Acute Asthma in Pediatric Patients: Management in the Emergency Department

Emergency Department Management of Pediatric Acute Asthma: An Evidence-Based Review (Pharmacology CME)

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Table of Contents

About This Issue

Asthma is the most common chronic illness in children, and many children with asthma require emergency department (ED) care at least once a year. Emergency clinicians must be able to identify and manage patients with worsening asthma symptoms and safely determine their disposition. This issue reviews evidence-based approaches to management of moderate to severe acute asthma in pediatric patients. In this issue, you will learn:

Etiologies included in the differential diagnosis of wheezing

Key history and physical examination findings that can predict ED course and clinical outcome

Scoring tools that can be used to guide pediatric asthma care and disposition

Which patients require diagnostic studies/monitoring, and which methods are recommended

Evidence-based treatment recommendations for acute asthma exacerbations, including guidance for medications/dosing, noninvasive respiratory support adjuncts, and invasive ventilation

Special considerations for management of patients who vape/use e-cigarettes and those who have COVID-19

Which children require admission, and which can be safely discharged from the ED

Recommendations for discharge instructions, including education regarding medication use, monitoring for recurrence of symptoms, follow-up instructions, and a written action plan

Table of Contents
  1. About This Issue
  2. Abstract
  3. Case Presentations
  4. Introduction
  5. Critical Appraisal of the Literature
  6. Etiology and Pathophysiology
  7. Differential Diagnosis
  8. Prehospital Care
  9. Emergency Department Evaluation
    1. History
    2. Physical Examination
    3. Scoring and Assessment Tools
  10. Diagnostic Studies
    1. Blood Gas Testing and Pulse Oximetry
    2. Radiography
    3. Point-of-Care Ultrasound
    4. Peak Expiratory Flow Measurement
  11. Treatment
    1. Short-Acting Beta-Agonists
      1. Albuterol
      2. Levalbuterol
    2. Anticholinergic Agents
    3. Terbutaline and Epinephrine
      1. Terbutaline
      2. Epinephrine
    4. Corticosteroids
    5. Magnesium
    6. Ketamine
    7. Heliox
    8. Respiratory Support
      1. Noninvasive Ventilation
        • Conventional Oxygen Therapy
        • High-Flow Nasal Cannula
        • Noninvasive Positive-Pressure Ventilation
      2. Invasive Ventilation
        • Tracheal Intubation and Invasive Mechanical Ventilation
  12. Special Considerations
    1. Vaping/E-Cigarettes
    2. COVID-19
  13. Controversies and Cutting Edge
    1. Precision Medicine
    2. Genetic and mRNA Diagnostic Tools
  14. Disposition
  15. Summary
  16. Time- and Cost-Effective Strategies
  17. Risk Management Pitfalls in Children with Acute Asthma
  18. 5 Things That Will Change Your Practice
  19. Case Conclusions
  20. Clinical Pathways
    1. Clinical Pathway for Emergency Department Management of Pediatric Asthma Exacerbations
    2. Clinical Pathway for Emergency Department Management of Persistent, Severe Pediatric Asthma Exacerbations
  21. Tables
  22. References


Asthma is the most common chronic disease of childhood. Although home action plans and the use of maintenance medications have improved daily management and control of asthma, many children still require emergency department care at least once per year. Emergency clinicians must be able to manage patients with acute asthma exacerbations and determine their safe disposition. This issue reviews the current evidence-based emergency department management recommendations for moderate to severe acute asthma in pediatric patients. Timely use of bronchodilators and systemic corticosteroids, as well as adjunct modalities, are discussed. Current challenges in asthma management related to vaping and COVID-19 are also addressed.

Case Presentations

A 3-year-old girl presents to the ED with cough, rhinorrhea, and increased work of breathing…
  • The child’s parents report she has had mild upper respiratory infection symptoms for the past 3 days that worsened overnight. The girl has a home nebulizer with albuterol for “wheezing” episodes, but she has not been formally diagnosed with asthma. Her breathing initially improved with 2 treatments overnight, but now her parents say she seems worse. They report no vomiting, and the girl is tolerating oral intake. The girl’s past medical history is significant for intermittent eczema and hospitalization for RSV bronchiolitis at 9 months of age. The girl was born at full term without complications. She currently attends day care. Her father smokes but “not in the house.”
  • On examination, the child is fussy but consolable and alert. She is febrile to 38°C, tachypneic to the 40s, with subcostal retractions and expiratory wheezes throughout all lung fields, with fair air movement. The girl’s oxygen saturation is 94% on room air.
  • Do you believe this girl likely has asthma? If so, what are her risk factors? What is your approach to this child’s management? If she responds to treatment, what criteria would you use for potential discharge?
An 8-year-old girl with a history of obesity and intermittent asthma presents with fever, cough, and difficulty breathing...
  • The girl’s father reports she required multiple puffs from her albuterol metered-dose inhaler overnight. Her symptoms improved initially, but this morning she is short of breath and can speak only in shortened sentences. Her history is significant for several prior asthma hospitalizations but no ICU admissions. She currently uses albuterol only as needed. Her primary care physician had prescribed an inhaled corticosteroid for daily use 4 months ago, but her father said the prescription “ran out” and was not refilled. Her older sister was diagnosed with COVID-19 2 days ago.
  • On examination, the girl is febrile to 38.5°C and appears tachypneic, with subcostal and intercostal retractions. You hear inspiratory and expiratory wheezing, with fair air entry throughout all lung fields. Her oxygen saturation is 90% on room air.
  • What first-line treatments should be initiated immediately? If the girl does not respond to initial therapy, what further treatments should you consider in her management? With potential COVID-19 as a concern, what are the possible considerations for the administration of her medications? Does she require any diagnostic studies?
A 15-year-old boy with a history of persistent asthma presents via EMS in severe respiratory distress …
  • EMS reports the teen had several nebulized albuterol treatments at home over the past 12 hours and 2 combined albuterol-ipratropium nebulizers en route to the ED. His mother states he “ran out” of inhaled corticosteroids a month ago. He has been hospitalized for asthma “many times,” including twice to the PICU in the past year, but he has never been intubated. The mother tells you this time he is “really bad.” She says he used to vape, but stopped 6 months ago.
  • On examination, the boy is leaning forward on the EMS stretcher as the oxygenated combined nebulization finishes. He has significant tachypnea; nasal flaring; and subcostal, intercostal, and suprasternal retractions. His lips appear bluish, and he has difficulty speaking. You hear faint expiratory wheezing in all lung fields with poor air movement. His oxygen saturation is 85%.
  • What is your initial approach to this adolescent’s management? If he fails to improve rapidly, what will your next steps be in attempting to stabilize his acute respiratory distress?

How would you manage these patients? Subscribe for evidence-based best practices and to discover the outcomes.

Clinical Pathways

Clinical Pathway for Emergency Department Management of Pediatric Asthma Exacerbations


Table 1. Differential Diagnosis of Wheezing (Potential Asthma Mimics)
Table 4. The Pulmonary Index (PI)
Table 5. Medications for Management of Acute Asthma Exacerbations

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

7. * National Heart, Lung and Blood Institute. National Asthma Education and Prevention Program, third expert panel on the diagnosis and management of asthma. Expert Panel Report 3: Guidelines for Diagnosis and Management of AsthmaNational Heart, Lung, and Blood Institute (US); 2007: Report No: 07-4051. (Clinical practice guideline)

17. * Hasegawa K, Craig SS, Teach SJ, et al. Management of asthma exacerbations in the emergency department. J Allergy Clin Immunol Pract. 2021;9(7):2599-2610. (Review) DOI: 10.1016/j.jaip.2020.12.037

31. * Ducharme FM, Zemek R, Chauhan BF, et al. Factors associated with failure of emergency department management in children with acute moderate or severe asthma: a prospective, multicentre, cohort study. Lancet Respir Med. 2016;4(12):990-998. (Prospective multicenter cohort study; 973 patients) DOI: 10.1016/S2213-2600(16)30160-6

38. * Gray MP, Keeney GE, Grahl MJ, et al. Improving guideline-based care of acute asthma in a pediatric emergency department. Pediatr. 2016;138(5):e20153339. (Prospective cohort study; 5552 patients) DOI: 10.1542/peds.2015-3339

41. * Kaiser SV, Johnson MD, Walls TA, et al. Pathways to improve pediatric asthma care: a multisite, national study of emergency department asthma pathway implementation. J Pediatr. 2020;223:100-107. (Multicenter quality improvement study, combined retrospective review and prospective intervention; 22,963 ED visits) DOI: 10.1016/j.jpeds.2020.02.080

42. * Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. 2021, Accessed June 1, 2023. (Clinical practice guideline)

64. * Cai K-J, Su S-Q, Wang Y-G, et al. Dexamethasone versus prednisone or prednisolone for acute pediatric asthma exacerbations in the emergency department: a meta-analysis. Pediatr Emerg Care. 2021;37(12):e1139-e1144. (Systematic review; 10 articles) DOI: 10.1097/PEC.0000000000001926

69. * Abaya R, Jones L, Zorc JJ. Dexamethasone compared to prednisone for the treatment of children with acute asthma exacerbations. Pediatr Emerg Care. 2018;34(1):53-58. (Review) DOI: 10.1097/PEC.0000000000001371

79. * Craig SS, Dalziel SR, Powell CVE, et al. Interventions for escalation of therapy for acute exacerbations of asthma in children: an overview of Cochrane Reviews. Cochrane Database Syst Rev. 2020(8):CD012977. (Systematic review; 13 articles) DOI: 10.1002/14651858.CD012977.pub2

82. * Schuh S, Sweeney J, Rumantir M, et al. Effect of nebulized magnesium vs placebo added to albuterol on hospitalization among children with refractory acute asthma treated in the emergency department: a randomized clinical trial. JAMA. 2020;324(20):2038-2047. (Post hoc analysis of a double-blind RCT; 816 patients) DOI: 10.1001/jama.2020.19839

104. *Smith A, França UL, McManus ML. Trends in the use of noninvasive and invasive ventilation for severe asthma. Pediatrics. 2020;146(4):e20200534. (Multicenter retrospective study; 95,204 patients) DOI: 10.1542/peds.2020-0534

116. *Howell JD, Redding G, Randolph AG. Acute severe asthma exacerbations in children younger than 12 years: endotracheal intubation and mechanical ventilation. In: TePas E, ed. UpToDate. Waltham, MA. 2022. (Electronic book chapter)

126. *Gaietto K, Freeman MC, DiCicco LA, et al. Asthma as a risk factor for hospitalization in children with COVID-19: a nested case-control study. Pediatr Allergy Immunol. 2022;33(1):e13696. (Prospective case-control study; 1392 patients) DOI: 10.1111/pai.13696

Subscribe to get the full list of 135 references and see how the authors distilled all of the evidence into a concise, clinically relevant, practical resource.

Keywords: asthma, pediatric asthma, acute asthma, asthma exacerbation, asthma flare, status asthmaticus, wheezing, asthma scoring scales, bronchoconstriction, bronchodilator, increased work of breathing, respiratory distress, stridor, recurrent wheezing, cough-variant asthma, silent chest, short-acting beta-agonists, SABA, albuterol, anticholinergic, ipratropium, corticosteroid, dexamethasone, nebulizer, metered-dose inhaler, MDI, Pediatric Respiratory Assessment Measure, PRAM, Pediatric Asthma Severity Score, PASS, pulmonary index, PI, magnesium sulfate, ketamine, heliox, noninvasive ventilation, conventional oxygen therapy, high-flow nasal cannula, noninvasive positive-pressure ventilation, invasive ventilation, tracheal intubation, invasive mechanical ventilation, IMV, vaping, e-cigarettes, COVID-19

Publication Information

Audrey Zelicof Paul, MD, PhD, FAAP; Kim A. Rutherford, MD; Stephanie M. Abuso, DO

Peer Reviewed By

Donna J. Lee, MD; Joanna Schwartz, MD, FAAP

Publication Date

July 1, 2023

CME Expiration Date

July 1, 2026    CME Information

CME Credits

4 AMA PRA Category 1 Credits™, 4 ACEP Category I Credits, 4 AAP Prescribed Credits, 4 AOA Category 2-B Credits.
Specialty CME Credits: Included as part of the 4 credits, this CME activity is eligible for 2 Pharmacology CME credit, subject to your state and institutional approval.

Pub Med ID: 37352408

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