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Childhood Asthma

April 26, 2017

The classification and management of acute asthma in children could feature in both the FRCEM Primary and Intermediate examinations. The tables below summarise the main points from the BTS/SIGN asthma guidelines but you should read around the pharmacology of the following drugs and the pathophysiology of asthma.

Classification of Acute Asthma in Children

This is an easily asked exam question and candidates should have a knowledge of the following criteria.

The nature of treatment required for the management of acute asthma depends on the level of severity, described as follows:

Severity Criteria
Moderate
  • Able to talk in sentences
  • SpO2 ≥ 92%
  • PEF ≥ 50% of best or predicted
  • Heart rate
    • ≤ 140/min in children aged 1 – 5 years
    • ≤ 125/min in children > 5 years
  • Respiratory rate
    • ≤ 40/min in children aged 1 – 5 years
    • ≤ 30/min in children > 5 years
Severe
  • Can’t complete sentences in one breath or too breathless to talk or feed
  • SpO2 < 92%
  • PEFR 33 – 50% of best or predicted
  • Heart rate
    • > 140/min in children aged 1 – 5 years
    • > 125/min in children > 5 years
  • Respiratory rate
    • > 40/min in children aged 1 – 5 years
    • > 30/min in children > 5 years
Life-threatening Any one of the following in a child with severe asthma:

  • PEFR < 33% of best or predicted
  • SpO2< 92%
  • Silent chest
  • Cyanosis
  • Poor respiratory effort
  • Hypotension
  • Exhaustion
  • Confusion

BTS/SIGN Management of Acute Asthma in Children

All candidates should have a sound knowledge of the BTS and SIGN Asthma Guidelines.

asthma1
asthma
Drug Dose
Oxygen High-flow oxygen at sufficient rates to achieve SpO2 94 – 98%
Inhaled salbutamol
  • pMDI + spacer (mild/moderate asthma): single puff inhaled with 5 tidal breaths, given every 30 – 60 seconds, up to maximum of 10 puffs
  • Oxygen-driven nebuliser: 2.5 – 5 mg salbutamol, given every 20 – 30 mins
Ipratropium bromide 250 micrograms/dose mixed with the nebulised β2 agonist solution given every 20 – 30 minutes
Oral prednisolone
  • Dose
    • Children < 2 years 10 mg
    • Children aged 2 – 5 years 20 mg
    • Children > 5 years 30 – 40 mg
  • Treatment for up to 3 days is usually sufficient
Intravenous hydrocortisone 4 mg/kg repeated four hourly, reserved for severely affected children who are unable to retain oral medication
Nebulised magnesium sulphate Consider adding 150 mg 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%
Antibiotics Not given routinely in acute asthma
Intravenous salbutamol
  • Consider early addition of a single bolus dose of 15 micrograms/kg over 10 minutes in a severe asthma attack where the child has not responded to initial inhaled therapy
  • A continuous intravenous infusion should be considered when there is uncertainty about reliable inhalation or for severe refractory asthma
Intravenous aminophylline Consider a 5 mg/kg loading dose over 20 minutes followed by continuous infusion at 1 mg/kg/hr for children with severe or life-threatening asthma unresponsive to maximal doses of bronchodilators and steroids
Intravenous magnesium sulphate Consider the addition of 40 mg/kg/day as first-line intravenous treatment in children who respond poorly to first-line treatments

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