Acute Asthma 

Acute severe asthma is a potentially life-threatening condition and requires urgent evaluation. 

Consider differentials in a breathless child, like Foreign Body, Croup, Bronchiolitis, LRTI, Pneumothorax etc

 

Clinical Presentation 

– Enquire about onset and duration of symptoms

– Trigger factor/s for current attack  e.g. URTI, pollen, animal dander etc

– History of atopy in child & in family

– Usual medication/s and route of administration 

– Compliance, use of spacer device and technique

– Frequency of attacks 

– Previous hospital attendances / PICU admission

– Repeat courses of oral glucocorticoids 

 

Rapid assessment to classify severity of attack, including:

– Temp, HR, RR, SaO2

– Audible wheeze 

– Increased work of breathing?

– Level of consciousness

– Full respiratory examination

– Any signs of alternative diagnosis 

   (e.g. Foreign body, Pneumonia, Croup)

– PEFR in >5y age

– CXR only required if suspecting pneumothorax, consolidation or deterioration

 

Management

Mild to moderate episode:

Salbutamol by MDI+spacer then review after 15 minutes to decide on timing of next dose. Can be given every 30 – 60 minutes in moderate episode

Oral prednisolone even if discharging home for moderate episodes

 

Also continue any background inhaled Corticosteroids / Leukotriene antagonists

Discharge home if improving and will manage 3-4 hours between inhalers

Severe episode:

Inform senior doctors

Oxygen to keep SaO2 >92%

Salbutamol by MDI+spacer every 20 minutes for 1 hour;

review 15 min after 3rd dose.  

Nebulised route if requiring Oxygen or not tolerating MDI+spacer

Ipratropium by MDI+spacer or Nebulised every 20 minutes for 1 hour only, then 4 to 6 hourly

Oral prednisolone (or Dexamethasone)

 

If improving, admit to ward and reduce frequency to 1-2 hourly with frequent reviews. Change back to MDI+spacer when not requiring O2 and clinically improving

 

If worsening, treat as life-threatening

Continue back-to-back Nebulised Salbutamol every 20 minutes for another hour

Give IV Magnesium sulphate & IV Hydrocortisone

 

Further 2ndline management as for Life threatening episode

Life threatening episode:

Initiate management as above for severe episode

Inform senior doctor, manage in HDU or resuscitation area if possible

 

Oxygen (high flow) to keep SaO2 >92%

Monitor SaO2, HR, RR (& ECG if escalating treatment)

Back-to-back nebulised Salbutamol & Ipratropium every 20 minutes

IV Hydrocortisone & IV Magnesium sulphate

IV Salbutamol Loading dose then continuous infusion; if required add
IV Aminophylline Loading (often adequate improvement) or follow with continuous infusion

 

– Consider CXR to exclude Pneumothorax/ alternative diagnosis

– Check CapGas/ ABG to monitor pH & pCO2

– Check U&E if prolonged Salbutamol therapy to check Potassium

 Seek PICU & Anaesthetic input for ongoing management, as ventilation can be difficult in severe Asthma

 

Inform PICU for transfer if:

– Life threatening features with no immediate response to treatment

– Consider if previous admissions have always required PICU treatment

– No improvement with IV salbutamol or loading dose of aminophylline

– Hypoxia persisting or worsening

– Exhaustion / shallow respirations, respiratory arrest or confusion or coma

 

At discharge, ensure:

– Inhaler and Spacer technique checked

– Discharge letter to include severity of episode, triggers, previous control

– Allergen avoidance advice given, including smoking cessation

– Home Asthma management plan to be provided, including when to seek help

– Follow up arranged – as appropriate

 

*All doses as per local policy

James DR, Lyttle MD. British guideline on the management of asthma: SIGN Clinical Guideline 141, 2014 Archives of Disease in Childhood – Education and Practice 2016;101:319-322.

 

White J, Paton JY, Niven R on behalf of the British Thoracic Society, et al. Guidelines for the diagnosis and management of asthma: a look at the key differences between BTS/SIGN and NICE Thorax 2018;73:293-297.