Quick-Relief for All Patients
Bronchodilator as needed for symptoms: Short-acting inhaled ß2-agonist by nebulizer (0.05 mg/kg in 2-3 cc of saline) or inhaler with face mask and spacer (2-6 puffs; for exacerbations, repeat every 20 minutes for up to 1 hour).
With Viral Respiratory Infection
The Expert Panel recommends the following actions for managing exacerbations due to viral respiratory infections, which are especially common in children. These exacerbations may be intermittent yet severe.
- If the symptoms are mild, short-acting inhaled ß2–agonists (every 4–6 hours for 24 hours, longer with a physician consult) may be sufficient to control symptoms and improve lung function. If this therapy needs to be repeated more frequently than every 6 weeks, consider a step up in long-term care.
- If the viral respiratory infection provokes a moderate-to-severe exacerbation, a short course of oral systemic corticosteroids should be considered (1 mg/kg/day prednisone or equivalent for 3–10 days).
- For those patients who have a history of severe exacerbations with viral respiratory infections, consider initiating oral systemic corticosteroids at the first sign of the infection.
- Referral to an asthma specialist for consultation or co-management if patient requires step 3 for children 0–4 years of age. Consider referral if patient requires step 2 for children 0–4 years of age.
Learn when to refer patients to an asthma specialist.
Poor Asthma Control
1. Assess Reasons for Poor Asthma Control – ICE
- Inhaler technique – Check patient's technique.
- Compliance – Ask when and how much medication the patient is taking.
- Environment - Ask patient/parent if something in his or her environment has changed.
Is there environmental tobacco smoke in the home? Find out about cotinine levels
, which can help track exposure to tobacco smoke and its toxic constituents using a saliva, blood or urine test.
You may also want to consider an alternative diagnosis. Assess patient for presence of other upper respiratory disease or alternative diagnosis.
2. Consider Increasing Long-Term Medications
It may be necessary to increase anti-inflammatory medication to regain control of a patient's asthma. Please see "Assessing Asthma Control and Adjusting Therapy in Children 0 – 4 Years of Age" for more information.
Medication Delivery in Young Children
Medication delivery devices should be selected based on the child's ability to use them well.
Nebulizer therapy is one option for administering short-acting inhaled ß2-agonists or inhaled corticosteroids in children. A metered-dose inhaler (MDI) with a spacer/valved-holding chamber that has a face mask may also be used to take inhaled steroids. MDI plus spacer/valved-holding chamber may be used by many children of this age. If the desired therapeutic effects are not achieved, a nebulizer or an MDI plus spacer/valved-holding chamber with a face mask may be required. An MDI plus spacer/valved-holding chamber is as effective as nebulizer for delivering short-acting inhaled ß2-agonists in mild to moderate exacerbations; data in severe exacerbations are limited.