ACUTE ASTHMA IN CHILDREN
5 yr old child presents with cold, cough and breathlessness. He had previous multiple episodes of breathlessness which responded to salbutamol nebulisation. His parents have bronchial asthma. They have a cat at home .
His rr is 40/mt,spo2 90%,retractions +,hr 145/mt, crt <2 seconds
He can speak in sentences . he was given 4 puff every 20 mts and prednisolone
He shows a marginal improvement but at 2 hour he is tachypneic, spo2 88%, cant speak a sentence
You added ipratropium to nebulisation and magnesium as slow infusion over 20 mts. His pr is increasing , cyanotic , rhonchi not heard at all and peripheries cold . you added aminophylline as i/v s/c b2 agonist not available . niv is also started
Resident sets ventilator as standby. Abg 7.2 po2 48 pco2 60 mmhg hco3 16
Pcv
Pip 22,
Peep 3 cm hg
I:e 1:3
Rr :12
Fio2 80%
how to assess a child and grade severity?
Before children can receive appropriate treatment for an acute asthma attack in any setting, it is essential to assess accurately the severity of their symptoms. The following clinical signs should be recorded:
Pulse rate
(increasing tachycardia generally denotes worsening asthma; a fall in heart rate in
life-threatening asthma is a pre-terminal event)
Respiratory rate and degree of breathlessness
(ie too breathless to complete sentences in one breath or to feed)
Use of accessory muscles of respiration
(best noted by palpation of neck muscles)
Amount of wheezing
(which might become biphasic or less apparent with increasing airways obstruction)
Degree of agitation and conscious level
(always give calm reassurance).
Clinical signs correlate poorly with the severity of airways obstruction.634-637 Some
children with acute severe asthma do not appear distressed.
PULSE OXIMETRY
Accurate measurements of oxygen saturation are essential in the assessment of all children with acute wheezing. Oxygen saturation monitors should be available for use by all healthcare professionals assessing acute asthma in both primary and secondary care settings
Moderate asthma
Able to talk in sentences
SpO2 ≥92%
PEF ≥50% 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
Acute severe asthma
Can’t complete sentences in one breath or too
breathless to talk or feed
SpO2 <92%
PEF 33–50% 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 asthma
Any one of the following in a child with severe asthma:
Clinical signs Measurements
Silent chest
SpO2 <92%
Cyanosis
PEF <33% best or predicted
Poor respiratory effort
Hypotension
Exhaustion
Confusion
treatment
OXYGEN
Children with life-threatening asthma or SpO2 <94% should receive high-flow oxygen via a tight fitting face mask or nasal cannula at sufficient flow rates to achieve normal saturations of 94–98%.
INHALED SHORT-ACTING β2 AGONISTS
Inhaled β2 agonists are the first line treatment for acute asthma in children aged 2 years and over. Assessment of response should be based on accurately recorded clinical observations and repeat measurements of oxygenation (SpO2 )
Inhaled β2 agonists are the first-line treatment for acute asthma in children. Discontinue long-acting β2 agonists when short-acting β2 agonists are required more often than four hourly. A A pMDI + spacer is the preferred option for children with mild to moderate asthma.
Individualise drug dosing according to severity and adjust according to the patient’s response. 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
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 (see section 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
IPRATROPIUM BROMIDE
There is good evidence for the safety and efficacy of frequent doses of ipratropium bromide (every 20–30 minutes) used in addition to β2 agonists for the first two hours of a severe asthma attack. Benefits are more apparent in the most severe patients.647 A If symptoms are refractory to initial β2 agonist treatment, add ipratropium bromide (250 micrograms/dose mixed with the nebulised β2 agonist solution). 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 sixhourly or discontinued.
STEROID THERAPY
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.592,593 Benefits can be apparent within three to four hours. In head-to-head comparisons there is insufficient evidence to suggest that dexamethasone offers an advantage over prednisolone for the management of mild to moderate acute asthma in children. Further studies may indicate whether a single dose of dexamethasone may offer clinical benefit over multiple doses of prednisolone
Give oral steroids early in the treatment of acute asthma attacks in children. B Oral prednisolone is the steroid of choice for asthma attacks in children unless the patient is unable to tolerate the dose.
Oral and intravenous steroids are of similar efficacy.594,652,653 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.654 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. A Do not use inhaled corticosteroids in place of oral steroids to treat children with an acute asthma attack.
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.
SECOND-LINE TREATMENT OF ACUTE ASTHMA IN CHILDREN
Three options, IV magnesium sulphate, IV β2 agonist or IV aminophylline can be considered
INTRAVENOUS MAGNESIUM SULPHATE
Intravenous magnesium sulphate is a safe treatment for acute asthma in children not responding to first-line treatment.607,665,669 Doses of up to 50 mg/kg/day (maximum 2 g) have been used. The potential side effect of hypotension is rare. 665 B In children who respond poorly to first-line treatments, consider the addition of intravenous magnesium sulphate as first-line intravenous treatment (40 mg/kg/day)
INTRAVENOUS SALBUTAMOL
The role of intravenous β2 agonists in addition to nebulised treatment remains unclear.584 One study has shown that an IV bolus of salbutamol given in addition to near-maximal doses of nebulised salbutamol results in clinically significant benefits for those with moderate to severe asthma.584 B Consider early addition of a single bolus dose of intravenous salbutamol (15 micrograms/kg over 10 minutes) in a severe asthma attack where the child has not responded to initial inhaled therapy.
INTRAVENOUS AMINOPHYLLINE
There is no evidence that aminophylline is of benefit for mild to moderate asthma and side effects are common and troublesome.609,667 One well-conducted study has shown evidence of benefit in children with acute severe asthma unresponsive to multiple doses of β2 agonists and steroids, although the loading dose used was double that currently recommended in the UK and a third of patients were withdrawn from active medication because of vomiting.668 A Aminophylline is not recommended in children with mild to moderate acute asthma. B Consider aminophylline for children with severe or life-threatening asthma unresponsive to maximal doses of bronchodilators and steroids
A 5 mg/kg loading dose should be given over 20 minutes (omit in those receiving maintenance oral theophyllines) with ECG monitoring followed by a continuous infusion at 1 mg/kg/hour. Measure serum theophylline levels in patients already receiving oral treatment and in those receiving prolonged treatment.
NON-INVASIVE VENTILATION
Non-invasive ventilation as a treatment approach for children admitted to hospital with status asthmaticus has been reported in two small studies, one a pilot study for an RCT.672,673 Although there is some evidence that NIV is safe and feasible for use in this population, there is little evidence of its effectiveness and insufficient evidence on which to base a recommendation
Document1 ASTHMA SEVERITY
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Superintendent, ICH.