Revised Aug23

ASTHMA ● 1/5

RECOGNITION AND ASSESSMENT

Definition
 A chronic inflammatory disorder of the airways with reversible obstruction

In children aged <2 yr who have an initial poor response to β agonists administered with adequate
2
technique, continue treatment if severe (see definition below), but consider alternative diagnosis and
other treatment options

Symptoms and signs

 Breathlessness
 Wheeze
 Cough
 Nocturnal cough
 Tight chest

 Symptoms and signs tend to be:

 variable
 intermittent
 worse at night
 provoked by triggers, including exercise

Mild/moderate
 Normal vital signs
 Mild wheeze
 Speaks in complete sentences or feeding
 No clinical features of severe asthma
 SpO2 >92% in air
 Peak expiratory flow rate (PEFR) >50% in patient aged ≥5 yr

Severe
 Too breathless to talk/feed/eat
 Tachypnoea
 aged <5 yr: >40 breaths/min
 aged 5–12 yr: >30 breaths/min
 aged 12–18 yr: >25 breaths/min
 Tachycardia
 aged <5 yr: >140 beats/min
 aged 5–12 yr: >125 beats/min
 aged 12–18 yr: >110 beats/min
 Use of accessory muscles, recession subcostal and intercostal, flaring of alae nasi
 SpO2 <92% in air
 ≤50% predicted/best peak expiratory flow rate (PEFR) aged ≥5 yr

Life-threatening
 Cyanosis/pallor
 Decreased air entry/silent chest
 Poor respiratory effort
 Altered conscious level
 Irritable/exhausted
 SpO2 <92% in air
 ≤30% predicted/best PEFR aged ≥5 yr

Patients with severe or life-threatening attacks may not be distressed and may not have all these
abnormalities. Presence of any one of these should alert doctor

Differential diagnosis
 Inhaled foreign body
 Pneumonia
 Pneumothorax
 Aspiration
 Revised Aug23

ASTHMA ● 2/5
 Cystic fibrosis
 Tracheobronchomalacia
 Gastro-oesophageal reflux
 Hyperventilation

Assessment
 Record:
 respiratory rate and effort
 recession
 heart rate
 air entry
 oxygen saturation in air
 if ≥5 yr, PEF
 conscious level
 CXR if severe and life-threatening sign/symptoms do not improve with medical management

Do not take any samples for routine blood tests or routine blood gases.
Routine CXR is unnecessary in a child with asthma

IMMEDIATE TREATMENT
 Follow algorithm Management of acute wheezing in children
 Prescribe oxygen on drug chart if required

Senior assessment
 If you are worried about child’s conscious level or there is no response to nebulised salbutamol or poor
respiratory effort:
 Call senior doctor for further assessment
 Site an IV line
 Initial bolus dose of salbutamol IV over 5 min
 aged <2 yr: 5 microgram/kg (maximum 250 microgram)
 aged >2 yr: 15 microgram/kg (maximum 250 microgram)
 Using 500 microgram/mL injection preparation dilute to a concentrate of 50 microgram/mL with sodium
chloride 0.9%
 e.g. withdraw 250 microgram = 0.5 mL and make up to a total volume of 5 mL using sodium chloride
0.9% = 250 microgram in 5 mL

Not responding within 15 min

 Magnesium sulphate IV injection over 20 min (aged 2–17 yr): 40 mg/kg single dose (maximum 2 g)
 use 50% injection and dilute to a 10% concentration by diluting required volume with 4x volume of
sodium chloride 0.9%

Not responding within 15 min of completion of magnesium sulphate

 Discuss with on-call paediatric consultant
 Salbutamol 1–2 microgram/kg/min continuous infusion (use 50 kg as maximum weight)
 if weight >50 kg PICU for contact dosing advice
 use 1 mg/mL solution for IV infusion, take 10 mg (10 mL) and make up to 50 mL with sodium chloride
0.9% giving a concentration of 200 microgram/mL
 If not responding increase up to 5 microgram/kg/min for 1 hr then reduce back to 2 microgram/kg/min
 If requiring >2 microgram/kg/min, admit to HDU or PICU depending on severity of illness
 Use TcCO2 monitor
 Continue with oxygen and continuous salbutamol nebuliser whilst waiting for infusion to be made up

Drug doses
 Salbutamol nebulised, driven by 6–8 L/min oxygen:
 aged <5 yr: 2.5 mg
 aged >5–12 yr: 2.5–5 mg
 aged >12 yr: 5 mg
®
 Ipratropium bromide (Atrovent ) nebulised:
 aged <12 yr: 250 microgram
 aged >12 yr: 500 microgram
 Revised Aug23

ASTHMA ● 3/5
 Prednisolone 1 mg/kg oral (round up to nearest 5 mg):
 aged <2 yr: maximum 10 mg once daily
 aged 2–5 yr: maximum 20 mg once daily
 aged >5 yr: maximum 30 mg once daily
 aged ≥12 yr: maximum 40 mg once daily
 if already on maintenance oral corticosteroids prednisolone 12 mg/kg (maximum 60 mg) and discuss
weaning plan with respiratory consultant
 consider if weaning plan required

 Hydrocortisone [preferably sodium succinate (until conversion to oral prednisolone possible)] slow IV
injection
 EITHER 4 mg/kg 6-hrly (maximum per dose 100 mg)
 OR:
 aged 1 month –1 yr: 25 mg 6-hrly
 aged 2–4 yr: 50 mg 6-hrly
 aged 5–18 yr: 100 mg 6-hrly
 Do not give antibiotics routinely
 If high prevalence of influenza with fever, coryza, generalised symptoms (headache, malaise, myalgia,
arthralgia) give oseltamivir

Monitoring
If treated with nebulised or IV salbutamol:
 Record heart rate and respiratory rate every 10 min
 Continuous SpO2
 Cardiac monitoring
 Baseline U&E
 Capillary blood gas and lactate
 12-hrly potassium for hypokalaemia

If treated with IV magnesium sulphate:

 Record heart rate, respiratory rate and blood pressure every 5 min
 Continuous SpO2
 Cardiac monitoring
 Baseline U&E
 Capillary blood gas and lactate

SUBSEQUENT MANAGEMENT
 Follow algorithm Management of acute wheezing in children

Previous history
 When recovering, ask about:
 previous episodes of wheeze, similar episodes
 triggering factors, seasonal variation
 nocturnal cough
 family history of asthma, hay fever, eczema, other atopy
 smokers in the family (including child)
 days off school because of asthma
 number of courses of prednisolone used in last year
 pets
 drug history (device and dose) especially any bronchodilators/inhaled corticosteroids and their effect,
particularly need to use beta-agonists

DISCHARGE AND FOLLOW-UP

Discharge criteria
 SpO2 in air ≥94%
 Respiratory rate:
 aged <5 yr: <40 breaths/min
 aged 5–12 yr: <30 breaths/min
 aged 12–18 yr: <25 breaths/min
 Heart rate:
 Revised Aug23

ASTHMA ● 4/5
 aged <5 yr: <140 beats/min
 aged 5–12 yr: <125 beats/min
 aged 12–18 yr: <110 beats/min
 Peak flow: ≥75% predicted/best (aged >5 yr)
 Stable on 4-hrly treatment

Discharge home same day if:

 Child has made a significant improvement and has remained stable for 4 hr
 Parents:
 understand use of inhalers
 have a written personal asthma action plan (PAAP)
 have a written discharge/weaning salbutamol information leaflet
 know how to recognise signs of deterioration and the actions to take

Discharge treatment
 Prescribe beta-agonist with spacer
 aged ≤3 yr with mask
 aged >3 yr without mask (e.g. Volumatic or aerochamber)
 Give prednisolone daily for 3–5 days (if already on oral prednisolone maintenance therapy speak to
respiratory consultant/nurse and discuss weaning plan)
 Educate on use of PEF meter if aged ≥5 yr
 Prescribe preventer as appropriate  see Chronic management
 Inhaled corticosteroids generally not required for recurrent viral induced wheeze
 Discuss follow-up in either the community, nurse-led asthma clinic or consultant clinic
 If there have been life-threatening features refer to paediatric respiratory specialist
 Advise follow-up with GP within 2 working days
 Refer smokers to smoking cessation services
 Identify trigger of acute attack and discuss future management plan for exposure

Chronic management
 Commence inhaled corticosteroid or escalate preventer treatment if any of following:
 frequent episodes
 bronchodilators used most days (>3 days/week)
 nocturnal and/or exercise-induced symptoms
 other atopic symptoms and strong family history of atopy
 If recurrent upper respiratory tract problems or allergic rhinitis triggering attacks, give oral antihistamines
+/- steroid nasal spray
 Revised Aug23

ASTHMA ● 5/5
 Algorithm: Management of acute wheezing in children
Assessment
MILD/MODERATE SEVERE LIFE-THREATENING
Normal vital signs Too breathless to talk/feed Assess ABC
Mild wheeze SpO2 <92% in air Cyanosis/pallor
Speaking in complete sentences or feeding Use of accessory muscles Silent chest
SpO2 >92% in air Age Respiratory rate Heart rate Poor respiratory effort
PEF >50% in those aged ≥5 yr <5 yr: >40 breaths/min >140 beats/min Altered consciousness
5–12 yr: >30 breaths/min >125 beats/min SpO2 <92% in air
Salbutamol MDI 2–10 puffs (200– 12–18 yr: >25 breaths/min >110 beats/min Irritable/exhausted
1000 microgram) via large volume spacer (LVS) Peak flow ≤50% predicted/best aged ≥5 yr PEF ≤30% in those aged ≥5 yr
+/- face mask
Oxygen if SpO2 <94% in air Oxygen via mask or nasal cannula Inform on-call consultant and PICU
Once daily oral prednisolone, if on maintenance Salbutamol MDI 10 puffs (1000 microgram) via large Oxygen via mask/nasal cannula
therapy, discuss with respiratory volume spacer +/- face mask, or: Continuous salbutamol nebulised, driven by
consultant/nurse Salbutamol nebulised, driven by 6–8 L/min oxygen: 6–8 L/min oxygen
 Aged <5 yr: 2.5 mg
• Aged <2 yr = max 10 mg once daily
 Aged >5–12 yr: 2.5–5 mg Ipratropium bromide nebulised:
• Aged 2–5 yr = max 20 mg once daily
 Aged >12 yr: 5 mg • Aged <12 yr = 250 microgram
• Aged >5 yr = max 30 mg once daily
• Aged >12 yr = 500 microgram
If poor response, give ipratropium bromide nebulised:
• Aged <12 yr = 250 microgram Hydrocortisone by slow IV injection aged
RE-ASSESS EVERY 15–30 MIN
• Aged >12 yr = 500 microgram ≥1 month 4 mg/kg 6-hrly (max per dose
100 mg) or:
DISCHARGE CRITERIA MET Once daily oral prednisolone, if on maintenance • Aged1 month 1 yr: 25 mg 6-hrly
SpO2 ≥94% in air therapy, discuss with respiratory consultant/nurse • Aged 2–4 yr: 50 mg 6-hrly
Age Respiratory rate Heart rate • Aged <2 yr: max 10 mg once daily • Aged 5–18 yr: 100 mg 6-hrly
• Aged 2–5 yr: max 20 mg once daily
<5 yr: <40 breaths/min <140 beats/min If signs of shock, sodium chloride 0.9%
5–12 yr: <30 breaths/min <125 beats/min • Aged >5 yr: max 30 mg once daily
20 mL/kg IV bolus
12–18 yr: <25 breaths/min <110 beats/min If oral steroids not tolerated give hydrocortisone by
NO Consider anaphylaxis as an alternative
Peak flow ≥75% predicted/best slow IV injection aged ≥1 month 4 mg/kg 6-hrly (max
Stable on 4-hrly inhaled treatment per dose 100 mg) or: NO IMPROVEMENT
• Aged 1 month1 yr: 25 mg 6-hrly
YES • Aged 24 yr: 50 mg 6-hrly RE-ASSESS
RESPONSE
• Aged 5–18 yr: 100 mg 6-hrly SYMPTOMS NO CHANGE
IMPROVING WORSENING
DISCHARGE HOME
Continue once daily oral prednisolone, YES DISCHARGE CRITERIA MET
complete a 3–5 day course Continuous nebulised salbutamol
Review long-term asthma control + treatment NO Repeat ipratropium bromide. If poor
• Check inhaler technique response, give every 20–30 min for first
• Provide PAAP ADMIT 2 hr
• Agree follow-up plan Continue oxygen via mask/nasal cannula • Salbutamol IV (see Salbutamol
• Complete respiratory discharge letter Nebulised salbutamol ¼–4 hrly infusion)
Repeat ipratropium bromide. If poor response, give • Consider magnesium sulphate IV
every 20–30 min for first 2 hr • Blood gas
DISCHARGE
• CXR

RE-ASSESS FREQUENCY OF
BRONCHODILATOR THERAPY YES SYMPTOMS IMPROVING

SYMPTOMS IMPROVING