Age >5 years - Management of acute asthma in children in emergency department

Asthma pathway (BTS, NICE, SIGN) [SIGN 244]
Healthcare Improvement Scotland

This content is from the BTS/SIGN British guideline on the management of asthma (SIGN 158), 2019.

Assess and record asthma severity

Moderate asthma

  • SpO2 ≥92%
  • PEF ≥50% best or predicted
  • No clinical features of severe asthma.

Acute severe asthma

  • SpO2 <92%
  • PEF 33–50% best or predicted
  • Heart rate >125/min
  • Respiratory rate >30/min
  • Use of accessory neck muscles.

Life-threatening asthma

SpO2<92% plus any of:

  • PEF<33% best or predicted
  • Silent chest
  • Poor respiratory effort
  • Altered consciousness
  • Cyanosis.

 

NB: If a patient has signs and symptoms across categories, always treat according to their most severe features.

 

      

Moderate asthma

  • β2 bronchodilator:
    • via spacer*
  • Oral prednisolone 30–40 mg.

Reassess within 1 hour.

* β2 bronchodilator via spacer given one puff at a time, inhaled separately using tidal breathing; according to response, give another puff every 60 seconds up to a maximum of 10 puffs

Acute severe asthma

  • Oxygen via facemask to maintain SpO2 94–98% if available
  • β2 bronchodilator
    • via nebuliser (preferably oxygen-driven), salbutamol 5mg
    • or, if nebuliser not available, via spacer*
  • Oral prednisolone 30–40mg or IV hydrocortisone 4mg/kg if vomiting
  • If poor response add 0.25mg nebulised ipratropium bromide to every nebulised β2 bronchodilator and repeat every 20 minutes for 2 hours according to response.

* β2 bronchodilator via spacer given one puff at a time, inhaled separately using tidal breathing; according to response, give another puff every 60 seconds up to a maximum of 10 puffs

Life-threatening asthma

  • Oxygen via facemask to maintain SpO2 94–98% if available
  • β2 bronchodilator with ipratropium:
    • via nebuliser (preferably oxygen-driven), salbutamol 5mg and ipratropium 0.25mg
  • Repeat bronchodilators every 20–30 minutes
  • Oral prednisolone 30–40mg or IV hydrocortisone 4mg/kg if vomiting.

Discuss with senior clinician, PICU team or paediatrician.

Discharge plan

  • Continue β2 bronchodilator 4 hourly as necessary
  • Continue prednisolone 30–40mg daily until recovery (minimum 3–5 days)
  • Advise to contact GP if not controlled on above treatment
  • Provide a written asthma action plan
  • Review regular treatment
  • Check inhaler technique
  • Arrange GP follow up within 48 hours
  • Arrange hospital asthma clinic follow up in 4–6 weeks if 2nd or subsequent attack in past 12 months.

Second line treatments

  • Consider 2nd line treatments – see Annex 8
  • Admit all cases if features of severe attack persist after initial treatment
  • Arrange transfer to PICU/HDU if poor response to treatment as per local guidelines.