page193
Management
o f
a c ut e as t hma
Important
Patients with severe or life-threatening acute asthma may not be distressed and may not have all of these
abnormalities; the presence of any should alert the doctor. Regard each emergency consultation as being for severe
acute asthma until shown otherwise
Moderate acute asthma
.
Able to talk
.
Respiration (breaths/minute) < 25;
CHILD
2–5 years 40,
5–12 years
30
.
Pulse (beats/minute) < 110;
CHILD
2–5 years 140, 5–12 years 125
.
Arterial oxygen saturation 92%
.
Peak flow > 50% of predicted or
best;
CHILD
5–12 years 50%
Treat at home or in surgery and
assess response to treatment
Treatment
.
Inhaled short-acting beta
2
ago-
nist via a large-volume spacer or
oxygen-driven nebuliser (if avail-
able);
give 2–10 puffs of salbut-
amol 100 micrograms/metered
inhalation each inhaled separately,
and repeat at 10–20 minute inter-
vals if necessary
or
give nebulised
salbutamol 5 mg (
CHILD
under 5
years 2.5 mg, 5–12 years 2.5–5 mg)
or terbutaline 10 mg (
CHILD
under
5 years 5 mg, 5–12 years 5–10 mg),
and repeat at 20–30 minute inter-
vals if necessary
.
Prednisolone 40–50 mg by mouth
for at least 5 days;
CHILD
1–2 mg/
kg (max. 40 mg) for up to 3 days, or
longer if necessary; if the child has
been taking an oral corticosteroid
for more than a few days,
give
prednisolone 2 mg/kg (max.
60 mg)
Monitor response for 15–30 minutes
If response is poor or a relapse
occurs in 3–4 hours, send immedi-
ately to hospital for assessment and
further treatment
Follow up in all cases
Monitor symptoms and peak flow.
Set up asthma action plan and check inhaler technique
Review by general practitioner or appropriate primary care health professional within 48 hours,
see also p.
171
Severe acute asthma
.
Cannot complete sentences in one
breath;
CHILD
too breathless to talk
or feed
.
Respiration (breaths/minute) 25;
CHILD
2–5 years > 40;
5–12 years
> 30
.
Pulse (beats/minute) 110;
CHILD
2–5 years > 140; 5–12 years > 125
.
Arterial oxygen saturation 92%;
CHILD
under 12 years < 92%
.
Peak flow 33–50% of predicted or
best;
CHILD
5–12 years 33–50%
Start treatment below and send
immediately to hospital
Treatment
.
High-flow oxygen (if available)
.
Inhaled short-acting beta
2
agonist
via a large-volume spacer or oxy-
gen-driven nebuliser (if available) as
for moderate acute asthma
.
Prednisolone by mouth as for
moderate acute asthma
or
intra-
venous hydrocortisone (preferably
as sodium succinate) 100 mg every
6 hours until conversion to oral
prednisolone is possible;
CHILD
4 mg/kg (
CHILD
under 2 years max.
25 mg, 2–5 years max.
50 mg,
6–12
years max.
100 mg)
Monitor response for 15–30 minutes
If response is poor:
.
Inhaled ipratropium bromide via
oxygen-driven nebuliser (if avail-
able) 500 micrograms every 4–6
hours (
CHILD
under 12 years
250 micrograms repeated every
20–30 minutes for the first 2 hours,
then every 4–6 hours as necessary)
Refer those who fail to respond and
require ventilatory support to an
intensive care or high-dependency
unit
.
Consider intravenous beta
2
ago-
nists,
aminophylline (p.
181) or
magnesium sulphate [unlicensed
indication] (p.
171) only after con-
sultation with senior medical staff
Life-threatening acute asthma
.
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
5–12 years < 33%
Start treatment below and send
immediately to hospital; consult with
senior medical staff and refer to
intensive care
Treatment
.
High-flow oxygen (if available)
.
Short-acting beta
2
agonist via
oxygen-driven nebuliser (if avail-
able); give salbutamol 5 mg (
CHILD
under 5 years 2.5 mg,
5–12 years
2.5–5 mg) or terbutaline 10 mg
(
CHILD
under 5 years 5 mg,
5–12
years 5–10 mg),
and repeat at 20–
30 minute intervals or as neces-
sary;
reserve intravenous beta
2
agonists for those in whom inhaled
therapy cannot be used reliably
.
Prednisolone by mouth as for
moderate acute asthma
or
intra-
venous hydrocortisone as for
severe acute asthma
.
Inhaled ipratropium bromide via
oxygen-driven nebuliser (if avail-
able) as for severe acute asthma
Monitor response for 15–30 minutes
If response is poor:
.
Consider intravenous aminophyl-
line (p.
181) or magnesium sul-
phate [unlicensed indication]
(p.
171) only after consultation
with senior medical staff
Advice on the management of acute asthma is based on the recommendations of the British Thoracic Society and
Scottish Intercollegiate Guidelines Network (updated June 2009);
updates available at www.brit-thoracic.org.uk
BNF 61
3.1 Bronchodilators
173
3
Respiratory system