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ROYAL FREE LONDON NHS FOUNDATION TRUSTPAEDIATRIC GUIDELINES Paediatric Asthma/Wheeze GuidelineAuthor(s):Richard Berg, Eli Safi, Neil ThompsonContact author:Shye-Wei Wong, Lynn SinitskyOther contributors:Chloe Benn, Colette Dat, Benita Morrissey, UCLP Asthma NetworkPrevious authors:Rahul ChodhariRelated guidelines or documents:2016 BTS/SIGN Guideline for the management of asthma NICE quality standard QS25Approved by:The Paediatric Guidelines Group on behalf of the Women, Children and Imaging Services DivisionIssue no (Version):November 2016 (version no. 1.0)File name:Paediatric Asthma_Wheeze GuidelineKey words: (up to 10)Paediatric Asthma Wheeze Supercedes:Asthma guideline 06/09/2006Significant change in practice:Use of magnesium IV bolus prior to salbutamol bolusPatients should receive a personalized asthma plan prior to dischargeImplementation plan: Dissemination of the guideline via the intranet, guideline events and department meetingsMonitoring via clinical audit via the local audit programmeService Line LeadPaediatrics: Rahul ChodhariClinical Director for Paediatrics Tim WickhamDivisional Director of NursingMai BuckleyFor Review: May 2017 or in response to practice developmentsContents TOC \o "1-3" \h \z \u Introduction PAGEREF _Toc466295847 \h 4SECTION A: MANAGEMENT OF CHILD WITH ACUTE WHEEZE/ASTHMA PAGEREF _Toc466295848 \h 5Assessment of acute wheeze/asthma PAGEREF _Toc466295849 \h 51.History PAGEREF _Toc466295850 \h 52.Examination PAGEREF _Toc466295851 \h 53.Assessing severity PAGEREF _Toc466295852 \h 64.Investigations PAGEREF _Toc466295853 \h 7Ensuring the correct diagnosis PAGEREF _Toc466295854 \h 8Wheeze in the preschool child PAGEREF _Toc466295855 \h 9Young people and adolescents PAGEREF _Toc466295856 \h 9Difficult Asthma PAGEREF _Toc466295857 \h 10Acute wheeze flowchart for children 2-16 years PAGEREF _Toc466295858 \h 11The deteriorating child with wheeze/asthma PAGEREF _Toc466295859 \h 12Medications for acute wheeze/asthma PAGEREF _Toc466295860 \h 13SECTION B: MEDICATION PAGEREF _Toc466295861 \h 13Weaning bronchodilators PAGEREF _Toc466295862 \h 15Preventer therapy for children >5 years PAGEREF _Toc466295863 \h 16Preventer therapy for children <5 years PAGEREF _Toc466295864 \h 17SECTION C: THE EVIDENCE FOR ACUTE ASTHMA MANAGEMENT PAGEREF _Toc466295865 \h 18SECTION D: DISCHARGE PLANNING PAGEREF _Toc466295866 \h 22Asthma education PAGEREF _Toc466295867 \h 23Asthma control PAGEREF _Toc466295868 \h 24Follow-up PAGEREF _Toc466295869 \h 25Discharge checklist PAGEREF _Toc466295870 \h 26SECTION E: HELPFUL RESOURCES PAGEREF _Toc466295871 \h 27Viral induced wheeze and asthma fact sheet for parents PAGEREF _Toc466295872 \h 28Peak flow chart PAGEREF _Toc466295873 \h 30My Asthma Plan PAGEREF _Toc466295874 \h 31ASTHMA CONTROL TEST <12y PAGEREF _Toc466295875 \h 32ASTHMA CONTROL TEST >12y PAGEREF _Toc466295877 \h 33MONITORING COMPLIANCE PAGEREF _Toc466295878 \h 34REFERENCES PAGEREF _Toc466295879 \h 35APPENDIX 1: EQUALITY ANALYSIS checklist PAGEREF _Toc466295881 \h 37EQUALITY STATEMENTThe equality analysis for this guideline is in Appendix 1.The Royal Free London NHS Foundation Trust is committed to creating a positive culture of respect for all individuals, including job applicants, employees, patients, their families and carers as well as community partners. The intention is, as required by the Equality Act 2010, to identify, remove or minimise discriminatory practice in the nine named protected characteristics of age, disability (including HIV status), gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex or sexual orientation. It is also intended to use the Human Rights Act 1998 to treat fairly and value equality of opportunity regardless of socio-economic status, domestic circumstances, employment status, political affiliation or trade union membership, and to promote positive practice and value the diversity of all individuals and communities.IntroductionAsthma affects 1.1million children in the UK. Many more pre-school children experience acute wheeze each year with viral infections. Acute wheeze is one of the commonest reasons for attendance to the emergency department and admission to hospital in children. Up to 75% of these admissions are thought to be avoidable. Evidence-based clinical pathways and guidelines have been shown to improve outcomes for children with acute wheeze and asthma, and reduce hospitalisation.This integrated clinical guideline has been developed for children (between 2 and 16 years of age) with acute wheeze presenting to hospital. Recommendations are based on the best available evidence. Children under two years are more likely to have an alternative diagnosis and may respond inconsistently to bronchodilators and therefore are not included in this guideline. The guideline has been developed for hospitals within UCL partners, to be used in emergency departments, paediatric ambulatory units and in-patient paediatric wards. It has been developed in collaboration with primary, secondary and tertiary care and the Children’s Acute Transport Service. It includes an acute wheeze admission proforma and quick-reference flow charts for use in a busy emergency department as well as links to asthma plans and checklists for discharge. To go straight to the acute asthma management flow-chart click here.Acknowledgments and ContributionsWe would like to thank the members of the UCLP asthma network whose contributions to this guideline were invaluable.SECTION A: MANAGEMENT OF CHILD WITH ACUTE WHEEZE/ASTHMAAssessment of acute wheeze/asthma HistoryTaking a history is an important step in assessing children with acute wheeze but should not delay starting treatment particularly in severe and life-threatening episodes. ADDIN EN.CITE <EndNote><Cite><Author>Society</Author><Year>2012</Year><RecNum>111</RecNum><DisplayText><style face="superscript">1</style></DisplayText><record><rec-number>111</rec-number><foreign-keys><key app="EN" db-id="5tawds0r7ex0z2evaznpezzqtratpaz2vzt5" timestamp="1410628759">111</key></foreign-keys><ref-type name="Report">27</ref-type><contributors><authors><author>British Thoracic Society</author></authors></contributors><titles><title>British Guideline on the Management of Asthma</title></titles><dates><year>2012</year></dates><urls><related-urls><url> consider the following:Is this really asthma? – See “Ensuring the correct diagnosis.”If this is asthma, is it well controlled?If it is not well controlled, what are the reasons for this?This is an important opportunity to identify children with poor control, and to do something about it. ADDIN EN.CITE <EndNote><Cite><Author>Anagnostou</Author><Year>2012</Year><RecNum>125</RecNum><DisplayText><style face="superscript">3</style></DisplayText><record><rec-number>125</rec-number><foreign-keys><key app="EN" db-id="5tawds0r7ex0z2evaznpezzqtratpaz2vzt5" timestamp="1408195607">125</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Anagnostou, Katherine</author><author>Harrison, Brian</author><author>Iles, Richard</author><author>Nasser, Shuaib</author></authors></contributors><titles><title>Risk factors for childhood asthma deaths from the UK Eastern Region Confidential Enquiry 2001-2006</title><secondary-title>Primary Care Respiratory Journal</secondary-title></titles><periodical><full-title>Primary Care Respiratory Journal</full-title></periodical><pages>71-77</pages><volume>21</volume><number>1</number><keywords><keyword>Asthma</keyword><keyword>deaths</keyword><keyword>allergy</keyword><keyword>inhaled corticosteroids</keyword><keyword>LABAs</keyword><keyword>SABAs</keyword><keyword>seasonal</keyword><keyword>adherence</keyword><keyword>behavioural</keyword><keyword>psychosocial</keyword><keyword>children</keyword><keyword>paediatric</keyword><keyword>risk factors</keyword></keywords><dates><year>2012</year><pub-dates><date>03//</date></pub-dates></dates><isbn>1471-4418</isbn><urls><related-urls><url> a focused medical history including: The acute episode: Symptoms, duration, triggers and prior drug treatment (including dosages, frequency of use, delivery method, time of last dose and response to treatment)Background asthma control: ask about interval symptoms in particular symptoms with exercise, symptoms at night and need for rescue SalbutamolPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5TYW1wYXlvPC9BdXRob3I+PFllYXI+MjAxMDwvWWVhcj48
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ADDIN EN.CITE.DATA 2 – The Asthma Control Test is a useful tool for assessing background asthma control.Medication history (including dosages, inhaler strength, delivery and frequency of use). More than 1 prescription per month of salbutamol and less than 1 prescription per month of inhaled steroids (if prescribed) may be a marker of poor control/adherence ADDIN EN.CITE <EndNote><Cite><Author>Physician</Author><Year>2014</Year><RecNum>110</RecNum><DisplayText><style face="superscript">4</style></DisplayText><record><rec-number>110</rec-number><foreign-keys><key app="EN" db-id="5tawds0r7ex0z2evaznpezzqtratpaz2vzt5" timestamp="1410628454">110</key></foreign-keys><ref-type name="Report">27</ref-type><contributors><authors><author>Royal College of Physician</author></authors></contributors><titles><title>Why Asthma Still Kills?: National Review of Asthma Deaths</title></titles><dates><year>2014</year></dates><urls><related-urls><url> hospitalisations with acute wheeze (including previous life-threatening episodes and any admissions to HDU and ICU)Prior visits to GP/Emergency Department (ED) with acute asthma and number of courses of systemic steroids in last 6 months. Number of repeat prescriptions for inhalers:Co-existing medical conditions (particularly allergic rhinitis, hay fever, eczema and allergies)Family and social history (including family history of atopy, smokers at home and pets)Number of school days missed due to asthmaUse of complementary therapies: this may be associated with poor adherence to prescribed therapiesExaminationAssess child on presentation using a structured approach (airway, breathing, circulation and disability) and record vital signs (pulse rate, respiratory rate and oxygen saturations in air.) Level of activity (or alertness) and work of breathing are important parameters in assessing the severity of the wheeze episode, along with initial oxygen saturations in air. Wheezing is not a good marker of severity, as with increasing obstruction it may become bi-phasic or less apparent.Often the priority is to do a respiratory examination, assess severity (next section) and start treatment. Then proceed to perform a full physical examination, including checking peak flow (if child is over five years and familiar with performing peak flow.) Plot height and weight on a growth chart.0-29083000Red Flags: A silent chest, drowsiness, agitation or confusion are signs of a life-threatening episode. Call for senior help and anaesthetic support immediatelyAssessing severityIt is important to assess the severity of the wheeze episode on presentation and classify into mild, moderate, severe or life threatening. ADDIN EN.CITE <EndNote><Cite><RecNum>124</RecNum><DisplayText><style face="superscript">5</style></DisplayText><record><rec-number>124</rec-number><foreign-keys><key app="EN" db-id="5tawds0r7ex0z2evaznpezzqtratpaz2vzt5" timestamp="1395502380">124</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors></contributors><titles><title>British Guideline on the Management of Asthma</title></titles><number>22nd March 2014</number><dates></dates><urls><related-urls><url> This will allow ensure that the correct treatment is given.If any feature is present (severe and Life threatening), this will automatically put the patient in this group.Clinical FeaturesMildModerateSevere Life-threateningAlertnessAlertAlertAgitated/distressedConfused/drowsyActivity LevelNormalNormalReducedExhaustionSpeechNormalAble to talk in short sentencesToo breathless to talk/feedNoneOxygen Saturations>94% in air>92% air<92% air<92% on oxygenCyanosisHeart Rate<5yrs <140≥5yrs <125<5yrs < 140≥5yrs < 125<5yrs> 140≥5yrs>125Bradycardia or hypotensionRespiratory Rate<5yrs <40≥5yrs <30<5yrs <40≥5yrs <30<5yrs >40≥5yrs >30Work of BreathingMinimal recessionSome increase.Mild to Moderate recession and accessory muscle useMarkedly Increased.Moderate to severe recession, marked accessory muscle useSevere recession/ poor respiratory effortSilent chestPeak Flow>50-75% best or predicted33-50% best or predictedNot appropriateInvestigationsPeak flow measurement can be helpful in assessing severity and response to treatment in children over five years who are familiar with the technique. The best of three Peak Expiratory Flow (PEF) measurements expressed ideally, as a percentage of personal best can be useful. (See Appendix: chart for normal ranges.)Peak flows should not be used for children with life-threatening asthma. Clinical assessment of severity may be more reliable especially in children under 10 years and those unfamiliar with these devices or who have poor technique. ADDIN EN.CITE <EndNote><Cite><Author>Gorelick</Author><Year>2004</Year><RecNum>114</RecNum><DisplayText><style face="superscript">7</style></DisplayText><record><rec-number>114</rec-number><foreign-keys><key app="EN" db-id="5tawds0r7ex0z2evaznpezzqtratpaz2vzt5" timestamp="1395083976">114</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Gorelick, Marc H.</author><author>Stevens, Molly W.</author><author>Schultz, Theresa</author><author>Scribano, Philip V.</author></authors></contributors><titles><title>Difficulty in Obtaining Peak Expiratory Flow Measurements in Children With Acute Asthma</title><secondary-title>Pediatric Emergency Care</secondary-title></titles><periodical><full-title>Pediatr Emerg Care</full-title><abbr-1>Pediatric emergency care</abbr-1></periodical><pages>22-26</pages><volume>20</volume><number>1</number><keywords><keyword>peak expiratory flow rate</keyword><keyword>pulmonary function testing</keyword><keyword>asthma</keyword><keyword>00006565-200401000-00006</keyword></keywords><dates><year>2004</year></dates><isbn>0749-5161</isbn><urls><related-urls><url> X-rays – Chest X-rays rarely provide additional information and are not routinely indicated. ADDIN EN.CITE <EndNote><Cite><Author>Rushton</Author><Year>1982</Year><RecNum>115</RecNum><DisplayText><style face="superscript">8</style></DisplayText><record><rec-number>115</rec-number><foreign-keys><key app="EN" db-id="5tawds0r7ex0z2evaznpezzqtratpaz2vzt5" timestamp="1395084171">115</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Rushton, Alan R.</author></authors></contributors><titles><title>The Role of the Chest Radiograph in the Management of Childhood Asthma</title><secondary-title>Clinical Pediatrics</secondary-title></titles><periodical><full-title>Clin Pediatr (Phila)</full-title><abbr-1>Clinical pediatrics</abbr-1></periodical><pages>325-328</pages><volume>21</volume><number>6</number><dates><year>1982</year><pub-dates><date>June 1, 1982</date></pub-dates></dates><urls><related-urls><url> A Chest X-ray should be performed if there is subcutaneous emphysema, persisting unilateral signs suggesting pneumothorax, lobar collapse, a foreign body, consolidation or an atypical history in a child with a first presentation of wheeze or life-threatening asthma not responding to treatment.Blood gas analysis should be avoided if possible as it may cause distress and further respiratory compromise. The child’s clinical state is a better guide to treatment. Capillary sampling can be considered if there are life-threatening features not responsive to treatment, or uncertainty about the clinical diagnosis. A normal or raised pCO2 indicates worsening asthma.Ensuring the correct diagnosisAsthma causes recurrent respiratory symptoms of wheezing, cough, difficulty breathing, and chest tightness in children due to variable airway obstruction. Asthma is a clinical diagnosis in children. ADDIN EN.CITE <EndNote><Cite><RecNum>124</RecNum><DisplayText><style face="superscript">5</style></DisplayText><record><rec-number>124</rec-number><foreign-keys><key app="EN" db-id="5tawds0r7ex0z2evaznpezzqtratpaz2vzt5" timestamp="1395502380">124</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors></contributors><titles><title>British Guideline on the Management of Asthma</title></titles><number>22nd March 2014</number><dates></dates><urls><related-urls><url> It is made more likely if these symptoms are frequent and recurrent, worse at night and in the early morning, worse after exercise or with other triggers (such as exposure to pets, cold or damp air or with emotions,) and occur apart from colds. Asthma is also more likely if children have other atopic conditions (such as eczema, allergic rhinitis or allergies,) or a family history of atopy or asthma.The following are found less often in children with asthma, and may be clues to alternative diagnoses in wheezy children: ADDIN EN.CITE <EndNote><Cite><RecNum>124</RecNum><DisplayText><style face="superscript">5</style></DisplayText><record><rec-number>124</rec-number><foreign-keys><key app="EN" db-id="5tawds0r7ex0z2evaznpezzqtratpaz2vzt5" timestamp="1395502380">124</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors></contributors><titles><title>British Guideline on the Management of Asthma</title></titles><number>22nd March 2014</number><dates></dates><urls><related-urls><url> ClueAlternative diagnoses to considerSymptoms present from birth or neonatal periodCongenital lung abnormality, cystic fibrosis, chronic lung disease of prematurity, ciliary dyskinesiaFamily history of respiratory diseaseCystic fibrosis, immunodeficiency, neuromuscular disorder.Severe upper respiratory tract diseaseCiliary dyskinesia, immunodeficiencyExcessive vomitingGastro-oesophageal reflux diseaseBreathlessness with light-headedness and peripheral tinglingHyperventilation/panic attacksPersistent moist coughCystic fibrosis, bronchiectasis, recurrent aspiration, ciliary dyskinesia, immunodeficiencyInspiratory StridorTracheal or laryngeal disorderAbnormal voice or cryLaryngeal problemFocal signs in chestInhaled foreign body, Congenital abnormality, Bronchiectasis, PneumoniaFinger clubbingCystic fibrosis, Bronchiectasis.Failure to thriveCystic fibrosis, Immunodeficiency, Gastro-oesophageal refluxFocal or persistent CXR changesCongenital abnormality, cystic fibrosis, recurrent aspiration, bronchiectasis, tuberculosisTachypnoea without wheezeSevere acidosis e.g. DKA, renal failureNew onset of wheeze in older child +/- orthopnoeaMediastinal massWheeze in the preschool childAcute wheeze, with viral upper respiratory tract infections, is very common in pre-school children. The vast majority of these children do not have asthma – and most will have stopped having episodes of wheeze by the age of six. Pre-school wheeze has a different natural history and pathophysiology to childhood asthma, and children with pre-school wheeze often respond differently to asthma treatment (particularly corticosteroids.)It is helpful to classify children with pre-school wheeze into two phenotypes: ADDIN EN.CITE <EndNote><Cite><Author>Bush</Author><Year>2014</Year><RecNum>113</RecNum><DisplayText><style face="superscript">9</style></DisplayText><record><rec-number>113</rec-number><foreign-keys><key app="EN" db-id="5tawds0r7ex0z2evaznpezzqtratpaz2vzt5" timestamp="1395083822">113</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Andrew Bush</author><author>Jonathan Grigg</author><author>Sejal Saglani</author></authors></contributors><titles><title>Managing wheeze in preschool children</title><secondary-title>BMJ</secondary-title></titles><periodical><full-title>Bmj</full-title><abbr-1>BMJ (Clinical research ed.)</abbr-1></periodical><volume>348</volume><dates><year>2014</year><pub-dates><date>2014-02-04 15:41:01</date></pub-dates></dates><urls></urls></record></Cite></EndNote>9Episodic Viral Wheeze – Child only wheezes with viral upper respiratory tract infections and is symptom-free in between episodes.Multi-trigger Wheeze – Child wheezes with upper respiratory tract infections but also with other triggers such as exercise, smoke and allergen exposure.Prednisolone should not be given to pre-school children with wheeze who are well enough to be managed in the community. In children admitted to hospital it should not be used routinely in children with episodic viral wheeze. ADDIN EN.CITE <EndNote><Cite><Author>Bush</Author><Year>2014</Year><RecNum>113</RecNum><DisplayText><style face="superscript">9</style></DisplayText><record><rec-number>113</rec-number><foreign-keys><key app="EN" db-id="5tawds0r7ex0z2evaznpezzqtratpaz2vzt5" timestamp="1395083822">113</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Andrew Bush</author><author>Jonathan Grigg</author><author>Sejal Saglani</author></authors></contributors><titles><title>Managing wheeze in preschool children</title><secondary-title>BMJ</secondary-title></titles><periodical><full-title>Bmj</full-title><abbr-1>BMJ (Clinical research ed.)</abbr-1></periodical><volume>348</volume><dates><year>2014</year><pub-dates><date>2014-02-04 15:41:01</date></pub-dates></dates><urls></urls></record></Cite></EndNote>9Prednisolone should be considered in children with multi-trigger wheeze and children with episodic wheeze with severe or life-threatening exacerbations, particularly those who require high dependency or intensive care.For further information – see the review article: Managing wheeze in pre-school children.Young people and adolescentsSee young people and adolescents on their own for part of the consultationAsk if they smoke – if they do offer them advice to stop and signpost to local NHS smoking cessation services. If they do not smoke, encourage them to avoid tobacco smoke and urge them not to start smokingAsk about recreational drugs and alcohol consumption and symptoms of anxiety and depression. These are significantly more prevalent amongst young people with asthma.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5MdTwvQXV0aG9yPjxZZWFyPjIwMTI8L1llYXI+PFJlY051
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ADDIN EN.CITE.DATA 6Difficult AsthmaDefinitionPersistent symptoms and/or frequent attacks despite treatment with high dose therapies.Why is this important?This is the group in which death from asthma is most likely to occur. The situation may not be obvious: children with chronic asthma may adapt to their symptoms, they may not wheeze and may not complain of difficulty in breathing.Suspecting difficult asthmaAcute attacks where symptoms and/or objective measures of airflow obstruction, such as PEFR do not respond as quickly as expected to adequate doses of oral steroids and nebulised bronchodilators.History of persistent symptoms: remember coughing and poor exercise tolerance as well as wheeze and shortness of breath.Low scores on ACT questionnaire.Variable home PEFR readings, frequently below predicted.Assessing difficult asthmaConfirm diagnosis of asthma.Identify the mechanism of persisting symptoms.Assess adherence to therapy.Consider coexistent psychological morbidity.Assessment should be facilitated through a multidisciplinary team including asthma nurse specialist and paediatric consultant with respiratory interest. Involve CAMHS for assessment of coexistent psychosocial morbidity.What to doOptimise steroid and bronchodilator treatment.Optimise adherence to maintenance therapy.Addressing precipitating factors.Referral to CAMHS for ongoing psychosocial therapy where coexistent features present. Consider monitoring induced sputum eosinophil counts to guide steroid treatment.Make a tertiary respiratory referral. For in-patients with difficult chronic symptoms, discuss with the respiratory team at either GOSH or the Brompton by phone.For out-patients, refer to these services via letterAcute wheeze flowchart for children 2-16 years-702945229870MildSaO2 >94% airMild recessionMild to moderate wheezeSevereSaO2 <92% in air<5yrs: RR >40, HR >140≥5yrs: RR>30, HR >125Unable to talk/feedMarked recessionLife threateningSaO2 <92% in O2Pallor/ cyanosisPoor respiratory effortAgitatedreduced GCSSilent chestGive Oxygen if needed to keep saturations >93%.ModerateSaO2 >92% airCan talk in short sentencesModerate recession and wheezeSalbutamol via spacerReassess after 20 minutes and repeat if needed up to 3 dosesConsider oral prednisolone if:Needs >1 dose salbutamol and/or:Known asthmatic≥5 years old< 5 years with multi-trigger wheezeSalbutamol via spacerOral prednisolone if:Known asthmatic≥5 years oldConsider if <5 years and multi-trigger wheezeIf poor response to first salbutamol add ipratropium to remaining salbutamol plete burst therapy of salbutamol +/- ipratropium every 20mins for 1st hourBurst therapy of Salbutamol and ipratropium via nebuliser 3 doses at 20 minute intervalsOral prednisolone, (or IV hydrocortisone if vomiting)REASSESS and if poor response:Repeat burst:IV magnesium bolusIV salbutamol bolus+/- infusionBack to back nebulised salbutamol and ipratropiumObtain IV accessU&E and blood gasIV hydrocortisone IV magnesium bolusREASSESS and if poor response:Continue nebulisersGive IV salbutamol bolus and then infusion or if salbutamol toxicity, give IV aminophyllineCall consultant +/-anaesthetist and CATS Assess response to treatment after 1 hour and 2 hours and re-categoriseMildSafe to discharge if stable and only requiring Salbutamol every 3-4 hoursComplete 3 days of prednisolone if started.Discharge with asthma plan.Advise review within 48 hours by GPModerateKeep O2 SaO2 >93%Continue salbutamol every 1-3 hrs as neededSafe to discharge when only requiring salbutamol every 3-4 hoursComplete 3 days of prednisolone if started. Give asthma plan. Advise review within 48 hours by GPSevereKeep O2 SaO2 >93%Continue salbutamol every 30-60 minutesContinue ipratropium every 20 minutes for first 2 hours and then every 4 hoursReassess frequentlyIf no improvement and not already done so give:IV magnesium IV salbutamol bolus +/- infusionAdmit HDUHigh flow oxygenLife threateningContinue nebulisersGive IV salbutamol +/- aminophylline if not already done so.Consider 2nd dose IV magnesium + antibioticsCall anaesthetist and CATSDo CXR and gasIf deteriorating consider intubation and ventilationCALL FOR HELP00MildSaO2 >94% airMild recessionMild to moderate wheezeSevereSaO2 <92% in air<5yrs: RR >40, HR >140≥5yrs: RR>30, HR >125Unable to talk/feedMarked recessionLife threateningSaO2 <92% in O2Pallor/ cyanosisPoor respiratory effortAgitatedreduced GCSSilent chestGive Oxygen if needed to keep saturations >93%.ModerateSaO2 >92% airCan talk in short sentencesModerate recession and wheezeSalbutamol via spacerReassess after 20 minutes and repeat if needed up to 3 dosesConsider oral prednisolone if:Needs >1 dose salbutamol and/or:Known asthmatic≥5 years old< 5 years with multi-trigger wheezeSalbutamol via spacerOral prednisolone if:Known asthmatic≥5 years oldConsider if <5 years and multi-trigger wheezeIf poor response to first salbutamol add ipratropium to remaining salbutamol plete burst therapy of salbutamol +/- ipratropium every 20mins for 1st hourBurst therapy of Salbutamol and ipratropium via nebuliser 3 doses at 20 minute intervalsOral prednisolone, (or IV hydrocortisone if vomiting)REASSESS and if poor response:Repeat burst:IV magnesium bolusIV salbutamol bolus+/- infusionBack to back nebulised salbutamol and ipratropiumObtain IV accessU&E and blood gasIV hydrocortisone IV magnesium bolusREASSESS and if poor response:Continue nebulisersGive IV salbutamol bolus and then infusion or if salbutamol toxicity, give IV aminophyllineCall consultant +/-anaesthetist and CATS Assess response to treatment after 1 hour and 2 hours and re-categoriseMildSafe to discharge if stable and only requiring Salbutamol every 3-4 hoursComplete 3 days of prednisolone if started.Discharge with asthma plan.Advise review within 48 hours by GPModerateKeep O2 SaO2 >93%Continue salbutamol every 1-3 hrs as neededSafe to discharge when only requiring salbutamol every 3-4 hoursComplete 3 days of prednisolone if started. Give asthma plan. Advise review within 48 hours by GPSevereKeep O2 SaO2 >93%Continue salbutamol every 30-60 minutesContinue ipratropium every 20 minutes for first 2 hours and then every 4 hoursReassess frequentlyIf no improvement and not already done so give:IV magnesium IV salbutamol bolus +/- infusionAdmit HDUHigh flow oxygenLife threateningContinue nebulisersGive IV salbutamol +/- aminophylline if not already done so.Consider 2nd dose IV magnesium + antibioticsCall anaesthetist and CATSDo CXR and gasIf deteriorating consider intubation and ventilationCALL FOR HELPStart by assessing severity and treat according to most severe featuresThe deteriorating child with wheeze/asthmaMost children with acute severe and life-threatening asthma will respond to initial medical therapy. In the very few children that do not respond and have a progressive respiratory deterioration, intubation and ventilation can be lifesaving. Complications are common post-intubation, the most common being hypotension requiring fluid resuscitation. Evidence has shown that maximal medical therapy had only been administered in 31% (9/29) of children who required intubation for progressive respiratory deterioration. ADDIN EN.CITE <EndNote><Cite><Author>Dinwiddie</Author><Year>2008</Year><RecNum>82</RecNum><DisplayText><style face="superscript">32</style></DisplayText><record><rec-number>82</rec-number><foreign-keys><key app="EN" db-id="5tawds0r7ex0z2evaznpezzqtratpaz2vzt5" timestamp="1391902608">82</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Dinwiddie, R.</author></authors></contributors><titles><title>Treatment of acute asthma in children. Which approach is best?</title><secondary-title>Allergol Immunopathol (Madr)</secondary-title><alt-title>Allergologia et immunopathologia</alt-title></titles><periodical><full-title>Allergol Immunopathol (Madr)</full-title><abbr-1>Allergologia et immunopathologia</abbr-1></periodical><alt-periodical><full-title>Allergol Immunopathol (Madr)</full-title><abbr-1>Allergologia et immunopathologia</abbr-1></alt-periodical><pages>185-6</pages><volume>36</volume><number>4</number><edition>2008/10/22</edition><keywords><keyword>Acute Disease</keyword><keyword>Administration, Inhalation</keyword><keyword>Anti-Asthmatic Agents/*administration & dosage/economics</keyword><keyword>Asthma/*drug therapy/economics</keyword><keyword>Child</keyword><keyword>Developing Countries/economics</keyword><keyword>Humans</keyword><keyword>Nebulizers and Vaporizers</keyword></keywords><dates><year>2008</year><pub-dates><date>Jul-Aug</date></pub-dates></dates><isbn>0301-0546 (Print)
0301-0546</isbn><accession-num>18928682</accession-num><urls></urls><remote-database-provider>NLM</remote-database-provider><language>eng</language></record></Cite></EndNote>32 Always ensure that a child has received maximal medical therapy and consider alternative diagnoses. Early discussion with the paediatric and anaesthetic consultant on call and CATS (Children Acute Transport Service) is essential. Indications for IntubationConsider intubation in any child with the following:TiredReducing conscious levelWorsening hypoxaemiaThe CATS website has an Asthma Guideline with specific instructions regarding intubation. To go to the CATS asthma guideline click hereTo make a referral to CATS call 0800 085 0003Medications for acute wheeze/asthmaSECTION B: MEDICATIONMedicationRoute of administrationDose < 5 yearsDose≥ 5 yearsKey treatment pointsOxygenOxygen should be given to all children with oxygen saturation levels < 94%.**Prescribe Oxygen on the drug chart**SalbutamolMDI and spacer6-10 puffs10 puffsSalbutamol should be given to all children presenting acutely with wheeze within 10 minutes of their arrival1 puff = 100mcgNebuliser2.5mg5mgBronchodilator therapy through MDI (Metered Dose Inhaler) with spacer should be first line as it is associated with fewer side effects.Ipratropium Bromide MDI and spacer4 puffs8 puffsGive Ipratropium Bromide with each dose of Salbutamol to all children with severe asthma for the first hour. Take care to protect childrens’ eyes as there is a risk of acute angle glaucoma1 puff=20mcgCan give every 20 minutes for first 2 hoursNebuliser<2 years 125mcg2-12 yrs 250mcg2-12 years 250 mcg> 12 years 500 mcgPrednisoloneOral1mg /kgOnce a day1mg/kg (Maximum 40mg)Once a dayConsider carefully if <5 years (see guideline)Prednisolone should be given as soon as possible afterarrival in the ED, and always within the first hourRound dose to nearest 5mgHydrocortisoneIntravenous4mg/kg every 6 hours (max 100mg)Or if weight unavailable use:< 2 years 25mg2-5 years 50mg> 5 years 100mgGive if vomiting or life-threatening episode of wheezeMagnesium SulphateIntravenousBolus40mg/kg (max 2g)Give IV magnesium sulphate to children with severe asthma who have responded poorly to initial burst therapy, or have on-going signs of a severe exacerbation at 1 hourGive over 20 minutesMonitor BP Cardiac monitor*SalbutamolIntravenous bolus< 2 years 5microgram/kg≥ 2 years 15microgram/kg (max 250microgram)Single bolusGive over 3-5 minutesCardiac monitor*Intravenous Infusion1-2 microgram/kg/minMonitor side effects including lactate and K+. Twice daily U&E’sCardiac monitor*AminophyllineIntravenous loading dose5mg/kg (max 500mg)(in obese child dose on ideal weight for height)Loading dose not needed if on oral aminophylline. Give over 20-30 minsCardiac monitor*Give antiemeticsIntravenous infusion< 12 years 1mg/kg/hr> 12 years 0.5-0.7 mg/kg/hr(in obese child dose on ideal weight for height)Cardiac monitor*Give antiemetics Levels 4-6 hrsWeaning bronchodilatorsBronchodilators should be weaned according to the child’s clinical state. While the child is an inpatient a minimum of hourly assessment while the child is requiring 1-2 hourly salbutamol, and two-three hourly assessment when requiring salbutamol 3-4 hourly should be undertaken. This should include assessment of saturations and work of breathing to determine when the next dose of bronchodilator should be given. Wheeze is not a good marker of asthma severity but the return of wheeze may be one indicator for the requirement of further bronchodilators. If appropriately trained staff are available, nurse led weaning and discharge may allow better patient focused weaning and discharge. A suggested salbutamol-weaning plan on discharge is as follows (also see patient information leaflet):Day 1: Give 6 puffs of salbutamol via spacer every 4 hoursDay 2: Give 4 puffs of salbutamol via spacer every 6 hoursDay 3: Give 2 puffs as required using usual inhaler deviceIf the child/young person is requiring more than 6 puffs every 4 hours they need to re-attend the Emergency department (ED).This is a guide for families and weaning at home should also be guided by the child’s condition and parents should be taught how to assess signs of respiratory distress in their children. Preventer therapy for children >5 yearsLTRA – Leukotriene receptor antagonistLABA – Long acting B2 agonistInhaled corticosteroids should be considered for patients with any of the following features:Asthma attacks in the last 2 yearsUsing B2 agonists 3 times a week or moreWaking one night a weekDoses should be started appropriate to the severity of diseaseExample paediatric doses of inhale corticosteroids(Ciclesonide is non formulary at RFH)Preventer therapy for children <5 years Episodic viral wheeze – Consider the use of interval or continuous Montelukast (a Leukotriene Receptor Antagonist) – this has been shown to reduce unscheduled health-care consultations and time off child-care, or off work for parents. Start treatment at the first sign of a viral cold and discontinue it when the child is clearly better.Multi-trigger wheeze – Give a trial of either inhaled corticosteroids or Montelukast for 4-8 weeks. After this period stop treatment. Only resume treatment if symptoms recur and then reduce treatment to the lowest level that controls treatment. If there is no benefit consider using whichever treatment not already tried. If this does not help refer for consideration of further investigations.SECTION C: THE EVIDENCE FOR ACUTE ASTHMA MANAGEMENT 8.1 OxygenOxygen should be given to all children with oxygen saturation levels < 94%.In life-threatening asthma give oxygen via a non-rebreathe mask (15 litres/minute). In severe asthma, oxygen can be given by nasal cannula or a facemask. Aim to keep oxygen saturations at 94-98%. Care should be taken not to over administer oxygen as this may mask signs of deterioration in moderate and severe asthma. Oxygen should be prescribed and documented.8.2 SalbutamolSalbutamol should be given to all children presenting acutely with wheeze within 10 minutes of their arrival. ADDIN EN.CITE <EndNote><Cite><Author>Medicine</Author><RecNum>127</RecNum><DisplayText><style face="superscript">10</style></DisplayText><record><rec-number>127</rec-number><foreign-keys><key app="EN" db-id="5tawds0r7ex0z2evaznpezzqtratpaz2vzt5" timestamp="1408395801">127</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>College of Emergency Medicine</author></authors></contributors><titles><title>Clinical Standards for Emergency Departments: Asthma</title></titles><dates><pub-dates><date>2011/2012</date></pub-dates></dates><urls><related-urls><url> is a short acting beta-2agonist, which should be used as first line bronchodilator therapy in childhood wheeze. It can be given by metered dose inhalers (by spacer) or by nebuliser. Both routes are equally efficacious as long as the doses used are sufficient (see medication doses.) In children giving Salbutamol via a spacer (as opposed to a nebulizer) results in less tachycardia and tremor and a reduced time in the emergency department, particularly for children with mild-moderate exacerbations. ADDIN EN.CITE <EndNote><Cite><Author>Cates</Author><Year>2013</Year><RecNum>116</RecNum><DisplayText><style face="superscript">11</style></DisplayText><record><rec-number>116</rec-number><foreign-keys><key app="EN" db-id="5tawds0r7ex0z2evaznpezzqtratpaz2vzt5" timestamp="1395173881">116</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Cates, Christopher J</author><author>Welsh, Emma J</author><author>Rowe, Brian H</author></authors></contributors><titles><title>Holding chambers (spacers) versus nebulisers for beta-agonist treatment of acute asthma</title><secondary-title>status and date: New search for studies and content updated (conclusions changed), published in</secondary-title></titles><periodical><full-title>status and date: New search for studies and content updated (conclusions changed), published in</full-title></periodical><number>9</number><dates><year>2013</year></dates><urls></urls></record></Cite></EndNote>11An oxygen requirement is not necessarily a contraindication to the use of spacers; Spacers have been shown to be safe and well tolerated even in severe asthma.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Qb3dlbGw8L0F1dGhvcj48WWVhcj4yMDAxPC9ZZWFyPjxS
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ADDIN EN.CITE.DATA 13-15 Currently the British Thoracic Society guidelines recommend consideration of a single bolus dose of intravenous Salbutamol in severe cases where the child has not responded to initial inhaled therapy.013462000Side effects of Salbutamol can include tachycardia, tremor, hypokalaemia, headache, lactic acidosis, hyperglycaemia, arrhythmias and palpitations and very rarely urticaria and paroxysmal bronchospasm. If the heart rate is >200 consider reducing/stopping salbutamol. 8.3 PrednisolonePrednisolone should be given as soon as possible afterarrival in the ED, and always within the first hour.Early administration of Prednisolone to children with acute asthma reduces hospital admission and results in reduced beta-2agonist use and earlier recovery. ADDIN EN.CITE <EndNote><Cite><Author>Smith</Author><Year>2003</Year><RecNum>119</RecNum><DisplayText><style face="superscript">16</style></DisplayText><record><rec-number>119</rec-number><foreign-keys><key app="EN" db-id="5tawds0r7ex0z2evaznpezzqtratpaz2vzt5" timestamp="1395179632">119</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Smith, M</author><author>Iqbal, SMSI</author><author>Elliott, TM</author><author>Everard, M</author><author>Rowe, BH</author></authors></contributors><titles><title>Corticosteroids for hospitalised children with acute asthma</title><secondary-title>Cochrane Database Syst Rev</secondary-title></titles><periodical><full-title>Cochrane Database Syst Rev</full-title><abbr-1>The Cochrane database of systematic reviews</abbr-1></periodical><volume>1</volume><dates><year>2003</year></dates><urls></urls></record></Cite></EndNote>16The earlier Prednisolone is given, the less likely a child is to need admission to hospital. ADDIN EN.CITE <EndNote><Cite><Author>Bhogal</Author><Year>2013</Year><RecNum>41</RecNum><DisplayText><style face="superscript">17</style></DisplayText><record><rec-number>41</rec-number><foreign-keys><key app="EN" db-id="5tawds0r7ex0z2evaznpezzqtratpaz2vzt5" timestamp="1391883803">41</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Bhogal, S. K.</author></authors></contributors><auth-address>Child Health Intervention & Longitudinal Development Program, University of New Brunswick, Fredericton, New Brunswick, Canada. sanjit.bhogal@</auth-address><titles><title>A question of time: systemic corticosteroids in managing acute asthma in children</title><secondary-title>Curr Opin Pulm Med</secondary-title><alt-title>Current opinion in pulmonary medicine</alt-title></titles><periodical><full-title>Curr Opin Pulm Med</full-title><abbr-1>Current opinion in pulmonary medicine</abbr-1></periodical><alt-periodical><full-title>Curr Opin Pulm Med</full-title><abbr-1>Current opinion in pulmonary medicine</abbr-1></alt-periodical><pages>73-8</pages><volume>19</volume><number>1</number><edition>2012/12/01</edition><keywords><keyword>Acute Disease</keyword><keyword>Adolescent</keyword><keyword>Adrenal Cortex Hormones/*therapeutic use</keyword><keyword>Age Factors</keyword><keyword>Asthma/*drug therapy</keyword><keyword>Child</keyword><keyword>Child, Preschool</keyword><keyword>*Disease Management</keyword><keyword>*Hospitalization</keyword><keyword>Humans</keyword><keyword>Risk Factors</keyword><keyword>Time Factors</keyword><keyword>Treatment Outcome</keyword></keywords><dates><year>2013</year><pub-dates><date>Jan</date></pub-dates></dates><isbn>1070-5287</isbn><accession-num>23197290</accession-num><urls></urls><electronic-resource-num>10.1097/MCP.0b013e32835b590a</electronic-resource-num><remote-database-provider>NLM</remote-database-provider><language>eng</language></record></Cite></EndNote>17PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5EYXZpczwvQXV0aG9yPjxZZWFyPjIwMTI8L1llYXI+PFJl
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ADDIN EN.CITE.DATA 18In children with severe asthma, no significant difference has been found between oral and intravenous steroids. ADDIN EN.CITE <EndNote><Cite><Author>Barnett</Author><Year>1997</Year><RecNum>118</RecNum><DisplayText><style face="superscript">19</style></DisplayText><record><rec-number>118</rec-number><foreign-keys><key app="EN" db-id="5tawds0r7ex0z2evaznpezzqtratpaz2vzt5" timestamp="1395179200">118</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Barnett, Peter L. J.</author><author>Caputo, Grace L.</author><author>Baskin, Marc</author><author>Kuppermann, Nathan</author></authors></contributors><titles><title>Intravenous Versus Oral Corticosteroids in the Management of Acute Asthma in Children</title><secondary-title>Annals of Emergency Medicine</secondary-title></titles><periodical><full-title>Annals of Emergency Medicine</full-title></periodical><pages>212-217</pages><volume>29</volume><number>2</number><dates><year>1997</year><pub-dates><date>2//</date></pub-dates></dates><isbn>0196-0644</isbn><urls><related-urls><url>(97)70270-1</electronic-resource-num></record></Cite></EndNote>19 Intravenous corticosteroids (IV hydrocortisone) should be reserved for children with life-threatening asthma or where there is vomiting or concern regarding the absorption of oral corticosteroids. Make up prednisolone in a concentrated solution, as the taste can be unpleasant.Children should be given a three-day course of steroids unless they remain hospitalised at three days in which case a five-day course can be considered.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5DaGFuZzwvQXV0aG9yPjxZZWFyPjIwMDg8L1llYXI+PFJl
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ADDIN EN.CITE.DATA 20Prednisolone should not be used routinely in children with episodic viral wheeze – see Wheeze in pre-school children.0254000There is no need to wean steroids if the course is <2 weeks. Children on long-term oral steroids should carry a steroid card. Consider the possibility of adrenal insufficiency in sick children on regular high dose inhaled steroids. 8.4 Ipratropium BromideGive Ipratropium Bromide with each dose of Salbutamolto all children with severe asthma for the first hour. Take care to protect childrens’ eyes as there is a risk of acute angle glaucoma.In moderate asthma, give after the first dose of Salbutamol if there is a poor response. Anticholinergics have a slower onset of action and weaker bronchodilating effect than short acting beta2-agonists but may specifically relieve cholinergic bronchial tone and reduce mucosal oedema. The addition of anticholinergics (usually 2-3 doses) to Salbutamol significantly reduced the risk of hospital admission. Children also showed a greater improvement in lung function, and experience less nausea and tremor.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5HcmlmZml0aHM8L0F1dGhvcj48WWVhcj4yMDEzPC9ZZWFy
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ADDIN EN.CITE.DATA 21-11430010477500Side effects may include nausea, diarrhoea, constipation, headache and dizziness.8.5 Magnesium SulphateGive IV magnesium sulphate to children with severe asthma who haveresponded poorly to initial burst therapy, or have on-going signsof a severe exacerbation at 1 hour.In children with life-threatening asthma IV magnesium sulphate shouldbe given alongside burst therapy.The use of intravenous magnesium sulphate, in addition to Salbutamol and systemic steroids, is associated with a significant improvement in respiratory function and reduction in hospital admission in children with moderate to severe asthma. Nebulised magnesium sulphate only appears to have beneficial effects in adults. PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Nb2hhbW1lZDwvQXV0aG9yPjxZZWFyPjIwMDc8L1llYXI+
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ADDIN EN.CITE.DATA 24Magnesium Sulphate can be repeated within in 1-2 hours. Serum magnesium level measurement is indicated if further doses are being considered. There is insufficient evidence comparing IV magnesium sulphate versus IV Salbutamol for acute severe asthma in children.014478000Side effects: Intravenous magnesium sulphate has been well tolerated in studies, but can cause hypotension so monitor blood pressure throughout. Flushing, pain at infusion site, a dry mouth, and facial warmth have also been described. ADDIN EN.CITE <EndNote><Cite><Author>Davalos Bichara</Author><Year>2009</Year><RecNum>76</RecNum><DisplayText><style face="superscript">25</style></DisplayText><record><rec-number>76</rec-number><foreign-keys><key app="EN" db-id="5tawds0r7ex0z2evaznpezzqtratpaz2vzt5" timestamp="1391902608">76</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Davalos Bichara, M.</author><author>Goldman, R. D.</author></authors></contributors><auth-address>Emergency Therapeutics program, BC Children's Hospital, Vancouver.</auth-address><titles><title>Magnesium for treatment of asthma in children</title><secondary-title>Can Fam Physician</secondary-title><alt-title>Canadian family physician Medecin de famille canadien</alt-title></titles><periodical><full-title>Can Fam Physician</full-title><abbr-1>Canadian family physician Medecin de famille canadien</abbr-1></periodical><alt-periodical><full-title>Can Fam Physician</full-title><abbr-1>Canadian family physician Medecin de famille canadien</abbr-1></alt-periodical><pages>887-9</pages><volume>55</volume><number>9</number><edition>2009/09/16</edition><keywords><keyword>Administration, Inhalation</keyword><keyword>Asthma/blood/*drug therapy</keyword><keyword>Calcium Channel Blockers/administration & dosage/therapeutic use</keyword><keyword>Child</keyword><keyword>Humans</keyword><keyword>Magnesium/*blood</keyword><keyword>Magnesium Sulfate/administration & dosage/*therapeutic use</keyword><keyword>Nebulizers and Vaporizers</keyword><keyword>Treatment Outcome</keyword></keywords><dates><year>2009</year><pub-dates><date>Sep</date></pub-dates></dates><isbn>0008-350x</isbn><accession-num>19752254</accession-num><urls><related-urls><url> AminophyllineAminophylline is not recommended as first-line therapy for children with severe acute asthma, but should be considered as an additional therapy in children who have not sufficiently responded to IV Salbutamol or Magnesium, or who have developed toxicities with these.It may be useful early in treatment in children who present with severe or life threatening asthma who have received multiple doses of salbutamol prior to presentation and are showing toxicity or poor response to salbutamol.The use of intravenous aminophylline has not been shown to result in additional bronchodilation or a significant reduction in the risk of hospital admission in patients with acute asthma in the ED, compared to standard care.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5OYWlyPC9BdXRob3I+PFllYXI+MjAxMjwvWWVhcj48UmVj
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ADDIN EN.CITE.DATA 27, so give with antiemetic cover.8.7 Other TherapiesMontelukast –The use of oral Montelukast is not currently recommenced in moderate to severe asthma exacerbations of asthma. ADDIN EN.CITE <EndNote><Cite><Author>Capsomidis</Author><Year>2010</Year><RecNum>62</RecNum><DisplayText><style face="superscript">28</style></DisplayText><record><rec-number>62</rec-number><foreign-keys><key app="EN" db-id="5tawds0r7ex0z2evaznpezzqtratpaz2vzt5" timestamp="1391902608">62</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Capsomidis, A.</author><author>Tighe, M.</author></authors></contributors><auth-address>Poole Hospital NHS Trust, Poole General Hospital, Longfleet Road, Poole, UK. mpt195@</auth-address><titles><title>Archimedes. Question 2. Is oral montelukast beneficial in treating acute asthma exacerbations in children?</title><secondary-title>Arch Dis Child</secondary-title><alt-title>Archives of disease in childhood</alt-title></titles><periodical><full-title>Arch Dis Child</full-title><abbr-1>Archives of disease in childhood</abbr-1></periodical><alt-periodical><full-title>Arch Dis Child</full-title><abbr-1>Archives of disease in childhood</abbr-1></alt-periodical><pages>948-50</pages><volume>95</volume><number>11</number><edition>2010/10/29</edition><keywords><keyword>Acetates/*therapeutic use</keyword><keyword>Acute Disease</keyword><keyword>Administration, Oral</keyword><keyword>Anti-Asthmatic Agents/*therapeutic use</keyword><keyword>Asthma/*drug therapy</keyword><keyword>Child, Preschool</keyword><keyword>Evidence-Based Medicine</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Quinolines/*therapeutic use</keyword></keywords><dates><year>2010</year><pub-dates><date>Nov</date></pub-dates></dates><isbn>0003-9888</isbn><accession-num>20980280</accession-num><urls><related-urls><url> A single dose of oral Montelukast added to standard therapy of inhaled bronchodilators and systemic glucocorticoids, did not provide additional clinical benefit in children (aged over 5) with acute moderate to severe asthma.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Ub2RpPC9BdXRob3I+PFllYXI+MjAxMDwvWWVhcj48UmVj
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ADDIN EN.CITE.DATA 31SECTION D: DISCHARGE PLANNINGChildren are usually ready for discharge when they require salbutamol no more frequently than every 3-4 hours, have no oxygen requirement, are drinking sufficiently and the child, family and medical staff feel comfortable with the child going home.Discharge planning should begin at admission using every opportunity for education of the child and family throughout the admission. One of the aims at discharge should be to try to minimise the risk of future preventable admissions through the use of a comprehensive education package. ADDIN EN.CITE <EndNote><Cite><Author>Anagnostou</Author><Year>2012</Year><RecNum>125</RecNum><DisplayText><style face="superscript">3</style></DisplayText><record><rec-number>125</rec-number><foreign-keys><key app="EN" db-id="5tawds0r7ex0z2evaznpezzqtratpaz2vzt5" timestamp="1408195607">125</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Anagnostou, Katherine</author><author>Harrison, Brian</author><author>Iles, Richard</author><author>Nasser, Shuaib</author></authors></contributors><titles><title>Risk factors for childhood asthma deaths from the UK Eastern Region Confidential Enquiry 2001-2006</title><secondary-title>Primary Care Respiratory Journal</secondary-title></titles><periodical><full-title>Primary Care Respiratory Journal</full-title></periodical><pages>71-77</pages><volume>21</volume><number>1</number><keywords><keyword>Asthma</keyword><keyword>deaths</keyword><keyword>allergy</keyword><keyword>inhaled corticosteroids</keyword><keyword>LABAs</keyword><keyword>SABAs</keyword><keyword>seasonal</keyword><keyword>adherence</keyword><keyword>behavioural</keyword><keyword>psychosocial</keyword><keyword>children</keyword><keyword>paediatric</keyword><keyword>risk factors</keyword></keywords><dates><year>2012</year><pub-dates><date>03//</date></pub-dates></dates><isbn>1471-4418</isbn><urls><related-urls><url> education is the responsibility of all health professionals. All children should have their inhaler technique checked prior to discharge and should be discharged with written asthma information and a personalized asthma action plan (see asthma education below).An assessment of long-term asthma control should be made and preventer therapy considered (see sections).Nurse led salbutamol weaning and criteria led discharge may speed up the discharge process and prevent unnecessary delays but requires junior medical staff or senior nursing staff to have the necessary knowledge of asthma management and appropriate clinical skills in the assessment of asthma severity.Asthma educationAsthma education during an acute asthma exacerbation has been shown to be effective in reducing exacerbations, oral steroid use, visits to the emergency department and future hospitalisations. PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Fc3Bpbm96YS1QYWxtYTwvQXV0aG9yPjxZZWFyPjIwMDk8
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ADDIN EN.CITE.DATA 33 Children using written symptom-based asthma plans also have been found to have a lower risk of exacerbations requiring an acute care visit. ADDIN EN.CITE <EndNote><Cite><Author>Bhogal</Author><Year>2006</Year><RecNum>98</RecNum><DisplayText><style face="superscript">34</style></DisplayText><record><rec-number>98</rec-number><foreign-keys><key app="EN" db-id="5tawds0r7ex0z2evaznpezzqtratpaz2vzt5" timestamp="1391903297">98</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Bhogal, S.</author><author>Zemek, R.</author><author>Ducharme, F. M.</author></authors></contributors><titles><title>Written action plans for asthma in children</title><secondary-title>Cochrane Database Syst Rev</secondary-title><alt-title>The Cochrane database of systematic reviews</alt-title></titles><periodical><full-title>Cochrane Database Syst Rev</full-title><abbr-1>The Cochrane database of systematic reviews</abbr-1></periodical><alt-periodical><full-title>Cochrane Database Syst Rev</full-title><abbr-1>The Cochrane database of systematic reviews</abbr-1></alt-periodical><pages>Cd005306</pages><number>3</number><edition>2006/07/21</edition><keywords><keyword>Adolescent</keyword><keyword>Asthma/*drug therapy/etiology</keyword><keyword>Child</keyword><keyword>Humans</keyword><keyword>*Patient Care Planning</keyword><keyword>Randomized Controlled Trials as Topic</keyword></keywords><dates><year>2006</year></dates><isbn>1361-6137</isbn><accession-num>16856090</accession-num><urls><related-urls><url> following is a guide as to what could be covered by the nurse or doctor discharging the patient with the parents. For adolescents part of the consultation should be offered without the parents. What is Asthma?Inflammatory condition causing airway changes: tightening of smooth muscle, inflammation and mucous productionDiscuss how to identify and monitor for signs and symptoms of asthma:Cough, breathlessness, wheeze, chest tightnessDiscuss differences between mild, moderate and severe exacerbationsDiscuss common triggers in childhood asthmaViral respiratory infections, exposure to allergens such as house dust mite, cigarette smoke, exercise, cold or damp air. Symptoms often worse at night/early morningThe role of medicationsReliever inhaler: Acute managementPreventer inhaler: Interval managementUsing asthma plan, discuss frequency and dose for acute and interval managementReinforce need for long term adherence to preventer therapyThe use of inhalersInhaler and spacer education essentialDemonstrate and check inhaler techniqueDiscuss cleaning and care of inhalers and spacersDischarge PlanningDiscuss use of reducing medication planDiscuss use of asthma action plan for home asthma management: acute and interval managementDiscuss annual flu vaccinationDiscuss smoking cessation if appropriateAdvise follow up with GP in 48 hoursInform if paediatric or respiratory follow up is requiredGive copy of asthma fact sheet to take homeAsthma controlAn assessment of asthma control is an essential part of the discharge process. In the national review of asthma deaths, 10% of those who died had been discharged from hospital within the month prior to death. Of those patients for whom severity could be estimated, nearly 60% were being treated for mild asthma or moderate asthma. It is likely that many of these patients had poorly controlled, under-treated asthma, rather than truly mild or moderate diseaseAsking children and families the following three questions has been shown to have good sensitivity for ascertaining poor asthma control in an Emergency Department in comparison with longer screening tools. PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5TYW1wYXlvPC9BdXRob3I+PFllYXI+MjAxMDwvWWVhcj48
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ADDIN EN.CITE.DATA 2Symptoms at nightSymptoms with exercise Need for rescue SalbutamolIf children are using >1 salbutamol inhaler a month this is likely to reflect poor control and should be referred for follow up.The asthma control test is a validated scale which may be useful in the clinic setting. Before considering alteration of drug therapy the following should be considered:1. Is the diagnosis correct?2. Are there any modifiable triggers?3. Does the child have allergic rhinitis- treating this may help asthma control4. Is there good adherence with existing therapy and if not, why? I.e. use of <1 steroid inhaler per month may indicate poor adherence.5. Is there good inhaler technique?The aim of asthma treatment is to control symptoms so children experience: ADDIN EN.CITE <EndNote><Cite><RecNum>124</RecNum><DisplayText><style face="superscript">5</style></DisplayText><record><rec-number>124</rec-number><foreign-keys><key app="EN" db-id="5tawds0r7ex0z2evaznpezzqtratpaz2vzt5" timestamp="1395502380">124</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors></contributors><titles><title>British Guideline on the Management of Asthma</title></titles><number>22nd March 2014</number><dates></dates><urls><related-urls><url> daytime symptomsNo night-time awakening due to asthmaNo need for rescue medicationNo asthma attacksNo limitations on activity including exerciseNormal lung function (PEF >80% predicted or best)Minimal side effects from medicationIt is suggested that patients should see their GP/ practice nurseWithin 48 hours of discharge: to assess recovery and to reiterate knowledge.After a month of starting preventer therapy or changing dose: to assess efficacyAfter 3 months if asthma has been well controlled: to see if medication can be reducedFor a yearly asthma reviewFollow-upEvery child should be advised to see GP within 48 hours of dischargeFamilies should be advised to see the GP within 48 hours of discharge. The purpose of this visit is to ensure that the acute symptoms are resolving but also to review long term asthma control, to consolidate asthma education, to discuss the asthma action plan and to plan on-going follow up. Asthma clinic follow-up criteriaPoor control on or above step 2 BTS therapy ladder.Atypical course during admission.Life-threatening presentation and/or PICU admission.Consider if safeguarding concerns, poor adherence to therapy, parental anxiety or diagnostic doubt.Viral-induced pre-school wheeze follow-up criteriaAtypical course during admission.Received IV therapy during admission.Life-threatening presentation and/or PICU admission.Consider if safeguarding concerns, poor adherence to therapy, parental anxiety or diagnostic doubt.Referral to tertiary respiratory centreStep 4 or above on BTS therapy ladder.Discuss with consultant e.g. atypical course; uncertain diagnosisDischarge checklistPlease print out a copy, sign and place in the notes following dischargePatient details/sticker:Inhaler technique checked ?Background asthma control assessed?Need to commence or step up preventer therapy considered?Written asthma action plan given?PEFR?Weaning plan?Asthma education discussed with child and family?Discharge summary written and copy given to parents ?Discharge medications prescribed and dispensed ?Parents advised to see GP appointment within 48hrs ?Outpatient clinic follow up arranged in 4-8 weeks if appropriate ?SECTION E: HELPFUL RESOURCES British Thoracic Society Clinical Guidelines - for children - website and guideline on acute asthma - UK - the Sick Child - , Sneezy, Wheezy - review article on wheeze in pre-school children - smoking cessation – quitnow.smokefree.nhs.ukViral induced wheeze and asthma fact sheet for parentsWhat is making my child wheeze?Asthma and viral induced wheeze affect the lungs. The airways in the lungs become inflamed and swollen, making it difficult for your child to breathe.164782516319500Does my child have asthma or viral induced wheeze?As many as one in three preschool children will have a wheezy episode, usually starting with a cough and runny nose caused by a virus. Only very few of these children will have asthma. Viral induced wheeze: Children with viral induced wheeze only wheeze when they have a viral infection. The treatment is usually a reliever inhaler (usually blue) and sometimes if children have repeated episodes, a medicine taken by mouth which reduces swelling of the airways. Asthma: Children with asthma cough and wheeze with viral infections but also with other triggers. The treatment for asthma is a reliever inhaler (usually blue) but also often a preventer inhaler, which should be taken every day to work properly. Asthma can be well controlled with the right medicine in nearly all children. You should see your doctor regularly if your child is on preventer medication. Asthma triggersAsthma triggers are things, which make the airways inflamed and swollen, and cause asthma. These are different for everyone but common ones include:Viruses including those causing coldsCigarette smoke Weather changeExercise PetsHouse dust mitePollen Smoking can make wheeze episodes more frequent and severe: quitnow.smokefree.nhs.ukAsthma treatmentAsthma is usually treated with inhalers, which deliver the medicine directly into the lungs where it is needed. Sometimes your doctor will prescribe a short course of oral steroids for an asthma attack. Reliever Inhalers- usually blueRelievers work by relaxing the muscles in the airways, which get tight during an attack. Reliever inhalers work quickly (within 5-10 minutes) and should last for at least 4 hours.Your child should use the reliever inhaler if: COUGHING/ WHEEZING or SHORT OF BREATH.113347538100Weaning salbutamol after a wheezy episode:Day 1: Give 6 puffs every 4 hoursDay 2: Give 4 puffs every 6 hoursDay 3: Give 2 puffs as needed00Weaning salbutamol after a wheezy episode:Day 1: Give 6 puffs every 4 hoursDay 2: Give 4 puffs every 6 hoursDay 3: Give 2 puffs as neededPreventer Inhalers- usually brown/orange or purplePreventers help to stop the airways becoming red and swollen. They do not work straight away and need to be taken EVERYDAY, even when your child is WELL. Using your inhalersALWAYS use your inhaler with a spacer- it helps more medicine to get to the lungs where it is needed.Remove the cap from the inhalerShake the inhaler well and put firmly into the end of the spacerPlace the mask over your child’s face, covering the nose and mouth and making a good seal.If your child is 5 or older they may prefer a spacer with a mouthpiece. Ask them to place the mouthpiece between their teeth and to close their lips around the entire mouthpiece so there are no gaps. Hold the spacer level so that it does not tip up or hang down. Press the inhaler once to release a dose of medicine into the spacer- do not remove the inhalerAllow your child to breathe in and out 4 or 5 times i.e. leave spacer in position for 15-20 secondsIf further doses are needed shake inhaler again and repeat steps 3-5.How to care for your spacerThe spacer should be cleaned once a weekTake the spacer apart and wash it in warm water containing a little washing up liquid or mild soapDO NOT RINSE. Do not wipe the spacer dry – allow it to air dry. This can be done overnight.Put spacer back together. If your child has been treated in A&E or admitted to the ward with a wheezy episode, it is important to make an appointment to see your GP within 48 hours of going home.550545013779500Further information and resources are available free from asthma UK: .ukPeak flow chart133350-838200My Asthma Plan 00My Asthma Plan 53340-221615ASTHMA CONTROL TEST <12y 00ASTHMA CONTROL TEST <12y 200660-74295ASTHMA CONTROL TEST >12y 00ASTHMA CONTROL TEST >12y MONITORING COMPLIANCEThis guideline will be subject to annual audit and multidisciplinary review as described in the monitoring table in Appendix 1.Element to be monitoredLeadToolFrequencyReporting arrangementsActing on recommendations and Lead(s)Change in practice and lessons to be sharedPeak expiratory flow rate measurement during admissionRC/KWAsthma audit tool6 monthlyReview of 20 notes at 6 monthly interval lead by nursing team 100% of nurses will have asthma education bundle – Lead Mike Cliff At audit meting Use of IV magnesium sulphate bolusesSWW/KJ/CBAsthma audit tool6 monthlyPharmacy to identify all children receiving iv magnesium with medical team to review case notes against guideline6m education sessions on management of asthma/wheeze from and to MDTAt audit metingFollow up arrangementsRC/ROAsthma audit tool6 monthlyReview of waiting time for asthma clinic - RCDemand/Supply assessment – RC/RO Reporting at CD/SLL meetingsAsthma plan given on dischargeRC/KWAsthma audit tool6 monthlyReview of 20 notes at 6 monthly interval lead by nursing teamStructured feedback to attending consultant on discharge planning At audit meetingIdentify repeat attenders to A&E or inpatient admission to wards RC/SWW/John KnightHAS data 6 monthly Monthly report by John Knight team Identify themes or targeted interventions eg asthma nurse home visitAt audit meetingWith local CCGsREFERENCES ADDIN EN.REFLIST Society BT. British Guideline on the Management of Asthma. 2012.Sampayo EM, Chew A and Zorc JJ. Make an M-PACT on asthma: rapid identification of persistent asthma symptoms in a pediatric emergency department. Pediatric emergency care. 2010; 26: 1-5.Anagnostou K, Harrison B, Iles R and Nasser S. Risk factors for childhood asthma deaths from the UK Eastern Region Confidential Enquiry 2001-2006. Primary Care Respiratory Journal. 2012; 21: 71-7.Physician RCo. Why Asthma Still Kills?: National Review of Asthma Deaths. 2014.British Guideline on the Management of Asthma.Lu Y, Mak KK, van Bever HP, Ng TP, Mak A and Ho RC. Prevalence of anxiety and depressive symptoms in adolescents with asthma: a meta-analysis and meta-regression. Pediatric allergy and immunology : official publication of the European Society of Pediatric Allergy and Immunology. 2012; 23: 707-15.Gorelick MH, Stevens MW, Schultz T and Scribano PV. Difficulty in Obtaining Peak Expiratory Flow Measurements in Children With Acute Asthma. Pediatric emergency care. 2004; 20: 22-6.Rushton AR. The Role of the Chest Radiograph in the Management of Childhood Asthma. Clinical pediatrics. 1982; 21: 325-8.Bush A, Grigg J and Saglani S. Managing wheeze in preschool children. BMJ (Clinical research ed). 2014; 348.Medicine CoE. Clinical Standards for Emergency Departments: Asthma.Cates CJ, Welsh EJ and Rowe BH. Holding chambers (spacers) versus nebulisers for beta-agonist treatment of acute asthma. status and date: New search for studies and content updated (conclusions changed), published in. 2013.Powell CV, Maskell GR, Marks MK, South M and Robertson CF. Successful implementation of spacer treatment guideline for acute asthma. Archives of disease in childhood. 2001; 84: 142-6.Browne GJ, Penna AS, Phung X and Soo M. Randomised trial of intravenous salbutamol in early management of acute severe asthma in children. The Lancet. 1997; 349: 301-5.Travers AH, Milan SJ, Jones AP, Camargo CA, Jr. and Rowe BH. Addition of intravenous beta(2)-agonists to inhaled beta(2)-agonists for acute asthma. The Cochrane database of systematic reviews. 2012; 12: Cd010179.Browne GJ, Trieu L and Van Asperen P. Randomized, double-blind, placebo-controlled trial of intravenous salbutamol and nebulized ipratropium bromide in early management of severe acute asthma in children presenting to an emergency department. Critical care medicine. 2002; 30: 448-53.Smith M, Iqbal S, Elliott T, Everard M and Rowe B. Corticosteroids for hospitalised children with acute asthma. The Cochrane database of systematic reviews. 2003; 1.Bhogal SK. A question of time: systemic corticosteroids in managing acute asthma in children. Current opinion in pulmonary medicine. 2013; 19: 73-8.Davis SR, Burke G, Hogan E and Smith SR. Corticosteroid timing and length of stay for children with asthma in the Emergency Department. The Journal of asthma : official journal of the Association for the Care of Asthma. 2012; 49: 862-7.Barnett PLJ, Caputo GL, Baskin M and Kuppermann N. Intravenous Versus Oral Corticosteroids in the Management of Acute Asthma in Children. Annals of Emergency Medicine. 1997; 29: 212-7.Chang AB, Clark R, Sloots TP, et al. A 5- versus 3-day course of oral corticosteroids for children with asthma exacerbations who are not hospitalised: a randomised controlled trial. The Medical journal of Australia. 2008; 189: 306-10.Griffiths B and Ducharme FM. Combined inhaled anticholinergics and short-acting beta2-agonists for initial treatment of acute asthma in children. The Cochrane database of systematic reviews. 2013; 8: Cd000060.Mohammed S and Goodacre S. Intravenous and nebulised magnesium sulphate for acute asthma: systematic review and meta-analysis. Emergency medicine journal : EMJ. 2007; 24: 823-30.Shan Z, Rong Y, Yang W, et al. Intravenous and nebulized magnesium sulfate for treating acute asthma in adults and children: a systematic review and meta-analysis. Respiratory medicine. 2013; 107: 321-30.Torres S, Sticco N, Bosch JJ, et al. Effectiveness of magnesium sulfate as initial treatment of acute severe asthma in children, conducted in a tertiary-level university hospital: a randomized, controlled trial. Archivos argentinos de pediatria. 2012; 110: 291-6.Davalos Bichara M and Goldman RD. Magnesium for treatment of asthma in children. Canadian family physician Medecin de famille canadien. 2009; 55: 887-9.Nair P, Milan SJ and Rowe BH. Addition of intravenous aminophylline to inhaled beta(2)-agonists in adults with acute asthma. The Cochrane database of systematic reviews. 2012; 12: Cd002742.Mitra A, Bassler D, Goodman K, Lasserson TJ and Ducharme FM. Intravenous aminophylline for acute severe asthma in children over two years receiving inhaled bronchodilators. The Cochrane database of systematic reviews. 2005: Cd001276.Capsomidis A and Tighe M. Archimedes. Question 2. Is oral montelukast beneficial in treating acute asthma exacerbations in children? Archives of disease in childhood. 2010; 95: 948-50.Todi VK, Lodha R and Kabra SK. Effect of addition of single dose of oral montelukast to standard treatment in acute moderate to severe asthma in children between 5 and 15 years of age: a randomised, double-blind, placebo controlled trial. Archives of disease in childhood. 2010; 95: 540-3.Edmonds ML, Milan SJ, Camargo CA, Jr., Pollack CV and Rowe BH. Early use of inhaled corticosteroids in the emergency department treatment of acute asthma. The Cochrane database of systematic reviews. 2012; 12: Cd002308.Upham BD, Mollen CJ, Scarfone RJ, Seiden J, Chew A and Zorc JJ. Nebulized budesonide added to standard pediatric emergency department treatment of acute asthma: a randomized, double-blind trial. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. 2011; 18: 665-73.Dinwiddie R. Treatment of acute asthma in children. Which approach is best? Allergologia et immunopathologia. 2008; 36: 185-6.Espinoza-Palma T, Zamorano A, Arancibia F, et al. Effectiveness of asthma education with and without a self-management plan in hospitalized children. The Journal of asthma: official journal of the Association for the Care of Asthma. 2009; 46: 906-10.Bhogal S, Zemek R and Ducharme FM. Written action plans for asthma in children. The Cochrane database of systematic reviews. 2006: Cd005306. APPENDIX 1: EQUALITY ANALYSIS checklistEquality GroupIdentify negative impactsWhat evidence, engagement or audit has been used?How will you address the issues identified?Identifies who will lead the work for the changes required and when?Please list positive impacts and existing support structures AgeNone identifiedN/A N/AN/AThis policy will ensure that that staff have appropriate guidance for the management of asthma/wheeze in paediatric patients.DisabilityNone identified N/AN/AN/AGender ReassignmentNone identifiedN/AN/AN/AMarriage and Civil PartnershipNone identifiedN/AN/AN/APregnancy and maternityNone identifiedN/AN/AN/ARaceNone identified N/AN/AN/AReligion or BeliefNone identifiedN/AN/AN/ASexNone identifiedN/AN/ASexual OrientationNone identifiedN/AN/ACarersNone identified N/AN/AGo through each protected characteristic below and consider whether the policy, practice, function, business case, project or service change could have any impact on groups from the identified protected characteristic, involve service users where possible and get their opinion, use demographic / census data (available from public health and other sources), surveys (past or maybe carry one out), talk to staff in PALS and Complaints and Patient Experience. Please ensure any remedial actions are Specific, Measureable, Achievable, Realistic, and Timely( SMART). ................
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