1

Reason for this Guideline

Asthma is a common condition in western society and children with it present frequently to
emergency departments. Some asthmatics attend with life-threatening symptoms and require
immediate life-saving intervention, while others come to the ED because the parents are under-
standably very worried about their wheezy childespecially if there are other family members
with asthma. Many lay between these extremes, and the real skill in caring for suffers lies in
rapid and accurate assessment of severity - and therefore urgency of need. This guideline is
designed to ensure that the clinicians in the Emergency Department have a framework that
guides both assessment and therapy, and in particular ensures that children needing resuscita-
tion receive it promptly.
When to use this Guideline
This guideline should be used in all children with known asthma who attend the Emergency De-
partment.
How to use this Guideline
The key to successful use of this guideline is an understanding of the clinical risk assessment
that has been derived from the BTS guidelines. The first aim is to identify children with life-
threatening asthma, and then to establish whether they need urgent intubation and ventilation
(after discussion with the Paediatric Team) or whether maximal medical therapy can be tried.
Children with severe asthma can also be identified early and treated appropriately, while those
with mild exacerbations can use their normal bronchodilators. Most importantly all children are
reassessed (using the same risk assessment) and treatment is modified as necessary. Those
who continue to have life-threatening features are admitted to the paediatric critical care ar-
eas, while those who have severe symptoms should be admitted to the paediatric wards. Chil-
dren who presented with mild symptoms, and those whose symptoms have improved significantly
with treatment will probably be suitable for discharge, possibly after a pe-
riod of observation and if there is suitable adult supervision. If they do go
home then community follow up should be considered, as should referral to
the paediatric asthma team.
Guideline FAQs
What is asthma?
Asthma is lower airway obstruction caused by bronchospasm.
Which children should this guideline be used for?
This guideline should be used for all patients presenting to the department with symp-
tomatic asthma.
Should I ever give asthmatic children anything to calm them down if they are anx
ious?
No! Sedating patients who are having difficulty breathing is absolutely contraindi-
cated. Treat the underlying cause (asthma).

Special points of inter-
est:
It is important to remem-
ber that normal physio-
logical values change with
age
The PEFR can be very
difficult to obtain in
children
Children under the age of
5 (and a significant num-
ber over this age) cannot
use inhalers effectively
without a spacer device
Children under the age of
18 months may wheeze for
a number of other rea-
sonsand may respond
poorly to treatment

in
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2003-52
CDSG
Asthma in Childhood
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3
PDI/520: SUITABILITY FOR PROTOCOL DRIVEN INVESTIGATION (ALL YES)

Order: T, P, BP, R, S
a
O
2,
PEFR, Weight
CDU/521 / 523: CLINICAL RISK ASSESSMENT OF Asthma CDU/061 CDU/063

Life threatening if any of LT, severe to moderate if none of LT and any of S or Mo and mild if none of LT, S or Mo. NB PEFR is not usually possible in children aged less than 3 years.
MEDICAL THERAPY ADVICE

CDU/522: Need for immediate review for IPPV (ANY YES)

CDU/524: Need for second review for IPPV (ANY YES)

CDU/524: Suitable for discharge (ALL YES)


Known Asthma Yes
Acute breathlessness / wheeze is the main complaint
Yes
LT
S/Mo LT S/Mo
Reduced level of consciousness / agitation

Cyanosis / SaO
2
< 92% on air

Poor respiratory effort / silent chest

Exhaustion

PEFR < 33% best or predicted

PaO
2
< 8 kPa / PaCO
2
> 4.6 kPa

Dysrhythmia (including bradycardia)

SBP < 90 mm Hg

Unable to talk in sentences or eat

Use of accessory neck muscles

PEFR 33 - 75% best or predicted

RR significantly elevated for age (>50 age 2-5, >30 age > 5)

P significantly elevated for age (>130 age 2-5, >120 age > 5)

Maximal medical therapy: This consists of continuous nebulised salbutamol (2.5mg < 5y, 5mg > 5y) together with steroids IV (hydrocortisone 4 mg/kg max
100 mg). IV bronchodilators (salbutamol or aminophylline) may be required.
Medical therapy This consists of intermittent nebulised salbutamol (2.5mg < 5y, 5mg > 5y) together with steroids orally (prednisolone 1-2 mg/kg max
40mg). IV bronchodilators (salbutamol or aminophylline) may be required. Antibiotics may be indicated.
Antiibiotics: Are indicated if there are clinical or radiographic signs of pneumonia. Start with amoxicillin po (erythromycin if allergic to penicillin), or cefu-
roxime IV tds if parenteral delivery is required.
Airway compromise Yes
Inadequate breathing Yes
Severe hypoxia (SaO
2
< 70% on air) Yes
Airway compromise Yes
Inadequate breathing Yes
Severe hypoxia (SaO
2
< 70% on air) Yes
Adequate social support Yes
Able to eat and drink Yes
Able to use inhaler with spacer device Yes
No consolidation or pneumothorax on CXR if indicated Yes
6h of stable observation for all children who have required nebulisers Yes
Alert Yes
Ref/526: Suitable for paediatric referral for admission

Ref/527: Suitable for Discharge and community follow-up

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Evidence Base

This guideline is based primarily on the following sources:



There are 6 relevant Cochrane reviews:



Additional reviews (BestBETs) have been undertaken as follows:


Additional sources of interest include:






Nice guidance is extant / pending / NOT CURRENTLY PLANNED

British Guideline on the Management of Asthma. A national clinical guideline. British Tho-
racic Society and the Scottish Intercollegiate Guidelines Network. http://www.brit-
thoracic.org.uk/docs/asthmafull.pdf
Anticholinergic drugs for wheeze in children under the age of two years. ML Everard, A Bara, M Kurian, TM Elliott, F Ducharme
Combined inhaled anticholinergics and beta2-agonists for initial treatment of acute asthma in children. LH Plotnick, FM Ducharme
Corticosteroids for hospitalised children with acute asthma. M Smith, S Iqbal, TM Elliott, BH Rowe
Interventions for educating children who have attended the emergency room for asthma. MM Haby, E Waters, CF Robertson, PG Gibson, FM
Ducharme
Intravenous aminophylline for acute severe asthma in children over 2 years using inhaled bronchodilators. A Mitra, D Bassler, FM Ducharme
Oral and systemic steroids at different doses for acute asthma in hospitalised children. M Smith, L McLoughlin

BB 43. Oral steroids are as effective as intravenous steroids in acute severe asthma http://www.bestbets.org/cgi-bin/bets.pl?record=00043
BB 212. Beta-agonists with or without anti-cholinergics in the treatment of acute childhood asthma? http://www.bestbets.org/cgi-bin/bets.pl?
record=00212
Bb 235. Lignocaine as a pretreatment to Rapid Sequence Induction in patients with status asthmaticus http://www.bestbets.org/cgi-bin/bets.pl?
record=00235
BB 239. Is IV aminophylline better than IV salbutamol in the treatment of moderate to severe asthma http://www.bestbets.org/cgi-bin/bets.pl?
record=00239
BB 444. Is homeopathy better than placebo in the treatment of bronchial asthma ? http://www.bestbets.org/cgi-bin/bets.pl?record=00444
BB 620. Nebulised magnesium in asthma http://www.bestbets.org/cgi-bin/bets.pl?record=00620
BB 686. Non-steroidal anti-inflammatory drugs and exacerbations of asthma in children http://www.bestbets.org/cgi-bin/bets.pl?record=00686
BB 768. Does magnesium sulphate have a role in the management of paediatric status asthmaticus? http://www.bestbets.org/cgi-bin/bets.pl?
record=00768

Disclaimer

This guideline has been developed by clinicians and its content has been reviewed by the
Clinical Effectiveness Committee of the British Association for Emergency Medicine.
Guidelines cannot always contain all the information necessary for determining appropriate
care and cannot address all individual situations, therefore individuals using these guidelines
must ensure they have the appropriate knowledge and skills to enable interpretation.
Guidelines can never substitute for sound clinical judgement. This guideline may not reflect
changes in clinical practice that have occurred since it was last reviewed.