Pregnancy
gWomen with asthma should be closely monitored
during pregnancy. It is particularly important that asthma be
well controlled during pregnancy; when this is achieved
there is little or no increased risk of adverse maternal or fetal
complications.
Women should be counselled about the importance and
safety of taking their asthma medication during pregnancy
to maintain good control. Women who smoke should be
advised about the dangers to themselves and to their baby
and be offered appropriate support to stop smoking.
Short-acting beta 2 agonists, LABAs, oral and inhaled
corticosteroids, sodium cromoglicate p. 167 and nedocromil
sodium p. 167 , and oral and intravenous theophylline p. 169
(with appropriate monitoring) can be used as normal during
pregnancy. There is limited information on use of a
leukotriene receptor antagonist during pregnancy, however,
where indicated to achieve adequate control, they should not
be withheld.hUseful Resources
Asthma: diagnosis, monitoring and chronic asthma
management. National Institute for Health and Care
Excellence. NICE guideline 80. November 2017.
http://www.nice.org.uk/guidance/ng 80
British guideline on the management of asthma. British
Thoracic Society and Scottish Intercollegiate Guidelines
Network. Full guidance - A national clinical guideline 153.
September 2016.
http://www.sign.ac.uk/assets/sign 153 .pdfAsthma, acute 30-Nov-2016
Child over 2 years
Levels of severity
The nature of treatment required for the management of
acute asthma depends on the level of severity, described as
follows:
Moderate acute asthma
.Able to talk in sentences
.Arterial oxygen saturation (SpO 2 ) 92 %
.Peakflow 50 % best or predicted
.Heart rate 140 /minute in children aged 2 – 5 years; heart
rate 125 /minute in children over 5 years
.Respiratory rate 40 /minute in children aged 2 – 5 years;
respiratory rate 30 /minute in children over 5 years
Severe acute asthma
.Can’t complete sentences in one breath or too breathless
to talk or feed
.SpO 2 < 92 %
.Peakflow 33 – 50 % best or predicted
.Heart rate> 140 /minute in children aged 2 – 5 years; heart
rate> 125 /minute in children aged over 5 years
.Respiratory rate> 40 /minute in children aged 2 – 5 years;
respiratory rate> 30 /minute in children aged over 5 years
Life-threatening acute asthma
Any one of the following in a child with severe asthma:
.SpO 2 < 92 %
.Peakflow< 33 % best or predicted
.Silent chest
.Cyanosis
.Poor respiratory effort
.Hypotension
.Exhaustion
.Confusion
Management
gFollowing initial assessment, supplementary highflow
oxygen should be given to all children with life-threateningacute asthma or SpO 2 < 94 % to achieve normal saturations of
94 – 98 %.
First-line treatment for acute asthma is an inhaled short-
acting beta 2 agonist (salbutamol p.^156 or terbutaline sulfate
p. 158 ) given as soon as possible, ideally via a metered dose
inhaler and spacer device in mild to moderate acute asthma.
Children with severe or life-threatening acute asthma should
be transferred to hospital urgently.
In all cases of acute asthma, children should be prescribed
an adequate once daily dose of oral prednisolone p. 442.
Treatment for up to 3 days is usually sufficient, but the
length of course should be tailored to the number of days
necessary to bring about recovery. Intravenous
hydrocortisone p. 440 should be reserved for severely
affected children who are unable to retain oral medication.
Nebulised ipratropium bromide p. 153 can be combined
with beta 2 agonist treatment for children with severe or life-
threatening acute asthma or in those with a poor initial
response to beta 2 agonist therapy to provide greater
bronchodilation. Consider adding magnesium sulfate p. 597
to nebulised salbutamol and ipratropium bromide in thefirst
hour in children with a short duration of acute severe asthma
symptoms presenting with an oxygen saturation less than
92 %.
Children with continuing severe asthma despite frequent
nebulised beta 2 agonists and ipratropium bromide plus oral
corticosteroids, and those with life-threatening features,
need urgent review by a specialist with a view to transfer to a
high dependency unit or paediatric intensive care unit
(PICU) to receive second-line intravenous therapies.
In a severe asthma attack where the child has not
responded to initial inhaled therapy, early addition of a
single bolus dose of intravenous salbutamol may be an
option. Continuous intravenous infusion of salbutamol,
administered under specialist supervision with continuous
ECG and electrolyte monitoring, should be considered in
patients with unreliable inhalation or severe refractory
asthma. Aminophylline p. 167 may be considered in children
with severe or life-threatening acute asthma unresponsive to
maximal doses of bronchodilators and corticosteroids.
Aminophylline is not recommended in children with mild to
moderate acute asthma. Intravenous magnesium sulfate has
been used for acute asthma [unlicensed use] although its
place in management is not yet established.hChild under 2 years
gInhaled short-acting beta 2 agonists are the initial
treatment of choice for acute asthma in children under
2 years. For mild to moderate acute asthma attacks, a
metered-dose inhaler with a spacer and mask is the optimal
drug delivery device. In a hospital setting, consider oral
prednisolone daily for up to 3 days, early in the management
of severe asthma attacks. For more severe symptoms,
inhaled ipratropium bromide in combination with an inhaled
beta 2 agonist is also an option.hFollow up in all cases
gEpisodes of acute asthma may be a failure of
preventative therapy, review is required to prevent further
episodes. A careful history should be taken to establish the
reason for the asthma attack. Inhaler technique should be
checked and regular treatment should be reviewed. Children
and their carers should be given a written asthma action plan
aimed at preventing relapse, optimising treatment, and
preventing delay in seeking assistance in future attacks. It is
essential that the child’s GP practice is informed within
24 hours of discharge from the emergency department or
hospital following an asthma attack. Children who have had
a near-fatal asthma attack should be kept under specialist
supervision indefinitely. A respiratory specialist should
follow up all patients admitted with a severe asthma attack
for at least one year after the admission.h150 Airways disease, obstructive BNFC 2018 – 2019
Respiratory system3