How to manage acute asthma and wheezing in children in primary care

Step by step: How to manage acute asthma and wheezing in

children in primary care
Step 1: Identify the features of an acute attack
International guidelines define an asthma attack as “an acute or subacute worsening in
symptoms and lung function from the patient’s usual status, or in some cases, the initial
presentation of asthma.” The term “exacerbation” is often used in the scientific literature,
but patients and carers may use words including “attack”, “episode”, or “flare up”. [5]
The term “attack” is used in the asthma guideline from the British Thoracic Society and
the Scottish Intercollegiate Guidelines Network (BTS/SIGN). [2]
Identifying when a child is having an acute asthma attack can be challenging. The
presentation varies widely depending on the child’s age. In children aged five years and
under, recurrent wheezing triggered by viral upper respiratory tract infections is common.
In these children, it is difficult to decide whether or not this is an early presentation of
asthma. [5] In older children, a firm diagnosis of asthma may not yet have been made.
Therefore, we use the term “wheezing/asthma attack” here to acknowledge that the child
may not have a definitive diagnosis of asthma.

Learning bite: early recognition

Most wheezing/asthma attacks develop over one to two days. This means that with early
recognition of an attack, there is an opportunity to start early treatment and arrange
urgent referral to hospital if necessary, which can help to prevent the attack progressing.
[9] Children with low oxygen saturations (under 92%), or those with other features of a
severe or life threatening attack, will need urgent transfer to hospital in an ambulance [2]
[16]; see step 2 for more details.
Children aged over five years
Older children and adolescents present in a similar way to adult patients with asthma.
Symptoms and signs include [5]:
 Progressive increase in symptoms of shortness of breath, cough, wheeze, and/or
chest tightness
 Progressive decrease in lung function (eg peak expiratory flow compared with
previous or predicted values)
 Difficulty talking
 Increased heart rate
 Increased respiratory rate, with use of accessory muscles of respiration
 Reduced oxygen saturation.
Children aged one to five years:
Infants and preschool children often present in more subtle ways than older children, with
parents/caregivers reporting symptoms related to upper respiratory tract infections such
as a runny nose, coughing, and noisy breathing, before they notice any wheezing. In
addition, what parents understand by the term “wheeze” is often different to what doctors
understand by the term. [3] Parents often use the term “wheeze” for any noise coming
from the respiratory tract. It is therefore important to consider the possible differential
diagnoses, especially in this age group (see Learning bite below).
Early symptoms of wheezing/asthma attacks in pre-school children may include [5]:
 An increase in wheeze and difficulty breathing
 An increase in coughing, especially when asleep
 Lethargy or reduced exercise tolerance
 Impairment of daily activities, including feeding
 A poor response to reliever medication, if the child has a diagnosis of asthma.
Many preschool children have no history of a previous asthma/wheezing attack. [1] Even
if children have had previous attacks of wheezing triggered by an upper respiratory tract
infection, most will have few or no respiratory symptoms, such as wheezing or
breathlessness, between the attacks. These interval symptoms become more common as
children get older.
Children under one year
You should consider referring children with acute wheeze who are aged under one year to
hospital if they have signs of respiratory distress, including low oxygen saturation (under
92%), increased work of breathing, or reduced feeding. A large proportion of children
under one year will have bronchiolitis, and only need hospital review if they have signs
of respiratory distress. If reviewed in hospital, management of children with acute
wheeze should be under the initial direction of an emergency medicine consultant, with
discussion with an acute general paediatric consultant as needed.

Clinical tip: wheeze

Wheeze is most accurately identified through auscultation of the chest. It is important to
distinguish wheezing from other respiratory noises, such as stridor or crackles:
 Stridor: a high-pitched sound due to turbulent air flow, usually heard during
inspiration and localised over the throat; often occurs in children with croup
 Crackles: may occur in a range of diseases, including pneumonia and tuberculosis.
If wheezing is heard on auscultation it is important to document this in the child’s
medical records, because it may be useful information when it comes to later confirming
a diagnosis of asthma.
The presence of wheeze alone is not typical of an acute asthma attack. Breathlessness and
difficulty breathing in combination with wheeze are usually present, and are better
indicators of an acute asthma attack. In younger children who cannot yet communicate,
these findings can be difficult to assess.

Clinical tip: reception staff

Make sure that your reception staff are aware that an asthma patient with any acute
respiratory symptoms may be at risk, and needs immediate access to a doctor or trained
asthma nurse. [2] The practice’s front line team of receptionists are part of the care
pathway and need to recognise a patient whose asthma is deteriorating, and that they
should be treated as an emergency.

Learning bite: differential diagnosis

The child’s age, combined with a detailed history from the parents, usually helps to rule
out other causes of acute respiratory distress. [2]
Here are some important differential diagnoses to consider. It is worth bearing in mind
that asthma/acute wheeze may coexist with a number of these diagnoses [23]:
Common
 Bronchiolitis: occurs in children under two years old and most commonly in the
first year of life, peaking between three and six months. Symptoms include coryzal
prodrome lasting one to three days, followed by persistent cough, and either
tachypnoea or chest recession (or both), and either wheeze or crackles on chest
auscultation (or both) [24]
 Pneumonia: child may have focal respiratory sounds, a dull percussion note, and a
fever
 Croup: characteristic sudden onset, barky cough, often accompanied by stridor and
indrawing of chest wall or sternum
 Whooping cough (pertussis): characteristic cough, although this may not be evident
in younger children
Rare
 Anaphylaxis: urticaria and signs of upper airway obstruction may be present; the
child may have been exposed to a possible or known anaphylactic stimulus
 Inhaled foreign body: symptoms usually come on very suddenly in a previously
well child; unilaterally reduced breath sounds may be present
 Congenital anomalies (tracheo- or bronchomalacia): chronic or intermittent
wheeze since birth in a child under 12 months
 Pneumothorax: may complicate an asthma attack; there may be signs of decreased
air entry and a hyper-resonant percussion note.

Learning bite: taking a history

It may be difficult to conduct a history with an acutely unwell child and their family.
Especially in children with more severe asthma, you may need to start treatment
immediately; lengthy history taking and examination shouldn’t delay urgent treatment.
While treating the attack, asking the following key questions where appropriate can
inform immediate and future treatment [2]:
  Were there any triggers to the attack?
 Have they had an attack before? Have they ever been admitted to hospital for asthma
(especially in the last year)?
 Is there any past history of wheezing between attacks?
 Have they taken or been given any medications?
o Do they have any reliever medication? If so, have they used any of it?
o Do they use any preventer medication? If so, do they use it every day?
 What are their social circumstances?

Step 2: Assess the severity of the attack

Once a child is identified as having an acute wheezing/asthma attack, the next priority is
to make an accurate assessment of the severity of the attack. This will guide initial
treatment, subsequent management, and (in a hospital setting) discharge planning. An
acute attack may be mild, moderate, severe, or life threatening in severity.
Clinical signs may correlate poorly with the severity of airways obstruction, and some
children with a severe attack may not appear distressed. The timing and intensity of
wheezing is not a good marker of severity. [6] Biphasic wheeze (both inspiratory and
expiratory) or less obvious wheezing, with a quiet chest, may indicate progression to
increased airways obstruction. A silent chest is a sign of a life threatening attack. All
children with features of a severe or life threatening attack should be admitted to hospital
as an emergency. [2]
The more reliable factors for assessing the severity of a wheezing/asthma attack are [2]:
 General appearance
 Degree of agitation
 Conscious level
 Respiratory rate
 Respiratory effort (eg use of accessory neck muscles, chest wall recession)
 Heart rate
 Pulse oximetry.
Any of these parameters taken in isolation are not specific or reliable in assessing the
severity of an acute attack; however, in combination they provide valuable guidance in
assessing severity.
Table 1 is based on several key guidelines and our experience, and shows how the
parameters can be used to assess the severity of an acute wheezing/asthma attack.
Children in any of these categories may need referral to hospital if they respond poorly to
initial treatment.
If a child has signs and symptoms across different categories, treat according to their
most severe features. [2]
Table 1. Assessing the severity of acute wheezing/asthma attacks in children aged 12
months and over. Based on the BTS/SIGN guideline, [2] the Global Initiative for
Asthma (GINA) guideline, [5] and the Royal Children's Hospital Melbourne acute
asthma guideline. [6]

Severity Markers of severity

 Normal mental state (not agitated or distressed)

 Able to talk normally
Mild  Prefers sitting to lying
 Subtle or no increased work of breathing
(no accessory muscle use and no evidence of chest wall recession)
 Oxygen saturation (SpO2) ≥92%

 Normal mental state (not agitated or distressed)

 Some limitation of ability to talk
 Prefers sitting to lying
 Some increased work of breathing (accessory muscle use and/or
chest wall recession)
 SpO2 ≥92%
Moderate  Heart rate:
o ≤140/min in children aged one to five years
o ≤125/min in children over five years
 Respiratory rate:
o ≤40/min in children aged one to five years
o ≤30/min in children aged over five years
 Peak expiratory flow (PEF) ≥50% of personal best or predicted
in children over five years who can complete the test correctly)

SpO2 below 92% plus any of:

Severe
 Agitated and/or distressed
 Moderate to marked increased work of breathing
Severity Markers of severity

(accessory muscle use and/or chest wall recession)

 Marked limitation of ability to talk: cannot complete sentences
in one breath, too breathless to talk or feed
 Sits hunched forwards
 Heart rate:
o Above 140/min in children aged one to five years
o Above 125/min in children over five years
 Respiratory rate:
o Above 40/min in children aged one to five years
o Above 30/min in children over five years
 PEF 33 to 50% of personal best or predicted

Any one of the following in a child with severe asthma:

 Confusion and/or drowsiness
 Maximal work of breathing (accessory muscle use and/
or chest wall recession)
 PEF less than 33% of best or predicted
Life threatening/critical  Exhaustion
 Unable to talk
 Silent chest (wheeze may be absent if there is poor air entry)
 Cyanosis
 Poor respiratory effort
 Hypotension

You should always measure oxygen saturation using a pulse oximeter. A level of less
than 92% on air after initial short acting β2-agonist treatment marks out a group of
children with more severe asthma needing urgent referral to hospital. [4] [16] It is
therefore vital that your GP practice has a pulse oximeter suitable for children/infants.
Peak expiratory flow (PEF) can be used as an additional objective test for assessing
severity of an acute wheezing/asthma attack in children over five years of age who can
perform the test correctly. PEF less than 50% of the predicted value, or of their best
previous value, with poor improvement after initial treatment may predict a more
prolonged attack. [2] Children under five years old are usually not able to perform a peak
flow manoeuvre reliably.
Key point: recognising children at high risk of a more severe episode
When assessing an acutely wheezy child, always review their past history of respiratory
illnesses; specifically, is there any past history of wheezing attacks or of symptoms of
wheezing between attacks?
A history of one or more severe attacks identifies a patient cohort that is at risk for
similar severe events in the future, [7] even if at the time of initial assessment their
severity markers are mild. Hospital admission and the need for intravenous drugs for
asthma management signifies a severe attack.
Children with a past history of admission to the intensive care unit for acute wheezing
episodes, with or without ventilator support, have been identified as being at particular
risk of developing further life threatening wheezing attacks. [8]
You should take into account a past history of severe and/or life threatening attacks when
assessing appropriate management and discharge planning, and this should be
independent of severity at the current assessment. You should have a low threshold for
referral to secondary care for further review and observation for these patients. [2]
Clinical tip: assessing breathlessness in children
In children who are old enough to talk, look for an inability to complete sentences in one
breath. In children who cannot yet talk, interrupting a cry for a breath, or an inability to
complete feeds, indicates breathlessness.
In preschool children, and especially in children under two years, the degree of
breathlessness can often be difficult to assess, and the main presenting symptoms may be
agitation and distress. In this situation you may have to rely on other parameters such as
pulse oximetry.
Continue
Step 3: Consider urgent transfer to hospital; give oxygen, short acting β2-
agonists, and steroids
The key treatments in the initial management of acute asthma/wheeze in primary care are
[2]:
 Oxygen
 Inhaled short acting β2-agonists
 Oral corticosteroids.
However, not every child will need all of these treatments, and treatment needs to be
adjusted according to the severity of the attack and the response to treatment.
The following groups of children need urgent transfer to hospital in an ambulance [2]
[16]:
 Children with low oxygen saturations (under 92%), or those with other features of a
severe or life threatening attack
  Children with a poor response to initial treatment, with ongoing signs and symptoms
after treatment with β2-agonists.
Learning bite: transferring children to hospital
Evidence from asthma death reviews suggests that the safest mode of transport to hospital
is by ambulance, and not by private transport. An ambulance has the capability to give
oxygen and β2-agonists via an oxygen driven nebuliser on the way to hospital.
In children with a history of asthma who already have a personalised asthma action plan
(PAAP), many parents/caregivers will have started asthma treatment at home. This needs
to be taken into account when deciding on treatment and assessing response in the
surgery or in hospital.
Children with milder attacks can usually be managed in a primary care setting, depending
on resources and expertise. [5]

Oxygen
 You should use a pulse oximeter to measure oxygen saturation in all children with an
acute attack
 Many children with a mild/moderate attack will have a normal oxygen saturation
level (≥94%). These children do not need oxygen therapy
 If the child has a low oxygen saturation (under 94%) or is having a severe or life
threatening attack, you should give them oxygen. Use a tight fitting face mask or
nasal cannula with flow rates adjusted as necessary to maintain a target saturation of
94% to 98% [2]
 Low oxygen saturations after initial treatment are found in children with more severe
asthma

Inhaled short acting β2-agonists

 Inhaled short acting β2-agonists are the first line treatment for acute asthma in
children, and are useful even in very young children [2]
 A pressurised metered dose inhaler (pMDI) and spacer is the preferred method of
delivery for children with a mild/moderate asthma attack, and is as effective as a
nebuliser for treating a moderate attack. [2] [10]
 β2-agonists given via a pMDI and spacer have been found to have fewer side effects
such as tachycardia and hypoxia than when administered via an air compressor
nebuliser (ie home nebuliser that is not driven by oxygen) [10]
 A face mask will usually need to be fitted to the spacer for children under three years
of age [5]
 The dose of β2-agonist should be adjusted according to the severity of the attack and
the response to treatment. Two to four puffs may be enough for a mild attack; up to
10 puffs may be needed for more severe attacks [10]
 The most commonly used β2-agonist is salbutamol at a dose of 100 micrograms/puff,
and our advice here relates to the 100 micrograms/puff formulation delivered via a
pMDI plus spacer for an acute attack
  If the child is having a severe or life threatening attack, you should give them β2-
agonist (salbutamol) via an oxygen driven nebuliser [2]
 Relief from symptoms should last for three to four hours. If parents are treating their
children at home, advise them that if symptoms return within three to four hours, a
further large dose of β2-agonist (up to 10 puffs by spacer) can be repeated while the
parents seek urgent medical advice [2]
 Frequent, high doses of inhaled β2-agonist are safe, although as a result children will
usually have tachycardia and tremor and may be hyperactive
 Doses of 10 puffs should not be given more than every four hours at home without
seeking medical advice

Oral corticosteroids
 In school age children, the early use of oral corticosteroids during an asthma attack
can reduce hospital admission and prevent relapses. [15] Benefits can be seen as
soon as three to four hours after giving the drug [12] [13]
 In preschool children, the role of oral corticosteroids is less certain. A large
randomised controlled trial of preschool children in the UK with mild to moderate
wheezing treated with five days of oral prednisolone showed no reduction in hospital
stay or other outcomes. [14] Current advice is that preschool children with a severe
attack should receive oral prednisolone [2]
 Children with mild to moderate attacks who have had a good response to β 2-agonists
can be managed using β2-agonists alone. [2]
 Current guidelines recommend oral prednisolone (table 2), although the BTS/SIGN
guideline also includes studies using single dose dexamethasone, and so this
recommendation may change in the future [2]
Table 2. Doses of oral prednisolone. [2]

Age of child Prednisolone dose

Under two years 10 mg

Two to five years 20 mg

Above five years 30 mg to 40 mg

 Children who normally take steroid tablets every day for their chronic management
may require larger doses during an acute attack, up to 2 mg/kg/day (maximum 60
mg) [2]
 If a child vomits the steroids the dose should be repeated, and if vomiting continues
intravenous steroids should be used [2]
 Children who already take inhaled corticosteroids or other preventers should be
advised to continue with their usual dose during an acute attack, even while
receiving additional treatment. [2] The exception to this is long acting
bronchodilators: these should be stopped while the child is taking frequent high dose,
short acting bronchodilators
 Increasing the dose of inhaled corticosteroids by up to five times has not been shown
to be effective in the management of acute asthma in children [15] [27]
 Treatment with oral corticosteroids for up to three days is usually sufficient,
especially in younger children. Older children may need up to five days of treatment.
However, the length of the course should be tailored to the number of days necessary
to bring about recovery. A tapered reduction is not needed for short courses of
steroids [2]
Learning bite: how to deliver multiple doses of
β2-agonist using a spacer
With a face mask
1. Gather everything needed: inhaler, spacer device, and mask
2. Shake the inhaler and attach to the spacer [11]
3. Make sure the child is in a comfortable position (lying on her/his back if a baby). Tilt
young infants to 45 degrees
4. Put the mask over the child’s nose and mouth; press very gently to make a seal
5. Press the inhaler once and count slowly to 10 (this should take 10 to 20 seconds)
6. Take the spacer away from the child’s face
7. Take the inhaler out of the spacer
8. Repeat steps 2 to 8 according to response, up to a maximum of 10 puffs if needed,
leaving about 60 seconds in between each puff

Using the mouthpiece (without a face mask)

1. Gather everything needed: inhaler and spacer device
2. Shake the inhaler and attach to the spacer [11]
3. Make sure the child is in a comfortable position
4. Place the spacer in the child’s mouth; ensure there is a seal around the lips
5. Press the inhaler once and count five of the child’s breaths
 6. Remove the spacer from the child’s mouth
7. Take the inhaler out of the spacer
8. Repeat steps 2 to 8 according to response, up to a maximum of 10 puffs if needed,
leaving about 60 seconds in between each puff
Learning bite: treatment of a mild or moderate attack
Children with milder attacks can usually be managed in a primary care setting with a
pMDI and spacer until they have sufficiently stabilised, depending on resources and
expertise. [5]
Start initial treatment and assess response. [2]
 Give β2-agonist via a spacer +/- face mask, one puff at a time, as per the instructions
above
 Give up to a maximum of 10 puffs at any one time
 It is useful to get parents to administer the β2-agonist, as this allows you to check
inhaler technique
 In children with a mild/moderate attack, β2-agonist alone may be sufficient to treat
symptoms
 If symptoms do not settle with 10 puffs of β2-agonist alone, or the effects do not last
for three to four hours (indicating a more severe attack), then you should give oral
corticosteroids
 Make frequent clinical observations, including oxygen saturations measured with an
appropriately sized probe, in order to assess the child’s response to treatment.
Consider urgent transfer to hospital if there is a poor response to initial treatment, or
a worsening of symptoms and/or signs
Continue

Step 4: Adjust treatment according to severity of the attack

and response to initial treatment
Monitoring after initial treatment
After giving initial treatment to children with a mild/moderate attack, you need to
monitor them closely for one to two hours. During this time you need to look out for [5]:
 Any improvement in symptoms and signs following the β2-agonist
 Any features of a severe or life threatening attack
 Any change in respiratory rate or heart rate
 Any change in oxygen saturation.
In children over five years old who are accustomed to performing the test, peak
expiratory flow may give further objective evidence of response to treatment and return
to stability.
If the child needs to use β2-agonists more often than 10 puffs every four hours, you
should refer them to hospital. [2]
You should also have a lower threshold for referral to hospital if [2]:
 The child presented in the late afternoon or at night
 They have had a recent hospital admission or previous severe attack
 You have concerns about their social circumstances or their ability to cope at home

Urgent treatment while waiting for transfer

Children who have had a poor response to initial treatment, or who have oxygen
saturations under 92%, or who have other features of severe or life threatening attacks,
are high risk and should be transferred to hospital by ambulance. While waiting for
transfer, take the following steps [2]:
 Give oxygen via a tight fitting face mask or nasal cannula with flow rates adjusted as
necessary to maintain a target saturation of 94% to 98% [2]
 Give oral prednisolone: aim to start within the first hour of medical care
 Give salbutamol via an oxygen driven nebuliser. Nebulised salbutamol can be
repeated every 20 minutes as required
 If there is a poor response to an initial dose of nebulised salbutamol, ipratropium
bromide can be added to each subsequent nebuliser. This can be done every 20 to 30
minutes for up to two hours
 Oxygen should always be continued in hypoxic children (with oxygen saturation
below 94%), and treatment with salbutamol using an oxygen driven nebuliser should
continue as needed during transfer
 In children under the age of two years who fail to respond to salbutamol, it is worth
considering alternative diagnoses

Table 3. Summary of initial management of acute wheezing/asthma attacks in

primary care. [2]

Severity Initial management in primary care

 Give inhaled short acting β2-agonists via spacer

 Consider corticosteroid tablets
Mild/moderate
 Give oxygen if SpO2 under 94%
 Consider urgent transfer to hospital by ambulance if poor response to initial
treatment

Severe  Give oxygen

 Give nebulised salbutamol via oxygen driven nebuliser
Severity Initial management in primary care

 Give corticosteroid tablets

 Arrange urgent transfer to hospital by ambulance
 If poor response to initial dose of nebulised salbutamol, ipratropium can be
added to each subsequent nebuliser

 Give oxygen
Life  Give nebulised salbutamol with ipratropium via oxygen driven nebuliser (or, if
threatening/critical nebuliser and ipratropium not available, salbutamol via spacer)
 Give corticosteroid tablets or intravenous hydrocortisone if vomiting
 Arrange urgent transfer to hospital by ambulance
Continue

Step 5: Ensure the child and their family have

enough information and medication before they
go home
As long as the child has responded well to initial treatment, has not needed hospital
admission, and has the appropriate “safety netting” advice (see below), guidance from
BTS/SIGN states that it is safe for them to go home when β2-agonists are needed no more
frequently than 10 puffs every four hours. [2] In addition, oxygen saturation should be
greater than 94%, and if available, PEF or FEV1 should be greater than 75% of best or
predicted. [2] If the child needs to use β2-agonists more often than 10 puffs every four
hours, they need ongoing medical review and monitoring in hospital. [2]
If possible try to avoid sending children home in the late evening, as symptoms are
frequently worse at night.
Before going home, it is important to ensure that families have the correct inhaler and an
appropriate spacer for the age of the child, and know how to use them. After the initial
treatment of an acute attack, the child should continue taking β2-agonists until their
symptoms have settled fully. The time for resolution of symptoms depends on the nature
of the trigger (often a virus) and the severity of the attack, but it is likely to be a number
of days. Parents should give the β2-agonist by pMDI and spacer, up to a maximum of 10
puffs every four hours. [2] The standard salbutamol pMDI contains 200 puffs, so it is
important to ensure there is enough medication to continue treatment until the next
review.
When discharging a child home following emergency treatment for an asthma attack, it is
important to provide written safety netting information. This should include advice on
how to gradually step down treatment with β2-agonists. The step down regimen should
tell the parents how to adjust the β2-agonist dose depending on the severity of the
symptoms as their child improves. It should also clearly advise the parents on how to
recognise if their child is not improving and emphasise that they should then seek urgent
medical advice.
There is some variation, nationally and internationally, [2] [5] in the specific discharge
advice used to guide parents in stepping down the dose of β2-agonist over a period of a
few days. The further resources section at the end of this module includes two examples
of step down regimens used by clinicians in the UK that are consistent with the
BTS/SIGN guideline. [2] It is important to check and follow the plan recommended by
your local specialists, which may differ from what is recommended here.
In children, around 80% of attacks are triggered by viral upper respiratory tract infections
(“colds”), particularly rhinoviruses. [25] At present, bacterial infections are not thought to
be an important trigger. Most children will not require or benefit from an antibiotic.
The BTS/SIGN guideline states that routine prescription of antibiotics is not indicated for
children with acute asthma. [2]
Oral steroids, if prescribed, should be continued until symptoms have resolved: usually
three to five days. A clinician should review the response during this period in case a
longer course is needed.
It is good practice to continue any preventer treatment for asthma throughout the acute
attack. The exception to this is long acting bronchodilators: these should be stopped while
the child is taking frequent high dose, short acting bronchodilators.
If the child is going home, you should arrange a review with them within 48 hours of the
attack. [2]
You should also make sure that parents/caregivers have a written personalised asthma
action plan (PAAP) for their child. The PAAP should include information on how to
manage the current attack, and what to do if symptoms worsen.
Learning bite: safety netting advice for families [2] [5]
 Parents/caregivers should be aware of the symptoms that indicate current treatment
is not working.
 These may include the need to give β2-agonist more often than 10 puffs every four
hours, and their child becoming more short of breath, showing increased labour of
breathing, or becoming unusually drowsy. In these circumstances, advise parents to
call an ambulance
 Multiple dosing with up to 10 puffs of β2-agonist should provide relief from
symptoms for three to four hours
 If symptoms recur within this period, parents/caregivers should give a further 10
puffs of the β2-agonist via spacer and seek urgent medical attention or call an
 ambulance. Parents often need reassurance that it is safe to give 10 puffs of β2-
agonist in this situation
Learning bite: checklist before the child goes home
1. Is their inhaler technique adequate?
2. Do they have the correct inhaler and an appropriate spacer for the age of the child?
3. Do they have enough β2-agonist to provide the doses needed for multiple doses?
4. Are they or their parents/caregivers able to identify signs of deterioration?
5. Will they be observed adequately (ie responsible adult available to closely observe
the child)?
6. Do their parents/caregivers know to give more β2-agonist if needed?
7. Do their parents/caregivers know when to call an ambulance if the child deteriorates?
8. Have you made arrangements for review within 48 hours of the attack?
9. Do they have a written personalised asthma action plan (PAAP)?

Step 6: Review the acute attack

within 48 hours
10. Early follow up in primary care within 48 hours of the attack is an important part
of the care of acute asthma. [2] It allows the health practitioner to check whether
symptoms are settling and if acute treatment can be adjusted down. It usually takes
some weeks for an asthma attack to resolve fully. Early follow up also provides an
opportunity to review the management of the recent attack, and to reappraise
ongoing asthma care.
11. An asthma attack may be a signal that something has gone wrong in a child’s
asthma management and that action is needed. Recent attacks have been identified
as one of the strongest risk factors for a future attack. [7] [18] Incomplete or slow
resolution of an attack leads to continuing morbidity and increases the risk of
further hospitalisation.
12. The National Review of Asthma Deaths (NRAD) recommended that follow up
arrangements must be made after every attendance for an asthma attack at an
emergency department or out of hours service. [17] The BTS/SIGN guideline
recommends a review within 48 hours (two working days) by the patient’s own
GP practice. [2] This should include children discharged from hospital following
an acute attack, as well as those where the attack was managed entirely in the
community, either by the family or with the involvement of the GP.
13. Secondary care services need to have systems that allow timely and appropriate
communication with primary care. Primary care teams will need to have
 arrangements in place to identify and follow up children who have had asthma
attacks.
14. The review of the acute attack should be structured to:
15. 1. Check the attack has been controlled and is resolving
16. Questionnaires for symptoms, such as the Asthma Control Test (ACT), and a
measure of lung function, such as PEF or FEV1, can provide a more objective
assessment of ongoing airways obstruction. [2] There is also a childhood version
of the ACT for children aged four to 11 years.
17. It is important to document reversible airways obstruction during an acute attack
(eg an improvement in PEF after bronchodilator) as it provides objective evidence
in support of a diagnosis of asthma. [2] If the child does not have a diagnosis of
asthma you will need to gather other pieces of objective evidence before making a
firm diagnosis, eg recorded observation of wheeze, symptom variability, and
recurrent episodes of symptoms, as well as a subsequent trial of treatment. [2]
18. The timing of return to school and activities can be agreed.
19. 2. Determine the length of treatment with oral corticosteroids
20. Treatment with oral corticosteroids may need to be continued beyond the usual
three to five days if resolution of asthma symptoms is slow. [2]
21. 3. Assess inhaler technique
22. You should check the child’s inhaler and spacer technique.
23. 4. Review ongoing weaning of β2-agonists.
24. You should discuss how and when to wean β2-agonists back to an as-needed basis.
25. 5. Assess chronic asthma management
26. If no preventer has been prescribed previously, consider starting very low
dose ICS (or a leukotriene receptor antagonist in children under five years who are
unable to take ICS) if chronic asthma symptoms have been present, or if attacks
have been frequent and/or severe. [2]
27. Asking about adherence, in a non-judgemental way, using open questions, and
acknowledging that poor adherence is common, may open up a conversation with
the child and their parents/caregivers. They may reveal that they have not been
using the medication regularly. Review of prescription records may reveal failure
to obtain enough preventer medication, or excessive use of β2-agonist medication
(prescription of more than 12 salbutamol inhalers per year).
28. If adherence has been good, consider increasing preventative treatment.
29. In preschool children presenting with a first episode of wheeze triggered by
viruses but no interval symptoms and no preventable risk factors, inhaled
corticosteroids may not always be indicated. It may be reasonable to adopt a “wait
and see” approach, and review the child over a few months. [2]
30. 6. Identify and document the trigger(s) of the attack
31. It is important to recognise the trigger(s) of the attack.
32. In children, around 80% of attacks are triggered by viral upper respiratory tract
infections (“colds”), particularly rhinoviruses. [25] At present, bacterial infections
are not thought to be an important trigger.
 33. Allergic triggers are less common, [25] but if identified, may be confirmed by
further testing. They are important to identify because they may be avoidable.
34. Exposure to environmental tobacco smoke is another important trigger (see point
9). [20]
35. 7. Assess initial home acute management and identify improvements required
for future attacks
36. Potential improvements can be included in an updated personalised asthma action
plan (see next page).
37. 8. Identify and consider any psychosocial factors and their impact
38. Of children who died in the National Review of Asthma Deaths (NRAD), 94%
had one or more preventable risk factors. [17] This included poor adherence to
medical advice, psychosocial factors, and a history of allergic disease. Identifying
this information can help you to refine the child’s management plan.
39. 9. Consider exposure to irritants, particularly environmental tobacco smoke
40. Although smoking is decreasing in the general population, children admitted with
asthma attacks are more commonly exposed to environmental tobacco smoke. [20]
Forty percent of children who died in the NRAD were exposed to environmental
tobacco smoke. [17] NRAD recommended that history of smoking and/or
exposure to second-hand smoke should be documented in the medical records of
all people with asthma. You should offer referral to a smoking cessation service to
any current smokers among the child’s carers. [17]
41. 10. Update and/or issue a written personalised asthma action plan (PAAP)
42. See next page.
43. Clinical tip: specialist review
44. If the child experienced a life threatening attack, you should make sure that an
appointment with a paediatric respiratory specialist has been arranged, and that the
family are able to attend.
45. You should also ensure that hospital follow up is arranged if the child has had two
attacks or has needed oral steroids twice within 12 months.

Step 7: Provide self management

education and develop a written
personalised asthma action plan
There is strong evidence that PAAPs improve asthma management. [2] [26] The majority
of children in the National Review of Asthma Deaths had never been given a PAAP. [17]
A PAAP should always include advice about managing acute attacks, as well as details of
current preventer treatment, if any is prescribed, and an outline of a patient’s recognised
triggers. Evidence suggests that symptom based PAAPs are superior to peak flow based
PAAPs for preventing acute care visits. [21] [22] See Asthma UK for an example of a
PAAP.
Learning bite: what should be in a personalised asthma action plan
(PAAP)?
A PAAP should include information on:
Coping with attacks
 How to spot when symptoms are getting worse
 What to do when symptoms do get worse
 What to do in an emergency
 When and how to call for emergency help
Managing asthma between attacks
 Avoiding triggers, eg minimising exposure to allergic triggers and avoiding exposure
to environmental tobacco smoke, particularly in the home
 Being able to use inhaler device +/- spacer
 Using regular preventer medication, if prescribed, and as-required bronchodilator
Any asthma attack is a significant and alarming event that families want to avoid
happening again. However, an attack provides a “teachable moment” when everyone’s
attention is focused on asthma. Provision of a written PAAP as part of an emergency visit
for asthma has been shown to reduce emergency use of healthcare resources, including
emergency department visits and hospital admissions, as well as improving markers of
asthma control. [2] [26]
Evidence suggests that asthma attacks may develop in different ways in different
children, but that the pattern of development tends to be consistent within a particular
child. [9] [19] Since most asthma attacks develop over one to two days, spotting early
warning signs can allow parents to recognise that an attack is developing and to start
treatment early. [9] This means that the details of how a recent attack developed, what the
parents noticed, and how they responded can be used as a template for planning what
should be done in any future attack, and shared with colleagues in primary and secondary
care.
Families need to be clear about what to do if an asthma attack is developing and things
are not getting better. They should know that if a child’s symptoms are getting worse, or
if relief from a β2-agonist lasts less than four hours, they should give up to 10 puffs of β2-
agonist via a spacer and call for an ambulance straight away.
Families also need to know about safety netting measures (see step 5). In some cases it
may be helpful to rehearse what they should say if they call the emergency services, or
help them to come up with a checklist.
In the event that families need to call your GP practice, make sure that they know to
clearly tell your receptionists that they think their child is having an asthma attack, and
that they need an urgent appointment to see a doctor or trained asthma nurse.