Age >5 years - Management of acute asthma in children in general practice

Asthma pathway (BTS, NICE, SIGN) [SIGN 244]

This content is from the BTS/SIGN British guideline on the management of asthma (SIGN 158), 2019.

Assess and record asthma severity

Moderate asthma

  • SpO2 ≥92%
  • Able to talk
  • Heart rate ≤125/min
  • Respiratory rate ≤30/min
  • PEF ≥50% best or predicted.

Acute severe asthma

  • SpO2 <92%
  • Too breathless to talk
  • Heart rate >125/min
  • Respiratory rate >30/min
  • Use of accessory neck muscles
  • PEF 33–50% best or predicted.

Life-threatening asthma

SpO2<92% plus any of:

  • Silent chest
  • Poor respiratory effort
  • Agitation
  • Confusion
  • Cyanosis
  • PEF <33% best or predicted.

 

NB: If a patient has signs and symptoms across categories, always treat according to their most severe features.

Lower threshold for admission if:

  • Attack in late afternoon or at night
  • Recent hospital admission or previous severe attack
  • Concern over social circumstances or ability to cope at home

 

       

Moderate asthma

  • β2 bronchodilator:
    • via spacer*
  • Consider oral prednisolone 30–40mg.

If poor response, arrange admission.

* β2 bronchodilator via spacer given one puff at a time, inhaled separately using tidal breathing; according to response, give another puff every 60 seconds up to a maximum of 10 puffs

Acute severe asthma

  • Oxygen via facemask to maintain SpO2 94–98% if available
  • β2 bronchodilator
    • via nebuliser (preferably oxygen-driven), salbutamol 5mg
    • or, if nebuliser not available, via spacer*
  • Oral prednisolone 30-40mg.

Assess response to treatment 15 mins after β2 bronchodilator.

If poor response, repeat β2 bronchodilator and arrange admission.

* β2 bronchodilator via spacer given one puff at a time, inhaled separately using tidal breathing; according to response, give another puff every 60 seconds up to a maximum of 10 puffs

Life-threatening asthma

  • Oxygen via facemask to maintain SpO2 94–98% if available
  • β2 bronchodilator with ipratropium:
    • via nebuliser (preferably oxygen-driven), salbutamol 5mg and ipratropium 0.25mg every 20 minutes
    • or, if nebuliser and ipratropium not available, β2 bronchodilator via spacer*
  • Oral prednisolone 30–40mg or IV hydrocortisone 100mg if vomiting.

Repeat β2 bronchodilator via oxygen-driven nebuliser whilst arranging immediate hospital admission.

* β2 bronchodilator via spacer given one puff at a time, inhaled separately using tidal breathing; according to response, give another puff every 60 seconds up to a maximum of 10 puffs

If good response

  • Continue β2 bronchodilator via spacer or nebuliser, as needed but not exceeding 4 hourly
  • If symptoms are not controlled repeat β2 bronchodilator and refer to hospital
  • Continue prednisolone until recovery (minimum 3-5 days)
  • Arrange follow-up clinic visit within 48 hours
  • Consider referral to secondary care asthma clinic if 2nd attack within 12 months.

If poor response

  • Stay with patient until ambulance arrives
  • Send written assessment and referral details
  • Repeat β2 bronchodilator via oxygen-driven nebuliser in ambulance.