The use of structured care protocols detailing bronchodilator usage, clinical assessment, and specific criteria for safe discharge is recommended.The use of structured care protocols detailing bronchodilator usage, clinical assessment, and specific criteria for safe discharge is recommended.
Children with life threatening asthma or SpO2 <92% should receive high flow oxygen via a tight fitting face mask or nasal cannula at sufficient flow rates to achieve normal saturations.
Inhaled beta2 agonists are the first line treatment for acute asthma.
pMDI + spacer are the preferred option in mild to moderate asthma.
Information about implementing evidence-based guidelines using such devices has been published. Children aged <3 years are likely to require a face mask connected to the mouthpiece of a spacer for successful drug delivery. Inhalers should be actuated into the spacer in individual puffs and inhaled immediately by tidal breathing.
Individualise drug dosing according to severity and adjust according to the patient's response.
Two to four puffs repeated every 20-30 minutes according to clinical response might be sufficient for mild attacks although up to 10 puffs might be needed for more severe asthma.
Children with acute asthma in primary care who have not improved after receiving up to 10 puffs of beta2 agonist should be referred to hospital. Further doses of bronchodilator should be given as necessary whilst awaiting transfer.
Treat children transported to hospital by ambulance with oxygen and nebulised beta2 agonists during the journey.
Transfer children with severe or life threatening asthma urgently to hospital to receive frequent doses of nebulised beta2 agonists (2.5-5 mg salbutamol or 5-10 mg terbutaline).
Doses can be repeated every 20-30 minutes. Continuous nebulised beta2 agonists are of no greater benefit than the use of frequent intermittent doses in the same total hourly dosage.
The role of intravenous beta2 agonists in addition to nebulised treatment remains unclear. One study has shown that an IV bolus of salbutamol given in addition to near maximal doses of nebulised salbutamol results in clinically significant benefits. Evidence level 1+
The early addition of a bolus dose of intravenous salbutamol (15 mcg/kg) can be an effective adjunct to treatment in severe cases.
Continuous intravenous infusion should be considered when there is uncertainty about reliable inhalation or for severe refractory asthma. Doses above 1-2 mcg/kg/min (200 mcg/ml solution) should be given in a Paediatric Intensive Care Unit (PICU) setting (up to 5 mcg/kg/min) with regular monitoring of electrolytes.
Give prednisolone early in the treatment of acute asthma attacks.
A soluble preparation dissolved in a spoonful of water is preferable in those unable to swallow tablets.
Use a dose of 20 mg for children 2-5 years old and 30-40 mg for children >5 years. Those already receiving maintenance steroid tablets should receive 2 mg/kg prednisolone up to a maximum dose of 60 mg.
Oral and intravenous steroids are of similar efficacy. Intravenous hydrocortisone (4 mg/kg repeated four hourly) should be reserved for severely affected children who are unable to retain oral medication.Evidence level 1+
Larger doses do not appear to offer a therapeutic advantage for the majority of children. There is no need to taper the dose of steroid tablets at the end of treatment. Evidence level 2+
Repeat the dose of prednisolone in children who vomit and consider intravenous steroids in those who are unable to retain orally ingested medication.
Treatment for up to three days is usually sufficient, but the length of course should be tailored to the number of days necessary to bring about recovery.
Do not initiate inhaled steroids in preference to steroid tablets to treat acute childhood asthma.
Children with chronic asthma not receiving regular preventive treatment will benefit from initiating inhaled steroids as part of their long term management. There is no evidence that increasing the dose of inhaled steroids is effective in treating acute symptoms, but it is good practice for children already receiving inhaled steroids to continue with their usual maintenance doses.
There is good evidence for the safety and efficacy of frequent doses of ipratropium bromide used in addition to beta2 agonists for the first two hours of a severe asthma attack. Benefits are more apparent in the most severe patients. Evidence level 1+
If symptoms are refractory to initial beta2 agonist treatment, add ipratropium bromide (250 mcg/dose mixed with the nebulised beta2 agonist solution).
Frequent doses up to every 20-30 minutes (250 mcg/dose mixed with the beta2 agonist solution in the same nebuliser) should be used early. The dose frequency should be reduced as clinical improvement occurs.
Repeated doses of ipratropium bromide should be given early to treat children poorly responsive to beta2 agonists.
Children with continuing severe asthma despite frequent nebulised beta2 agonists and ipratropium bromide and those with life threatening features need urgent review by a specialist with a view to transfer to a High Dependency Unit or PICU.
Aminophylline is not recommended in children with mild to moderate acute asthma.
Consider aminophylline in a High Dependency Unit or PICU setting for children with severe or life threatening bronchospasm unresponsive to maximal doses of bronchodilators and steroid tablets.
A 5 mg/kg loading dose should be given over 20 minutes with ECG monitoring (omit in those receiving maintenance oral theophyllines) followed by a continuous infusion at 1 mg/kg/hour. Estimate serum theophylline levels in patients already receiving oral treatment and in those receiving prolonged treatment.
There is no evidence to support the use of heliox or leukotriene receptor antagonists for the treatment of acute asthma in childhood.
There is insufficient evidence to support or refute the role of antibiotics in acute asthma, but the majority of acute asthma attacks are triggered by viral infection.
Do not give antibiotics routinely in the management of acute childhood asthma.
Children with prolonged severe asthma not tolerating oral fluids will require intravenous hydration. Two thirds of the child's maintenance requirement should be given because of the possibility of inappropriate antidiuretic hormone secretion. Serum electrolytes should be measured and hypokalaemia corrected if detected.
ECG monitoring is mandatory for all intravenous treatments.
Intravenous magnesium sulphate is a safe treatment for acute asthma although its place in management is not yet established. Doses of up to 40 mg/kg/day (maximum 2 g) by slow infusion have been used. Studies of efficacy for severe childhood asthma unresponsive to more conventional therapies have been inconsistent in providing evidence of benefit. Evidence level 1+
Children can be discharged when stable on 3-4 hourly inhaled bronchodilators that can be continued at home. 307 PEF and/or FEV1 should be >75% of best or predicted and SpO2 >94%.
Adult studies show that "optimal care" comprising self-monitoring, regular review and a written asthma action plan can improve outcomes. Acute asthma attacks should be considered a failure of preventive therapy and thought should be given about how to help families avoid further severe episodes. Discharge plans should address the following:
The assessment of acute asthma in early childhood can be difficult. Intermittent wheezing attacks are usually due to viral infection and the response to asthma medication is inconsistent. Prematurity and low birth weight are risk factors for recurrent wheezing. The differential diagnosis of symptoms includes aspiration pneumonitis, pneumonia, bronchiolitis, tracheomalacia, and complications of underlying conditions such as congenital anomalies and cystic fibrosis. These guidelines are intended for those who are thought to have asthma causing acute wheeze. They should not be used as a guide for treating acute bronchiolitis.
A trial of bronchodilator therapy should be considered when symptoms are of concern. If inhalers have been successfully administered but there is no response, review the diagnosis and consider the use of other treatment options.
Oral beta2 agonists are not recommended for acute asthma in infants.
Inhaled beta2 agonists are the treatment of choice for the initial treatment of acute asthma. Close fitting face masks are essential for optimal drug delivery. The dose received is increased if the child is breathing appropriately and not taking large gasps because of distress and screaming.
There is good evidence that pMDI + spacer is as effective as, if not better than, nebulisers for treating mild to moderate asthma in children aged <2 years. Evidence level 1+
For mild to moderate acute asthma, a pMDI + spacer is the optimal drug delivery device.
Whilst beta2 agonists offer marginal benefits to children aged <2 years with acute wheeze, there is little evidence for an impact on the need for hospital admission or length of hospital stay. Evidence level 1+
Consider steroid tablets in infants early in the management of moderate to severe episodes of acute asthma in the hospital setting.
Steroid tablet therapy (10 mg of soluble prednisolone for up to three days) is the preferred steroid preparation for use in this age group.
The addition of ipratropium bromide to beta2 agonists for acute severe asthma may lead to some improvement in clinical symptoms and reduce the need for more intensive treatment. It does not reduce the length of hospital stay either in combination with beta2 agonists or in comparison with placebo. Evidence level 1+
Consider inhaled ipratropium bromide in combination with an inhaled beta2 agonist for more severe symptoms.
Many children with recurrent episodes of viral-induced wheezing in infancy do not go on to have chronic atopic asthma. The majority do not require treatment with regular inhaled steroids. Parents should be advised about the relationship between cigarette smoke exposure and wheezy illnesses (see sections 3.1 &3.3 ). Referral to suitable agencies should be offered to those who wish to give up smoking.
Parents of wheezy infants should receive appropriate discharge plans along similar lines to those given for older children (see section 6.8.10 ).