In this section
Criteria Led Discharge
Wheeze in preschoolers may not only be caused by reversible bronchospasm - this age group may not respond well to bronchodilators and steroids may be less effective. Steroids should only be given in this age group for admitted patients or those with previous ICU admission - this should be discussed with a senior doctor.
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
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 due to 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.
Oxygen as above
Salbutamol by MDI/spacer - 1 dose (dose below)
every 20 minutes for 1 hour; review ongoing requirements 10-20 min after 3rd dose. If improving, reduce frequency. If no change, continue 20 minutely. If deteriorating at any stage, treat as critical.
Ipratropium by MDI/spacer - 1 dose (dose below) very 20 minutes for 1 hour only.
Aminophylline If deteriorating or child is very sick. Loading dose: 10 mg/kg i.v. (maximum dose 500 mg) over 60 min.
Unless markedly improved following loading dose, give continuous infusion (usually in ICU), or 6 hourly dosing (usually in ward).
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
Oral prednisolone (2 mg/kg); if vomiting give i.v. methylprednisolone (1 mg/kg)
Involve senior staff.
Arrange admission after initial assessment.
Magnesium sulphate as above. In ICU patients on Mg infusion, 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.
Note: 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
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.
Information Specific to RCH
Children with asthma are usually admitted under the General Paediatric team.
Consider ICU review in children with severe and critical asthma.
RCH Criteria Led Discharge
Long term asthma control
Last updated May 2015