ED Guidelines
CLINICAL GUIDELINE FOR ACUTE WHEEZE &
ASTHMA IN CHILDREN AGED OVER 5 YEARS
LIFE
THREATENING
Sats <92% plus any of

PEFR<33%
best/predicted

Silent chest

Poor Resp effort

Confusion/coma

Cyanosis

Bradycardia
GO TO PAGE 1
SEVERE






Sats<92%
PEFR<50%
best/predicted
HR>120
RR>30
Use of accessory
muscles
Unable to
complete
sentences
GO TO PAGE 2
MODERATE



Sats >92%
PEFR 50-75%
best/predicted
No features of
severe asthma
MILD




GO TO PAGE 3
Sats > 95%
PEFR >75%
best/predicted
No increase work
of breathing
HR within normal
limits
GO TO PAGE 4
LIFE THREATENING ASTHMA
Obtain senior Emergency Department help & paediatric registrar immediately (consider
anaesthetist). Patient must be managed in Resuscitation Area.
AIRWAY & BREATHING
1.
2.
3.
4.
Check airway
Give high flow oxygen with non re-breath mask
Give Salbutamol nebuliser 5mg
Give Ipratropium nebuliser 0.25mg
IV ACCESS
1. Insert appropriately sized IV cannula
2. Obtain samples for FBC, U&E, glucose & Venous gas
3. Give IV hydrocortisone 4mg/kg
OBSERVATIONS
PAWS should be calculated and documented every 15 minutes
CONTINUING MEDICATION
1. Continue nebulised Salbutamol every 20-30mins
FURTHER SUPPORT
Discuss case with Paediatric and Anaesthetic middle grades regarding:
1. IV Salbutamol infusion 1-5 micrograms/kg/min
2. Aminophylline infusion 1mg/kg (preceded by loading dose if not already taking
theophyllines)
3. Magnesium sulphate infusion 40mg/kg (max 2g) over 20 mins
ADMISSION/DISCHARGE
All children that present to Accident and Emergency with life-threatening asthma need admission
for a period of observation/treatment.
1
SEVERE ASTHMA
AIRWAY & BREATHING
1.
2.
3.
4.
5.
6.
Check airway
Give O2 via face mask to maintain oxygen saturations above 95%
Give Salbutamol nebuliser 2.5mg
Give Ipratropium nebuliser 250 micrograms
Give oral prednisalone 2mg/kg
Consider repeating nebuliser
CONTINUING MEDICATION
1. Continue nebulised bronchodilators every 20-30mins.
OBSERVATIONS
PAWS should be calculated and documented every 15 minutes.
ADMISSION/DISCHARGE
All children that present to Accident and Emergency with severe asthma need admission for a
period of observation/treatment.
2
MODERATE ASTHMA
AIRWAY & BREATHING
1. Check airway
2. Give oxygen via facemask to maintain SaO2 above 95%
3. Give Salbutamol inhaler 10 puffs via a spacer
CONTINUING MEDICATION
1. Repeat Salbutamol 4-10 puffs via a spacer after 30 mins in no improvement
2. Give oral prednisalone 2mg/kg
OBSERVATIONS
PAWS should be calculated and documented every 30 minutes
ADMISSION/DISCHARGE
If continues to have raised RR or increased work of breathing arrange admission.
If condition worsens, then reassess looking for features of life threatening and follow
appropriate guidance.
Consider discharge if HR & RR normal, no increased work of breathing, Oxygen Sats>95% on
air and fulfils all criteria of discharge plan
Have a low threshold for admission if there are any social concerns
3
MILD ASTHMA
INITIAL MANGEMENT
1. Give Salbutamol 4-6 puffs via spacer
CONTINUING MEDICATION
1. Continue inhaled bronchodilators every 20-30mins.
OBSERVATIONS
PAWS should be calculated and documented every 30 minutes
If continues to have raised RR or increased work of breathing arrange admission.
If condition worsens, then reassess looking for features of life threatening
Consider discharge if HR & RR normal, no increased work of breathing, Oxygen Sats>95% on
air and fulfils all criteria of discharge plan
ADMISSION/DISCHARGE
If continues to have raised RR or increased work of breathing arrange admission.
If condition worsens, then reassess looking for features of life threatening and follow
appropriate guidance.
Consider discharge if HR & RR normal, no increased work of breathing, Oxygen Sats>95% on
air and fulfils all criteria of discharge plan (page 5 of this document)
Have a low threshold for admission if there are any social concerns
4
DISCHARGE PLAN
BEFORE DISCHARGE CONSIDER
1. The patient must be stable, have a heart rate within normal limits for their age, have
no recessions or use of accessory muscles.
2. Any patient with signs of life threatening or severe asthma at any time MUST BE
ADMITTED
3. Children must be observed for at least 2 hours after a nebuliser (including those
given by the paramedics) has been given before discharge can be considered. If the
patient is going to breach the child needs to be admitted to complete this period of
observation
4. If a patient presented with intercostal recessions that has settled at the time of
discharge consider discharge on oral prednisalone 10-20mg for 5 days
5. If a patient has re-attended within 6 hours a period of extended observation must
be considered
CONSIDER REFFERAL FOR ADMISSION/PAU REVIEW IF ANY OF THE FOLLOWING
1.
2.
3.
4.
5.
6.
7.
Signs of Life threatening/severe asthma
Significant co-morbidity
Taking oral steroids prior to presentation
History of poor compliance
Previous near fatal attack / brittle asthma
Psychological problems/ learning difficulties
Poor social circumstances
AT TIME OF DISCHARGE
1.
2.
3.
4.
Check inhaler technique
Ensure the patient is clear about their treatment
Ensure the patient has an adequate supply of inhalers and oral medications
Give the patient a copy of their treatment plan and advise them to see their
GP/asthma nurse within 2 days
5. Advise the patient to seek further medical advice if there is any deterioration in their
symptoms
Dr Paul Jarvis, Consultant in Emergency Medicine
Dr Nadeem Akhtar, Foundation Year 2 Doctor
5
February 2010