Bibliographic information
GuidelineWHO consolidated guidelines for the management of common childhood illness: management of asthma in children and adolescents and bronchiolitis in infants and young children
Year of Publication2026
Issuing InstitutionWorld Health Organization
Recommendation
New
Nebulized ipratropium bromide should be added to standard first-line therapy with inhaled short-acting beta2 agonist (SABA) and systemic corticosteroids for severe paediatric asthma exacerbations in health facilities.
Recommended in favor
Strong
Certainty of evidence
Low
Notes and Remarks
- Ipratropium bromide should be given in addition to standard inhaled or nebulized SABA and systemic corticosteroids in cases where children are not responding or when the severity of the exacerbation is extreme and impending collapse is likely.
- It is essential that first-level health care providers are trained and competent to assess the severity of an acute asthma exacerbation, start first-line therapy appropriately and monitor response.
- The results of the systematic review favoured the use of nebulized ipratropium bromide but could not confirm similar effects with administration via MDI, mask and spacer.
- Ipratropium bromide will need to be included on the EMLc, and equipment for nebulization should be included on the essential equipment list.
- To lower the cost of ipratropium bromide administration, use of an MDI, mask and spacer, which is as effective as nebulized therapy, should be considered in settings where oxygen and the equipment for nebulization are not immediately available.
- A 500 mL bottle spacer is an effective alternative to a conventional commercial spacer, but should be constructed following the methods that have been demonstrated as effective (59-61
- In severe asthma, children should receive frequent doses of nebulized bronchodilators driven by oxygen, and, after improvement, treatment can be adjusted to MDI as tolerated (30).
- There is an opportunity to tailor the intervention based on the severity of the exacerbation and the availability of equipment.
- Once clinically stable and ready for discharge, patients and families must have a clear understanding of the treatment to be continued at home, how to monitor symptoms and signs, and action to take in case of a deterioration.
- Educating families on asthma self-management improves outcomes in children, including a reduction in school absence and emergency care visits (62).
- Patients should be provided with written action plans to guide home management of asthma.
- Asthma action plans based on monitoring of symptoms, rather than peak flow measurements, are preferred by children and are more likely to prevent acute care visits (63).