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Asthma is a common condition in western society and children with it present frequently to emergency departments. This guideline is designed to ensure that the clinicians in the Emergency Department have a framework that guides both assessment and therapy. Key to success is an understanding of the clinical risk assessment that has been derived from the BTS guidelines.
Asthma is a common condition in western society and children with it present frequently to emergency departments. This guideline is designed to ensure that the clinicians in the Emergency Department have a framework that guides both assessment and therapy. Key to success is an understanding of the clinical risk assessment that has been derived from the BTS guidelines.
Asthma is a common condition in western society and children with it present frequently to emergency departments. This guideline is designed to ensure that the clinicians in the Emergency Department have a framework that guides both assessment and therapy. Key to success is an understanding of the clinical risk assessment that has been derived from the BTS guidelines.
Asthma is a common condition in western society and children with it present frequently to emergency departments. Some asthmatics attend with life-threatening symptoms and require immediate life-saving intervention, while others come to the ED because the parents are under- standably very worried about their wheezy childespecially if there are other family members with asthma. Many lay between these extremes, and the real skill in caring for suffers lies in rapid and accurate assessment of severity - and therefore urgency of need. This guideline is designed to ensure that the clinicians in the Emergency Department have a framework that guides both assessment and therapy, and in particular ensures that children needing resuscita- tion receive it promptly. When to use this Guideline This guideline should be used in all children with known asthma who attend the Emergency De- partment. How to use this Guideline The key to successful use of this guideline is an understanding of the clinical risk assessment that has been derived from the BTS guidelines. The first aim is to identify children with life- threatening asthma, and then to establish whether they need urgent intubation and ventilation (after discussion with the Paediatric Team) or whether maximal medical therapy can be tried. Children with severe asthma can also be identified early and treated appropriately, while those with mild exacerbations can use their normal bronchodilators. Most importantly all children are reassessed (using the same risk assessment) and treatment is modified as necessary. Those who continue to have life-threatening features are admitted to the paediatric critical care ar- eas, while those who have severe symptoms should be admitted to the paediatric wards. Chil- dren who presented with mild symptoms, and those whose symptoms have improved significantly with treatment will probably be suitable for discharge, possibly after a pe- riod of observation and if there is suitable adult supervision. If they do go home then community follow up should be considered, as should referral to the paediatric asthma team. Guideline FAQs What is asthma? Asthma is lower airway obstruction caused by bronchospasm. Which children should this guideline be used for? This guideline should be used for all patients presenting to the department with symp- tomatic asthma. Should I ever give asthmatic children anything to calm them down if they are anx ious? No! Sedating patients who are having difficulty breathing is absolutely contraindi- cated. Treat the underlying cause (asthma).
Special points of inter- est: It is important to remem- ber that normal physio- logical values change with age The PEFR can be very difficult to obtain in children Children under the age of 5 (and a significant num- ber over this age) cannot use inhalers effectively without a spacer device Children under the age of 18 months may wheeze for a number of other rea- sonsand may respond poorly to treatment
in th e E m e rge ncy D e pa rtm e nt 2003-52 CDSG Asthma in Childhood 2 3 PDI/520: SUITABILITY FOR PROTOCOL DRIVEN INVESTIGATION (ALL YES)
Order: T, P, BP, R, S a O 2, PEFR, Weight CDU/521 / 523: CLINICAL RISK ASSESSMENT OF Asthma CDU/061 CDU/063
Life threatening if any of LT, severe to moderate if none of LT and any of S or Mo and mild if none of LT, S or Mo. NB PEFR is not usually possible in children aged less than 3 years. MEDICAL THERAPY ADVICE
CDU/522: Need for immediate review for IPPV (ANY YES)
CDU/524: Need for second review for IPPV (ANY YES)
CDU/524: Suitable for discharge (ALL YES)
Known Asthma Yes Acute breathlessness / wheeze is the main complaint Yes LT S/Mo LT S/Mo Reduced level of consciousness / agitation
Cyanosis / SaO 2 < 92% on air
Poor respiratory effort / silent chest
Exhaustion
PEFR < 33% best or predicted
PaO 2 < 8 kPa / PaCO 2 > 4.6 kPa
Dysrhythmia (including bradycardia)
SBP < 90 mm Hg
Unable to talk in sentences or eat
Use of accessory neck muscles
PEFR 33 - 75% best or predicted
RR significantly elevated for age (>50 age 2-5, >30 age > 5)
P significantly elevated for age (>130 age 2-5, >120 age > 5)
Maximal medical therapy: This consists of continuous nebulised salbutamol (2.5mg < 5y, 5mg > 5y) together with steroids IV (hydrocortisone 4 mg/kg max 100 mg). IV bronchodilators (salbutamol or aminophylline) may be required. Medical therapy This consists of intermittent nebulised salbutamol (2.5mg < 5y, 5mg > 5y) together with steroids orally (prednisolone 1-2 mg/kg max 40mg). IV bronchodilators (salbutamol or aminophylline) may be required. Antibiotics may be indicated. Antiibiotics: Are indicated if there are clinical or radiographic signs of pneumonia. Start with amoxicillin po (erythromycin if allergic to penicillin), or cefu- roxime IV tds if parenteral delivery is required. Airway compromise Yes Inadequate breathing Yes Severe hypoxia (SaO 2 < 70% on air) Yes Airway compromise Yes Inadequate breathing Yes Severe hypoxia (SaO 2 < 70% on air) Yes Adequate social support Yes Able to eat and drink Yes Able to use inhaler with spacer device Yes No consolidation or pneumothorax on CXR if indicated Yes 6h of stable observation for all children who have required nebulisers Yes Alert Yes Ref/526: Suitable for paediatric referral for admission
Ref/527: Suitable for Discharge and community follow-up
4 Evidence Base
This guideline is based primarily on the following sources:
There are 6 relevant Cochrane reviews:
Additional reviews (BestBETs) have been undertaken as follows:
Additional sources of interest include:
Nice guidance is extant / pending / NOT CURRENTLY PLANNED
British Guideline on the Management of Asthma. A national clinical guideline. British Tho- racic Society and the Scottish Intercollegiate Guidelines Network. http://www.brit- thoracic.org.uk/docs/asthmafull.pdf Anticholinergic drugs for wheeze in children under the age of two years. ML Everard, A Bara, M Kurian, TM Elliott, F Ducharme Combined inhaled anticholinergics and beta2-agonists for initial treatment of acute asthma in children. LH Plotnick, FM Ducharme Corticosteroids for hospitalised children with acute asthma. M Smith, S Iqbal, TM Elliott, BH Rowe Interventions for educating children who have attended the emergency room for asthma. MM Haby, E Waters, CF Robertson, PG Gibson, FM Ducharme Intravenous aminophylline for acute severe asthma in children over 2 years using inhaled bronchodilators. A Mitra, D Bassler, FM Ducharme Oral and systemic steroids at different doses for acute asthma in hospitalised children. M Smith, L McLoughlin
BB 43. Oral steroids are as effective as intravenous steroids in acute severe asthma http://www.bestbets.org/cgi-bin/bets.pl?record=00043 BB 212. Beta-agonists with or without anti-cholinergics in the treatment of acute childhood asthma? http://www.bestbets.org/cgi-bin/bets.pl? record=00212 Bb 235. Lignocaine as a pretreatment to Rapid Sequence Induction in patients with status asthmaticus http://www.bestbets.org/cgi-bin/bets.pl? record=00235 BB 239. Is IV aminophylline better than IV salbutamol in the treatment of moderate to severe asthma http://www.bestbets.org/cgi-bin/bets.pl? record=00239 BB 444. Is homeopathy better than placebo in the treatment of bronchial asthma ? http://www.bestbets.org/cgi-bin/bets.pl?record=00444 BB 620. Nebulised magnesium in asthma http://www.bestbets.org/cgi-bin/bets.pl?record=00620 BB 686. Non-steroidal anti-inflammatory drugs and exacerbations of asthma in children http://www.bestbets.org/cgi-bin/bets.pl?record=00686 BB 768. Does magnesium sulphate have a role in the management of paediatric status asthmaticus? http://www.bestbets.org/cgi-bin/bets.pl? record=00768
Disclaimer
This guideline has been developed by clinicians and its content has been reviewed by the Clinical Effectiveness Committee of the British Association for Emergency Medicine. Guidelines cannot always contain all the information necessary for determining appropriate care and cannot address all individual situations, therefore individuals using these guidelines must ensure they have the appropriate knowledge and skills to enable interpretation. Guidelines can never substitute for sound clinical judgement. This guideline may not reflect changes in clinical practice that have occurred since it was last reviewed.