Clinical Assessment Tool - Children over 2 with acute asthma and ...

Out of Hospital Clinical Assessment Tool for ChildrenAged Over 2 years with Acute Asthma and WheezeChild presenting with cough, wheeze and difficulty breathing:Any of the following may indicate diagnoses otherthan asthma or viral induced wheeze:• Fever >38.5 O C• Inspiratory stridor• Excessive vomiting• Asymmetrical findings on auscultation• Possibility of foreign body aspiration• Possibility of anaphylaxisConsider referral to the appropriate specialtyThese children are at increased risk ofdeterioration in acute asthma and wheeze:• Attack in late afternoon, at night or early morning• Recent admission or previous severe attack• Poorly controlled interval symptoms• Already taking oral steroids• Significant co-morbidity• Social needs that make care at home difficultChildren with all of the following canbe managed safely at home:Children with any of the following signs or symptoms need furtherassessment:Alert, active Altered response to social cues Unable to rousePink in airCyanosedAble to talk in sentences Too breathless to talk or feed Poor respiratory effortNo or mild increased work of breathing Much increased work of breathing ExhaustionResp rate: ≤40/min aged 2-5 years≤ 30/min over 5 yearsHeart rate: ≤140 aged 2-5 years≤ 125 over 5 yearsNo risk factors for deteriorationResp rate: >40/min aged 2-5 years> 30/min over 5 yearsHeart rate: >140 aged 2-5 years> 125 over 5 yearsRisk factors for deteriorationAgitation or confusionSilent chest on auscultationMild to moderate exacerbation• Give 2-10 puffs of inhaled salbutamolvia a spacer device +/- face mask• Increase by 2 puffs every 2 minutes upto 10 puffs according to responseIf goodresponse andall greenIf poor response,consider if nowamber or redSafe to be managed at home• Advise to keep using inhaledsalbutamol via spacer 2-10 puffs asneeded – not exceeding 4 hrly• Review inhaler technique• Consider prednisolone for 3 days(most effective in children over 5 oryounger children with atopy)• Give personalised asthmamanagement advice leaflet e.g.www.asthma.org.uk• Discuss how to recognise signs ofdeterioration and how to seek help• Arrange review within 48 hoursModerate to severe exacerbationNeeds further assessment andtreatment• Give oxygen if available• Give 10 puffs salbutamol viaspacer device OR nebulisedsalbutamol driven by oxygen (box2)• Give soluble prednisolone (box 3)If improvingafter 15 minsIf not improvingafter 15 minsRefer to paediatrics and ask toattend A&E straight away, or call999 if indicatedLife threatening exacerbation• Give high flow oxygen if available• Call 999 for urgent transfer tohospital• Give nebulised salbutamol PLUSAtrovent driven by oxygen (box 2)• Give soluble prednisolone if ableto swallow (box 3)• Give nebulised salbutamol every15 mins as needed• Stay with the child until LAS arriveContact numbers:QH: paediatric consultant DECT 6134KGH: paediatric registrar bleep 8384Date: October 2012 Review date: October 2014Authors: Dr S Wong, Dr L Etheridge and Dr Z Rooney, department of paediatrics, BHRUTThis guideline has been written based on the BTS and SIGN guideline for the management of asthma

Out of Hospital Clinical Assessment Tool for ChildrenAged Over 2 years with Acute Asthma and WheezeBox 1: Normal Paediatric Values:Age Resp Rate Heart Rate 12 yr 15 – 20 60 - 100Box 2: Guidelines for use of bronchodilatorsInhaled β 2 agonists are the first line treatment for acute asthma and wheeze, except in life threateningcases• Salbutamol: up to 10 puffs of a metered dose inhaler (MDI) via a spacer device can be safelygiven, up to 4 hourly. MDIs should never be given directly into the mouth in children. Childrenunder 3 years will need a face mask connected to the mouthpiece of the spacer. After each puffof the MDI allow the child to take 5 breaths and then repeat.Oxygen driven nebulised bronchodilators should be used in children with red features (life threateningcases), those who cannot tolerate a spacer device, or who are worsening despite inhaled treatment• Salbutamol: dose 2-5 years give 2.5mg, over 5 years give 5mg• Ipratropium: dose under 12 years give 250micrograms, 12-16 years give 500microgramsBox 3: Guidelines for oral corticosteroids• Give soluble prednisolone by mouth once daily for 3 days• Dose is 20mg for children aged 2-5 years and 30-40mg for children aged 5-16 years• If the child has already been taking an oral corticosteroid for more than a few days then increasethe dose to 2mg/kg (max 60mg) for the time needed to bring about recovery• Weaning is unnecessary unless the length of steroid treatment exceeds 14 days• Children can continue with their usual maintenance inhaled steroids while taking oral steroids• There is limited evidence for the benefit of steroids in pre-school children with simple viral inducedwheeze and there are potential side effectsBox 4: Guidelines for using peak expiratory flow rate (PEF) in the assessment of acute asthmaMeasurement of PEFR can help guide assessment of the severity of exacerbations in children overthe age of 5 years who are able to perform a PEFR. Take the best of 3 measurements.• PEFR >50% predicted = green (mild to moderate)• PEFR 33-5-% predicted = amber (moderate to severe)• PEFR