Acute Asthma, Children
Description Medicine Treatment Referral J46/J45.0-1/J45.8-9 DESCRIPTION Bronchospasm in children is usually associated with asthma or with infections such as bronchiolitis or bronchopneumonia. Consider foreign bodies or obstruction of airways due to tuberculous nodes or congenital malformation, especially if the wheeze is unilateral. Recognition and assessment of severity of attacks in children &
J46/J45.0-1/J45.8-9
DESCRIPTION
Bronchospasm in children is usually associated with asthma or with infections such as bronchiolitis or bronchopneumonia. Consider foreign bodies or obstruction of airways due to tuberculous nodes or congenital malformation, especially if the wheeze is unilateral.
Recognition and assessment of severity of attacks in children
| Mild/Moderate | Severe | Life-threatening | |
| Oxygen saturation | >90% | <90% | <90% |
| Respiratory rate | <40 breaths/minute | >40 breaths/minute | >60 breaths/minute |
| Chest indrawing/recession | present | present | present |
| PEF (if > 5 years of age) | >60% of predicted | <60% of predicted | <33% of expected or unable to blow |
| Speech | normal | difficult | unable to speak |
| Feeding | normal | difficulty with feeding | unable to feed |
| Wheeze | present | present | absent |
| Consciousness | normal | normal |
impaired |
MEDICINE TREATMENT
See Appendix II: Devices for Respiratory Conditions for guidance on inhaler, spacer and nebuliser device techniques.
Mild to moderate attacks
- Salbutamol 100 mcg metered-dose inhaler (MDI),
Children ≥ 5 years:
- Salbutamol inhaler 400–1000 mcg (4-10 puffs) using a spacer
- Shake the inhaler between each puff
- If no relief, repeat every 20–30 minutes in the first hour
- Thereafter, repeat every 2–4 hours if needed
LoE:IVb14
Children < 5 years:
- Salbutamol inhaler 200–600 mcg (2-6 puffs) using a spacer
- For children ≥ 3 years, use a spacer with a mouthpiece
- If child < 3 years of age, use a mask attached to the spacer. Apply the mask to the face to create a seal so that the child breathes through the spacer
- Inhale one puff at a time. Use a single breath inhalation technique. If single inhalation technique not possible, allow for 6 breaths through the spacer between puffs. If no relief, repeat every 20–30 minutes in the first hour
- Thereafter, repeat every 2–4 hours if needed
LoE:IVb15
Note:
Administering salbutamol via a spacer is as effective as, and cheaper than, using a nebuliser.
OR
- Salbutamol 0.5% (5 mg/mL), solution,
- 0.5–1 mL (2.5–5 mg) salbutamol 0.5% solution, made up to 4 mL with sodium chloride 0.9%, preferably delivered at a flow rate of 8 L/min with oxygen
- If no relief, repeat every 20–30 minutes in the first hour
- Thereafter, repeat every 2–4 hours if needed.
LoE:IVb16
PLUS
- Corticosteroids (intermediate-acting) e.g.:
- Prednisone, oral, 1–2 mg/kg immediately and follow with same dose for 7 days:
LoE:IVb17
| Weight (kg) | Dose (mg) | Tablet (5 mg) | Age (years) |
| >11–14 kg | 20 mg | 4 tablets | >2–3 years |
| >14–17.5 kg | 30 mg | 6 tablets | >3–5 years |
| >17.5 kg | 40 mg | 8 tablets | >5 years |
Severe attacks (while awaiting referral)
- Oxygen to keep oxygen saturation 93-95%
AND
- Salbutamol 0.5% (5mg/mL) nebuliser solution,
- 0.5–1 mL (2.5–5 mg) salbutamol 0.5% solution, made up to 4 mL with sodium chloride 0.9%, preferably delivered at a flow rate of 8 L/min with oxygen
- If no relief, repeat every 20–30 minutes depending on clinical response
OR
- Salbutamol, inhalation using an MDI,
- Salbutamol, 400-1000 mcg (4-10 puffs), using a spacer
- For children ≥ 3 years, use a spacer with a mouthpiece
- If child < 3 years of age, use a mask attached to the spacer. Apply the mask to the face to create a seal so that the child breathes through the spacer
- Inhale one puff at a time. Use a single breath inhalation technique. If single inhalation technique not possible, allow for 6 breaths through the spacer between puffs
- If no relief, repeat every 20–30 minutes depending on clinical response
Note:
Administering salbutamol via a spacer is as effective as, and cheaper than, using a nebuliser.
If poor response after first salbutamol nebulisation/inhalation:
ADD
- Ipratropium bromide 0.25 mg/2ml; nebuliser solution
- Ipratropium bromide, 2 mL (0.25 mg) solution, nebulised with salbutamol 0.5 mL (2.5 mg) and made up to 4 mL with sodium chloride 0.9%
- Administer every 20–30 minutes depending on clinical response for 4 doses over 2 hours
LoE:IIb18
OR
- Ipratroprium bromide, MDI, 80–160 mcg (2– 4 puffs), using a spacer every 20–30 minutes as needed for up to 3 hours
AND
- Corticosteroids (intermediate-acting), e.g.:
- Prednisone, oral, 1–2 mg/kg immediately and follow with same dose for 7 days:
LoE:IVb19
| Weight (kg) | Dose (mg) | Tablet (5 mg) | Age (years) |
| >11–14 kg | 20 mg | 4 tablets | >2–3 years |
| >14–17.5 kg | 30 mg | 6 tablets | >3–5 years |
| >17.5 kg | 40 mg | 8 tablets |
>5 years and adult |
OR
If oral prednisone cannot be taken:
- Hydrocortisone IM/slow IV, 4 mg/kg (maximum 100 mg) immediately. See: dosing table
Followed with:
- Prednisone 1–2 mg/kg daily for 7 days as per dosing table above
CAUTION
Avoid sedation of any kind.
Note:
If poor response to treatment, consider alternate diagnosis and refer urgently.
Life- threatening attacks
- Oxygen, to keep oxygen saturation 93-95%
AND
- Salbutamol 0.5% (5 mg/mL) with ipratropium bromide 0.5 mg/2mL nebuliser solution:
- Salbutamol 0.5%, 2 mL (10 mg) plus ipratroprium bromide, 2 mL (0.5 mg) every 20–30 minutes depending on clinical response for 4 doses over 2 hours
- Delivered at a flow rate of 8 L/min with oxygen
- If no relief, repeat every 20–30 minutes until asthma severity category moves from life-threatening to severe
- Parenteral corticosteroids (intermediate-acting) e.g.:
- Hydrocortisone IM/slow IV, 4 mg/kg (maximum 100 mg) immediately. See: dosing table
LoE:IVb20
Followed with:
- Oral corticosteroids (intermediate-acting) e.g.:
- Prednisone 1–2 mg/kg daily for 7 days
CAUTION
Avoid sedation of any kind.
Note:
If response to treatment is adequate and severity improves to become severe but not life threatening, treat as per severe asthma exacerbation above.
Assessment of response in children
| Response | No response | |
| PEFR (if possible) | improvement by >20% | improvement by <20% |
| Respiratory rate | <40 breaths/minute | >40 breaths/minute |
| Chest indrawing or recession | absent | present |
| Speech | normal | impaired |
| Feeding | normal | impaired |
Patients responding to treatment
- Routine prescription of antibiotics is not indicated for acute asthma
- Review current treatment and possible factors causing acute attack including poor adherence and poor inhaler technique
- Advise patient/caregiver on further care at home, danger signs and that follow up is required
- Caution patient/carer on the high chance of further wheezing in the week following an acute attack
- Patients with a first attack should be fully assessed for maintenance treatment
Note:
Patients needing repeated courses of oral corticosteroids (more than twice over 6 months) should be assessed by a doctor for maintenance therapy. (See Chronic asthma).
REFERRAL
Urgent (after commencing treatment):
- All patients with severe attack
- Poor response to initial treatment
- PEFR < 75% of the predicted normal or of personal best value 15–30 minutes after nebulisation
- A lower threshold to admission is appropriate in patients when:
- Seen in the afternoon or evening, rather than earlier in the day
- Recent onset of nocturnal symptoms or aggravation of symptoms
- Previous severe attacks, especially if the onset was rapid
Standard Treatment Guidelines and Essential Medicines List for South Africa, Primary Healthcare, 2020-4-Version 1.0_16 September 2024
Chapter 17: Respiratory Conditions_17.1. Conditions with Predominant Wheeze_17.1.2. Acute Asthma, Children