Categorise as acute severe or life-threatening

Life-threatening asthma

SpO₂ <92%
PEF <33% best or predicted

Exhaustion
Hypotension
Cyanosis
Silent chest
Poor respiratory effort
Confusion

Acute severe asthma

SpO₂ <92%
PEF 33–50% best or predicted

Can’t complete sentences in one breath or too breathless to talk or feed

Heart rate >140/min (1-5 years) or >125/min (>5 years)

Respiratory rate >40/min (1-5 years) or >30/min (>5 years)

First-line treatment

Steroid therapy (three day duration)

<2yr use 10 mg prednisolone
2–5 years use 20 mg prednisolone
>5 years use 30–40 mg prednisolone

Immediate β₂ agonist, one puff every 30–60s, up to 10 puffs, via pMDI + SPACER

Urgent admission if not controlled:

1. Start with 2.5mg salbutamol nebuliser AND oxygen (if SpO₂ <94%) AND steroids

2. If refractory, add in 250mcg ipratropium bromide to nebuliser

3. If refractory, add in 150mg magnesium sulphate to nebuliser (dose mixed with salbutamol and ipratropium nebulised doses)

Second-line treatment

1. Initial single bolus dose iv salbutamol (15 micrograms/kg over 10 minutes)

2. Intravenous aminophylline

3. Intravenous magnesium sulphate (40 mg/kg/day)

Discharge planning and follow up

Children can be discharged when stable on 3-4 hourly inhaled bronchodilators that can be continued at home.
PEF and/or FEV₁ should be >75% of best or predicted and SpO₂ >94%.

• Arrange follow up by primary care services within two working days

• Arrange follow up in a paediatric asthma clinic at about one month after admission

• Arrange referral to a paediatric respiratory specialist if there have been life-threatening features