Pediatric Acute Asthma Exacerbation (GINA 2025)

Algorithm Steps

1. ▶

   Start

   Pediatric Acute Asthma Exacerbation

   Child with acute wheeze/dyspnea

   1. ●

      Action

      Assess Severity

      Clinical assessment

      • MILD-MODERATE:
      • • Talks in phrases, prefers sitting
      • • Not agitated, SpO2 ≥92%
      • • HR increased but not severe
      • SEVERE:
      • • Talks in words only, sits hunched forward
      • • Agitated, SpO2 <92%
      • • Accessory muscle use, RR >30
      • LIFE-THREATENING:
      • • Silent chest, cyanosis, exhaustion
      • • Altered consciousness, SpO2 <90%
      1. ●

         Action

         Mild-Moderate Treatment

         Initial bronchodilator therapy

         • SABA: Salbutamol (albuterol)
         • • pMDI + spacer: 4-6 puffs
         • • OR nebulizer: 2.5 mg (5 mg if >40 kg)
         • • Repeat every 20 min x3 in first hour
         • ORAL CORTICOSTEROID:
         • • Prednisolone 1-2 mg/kg (max 40 mg)
         • • Give within first hour
         • Maintain SpO2 ≥94% (≥92% for age ≥12)
         1. ◆

            Decision

            Response After 1 Hour?

            Reassess after initial treatment

            1. ✓

               Outcome

               Good Response

               Improving - consider discharge

               • Observe 1-2 hours
               • SpO2 ≥94% on room air
               • PEF/FEV1 ≥60-80% predicted
               • DISCHARGE WITH:
               • • Continue SABA q3-4h prn
               • • Oral prednisolone 3-5 days
               • • Review ICS adherence
               • • Follow-up within 1-2 weeks
            2. ●

               Action

               Poor Response

               Escalate therapy

               • Continue SABA q1h or continuous neb
               • Continue ipratropium q4-6h
               • ADD MAGNESIUM SULFATE IV:
               • • 25-50 mg/kg (max 2 g)
               • • Infuse over 20-30 minutes
               • • Single dose (may repeat once)
               • Consider high-flow nasal cannula
               • ICU consultation if not improving
               1. ✓

                  Outcome

                  Admit to Hospital

                  Criteria for admission

                  • SpO2 <92% on room air
                  • Requiring ongoing O2/frequent SABA
                  • Poor response to initial treatment
                  • Previous severe exacerbations
                  • Unable to take oral steroids
                  • Inadequate home support
               2. ⚠

                  Warning

                  Life-Threatening/ICU

                  Critical care required

                  • IMMEDIATE:
                  • • Nebulized SABA continuous
                  • • Ipratropium + magnesium sulfate IV
                  • • IV corticosteroids
                  • CONSIDER:
                  • • IV salbutamol 5-15 mcg/kg loading, then 1-5 mcg/kg/min
                  • • Aminophylline (limited evidence)
                  • • BiPAP or intubation if failing
                  • • Ketamine for intubation
                  • AVOID: Aggressive sedation, high PEEP
      2. ●

         Action

         Severe Exacerbation

         Intensive initial treatment

         • SABA: Salbutamol continuous/q20min
         • • 2.5-5 mg neb back-to-back x3
         • ADD IPRATROPIUM:
         • • 250-500 mcg neb with SABA
         • • For first hour (3 doses)
         • OXYGEN: Target SpO2 94-98%
         • SYSTEMIC STEROIDS:
         • • Prednisolone 1-2 mg/kg PO (max 40 mg)
         • • OR Methylprednisolone 1-2 mg/kg IV