Examination:

Moderate exacerbation (all of)

Speech normal, able to talk

RR < 25 (> 5-12 y: ≤ 30, 2-5 y: 40) bpm

P < 110 (> 5-12 y: ≤ 125, 2-5 y: ≤ 140) bpm

SpO2 ≥ 92%

PEFR > 50-75% best or predicted

Severe exacerbation (any one of)

Can’t complete sentences (2-12 y: too breathless to talk)

2-12 y: use of accessory neck muscles

RR ≥ 25 (> 5-12 y: > 30, 2-5 y: > 40) bpm

P ≥ 110 (> 5-12 y: > 125, 2-5 y: > 140 ) bpm

SpO2 ≥ 92 (2-12 y.: < 92)%

PEFR > 33-50% best or predicted

Life threatening exacerbation (any one of)

Exhaustion, altered consciousness

Arrhythmia or hypotension

Silent chest, cyanosis or poor respiratory effort

2-12 y: silent chest, poor respiratory effort, agitation, confusion, cyanosis

SpO2 < 92%

PEFR < 33% best or predicted

Near-fatal asthma

Raised PaCO2 +/- requiring mechanical ventilation

Management:

Moderate exacerbation

Admit:

If worsening symptoms despite initial bronchodilator treatment

Previous episode of near-fatal asthma

Oxygen:

If hypoxic via venturi mask

Aim for SpO2 94-98%

Bronchodilators:

Salbutamol:

> 12 y: via pMDI + spacer:

- 4 puffs initially + 2 puffs every 2 mins up to 10 puffs

- Repeat every 10-20 mins if required

2-12 y: via pMDI + spacer (if < 3 years + mask):

- 1 puff every 30-60 secs up to 10 puffs (each puff should be given one at a time and inhaled with five

tidal breaths)

- Repeat every 10-20 mins if required

Antibiotics:

Do NOT prescribe antibiotics unless symptoms and signs of infectionPrednisolone:

> 12 years: Prednisolone 40-50mg PO 5/7

> 1-12 years: Prednisolone usually 3 days sufficient but tailor course to the individual:

- > 5 years 30-40mg PO

- 2-5 years 20mg PO

- < 2 years 10mg PO

Acute severe:

Admit all children and adults

Oxygen

If hypoxic via venturi mask

Aim for SpO2 94-98%

Bronchodilators via (ideally O2 driven (flow rate 6 L/min)) nebuliser:

Salbutamol:

> 5 y:

5 mg, repeat salbutamol every 20-30mins if required

2-5 y:

2.5 mg, repeat salbutamol every 20-30 mins if required

Ipratropium bromide:

> 12 y:

500 mcg

2-12 y:

250 mcg

Do not repeat ipratropium within 4 hours

Antibiotics:

Do NOT prescribe antibiotics unless symptoms and signs of infection

Doses as above

(Notes on prednisolone:

If already on maintenance steroids, increase to 2 mg/kg for children and up to 60 mg for adultsDuration: 3 days for children and 5 days for adults is usually sufficient, but tailor to the individual Weaning is not needed if the course is less than 14 days longRepeat dose if the child vomits)

Review:

Within 2 working days

Assessment of asthma control (eg Asthma Control Test (ACT))?

Review of reliever use (eg Asthma slide rule)?

(Note: no consensus on how many SABA inhalers per year is too much, Primary Care Respiratory

Society suggests 3 per year)

Review of chronic management with a low threshold to titrate treatment +/refer?

Educated and supported self management?

- Adult PAAP

- Child PAAP

If acute severe attacks follow-up in secondary care for 1 year?

If life threatening and near-fatal attack follow-up in secondary care indefinitely?

Resource(s):

BTS/SIGN: British Guideline on the Management of Asthma