Bronchial asthma

6 yr old is noted have wheezing once in every 10 days. She has night symptoms once or 2 times a month

She has a cat at home and grandfather smokes regularly

She had oozing skin lesions in infancy and mother is a known asthmatic

She was admitted because of wheezing 6 months ago to icu

She is now brought with rr of 50,hr of 130  spo2 90% and is agitated

How do you treat the acute episode?


 Children with life-threatening asthma or SpO2 <94% should receive highflow oxygen via a tight-fitting face mask or nasal cannula at sufficient flow rates to achieve normal saturations of 94–98%


Inhaled β2 agonists are the first-line treatment for acute asthma in children.

A pMDI + spacer is the preferred option for children with mild to moderate asthma.

Two to four puffs of salbutamol (100 micrograms via a pMDI + spacer) might be sufficient for mild asthma attacks, although up to 10 puffs might be needed for more severe attacks.

Nebulisation .5ml 1%salbutamol and 2.5 ml nd every 20 minutes for 3 times is done in severe attack

Ipratropium bromide

There is good evidence for the safety and efficacy of frequent doses of ipratropium bromide (every 20–30 minutes) used in addition to β2 agonists for the first two hours of a severe asthma attack. Benefits are more apparent in the most severe patients.

Steroid therapy

The early use of steroids in emergency departments and assessment units can reduce the need for hospital admission and prevent a relapse in symptoms after initial presentation.598, 599 Benefits can be apparent within three to four hours. In head-to-head comparisons there is insufficient evidence to suggest that dexamethasone offers an advantage over prednisolone for the management of mild to moderate acute asthma in children.

Give oral steroids early in the treatment of acute asthma attacks in children. B Oral prednisolone is the steroid of choice for asthma attacks in children unless the patient is unable to tolerate the dose.


In children who respond poorly to first-line treatments, consider the addition of intravenous magnesium sulphate as first-line intravenous treatment (50 mg/kg/day).


Subcutaneous epinephrine or terbutaline. 01mg/kg


if not improving

inj aminophylline 5mg/kg


Inj ketamine and sevoflurane are used in critical care setting


What investigations you?

Pefr Ina xhild above 4 yrs

Spirometry in children above 6 yrs

Others tests are not usually necessary


What is the long term treatment plan

Assess the severity of symptoms

And decide it is intermittent or persistent

daytime symptoms,night time symptoms ,saba use,activity limitation,and  lung function are the basic criteria

Risk factors  may also be included

Write a plan for acute exacerbation

What history you specifically ask?

Night symptoms

Day symptoms

activity limitation

saba use

Lung function

Ask for exacerbation

steroid use

exposure to tobaccosmoke,pets,dust mite exposure,mold,cockroach

h/o allergic rhinitis

Atopic dermatitis




How do you dx asthma?

Look for variable respiratory symptoms




Chest tightness(may not be applicable in young child)

Confirmed variable expiratory limitation

Excessive variability in peak exp flow >13%


(it may not be practical below 4 yrs)

What are the physical signs in asthma?

Variable respiratory symptoms and documented airflow limitation are necessary to confirm asthma

Gina 2020

How to assess the severity?

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What is the longterm treatment?

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What are the d/d?


How do you dx asthma in less than 5 yrs?



Acute sever asthma








About Dr. Jayaprakash

Asst. Prof. of Pediatrics, ICH. Institute of Child Health. Gov. Medical College Kottayam. Kerala, India.

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