HNY Policy and Pathway Repository - York

Acute asthma is the progressive worsening of asthma symptoms, including breathlessness, wheeze, cough and chest tightness.

Paediatric Normal Values (adapted from APLS)
Age	Resp Rate	Heart Rate	Systolic BP
Neonate <4w	40-6	120-160	>60
Infant <1 y	30-40	110-160	70-90
Toddler 1-2 yrs	25-35	100-150	75-95
2-5 yrs	25-30	95-140	85-100

• SpO2 <92%, cyanosis
• Bradycardia <100 bpm
• Apnoea
• Marked sternal recession
• Persistent or worsening shortness of breath
• Inability to speak in full sentences/too breathless to feed
• May complain that the chest feels ‘closed’
• Poor air entry
• Agitation, confusion and inability to concentrate
   

Low Threshold for Admission

• Extreme low birth weight
• Prolonged NICU/SCBU
• Congenital heart disease
• Significant co-morbidity
• Reduced feeding <50%
• Previous severe episode
• Attack in late afternoon, at night or early in the morning
• Poor mental health or psychosocial stressors
• Recent hospital admission
• Already taking oral steroids or high doses of inhaled steroids
• Food allergy

General Points

• Acute wheeze is one of the most common reasons for emergency department attendance and hospital admission in children
• Triggers can include viral infections, dust, smoke, fumes, changes in the weather, grass and tree pollen, animal fur and feathers, strong soap and perfume
• Each year, there are still a small proportion of avoidable deaths in children and young people resulting from asthma
   

Differential Diagnoses

It is important to differentiate between viral induced wheeze, other causes of wheeze and asthma.

• Pneumonia: pyrexia >38.5°C, productive cough, asymmetry on auscultation
• Epiglottitis: dysphagia, drooling
• Croup: inspiratory stridor
• Hyperventilation: breathlessness with light headedness and peripheral tingling  
• Foreign body: localized wheeze and reduced air entry
• GORD: excessive vomiting
• Anaphylaxis

Management

Acute asthma drug doses
Treatment	Age (years)	Dose (mg)
Prednisolone (oral)	<2	10
	2-5	20
	5-7	30-40
	>7	40
(1-2mg/kg per dose)
Salbutamol (nebs)	2-5	2.5
	>5	5
Ipratropium bromide (nebs)	2-11	0.25 (250 micrograms)
	12-17	0.5 (500 micrograms)

 

Prednisolone

• Three days is usually sufficient, but tailor length to response
• Those already receiving maintenance steroid tablets should receive prednisolone 2mg/kg (max 60mg)
• Tapering unnecessary unless course exceeds 14 days
   

Indicators for Nebulised Bronchodilators

• SpO2 <94%
• Unable to use inhaler and spacer
• Severe respiratory distress

None provided

Patient information leaflets/ PDAs

Patient.info/chest-lungs/asthma-leaflet

Oxfordhealth.nhs.uk/Asthma-advice-for-children.pdf

Acute asthma pathway leaflet

Acute asthma parent information

 

Personalised Patient Action Plan

Child Asthma.org.uk/globalassets/health-advice/resources/children/my-asthma-plan 

Young Person Asthma.org.uk/globalassets/health-advice/resources/adults/asthma-action-plan

 

References

• National Institute for Clinical Excellent [NICE] (2020) Asthma: Diagnosis, monitoring and chronic asthma management [Viewed 16 Aug 2021]
• British Thoracic Society/Scottish Intercollegiate Guidelines Network 2019. British guidelines on management of asthma. [online]
• Royal College of Physicians of London, British Thoracic Society and British Lung Foundation. Why asthma skill kills: The national review of asthma deaths (NRAD). Confidential enquiry report. London (2015) [Viewed 16 Aug 2021] https://www.rcplondon.ac.uk/projects/outputs/why-asthma-still-kills
• National Institute for Clinical Excellent [NICE] (2021) Asthma – Clinical Knowledge Summaries. [Viewed 16 Aug 2021]