Severity Assessment

Inital Therapy

1. Administer oxygen to maintain SpO₂ >94%.
2. Nebulised Salbutamol:
   • <5 years: 2.5 mg
   • ≥5 years: 5 mg
3. Nebulised Ipratropium Bromide:
   • <12 years: 250 micrograms
   • ≥12 years: 500 micrograms
4. Nebulised magnesium sulfate 150 mg (consider ≥2 years)
   • With each nebulized Salbutamol and Ipratropium in the first hour in children with a short duration of acute severe asthma symptoms with SpO₂ <92%.
   • Nebulised Magnesium is not recommended for mild to moderate asthma attacks.
   • Further studies are needed to identify which clinical group would benefit the most from nebulised Magnesium. Hence, continued use of nebulized Magnesium beyond the first hour is not recommended as it might delay initiation of IV treatment.  See appendix 1 for details of administration.
5. Steroids: (Oral Prednisolone)
   • <2 years – 10mg
   • 2-5 years – 20mg
   • >5 years – 30-40mg
   • ≥12 years: 40–50 mg daily for 3–5 days
   • Needs to be given within 1 hour of admission
   • If oral route not tolerated: IV Hydrocortisone 4 mg/kg QDS (max 100 mg)
6. Reassess after initial treatment.
7. Escalate care if poor response: IV access, VBG, U&E, theophylline level if relevant.
8. Start 80% maintenance IV fluids: with KCl if K+ <4 mmol/L.

Second-Line Management – Paediatric Senior must be involved

Any patient needing or may need second line management should be discussed with the Paediatric team. All such patients after stabilisation will need admission or a period of observation in SDEC/Children’s ward.

IV Magnesium Sulfate:

• 40 mg/kg (max 2 g) over 20 minutes
• Use separate IV line from salbutamol/aminophylline
• Adverse effects – Bradycardia and Hypotension.
• Monitor HR, BP every 15 mins.
• Contraindicated in renal failure and heart block

IV Aminophylline:

• Loading dose: 5 mg/kg over 20 mins (omit if on theophylline)
  Infusion: 1–12 yrs: 1 mg/kg/hr, ≥12 yrs: 0.5–0.7 mg/kg/hr
• Should be nursed in Enhance Care Area
• Monitor theophylline levels 4-6 hours after starting treatment (target 10–20 mg/L)
• Adjust IV fluids to account for infusion volume
• IV Aminophylline is compatible with fluids containing potassium.
• IV Aminophylline is NOT COMPATIBLE to run in the same line as IV Salbutamol.
• Dose should be calculated on the basis of ideal weight for height in obese patients to avoid toxicity.  Ideal weight can be inferred from the height centile using a standard WHO growth chart  (Moore’s method) – Check height centile on growth chart – check corresponding weight for that centile and age and use this weight – more information can be found at: UKMIQA-drug-dosing-in-childhood-obesity.pdf .
• If no height is available then the approximate weights can be used in the BNF online ‘Approximate Conversions and Units’ section
• For further information please see CHFT guideline – ‘Guidance For Use of Aminophylline Infusion 1mg/1ml In Children’

IV Salbutamol:

• Inform the on-call consultant if IV Salbutamol is being started.
• Continue mixed nebulisers (Salbutamol/Ipratropium) every 30-60 minutes for first 2-3 hours.
• Loading dose:
  • <2 years: 5mcg/kg over 5 mins
  • 2-18 year: 15 mcg/kg (max 250 mcg) over 5 mins and reassess. Dose to be calculated on actual body weight.
  • Infusion: 1–5 mcg/kg/min

Discuss with Embrace/PICU if >2 mcg/kg/min required

• Consider chest X-Ray if on IV Salbutamol.
• Close monitoring of Heart rate and Blood pressure is needed.
• Monitor potassium on U+E/Blood gas
• Watch for lactic acidosis

Oxygen and Vapotherm

• Maintain saturation >94%
• If deterioration despite second line measures Nasal High Flow Oxygen can be considered but this is a consultant decision – evidence base is limited for High Flow in asthma.
• Acute Asthma patients on high flow need to be monitored carefully for deterioration, pneumothorax and/or air trapping
• CXR should be performed for any children/young people managed on high flow
• Administer nebulisers via Aerogen chamber

Monitoring

• All patients who need IV treatment should be on continuous cardiac monitoring.
• Observations: BP every 15 mins (1st hr), then 30 mins, then hourly if stable
• Clinical review every 30 mins for first 2 hrs
• U&E and glucose at the start and every 6 hours on IV therapy- Hypokalaemia and Hyperglycaemia are common side effects on treatment with Salbutamol.
• Blood gases as clinically indicated– beware of lactic acidosis with prolonged use Salbutamol (both nebulized and IV treatment).
• Theophylline level 4–6 hours after infusion start (Target level between 10 – 15 mg/L).

Special Considerations

SVT with beta-agonists:

• Stop IV salbutamol if SVT suspected
• Alert senior staff, inform on-call consultant – Anaesthetics and ICU presence to be considered early.
• Attempt vagal manoeuvres
• Ensure has two sites of IV access.
• DC cardioversion under sedation (Propofol has bronchodilator effect, to be guided by the anaesthetics/ICU team) if needed- 1st shock: 1 J/kg – if needed 2nd shock: 2 J/kg

Adenosine is contraindicated in life-threatening asthma as Adenosine causes bronchoconstriction, worsen inflammation and increases airway plasma exudation.

Observe in-hospital for at least 24 hours after IVs have been stopped due to the risk of rebound

Discharge checklist:

• Normal HR, RR
• Off oxygen ≥6 hrs
• Sustained good response to inhaled Bronchodilator – on pMDI and spaced to at least 4 hours between inhalers and needing 6 puffs or less.
• After discharge do not recommend regular salbutamol puffs (weaning plan), instead advise use of salbutamol or MART inhaler doses as required and as per PAAP (Personalised Asthma Action Plan) – these are available on the ward or on the childrens’ drive for both MART and salbutamol.

For those on MART regime:

• Once ready to space to 6 puffs 4 hourly Salbutamol – give 1 puff of Symbicort (MART reliever dose), then observe for 4 hours – if the child/young person remains well they can be discharged home with use of Symbicort as required as per their MART PAAP.

Follow Up:

• Any child/young person with >1 admission for wheeze should be followed up in clinic
• If known asthma please message Dr Houston on EPR for asthma clinic follow up
• If recurrent viral wheeze picture follow up in general paediatric clinic

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