Management of acute asthma

Moderate acute asthma	Severe acute asthma	Life-threatening acute asthma
·          Able to talk ·          Respiration(breaths/min)<25; CHILD 2-5years≤40,5-12years ≤30 ·          Pulse(beats/min)<110; CHILD 2-5years≤140, 5-12years≤125 ·          Arterial oxygen saturation ≥92%. ·          Peak flow>50% of  predicted or best; CHILD 5-12years≥50% Treat at home or in surgery and assess response to treatment. Treatment ·          Inhaled short acting ß2 agonist via a large-volume spacer or oxygen-driven nebulizer(if available); give 2-10 puffs of Salbutamole 100mcg/metered inhalation each inhaled separately, and repeat at 10-20 min. intervals if necessary or give nebulised Salbutamol 5mg (CHILD under 5years 2.5 mg, 5-12 years,2.5-5mg) or Terbutaline 10mg (CHILD under 5 years 5mg, 5-12years 5-10mg), and repeat at 20-30min. intervals if necessary. ·          Prednisolone 40-50 mg by mouth for at least 5 days; CHILD 1-2mg/kg my mouth for 3-5 days, if the child has been taking an oral corticosteroid for more than a few days, give Prednisolone 2mg/kg (CHILD under 2 years max. 40mg, over 2 years max. 50mg) Monitor response for 15-30min, if response is poor or a relapse occurs in 3-4hr, send immediately to  hospital for assessment and future treatment	·          Cannot complete sentences in one breath; CHILD too breathless to talk or feed ·          Respiration(breaths/min)≥25; CHILD 2-5 years >40;5-12years >30 ·          Pulse(beats/min)≥110;CHILD 2-5years>140;5-12years>125 ·          Arterial oxygen saturation≥92%; CHILD under 12years<92% ·          Peak flow 33-50% of predicted or best; CHILD 5-12years 33-50%. Send immediately to hospital. Treatment ·          High-flow oxygen(if available) ·          Inhaled short acting ß2 agonist via a large-volume spacer or oxygen-driven nebulizer(if available); give 2-10 puffs of Salbutamole 100mcg/metered inhalation each inhaled separately, and repeat at 10-20 min. intervals if necessary or give nebulised Salbutamol 5mg (CHILD under 5years 2.5 mg, 5-12 years,2.5-5mg) or Terbutaline 10mg (CHILD under 5 yearrs 5mg, 5-12years 5-10mg), and repeat at 20-30min. intervals if necessary. ·          Prednisolone by mouth as for moderate acute asthma or Hydrocortisone intravenous (preferably as sodium succinate) 100mg every 6 hr until conversion to oral prednisolone is possible; CHILD 4mg/kg(under 2 years max. 25mg, 2- 5 years 50 mg, 6- 12years 100mg). Monitor response for 15-30min, if response is poor: ·          Inhaled Ipratropium bromide via oxygen-driven nebulliser(if available) 500mcg(CHILD under 12 years 250mcg)repeated every 20-30min. for the first 2hr, then every 4-6hr as necessary. Refer those who fail to respond and require ventilatory  support to an intensive care or high-dependency unit. ·          Consider IV ß2 agonist, Aminophylline or Magnesium sulphate(unlicensed indication), only after consultation with senior medical staff.	·          Silent chest, feeble respiratory effort, cyanosis ·          Hypotension, Bradycardia, arrhythmia, exhaustion, agitation (in children), or reduced level of consciousness. ·          Arterial oxygen saturation<92% ·          Peak flow<33% of predicted or best; CHILD 5-12years<33%. Send immediately to hospital; consult with senior medical staff and refer to intensive care. Treatment ·          High flow oxygen (if available). ·          Short acting ß2 agonist via oxygen-driven nebulizer(if available);give Salbutamol 5mg(CHILD under 5 years 2.5mg, 5-12 years 2.5-5mg) or Terbutaline 10 mg(CHILD under 5years 5mg, 5-12years 5-12mg), and repeat at 20 30 min intervals or as necessary; reserve intravenous ß2 agonists for those in whom inhaled therapy can’t be used reliably. ·          Prednisolone by mouth as for moderate acute asthma or intravenous Hydrocortisone (preferably as sodium succinate) 100mg every 6 hr until conversion to oral prednisolone is possible; CHILD 4mg/kg(under 2 years max. 25mg, 2- 5 years 50 mg, 6- 12years 100mg). ·          Inhaled Ipratropium bromide via oxygen-driven nebulliser(if available) 500mcg (CHILD under 12 years 250mcg)repeated every 20-30min. for the first 2hr, then every 4-6hr as necessary. Monitor response for 15-30min. if response is poor: ·          Consider IV Aminophylline or Magnesium sulphate(unlicensed indication), only after consultation with senior medical staff.
Follow up in all cases: Monitor symptoms and peak flow. Setup asthma action plan and check inhaler technique review by general practitioner or appropriate primary care health professional with in 48hr.
Advice on the management of acute asthma is based on the recommendations of the British thoracic society and Scottish intercollegiate guidelines network(updated on June 2012),www.britt-thoracic.org.uk