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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 > 5 years with additional medications given in more severe cases.
  • A wheezing illness in children < 5 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 therapy.

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 1 to 5 years who present with a wheezing illness may is outlined in the Pre-school Wheeze Emergency Management in Children.

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 Statewide Emergency Care of Children Working Group in partnership with the Queensland Emergency Department Strategic Advisory Panel and the Healthcare Improvement Unit, Clinical Excellence Division.

Introduction

Asthma is a chronic inflammatory disorder of the airways involving reversible airway obstruction. It is estimated to affect 1 in 6 Australian children.1 Asthma is one of the most common paediatric ED presentations accounting for approximately 3.5% of ED presentations in Australia and New Zealand.2

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 asthmatic 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.

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 not present 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> 94% SpO2 90 – 94% SpO2 < 90% SpO2 < 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 of acute asthma include:

  • inhaled foreign body
  • gastro-oesophageal reflux
  • diabetic ketoacidosis
  • pneumonia
  • croup
  • anaphylaxis

Investigations

Investigations (such as chest X-ray, blood gas analysis and serum electrolytes) are not routinely required in a child with acute asthma.5 They may be considered in specific situations such as life-threatening asthma or the child with severe asthma who is not responding to treatment.5

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. A spacer should always be used with a MDI.

Inhaled salbutamol dosing for the treatment of asthma in children
MDI * 100mcg < 20 kg: 6 puffs >20kg: 12 puffs
Nebulised < 20 kg: 2.5mg >20kg: 5mg
Salbutamol burst Administer 3 doses as above at 20-minute intervals
Continuous nebulised salbutamol Neat salbutamol nebuliser solution (5mg/mL), replenish where reservoir empty

* Always use via spacer. Use mask also if unable to form a reliable seal on spacer

MDI and spacer vs nebuliser

  • Both modes of administration are equally effective for acute asthma symptoms.
  • 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 1 puff at a time into the spacer.
  • The medication is cleared from the spacer by the child taking 5 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 ie. 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 used to treat the airway oedema and increased mucous production associated with the inflammation in acute asthma.7

Corticosteroid therapy is recommended for moderate-to-severe acute asthma episode, or if there is incomplete response to inhaled beta2-agonists.8 A Cochrane review reported that hospital admission rates for children with acute asthma were significantly reduced for those who received corticosteroids within 1 hour of ED presentation.9 Oral corticosteroid treatment is particularly effective in children and has minimal side effects.9 Maximum benefit occurs within 4 to 6 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 (PO) Day 1: 2mg/kg (max 50mg)

Day 2 and 3: 1mg/kg

Can extend course to 5 days if still symptomatic after 3-day course

Hydrocortisone (IV) 4mg/kg (max 200mg), 6 hourly
OR
Methylprednisolone (IV)
Initial loading dose: 2mg/kg (max 60mg)

Then:

Day 1: 1mg/kg 6 hourly

Day 2: 1mg/kg 12 hourly

Day 3 onwards: 1mg/kg daily

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)

Anticholinergics may be useful in combination with inhaled beta2-agonists 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

A number of studies show that combined ipratropium bromide and salbutamol therapy is superior to salbutamol therapy alone.12-15 There is good evidence to suggest that its use with salbutamol in the first 2 hours (ideally given with the first 3 doses) of treatment is safe and results in  a significant improvement in the peak expiratory flow rate, ultimately decreasing hospitalisation rates.16 The benefits of ipratropium bromide are more apparent in the more severe presentations or those that have not had a response to inhaled salbutamol alone.5

Ipratropium (INH) dosing for treatment of asthma in children
< 6 years 4 puffs OR 250 mcg nebulised every 20 minutes x 3 doses

Then 2 puffs (42 mcg) 6 hourly

> 6 years 8 puffs OR 500 mcg nebulised every 20 minutes x 3 doses

Then 4 puffs (84 mcg) 6 hourly

Magnesium sulphate

  • Seek senior emergency/paediatric advice as per local escalation protocols for children requiring magnesium sulphate. Consider seeking paediatric critical care input (onsite or via RSQ).

Magnesium sulphate IV should be considered 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 for treating 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 Magnesium 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 over 20 minutes

(max 10 mmol = equivalent to 2,500mg)

Side effects Usually minor, including:

  • epigastric or facial warmth and flushing
  • pain and/or numbness at infusion site
  • dry mouth
  • malaise

Severe reactions include allergy, hypotension, respiratory depression and circulatory collapse.

Monitoring Full cardiac monitoring with blood pressure every 5 minutes.

Cease infusion if hypotension persists.

Monitor knee reflexes if repeating doses to assess for magnesium toxicity which can result in respiratory failure. Magnesium should be ceased/no further doses given if reflexes are absent.

  • ALERT – Magnesium should always be prescribed in mmols and administered using safety software syringe drivers to avoid medication errors.

Magnesium sulphate should be administered 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 0.2mmol/kg = 2 mmol. This translates to 4ml of 0.5 mmol/ml solution, and must be administered through a safety software syringe driver over 10 to 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. Near or complete airway obstruction may be present in life-threatening asthma and 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 e.g. 5 micrograms/kg/minute for the first hour, then 1–2 micrograms/kg/minute until symptoms improve.25-27

Salbutamol (IV) dosing for the treatment of asthma in children
Bolus dose 100mcg/kg infused over 20 minutes
(max 5 milligrams)
Infusion 1 -10 mcg/kg/min (max weight 50kg)
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 PICU to manage children with severe asthma unresponsive to maximum doses of bronchodilators and steroids. Aminophylline improves lung function within 6 hours of treatment, however there is limited improvement in symptoms, number of treatments and 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)

  • Contact paediatric critical care specialists (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 SaO2 > 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 the intubation is underway in children with a deteriorating level of consciouness.25 

Potential concerns have been raised regarding the use of HFNC therapy. Follow local policies and procedures.

For CHQ staff, in accordance with CHQ HFNC therapy protocols, the child:

  • should be nursed at an appropriate (1:1 or 1:2) nurse to patient ratio
  • should be in an acute area such as a resuscitation room with continuous oximetry and ECG monitoring
  • must have vascular access secured
  • must remain nil by mouth with consideration given to the placement of a nasogastric tube to prevent gastric insufflation.
  • Contact paediatric critical care specialists (onsite or via RSQ) prior to intubation and ventilation.

When to escalate care

Follow your local facility escalation protocols for children of concern. Transfer is recommended if the child requires care beyond the level of comfort of the treating hospital. Clinicians can contact the services outlined below to escalate the care of a paediatric patient.

Service Reason for contact by clinician Contact
Local Paediatric service For specialist paediatric advice and assistance with local transfers as per local arrangements. As per local arrangements
Children’s Advice and Transport Coordination Hub (CATCH) For access to specialist paediatric advice and assistance with inter-hospital transfer of non-critical patients into and out of Queensland Children’s Hospital.

For assistance with decision making regarding safe and appropriate inter-hospital transfer of children in Queensland.

For QH staff, click here for further information including the QH Inter-hospital transfer request form (access via intranet).

(07) 3068 4510
24 hours
CATCH website
Telehealth Emergency Management Support Unit (TEMSU) For access to generalist and specialist acute support and advice via videoconferencing, as per locally agreed pathways, in regional, rural and remote areas in Queensland.

For QH staff, click here for further information (access via intranet).

TEMSU QHEPS website

24 hours

Retrieval Services Queensland (RSQ) For access to telehealth support for, and to notify of, critically unwell patients requiring retrieval in Queensland.

For any patients potentially requiring aeromedical retrieval or transfer in Queensland.

For QH staff, click here for further information and relevant forms (access via intranet).

RSQ QHEPS website

24 hours

Disposition

When to consider discharge

Discharge can be considered for a child who

  • can maintain SpO2 ≥ 93% in room air
  • is not tachypnoeic
  • no/mild work of breathing
  • good air entry with minimal wheeze
  • clinically stable on 3rd hourly bronchodilator
  • has a parent/caregiver who can safely manage the child at home, return in event of deterioration and access further medication

Patients who are at high risk for deterioration with more severe disease or inadequate management in the community should be considered for a period of longer short stay or inpatient observation despite looking well. This includes:

  • those with previous PICU admission
  • non-English-speaking background
  • families living > 30 minutes from a local hospital
  • 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 (QH staff only) 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 if:

  • severe illness – defined as respiratory distress, failure to respond to initial bronchodilator and steroids or requiring oxygen
  • unable to stretch bronchodilators and discharge by 4 hours

Despite meeting the clinical discharge criteria admission may be considered for the following patients:

  • high risk including those with past PICU admission or previous sudden deterioration
  • social issues including those who are geographically isolated from a hospital or have family issues affecting the ability to provide care at home

Facilities with a Short Stay Unit (SSU)

Consider admission to an SSU if:

  • symptoms occur within 1-2 hours of initial treatment with bronchodilator/steroids AND
  • no further investigations are required

Children who require bronchodilator therapy more frequently than 1 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 protocols
When to consider admission to inpatient ward from SSU

Local protocols 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 3rd hourly after 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].  Available from:  http://www.nationalasthma.org.au/cms/images/stories/amh2006_web_5.pdf
  2. Acworth J., Babl F., Borland M., et al. Patterns of presentations to the Australian and New Zealand paediatric emergency research network.  Emergency Medicine Australasia.  2009; 21 (1): 59-66.
  3. Mannix R., Bachur R. Status asthmaticus in children.  Current Opinion in Pediatrics.  2007; 19 (3): 281-287.
  4. Lugogo NJ., MacIntyre NR. Life-threatening asthma:  Pathophysiology and management.  Respiratory Care.  53 (6): 726-739.
  5. 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:  http://www.britthoracic.org.uk/Portals/0/Clinical%20Information/Asthma/Guidelines/sign101%20revised%20June%2009.pdf
  6. BTS/SIGN British Guidelines on the management of asthma. Oct 2014
    https://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]. Available from: 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. DOI: 10.1002/14651858.CD003898.pub5
  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. DOI: 10.1002/14651858.CD006100.pub2
  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.
  30. Boyd M, Lasserson TJ, McKean MC, Gibson PG, Ducharme FM, Haby M. Interventions for educating children who are at risk of asthma-related emergency department attendance. Cochrane Database of Systematic Reviews 2009, Issue 2. Art. No.: CD001290. DOI: 10.1002/14651858.CD001290.pub2

Guideline approval

Guideline approval history
Document ID CHQ-GDL-60002 Version no. 1.0 Approval date 13/8/18
Executive sponsor Executive Director Medical Services Effective date 13/8/18
Author/custodian Statewide Emergency Care Children Working Group Review date 13/8/21
Supersedes CHQ-GDL-00700 (CHQ Asthma Guideline)
Applicable to Queensland Health medical and nursing staff
Authorisation Executive Director Clinical Services QCH
Keywords Asthma, Wheeze, Emergency, 00700, paediatric, guideline, 600002
Accreditation references NSQHS Standard: 1,4,9

Disclaimer

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