Last reviewed: March 2026
Contents
MDM Templates
Mild-Moderate Asthma Exacerbation
Child presents with cough, wheezing, and respiratory distress consistent with asthma exacerbation. Well appearing, speaking in phrases or sentences, with bilateral wheezing and adequate air movement. No signs of impending respiratory failure.
Presentation not consistent with pneumonia, foreign body aspiration, croup, anaphylaxis, or cardiac disease.
Plan: Albuterol, ipratropium, and systemic corticosteroids administered. Patient improved with treatment — wheezing reduced, work of breathing improved, tolerating PO, maintaining SpO2 ≥94% on room air. Discharge with albuterol inhaler and spacer, short steroid course, PCP follow-up within 48 hours. Return precautions for increased work of breathing, inability to speak in sentences, poor feeding, or persistent wheezing despite albuterol.
Severe Asthma Exacerbation
Child presents with significant respiratory distress, poor air movement, and inability to speak in complete sentences. Accessory muscle use and nasal flaring present. Not responding adequately to initial bronchodilator therapy.
Concern for severe exacerbation given degree of respiratory distress and inadequate response to first-line treatment. Not consistent with pneumonia, foreign body, anaphylaxis, or alternative diagnosis.
Plan: Continuous albuterol nebulization, IV magnesium sulfate, systemic corticosteroids. Admit to pediatrics for ongoing bronchodilator therapy and monitoring.
If impending respiratory failure (fatigue, altered mental status, worsening hypoxia): Consider IV terbutaline infusion, IM epinephrine, or BiPAP/NIPPV trial. PICU consultation for possible intubation and mechanical ventilation.
Status Asthmaticus / Intubated Asthma
Respiratory failure despite maximal medical therapy including continuous albuterol, IV magnesium, and systemic corticosteroids. Intubation required for airway protection and ventilatory support.
Plan: Intubation with ketamine induction. Ventilator settings targeting low respiratory rate, low tidal volume, prolonged I:E ratio, and permissive hypercapnia to minimize auto-PEEP and barotrauma. PICU admission.
Clinical Education
Severity Assessment
Wheezing alone does not determine severity — a silent chest is worse than loud wheezing. Silent chest or severely diminished air movement indicates poor ventilation and may signal impending respiratory failure. The Pediatric Asthma Severity Score or Modified Pulmonary Index Score can aid objective assessment.[1]
| Feature | Mild-Moderate | Severe |
| Speech | Phrases or sentences | Words only or unable to speak |
| SpO2 | ≥94% on room air | <90% on room air |
| Air Entry | Bilateral wheezing, adequate movement | Silent chest or markedly diminished |
| Accessory Muscles | Minimal or suprasternal only | Intercostal, subcostal retractions, nasal flaring |
| Mental Status | Normal, alert | Agitated, drowsy, or confused |
First-Line Treatment
Albuterol: 2.5 mg nebulized every 20 minutes for 3 doses, then every 1-4 hours based on response. MDI with spacer (4-8 puffs) is equivalent to nebs in mild-moderate exacerbations. Continuous nebulization (10-15 mg/hour) reserved for severe exacerbations.[1]
Ipratropium: 0.5 mg nebulized with albuterol for the first 3 doses during the first hour. No benefit beyond the first hour — do not continue ipratropium after initial treatment.[5]
Systemic corticosteroids — give early and universally. Dexamethasone 0.6 mg/kg PO/IM (max 16 mg) for 1-2 days is equivalent to prednisone/prednisolone 2 mg/kg/day (max 60 mg) for 5 days, with significantly better compliance. Single-dose or 2-day dexamethasone is now preferred by many institutions.[2]
Escalation Therapies
IV Magnesium sulfate: 50-75 mg/kg (max 2g) over 20 minutes for severe exacerbations not responding to initial bronchodilator therapy. Smooth muscle relaxant with bronchodilatory properties. Monitor for hypotension and flushing.[3]
Epinephrine IM: 0.01 mg/kg (max 0.5 mg) of 1 mg/mL solution. Consider when aeration is too poor for effective nebulization. Provides both alpha (mucosal edema reduction) and beta-2 (bronchodilation) effects.
Terbutaline SQ: 0.01 mg/kg (max 0.4 mg) as an alternative to IM epinephrine. IV terbutaline infusion (0.5-2 mcg/kg/min) available for status asthmaticus in the ICU setting.
Ketamine: Subdissociative dose (0.5 mg/kg IV) has bronchodilatory properties. Also the induction agent of choice if intubation becomes necessary — avoid propofol and succinylcholine which can worsen bronchospasm via histamine release.
Ventilator Management in Asthma
Avoid intubation if at all possible — asthma kills on the vent. Trial BiPAP/NIPPV first in impending respiratory failure. If intubation is unavoidable:[4]
| Parameter | Setting | Rationale |
| Induction | Ketamine 1-2 mg/kg IV | Bronchodilatory, preserves respiratory drive |
| RR | 10-12 (children), 8-10 (adolescents) | Allow complete exhalation, prevent air trapping |
| TV | 6-8 mL/kg | Minimize barotrauma |
| I:E Ratio | 1:3 to 1:5 | Prolonged expiration to minimize auto-PEEP |
| PEEP | Low (start 5 cmH2O) | High PEEP worsens air trapping — auto-PEEP is the enemy |
| pCO2 | Permissive hypercapnia (target pH >7.2) | Accept elevated CO2 to keep RR low |
If sudden decompensation on the vent: Disconnect from ventilator and manually decompress. Differential: tension pneumothorax, mucus plugging, or severe auto-PEEP. Needle decompression if PTX suspected.
Discharge Criteria
All of the following should be met before discharge: sustained improvement for ≥1 hour after last bronchodilator treatment, SpO2 ≥94% on room air, tolerating PO, speaking comfortably in sentences, reliable caretaker present, access to medications (albuterol inhaler with spacer), and PCP follow-up confirmed within 48 hours.[1]
Discharge prescriptions: Albuterol MDI with spacer (or nebs if <4 years and unable to use MDI effectively). Short steroid course — dexamethasone 0.6 mg/kg x1-2 days or prednisolone 2 mg/kg/day x5 days. Consider adding inhaled corticosteroid (ICS) if not already on controller therapy.
Disposition Decision Guide
| Disposition | Criteria |
| Discharge | Meets all discharge criteria. Good response to initial therapy. SpO2 ≥94% on RA. Reliable caretaker and follow-up confirmed. |
| Admit — Floor | Persistent O2 requirement after treatment. Ongoing need for frequent or continuous nebs. Poor response after ≥3 hours. Prior ICU admission for asthma. Unreliable follow-up. |
| Admit — PICU | Impending or frank respiratory failure. AMS or fatigue. Requiring IV terbutaline, epinephrine, or BiPAP. Status asthmaticus. Intubation needed. |
References
- National Asthma Education and Prevention Program. Expert Panel Report 4 (EPR-4): Guidelines for the Diagnosis and Management of Asthma. NHLBI. 2020. NHLBI
- Keeney GE, Gray MP, Morrison AO, et al. Dexamethasone for acute asthma exacerbations in children: a meta-analysis. Pediatrics. 2014;133(3):e493-e499. PubMed
- Griffiths B, Kew KM. Intravenous magnesium sulfate for treating children with acute asthma in the emergency department. Cochrane Database Syst Rev. 2016;4:CD011050. PubMed
- Global Initiative for Asthma (GINA). Global Strategy for Asthma Management and Prevention. 2023 Update. GINA
- Plotnick LH, Ducharme FM. Combined inhaled anticholinergics and short-acting beta2-agonists for initial treatment of acute asthma in children. Cochrane Database Syst Rev. 2000;(4):CD000060. PubMed
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