Management of Acute Asthma Exacerbations in the Pediatric Emergency Department

Asthma exacerbations remain one of the most common reasons for pediatric emergency department visits, accounting for approximately 1.6 million ED visits and 183,000 hospitalizations annually in the United States alone. Despite advances in outpatient asthma management, acute exacerbations continue to impose substantial morbidity, healthcare costs, and missed school days on affected children and their families. This narrative review synthesizes current evidence on the assessment and management of acute asthma exacerbations in the pediatric emergency department setting. We conducted a comprehensive literature search of PubMed, MEDLINE, and Cochrane Database of Systematic Reviews for articles published between 2010 and 2024, prioritizing systematic reviews, randomized controlled trials, and clinical practice guidelines from the Global Initiative for Asthma and the National Asthma Education and Prevention Program. Current evidence supports a structured approach beginning with rapid severity assessment using validated clinical scoring systems such as the Pediatric Respiratory Assessment Measure. First-line therapy includes oxygen supplementation as needed, frequent administration of inhaled short-acting beta-agonists during the initial hour, and early systemic corticosteroids. For moderate-to-severe exacerbations, the addition of ipratropium bromide has demonstrated benefit, while intravenous magnesium sulfate shows efficacy in severe cases unresponsive to initial treatment. High-flow nasal cannula therapy has emerged as a promising adjunctive intervention, though evidence in the emergency department setting continues to evolve. A systematic approach emphasizing early corticosteroids and appropriate escalation for refractory cases can reduce admission rates and improve outcomes. Ongoing research into adjunctive therapies and phenotype-specific treatment strategies may further refine emergency department management in the coming years.