2017

3. 3

4. 4
Acute asthma exacerbations are a frequent cause of
emergency department (ED) visits .
More than 50% of children who present to the ED with
an asthma exacerbation are preschool age (<5 years) .

5. 5
A flare-up or exacerbation of asthma in children 5 years
and younger is defined as :
an acute or sub-acute deterioration in symptom control
that is sufficient to cause distress or risk to health, to the
extent that a visit to a health care provider or treatment
with systemic corticosteroids becomes necessary, they
are sometimes called ‘episodes’.

6. 6
Early symptoms of an exacerbation may include any of
the following:
1. An acute or sub-acute increase in wheeze and shortness of
breath .
2. An increase in coughing, especially while the child is asleep.
3. Lethargy or reduced exercise tolerance .
4. Impairment of daily activities, including feeding .
5. A poor response to reliever medication.

7. 7
In a study of children aged 2–5 years , the combination of :
increased daytime cough, daytime wheeze, and night-time
beta2-agonist use was a strong predictor at a group level
of an imminent exacerbation (1 day later) .
This combination predicted around 70% of exacerbations,with
a low false positive rate of 14%.
In contrast , no individual symptom was predictive of an
imminent asthma exacerbation.

8. 8
The most common triggers for asthma exacerbations in
both younger and older children are viral respiratory
tract infections , frequently precede the onset of an
asthma exacerbation .
Other typical factors are exposure to allergens and a
suboptimal control of asthma as a baseline .

9. 9
Initial home management of asthma exacerbation:
Initial management includes an action plan to :
1) Enable the child’s family members and carers to recognize
worsening asthma and initiate treatment .
2) Recognize when it is severe, identify when urgent hospital
treatment is necessary .
3) Provide recommendations for follow up (Evidence D) .

10. 10
Initial home management of asthma exacerbation:
Inhaled SABA via a mask or spacer, and review response :
The parent/carer should initiate treatment with two puffs of
inhaled SABA (200 mcg salbutamol or equivalent), given one
puff at a time via a spacer device with or without a facemask
(Evidence D).
This may be repeated a further two times at 20 minute intervals
, if needed .

11. 11
The child should be observed by the family/carer and, if
improving, maintained in a restful and reassuring
atmosphere for an hour or more.
Medical attention should be sought urgently on the same
day if more than 6 puffs of inhaled SABA are required for
symptom relief within the first 2 hours, or if the child
has not recovered after 24 hours.

12. 12
Need for urgent medical attention
Parents/carers should know that immediate medical attention
should be sought if:
1) The child is acutely distressed
2) The child’s symptoms are not relieved promptly by SABA
3) The period of relief after doses of SABA becomes
progressively shorter
4) A child younger than 1 year requires repeated inhaled
SABA over several hours

13. 13
Family/carer-initiated corticosteroids
Although practiced in some parts of the world, the evidence to
support the initiation of oral corticosteroid (OCS) treatment
by family/carers in the home management of asthma
exacerbations in children is weak .......
Because of the high potential for side-effects, especially if the
treatment is continued inappropriately or is given frequently

14. 14
Initial treatment at home is with inhaled short-acting beta2-
agonist (SABA), with review after 1 hour or earlier.
Parents/carers should seek urgent medical care if the child
is acutely distressed, lethargic, fails to respond to initial
bronchodilator therapy, or is worsening, especially in
children <1 year of age.
Medical attention should be sought on the same day if
inhaled SABA is needed more often than 3-hourly or for
more than 24 hours.

15. 15

16. 16
≤

17. 17
Before children can receive a ppropriate treatment for an
acute asthma attack in any setting, it is essential to assess
accurately the severity of their symptoms , so that
appropriate management can be instituted.
Assessment of exacerbation severity

18. 18
The signs that should be assessed are:
1) Respiratory rate
2) Pulse rate
3) Amount of breathlessness (ability to talk and feed)
4) Ability to speak in full sentences
5) Use of accessory muscles of respiration
6) Extent and loudness of wheezing (which becomes less
audible with increasingly severe airways obstruction)
7) Level of consciousness and presence of agitation
(suggesting hypoxaemia)

19. 19

20. 20

21. 21

22. 22

23. 23

24. 24
There are different clinical tools for assessing disease
severity in patients with acute asthma exacerbation :
1) Clinical Assessment Score
2) Pediatric Respiratory Assessment Measure (PRAM)
both reliably assess the severity of an acute
Assessment of exacerbation severity

25. 25

26. 26
It is important to assess the severity of the wheeze
episode on presentation and classify into moderate,
severe or life threatening.
If any feature is present (severe and life threatening),
this will automatically put the patient in this group.
This will allow ensure that the correct treatment is
given.

27. 27
Independent of the method of assessment, the same
parameters used to estimate disease severity at
baseline should be used after each treatment,
on a regular basis, and at discharge.

28. 28
Indications for immediate transfer to hospital
for children ≤5 years

29. 29
Transfer immediately to hospital if ANY of the following are present:
Features of severe exacerbation at initial or subsequent assessment
▪ Child is unable to speak or drink
▪ Cyanosis
▪ Subcostal retraction
▪ Oxygen saturation <92% when breathing room air
▪ Silent chest on auscultation
Lack of response to initial bronchodilator treatment
▪ Lack of response to 6 puffs of inhaled SABA (2 separate puffs, repeated
3 times) over 1-2 hours
▪ Persisting tachypnea* despite 3 administrations of inhaled SABA, even if the child
shows other clinical signs of improvement
Unable to be managed at home
▪ Social environment that impairs delivery of acute treatment
▪ Parent/carer unable to manage child at home

30. Children’s Healthcare of Atlanta

31. 31

32. 32

33. 33
 Peak expiratore flow rate
Can be helpful in assessing severity and response to
treatment in children over five years who are familiar with
the technique.
The best of three Peak Expiratory Flow (PEF) measurements
ideally expressed, as a percentage of personal best can be
useful.

34. 34

35. 35
 Peak expiratore flow rate
A measurement of <50% predicted PEF or FEV1 with poor
improvement after initial bronchodilator treatment is
predictive of a more prolonged asthma attack.
Peak flows should not be used for children with life-
threatening asthma.

36. 36
 Peak expiratore flow rate
Clinical assessment of severity may be more reliable
especially in children under 10 years and those unfamiliar
with these devices or who have poor technique.

37. 37
 Pulse oximetry
Accurate measurements of oxygen saturation are essential
in the assessment of all children with acute wheezing.
Oxygen saturation monitors should be available for use
by all health professionals assessing acute asthma in both
primary and secondary care settings.

38. 38
Oxygen saturation from pulse oximetry of <92% on
presentation (before oxygen or bronchodilator
treatment) is associated with high morbidity and likely
need for hospitalization
Consider intensive inpatient treatment of children with
SpO2 <92% in air after initial bronchodilator treatment.

39. 39
 Chest X-Ray
Chest X-rays rarely provide additional useful information
and are not routinely indicated.
A chest X-ray should be performed if there is :
1) Persisting unilateral signs suggesting pneumothorax
2) Lobar collapse or consolidation
3) Life-threatening asthma not responding to
treatment.
4) Subcutaneous emphysema
5) a foreign body

40. 40
 Blood gases
Blood gas measurements should be considered if there are
life-threatening features not responding to treatment.
Arteriolised ear lobe blood gases can be used to obtain an
accurate measure of pH and PaCO2.
If ear lobe sampling is not practicable a finger prick
sample can be an alternative.

41. 41
The routine use of ABG testing in all children with acute
asthma is not justified.
Less-invasive means of assessing respiratory status are
widely available via pulse oximetry (for evaluating
oxygenation)

42. 42
Most children with exacerbations have a ventilation-
perfusion mismatch and mild hypoxemia (> 90%) that is
often made temporarily worse by inhaled beta2-agonist
treatment.
Mild-to-moderate hypoxemia (along with hypocapnia and
respiratory alkalosis) are common ABG findings in severe
acute asthma.

43. 43
The 4 stages of blood gas progression in acute asthma
exacerbations are :
The 1st stage is characterised by hyperventilation with a normal
pO2 and low pCO2
The 2nd stage has hyperventilation but hypoxemia so that both
pO2 and pCO2 are low
The 3rd stage gives a "false-normal" pCO2 as ventilation has
decreased. This is extremely serious and indicates respiratory
muscle fatigue with the need for admission to the ICU
The 4th stage has a low pO2 and a high pCO2 as respiratory
muscles fail. This is even more serious and requires intubation
and ventilatory support

44. 44
ABG during various stages of asthma

45. 45
Blood gases
If airflow obstruction is severe and unrelieved, there may
be progression to hypercapnia and metabolic acidosis due
to muscle fatigue and inability to maintain adequate
alveolar ventilation as well as lactate production by the
overuse of respiratory muscles

46. 46
Blood gases
Normal or raised PaCO2 levels are indicative of worsening
asthma.
A more easily obtained free flowing venous blood PaCO2
measurement of <6 kPa (45 millimetres of mercury)
excludes hypercapnia .

47. 47
Blood gases
The PaCO2 is low in the early stages of acute asthma as a
compensatory mechanism.
A normal or raised PaCO2 indicates worsening asthma and
often predictive of respiratory failure.
Routine ABG on all asthma patients is unnecessary.

48. 48
The decision to intubate a child with severe acute asthma
should be based on the child's clinical status and not
simply the arterial blood gas values

49. 49
Medical management steps

50. 50
The initial treatment of acute asthma in
preschoolers presenting to primary
&secondary healthcare resources

51. 51
Medical management steps
1. Treat hypoxemia (Oxygen)
2. Give short-acting ß2-agonists
3. Prescribe corticosteroids
4. Assess treatment response
5. Consider other modalities of treatment.

52. 52

53. 53
Assessment of oxygen status in acute asthma
Hypoxia is the main cause of death that is due to acute asthma.
Routine objective assessment of oxygen saturation at initial
assessment of acute asthma is needed because clinical signs
may not correlate with hypoxaemia.
Pulse oximetry is the internationally accepted method for
routine assessment of oxygen status in patients with
acute asthma.

54. 54
Oxygen
Oxygen is a treatment for hypoxaemia, not breathlessness.
When oxygen supplementation is used, pulse oximetry is
necessary to monitor oxygen status and titrate to target.

55. 55
Oxygen
Children with life-threatening asthma , severe asthma or
SpO2 <94% should receive urgently high flow oxygen via a
tight fitting face mask or nasal cannula at sufficient flow
rates to achieve and maintain normal saturations of
94–98% (Evidence A).

56. 56
Oxygen
Oxygen should be given to all children with oxygen
saturation levels < 94%.
In life-threatening asthma give oxygen via a non-rebreathe
mask (15 litres/minute.)
In severe asthma, oxygen can be given by nasal cannula or a
facemask. Aim to keep oxygen saturations at 94-98%.

57. 57
Oxygen
Humidified Oxygen is administered as the first line treatment
for acute asthma
Oxygen must always accompany the administration of B2 agonists
delivered by air compressors to offset the further aggravation
of hypoxia by their brochodilator action and the subsequent
enhanced perfusion of the relatively poorly ventilated are
of the lung (ventilation-perfusion mismatch) .

58. 58
Oxygen
To avoid hypoxemia during changes in treatment, children
who are acutely distressed should be treated immediately
with oxygen and SABA (2.5 mg of salbutamol or equivalent
diluted in 3 mL of sterile normal saline) delivered by an
oxygen-driven nebulizer (if available).

59. 59
Oxygen
Administer the lowest flow of oxygen required to maintain
oxygen saturation ≥ 94% .
If oxygen therapy is commenced it should be reviewed
regularly as requirement for oxygen may decrease rapidly

60. 60
Bronchodilator therapy
Wheezing episodes in young children should be treated
initially with inhaled short-acting beta2-agonists,
regardless of whether the diagnosis of asthma
has been made .
β2 agonists are the first-line treatment for acute asthma
or wheezes in children .

61. 61
Inhaled Short-acting ß2-agonists : Salbutamol (albuterol)
should be given to all children presenting acutely with
wheeze , it is the first line bronchodilator of choice .
A metered-dose inhaler (MDI) with a spacer is the preferred
device for salbutamol administration because it is more
efficient than a nebulizer for bronchodilator delivery .

62. 62
MDI can be used in almost all situations except for very
severe episodes with impending respiratory failure..
Even in the presence of hypoxemia, oxygen can be given by
nasal canulae at the same time that salbutamol is given by
MDI and spacer.

63. 63
Children receiving β2agonists via a pMDI + spacer are less
likely to have tachycardia and hypoxia than when the
same drug is given via a nebuliser.

64. 64
.
The initial dose of SABA may be given by a pMDI with spacer
and mask or mouthpiece or an air-driven nebulizer; or, if
oxygen saturation is low, by an oxygen-driven nebulizer .
For most children, pMDI plus spacer is favored as it is more
efficient than a nebulizer for bronchodilator delivery
(Evidence A).

65. 65

66. 66

67. 67
With Spacer
Without Spacer

68. MDIs must be used
with spacer in
children

69. Children’s Healthcare of Atlanta

70. 70
Home-made spacers are as
effective as commercial spacers
in the treatment of acute asthma

71. Children’s Healthcare of Atlanta
Choosing an Inhaler Device
A pressurized metered-dose inhaler (MDI) with a valved spacer
(with or without a face mask, depending on the child’s age) is
the preferred delivery system
Choosing an Inhaler Device
Age group Preferred device Alternative device
Younger than 4 years
Pressurized metered-dose
inhaler plus dedicated
spacer with face mask
Nebulized with face mask
4-5 years
Pressurized metered-dose
inhaler plus dedicated
spacer with mouth piece
Pressurized metered-dose
inhaler plus dedicated
spacer with mouth piece, or
Nebulizer with mouthpiece
or face mask

72. 72
Inhalers should be actuated into the spacer in individual
puffs and inhaled immediately by tidal breathing (for
five tidal breaths).
Frequent doses of β2 agonists are safe for the treatment
of acute asthma .

73. 73
.
The initial dose of SABA is two puffs of salbutamol (100
mcg per puff) or equivalent, except in acute, severe asthma
when six puffs should be given.
When a nebulizer is used, a dose of 2.5 mg salbutamol
solution is recommended.

74. 74
• In the emergency room a standard nebuliser driven with
8 l/min of oxygen takes approximately 10 min to
complete.
• In children we usually nebulise 0.15 mg/kg of salbutamol
up to a maximum of 5 mg made up to 3 ml with normal
saline.

75. 75
Patients with acute asthma have ventilation-perfusion
(V/Q) mismatch.
Beta 2-agonists may worsen this mismatch by causing
increased blood flow in areas of the lung that are poorly
ventilated. This can result in decreased SaO2.
This is easily treated with supplemental oxygen (which
might only be needed for a short period of time) .

76. 76

77. 77
The frequency of dosing depends on the response observed
over 1–2 hours .
Salbutamol dose should be tapered to one- to two-hourly
thereafter according to clinical response.
Assessment of response should be based on accurately
recorded clinical observations and repeat measurements of
oxygenation (SpO2).

78. 78
Once improving on two to four-hourly salbutamol, patients
should be switched to pMDI and spacer treatment as
tolerated
Continuous nebulised β2 agonists are of no greater benefit
than the use of frequent intermittent doses in the same
total hourly dosage.
.

79. 79
For children with moderate-severe exacerbations and a
poor response to initial SABA, ipratropium bromide may be
added , as 2 puffs of 80mcg (or 250mcg by nebulizer) every
20 minutes for 1 hour only .

80. 80
Children with severe or life-threatening asthma (SpO2 <92%)
should receive frequent doses of nebulised bronchodilators
driven by oxygen (2.5–5 mg salbutamol) .
If there is poor response to the initial dose of β2 agonists,
subsequent doses should be given in combination with
nebulised ipratropium bromide .

81. 81
The side effects of salbutamol include tachycardia,
hyperglycemia and hypokalemia, which are generally
well tolerated.
There is no evidence in the paediatric age group of
reversible arrhythmias following treatment with
ß2-agonists .

82. 82
In children under two who have a poor initial response
to β2 agonists administered with adequate technique ,
consider an alternative diagnosis and other treatment
options.

83. 83
Inhaled anticholinergics:
Inhaled ipratropium bromide can be used as an add-on
therapy to ß2-agonists (NOT as a monotherapy).
Repeated doses of ipratropium bromide should be given
early to treat children who are poorly responsive to
β2 agonists.

84. 84
The recommendations of the British Thoracic Society/SIGN
Guidelines for the management of asthma,If symptoms are
refractory to initial b2 agonist treatment, then ipratropium
bromide mixed with the nebulised b2 agonist solution in
the same nebuliser .
• Nebulised ipratropium bromide (125–250 mg per dose) in
addition to b2 agonists for the first 2 h of a severe attack
in children
• It is recommended that this is repeated every 20 min for
the first hour and every 4-6 h thereafter.

85. 85
Give Ipratropium Bromide with each dose of Salbutamol
to all children with severe asthma for the first hour.

86. 86

87. 87
Pre-mixed combination β2-agonist and
anticholinergic inhalant solutions should
be used with caution in children, as the
concentrations of the individual drugs
are higher than recommended for the
paediatric population .

88. 88

89. 89
Nebulised magnesium sulphate
Nebulised magnesium sulphate is not recommended for children
with mild to moderate asthma attacks.
Consider adding 150 mg magnesium sulphate to each nebulised
salbutamol and ipratropium in the first hour in children with a
short duration of acute severe asthma symptoms presenting
with an oxygen saturation less than 92%.

90. 90
MAGNISOL 10% 6 AMP 5 ML
Magnesium sulphate 0.5 g - Memphis

91. 91
Magnesium sulfate Sterile Ampoule 10 ml.
100 mg / ml (E.I.P.I.CO.)

92. 92
Nebulised Magnesium sulfate
Nebulized isotonic magnesium sulfate may be considered as an
adjuvant to standard treatment with nebulized salbutamol and
ipratropium (3 doses) in the first hour of treatment for children
≥2 years old with acute severe asthma (e.g. oxygen saturation
<92%), particularly those with symptoms lasting <6 hours.

93. 93
Intravenous Magnesium Sulfate
Intravenous magnesium sulfate in a single dose of 40-50 mg/kg
(maximum 2 g) by slow infusion (20–60 minutes) can been
used In children who respond poorly to first-line treatments .
The potential side effect of hypotension is rare .

94. 94
Steroid Therapy
For children with severe exacerbations, a dose of OCS ( oral
coticosteroid) equivalent to prednisolone 1–2 mg/kg/day, with
a maximum of 20 mg/day for children under 2 years of age
and 30 mg/day for children aged 2–5 years, is currently
recommended (Evidence A)

95. 95
Steroid Therapy
A 3–5 day course is sufficient in most children and can be
stopped abruptly (Evidence D).
Treatment for up to three days is usually sufficient, but the
length of course should be tailored to the number of days
necessary to bring about recovery.
Tapering is unnecessary unless the course of steroids exceeds
14 days.

96. 96
The early use of systemic steroids in emergency departments
can reduce the need for hospital admission and prevent a
relapse in symptoms after initial Presentation
Benefits can be apparent within three to four hours.

97. 97
Give oral steroids early in the treatment of acute asthma
attacks.
Oral prednisolone is the steroid of choice for asthma
attacks in children unless the patient is unable to tolerate
the dose.

98. 98
Repeat the dose of prednisolone in children who vomit
and consider intravenous steroids in those who are unable
to retain orally ingested medication.
Oral and intravenous steroids are of similar efficacy.

99. 99
Intravenous steroids should be reserved for children with
life-threatening asthma or those who cannot tolerate or
unable to retain oral CS.
o Hydrocortisone 4 mg/kg - 6 hourly
o Methylprednisolone 2 mg/kg 8-hourly IV
o Dexamethasone 0.6 mg/kg IV daily

100. 100

101. 101

102. 102

103. 103

104. 104

105. 105

106. 106
Therapy Dose and administration
Supplemental
oxygen
24% delivered by face mask (usually 1L/min) to maintain
oxygen saturation 94-98%
Inhaled SABA 2–6 puffs of salbutamol by spacer, or 2.5mg by nebulizer, every
20 min for first hour, then reassess severity. If symptoms
persist or recur, give an additional 2-3 puffs per hour. Admit to
hospital if >10 puffs required in 3-4 hours.
Systemic
corticosteroids
Give initial dose of oral prednisolone (1-2mg/kg up to maximum
of 20mg for children <2 years; 30 mg for 2-5 years)
Initial management of asthma exacerbations
in children ≤5 years

107. 107
Therapyx 3 Dose and administration
Supplemental
oxygen
24% delivered by face mask (usually 1L/min) to maintain
oxygen saturation 94-98%
Inhaled SABA 2–6 puffs of salbutamol by spacer, or 2.5mg by nebulizer, every
20 min for first hour, then reassess severity. If symptoms
persist or recur, give an additional 2-3 puffs per hour. Admit to
hospital if >10 puffs required in 3-4 hours.
Systemic
corticosteroids
Give initial dose of oral prednisolone (1-2mg/kg up to maximum
of 20mg for children <2 years; 30 mg for 2-5 years)
Additional options in the first hour of treatment
Ipratropium
bromide
For moderate/severe exacerbations, give 2 puffs of
ipratropium bromide 80mcg (or 250mcg by nebulizer) every
20 minutes for one hour only
Magnesium
sulfate
Consider nebulized isotonic MgSO4 (150mg) 3 doses in first
hour for children ≥2 years with severe exacerbation
Initial management of asthma exacerbations
in children ≤5 years

108. 108

109. 109

110. Add-on treatment options for acute asthma
IV Magnesium Sulphate
Inhaled Ipratropium Bromide
Nebulized Budesonide
Nebulized Isotonic Magnesium Sulfate

111. - 2
nd
line (if inadequate response to salbutamol)
- Add on therapy within first hour
- 3 doses over 1 hour via nebulizer
▪ Children 6 year and over: 500 mcg nebule
Add-on treatment options for acute asthma
Nebulized Budesonide
Inhaled Ipratropium Bromide
Nebulized Isotonic Magnesium Sulfate
IV Magnesium Sulphate

112. 112
2014

113. 113

114. 2013

115. 0.25 mg/ml. Each 2 ml Respule contains 0.5 mg of budesonide.

117. Global
INitiative for
Asthma
www.ginasthma.com

118. 118

119. 119
Primary care management of acute asthma or wheezing in children 5 years and younger

120. 120
O
D.

121. 121
Do not use inhaled corticosteroids in place of oral steroids to
treat children with an acute asthma attack.
There is no evidence that increasing the dose of ICS is effective
in treating acute symptoms
Children with chronic asthma not receiving regular preventative
treatment will benefit from starting ICS as part of their long-
term management.

122. 122
For children not previously on ICS, an initial dose of ICS twice the low daily
dose indicated in the following Box may be given and continued for a few
weeks or months (Evidence D).

123. 123
Maintain current controller treatment (if prescribed):
Children who have been prescribed maintenance therapy
with ICS, LTRA or both should continue to take the
prescribed dose during and after an exacerbation
(Evidence D).

124. 124
The role of Antibotics
The majority of acute asthma attacks are triggered by viral
infection.
Do not give antibiotics routinely in the management of
children with acute asthma.

125. 125
Second Line Treatment Of Acute Asthma
In Children

126. 126
Children with continuing severe asthma despite frequent
nebulised β2 agonists and ipratropium bromide plus oral
steroids, and those with life-threatening features ,
need urgent review by a specialist , transfer to a high
dependency unit or paediatric intensive care unit (PICU)
to receive second line intravenous therapies.

127. 127
Second line intravenous therapies
1) IV salbutamol
2) IV aminophylline
3) IV magnesium sulphate.

128. 128

129. 129
IV aminophylline
A 5 mg/kg loading dose should be given iover 20 minutes
with ECG monitoring (omit in those receiving maintenance
oral theophyllines) followed by a continuous infusion at
1mg/kg/hour.
Measure serum theophylline levels in patients already
receiving oral treatment and in those receiving prolonged
treatment.

130. 130
Nebulised bronchodilators should be continued while
the patient is receiving intravenous bronchodilators.
Once the patient is improving the intravenous infusion
should be reduced before reducing the frequency of
nebulised bronchodilators.

131. 131
Non-invasive ventilation
Although respiratory failure is infrequent in asthma, children
experiencing severe asthma exacerbations occasionally
deteriorate, and respiratory support may be required.
Bilevel positive airway pressure (BiPAP) is safe and is generally
well tolerated, and it may improve oxygenation and decrease
the work of breathing.
Clear guidelines for its use are not yet established, but for the
child with a severe exacerbation that is refractory to other
interventions, BPAP may offer an alternative to intubation
if it is used in a timely fashion.

132. 132
For children with refractory symptoms and impending
respiratory failure, intubation may be necessary.
All other therapies should be attempted and maximized
prior to intubation.

133. 133
Indications For Intubation
1) Poor response to therapy
2) Rising CO2 (PCO2 > 50 mm Hg)
3) Worsening or Severe hypoxia (PO2 < 60 mm Hg)
4) Rapid deterioration in mental status or fatigue
5) Impending respiratory arrest
6) Cardiopulmonary arrest
Blood gas analysis on its own is not a substitute for
clinical assessment. Need for intubation should not
be made solely on a Blood Gas.

134. 134

135. 135
Discharge and follow up after an exacerbation
Before discharge, the condition of the child should be stable (e.g.
he/she should be out of bed and able to eat and drink without
problems).
Children who have recently had an asthma exacerbation are at
risk of further episodes and require follow up.

136. 136
Prior to discharge from the emergency department or hospital,
family/carers should receive the following advice and
information :
1. Instruction on recognition of signs of recurrence &worsening
of asthma. The factors that precipitated the exacerbation
should be identified, and strategies for future avoidance
of these factors implemented.
2. A written, individualized action plan, including details of
accessible emergency services.
3. Careful review of inhaler technique.

137. 137
Assess exposure to environmental
tobacco smoke

138. 138
Further treatment advice explaining that:
o SABAs should be used on an as-needed basis, but the daily
requirement should be recorded to ensure it is being decreased
over time to pre-exacerbation levels
o ICS has been initiated where appropriate (at twice the low
initial dose for the first month after discharge, then adjusted as
needed) or continued, for those previously prescribed controller
medication.

139. 139
Further treatment advice explaining that:
• A supply of SABA and, where applicable, the remainder of the
course of oral corticosteroid, ICS or LTRA.
• A follow-up appointment within 2–7 days and another within
1–2 months, depending on the clinical, social and practical
context of the exacerbation.

140. 140
Acute asthma attacks should be considered a failure
of preventive therapy and thought should be given
about how to help families avoid further severe
episodes.

141. 141
Thank
you