Mild |
Normal mental state
Subtle or no increased work of breathing
Able to talk normally |
Salbutamol by MDI/spacer - give one dose (see dosing below) and review after 20 mins. Ensure device / technique appropriate. Nebulised salbutamol (5 mg) may be considered in children with severe asthma who cannot coordinate MDI use
Good response:
- Discharge on short acting B2-agonist as needed
- Provide an Asthma Action Plan (see Resources section below). Consider overall control and family's knowledge. Arrange follow-up as appropriate
Poor response:
Consider oral prednisolone (see below) |
Moderate |
Normal mental state
Some increased work of breathing
Tachycardia
Some limitation of ability to talk |
Oxygen (humidified) if SpO2 persistently
<90%
Ongoing need for oxygen should be reassessed regularly
Oxygen may be required for low saturations. DO NOT give oxygen for wheeze or increased work of breathing. (See Additional notes: SpO2)
Salbutamol by MDI/spacer - 1 dose every 20 min for 1 hr; review 10-20 min after 3rd dose to decide on timing of next dose
Ipratropium by MDI/spacer - 1 dose every 20 min for 1 hr only
Consider oral prednisolone (see below) |
Severe |
Agitated/distressed
Moderate-marked increased work of breathing, accessory muscle use/recession
Tachycardia
Marked limitation of ability to talk
Note: wheeze is a poor predictor of severity
Other signs of
Anaphylaxis |
Involve senior staff
Oxygen (humidified) as above
Salbutamol by MDI/spacer - 1 dose (see below) every 20 min for 1 hr; review ongoing requirements 10-20 min after 3rd dose. If improving, reduce frequency. If no change, continue 20 minutely
Nebulised salbutamol (5 mg doses) may be considered in children requiring oxygen
If deteriorating at any stage, treat as critical
Ipratropium by MDI/spacer - 1 dose every 20 minutes for 1 hour only
Oral prednisolone (see below)
If vomiting, give IV corticosteroid
- Methylprednisolone 1 mg/kg (max 60 mg) 6 hourly
- Hydrocortisone 4 mg/kg (max 100 mg) 6 hourly
If poor response to the above treatment give:
Magnesium sulfate 50%* (500 mg/mL = 2 mmol/mL)
Dilute to 0.8 mmol/mL (by adding 1.5 mL of sodium chloride 0.9% to each 1 mL of magnesium sulfate) for intravenous administration
- 0.2 mmol/kg over 20 mins (maximum 8 mmol)
- If going to ICU, this may be continued with 0.12 mmol/kg/hour by infusion
*Magnesium sulfate 49.3% (493 mg/mL) is used in some areas Be careful with dosage, volumes and concentrations. See Additional notes below
Aminophylline
Loading dose 1-18 years: 10mg/kg (maximum 500mg) over 30-60 minutes Unless markedly improved following loading dose, give continuous infusion (usually in ICU), or 6 hourly dosing (usually in ward)
Consider Adrenaline 10 microg/kg or 0.01 mL/kg of 1:1000 (maximum 0.5 mL) IM, into lateral thigh which should be repeated after 5 min if the child is not improving
Arrange admission after initial assessment |
Critical |
Confused/drowsy
Maximal work of breathing, accessory muscle use/recession
Exhaustion
Marked tachycardia
Unable to talk
SILENT CHEST: wheeze may be absent if there is poor air entry
Other signs of
Anaphylaxis |
Involve senior staff and consider transfer to an appropriate children's facility/PICU
Oxygen (humidified)
Continuous nebulised salbutamol: Place 2 nebules into nebuliser chamber and give via continuous nebulisation. - 6 months – 6 years, use 2.5 mg nebules
- ≥6 years, use 5 mg nebules
Monitor for hypokalaemia and toxicity as discussed below
Nebulised ipratropium added to salbutamol, every 20 minutes for 3 doses only
-
<6 years old: 250 microg
- ≥6 years old: 500 microg
Methylprednisolone 1 mg/kg (max 60 mg) IV 6 hourly
Magnesium sulfate as above
Aminophylline as above
May also consider IV salbutamol. Limited evidence for benefit. - 5-15 microg/kg (max 300 microg) over 10 minutes
- Repeat dose if required or follow with IV infusion 1-2 microg/kg/min (max 200 microg/min)
- Adjust infusion according to response and heart rate, increase if necessary, up to 5 microg/kg/min (max 200 microg/min)
- Alternatively, can give the IV infusion as initial treatment
Aminophylline, magnesium and salbutamol must be given via separate IV lines
Consider Adrenaline 10 microg/kg or 0.01 mL/kg of 1:1000 (max 0.5 mL) IM, into lateral thigh which should be repeated after 5 minutes if the child is not improving
Intensive care admission for respiratory support (face mask CPAP, BiPAP, or intubation/IPPV) may be needed |