In this section
This guideline has been adapted for statewide use with the support of the Victorian Paediatric Clinical Network
Background to condition:
Inquire specifically about the duration and nature of symptoms, treatments used (relievers, preventers), trigger factors (including upper respiratory tract infection, allergy, passive smoking), pattern and course of previous acute episodes (eg. admission or ICU admissions), parental understanding of the treatment of acute episodes, and the presence of interval symptoms (see Long Term Asthma Control below).
Wheeze is not a good marker of severity.
The most important parameters in the assessment of the severity of acute childhood asthma are general appearance/mental state and work of breathing (accessory muscle use, recession), as indicated in the table. Initial SaO2 in air, heart rate and ability to talk are helpful but less reliable additional features. Wheeze intensity, pulsus paradoxus, and peak expiratory flow rate are not reliable.
Asymmetry on auscultation is often found due to mucous plugging, but warrants consideration of foreign body.
Children with respiratory distress should have minimal handling.SaO2: Oxygen may be required for low saturations, DO NOT give for wheeze or increased work of breathing. The arterial oxygen saturation (SaO2) may be reduced in the absence of significant airway obstruction by factors such as atelectasis and mucous plugging of airways. SaO2 is purely a measure of oxygenation, which may be preserved in the presence of deteriorating ventilation (with CO2 retention).
Tachycardia can be a sign of severity - but is also a side effect of beta agonists such as salbutamol.
Magnesium sulphate 50% (500 mg/mL) Dilute to 200 mg/mL (by adding 1.5mls of sodium chloride 0.9% to each 1ml of Mg Sulphate) for intravenous administration
In ICU patients - aim to keep serum Mg between 1.5 and 2.5mmol/L.May also consider i.v. salbutamol. Limited evidence for benefit.5 mcg/kg/min for one hour as a load, followed by 1-2 mcg/kg/min.Beware salbutamol toxicity: tachycardia, tachypnoea, metabolic acidosis. Can occur with both IV and inhaled therapy. Lactate commonly high. Consider stopping/reducing salbutamol as a trial if you think this may be the problem.Aminophylline, magnesium and salbutamol must be given via separate IV lines.Intensive care admission for respiratory support (facemask CPAP, BiPAP, or intubation/IPPV) may be needed.
Salbutamol dose: 6 puffs if < 6 years old, 12 puffs if >6 years oldNote: In hospital, the next dose of salbutamol should be given only when symptoms of asthma return. It does not need to be weaned.Ipratropium (Atrovent 20mcg/puff) dose: 4 puffs if < 6 years old, 8 puffs if >6 years old Drug doses
Chest x-ray is not generally required (discuss with senior doctor if considering). Arterial blood gas and spirometry are NOT required in the assessment of acute asthma in children.Blood gases are distressing and can cause a child with respiratory compromise to deteriorate further. They are not usually required and the child's clinical state is more important in guiding therapy.
For advice and inter-hospital (including ICU level) transfers ring the Sick Child Hotline: (03) 9345 7007
Information Specific to RCH
Children with asthma are usually admitted under the General Paediatric Team.Consider ICU (5211) review in children with severe and critical asthma.
RCH Criteria Led Discharge form
Long Term Asthma Control
Last updated March 2014