11. 11
A flare-up or exacerbation of asthma in children 5
years and younger is defined as :
an acute or sub-acute deterioration in symptom
control that is sufficient to cause distress or risk to
health, and necessitates a visit to a health care
provider or requires treatment with systemic
corticosteroids. , they are
sometimes called ‘episodes’.
12. 12
Before children can receive appropriate treatment
for an acute asthma attack in any setting, it is
essential to assess accurately the severity of their
symptoms.
It is essential to assess the severity of an acute
attack of asthma so that appropriate management
can be instituted.
13. 13
The signs that should be assessed are:
1)Respiratory rate
2)Pulse rate
3)Amount of breathlessness (ability to talk and feed)
4)Use of accessory muscles of respiration
5)Extent and loudness of wheezing(which becomes
less audible with increasingly severe airways
obstruction)
6)Level of consciousness and presence of agitation
(suggesting hypoxaemia)
21. 21
Early symptoms of an exacerbation may include
any of the following:
1.An acute or sub-acute increase in wheeze and
shortness of breath
2.An increase in coughing, especially while the
child is asleep
3.Lethargy or reduced exercise tolerance
4.Impairment of daily activities, including feeding
5.A poor response to reliever medication.
22. 22
Upper respiratory symptoms frequently precede
the onset of an asthma exacerbation,
indicating the important role of viral URTI
in precipitating exacerbations in many, although
not all, children with asthma.
23. 23
Parents/carers should know that immediate
medical attention should be sought if:
1)The child is acutely distressed
2)The child’s symptoms are not relieved promptly
by inhaled bronchodilator
3)The period of relief after doses of SABA
becomes progressively shorter
4)A child younger than 1 year requires repeated
inhaled SABA over several hours
Need for urgent medical attention
25. 25
Transfer immediately to hospital if ANY of the following are present:
Features of severe exacerbation at initial or subsequent assessment
Child is unable to speak or drink
Cyanosis
Subcostal retraction
Oxygen saturation <92% when breathing room air
Silent chest on auscultation
Lack of response to initial bronchodilator treatment
Lack of response to 6 puffs of inhaled SABA (2 separate puffs, repeated
3 times) over 1-2 hours
Persisting tachypnea* despite 3 administrations of inhaled SABA, even if the
child shows other clinical signs of improvement
Unable to be managed at home
Social environment that impairs delivery of acute treatment
Parent/carer unable to manage child at home
26. 26
Children with features of a severe exacerbation
that fail to resolve within 1–2 hours despite
repeated dosing with inhaled SABA, with or without
OCS, must be referred to hospital for observation
and further treatment
Recurrence of signs of a severe exacerbation
within 48 hours (particularly if treatment with OCS
has already been given)
Indications for immediate transfer to
hospital for children ≤5 years
27. 27
The presence of any of the features of a severe
exacerbation are an indication of the need for urgent
treatment and immediate transfer to hospital :
Oxygen saturation from pulse oximetry of <92% on
presentation (before oxygen or bronchodilator
treatment) is associated with high morbidity and likely
need for hospitalization
Saturation of 92–95% is also associated with higher
risk
28. 28
Pulse oximetry
Accurate measurements of oxygen saturation are
essential in the assessment of all children with
acute wheezing.
Oxygen saturation monitors should be available for
use
by all health professionals assessing acute asthma
in both primary and secondary care settings.
29. 29
Pulse oximetry
Consider intensive inpatient treatment of children with
SpO2 <92% in air after initial bronchodilator
treatment.
Regardless of oxygen saturation early in the course,
experts emphasize that serial pulse oximetry
throughout the ED course plays a vital role, as it
allows children who require admission for
supplemental oxygen to be identified
30. 30
Chest X-Ray
Chest X-rays rarely provide additional useful
information and are not routinely indicated.
•A chest X-ray should be performed if there is :
1) Persisting unilateral signs suggesting
pneumothorax
2) Lobar collapse or consolidation
3) Life-threatening asthma not responding to
treatment.
4) Subcutaneous emphysema
31. 31
Blood gases
Blood gas measurements should be considered if
there are life-threatening features not responding
to treatment.
Arteriolised ear lobe blood gases can be used to
obtain an accurate measure of pH and PaCO2.
If ear lobe sampling is not practicable a finger prick
sample can be an alternative.
32. 32
Blood gases
The routine use of ABG testing in all children with
acute asthma is not justified.
Less-invasive means of assessing respiratory
status are widely available via pulse oximetry (for
evaluating oxygenation)
There is evidence that an initial oxygen saturation
of < 90% predicts a substantially higher
likelihood of poor outcome
33. 33
Blood gases
Most children with exacerbations have a
ventilation-perfusion mismatch and mild
hypoxemia (> 90%) that is often made temporarily
worse by inhaled beta2-agonist treatment.
Mild-to-moderate hypoxemia (along with
hypocapnia and respiratory alkalosis) are common
ABG findings in severe acute asthma.
34. 34
Blood gases
If airflow obstruction is severe and unrelieved, there
may be progression to hypercapnia and metabolic
acidosis due to muscle fatigue and inability to
maintain adequate alveolar ventilation as well as
lactate production by the overuse of respiratory
muscles
35. 35
Blood gases
Normal or raised PaCO2 levels are indicative of
worsening asthma.
A more easily obtained free flowing venous blood
PaCO2 measurement of <6 kPa (45 millimetres of
mercury (mm Hg) excludes hypercapnia
36. 36
Blood gases
Routine ABG on all asthma patients is
unnecessary. However, in a child with severe,
acute asthma, a rising PCO2 is worrisome and is
often predictive of respiratory failure.
37. 37
Blood gases
Arterial blood gas measurement provides objective
information on gas exchange.
Early in the course of asthma, hypoxemia and
hypocapnia are found due to ventilation/perfusion
mismatch and hyperventilation.
As the airflow obstruction progresses, PaCO2
measurement returns to normal values, though in a
tachypneic and hyper-ventilating child, a normal
PaCO2 value should be interpreted as a sign of early
38. 38
Blood gases
Sicker patients often have a mixed respiratory and
metabolic acidosis.
Lactic acidosis reflects a combination of excess
production from respiratory muscles, tissue hypoxia ,
and dehydration (due to decreased intake and
increased insensible losses).
The decision to intubate a child with severe acute
asthma should be based on the child's clinical status
and not simply the arterial blood gas values
40. 40
The goals of asthma management in young children
are similar to those in older patients:
To achieve good control of symptoms and maintain
normal activity levels
To minimize the risk of asthma flare-ups, impaired
lung development and medication side-effects.
Wheezing episodes in young children should be
treated initially with inhaled short-acting beta2-
agonists, regardless of whether the diagnosis of
asthma has been made.’
41. 41
The initial treatment of acute asthma in
children aged 2 years and above
presenting to primary and secondary
healthcare resources
44. 44
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 of 94–98%.
Treat hypoxemia urgently with oxygen by face
mask to achieve and maintain percutaneous
oxygen saturation 94–98% (Evidence A).
45. 45
Oxygen
To avoid hypoxemia during changes in treatment,
children who are acutely distressed should be treated
immediately with oxygen and SABA (2.5 mg of
salbutamol or equivalent diluted in 3 mL of sterile
normal saline) delivered by an oxygen-driven nebulizer
(if available).
This treatment should not be delayed, and may be
given before the full assessment is completed..
46. 46
Oxygen
To be commenced if SaO2 < 94%
Administer the lowest flow of oxygen required to
maintain oxygen saturation ≥ 94%.
If oxygen therapy is commenced it should be
reviewed regularly as requirement for oxygen may
decrease rapidly
47. 47
Inhaled short acting β2 agonists
The initial dose of SABA may be given by a pMDI
with spacer and mask or mouthpiece or an air-driven
nebulizer; or, if oxygen saturation is low, by an
oxygen-driven nebulizer .
For most children, pMDI plus spacer is favored as it
is more efficient than a nebulizer for bronchodilator
delivery (Evidence A).
53. Children’s Healthcare of Atlanta
Choosing an Inhaler Device
A pressurized metered-dose inhaler (MDI) with a valved
spacer (with or without a face mask, depending on the
child’s age) is the preferred delivery system
Choosing an Inhaler Device
Age group Preferred device Alternative device
Younger than 4 years
Pressurized metered-dose
inhaler plus dedicated
spacer with face mask
Nebulized with face mask
4-5 years
Pressurized metered-dose
inhaler plus dedicated
spacer with mouth piece
Pressurized metered-dose
inhaler plus dedicated
spacer with mouth piece,
or
Nebulizer with
mouthpiece or face mask
54. 54
The initial dose of SABA is two puffs of salbutamol
(100 mcg per puff) or equivalent, except in acute,
severe asthma when six puffs should be given.
When a nebulizer is used, a dose of 2.5 mg
salbutamol solution is recommended.
The frequency of dosing depends on the response
observed over 1–2 hours.
55. 55
Inhaled β2 agonists are the first line treatment for
acute asthma in children aged 2 years and over.
Assessment of response should be based on
accurately recorded clinical observations and repeat
measurements of oxygenation (SpO2).
Children receiving β2 agonists via pMDI + spacer
are less likely to have tachycardia and hypoxia than
when the same drug is given via a nebuliser.
56. 56
Children less than three years of age 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 (for five breaths).
Frequent doses of β2 agonists are safe for the
treatment of acute asthma
57. 57
Two to four puffs of salbutamol 100 micrograms
pMDI via a spacer might be sufficient for mild
asthma attacks, although up to 10 puffs might be
needed for more severe attacks.
Single puffs should be given one at a time and
inhaled separately with five tidal breaths.
58. 58
The Relief from symptoms should last 3–4 hours.
If symptoms return within this time a further or
larger dose (maximum 10 puffs) should be given
and the parents/ carer should seek urgent medical
advice.
59. 59
Children with severe or life-threatening asthma (SpO2
<92%) should receive frequent doses of nebulised
bronchodilators driven by oxygen (2.5–5 mg
salbutamol).
If there is poor response to the initial dose of β2
agonists, subsequent doses should be given in
combination with nebulised ipratropium bromide.
Doses of nebuliser bronchodilator can be repeated
every 20–30 minutes.
60. 60
For children with moderate-severe exacerbations
and a poor response to initial SABA, ipratropium
bromide may be added, as 2 puffs of 80mcg (or
250mcg by nebulizer) every 20 minutes for 1 hour
only.
61. 61
Salbutamol administration via pMDI-spacer is
preferred except in severe or critical asthma
In severe or critical asthma pMDI-spacer use may
interfere with oxygen administration - making
nebuliser use more practical.
62. 62
Continuous nebulised β2 agonists are of no greater
benefit than the use of frequent intermittent doses
in the same total hourly dosage.
Once improving on two to four-hourly salbutamol,
patients should be switched to pMDI and spacer
treatment as tolerated.
65. 65
• In the emergency room a standard nebuliser
driven with 8 l/min of oxygen takes
approximately 10 min to complete.
• In children we usually nebulise 0.15 mg/kg of
salbutamol up to a maximum of 5 mg made up
to 3 ml with normal saline.
67. 67
Salbutamol side effects:
Increased V/Q mismatch:
-Consider if early (within first 30 mins after giving
salbutamol) O2 desaturation.
-Patients with acute asthma have ventilation-perfusion (V/Q)
mismatch.
-Beta 2-agonists may worsen this mismatch by causing
increased blood flow in areas of the lung that are poorly
ventilated. This can result in decreased SaO2. This is easily
treated with supplemental oxygen (which might only be
needed for a short period of time).
68. 68
Lactic acidosis:
Rarely after prolonged therapy salbutamol can
increase oxygen consumption in tissues especially
given already limited ventilatory reserve resulting in
lactic acidosis
Electrolyte imbalance:
K+, Mg, & PO4 are transiently decreased with high
dose beta agonist therapy. Routine checking
electrolytes is not necessary unless deterioration.
69. 69
Anticholinergic Agents
Anticholinergic agents (such as ipratropium) have been
shown to be a beneficial adjunct treatment for acute
asthma.
Although ineffective as monotherapy for patients with
mild exacerbations, ipratropium coadministered with
beta agonists can improve lung function and reduce
hospitalization rates in children with moderate-to-severe
exacerbations.
-
70. 70
For children with moderate-severe exacerbations and
a poor response to initial SABA, ipratropium bromide
may be
added, as 2 puffs (or 250mcg by nebulizer) every 20
minutes for 1 hour only.
Ipratropium has only been shown to be effective in
the acute setting.
72. 72
• The recommendations of the British Thoracic
Society/SIGN Guidelines for the management of
asthma If symptoms are refractory to initial b2
agonist treatment, then ipratropium bromide mixed
with the nebulised b2 agonist solution should be
given.
• Nebulised ipratropium bromide (125–250 mg per
dose) in addition to b2 agonists for the first 2 h of a
severe attack in children
• It is recommended that this is repeated every 20 min
for the first hour and every 4 h thereafter.
73. 73
There is good evidence for the safety and efficacy
of frequent doses of ipratropium bromide (every
20–30 minutes) used in addition to β2 agonists for
the first two hours of a severe asthma attack.
Benefits are more apparent in the most severe
patients.
74. 74
Salbutamol dose should be weaned to one to two-
hourly thereafter according to clinical response.
The ipratropium dose should be weaned to four to
six hourly or discontinued.
Repeated doses of ipratropium bromide should be
given early to treat children who are poorly
responsive to β2 agonists.
75. 75
Nebulised magnesium sulphate
Nebulised magnesium sulphate is not
recommended for children with mild to moderate
asthma attacks.
Consider adding 150 mg magnesium sulphate to
each nebulised salbutamol and ipratropium in the
first hour in children with a short duration of
acute severe asthma symptoms presenting with an
oxygen saturation less than 92%.
76. 76
Nebulised Magnesium sulfate
The role of magnesium sulfate is not yet established for
children 5 years and younger, because there are few
studies in this age group.
Nebulized isotonic magnesium sulfate may be
considered as an adjuvant to standard treatment with
nebulized salbutamol and ipratropium in the first hour
of treatment for children ≥2 years old with acute severe
asthma (e.g. oxygen saturation <92%), particularly
those with symptoms lasting <6 hours.
77. 77
Nebulised epinephrin
Nebulized epinephrine is an alpha and beta agonist
that may be useful for acute asthma, though there is
a paucity of literature on the topic.
Inhaled racemic epinephrine has been used for years
to treat obstructive airway conditions such as croup
and bronchiolitis.
Efficacy and safety of multiple doses of racemic
epinephrine has not been established
78. 78
Nebulised epinephrin
In addition to its vasoconstrictive effects,
epinephrine may also decrease mucus production
and is an effective bronchodilator and pulmonary
vasodilator
Nebulized racemic epinephrine (0.5 mL diluted in 3-5
mL normal saline) has been shown to be as effective
and as safe as albuterol,but the incidence of minor
side effects (such as nasal discharge or cough) is
increased with epinephrine
79. 79
Oral corticosteroids
For children with severe exacerbations, a dose of
OCS equivalent to prednisolone 1–2 mg/kg/day,
with a maximum of 20 mg/day for children under 2
years of age and 30 mg/day for children aged 2–5
years, is currently recommended (Evidence A)
A 3–5 day course is sufficient in most children and
can be
stopped abruptly (Evidence D).
80. 80
• 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.
• Tapering is unnecessary unless the course of
steroids exceeds 14 days.
81. 81
The early use of steroids in emergency
departments can reduce the need for hospital
admission and prevent a relapse in symptoms after
initial Presentation
Benefits can be apparent within three to four hours.
82. 82
Give oral steroids early in the treatment of acute
asthma attacks.
Oral prednisolone is the steroid of choice for
asthma attacks in children unless the patient is
unable to tolerate the dose.
83. 83
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.
84. 84
In head-to-head comparisons there is insufficient
evidence to suggest that dexamethasone offers an
advantage over prednisolone for the management
of mild to moderate acute asthma in children.
85. 85
Repeat the dose of prednisolone in children who
vomit and consider intravenous steroids in those
who are unable to retain orally ingested medication.
There is no need to taper the dose of steroid tablets
at the end of treatment
86. 86
Do not use inhaled corticosteroids in place of oral
steroids to treat children with an acute asthma
attack.
There is no evidence that increasing the dose of
ICS is effective in treating acute symptoms
Children with chronic asthma not receiving regular
preventative treatment will benefit from starting ICS
as part of their long-term management.
87. 87
It is good practice for children already receiving
inhaled corticosteroids to continue with their usual
maintenance dose during an asthma attack whilst
receiving additional treatment.
88. 88
Initiating oral montelukast in primary care settings,
early after the onset of an acute asthma attack, can
result in decreased asthma symptoms and the need
for subsequent
healthcare attendances in those with mild asthma
attacks.
89. 89
Maintain current controller treatment (if
prescribed):
• Children who have been prescribed
maintenance therapy with ICS, LTRA or both
should continue to take the prescribed dose
during and after an exacerbation
91. 91
Children with continuing severe asthma despite
frequent nebulised β2 agonists and ipratropium
bromide plus oral steroids, and those with life-
threatening features, need
urgent review by a specialist with a view to transfer
to a high dependency unit or paediatric intensive
care unit (PICU) to receive second line intravenous
therapies.
92. 92
Second line intravenous therapies
There are three options to consider , IV salbutamol,
aminophylline and magnesium sulphate.
There is no clear evidence that one IV therapy is
preferential to another.
93. 93
Both IV salbutamol and IV aminophylline can cause
side effects and should be administered with
appropriate monitoring.
There are no head-to-head studies of magnesium
sulphate and another IV therapy
96. 96
IV aminophylline
Aminophylline is not recommended in children with
mild to moderate acute asthma.
Consider aminophylline for children with severe or
life-threatening asthma unresponsive to maximal
doses of bronchodilators and steroids.
97. 97
IV aminophylline
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.
Measure serum theophylline levels in patients
already receiving oral treatment and in those
receiving prolonged treatment.
98. 98
IV SALBUTAMOL
Consider early addition of a single bolus dose of
intravenous salbutamol (15micrograms/kg over 10
minutes) in a severe asthma attack where the patient
has not responded to initial inhaled therapy.
This should be given in a high dependency unit with
continuous ECG monitoring and twice daily electrolyte
monitoring
99. 99
Epinephrine can be given subcutaneously as well as
intramuscularly (0.01 mg/kg); however, the
intramuscular route is generally preferred due to
better absorption.
Major side effects are rare, but they can be
significant, with arrhythmias, tachycardia,
hypertension, and cardiac ischemia among the most
serious.
101. 101
Parenteral administration of beta agonists should be
reserved for children who are unable to use or who
are unresponsive to the inhaled route; these patients
may require intubation and assisted ventilation.
The efficacy of parenteral beta agonists, in the
pediatric population remains unclear since too few
pediatric clinical trials were identified
102. 102
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 children with acute asthma.
103. 103
Bilevel Positive Airway Pressure
Although respiratory failure is infrequent in asthma,
children experiencing severe asthma exacerbations
occasionally deteriorate, and respiratory support may
be required.
Bilevel positive airway pressure (BPAP) ventilation
can offer significant respiratory support to select
children with status asthmaticus and may allow these
children to avoid intubation.
104. 104
Bilevel Positive Airway Pressure
For children in severe distress, BPAP may facilitate
administration of inhaled beta agonists. BPAP is safe
and is generally well tolerated, and it may improve
oxygenation and decrease the work of breathing.
Clear guidelines for its use are not yet
established,but for the child with a severe
exacerbation that is refractory to other interventions,
BPAP may offer an alternative to intubation if it is
used in a timely fashion.
105. 105
Considerations For Intubation Of A Child With
Acute Asthma
Indications
1)Poor response to therapy
2)Rising CO2 (PCO2 > 50 mm Hg)
3)Severe hypoxia (PO2 < 60 mm Hg)
4)Rapid deterioration in mental status or fatigue
5)Impending respiratory arrest
6)Cardiopulmonary arrest
106. 106
For children with refractory symptoms and impending
respiratory failure, intubation may be necessary.
All other therapies should be attempted and
maximized prior to intubation.
110. 110
β2 agonist Bronchodilators
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
Treatment of acute asthma in
children aged less than 2 years
111. 111
β2 agonist Bronchodilators
Inhaled β2 agonists are the initial treatment of choice
for acute asthma. Close fitting face masks are
essential for optimal drug delivery
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
112. 112
β2 agonist Bronchodilators
For mild to moderate acute asthma attacks, a pMDI
+ spacer and mask is the optimal drug delivery
device
Oral β2 agonists are not recommended for acute
asthma in infants.
Consider inhaled ipratropium bromide in combination
with an inhaled β2agonist for more severe
113. 113
Steroid therapy
In infants, consider steroid tablets early in the
management of severe asthma attacks in the
hospital setting.
Steroid tablets in conjunction with β2 agonists have
been shown to reduce hospital admission rates
when used in the emergency department.
Steroid tablets have also been shown to reduce the
length of hospital stay.
114. 114
In the acute situation it is often difficult to determine
whether a pre-school child has asthma or episodic
viral wheeze.
Children with severe symptoms requiring hospital
admission should still receive oral steroids.
In children who present with moderate to severe
wheeze without a previous diagnosis of asthma it
may still be advisable to give oral steroids.
115. 115
Discharge planning
Before discharge, the condition of the child should be
stable (e.g. he/she should be out of bed and able to eat
and drink without problems).
Children who have recently had an asthma
exacerbation are at risk of further episodes and require
follow up.
The purpose is to ensure complete recovery, to
establish the cause of the exacerbation, and, when
116. 116
Discharge planning
Children can be discharged when stable on 3–4
hourly inhaled bronchodilators that can be
continued at home and SpO2 >94%.
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.
117. 117
Discharge plans should address the following:
1.Check inhaler technique
2.Consider the need for preventer treatment
3.Provide a written PAAP for subsequent asthma
attacks with clear instructions about the use of
bronchodilators and the need to seek urgent medical
attention in the event of worsening symptoms
4.Arrange follow up by primary care services within
48 hours
5.Arrange follow up in a paediatric asthma clinic
within one to two months
118. 118
Initial home management of asthma
exacerbation:
Initial management includes an action plan to
enable the child’s family members and carers to
recognize worsening
asthma and initiate treatment, recognize when it is
severe, identify when urgent hospital treatment is
necessary, and
provide recommendations for follow up (Evidence
D).
119. 119
Need for urgent medical attention
Parents/carers should know that immediate
medical attention should be sought if:
1)The child is acutely distressed
2)The child’s symptoms are not relieved promptly
by inhaled bronchodilator
3)The period of relief after doses of SABA
becomes progressively shorter
4)A child younger than 1 year requires repeated
inhaled SABA over several hours
120. 120
Initial home management of asthma
exacerbation:
Inhaled SABA via a mask or spacer, and review
response
The parent/carer should initiate treatment with two
puffs of inhaled SABA (200 mcg salbutamol or
equivalent), given one puff at a time via a spacer
device with or without a facemask (Evidence D).
This may be repeated a further two times at 20
121. 121
Initial home management of asthma
exacerbation:
Inhaled SABA via a mask or spacer, and review
response
The parent/carer should initiate treatment with two
puffs of inhaled SABA (200 mcg salbutamol or
equivalent), given one puff at a time via a spacer
device with or without a facemask (Evidence D).
This may be repeated a further two times at 20
122. 122
The child should be observed by the family/carer
and, if improving, maintained in a restful and
reassuring atmosphere for an hour or more.
Medical attention should be sought urgently if any of
the features listed above apply; or on the same day
if more than 6 puffs of inhaled SABA are required for
symptom relief within the first 2 hours, or if the child
has not recovered after 24 hours.
123. 123
Although practiced in some parts of the world, the
evidence to support the initiation of oral
corticosteroid (OCS)treatment by family/carers in
the home management of asthma exacerbations in
children is weak.
124. 124
Because of the high potential for side-effects,
especially if the treatment is continued
inappropriately or is given frequently, family
administered OCS or high dose ICS should be
considered only where the health care provider is
confident that the medications will be used
appropriately, and the child is closely monitored for
side-effects
125. 125
Discharge criteria
• Patients may be discharged home if :
o Tolerating 3 hours between bronchodilator doses
o Normal saturations in air
o Sensible carers and easy access to medical care
in the event of an acute deterioration.
126. 126
Discharge Medications
o Wean by extending time between doses by 30-
60 mins aiming for 3 hours or greater between
doses
o Patients can be safely discharged if they are
stable after 2 consecutive 3 hour periods between
Salbutamol doses.
o Salbutamol initially 3-4 hourly with a weaning
plan over the next 3-4 days..
127. 127
Discharge Medications
o Continue oral Prednisolone to finish 3-5 days (no
need for a weaning dose for courses less than 14
days).
o Inhaler device and spacer technique should be
checked before discharge.
o Preventer if required.
128. 128
Prior to discharge from the emergency department
or hospital, family/carers should receive the
following advice and information :
1)Instruction on recognition of signs of recurrence
and worsening of asthma.
2)The factors that precipitated the exacerbation
should be identified, and strategies for future
avoidance of these factors implemented.
3)A written, individualized asthma action plan.
4)Careful review of inhaler technique.
129. Allergy /
Trigger
The Chronic Inflammation of Asthma
• Identifying and avoiding allergens & triggers is
at least as important as medication
130. Medication
Allergy / Trigger
The Chronic Inflammation of Asthma
When the extinguishing power of
medication is greater than the allergy or
trigger exposure – asthma symptoms
can be controlled
131. 131
Further treatment advice explaining that:
o SABAs should be used on an as-needed basis,
but the daily requirement should be recorded to
ensure it is
being decreased over time to pre-exacerbation
levels
o ICS has been initiated where appropriate (at
twice the low initial dose for the first month after
discharge, then adjusted as needed) or continued,
132. 132
Further treatment advice explaining that:
o A supply of SABA and, where applicable, the
remainder of the course of oral corticosteroid, ICS
or LTRA.
o A follow-up appointment within 2–7 days and
another within 1–2 months, depending on the
clinical, social and
practical context of the exacerbation.
135. 135
Therapy Dose and administration
Supplemental
oxygen
24% delivered by face mask (usually 1L/min) to maintain
oxygen saturation 94-98%
Inhaled SABA 2–6 puffs of salbutamol by spacer, or 2.5mg by nebulizer, every
20 min for first hour, then reassess severity. If symptoms
persist or recur, give an additional 2-3 puffs per hour. Admit to
hospital if >10 puffs required in 3-4 hours.
Systemic
corticosteroids
Give initial dose of oral prednisolone (1-2mg/kg up to maximum
of 20mg for children <2 years; 30 mg for 2-5 years)
Initial management of asthma
exacerbations in children ≤5 years
136. 136
Therapyx 3 Dose and administration
Supplemental
oxygen
24% delivered by face mask (usually 1L/min) to maintain
oxygen saturation 94-98%
Inhaled SABA 2–6 puffs of salbutamol by spacer, or 2.5mg by nebulizer, every
20 min for first hour, then reassess severity. If symptoms
persist or recur, give an additional 2-3 puffs per hour. Admit to
hospital if >10 puffs required in 3-4 hours.
Systemic
corticosteroids
Give initial dose of oral prednisolone (1-2mg/kg up to maximum
of 20mg for children <2 years; 30 mg for 2-5 years)
Additional options in the first hour of treatment
Ipratropium
bromide
For moderate/severe exacerbations, give 2 puffs of
ipratropium bromide 80mcg (or 250mcg by nebulizer) every
20 minutes for one hour only
Magnesium
sulfate
Consider nebulized isotonic MgSO4 (150mg) 3 doses in first
hour for children ≥2 years with severe exacerbation
Initial management of asthma
exacerbations in children ≤5 years
