations unresponsive to first-line therapy.[7][57][59][78][79]
[ ]
Its use can reduce the length of hospital stay.[87] However, it does not have an established role in children 5 years and younger due to a lack of evidence.[7] Nebulized magnesium sulfate can be considered if there is no intravenous access, but this offers only modest benefit in severe exacerbations.[7][57][81][82][83]
[ ]
Nebulized magnesium sulfate can be added to a nebulized short-acting beta-2 agonist and anticholinergic in the first hour of treatment for children 2-5 years with severe asthma (e.g., oxygen saturation <92%), particularly if symptoms have lasted <6 hours.[7][57] However, this may not be as effective as intravenous therapy.[7][76][77]
[ ]
Intravenous SABA (albuterol or subcutaneous terbutaline where intravenous albuterol is not available) or a methylxanthine (aminophylline or theophylline) are listed as second-line intravenous bronchodilators by the BTS/NICE/SIGN guideline for use in children 2-11 years old, but only under expert supervision and with extreme caution.[57][59] Neither approach is recommended by GINA.[7]
Treatment with intravenous magnesium sulfate requires close monitoring for respiratory depression. During intravenous treatment with beta-2 agonists, monitor and replace potassium levels as required.[57] If patients receive intravenous aminophylline, adverse effects are more likely in those taking sustained-release theophylline as part of their chronic management.[7] Serum theophylline levels should be checked regularly and the dose adjusted accordingly if patients receive continuous therapy.
Primary options
magnesium sulfate: children ≥2 years of age: 40-50 mg/kg intravenously by slow infusion over 20-60 minutes, maximum 2000 mg/dose
Secondary options
terbutaline: consult specialist for guidance on dose
OR
magnesium sulfate: children ≥2 years of age: 150 mg nebulized every 20 minutes for 3 doses
MoreTertiary options
aminophylline: consult specialist for guidance on dose
inhaled short-acting beta-2 agonist
Give an inhaled short-acting beta-2 agonist (SABA) immediately, reassess after 15-20 minutes, and give a further dose if response is inadequate (up to 3 doses in the first hour). The response to treatment should be immediate and sustained for 3-4 hours. [7]
A metered-dose inhaler plus a spacer is just as effective as a nebuliser for mild to moderate exacerbations.[84]
[ ]
Use a face mask for children ages <3 years and a mouthpiece used for older children.[7]
Mild exacerbations do not usually require hospital admission and can be treated appropriately at home using the child's personalized asthma action plan. Some moderate exacerbations may require hospital admission.[7][57][75]
[ ]
Primary options
albuterol inhaled: (90 micrograms/dose metered-dose inhaler) children <12 years of age: 360-720 micrograms (4-8 puffs) every 20 minutes for 3 doses, followed by 4-8 puffs every 1-4 hours when required
oral corticosteroid
Treatment recommended for SOME patients in selected patient group
Oral corticosteroids are not usually required in a mild exacerbation, but may be needed to prevent deterioration when response to an inhaled short-acting beta-2 agonist (SABA) is incomplete. For children 5 years and younger with mild to moderate exacerbations, a systemic corticosteroid should only be given if symptoms recur within 3-4 hours of treatment with a SABA.[7]
Corticosteroids produce a treatment response by 4-6 hours.[7][85] Early administration within the first hour of arrival reduces admission rates compared with placebo.[85]
A pragmatic approach is to prescribe treatment for 3 days and then review the need for a longer course.[7][57]
Adjusting the ICS dose may be considered on a case-by-case basis to reduce hospitalizations (e.g., adding a short course of daily ICS to a SABA reliever at the onset of a respiratory illness in children ages 0-4 years), but this is not recommended routinely.[7][55][92][93][94][95][97][98]
[ ]
Primary options
prednisone: 1-2 mg/kg/day orally, maximum 60 mg/day
inhaled anticholinergic
Treatment recommended for SOME patients in selected patient group
An inhaled anticholinergic can be added to the short-acting beta-2 agonist (SABA) if there is a poor response to initial treatment in children with a moderate to severe exacerbation.[7][57]
[ ]
[ ]
Anticholinergics produce a weaker bronchodilation response with a slower onset of action (30-90 minutes) than beta-2 agonists (5-15 minutes).[88] Give the anticholinergic at 20-minute intervals and reassess response.[7]
The use of spacers with pressurized metered-dose inhalers is recommended, especially for young children (i.e., ≤5 years old).[7] Use a face mask if <3 years old and a mouthpiece if older.
Routine use of an anticholinergic is not recommended in children <2 years of age, except for those with bronchiolitis or chronic lung disease of prematurity.[89]
Cardiac stimulation occurs but is less marked than that produced by beta-2 agonists.
Primary options
ipratropium bromide inhaled: (17 micrograms/dose metered-dose inhaler) children ≤5 years of age: 34 micrograms (2 puffs) every 20 minutes for 3 doses; children 6-11 years of age: 68-136 micrograms (4-8 puffs) every 20 minutes for 3 doses
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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer
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