CHILDREN’S EMERGENCY DEPARTMENT

Acute Wheeze Flow-Chart: For children 2-16 years

Start by assessing severity and treat accordingly

Mild
• SaO2 >94% air
• Mild recession
• Mild to moderate
wheeze
Moderate Severe Life threatening
• SaO2 ≥ 92% air • SaO2 <92% in air • SaO2 <92% in O2
• Can talk in short • <5yrs: RR >40, HR • Pallor/ cyanosis
sentences >140 • Poor respiratory
• Moderate recession • ≥5yrs: RR>30, HR >125 effort
and wheeze • Unable to talk/feed • Agitated
• Marked recession • Reduced GCS
• Silent chest

CALL FOR
HELP
Blp Paed Reg

Give Oxygen if needed to keep saturations >93%. High flow oxygen

Salbutamol via spacer
Reassess after 20
minutes and repeat if
needed up to 3 doses
Consider oral
prednisolone if:
Needs >1 dose
salbutamol and/or:
• Known asthmatic
• ≥5 years old
• < 5 years with multi-
trigger wheeze
Salbutamol via spacer Burst therapy of Back to back nebulised
Reassess after 20 minutes Salbutamol and salbutamol and
and repeat if needed up ipratropium via spacer ipratropium
to 3 doses (nebuliser if not tolerating • Obtain IV access
spacer or sats <92%) every • U&E and blood gas
If response to 1st Salb: 20minutes • IV hydrocortisone
a) Good consider re- • IV magnesium bolus
categorising to mild Oral prednisolone, (or IV
b) Poor Inform Paed Reg hydrocortisone if vomiting) REASSESS and if poor
but continue to manage. response:
Add ipratropium to REASSESS and if poor • Continue nebulisers
remaining salbutamol. response: • Give IV salbutamol
• Repeat burst: bolus and then infusion
Oral prednisolone if: • IV magnesium bolus or if salbutamol toxicity,
• Known asthmatic • IV salbutamol bolus+/- give IV aminophylline
• ≥5 years old infusion • Call consultant +/-
• Consider if <5 yrs and anaethetist and CATS
multi-trigger wheeze

Assess response to treatment after 1 hour and 2 hours and re-categorise

MILD MODERATE SEVERE LIFE THREATENING

Only discharge if stable
and requiring Salbutamol
every 3-4 hours
Complete 3 days of
prednisolone if started.
Discharge with asthma plan.
Advise review within 48
hours by GP
Keep O2 SaO2 >93% Keep O2 SaO2 >93%
Continue salbutamol Continue salbutamol
every 1-3 hrs as needed every 30-60 minutes
Safe to discharge when Continue ipratropium
only requiring salbutamol every 20 minutes for first 2
every 3-4 hours hours and then every 4 hours
Complete 3 days of Reassess frequently
prednisolone if started. If no improvement and not
already done so give:
Give asthma plan. • IV magnesium
• IV salbutamol bolus +/-
Advise review within 48 infusion
hours by GP Admit HDU
Continue nebulisers
Give IV salbutamol +/-
aminophylline if not
already done so.
nd
Consider 2 dose IV
magnesium + antibiotics
Call anaesthetist and
CATS
Do CXR and gas
If deteriorating consider
intubation and ventilation
 CHILDREN’S EMERGENCY DEPARTMENT
Medication Doses for Acute Asthma
Bronchodilator therapy through MDI (Metered Dose Inhaler) with spacer should be first line as it is associated
with fewer side effects.

Burst therapy refers to 3-Sets of inhalers/nebs (back-to-back). *Atrovent is only given in sever and life
threatening asthma attacks!
Route of Dose Dose Comments
administration < 5 years ≥ 5 years
Each Set MDI and spacer 6 puffs Salbuatmol 10 puffs 1 puff = 100mcg
SaO2 ≥ 92% air 1 puffs Atrovent* 2 puffs Atrovent*
Nebuliser 2.5 mg Salbutamol 5mg
SaO2 <92% in air ---mg Atrovent* ---mg Atrovent*

Medication Route of Dose Dose Comments

administration < 5 years ≥ 5 years

Salbutamol MDI and spacer 6 puffs 10 puffs 1 puff = 100mcg

Nebuliser 2.5mg 5mg

Ipratropium Bromide MDI and spacer 20 mcg (I puff) 20 mcg (1 puff) x 6 20-40 mcg every 20
(Atrovent) ratio: 1:6 salb min for first 2 hrs
Nebuliser <2 years 125mcg 2-12 years 250 mcg
2-12 yrs 250mcg > 12 years 500 mcg

Prednisolone Oral 20mg 40mg Consider carefully if

<5 years (see
guideline)
Hydrocortisone Intravenous 4mg/kg every 6 hours (max 100mg) Give if vomiting or
Or if weight unavailable use: life-threatening
< 2 years 25mg episode of wheeze
2-5 years 50mg
> 5 years 100mg

Magnesium Sulphate Intravenous 40mg/kg (max 2g) Give over 20 min

Bolus If overweight use “ideal weight” based on BP+ Cardiac monitor*
their height centile or chart in back of cBNF Can repeat within 1-2
hrs (further doses
need Mg Levels)

Salbutamol Intravenous bolus < 2 years 5mcg/kg Single bolus

Please use the Salbutamol ≥ 2 years 15mcg/kg (max 250mcg) Give over 3-5
sticker (kept in HDU on Ifor & If overweight use “ideal weight” based on minutes
ED) their height centile or chart in back of cBNF Cardiac monitor*
Intravenous 1-2 mcg/kg/min (If weight over 40kg, Monitor side effects
Infusion calculate rate on 40kg) including lactate and
If overweight use “ideal weight” based on K+.
their height centile or chart in back of cBNF Cardiac monitor*

Aminophylline Intravenous 5mg/kg (max 500mg) Give over 20-30 mins.

Please use the Aminophylline
sticker (kept in HDU on Ifor &
ED)
loading dose If overweight use “ideal weight” based on Cardiac monitor*.
their height centile or chart in back of cBNF Give antiemetics.
- Loading not needed if
on oral Aminophylline.
Intravenous < 12 years 1mg/kg/hr Cardiac monitor*
infusion > 12 years 0.5-0.7 mg/kg/hr Give antiemetics
If overweight use “ideal weight” based on Levels 4-6 hrs
their height centile or chart in back of cBNF