BNF for Children 2011-2012

136 3.1 Bronchodilators BNFC 2011–2012Management of acute asthmaImportant The assessment of acute asthma in early childhood can be difficult. Children with severe or lifethreateningacute asthma may not be distressed and may not have all of these abnormalities; the presence of anyshould alert the doctor. Regard each emergency consultation as being for severe acute asthma until shown otherwiseModerate acute asthmaSevere acute asthmaLife-threatening acute asthma3 Respiratory system. Able to talk. Respiration (breaths/minute)Child 2–5 years 40, 5–12 years 30, 12–18 years < 25. Pulse (beats/minute) Child 2–5years 140, 5–12 years 125,12–18 years < 110. Arterial oxygen saturation 92%. Peak flow Child 5–12 years 50%of predicted or best, 12–18 years> 50%Treat at home or in surgery andassess response to treatmentTreatment. Inhaled short-acting beta 2 agonistvia a large-volume spacer (and aclose-fitting face mask if child under3 years) or oxygen-driven nebuliser(if available); give 2–10 puffs ofsalbutamol 100 micrograms/metered inhalation each inhaledseparately, and repeat at 10–20minute intervals if necessary or givenebulised salbutamol, Child under 5years 2.5 mg, 5–12 years 2.5–5 mg,12–18 years 5 mg or terbutaline,Child under 5 years 5 mg, 5–12years 5–10 mg, 12–18 years 10 mg,and repeat at 20–30 minute intervalsas necessary. Prednisolone by mouth Child under12 years 1–2 mg/kg (max. 40 mg)daily for up to 3 days or longer ifnecessary; if the child has beentaking an oral corticosteroid formore than a few days, give prednisolone2 mg/kg (max. 60 mg);Child 12–18 years 40–50 mg dailyfor at least 5 daysMonitor response for 15–30 minutesIf response is poor or a relapseoccurs in 3–4 hours, send immediatelyto hospital for assessment andfurther treatment. Child under 12 years too breathlessto talk or feed, 12–18 years cannotcomplete sentences in one breath. Use of accessory breathing muscles. Respiration (breaths/minute) Child2–5 years > 40, 5–12 years > 30,12–18 years 25. Pulse (beats/minute) Child 2–5 years> 140, 5–12 years >125, 12–18years 110. Arterial oxygen saturation Childunder 12 years < 92%, 12–18 years 92%. Peak flow Child 5–12 years < 50% ofpredicted or best, 12–18 years 33–50%Start treatment below and sendimmediately to hospitalTreatment. High-flow oxygen (if available). Inhaled short-acting beta 2 agonistvia a large-volume spacer (and aclose-fitting face mask if child under3 years) or oxygen-driven nebuliser (ifavailable) as for moderate acuteasthma. Prednisolone by mouth as for moderateacute asthma or intravenoushydrocortisone (preferably as sodiumsuccinate) 4 mg/kg (max.100 mg) (alternatively, if weight unavailable,Child under 2 years 25 mg,2–5 years 50 mg, 5–18 years100 mg) every 6 hours until conversionto oral prednisolone is possibleMonitor response for 15–30 minutesIf response is poor:. Inhaled ipratropium bromide via oxygen-drivennebuliser (if available),Child under 12 years, 250 microgramsrepeated every 20–30 minutesfor the first 2 hours, then every4–6 hours as necessary; Child 12–18years, 500 micrograms every 4–6hours as necessaryRefer those who fail to respond andrequire ventilatory support to apaediatric intensive care or highdependencyunit. Consider intravenous beta 2 agonists,aminophylline, or magnesium sulphate[unlicensed indication] onlyafter consultation with senior medicalstaff. Silent chest, cyanosis, poor respiratoryeffort. Arrhythmia, hypotension. Exhaustion, altered consciousness,agitation, confusion. Arterial oxygen saturation