Questionnaire/history:

Symptoms for < 10 days during URTI?

2-3 episodes per year?

No symptoms between episodes

Past medical history (eg atopy, food allergy)?

Family history?

Current medication?

Known drug allergies?

Management:

Severe/life-threatening illness:

Child unable to speak or drink?Cyanosis?RR > 40?SpO2 < 92%?

Silent chest?

Lack of response to 6 puffs salbutamol or persisting tachypnoea after 3 rounds of SABA?

Immediate hospital transfer via 999

While waiting for ambulance:

Salbutamol MDI via spacer 6 puffs every 20 minutes as needed (or 2.5mg via nebuliser)

Oxygen if required to maintain SpO2 94-98%

Prednisolone 2mg/kg - max. per day 20mg for < 2 years and 30mg for 2-5 years

Consider 1-2 doses of nebulised ipratropium bromide

Mild > moderate illness:

Salbutamol MDI 2 puffs via spacer or 2.5mg via nebuliser every 20 mins for 1st hour

O2 if needed, consider ipratropium if needed

Spacers will require a face mask for < 3 years and a mouthpiece for most 3-5 year olds

Monitor closely for 1-2 hours - refer if lack of response to treatment, any signs of severe exacerbation, increasing respiratory rate, decreasing SpO2

If improving continue to monitor, if symptoms recur within 3-4h give 2-3 puffs salbutamol per hour

If worsening:

Give 10 puffs salbutamol over 3-4h, prednisolone for 3-5 days (dose as per severe illness) and treat as per severe illness

Discharge and follow-up:

Ensure adequate resources at home, continue reliever, continue/adjust/add controller, check inhaler technique, provide an asthma action plan

Follow up 1-2 working days and at 1-2 months

Chronic/acute-on-chronic management:

Step 1: infrequent viral wheezing and no interval symptoms

SABA prn

Step 2: symptom pattern not consistent with asthma but frequent wheezing episodes eg ≥ 3/year; give ICS diagnostic trial for 3 months, symptom pattern consistent with asthma and asthma symptoms not well controlled or ≥ 3 exacerbations/year

Daily low doses ICS + SABA prn

Alternative option: Daily LRTA or intermittent short course of ICS at onset of respiratory illness

Step 3: asthma diagnosis and asthma not well controlled on low dose ICS*

Double low dose ICS + SABA prn

Alternative option: low dose ICS + LRTA

Step 4:

Refer to specialist assessment: asthma not well controlled on double dose ICS*

Alternative option: add LRTA or increase ICS dose or frequency

*Before stepping up: Check for alternative diagnoses, check inhaler skills, review adherence and exposures

Resource(s):

Global Initiative for Asthma (GINA): 2022 GINA Report, Global Strategy for Asthma Management and Prevention