Key points
- Albuterol: 4–8 puffs by MDI with spacer, or 0.15 mg/kg nebulized (minimum 2.5 mg, maximum 5 mg), every 20 minutes for 3 doses.
- Moderate or severe attack: add ipratropium 0.25–0.5 mg nebulized with the first 3 albuterol treatments.
- Systemic steroid early, ideally within the first hour: prednisone or prednisolone 1–2 mg/kg/day (max 60 mg), or dexamethasone 0.6 mg/kg (max 16 mg).
- Severe or not responding: IV magnesium sulfate 25–75 mg/kg (commonly 50 mg/kg, max 2 g) and continuous albuterol.
- Impending respiratory failure (drowsy, silent chest, poor effort): resuscitate, continuous albuterol, IV steroid and magnesium, PICU.
- No routine chest X-ray in a typical exacerbation.
- Discharge with a spacer, inhaler teaching, a controller plan, a written action plan and follow-up.
Judging severity
Severity guides every step. Judge it by how the child talks and breathes, the work of breathing, oxygen saturation and, in older children, peak flow. Reassess after each round of treatment.
- A child who stops wheezing may be getting worse, not better, if air entry is falling.
- Give oxygen for hypoxemia.
| Severity | Clinical picture | Peak flow (% predicted or best) |
|---|---|---|
| Mild | Talks in sentences, mild wheeze, little or no retractions | 70% or more |
| Moderate | Talks in phrases, clear retractions, wheeze throughout | 40–69% |
| Severe | Talks in words, marked retractions, accessory muscles, hypoxemia | Below 40% |
| Impending respiratory failure | Drowsy or confused, poor air entry (silent chest), tiring, cyanosis | Below 25% or unable |
First-hour treatment by severity
Ipratropium helps in the emergency department for moderate and severe attacks. It adds little once the child is admitted.
- Mild: albuterol alone, up to 3 doses in the first hour. Give a systemic steroid if the response is not prompt and complete.
- Moderate: albuterol plus ipratropium for 3 treatments, plus a systemic steroid, then reassess.
- Severe: resuscitation area, albuterol plus ipratropium for 3 treatments, a systemic steroid and IV access; consider IV magnesium early.
- Impending respiratory failure: resuscitation, continuous albuterol, IV corticosteroid and IV magnesium, and urgent respiratory support with PICU care.
Doses to know
Start the systemic steroid early, ideally within the first hour, because its effect takes several hours to appear. Oral and IV steroids work equally well when the child can swallow.
| Drug | Dose | Notes |
|---|---|---|
| Albuterol (MDI with spacer) | 4–8 puffs every 20 minutes × 3, then as needed | As effective as a nebulizer for most children |
| Albuterol (nebulized) | 0.15 mg/kg (minimum 2.5 mg, maximum 5 mg) every 20 minutes × 3 | Continuous: about 0.5 mg/kg/h for severe attacks |
| Ipratropium (nebulized) | 0.25–0.5 mg with each of the first 3 albuterol treatments | Moderate and severe attacks only |
| Prednisone or prednisolone | 1–2 mg/kg/day by mouth, maximum 60 mg/day | Usually 3–10 days in total; no taper needed for short courses |
| Dexamethasone | 0.6 mg/kg by mouth, maximum 16 mg | 1 or 2 doses; fewer doses and less vomiting |
| Magnesium sulfate | 25–75 mg/kg IV over 20 minutes (often 50 mg/kg), maximum 2 g | Severe attacks not responding after the first hour |
Escalation and what not to do
- Persistent severe asthma after the first hour: continuous albuterol, IV magnesium and PICU admission.
- Watch for rising CO2, tiring and confusion; a normal or rising PaCO2 in a breathless child is a danger sign.
- Chest X-ray only for atypical findings, suspected complications (pneumothorax, pneumonia) or a poor response.
- No routine antibiotics, chest physiotherapy, mucolytics or sedation.
Admission or discharge
Discharge depends on a sustained response, not on one good moment after a treatment. The child should stay well for about an hour or more after the last bronchodilator.
- Ready for home: minimal distress, good air entry, normal oxygen saturation in room air, and peak flow 70% or more where measured.
- Reliever needs should be spacing out to every 3–4 hours or longer at home.
- Admit if the child still needs frequent albuterol, needs oxygen, or the response is incomplete (peak flow 40–69%).
- PICU for peak flow below 40%, rising CO2, drowsiness or impending respiratory failure.
- Tolerating albuterol every 2 hours alone does not mean the child is ready for home.
Discharge plan and inhaler technique
- Prescribe the MDI with a spacer (valved holding chamber) and teach its use before the child leaves.
- A child who cannot seal the lips around the mouthpiece (usually under 4 years) uses a well-fitting face mask on the spacer.
- Give one puff at a time and let the child breathe in after each puff (or take several tidal breaths); do not spray several puffs into the chamber together.
- Finish the oral steroid course.
- Review or start controller therapy; for children 4 years and older with moderate persistent asthma, NAEPP 2020 prefers a single inhaled steroid–formoterol inhaler used daily and as the reliever.
- Give a written asthma action plan, clear return precautions, and follow-up with the primary care clinician within days to a few weeks.
Common questions
What is the dexamethasone dose for an asthma attack in a child?
0.6 mg/kg by mouth, maximum 16 mg, as 1 or 2 doses. Prednisone or prednisolone 1–2 mg/kg/day (maximum 60 mg) for 3–10 days is the alternative.
When is IV magnesium given in pediatric asthma?
For a severe exacerbation that is not responding after the first hour of albuterol, ipratropium and steroids: 25–75 mg/kg IV over 20 minutes, maximum 2 g.
Does a child with an asthma attack need a chest X-ray?
Not routinely. Reserve it for atypical findings, a suspected complication such as pneumothorax or pneumonia, or a poor response to treatment.
Study this topic
Sources
- NAEPP 2020 Focused Updates to the Asthma Management Guidelines (J Allergy Clin Immunol)
- NHLBI: Guidelines for the diagnosis and management of asthma (EPR-3)
Written for Pedemy in our own words from the sources above; checked November 2026. For education only, not medical advice; check doses and local protocols before treating a patient. Pedemy is independent and not affiliated with or endorsed by the organizations cited.