DOCUMENT CONTROL PAGE
Title Title: Management of Acute Severe Asthma in Children >1yr
Version: Version 2
Reference Number: PCCN3
Supersedes Supersedes: Version 1
Description of Amendment(s): Repeat doses of magnesium; reduction in salbutamol
dose; advice on arrhythmias; reduction of aminophylline dose per BNFc guidance;
Minor Date:
Amendment
Notified To: Date:
Summary of amendments:
Originated By: North West and North Wales Paediatric Critical Care Network
Author Guideline authors:
Pete Murphy, Transport Consultant NWTS and Consultant Paediatric Anaesthetist, AHFT
Rachael Barber, NWTS Consultant and PICU Consultant, RMCH
Aradhana Ingley, Associate Specialist in Paediatrics, Glan Clwyd Hospital, North Wales
Adam Sutherland, Senior Clinical Pharmacist, RMCH
Fran Child, Consultant Paediatric Respiratory Consultant, RMCH
Jon Couriel, Consultant Paediatric Respiratory Consultant, AHFT
Version 2:
Rachael Barber, NWTS Consultant and PICU Consultant, RMCH
Carrick Allison, Paediatric Anaesthetic Trainee, RMCH
Adam Sutherland, Lead Pharmacist, RMCH
Elly Turner, Lead respiratory pharmacist, RMCH
Ratified by:
Ratification 1. MFT (Host Trust):
- Paediatric Medicines Management Committee (MMC) on: 05/09/2018
2. AHFT:
- Critical Care Clinical Business Unit on:
- CDEG (Clinical Development & Evaluation Group) on: TBC
Application Children only
Issue Date: TBC
Circulation Circulated by: Clinical Lead, North West & North Wales Paediatric Critical Care Net-
work
Dissemination and Implementation: NWTS & Network circulation lists
Review Date: TBC—3 years
Review Responsibility of: Clinical Lead & Network Manager, North West & North Wales
Paediatric Critical Care Network
1
Date placed on the Intranet: Please enter your EqIA Registration Number here:
1. Detail of Procedural Document
Guidelines for Management of Acute Severe Asthma in Children >2yrs.
2. Equality Impact Assessment
EqIA Registration Number: 150/12
3. Consultation, Approval and Ratification Process
This guideline was developed with input from:
· North West and North Wales Paediatric Transport Service (NWTS).
· Representatives from the North West and North Wales Paediatric Critical Care Network (PCCN).
· Representatives from both Paediatric Intensive Care Units (Royal Manchester Children’s Hospital and
Alder Hey Children’s Hospital).
· Representatives from the District General Hospitals within the PCCN.
These guidelines were circulated amongst the North West and North Wales Paediatric Critical Care
Network for comments on the
All comments received have been reviewed and appropriate amendments incorporated.
These guidelines were signed off by the Network’s Clinical Lead
For ratification process see appendix 1.
.
4. References and Bibliography
See guidelines.
5. Disclaimer
These clinical guidelines represent the views of the North West and North Wales Paediatric Critical Care
Network and North West and North Wales Paediatric Transport Service, which were produced after
careful consideration of available evidence in conjunction with clinical expertise and experience.
The guidance does not override the individual responsibility of healthcare professionals to make
decisions appropriate to the circumstances of the individual patient.
Management of acute wheeze in children under 2 years of age : This guideline is not appro-
priate for this age group. Early consultant involvement is recommended. Patients may respond clini-
cally to magnesium and aminophylline rather than salbutamol. There is no evidence to support High
flow humidified oxygen at present.
Clinical advice is always available from NWTS on a case by case basis. Please feel free to contact NWTS
(01925 853 550) regarding these documents if there are any queries.
2
Guidelines for Management of
Acute Severe Asthma in Children >2yr
SEVERE LIFE THREATENING
SaO2 <92% in air NEAR FATAL
Use of accessory muscles SaO2 <92% in O2 plus any of:
Difficulty talking or eating Silent chest
Agitated Poor respiratory effort
Heart rate >140(under 5yr), >125bpm (over 5yr) Cyanosis
Resp rate >40(under 5yr), >30 (over 5yr) Altered Consciousness/Exhausted
Increased pCO2 or hypotension are
pre-terminal signs
Summon senior help (if life-threatening, contact Consultant Anaesthetist and Paediatrician)
Give high flow oxygen to achieve normal saturations (>94%)
Consider High Flow Humidified Oxygen
Nebulised β2agonist every 20 mins
Nebulised Ipratropium bromide every 20 mins
Oral prednisolone or intravenous hydrocortisone
If poor response after 3 nebules: If not improving rapidly:
Give IV magnesium sulfate (unlicensed) 40mg/kg (Max Give intravenous magnesium sulphate
2g) (0.16mmol/kg, max 8mmol) over 20 mins Give intravenous salbutamol bolus
Start salbutamol infusion 2microgram/kg/min
If poor response after 1 hour:
Continuous nebulisers
Start salbutamol infusion at 2microgram/kg/min If no improvement within 30 minutes
or
continuing to deteriorate:
Aminophylline loading 5mg/kg (max 500mg)
Continuous monitoring: Improving over 20 mins if not on oral theophyllines
ECG, SpO2, RR Aminophylline infusion 0.5 - 1mg/kg/hr
Consultant review Consultant Anaes/Paeds Review
Admit to Paeds HDU
Improving
Improving
Still no improvement:
Consider second dose of intravenous magnesium
Admit to ward sulphate (D/W NWTS)
Oxygen to maintain saturations >94% Increase salbutamol infusion (max 5microgram/kg/
min)
Nebulised salbutamol 1-4 hourly Consider CXR/antibiotics/alternative diagnosis
Nebulised Ipratropium bromide 4 hourly Blood gas + lactate
Continue Steroids Prepare for intubation
3
Guidelines for Management of Acute Severe Asthma in Children <2 years
Oxygen: Children with life-threatening asthma or SpO2 <94% should receive high-flow oxygen via a
tight-fitting face mask or nasal cannula at sufficient flow rates to achieve normal saturations. High-flow
humidified oxygen (optiflow or vapotherm) may be considered early and used on HDU aiming for flow 2
L/kg/min.
Nebulisers: Oxygen-driven nebulisation is recommended
Salbutamol: 2 to 5yrs 2.5mg
5yrs 5mg
Ipratropium bromide Under 12yrs 250 micrograms
Over 12yrs 500 micrograms
Combining nebulised ipratropium bromide with nebulised β2-agonist produces significantly more
bronchodilatation than β2agonist alone. If a child has poor response to initial dose of β2agonist subse-
quent doses should be given in combination with ipratropium every 20 minutes for the first hour then
four hourly.
Steroids:
Prednisolone: 2mgkg od started within 1 hour of presentation
Max 40mg unless on maintenance steroids when max dose is 60mg
Hydrocortisone: 4 mg/kg 6 hourly intravenously (max 100 mg per dose) started within 1 hour of
presentation
Higher doses may be given in patients on maintenance steroids. Benefits apparent within 3-4 hours.
Oral and intravenous steroids are of equivalent efficacy so intravenous steroids should be reserved for
those unable to retain oral medications or most severely affected. Continue until clinically improved.
Tapering unnecessary unless course of steroids continues for >14 days.
Magnesium sulfate (unlicensed): 40mg/kg (max 2g) (0.16mmol/kg, max 8mmol) intravenous-
ly over 20 min. For ease of prescribing and administration, doses are banded according to patient
weight (see page 10).
In practice this is first intravenous therapy used as it is safe and causes less tachycardia. Dose may be
repeated in severe cases.
Intravenous Salbutamol:
Bolus: Over 2 years of age 15 microgram/kg (MAX DOSE 250 microgram). Give over 10 mins
Infusion: 1-2 microgram/kg/min (Rarely doses as high as 5microgrm/kg/min may be used on
PICU) Start at 2 micrograms/kg/minute
Patients should be on continuous cardiac monitoring & have minimum of 12 hourly U&Es. Nebulised β2
-agonists should be continued 4 hourly whilst patient is receiving intravenous salbutamol unless there
are signs of salbutamol toxicity when they should be stopped. Salbutamol (nebulised or iv infusion)
may cause a marked metabolic and lactic acidosis especially if patient is underfilled due to poor fluid
intake and increased insensible losses.
NB: Doses above 2microgram/kg/min MUST be discussed with paediatric/anaesthetic consultant and
NWTS as they are associated with significant toxicity
Aminophylline
Loading dose: 5 mg/kg over 20 min (Omit if on oral theophyllines/aminophylline)
MAX DOSE 500mg
Infusion: Child 1month to 11 years: 1mg/kg/hr
Child 12-17 years: 0.5mg/kg/hr
Doses should be adjusted according to plasma theophylline levels (see page 13)
Intravenous salbutamol and aminophylline are incompatible.
Salbutamol is compatible with magnesium 4
Guidelines for Management of Acute Severe Asthma in Children >2yrs
Non-pharmacological interventions in acute severe asthma
CXR should be considered in following situations
Surgical emphysema
Persistent unilateral signs suggesting pneumothorax, lobar collapse or consolidation
Previous pneumothorax
Severe/Life-threatening asthma not responding to treatment
Mechanically ventilated patient
Blood gas measurements
Should be considered if there are life-threatening features not responding to treatment
Normal or raised pCO2 indicates worsening asthma and imminent respiratory failure
Capillary blood gases will give an accurate measure of pH and pCO 2
Children receiving large doses of β2agonists may develop a lactic acidosis which will resolve as the
dose of β2agonist is reduced, but may need fluid bolus . Discuss with consultant.
Antibiotics
The majority of acute asthma attacks are triggered by viral infections
Decision for antibiotics should be made on clinical grounds
Physiotherapy
No role in unventilated asthmatic patient
Alternative Diagnoses to consider in child that is not improving
Anaphylaxis/Allergic Reaction Severe Pneumonia Atypical Infection
Hyperventilation Inhalational injury Foreign body
Pulmonary oedema
5
Guidelines for Management of Acute Severe Asthma in Children >2yrs
Intubation in Acute Severe Asthma is a High Risk Procedure
Cardiac/Respiratory Arrest
Exhaustion
Indications for
Hypoxia despite high flow oxygen
Intubation
Worsening respiratory acidosis
Altered sensorium (agitation, confusion, decreased GCS)
Pre-oxygenation
Low oxygen reserve
Most experienced available operator
Rapid desaturation
Use largest fitting/cuffed ET tube
Difficult to ventilate
Anticipate hypotension. Good iv access
Risks of Give 20ml/kg fluid bolus pre-induction
Relative hypovolaemia
Intubation Prepare vasopressors e.g. 0.1 ml/kg adrenaline
1 in 10,000 made up to 10 mls 0.9% sodium
chloride (use 1-2 ml aliquots to maintain BP)
Rapid sequence induction
Delayed gastric emptying
eg ketamine + suxamethonium
Avoid histamine-releasing drugs if possible (atracurium, thiopentone, morphine)
Drugs for
Use ketamine or fentanyl
induction
Volatile anaesthetic agent available for immediately post-intubation
Ketamine
Other
Volatile anaesthetic agents
bronchodilators
Adrenaline 1:10,000 0.1ml/kg iv/via ETT can be used in extremis
Use ketamine and fentanyl or midazolam
On-going sedation
Avoid morphine as causes histamine release
6
Guidelines for Management of Acute Severe Asthma in Children >2yrs
Difficulties with Ventilation in Acute Severe Asthma
REMEMBER HYPOXIA KILLS, HYPERCAPNOEA DOES NOT!
High Peak Pressures causing barotrauma/pneumothorax/air leaks/reduced cardiac
output
Strategies: Try PCV or square wave ventilation
Limit Pmax(<35-40)
Permissive hypercapnia (pH>7.15)
Large, cuffed ETT will reduce resistance and leak
Keep muscle relaxed initially especially whilst high pCO2
Incomplete Expiration Slow emptying of alveolus causes poor gas exchange,
progressive gas trapping and ↑ residual volume
Strategies: Try low respiratory rates 10-20 and long expiratory times (I:E ratio ≥1:3 )
Manual decompression (disconnect ETT and manually compress chest)
Physiotherapy with saline lavage may help but use slow bagging rate
Intrinsic PEEP
Aim to match extrinsic PEEP to intrinsic PEEP to reduce gas trapping
Mucus Plugging
Suction and physiotherapy with saline lavage (can make worse if inadequately
sedated). In extreme cases, instillation of Dornase Alpha may improve severe mucous
plugging.
Discuss EARLY with NWTS
7
Guidelines for Management of Acute Severe Asthma in Children >2yrs
Criteria for reducing bronchodilator therapy
Normal respiratory effort
Normal ability to speak
Reduction in oxygen requirement
Discontinuing Intravenous Bronchodilators
Aminophylline: Elimination half-life 3-5 hours
Reduce dose by 50% of original dose every 6 hours
After discontinuing infusion, aminophylline will be cleared within 24hours
Salbutamol: Elimination half-life 4-6 hours
Reduce dose by 1microgram/kg/min every 6 hours
After discontinuing infusion, salbutamol will be cleared within 24 hours
NB: Substantial systemic absorption of salbutamol occurs via GI tract
when administered by inhalation so intravenous infusions should be
discontinued before stopping nebulised salbutamol
Patients should receive nebulised β2agonists every 2 hours and nebulised ipratropium
bromide every 4 hours whilst weaning off intravenous bronchodilators.
NB: Rebound may occur 24—48 hours after stopping either infusion so observe in hospi-
tal for this time. Some patients with particularly brittle asthma may require a slower
weaning regime.
Discharge planning after severe asthma attack:
Check inhaler technique
Start or review dosage of preventer treatment
Written asthma plan for subsequent attacks with clear instructions about use of bronchodila-
tors and need to seek urgent medical attention if worsening symptoms
Contact GP to arrange Primary care follow up within 48 hours
Paediatric team follow up within 2 months
Refer to Paediatric Respiratory Specialist if life-threatening features, required intra-
venous aminophylline or salbutamol or invasive ventilation.
8
Management of acute wheeze in children under
2 years of age
This guideline is not appropriate for use in children under the age of 2 years. In such children, a
number of different diagnoses need to be considered and the response to treatment is variable.
Such children should be managed on an individualised basis and early consultant involvement
should be obtained.
If intravenous salbutamol is given to children under 2 years the loading dose should be
5 microgram/kg
Children under two years with a clinical picture consistent with asthma may respond better to mag-
nesium sulphate and aminophylline rather than salbutamol
Patients at risk of near-fatal/fatal asthma
Severe asthma Previous near-fatal asthma
Previous hospital admission for asthma
Requiring 3 or more classes of asthma medication
Repeated attendances at emergency department for asthma care
History of anaphylaxis
Plus Adverse behavioural/psychological features
Poor compliance
Failure to attend appointments
Fewer GP contacts
Self-discharge from hospital
Psychosis, depression, psychiatric illness or deliberate self harm
Alcohol or drug abuse
Obesity
Learning difficulties
Looked after children
Staff should have a lower threshold for admission to hospital for children with above risk
factors
9
Appendix 1: Additional Drug Information
Magnesium
Nebulised Magnesium: There is some limited evidence to support the use of nebulised magnesium in
addition to standard treatment (Cochrane review 2017) and its use does not seem to be associated with
adverse events.
Intravenous Magnesium Sulfate (unlicensed)
This can be given anywhere in the hospital if needed acutely. If the patient improves, they can continue
to be managed within the general ward environment. In practice this is often first intravenous therapy
used as is safe and causes less tachycardia.
All children who receive intravenous magnesium sulfate must be admitted to hospital.
There is some evidence that higher doses of magnesium may be of benefit clinically but this is not cur-
rently recommended in the BTS guidelines. In practice repeating the dose 1-2 hours after initial dose is
clinically safe. Patients requiring multiple doses should be discussed with NWTS.
Form: Magnesium sulfate 50% injection containing 500mg/ml of magnesium sulfate. This is
available in 2ml and 10ml ampoules. Caution if using other strengths as the table below will not be ap-
plicable
Dose: 40mg/kg over 20 minutes. The maximum dose is 2g. Can be administered centrally or pe-
ripherally. Dilute volumes below to 20ml for administration. Doses are banded by weight below for
ease of prescribing and administration.
Contra-indications: Myasthenia gravis
Severe renal impairment
Overdose: Hypermagnesaemia. Dependent on the size of the overdose, progressive muscle
weakness, significant hypotension and ultimately respiratory failure have been reported.
Patient WEIGHT (kg) DOSE Magnesium VOLUME Magnesium sulfate Further DILUTION
sulfate (40mg/kg) 50%
5-5.9kg 200mg 0.4mL
6-6.9kg 250mg 0.5mL
7-7.9kg 300mg 0.6mL
8-8.9kg 300mg 0.6mL
9-9.9kg 350mg 0.7mL
10-11.9kg 400mg 0.8mL
12-13.9kg 500mg 1 mL
14-15.9kg 550mg 1.1mL
16-17.9kg 600mg 1.3ml Then further dilute the
required dose of magnesi-
18-19.9kg 700mg 1.4mL
um sulfate 50% to 20ml
20-21.9kg 800mg 1.6mL with sodium chloride
22-23.9kg 900mg 1.8mL 0.9% for administration
24-25.9kg 950mg 1.9mL
26-27.9kg 1000mg 2 mL
28-29.9kg 1100mg 2.2mL
30-34.9kg 1200mg 2.4mL
35-39.9kg 1400mg 2.8mL
40-44.9kg 1600mg 3.2mL
45-49.9kg 1800mg 3.6mL
50kg & above 2g 4mL
10
Intravenous
. Salbutamol for Severe/Life-threatening Asthma
A bolus dose is recommended whilst the infusion is being drawn up (as infusion can take time to
prepare) to minimise delays, however this is not required if there is no delay in starting the
infusion.
Form: Salbutamol 1mg/ml Injection.
Bolus IV Salbutamol < 2 years of age 5 microgram/kg
>2 years of age 15 microgram/kg
(MAXIMUM DOSE 250 microgram)
Give over 10 minutes. Dilute injection to 50 microgram/ml (1ml of salbutamol 1mg/1ml diluted to
20ml with water for injection, sodium chloride 0.9% or glucose 5%)
15microgram/kg bolus over 10 minutes is equivalent to 1.5 microgram/kg/min infusion for the
same period
Continuous IV infusion: 1 to 2 microgram/kg/minute (Rarely doses up to 5microgram/
kg/min can be given on PICU)
Usual starting dose is 2micrograms/kg/min
Doses >2micrograms/kg/min should be used with extreme caution especially in
patients > 50kg as there is an increased incidence of side effects. We would strongly advise dis-
cussion with NWTS if increasing infusion above 2microgram/kg/min.
High doses of salbutamol (ie 3-5 microgram/kg/min) may cause tachycardia and SVT
without any additional benefit.
Management of SVT following Salbutamol Infusion
SVT has been reported in patients receiving salbutamol loading doses and infusions
at the higher dose range. Adenosine can cause bronchospasm in known patients
with asthma so should be used with caution in acute severe asthma. Please discuss
with NWTS/ Paeds cardiology consultant on call for further advice.
NOTE: CRASHCALL currently gives values for central administration of
salbutamol. If use of this is planned please discuss with NWTS first.
11
Guidelines for Management of Acute Severe Asthma in Children
Salbutamol infusion for Peripheral administration:
Draw up 10 mg of salbutamol (= 10ml of salbutamol 1 mg/ml)
Make up to 50mls with 5% glucose or 0.9% sodium chloride
Final concentration = 10 mg in 50 ml i.e. 200 micrograms/ml salbutamol
PERIPHERAL infusion rate: 0.3ml/kg/hr = 1microgram/kg/minute.
Example Dose Calculation:
For a 30kg child to run the infusion at 2microgram/kg/minute:
2microgram/kg/minute x 30kg = 60microgram/minute
60microgram/minute x 60minutes = 3600microgram/hour
Infusion contains 200microgram in 1ml therefore to calculate ml/hour:
3600 microgram/200microgram x 1ml = 18ml per hour
Weight 1microgram/kg/min 2microgram/kg/min 3microgram/kg/
min (discuss
with NWTS/
PICU)
5kg 1.5mls/hr 3mls/hr 4.5mls/hr
10kgs 3mls/hr 6mls/hr 9mls/hr
15kgs 4.5mls/hr 9mls/hr 13.5mls/hr
20kgs 6mls/hr 12mls/hr 18mls/hr
25kgs 7.5mls/hr 15mls/hr 22.5mls/hr
30kgs 9mls/hr 18mls/hr 27mls/hr
35kgs 10.5mls/hr 21mls/hr 31.5mls/hr
40kgs 12mls/hr 24mls/hr 36mls/hr
45kg 13.5mls/hr 27mls/hr 40.5mls/hr
50kgs 15mls/hr 30mls/hr
55kgs 16.5mls/hr
60kgs 18mls/hr
12
Aminophylline infusion for Peripheral administration:
Draw up 500mg of aminophylline and add to 500mls 0.9% sodium chloride
Final concentration = 500mg in 500mls i.e. 1mg/ml aminophylline
Aminophylline is compatible with up to 40mmol/litre of Potassium chloride
Loading Dose: 5mg/kg over 20 mins (max dose 500mg). Omit if on oral theophyllines
Infusion rate: 1 month to 11 years 1mg/kg/hr = 1ml/kg/hr
12-17 years 0.5mg/kg/hr = 0.5ml/kg/hr
Therapeutic monitoring: Check levels at 4-6 hours until stable and then every 24 hours
Therapeutic range 10-20mg/l
Plasma levels correlate well with clinical effect but NOT with toxicity
Response to monitoring: <5mg/L Increase dose by 50% and recheck in 6 hours
5-15mg/L Continue. Recheck 24 hours
15-20mg/L Half infusion rate and recheck in 6 hours
>20mg/L STOP infusion and recheck levels in 6 hours. Restart
at half the previous infusion rate once levels <15mg/l
Weight 1mg/kg/hr
5kg 5mls/hr
10kgs 10mls/hr
15kgs 15mls/hr
20kgs 20mls/hr
25kgs 25mls/hr
30kgs 30mls/hr
35kgs 35mls/hr
40kgs 40mls/hr
45kg 45mls/hr
50kgs 50mls/hr
55kgs 55mls/hr
60kgs 60mls/hr
13
Guidelines for Management of Acute Severe Asthma in Children >2yrs
References
Magnesium sulfate for treating exacerbations of acute asthma in the emergency department
(Review) Griffiths B, Kew KM. Cochrane Database Syst Rev. 2016 Apr 29;4
Inhaled magnesium sulfate in the treatment of acute asthma (Review). Knightly R, Milan SJ.
Cochrane Database Syst Rev 2017, Issue 11 . CD003898
MAGNEsium Trial In Children (MAGNETIC): a randomised, placebo-controlled trial and economic
evaluation of nebulised magnesium sulphate in acute severe asthma in children. Powell CV, Ko-
lamunnage-Dona R. MAGNETIC study group. Health Technol Assess. 2013 Oct;17(45):v-vi, 1-216.
Clinical pharmacokinetics of magnesium sulphate in the treatment of children with severe acute
asthma. Rower JE, Liu X, Yu T, Mundorff M, Sherwin CM, Johnson MD. Eur J Clin Pharmacol. 2017
Mar;73(3):325-331. doi: 10.1007/s00228-016-2165-3. PMID:27909740
BTS/SIGN British Guideline on the Management of Asthma—a National Clinical Guideline May
2008, Revised September 2016
Management of Acute Severe Asthma in children (aged >2years) version 4 Royal Manchester Chil-
dren’s Hospital, CMFT. September 2015. Originated by Rachael Barber, PICU Consultant, Clare Mur-
ray, Respiratory Consultant.
Intravenous salbutamol for childhood asthma: evidence-based medicine? Starkey E, Mulla H, Pan-
dya H, Archives of Disease in Childhood 2014;99:873-877.
Lexicomp 18th Edition
British National Formulary for Children 2016-17
www.crashcall.net for drug doses
14
Guidelines for Management of Acute Severe Asthma in Children >2yrs
Appendix 1
15
Guidelines for Management of Acute Severe Asthma in Children >2yrs
Appendix 1 continued
16
Guidelines for Management of Acute Severe Asthma in Children >2yrs
Resources
www.crashcall.net - for intubation drugs / sedation regime
Contact numbers:
Regional Paediatric Intensive Care Unit Alder Hey Childrens Hospital 0151 252 5241
Regional Paediatric Intensive Care Unit Royal Manchester Childrens Hospital 0161 701 8000
NWTS (North West & North Wales Paediatric Transport Service) 01925 853 550
Guideline authors:
Authors:
Pete Murphy, Transport Consultant NWTS and Consultant Paediatric Anaesthetist, Alder Hey
Rachael Barber, NWTS Consultant and PICU Consultant, Royal Manchester Children’s Hospital
Aradhana Ingley, Associate Specialist in Paediatrics, Glan Clwyd Hospital, North Wales
Adam Sutherland, Senior Clinical Pharmacist, Royal Manchester Children’s Hospital
Fran Child, Consultant Paediatric Respiratory Consultant, Royal Manchester Children’s Hospital
Jon Couriel, Consultant Paediatric Respiratory Consultant, Alder Hey
Consulted parties:
North West & North Wales Paediatric Transport Service (NWTS)
North West and North Wales Paediatric Critical Care Network
PICU, Royal Manchester Children’s Hospital
PICU, Alder Hey Children’s Hospital
Date of Approval by Host Trust:
Date of Review:
Please visit our website for the most up to date version of this guideline: www.nwts.nhs.uk
17
