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Acute Asthma in children – Clinical Guideline and Treatment Proforma.

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MANAGEMENT OF ACUTE ASTHMA IN CHILDREN – CLINICAL GUIDELINE AND TREATMENT PATHWAYS

1. Aim/Purpose of guideline 1.1 To provide guidance on the local management of acute asthma in children (age 2 to 16 years). This guidance applies to all staff caring for children with a presentation of acute asthma in the Emergency Department, Paediatric Observation unit/wards, Paediatric HDU and Adult ICU managing children with acute asthma. The management pathways may also be used to manage children over 2 years of age presenting with acute viral induced wheeze. Please see section 2.8 for specific management of pre-school children (<5yrs), and section 2.10 for management of children <2yrs.

2. Guidance 2.1 Background. The number of deaths from asthma each year has not decreased for many years, and the National Review of Asthma Deaths (NRAD) continues to show preventable factors in at least 90% of cases. Acute exacerbations of asthma remain the most common reason for a child to be admitted to hospital in the UK, and account for 10-20% of all acute medical admissions in children.

2.2 History – please complete in paediatric proforma or ED Admission notes

and use the following guidance. IMPORTANT - Commence urgent treatment before taking full history.

Duration and nature of symptoms

Treatments used (relievers & preventers) – please state dose, inhaler type, number of inhalations and whether spacer used. Ask how many prophylactic doses they miss per week.

How many courses of steroids in last 6 months – do they have poorly controlled asthma? Any failure to respond to treatment/deterioration whilst on steroids?

Last exacerbation details - Pattern and course of previous acute admissions (admissions/PICU) – any life-threatening attacks?


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Trigger factors (including URTI’s, allergy/atopy, passive smoking – detail the exposure) – are there interval symptoms?

Parental understanding of the treatment of acute episodes

Poor compliance and appointment non-attendance

Perception of severity of attacks

Social support Consider Differential Diagnoses:

Infection e.g. atypical pneumonia

Inhaled foreign body

Bronchiolitis (especially in young children <2yrs)

Anaphylaxis

Gastro-oesophageal reflux with aspiration

Cardiac

Congenital or structural abnormalities e.g. bronchomalacia


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Patient ID sticker

2.3 Assessment and pathways Depending on your assessment using the table below; please go to appropriate management page. Please tick the signs observed and examined. If there are any signs of severe or life-threatening asthma, then the child should be managed with these pathways, even if most signs are in the mild-moderate box. Please use PEFR in all children over 5yrs of age. Please note – Wheeze is a poor predictor of severity Remember to re-assess frequently and change to the severe or life threatening management pathway if the child deteriorates. We should regard each emergency presentation with acute wheeze/asthma as being “Severe” until shown to be otherwise.

Severity Signs

Mild - Moderate Normal mental state Some accessory muscle use/recession Only minor limitation of speech SpO2 >92% in air Mild tachycardia (<125 for 5yrs+, <140 for 2-5yrs)

Severe Agitated/distressed Marked accessory muscle use Unable to complete sentences or feed SpO2 <92% in air PEFR 33-50% predicted Tachypnoea (RR >30 for 5yrs+, or >40 for 2-5yrs) Tachycardia (>125 for 5yrs+ or >140 for 2-5yrs)

Life Threatening Confusion -> Coma Maximal accessory muscle use/recession Exhaustion with poor respiratory effort Unable to talk PEFR <33% predicted Silent chest Cyanosis/SpO2 <92% in air Hypotension Marked tachycardia

Assessment Outcome Date …/…/… Time ……… Signature…………………. REF : Bristol Children’s hospital guideline for acute asthma.

Mild – moderate

Severe

Life Threatening


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Patient ID sticker

2.4 Mild-Moderate Asthma Pathway

Weight……..kg (is this an estimate – Y / N) Please prescribe drugs onto MAXIMS or if not available please use below chart:

Date Time Drug Route Dose Signature Time given

Given by

Checked by

Salbutamol Inhaled 10puffs



Prednisolone oral mg

Continue on severe asthma pathway and drug chart if not improving

Give 10 puffs salbutamol via spacer 100mcg metered dose inhaler

<3yrs please use spacer with close-fitting facemask

If good response -

Discharge home with salbutamol

Consider 3 day course oral prednisolone (1-2mg/kg, max 40mg) Doses: 20mg (2-5yrs), 30-40mg (>5yrs)

Written discharge plan

If poor response –

Re-assess – move to the severe or life threatening pathway if deterioration or sats < 92%

Give a further 2 sets of salbutamol 10 puffs via spacer (every 20mins)

Give oral prednisolone 1-2mg/kg (max 40mg)

Mild – Moderate asthma

If improvement following further salbutamol –

Slowly stretch out salbutamol doses ; child likely to need period of observation

Continue to use MDI and spacer UNLESS sats <92%

Discharge when child is reliably spacing 4 hours between inhalers

Review inhaler/spacer technique of child/parents

Will need written discharge plan – see section 2.8-2.9 for details


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Patient ID sticker

2.5 Severe Asthma Pathway

Weight……..kg (is this an estimate – Y / N)

Please prescribe drugs onto MAXIMS or if not available please use below chart:

Date Time Drug Route Dose Signature Time given

Given by

Checked by

Salbutamol Neb

Salbutamol Neb

Salbutamol Neb

Ipratropium Neb

Ipratropium Neb

Ipratropium Neb

Prednisolone Oral

Hydrocortisone IV 4mg/kg =

If deteriorating further – please use life threatening asthma pathway and IV drug chart. Ensure senior help available and paediatrics informed (bleep SHO 3516, REG 3514, Consultant via Switch or use PAEDIATRIC CRASH CALL via SWITCH 2222)

Give High-flow Oxygen to maintain sats ≥94%

Give 3 Salbutamol Nebulisers 20mins apart over 1 hour (back to back nebs) Doses: 2.5mg <5yrs, 2.5-5mg 5-12yrs, 5mg >12yrs

Give Prednisolone 1-2mg/kg (max 40mg) Stat Doses: 20mg (2-5yrs), 30-40mg (>5yrs)

Severe Asthma

Establish IV access if not improving Give IV hydrocortisone 4 mg/kg, max dose 100mg if child has vomited prednisolone or deteriorating.

Move to Life-threatening asthma pathway if deteriorating

Consider adding Ipratropium Bromide (Atrovent) to further salbutamol nebulisers every 20 mins (Up to 6 doses over 2 hours)

Doses: 250mcg <12yrs, 500mcg over 12yrs


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Patient ID sticker

2.6 Life-threatening Asthma Pathway

Consider the following

Anaphylaxis

Pneumothorax

Collapsed lobe

Inadequate drug delivery

Dehydration

Alternate diagnoses

Life-Threatening asthma

Continue regular nebulisers as per Severe Asthma pathway Ensure IV Access obtained and IV hydrocortisone given 4mg/kg 6 hourly max 100mg

Oxygen, ECG and sats monitor, Senior Paediatric team + ICU informed

Consider IV Magnesium Sulphate bolus as an adjunct Doses – see IV drug calculation chart below

Start IV Salbutamol loading over 1 hour (then continue infusion) Doses – see IV drug calculation chart below. Monitor U+E.

If deteriorated despite frequent inhaled salbutamol or signs of salbutamol toxicity (severe tachycardia, tachypnoea, metabolic acidosis with high lactate, hypokalaemia – check U+E)

And if not taken oral Theophylline in last 24rs Start Aminophylline loading dose

Doses – see IV drug calculation chart below

If poor response –add in the other IV drug which was not initially commenced (IV Salbutamol/Aminophylline)

ICU to review patient. PICU informed IV salbutamol is not compatible with IV aminophylline. IV salbutamol is Y-site compatible with potassium infusions, only if mixed

with sodium chloride 0.9%


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Patient ID sticker

IV Drug Calculations: Weight……..kg (is this an estimate – Y / N) Please prescribe these onto a Paediatric Fluid chart, using the calculations below:

Infusion solution +

Drug

Dose Instructions for preparation

Rate Route

40ml 0.9% sodium chloride

CHILDREN <40kg 10mg Salbutamol (2 vials of 5mg/5ml)

1-5mcg /kg/min

Make solution of 10mg in 50mls (200mcg/ml) Ensure ECG and sats monitoring in place. Reduce loading dose if extreme tachycardia

Loading dose – 5mcg/kg/min for 1 hour (1.5 ml/kg/hour) Use volume settings on IV pump for first hour After loading reduce the infusion rate to 1 -2 mcg/kg/min (0.3-0.6 ml/kg/hour)

IV

400ml 0.9% sodium chloride

CHILDREN >40kg 100mg Salbutamol (20 vials of 5mg in 5ml strength)

1-5mcg /kg/min (mcg = micrograms)

Make solution of 100mg in 500ml (200mcg/ml) Ensure ECG and sats monitoring in place. Reduce loading dose if extreme tachycardia

Loading dose – 5mcg/kg/min for for 1 hour (1.5 ml/kg/hour) After loading reduce the infusion rate to 1 -2 mcg/kg/min (0.3-0.6 ml/kg/hour)

IV

Example for 10kg child 40ml 0.9% NaCl

10mg Salbutamol 1-5mcg /kg/min

200mcg/ml solution Loading dose of 5mcg/kg/min = 3000mcg/hr. Solution is 200mcg/ml therefore 3000÷200 = 15ml/hr rate for 1

st hour (1.5ml/kg/hr).

Then drop to 3 – 6ml/hr

IV

480ml sodium chloride

500mg Aminophylline (2 vials of 250mg/10ml)

Loading – 5mg/kg (5ml/kg) Maximum dose 500 mg (500ml)

Make solution of 1mg/ml Ensure ECG and saturation monitoring are in place Check Aminophylline levels 4-6hrs after dose

Over 20 minutes (If weight over 66 kg then loading dose should be given over 30 minutes) Infusion – CHILDREN <40kg: 1 mg/kg/hour (1 ml/kg/hour) CHILDREN >40kg: 0.5-1 mg/kg/hour (0.5-1ml/kg/hour)

IV IV

16 ml 0.9% sodium chloride

2g Magnesium (4ml of 5g/10ml)

40mg/kg (0.4ml/kg) Max dose 2g (20ml of 100mg/ml solution)

Make up to a 100mg/ml solution Ensure ECG and sats monitoring in place

Over 20mins using syringe driver. Can be given as slow push.

IV


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Patient ID sticker

NB As per Bristol’s guideline, a salbutamol bolus is no longer suggested (5 microgram/kg or 15

microgram/kg as per Children’s BNF) Bristol children’s hospital audit data has shown that this rarely stops and often delays a child going on to receive a loading dose or infusion. However, experienced consultants may still recommend a salbutamol bolus over 10minutes in individual cases (e.g. cases of moderate asthma slow to respond to inhaled broncodilator therapy).

FURTHER INFORMATION

2.7 Investigations

CXR is NOT generally required

Significant abnormalities are present in only 1-5% patients

CXR should be done in all children who suddenly deteriorate to exclude pneumothorax, or with atypical presentation to exclude other disease entities e.g. foreign body/pneumonia.

NB Radiographic evidence of atelectasis is common in acute asthma but does not imply infection

Blood gases are RARELY required in the assessment of acute asthma

useful in severe/life-threatening cases

Further blood tests are required in severe/life-threatening cases to monitor for evidence of Salbutamol toxicity (e.g. hypokalaemia, high lactate) – check regular U+E.

2.8 Discharge – please tick box when completed

Please prescribe to complete at least 3 days Prednisolone course Every child should be discharged with a written action plan detailing their reliever and preventer strategy which should be copied to their GP. This plan should also include advice for use of inhalers over the 48-72 hours following discharge from hospital. Please use the coloured asthma action plans available on the ward, or use Asthma UK: https://www.asthma.org.uk/advice/resources/#action-plans Children are 4 times more likely to need emergency treatment if they do not have an asthma action plan. Observe inhaler/spacer technique before discharge

Pre-School Children (<5yrs) without a diagnosis of asthma:

Around 1/3 of children <5yrs may respond to Montelukast. This can be given intermittently at the onset of URTI symptoms, or if frequent episodes, then can be given daily.

Children <5yrs who have multiple trigger wheeze have higher risk of long term asthma, and a preventer inhaler should be started if having frequent episodes.

Children <5yrs with repeated episodes of viral induced wheeze (especially those with strong family/personal history of atopy) may also be considered for inhaled steroid preventer.

2.9 Follow up –please tick box when arranged

Ensure follow up with GP – within 2 working days from discharge.

https://www.asthma.org.uk/advice/resources/#action-plans


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All children admitted with severe or life-threatening asthma should be reviewed by the paediatric respiratory team in clinic within 1 month. Please contact: Dr Anne Prendiville, Dr Rajesh Srikantaiah.

2.10 Children <2yrs age – acute management of wheeze

Wheezing episodes in very young children are often different from those in older children with asthma. They are usually due to viral infections alone and they often respond differently (or do not respond) to asthma medication. In children over 12 months of age, trial of medication as follows might be indicated:

Up to 10 puffs of Salbutamol 4 hourly via a MDI/spacer

Consider the addition of inhaled Ipratropium Bromide

Consider oral Prednisolone (10 mg once per day for 3 days) It is important to re-assess after administration of salbutamol to evaluate its effectiveness in terms of saturations and respiratory distress Infants (<12 months) who present with wheeze may have bronchiolitis, and you should refer to the bronchiolitis guideline for information regarding management.


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3. Monitoring compliance and effectiveness

Element to be monitored

Compliance with pathways Achieving all elements of the management and follow up/discharge

plan.

Lead Audit Lead Paediatric Consultants

Tool Asthma Audit

Frequency As required. NB National audit is annual.

Reporting arrangements

Child Health Audit and Guidelines Committee Meeting Audit Lead

Paediatric Consultants

Acting on recommendations and Lead(s)

Child Health Audit and Guidelines Committee Audit Lead

Paediatric Consultants

Change in practice and lessons to be shared

Required changes to practice to be identified and actioned within 3 – 6 months. Lead member of the team will be identified to take

each change forward where appropriate

4. Equality and Diversity 4.1. This document complies with the Royal Cornwall Hospitals NHS Trust service Equality and Diversity statement which can be found in the 'Equality, Diversity & Human Rights Policy' or the Equality and Diversity website.

http://www.rcht.nhs.uk/GET/d10268876

http://www.rcht.nhs.uk/GET/d10268876

http://www.rcht.nhs.uk/RoyalCornwallHospitalsTrust/OurOrganisation/EqualityAndDiversity/HumanRightsEqualityAndInclusion.aspx


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Appendix 1. Governance Information

Document Title Paediatric Acute Asthma Guideline and Treatment Pathways

Date Issued/Approved: March 2016

Date Valid From: March 2016

Date Valid To: March 2019

Directorate / Department responsible (author/owner):

Dr Anne Prendiville, Paediatric Respiratory consultant. Dr Kathryn Thomas – original format

Contact details: 01872 252463

Brief summary of contents Clinical guideline for management of acute asthma in children. Includes clear treatment pathways.

Suggested Keywords:

Asthma Paediatric Wheeze Child

Target Audience RCHT PCH CFT KCCG

Executive Director responsible for Policy:

Date revised: March 2016

This document replaces (exact title of previous version):

New document

Approval route (names of committees)/consultation:

Child health audit and guidelines meeting. Paediatric Critical Care group (Dr S Robertson, Dr J Berry, Dr A Shekhdar). Paediatric Pharmacist P Dale.

Divisional Manager confirming approval processes

David Smith (Associate Director Women, Children’s and Sexual health division)

Name and Post Title of additional signatories

Not required

Signature of Executive Director giving approval

{Original Copy Signed}

Publication Location (refer to Policy on Policies – Approvals and Ratification):

Internet & Intranet Intranet Only

Document Library Folder/Sub Folder Child Health/Paediatric Guidelines


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Links to key external standards

Related Documents:

1. Bristol PICU guidance for Acute Severe Asthma – found on intranet link to Bristol guidelines

2. Bristol Acute Asthma guideline – found on intranet link to Bristol guidelines

3. National Review of Asthma Deaths NRAD - https://www.rcplondon.ac.uk/projects/national-review-asthma-deaths and “Why Asthma still kills” August 2015 - https://www.rcplondon.ac.uk/projects/outputs/why-asthma-still-kills

4. British Thoracic Society – https://www.brit-thoracic.org.uk/guidelines-and-quality-standards/asthma-guideline/

5. Big 6 guidelines– found on intranet under General Paediatric guidelines

6. BNF for Children 2015-2016 – medical emergencies back page (after index), and page 133-134.

7. Asthma UK – www.asthma.org.uk

Training Need Identified? Implementation will be disseminated across directorate.

Version Control Table

Date Version No

Summary of Changes Changes Made by

(Name and Job Title)

March 2016

V1.0 Initial Issue from guidelines meeting. Dr Kathryn Thomas, Paediatric Registrar.

All or part of this document can be released under the Freedom of Information Act 2000

https://www.rcplondon.ac.uk/projects/national-review-asthma-deaths

https://www.rcplondon.ac.uk/projects/national-review-asthma-deaths

https://www.rcplondon.ac.uk/projects/outputs/why-asthma-still-kills

https://www.rcplondon.ac.uk/projects/outputs/why-asthma-still-kills

https://www.brit-thoracic.org.uk/guidelines-and-quality-standards/asthma-guideline/



http://www.asthma.org.uk/


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This document is to be retained for 10 years from the date of expiry.

This document is only valid on the day of printing

Controlled Document

This document has been created following the Royal Cornwall Hospitals NHS Trust Policy on Document Production. It should not be altered in any way without the

express permission of the author or their Line Manager.