Managing severe asthma exacerbations in children

In children with severe asthma exacerbations, the best clinical indicators of severe airflow obstruction are the use of accessory muscles of respiration, severe dyspnea, and pulsus paradoxus. Patients with obvious signs of worsening respiratory distress should have immediate arterial blood gas sampling. Standard therapies include supplemental oxygen, 2 to 4 L/min by nasal cannula or 6 to 8 L/min by simple face mask; continuous nebulization of a β₂-agonist; and systemic corticosteroids (oral administration is appropriate if the child does not have nausea or vomiting). Intravenous β₂-agonists may be considered in patients with respiratory deterioration who do not respond to nebulized β₂-agonist therapy. The addition of ipratropium in the emergency department (ED) may improve pulmonary function and obviate the need for hospitalization. Intravenous magnesium may be a safe adjunct to therapy for children who do not respond adequately to standard therapy in the ED.