1. Paediatric asthma
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2. Diagnosis of asthma in children
Presenting features
wheeze
dry cough
breathlessness
noisy breathing
Detailed history and physical examination
pattern of illness
severity/control
differential clues
Is it asthma?
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3. Clues to alternative diagnoses in wheezy children
Clinical clue
Possible diagnosis
Perinatal and family history
symptoms present from birth or perinatal lung problem
family history of unusual chest disease
severe upper respiratory tract disease
cystic fibrosis; chronic lung disease; ciliary dyskinesia; developmental anomaly
cystic fibrosis; developmental anomaly; neuromuscular disorder
defect of host defence
Symptoms and signs
persistent wet cough
excessive vomiting or posseting
dysphagia
abnormal voice or cry
focal signs in the chest
inspiratory stridor as well as wheeze
failure to thrive
cystic fibrosis; recurrent aspiration; host defence disorder
reflux (aspiration)
swallowing problems (aspiration)
laryngeal problem
developmental disease; postviral syndrome; bronchiectasis; tuberculosis
central airway or laryngeal disorder
cystic fibrosis; host defence defect; gastro-oesophageal reflux
Investigations
focal or persistent radiological changes
developmental disorder; postinfective disorder; recurrent aspiration; inhaled foreign body; bronchiectasis; tuberculosis
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4. Delivery of ß2 agonists  A
Adults
Children 5-12 years
Children <5 years A
Use pMDI and large volume spacer for adults and children aged 2-12 years with mild and moderate exacerbations of asthma 
pMDI + spacer preferred delivery method for children aged 0-5 years
In children aged 5-12 years with chronic asthma, pMDI + spacer is as effective as any other hand held inhaler
In adults, pMDI ± spacer is as effective as any other hand held inhaler, but patients may prefer dry powder inhalers
Base choice of reliever inhaler for stable asthma on patient preference/ability to use, as many patients will not carry a spacer
Salbutamol non-CFC pMDI can be substituted for CFC pMDI at 1:1 dosing
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5. Delivery of inhaled steroids
Adults
Children 5-12 years
Children <5 years 
pMDI + spacer preferred delivery method for children aged 0-5 years A
For children aged 5-12 years, pMDI + spacer is as effective as any dry powder inhaler
In adults, a pMDI ± spacer is as effective as any dry powder inhaler
HFA-BDP pMDI can be substituted for CFC-BDP pMDI at 1:2 dosing, but should incorporate period of close monitoring
Fluticasone non-CFC pMDI can be substituted for CFC pMDI at 1:1 dosing
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6. Initial assessment of acute asthma in children aged >2 years in A&E
Moderate exacerbation
Severe exacerbation
Life threatening asthma
SpO2 92%
PEF 50% best/ predicted (>5 years)
No clinical features of severe asthma
Heart rate:
- 130/min (2-5 years)
- 120/min (>5 years)
Respiratory rate:
- 50/min (2-5 years)
- 30/min (>5 years)
SpO2 <92%
PEF <50% best/ predicted (>5 years)
Too breathless to talk or eat
- >130/min (2-5 years)
- >120/min (>5 years)
- >50/min (2-5 years)
- >30/min (>5 years)
Use of accessory neck muscles
PEF <33% best/ predicted (>5 years)
Silent chest
Poor respiratory effort
Agitation
Altered consciousness
Cyanosis
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7. Management of acute asthma in children aged >2 years in A&E
Moderate exacerbation
Severe exacerbation
Life threatening exacerbation
ß2 agonist 2-10 puffs via spacer ± facemask
Reassess after 15 minutes
Give nebulised ß2 agonist: salbutamol (2-5 years: 2.5mg; >5 years: 5mg) or terbutaline (2-5 years: 5mg; >5 years: 10mg) with oxygen as driving gas
Continue oxygen via facemask/nasal prongs
Give prednisolone (2-5 years: 20mg; >5 years 30-40mg) or IV hydrocortisone (2-5 years: 50mg; >5 years: 100mg)
RESPONDING
Continue inhaled ß2 agonists 1-4 hourly
Add soluble oral prednisolone - 20mg (2-5 years) mg (>5 years)
NOT RESPONDING
Repeat inhaled ß2 agonist every minutes
Add soluble oral prednisolone - 20mg (2-5 years) mg (>5 years)
IF LIFE THREATENING FEATURES PRESENT
Discuss with senior clinician, PICU team or paediatrician. Consider:
Chest x-ray and blood gases
Repeat nebulised ß2 agonists plus ipratropium bromide 0.25mg nebulised every minutes
Bolus IV salbutamol 15g/kg of 200g/ml solution over 10 minutes
IV aminophylline
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8. Response to treatment of acute asthma in children aged >2 years in A&E
Moderate exacerbation
Severe exacerbation
Life threatening exacerbation
RESPONDING TO TREATMENT
NOT RESPONDING TO TREATMENT
IF POOR RESPONSE TO TREATMENT
DISCHARGE PLAN
Continue ß2 agonists 1-4 hourly prn
Consider prednisolone 20mg (2-5 years) 30-40mg (>5 years) daily for up to 3 days
Advise to contact GP if not controlled on above treatment
Provide a written asthma action plan
Review regular treatment
Check inhaler technique
Arrange GP follow up
ARRANGE ADMISSION
(lower threshold if concern over social circumstances)
ARRANGE IMMEDIATE TRANSFER TO PICU/HDU
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9. Treatment of acute asthma in children aged >2 years
Use structured care protocols detailing bronchodilator usage, clinical assessment, and specific criteria for safe discharge 
Children with life threatening asthma or SpO2 <92% should receive high flow oxygen via a tight fitting face mask or nasal cannula at sufficient flow rates to achieve normal saturations A
Inhaled ß2 agonists are first line treatment for acute asthma *
pMDI and spacer are preferred delivery system in mild to moderate asthma B
Individualise drug dosing according to severity and adjust according to response
IV salbutamol (15mg/kg) is effective adjunct in severe cases
* Dose can be repeated every minutes
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10. Steroid therapy for acute asthma in children aged >2 years
Give prednisolone early in the treatment of acute asthma attacks 
Use prednisolone 20mg (2-5 years), 30-40mg (>5 years)
Those already receiving maintenance steroid tablets should receive 2 mg/kg oral prednisolone up to a maximum dose of 60 mg
Repeat the dose of prednisolone in children who vomit and consider IV steroids
Treatment up to 3 days is usually sufficient, but tailor to the number of days for recovery
Do not initiate inhaled steroids in preference to steroid tablets to treat acute childhood asthma
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11. Other therapies for acute asthma in children aged >2 years
If poor response to 2 agonist treatment, add nebulised ipratropium bromide (250mcg/dose mixed with 2 agonist) *
Aminophylline is not recommended in children with mild to moderate acute asthma C
Consider aminophylline for children in high dependency/intensive care with severe or life threatening bronchospasm unresponsive to maximal doses of bronchodilators and steroid tablets 
Do not give antibiotics routinely in the management of acute childhood asthma
ECG monitoring is mandatory for all intravenous treatments
* Dose can be repeated every minutes
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12. Hospital admission for acute asthma in children aged >2 years
Children with acute asthma failing to improve after 10 puffs of 2 agonist should be referred to hospital. Further doses of bronchodilator should be given as necessary whilst awaiting transfer
Treat with oxygen and nebulised 2 agonists during the journey to hospital
Transfer children with severe or life threatening asthma urgently to hospital to receive frequent doses of nebulised 2 agonists (2.5-5mg salbutamol or 5-10 mg terbutaline)
Decisions about admission should be made by trained physicians after repeated assessment of the response to further bronchodilator treatment B
Consider intensive inpatient treatment for children with SpO2 <92% on air after initial bronchodilator treatment
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13. Treatment of acute asthma in children aged <2 yearsB
Oral 2 agonists are not recommended for acute asthma in infants A
For mild to moderate acute asthma, a pMDI with spacer is the optimal drug delivery device C
Consider steroid tablets in infants early in the management of moderate to severe episodes of acute asthma in the hospital setting 
Steroid tablet therapy (10 mg of soluble prednisolone for up to 3 days) is the preferred steroid preparation
Consider inhaled ipratropium bromide in combination with an inhaled 2 agonist for more severe symptoms
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