Discontinue long-acting β₂ agonists when short-acting β₂ agonists are required more often than four hourly.

Increase β₂ agonist dose by giving one puff every 30–60 seconds, according to response, up to a maximum of ten puffs.

Parents/carers of children with an acute asthma attack at home, and symptoms not controlled by up to 10 puffs of salbutamol via a pMDI and spacer, should seek urgent medical attention.

If symptoms are severe additional doses of bronchodilator should be given as needed whilst awaiting medical attention.

Paramedics attending to children with an acute asthma attack should administer nebulised salbutamol, using a nebuliser driven by oxygen if symptoms are severe, whilst transferring the child to the emergency department.

Children with severe or life-threatening asthma should be transferred to hospital urgently.

Inhaled β₂ agonists are the first-line treatment for acute asthma in children aged two years and over.^647-650 Assessment of response should be based on accurately recorded clinical observations and repeat measurements of oxygenation (SpO2) (link to what would be table 17 in guideline). Children receiving β₂ agonists via a pMDI + spacer are less likely to have tachycardia and hypoxia than when the same drug is given via a nebuliser.⁵³¹ In children under two who have a poor initial response to β₂ agonists administered with adequate technique, consider an alternative diagnosis and other treatment options.

Children under three years of age are likely to require a face mask connected to the mouthpiece of a spacer for successful drug delivery. Inhalers should be actuated into the spacer in individual puffs and inhaled immediately by tidal breathing (for five breaths).

Frequent doses of β₂ agonists are safe for the treatment of acute asthma,^647-649 although children with mild symptoms benefit from lower doses.⁶⁵⁰

Two to four puffs of salbutamol (100 micrograms via a pMDI + spacer) might be sufficient for mild asthma attacks, although up to 10 puffs might be needed for more severe attacks. Single puffs should be given one at a time and inhaled separately with five tidal breaths. Relief from symptoms should last 3–4 hours. If symptoms return within this time a further or larger dose (maximum 10 puffs) should be given and the parents/carer should seek urgent medical advice.

Children with severe or life-threatening asthma (SpO2 <92%) should receive frequent doses of nebulised bronchodilators driven by oxygen (2.5–5 mg salbutamol). If there is poor response to the initial dose of β₂ agonists, subsequent doses should be given in combination with nebulised ipratropium bromide (Link to what would be 9.8.3). Doses of nebulised bronchodilator can be repeated every 20–30 minutes. Continuous nebulised β₂ agonists are of no greater benefit than the use of frequent intermittent doses in the same total hourly dosage.⁶⁵¹, ⁶⁵² Once improving on two- to four-hourly salbutamol, patients should be switched to a pMDI and spacer treatment as tolerated.

Schools can hold a generic reliever inhaler enabling them to treat an acutely wheezy child whilst awaiting medical advice. This is safe and potentially life saving.

Repeated doses of ipratropium bromide should be given early to treat children who are poorly responsive to β₂ agonists.

Frequent doses up to every 20–30 minutes (250 micrograms/dose mixed with 5 mg of salbutamol solution in the same nebuliser) should be used for the first few hours of admission. Salbutamol dose should be tapered to one to two hourly thereafter according to clinical response. The ipratropium dose should be tapered to four to six hourly or discontinued.

The early use of steroids in emergency departments and assessment units can reduce the need for hospital admission and prevent a relapse in symptoms after initial presentation.⁵⁹⁸, ⁵⁹⁹ Benefits can be apparent within three to four hours.

In the acute situation, it is often difficult to determine whether a preschool child has asthma or episodic viral wheeze. Children with severe symptoms requiring hospital admission should still receive oral steroids. In children who present with moderate to severe wheeze without a previous diagnosis of asthma it is still advisable to give oral steroids. For children with frequent episodes of wheeze associated with viruses caution should be taken in prescribing multiple courses of oral steroids.⁶⁵⁷

• Use a dose of 10 mg prednisolone for children under two years of age, 20 mg for children aged 2–5 years and 30–40 mg for children older than five years. Those already receiving maintenance steroid tablets should receive 2 mg/kg prednisolone up to a maximum dose of 60 mg.
• Repeat the dose of predisolone in children who vomit and consider intravenous steroids in those who are unable to retain orally ingested medication.
• Treatment for up to three days is usually sufficient, but the length of course should be tailored to the number of days necessary to bring about recovery. Tapering is unnecessary unless the course of steroids exceeds 14 days

Use a dose of 10 mg of prednisolone for children under two years of age, a dose of 20 mg for children aged 2–5 years and a dose of 30–40 mg for children older than five years.

Oral and intravenous steroids are of similar efficacy.⁶⁰⁰, ⁶⁵⁸, ⁶⁵⁹ Intravenous hydrocortisone (4 mg/kg repeated four hourly) should be reserved for severely affected children who are unable to retain oral medication.

Larger doses do not appear to offer a therapeutic advantage for the majority of children.⁶⁶⁰ There is no need to taper the dose of steroid tablets at the end of treatment.

Inhaled corticosteroids

There is insufficient evidence to support the use of ICS as alternative or additional treatment to steroid tablets for children with acute asthma.⁶⁰⁴, ^661-668

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.

Children with chronic asthma not receiving regular preventative treatment will benefit from starting ICS as part of their long-term management. There is no evidence that increasing the dose of ICS is effective in treating acute symptoms, but it is good practice for children already receiving ICS to continue with their usual maintenance doses.

Do not give antibiotics routinely in the management of children with acute asthma.

There is insufficient evidence to support or refute the role of antibiotics in acute asthma, but the majority of acute asthma attacks are triggered by viral infection.⁴⁵⁸

Initiating oral montelukast in primary care settings, early after the onset of an acute asthma attack, can result in decreased asthma symptoms and the need for subsequent healthcare attendances in those with mild asthma attacks.⁵⁰⁸

There is no evidence to support the use of nebulised magnesium sulphate, either in place of or in conjunction with inhaled β₂ agonists, in children with mild to moderate asthma.⁶⁰⁹ A subgroup analysis from a large RCT suggests a possible role in children with more severe asthma attacks (SpO2 <92%) or with short duration of deterioration. Further studies are required to evaluate which clinical groups would benefit the most from this intervention.⁶⁷⁰

1. 458. Scottish Intercollegiate Guidelines Network (SIGN). Pharmacological management of asthma. Evidence table 4.24a: Other preventor therapies - Chromones in children aged 5-12. Edinburgh: SIGN; 2005. Available from http://www.sign.ac.uk/guidelines/published/support/guideline63/index.html: [Accessed. 10 Jul 2014].
2. 508. Robertson CF, Price D, Henry R, Mellis C, Glasgow N, Fitzgerald D, et al. Short-course montelukast for intermittent asthma in children: a randomized controlled trial. Am J Manag Care 2007;175(4):323-9
3. 598. Rowe BH, Spooner C, Ducharme FM, Bretzlaff JA, Bota GW. Early emergency department treatment of acute asthma with systemic corticosteroids (Cochrane Review). In: The Cochrane Library, 2001.
4. 599. Rowe BH, Spooner CH, Ducharme FM, Bretzlaff JA, Bota GW. Corticosteroids for preventing relapse following acute exacerbations of asthma (Cochrane Review). In: The Cochrane Library, 2001.
5. 600. Manser R, Reid D, Abramson M. Corticosteroids for acute severe asthma in hospitalised patients (Cochrane Review). In: The Cochrane Library, 2001.
6. 604. Edmonds ML, Camargo CA, Pollack CV Jr, Rowe BH. Early use of inhaled corticosteroids in the emergency department treatment of acute asthma (Cochrane Review). In: The Cochrane Library, (3) 2003.
7. 609. Knightly R, Milan Stephen J, Hughes R, Knopp-Sihota Jennifer A, Rowe Brian H, Normansell R, et al. Inhaled magnesium sulfate in the treatment of acute asthma. Cochrane Database of Systematic Reviews 2017: Issue 11.
8. 657. Panickar J, Lakhanpaul M, Lambert PC, Kenia P, Stephenson T, Smyth A, et al. Oral prednisolone for preschool children with acute virus-induced wheezing. N Engl J Med 2009;360(4):329-38.
9. 658. Becker JM, Arora A, Scarfone RJ, Spector ND, Fontana-Penn ME, Gracely E, et al. Oral versus intravenous corticosteroids in children hospitalized with asthma. J Allergy Clin Immunol 1999;103(4):586-90.
10. 659. Barnett PL, Caputo GL, Baskin M, Kuppermann N. Intravenous versus oral corticosteroids in the management of acute asthma in children. Ann Emerg Med 1997;29(2):212-7
11. 660. Langton Hewer S, Hobbs J, Reid F, Lenney W. Prednisolone in acute childhood asthma: clinical responses to three dosages. Respir Med 1998;92(3):541-6.
12. 661. Edmonds ML, Brenner BE, Camargo CA, Rowe BH. Inhaled steroids in acute asthma following emergency department discharge (Cochrane Review). In: The Cochrane Library, (3) 2000.
13. 662. McKean MC, Ducharme F. Inhaled steroids for episodic viral wheeze of childhood (Cochrane Review). In: The Cochrane Library, 2000.
14. 663. Schuh S, Reisman J, Alshehri M, Dupuis A, Corey M, Arseneault R, et al. A comparison of inhaled fluticasone and oral prednisone for children with severe acute asthma. N Engl J Med 2000;343(10):689-94.
15. 664. Ducharme FM, Lemire C, Noya FJ, Davis GM, Alos N, Leblond H, et al. Preemptive use of high-dose fluticasone for virus-induced wheezing in young children. New England Journal of Medicine 2009;360(4):339-53.
16. 665. Papi A, Nicolini G, Boner AL, Baraldi E, Cutrera R, Fabbri LM, et al. Short term efficacy of nebulized beclomethasone in mild-to-moderate wheezing episodes in pre-school children. Italian Journal of Pediatrics 2011;37:39.
17. 666. Schuh S, Dick PT, Stephens D, Hartley M, Khaikin S, Rodrigues L, et al. High-dose inhaled fluticasone does not replace oral prednisolone in children with mild to moderate acute asthma. Pediatrics 2006;118(2):644-50.
18. 667. Upham BD, Mollen CJ, Scarfone RJ, Seiden J, Chew A, Zorc JJ. Nebulized budesonide added to standard pediatric emergency department treatment of acute asthma: a randomized, double-blind trial. Academic Emergency Medicine 2011;18(7):665-73.
19. 668. Volovitz B, Bilavsky E, Nussinovitch M. Effectiveness of high repeated doses of inhaled budesonide or fluticasone in controlling acute asthma exacerbations in young children. Journal of Asthma 2008;45(7):561-7.
20. 670. Powell C, Kolamunnage-Dona R, Lowe J, Boland A, Petrou S, Doull I, et al. Magnesium sulphate in acute severe asthma in children (MAGNETIC): a randomised, placebo-controlled trial. [Erratum appears in Lancet Respir Med. 2013 Jun;1(4):285]. The Lancet Respiratory Medicine 2013;1(4):301-8.