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Asthma – Emergency

Asthma – Emergency management in children

Key points

  • Asthma is a chronic inflammatory disorder of the airways involving reversible airway obstruction.
  • Children with acute asthma usually present with cough, wheeze and/or difficulty breathing.
  • Salbutamol and steroids are the first-line treatment for children greater than five years with additional medications given in more severe cases.
  • A wheezing illness in children less than five years is managed differently with steroids not routinely recommended (see Pre-school wheeze Guideline).
  • A thorough assessment and continuous review is necessary for each child during their presentation.
  • Acute asthma episodes can be life-threatening. Seek senior emergency /paediatric advice promptly for a child with severe symptoms or who is not responding to treatment. .

Purpose

This document provides clinical guidance for all staff involved in the care and management of a child presenting to an Emergency Department (ED) with asthma symptoms in Queensland. The management of children aged one to five years who present with a wheezing illness may is outlined in the Pre-school wheeze – Emergency management in children Guideline.

This guideline has been developed by senior ED clinicians across Queensland, with input from Paediatric Respiratory specialists, Queensland Children’s Hospital, Brisbane. It has been endorsed for use across Queensland by the Queensland Emergency Care of Children Working Group in partnership with the Queensland Emergency Department Strategic Advisory Panel and the Healthcare Improvement Unit, Clinical Excellence Queensland.

Introduction

Asthma is a chronic inflammatory disorder of the airways involving reversible airway obstruction. It is estimated to affect one in six Australian children.1 Asthma is one of the most common paediatric ED presentations.

Children with asthma have sensitive airways which react to triggers (such as viral illnesses) causing airway inflammation, thickened mucous and bronchospasm leading to a narrowing of the airways, reduced airflow and air trapping.3 Children with acute asthma usually present with cough, wheeze and/or difficulty breathing. In an acute asthma episode, a wheeze may not always be heard but a prolonged respiratory phase of expiration may be present. Acute bronchospasm may lead to respiratory failure and life-threatening acute asthma if not identified and treated promptly.3,4 The diagnosis of asthma is confirmed by demonstrating reversible airway obstruction. Other diagnoses can also cause recurrent respiratory symptoms.

Assessment

Children with asthma may present with a range of symptoms and varying levels of severity. Initial assessment should be within the time frame recommended by the patient’s triage (ATS) category. The child’s general appearance or mental state and level of respiratory distress are the most important markers of severity.

The aim of the initial assessment is to:

  • confirm an asthma episode
  • identify symptom pattern, severity and possible trigger factors
  • look for features suggestive of an alternative diagnosis or associated condition

History

History taking should include specific information on:

  • signs and symptoms (including wheeze, cough and respiratory distress) and management to date for the current episode
  • history of previous wheezing episodes (including severity, previous management and hospitalisations, including PICU admission) and previous asthma diagnosis
  • regular asthma management plan (if any)
  • family history (including mother and sibling/s) of asthma and atopy
  • smoking history of household members

All health professionals have a role in advocating for their patients by advising parents about the increased risk of wheezing associated with parental smoking.

Examination

  • ALERT – Wheeze may be absent in severe cases due to severe airway obstruction or extreme fatigue. A “silent chest” (chest with little or no breath sounds) is a warning sign of life-threatening respiratory failure and/or respiratory arrest.

The clinical assessment of an asthmatic child should include:

  • respiratory rate and phases of respiration
  • work of breathing and use of accessory muscles (nasal flaring, tracheal tug, intercostal or substernal recession)
  • oxygen saturation (in room air or with supplemental oxygen)
  • heart rate
  • skin colour (pallor or cyanosis)
  • blood pressure and pulse volume
  • level of consciousness (irritability or drowsiness)

The modified version of the National Asthma Council Australia severity assessment criteria and the Australasian Triage Scale (ATS) is displayed in the table below.

  • Seek senior emergency/paediatric assistance as per local escalation practices for a child with severe or life-threatening asthma. Consider contacting paediatric critical care specialists (onsite or via Retrieval Services Queensland (RSQ)) for life-threatening cases.
Initial assessment of acute asthma in children
Mild Moderate Severe Life-threatening
Normal conscious state Normal conscious state Agitated

Restlessness

Distressed

Exhaustion

Confused

Altered level of consciousness

No accessory muscle use Minimal accessory muscle use Moderate muscle use

Nasal flaring

Tracheal tug

Hyperinflated chest

Excessive muscle use

Nasal flaring

Tracheal tug

Hyperinflated chest

Normal to a mild increase in respiratory rate Tachypnoea Tachypnoea

Dyspnoea

Prolonged expiration

Decreasing respiratory rate

May only gasp occasionally

Normal pulse Tachycardia Tachycardia Decreasing heart rate

Pulse may be hard to feel

Pulsus paradoxus not present Pulsus paradoxus may be palpable Pulsus paradoxus palpable Pulsus paradoxus palpable
Talks in sentences Talks in phrases Talks in 1 – 2-word gasps Unable to talk
No central cyanosis No central cyanosis Cyanosis likely Cyanosis
Variable wheeze Moderate to loud wheeze Often quiet wheeze Often quiet wheeze (silent chest)
SpO2 more than 94% SpO2 90 – 94% SpO2 less than 90% SpO2 less than 90%

Adapted from: National Asthma Council Australia1 and Department of Health and Ageing, Australian Government 5

Differential diagnosis

Alternative conditions which can present with clinical features similar to acute asthma include:

Investigations

Investigations are not routinely recommended in the initial management of acute asthma.5 They may be considered in a child with life-threatening asthma or severe asthma who is not responding to treatment, or where alternate or concurrent diagnoses are being considered.5

Venous blood gas will allow monitoring of venous carbon dioxide, and serum potassium, lactate and glucose as markers of potential Salbutamol toxicity. CXR may assist if considering either alternate diagnosis or to exclude complications of acute asthma such as collapse or pneumothorax.

Management

For the management of asthma symptoms in pre-school children refer to the Pre-school Wheeze Guideline.

Refer to the flowchart for a summary of the recommended emergency management of children with asthma.

The initial management of acute asthma in children comprises of inhaled beta2-agonists (Salbutamol) and steroids while maintaining adequate oxygenation.3,6 Other useful adjuncts for severe episodes or escalation of treatment may include inhaled anticholinergics (Ipratropium Bromide), Magnesium sulphate IV, Salbutamol IV and Aminophylline IV.3,6

Frequent repeated clinical assessment is the best indicator to guide management.

Inhaled salbutamol

Salbutamol may be effectively administered by nebuliser or by metered dose inhaler (MDI) with a spacer device.

Inhaled salbutamol dosing for the treatment of asthma in children
Metered dose inhaler (MDI)* 100 micrograms
(spacer recommended)
Age 5 years: 6 puffs
Age 6 years or more: 12 puffs
Nebulised Age 5 years: 2.5 mg
Age 6 years or more: 5 mg
Salbutamol burst Administer three doses as above at twenty-minute intervals
Continuous nebulised salbutamol Neat salbutamol nebuliser solution (5 mg/mL), replenish where reservoir empty. Use 5 mg/1 mL nebules or 30 mL multi-use bottle.

*Use mask also if unable to form a reliable seal on spacer

MDI and spacer vs nebuliser

  • MDI is preferred as faster (nebulisation requires a child to sit still for at least 10 minutes) and more efficient.
  • Delivery of salbutamol by nebuliser results in greater facial and oropharyngeal deposition of medication delivering at best 10% of the prescribed drug to the lungs, with consequent systemic absorption and side effects such as tachycardia and tremor.
  • Children who are struggling with their breathing and who are not able to co-ordinate taking a deep breath through the spacer should be given nebulised medication.

How to use a spacer

  • Prime spacer before use to negate electrostatic charge (and optimise drug delivery) with 10 puffs of Salbutamol.
  • Shake MDI before each puff.
  • Administer one puff at a time into the spacer.
  • The medication is cleared from the spacer by the child taking four breaths following each puff of medication.
  • If the child is unable to form a reliable seal around the spacer, a mask should be used.

Weaning salbutamol

Stretching the time between salbutamol doses should be based on an assessment on the child. This should be done in collaboration with the child and caregiver and include:

  • respiratory distress: decreased work of breathing (subcostal & intercostal recession/ tracheal tug /nasal flaring)
  • activity level: decreasing lethargy, increasing alertness
  • respiratory rate: decreasing to within normal limits for age
  • heart rate: decreasing to within normal limits for age. Note bronchodilator therapy increases heart rate.
  • speech: able to talk in sentences
  • auscultation: air entry improved, wheeze reduced or appearance of wheeze in previously quiet chest (note wheeze alone is not an indication for giving Salbutamol)
  • cough: reduction or change in cough i.e. becomes looser
  • oxygen saturations: increasing oxygen saturations and decreasing oxygen requirement.
  • ALERT – Cumulative doses of Salbutamol can cause agitation, tremor, tachycardia, tachypnoea and rarely, hypertension. Raised lactate, hypokalaemia and raised glucose on VBG are markers of salbutamol toxicity.

Steroids

Corticosteroids are recommended to treat the airway oedema and increased mucous production in a child with a moderate-to-severe acute asthma episode, or with persistent symptoms following Salbutamol.7,8 A Cochrane review reported that hospital admission rates for children with acute asthma were significantly reduced for those who received corticosteroids within one hour of ED presentation.9 Oral corticosteroid treatment is particularly effective in children and has minimal side effects.9 Maximum benefit occurs within four to six hours after administration.

For pre-school children, particularly those with intermittent viral induced wheezing, corticosteroids should be limited to those with at least moderate but generally severe acute wheeze requiring hospital admission (see Pre-school wheeze Guideline).

Steroid dosing for the treatment of asthma in children
Prednisolone (oral) Day 1: 2 mg/kg (maximum 50 mg)

Day 2 and 3: 1 mg/kg

Can extend course to five days if still symptomatic after three-day course

Hydrocortisone (IV) 4 mg/kg (maximum 200 mg) then every six hours on day one.
OR
Methylprednisolone (IV)
1 mg/kg (maximum 60 mg) then every six hours on day one.

While there is some evidence for the benefit of inhaled corticosteroids and leukotriene receptor antagonists in acute asthma, oral or intravenous corticosteroids remain the current treatment of choice.10

Ipratropium bromide (Atrovent)

Ipratropium bromide may be useful in combination with Salbutamol in the early management of children presenting with moderate to severe acute asthma.1,5 The mechanism of action of anticholinergic bronchodilators remains unclear. However, it is thought that cholinergic pathways play an important role in the pathogenesis of asthma exacerbations.11

There is good evidence to suggest that combined Ipratropium bromide and Salbutamol therapy is superior to Salbutamol therapy alone.12-15 It has been demonstrated that combined therapy given in the first two hours (ideally combining Ipratropium bromide with the first three Salbutamol doses) is safe and results in  a significant improvement in the peak expiratory flow rate, ultimately decreasing hospitalisation rates.16 Ipratropium bromide has been shown to be of benefit in children that have not responded to inhaled Salbutamol alone.5

Ipratropium dosing for the treatment of asthma in children
Age 5 years 4 puffs (84 micrograms) via spacer OR 250 micrograms nebulised every twenty minutes for three doses. Can be mixed in nebuliser with Salbutamol.
Followed by 2 puffs (42 micrograms) every six hours
Age greater than 6 years 8 puffs (168 micrograms) via spacer OR 500 micrograms nebulized every twenty minutes for three doses. Can be mixed in nebuliser with Salbutamol.
Followed by 4 puffs (84 micrograms) every six hours

Magnesium sulphate

  • Seek senior emergency/paediatric advice as per local practices for a child requiring Magnesium sulphate. Consider seeking paediatric critical care input (onsite or via RSQ).

Consider magnesium sulphate IV for children with severe acute asthma who are not responding to conventional bronchodilators used in the first hour.17 A meta-analysis on the use of magnesium sulphate IV in acute to moderate to severe asthma in ED found benefits in pulmonary function tests and hospitalisation rates.18

The action of Magnesium sulphate remains unclear. It is thought that magnesium ions decrease the uptake of calcium by bronchial smooth muscle cells, which leads to bronchodilation.18,19 It may also have a role in inhibiting mast cell degranulation, which reduces inflammatory mediators.18,19

Magnesium sulphate (IV) dosing for the treatment of asthma in children
Bolus dose 0.2 mmol/kg (equivalent to 50 mg/kg) infused intravenously over twenty minutes (maximum 10 mmol = equivalent to 2,500 mg)
Doses up to 0.4 mmol/kg (maximum of 8 mmol) have been used.
Must be administered in syringe driver using safety software.
Side effects Usually minor, including epigastric or facial warmth and flushing, pain and/or numbness at infusion site and dry mouth. Severe reactions include allergy, hypotension, respiratory depression and circulatory collapse.
Monitoring Full cardiac monitoring with blood pressure every five minutes.
Cease infusion if hypotension persists.
Monitor knee reflexes if repeating dose to assess for magnesium toxicity which can result in respiratory failure. Cease magnesium if reflexes absent.
  • ALERT – Magnesium sulphate should always be prescribed in mmols and administered using safety software syringe drivers to avoid medication errors.

Administer magnesium sulphate using safety software syringe drivers with a standard concentration of 0.5 mmol/ml. e.g. if patient weighs 10 kg, the magnesium sulphate dose is 0.2 mmol/kg = 2 mmol. This translates to 4 mL of 0.5 mmol/mL solution and must be administered through a safety software syringe driver over 10 – 20 minutes to minimise the risk of too rapid administration and dosing errors.

Currently, there is no good evidence to support using inhaled Magnesium sulphate as an alternative to inhaled beta2-agonists.17,20 A preservative free preparation of magnesium sulphate suitable for nebuliser therapy is currently unavailable in Queensland.

Intravenous salbutamol

  • Contact paediatric critical care specialists (onsite or via RSQ) for children requiring salbutamol IV.

Salbutamol IV should be considered for children who present with severe or life-threatening acute asthma and who do not respond appropriately to initial continuous doses of inhaled beta2-agonists. The near or complete airway obstruction that can occur in life-threatening asthma can prevent effective aerosolised bronchodilator therapy.21

A single bolus dose of salbutamol IV can be given as a standalone dose or can be given prior to commencing an infusion. A single bolus of salbutamol IV administered over 10-20 minutes has been shown to shorten the duration of severe asthma attacks, improve recovery time and reduce the overall requirements for inhaled salbutamol.21-23

The approach to salbutamol IV dose can vary between starting at the lower or higher end and adjusting according to response. Concerns have been expressed that the current recommendations for children may be excessive and may unnecessarily raise the potential for adverse reactions such as lactic acidosis and tachycardia, and through increasing respiratory workload, exacerbate respiratory fatigue.24

The current recommended dosing practice is to use a higher rate initially and reduce thereafter.25-27

Salbutamol (IV) dosing for the treatment of asthma in children
Bolus dose 100 microgram/kg infused over twenty minutes (maximum 5 milligrams)
Infusion 1-2 microgram/kg/min (to maximum weight 50 kg)
Side effects Cumulative doses of salbutamol can cause agitation, tremor, tachycardia, tachypnoea and rarely, hypertension. Raised lactate, hypokalaemia and raised glucose on VBG are markers of salbutamol toxicity.
Monitoring Full cardiac monitoring
Monitor venous potassium levels.

Aminophylline

  • Contact paediatric critical care specialists (onsite or via RSQ) prior to administering aminophylline IV.

Traditionally, Aminophylline IV has been used in children with severe asthma who are unresponsive to maximum doses of bronchodilators and steroids in the critical care setting. Aminophylline improves lung function within six hours of treatment, however there is limited improvement in symptoms, and no reduction in duration of hospital admission.28 It is also associated with numerous side effects including vomiting.5 Aminophylline should not be given as an intravenous infusion in the patient already taking oral Theophylline.

High flow nasal cannula (HFNC) therapy and non-invasive ventilation (NIV)

  • Seek urgent paediatric critical care advice (onsite or via RSQ) if commencing HFNC therapy or NIV.

NIV and HFNC therapy are usually well tolerated in children with acute respiratory insufficiency due to asthma who have not responded to standard medical therapies. Early use may prevent the requirement for intubation and mechanical ventilation.29,30

Consider HFNC therapy, CPAP or BiPAP for a child who:

  • is unable to maintain SpO2 greater than 93% despite high flow oxygen via a non-rebreather mask
  • has deteriorating work of breathing with increasing fatigue, tachycardia, and tachypnoea

NIV should only be considered in a child with a normal level of consciousness. HFNC therapy may be valuable to provide pre-oxygenation while preparation for intubation is underway in children with a deteriorating level of consciouness.25

Potential concerns (access via QH intranet) have been raised regarding the use of HFNC therapy.

Follow local policies and procedures for nursing ratios and ward location. View CHQ Nasal High Flow Therapy Guideline.

  • Contact paediatric critical care specialists (onsite or via RSQ) if considering intubation and ventilation.

Escalation and advice outside of ED

Clinicians can contact the services below if escalation of care outside of senior clinicians within the ED is needed, as per local practices. Transfer is recommended if the child requires a higher level of care.

  • Critically unwell or rapidly deteriorating child

Includes children with the following (as a guide)
  • severe and not responding to treatment
  • requiring respiratory support e.g. HFNC or NIV
  • requiring salbutamol IV
  • if considering aminophylline IV
  • if considering intubation
5-11 years Over 12 years
• RR >40
• HR <70 or >150
• sBP <75
• SpO2 <93% in oxygen or <85% in air
• GCS ≤12
• RR >30
• HR <50 or >130
• sBP <85
• SpO2 <93% in oxygen or <85% in air
• GCS ≤12
Reason for contact Who to contact
For immediate onsite assistance including airway management The most senior resources available onsite at the time as per local practices.
Options may include:

  • paediatric critical care
  • critical care
  • anaesthetics
  • paediatrics
  • Senior Medical Officer (or similar)
Paediatric critical care advice and assistance Onsite or via Retrieval Services Queensland (RSQ).
If no onsite paediatric critical care service contact RSQ on 1300 799 127:

  • for access to paediatric critical care telephone advice
  • to coordinate the retrieval of a critically unwell child

RSQ (access via QH intranet)
Notify early of child potentially requiring transfer.
Consider early involvement of local paediatric/critical care service.
In the event of retrieval, inform your local paediatric service.

  • Non-critical child

May include children with:
  • previous admission requiring critical care
  • history of sudden deterioration
  • any other significant clinical concern
Reason for contact Who to contact
Advice
(including management, disposition or
follow-up)
Follow local practices. Options:

  • onsite/local paediatric service
  • Queensland Children’s Hospital experts via Children’s Advice and Transport Coordination Hub (CATCH) on 13 CATCH (13 22 82)
    (24-hour service)
  • local and regional paediatric videoconference support via Telehealth Emergency Management Support Unit TEMSU (access via QH intranet) on 1800 11 44 14 (24-hour service)
Referral First point of call is the onsite/local paediatric service

Inter-hospital transfers

Do I need a critical transfer?
Request a non-critical inter-hospital transfer
Non-critical transfer forms

Disposition

When to consider discharge from ED

Consider discharge for a child who has ALL of the following:

  • maintain SpO2 ≥ 93% in room air
  • not tachypnoeic
  • no/mild work of breathing
  • good air entry with minimal wheeze
  • clinically stable not requiring bronchodilator therapy more frequently than every three hours
  • has a parent/caregiver who can safely manage the child at home, return in event of deterioration and access further medication

Consider a longer period of observation despite meeting the clinical discharge criteria for the following children:

  • previous critical care admission or previous sudden deterioration
  • unable to get to a hospital within 30 minutes
  • social factors impacting upon ability to monitor and supervise child at home

An assessment of the family’s ability to safely manage the child at home should be done as per the Asthma Disease Education Checklist for all children with pre-school wheeze prior to discharge.

On discharge a child should be provided with:

Follow-up

  • With GP or Paediatrician within a week, depending upon the course of the illness

When to consider admission

Facilities without a Short Stay Unit (SSU)

Consider admission for the following children:

  • severe illness (defined as ongoing respiratory distress, failure to respond to initial treatment or requiring oxygen)
  • unable to stretch bronchodilators within four hours of ED presentation

Consider a longer period of observation despite meeting the clinical discharge criteria for the following children:

  • previous critical care admission or previous sudden deterioration
  • unable to get to a hospital within 30 minutes
  • social factors impacting upon ability to monitor and supervise child at home

Facilities with a Short Stay Unit (SSU)

Consider admission to an SSU if:

  • symptoms occur within one to two hours of initial treatment with bronchodilator/steroids AND
  • no further investigations are required

Children who require bronchodilator therapy more frequently than one hourly require vigilant monitoring and regular review by medical staff.23 Unless specifically discussed with SSU medical and nursing staff, the child should remain in the acute assessment area of the ED.

During admission to SSU:

  • vital signs and respiratory assessment should be recorded in line with bronchodilator frequency or hourly if requiring oxygen supplementation
  • Salbutamol frequency can be weaned (“stretched”) by appropriately trained nursing or medical staff, depending on local practices
When to consider admission to inpatient ward from SSU

Local practices will dictate criteria for admission from SSU to an inpatient ward. Some general criteria to consider include:

  • clinical deterioration with a need to escalate treatment
  • failure to progress and wean bronchodilators to every three hours in 12 – 24 hours (consider poor bronchodilator response, suboptimal administration or alternative diagnosis)
  • persisting supplemental oxygen requirement

Related documents

References

  1. National Asthma Council Australia. Asthma management handbook 2006 [internet].Melbourne (AU):National Asthma Council Australia;2006 [cited 2011 May 9]. www.nationalasthma.org.au/cms/images/stories/amh2006_web_5.pdf
  2. Mannix R., Bachur R. Status asthmaticus in children. Current Opinion in Pediatrics. 2007; 19 (3): 281-287.
  3. Lugogo NJ., MacIntyre NR. Life-threatening asthma:Pathophysiology and management.Respiratory Care.53(6):726-739.
  4. British Thoracic Society. British Guideline on the Management of Asthma: A National Clinical Guideline [internet]. London (UK): British Thoracic Society; 2009 [cited 2011 May 10]. Available from: www.britthoracic.org.uk/Portals/0/Clinical%20Information/Asthma/Guidelines/sign101%20revised%20June%2009.pdf
  5. BTS/SIGN British Guidelines on the management of asthma. Oct 2014
  6. www.brit-thoracic.org.uk/document-library/clinical-information/asthma/btssign-asthma-guideline-quick-reference-guide-2014/
  7. Rowe BH.,Edmonds M.L.,Spooner C.H.,et al.Corticosteroid therapy for acute asthma.Respiratory Medicine.2004;98(4): 275-284.
  8. Van Asperen PP., Mellis CM., Sly PD., et al. for the Thoracic Society of Australia & New Zealand. The role of corticosteroids in the management of childhood asthma [internet]. Sydney (AU): The Thoracic Society of Australia & New Zealand; 2010 [cited 2011 May 26]. http://www.thoracic.org.au/imagesDB/wysiwyg/Steroidsinasthma_2010.pdf
  9. Rowe BH., Spooner C., Ducharme F., et al. Early emergency department treatment of acute asthma with systemic corticosteroids. Cochrane Database of Systematic Reviews. 2001; Issue 1, Art. No.: CD002178.
  10. Powell C, Dwan K, Milan SJ, Beasley R, Hughes R, Knopp-Sihota JA, Rowe BH. Inhaled magnesium sulfate in the treatment of acute asthma. Cochrane Database of Systematic Reviews 2012, Issue 12. Art. No.: CD003898.
  11. Chakraborti A., Lodha R., Pandey RM., et al. Randomized controlled trial of ipratropium bromide and salbutamol alone in children with acute exacerbation of asthma. Indian Journal of Pediatrics. 2006; 73 (11): 979-983.
  12. Schuh S., Johnson DW., Callahan S., et al. Efficacy of frequent nebulized ipratropium bromide added to frequent high-dose albuterol therapy in severe childhood asthma. Journal of Pediatrics. 1995; 126 (4): 639-645.
  13. Qureshi, F., Zaritsky, A., & Lakkis, H. Efficacy of nebulized ipratropium in severely asthmatic children. Annals of Emergency Medicine. 1997; 29 (2): 205-211.
  14. Qureshi, F., Pestian, J., Davis, P., & Zaritsky, A. Effect of nebulized ipratropium on the hospitalization rates of children with asthma. The New England Journal of Medicine. 1998; 339 (15): 1030-1036.
  15. Zorc J., Pusic MV., Ogborn J., et al. Ipratropium bromide added to asthma treatment in the pediatric emergency department. Pediatrics. 1999; 103 (4): 748-752.
  16. Plotnick L., Ducharme F. Combined inhaled anticholinergics and beta2-agonists for initial treatment of acute asthma in children. Cochrane Database of Systematic Reviews. 2000; Issue 3, Art No.: CD000060.
  17. Ketamine for management of acute exacerbations of asthma in children. Cochrane Database of Systematic Reviews 2012, Issue 11. Art. No.: CD009293. DOI: 10.1002/14651858.CD009293.pub2
  18. Cheuk DKL., Chau TCH., Lee SL. A meta-analysis on intravenous magnesium sulphate for treating acute asthma. Archives of Disease in Childhood. 2005; 90 (1): 74-77.
  19. Rowe BH., Bretzlaff JA., Bourdon C., et al. Intravenous magnesium sulfate treatment for acute asthma in the emergency department: A systematic review of the literature. Annals of Emergency Medicine. 2000; 36 (3): 181-190.
  20. Rodrigo GJ., Pollack CV, Rodrigo C, Rowe BH. Heliox for non-intubated acute asthma patients. Cochrane Database of Systematic Reviews 2006, Issue 4. Art. No.: CD002884. DOI: 10.1002/14651858.CD002884.pub2
  21. Browne GJ., Penna AS. Randomised trial of intravenous salbutamol in early management of acute severe asthma in children. Lancet. 1997; 349 (9048): 301-305.
  22. Browne, G.J., & Lam, L.T. Single-dose intravenous salbutamol bolus for managing children with acute severe asthma in the emergency department: Re-analysis of data. Pediatric Critical Care Medicine. 2002; 3 (2): 117-123.
  23. Browne GJ., Trieu L., Van Asperen P. Randomized, double-blind, placebo-controlled trial of intravenous salbutamol and nebulized ipratropium bromide in early management of severe acute asthma in children presenting to an emergency department. Critical Care Medicine. 2002; 30 (2): 448-453.
  24. Watts K, Chavasse RJPG. Leukotriene receptor antagonists in addition to usual care for acute asthma in adults and children. Cochrane Database of Systematic Reviews 2012, Issue 5. Art. No.: CD006100.
  25. Starkey ES, Mulla H, Sammons HM, Pandya HC. Intravenous salbutamol for childhood asthma: evidence-based medicine? Arch dis child 2014;99:873-877
  26. Shann F: Dose of intravenous infusions of terbutaline and salbutamol. Crit Care Med 2000; 28: 2179-2180
  27. Shann, F. Intravenous Salbutamol. Pediatric Critical Care Medicine. 4(1):128, January 2003
  28. Mitra AAD., Bassler D., Watts K., et al. Intravenous aminophylline for acute severe asthma in children over two years receiving inhaled bronchodilators (Review).Cochrane Database of Systematic Reviews. 2005; Issue 2, Art No:CD001276.
  29. Deis JN., Estrade CM., Abramo TJ. Noninvasive ventilation techniques in the emergency department: Applications in pediatric patients. Pediatric Emergency Medicine Practice. 2009; 6 (6): 1-18.

Guideline approval

Guideline approval history
Document ID CHQ-GDL-60002 Version no. 2.0 Approval date 26/09/2019
Executive sponsor Executive Director Medical Services Effective date 26/09/2019
Author/custodian Statewide Emergency Care Children Working Group Review date 26/09/2022
Supersedes 1.0
Applicable to Queensland Health medical and nursing staff
Document source Internal (QHEPS) + External
Authorisation Executive Director Clinical Services (QCH)
Keywords Asthma, Wheeze, Emergency, 00700, paediatric, guideline, children, CHQ-GDL060002
Accreditation references NSQHS Standard: 1, 4, 8

Disclaimer

This guideline is intended as a guide and provided for information purposes only. View full disclaimer.
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