Age >5 years - Management of acute asthma in children in hospital

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
  • Confusion
  • 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.

Assess response to treatment - Record respiratory rate, heart rate and oxygen saturation every 1-4 hours.

* 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*
  • Repeat β2 bronchodilator up to every 20–30 minutes according to response
  • If poor response add 0.25mg nebulised ipratropium bromide to every nebulised β2 bronchodilator every 20 minutes for 1–2 hours.

Assess response to treatment - Record respiratory rate, heart rate and oxygen saturation every 1-4 hours.

* 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
  • Consider adding 150 mg magnesium sulphate to each β2 bronchodilator/ipratropium nebuliser in first hour.

Discuss with senior clinician, PICU team or paediatrician.

Assess response to treatment - Record respiratory rate, heart rate and oxygen saturation every 1-4 hours.

Responding

  • Continue bronchodilators 1–4 hours as necessary
  • Discharge when stable on 4-hourly treatment
  • Continue prednisolone 30–40mg daily until recovery (minimum 3–5 days).

At discharge

  • Ensure stable on 4–hourly inhaled treatment
  • Review the need for regular treatment and the use of inhaled steroids
  • Review inhaler technique
  • Provide a written asthma action plan for treating future attacks
  • Arrange GP follow up within 48 hours
  • Arrange hospital asthma clinic follow up in 4–6 weeks.

Not responding - second line treatments

  • Continue 20–30 minute nebulisers
  • Consider chest X-ray and blood gases
  • Discuss with senior clinician, paediatrician or PICU
  • Consider admission to HDU/PICU.

Consider risks and benefits of:

  • Bolus IV infusion of magnesium sulphate 40mg/kg (max 2 g) over 20 minutes
  • Bolus IV salbutamol 15 micrograms/kg if not already given
  • Continuous IV salbutamol infusion 1–5micrograms/kg/min (200micrograms/ml solution)
  • IV aminophylline 5mg/kg loading dose over 20 minutes (omit in those receiving oral theophyllines) followed by continuous infusion 1mg/kg/hour.

Assess response before initiating each new treatment.