Leeds Paediatric Acute Asthma Guidelines

• Background
• Acute management
• Mild to moderate
• Severe
• Life threatening
• Inpatient Management

Aims

To improve the management of acute asthma in the paediatric hospital inpatient population.

Background

This guideline for the acute management of asthma is based on The British Guideline on the Management of Asthma, updated 2019 (BTS). The BTS guidelines were developed by respiratory experts, and involved representation from Asthma UK.

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Acute management

Immediate assessment

* Airway
* Breathing
* Circulation

A thorough history of acute and chronic symptoms including aggravating factors is necessary each time a child with asthma presents with acute exacerbation. Always think of potential differential diagnoses. Assess and record all of the following criteria and categorise each patient as mild/moderate, severe or life threatening.

Record;

1. Respiratory rate
2. Pulse rate
3. Use of accessory muscles
4. Conscious level, and degree of agitation
5. Oxygen saturations
6. Presence or absence of wheeze
7. Peak Flow-if children are familiar with technique and use at home

Acute Management

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β2  agonist (salbutamol) 2 - 10 puffs (100 micrograms/puff of a pressurised Metered Dose Inhaler (pMDI)). Give one puff at a time inhaled with 5 tidal breaths, via spacer with mouthpiece (use facemask if necessary in younger children).

Reassess

Increase the dose according to response, using up to a further 10 puffs (100 micrograms/puff) and reassess.

Consider prednisolone in children 2 years or over for 3 days (1-2mg/kg up to a maximum of 40mg/dose - up to 60mg/dose can be used in those patients receiving maintenance steroid tablets).

Use of steroids in children under 2 years of age should be consultant decision only. For children aged 2-4 years who have mild/ moderate suspected viral induced wheeze and no atopy then the adverse risks of steroids are likely to outweigh the benefits.
Give oral steroids early in the treatment of acute asthma attacks in children. Oral prednisolone is the steroid of choice for asthma attacks in children unless the patient is unable to tolerate the dose. For a moderate attack NICE Quality standards are to give oral/IV steroids within 1 hour of diagnosis within the Emergency department.

Suspend long acting beta agonists when short acting beta agonists are required more often than 4 hourly (e.g. salmeterol).

Reassess

Continue inhaled salbutamol 1 - 4 hourly
Individualise drug dosing according to severity and adjust according to the patient’s response.
Initiate discharge plan (see later)

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Give oxygen at sufficient flow to achieve a normal oxygen saturation (94% or higher). If very high flow oxygen required, consider humidification. Consider intensive inpatient treatment of children with SpO2 <92% in air after initial bronchodilator treatment.

Give inhaled salbutamol 10 puffs of the 100 microgram/puff pMDI. Give one puff at a time inhaled with five tidal breaths, via spacer with mouthpiece (use facemask if necessary in younger children).

OR

Nebulised salbutamol driven with 100% oxygen
<5 years of age 2.5mg
>5 years of age 5mg

Reassess

Give prednisolone (as above) or IV hydrocortisone sodium succinate 4mg/kg (maximum 100mg per dose) every 6 hours.

Reassess response after each treatment

If poor response add nebulised ipratropium, driven with 100% oxygen, (child under 12 years 250 micrograms, 12 - 18 years 500 micrograms) every 20 - 30 minutes for the first 2 hours then every 4 - 6 hours thereafter. Reduce as clinical improvement occurs.
Consider adding 150 mg magnesium sulphate to each nebulised salbutamol
and ipratropium in the first hour in children with a short duration of acute
severe asthma symptoms presenting with an SpO2 <92%.( Nebulised magnesium sulphate is not recommended for children with mild
to moderate asthma attacks.)

Please see medicines formulary for nebulised magnesium sulphate monograph

Remember children can present with severe asthma and significant airway obstruction and not appear distressed.
Antibiotics should not be routinely used
CXR’s should not be routinely performed

Arrange admission

• If any features of acute severe or life threatening episode
• If any features of severe attack persisting after initial treatment
• If peak flow < 50% predicted 15 minutes after b2 agonist
• Have a lower threshold if social concerns or presents acutely during the night
• Consider admission if saturations are <92% after initial bronchodilator treatment

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If the child is in the emergency department consider moving them to resus.

Give high-flow oxygen via a tight fitting face mask or nasal cannula at sufficient flow rates to achieve normal saturations of 94-98%.

Nebulised salbutamol driven with 100% oxygen
<5 years of age 2.5mg
>5 years of age or 5mg

Consider early IV access

Plus

Give nebulised ipratropium bromide (child under 12 years 250 micrograms, 12 - 18 years 500 micrograms),driven with 100% oxygen. Can be used every 20-30 minutes for first 2 hours mixed with b2 agonist. Reduce as clinical improvement occurs.

Give IV hydrocortisone sodium succinate 4mg/kg (maximum 100mg per dose) every 6 hours.

Discuss with senior doctor on-call and consider whether 2222 call is required

Reassess

Repeat bronchodilators every 20-30 minutes or more frequently as symptoms indicate for first 1-2 hours.

Reassess response after each treatment

Consider the following;

A chest X-ray should be performed if there is subcutaneous emphysema, persisting unilateral signs suggesting pneumothorax, lobar collapse or consolidation and/or life-threatening asthma not responding to treatment.

Blood gases, full blood count, U&Es.

Second line treatments

IV aminophylline
OR
IV salbutamol
Consider early addition of a single bolus dose of intravenous salbutamol in a severe asthma attack where the patient has not responded to initial inhaled therapy.
OR
IV magnesium
In children who respond poorly to first-line treatments, consider the addition of intravenous magnesium sulphate as first-line intravenous treatment.

1. IV aminophylline (Link to monograph)

5mg/kg loading dose given over 20 minutes (maximum dose = 500mg)

DO NOT give the loading dose if the patient was taking oral theophylline prior to admission, an initial blood level is recommended. The loading dose should be followed by a continuous infusion;

Child 1 month - 12 years: 1mg/kg/hour

Child 12 - 18 years: 0.5-0.7 mg/kg/hour (500 - 700 micrograms/kg/hour)

Aminophylline levels are to be taken at clinician's discretion - there is a recommendation for daily monitoring if patient is in intensive or high dependency care areas, likely to continue on infusion for >24 hours, condition deteriorating, toxicity suspected, active influenza infection or recently received influenza immunisation.
Symptoms of toxicity include; vomiting (which may be severe and intractable), agitation, restlessness, dilated pupils, sinus tachycardia, and hyperglycaemia. More serious effects are haematemesis, convulsions, and supraventricular and ventricular arrhythmias. Severe hypokalaemia may develop rapidly.
Aminophylline dose should be adjusted based on levels taken 4-6 hourly after commencement of infusion.

The dose of aminophylline needs to be halved if the patient is on a macrolide antibiotic, such as clarithromycin, azithromycin, erythromycin, quinolone antibiotic such as ciprofloxacin or other interacting drug.

See further information included within monographs.

OR

2. IV salbutamol (Link to monograph)

1 month -< 2 years: 5 micrograms/kg bolus over 10 minutes
2-18 years: 15 micrograms/kg bolus over 10 minutes (max 250micrograms).

This should be followed by a continuous infusion of 1 microgram/kg/min, increasing to a maximum of 5 microgram/kg/minute if necessary. When inserting an IV cannula take a blood sample to measure serum electrolytes. Serum potassium levels are often low after multiple doses of β2 agonists and should be replaced. If intravenous β2 agonist infusions are used, consider monitoring serum lactate to monitor for toxicity.

Intravenous aminophylline and salbutamol can be used together if poor response.

If poor response discuss with Anaesthetist on-call and PICU team

If either or both IV aminophylline and salbutamol are needed, high dependency or intensive care must be considered. Patient must be nursed on a cardiac monitor

OR

3. IV magnesium (Link to monograph)

Child aged> 2 years old, and no or poor response to either of the above, give a bolus injection of magnesium sulphate 40mg/kg (max 2g) over 20 minutes. IV magnesium sulphate is a safe treatment for acute asthma, although studies have been inconsistent in providing evidence of benefit. Use of IV magnesium in patients under 2 years of age should be consultant decision only.

Reassess response after each treatment
Do not stop nebulised salbutamol. Adjust the dose according to response and heart rate.
Check potassium 6 hourly whilst on IV aminophylline or IV salbutamol.

It is important to involve a clinician with the appropriate skills in airway management and critical care support as early as possible or children with asthma not responding to standard treatment should be evaluated by a specialist with the appropriate experience and skills to use and assess medication familiar to those in critical care settings.

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Assessment

• Ongoing assessment of response to treatment and severity of respiratory distress
• Oxygen saturations, respiratory and heart rate should be recorded as frequently as inhaled treatment is required

Peak flows should be considered for home monitoring twice daily pre and post bronchodilator for children over 5 years of age

• It is good practice for children already receiving inhaled corticosteroids to

continue with their usual maintenance dose during an asthma attack whilst
receiving additional treatment.

Treatment

• Oxygen to maintain saturations at 94% and above
• Use inhaled or nebulised salbutamol depending on severity.
• If on IV aminophylline and/or salbutamol consider high dependency or intensive care assessment. Nurse on a cardiac monitor and assess frequently.
• Nebulised bronchodilators to be given if life threatening episode, with the frequency and dose adjusted according to clinical need.
• High dose inhaled bronchodilators via a spacer can be used, with the frequency and dose to be adjusted according to clinical need
• Prednisolone ideally given after food for up to 3 days, should be tailored to the number of days necessary to bring about recovery
• Ongoing assessment and education of asthma management and treatments

Guidelines for discharge from the ward
A hospital admission represents a window of opportunity to review self-management skills. All patients should be discharged with a written personalised asthma action plan which has been explained.

• Ensure that the patient is stable on 4 hourly inhaled bronchodilator at 600 micrograms per dose
• Ensure that the patient is discharged with appropriate treatment and advise to reduce salbutamol over a few days as symptoms settle and to be then used as required. Education should include personalised discussion of issues such as trigger avoidance and achieving a smoke-free environment to support people and their families living with asthma.
• Advise to contact the GP if symptoms persist despite above treatment
• Review the doses and need for regular treatment
• Record devices and doses of all treatment on discharge
• Review and record inhaler technique
• Provide a personalized asthma/wheeze action plan for treating future episodes to support the family and child in self-management of their asthma
• If discharged on oral steroids for longer than 7 days, issue a steroid card.
• Tapering is unnecessary unless the course of steroids exceeds 14 days.
• To assess adherence, ask specific questions about medication use and assess prescribing and any other data available. Explore attitudes to medication as well as practical barriers to adherence in a non-judgemental way.
• Advise parents to arrange follow up with GP/asthma nurse within 2 working days following discharge from hospital.
• The National Review of Asthma Deaths (NRAD) report highlighted that there is an increased risk of death within one month of discharge from hospital following an acute attack and that follow up in primary care is therefore essential.

GP needs to be informed of admission within 24 hours (NICE Quality Standard)- Ideally this communication should be directly with a named individual responsible for asthma care within the practice.

Discharge plans should address the following:

1. The diagnosis – clearly document the criteria used to diagnose asthma
2. Consider the need for preventer treatment or optimising/adjusting previously prescribed preventer treatments provide a written personalised asthma action plan for subsequent asthma attacks with clear instructions about the use of bronchodilators and the need to seek urgent medical attention in the event of worsening symptoms not controlled by up to 10 puffs of salbutamol 4 hourly
3. Assess exposure to environmental tobacco smoke or actual smoking in older children and refer to suitable agencies where appropriate
4. Identify the triggers of the acute attack and discuss future management plans for exposure
5. Arrange follow up by primary care services within two working days
6. Arrange follow up in a general paediatric asthma clinic within one to two months
7. Arrange referral to a paediatric respiratory specialist if there have been life threatening features or patients who have had 1-2 admissions per year despite step 4-5 treatment.( https://ginasthma.org/severeasthma/)
8. Document clearly all the above

An asthma care bundle developed by BTS is also available from the BTS website (www.brit-thoracic.org.uk).

Discharge information links
Follow up appointment pathway
Asthma Plan- https://www.asthma.org.uk/advice/child/manage/action-plan/
Wheeze Plan- available pre printed on the ward
Asthma UK- https://www.asthma.org.uk/
British Thoracic Society- https://www.brit-thoracic.org.uk
Global Initiative For Asthma- https://ginasthma.org/

Healthcare professionals must be aware that patients with severe asthma and one or more adverse psychosocial factors are at risk of death.

A combination of severe asthma is recognised by one or more of:

• previous near-fatal asthma, eg previous ventilation or respiratory acidosis
• previous admission for asthma especially if in the last year
• requiring three or more classes of asthma medication
• heavy use of β2 agonist
• repeated attendances at ED for asthma care especially if in the last year

AND adverse behavioural or psychosocial features recognised by one or more of:

• non-adherence with treatment or monitoring
• failure to attend appointments
• fewer GP contacts
• frequent home visits
• obesity
• parental self discharge from hospital
• psychosis, depression, other psychiatric illness or deliberate self harm in parents or older children
• current or recent major tranquilliser use
• denial
• alcohol or drug abuse
• learning difficulties
• employment problems
• income problems
• social isolation
• childhood abuse
• severe domestic, marital or legal stress

Acute asthma attacks should be considered a failure of preventive therapy and thought should be given about how to help families avoid further severe episodes.