High flow oxygen via face mask
Salbutamol 5 mg or terbutaline 10 mg via an oxygen driven nebuliser (half doses in very young children)
Prednisolone 1-2 mg/kg body weight orally (maximum 40 mg)
IF LIFE THREATENING FEATURES ARE PRESENT
Give intravenous aminophylline 5 mg/kg over 20 minutes followed by maintenance infusion 1 mg/kg/h; omit the loading dose if child already receiving oral theophyllines
Give intravenous hydrocortisone 100 mg 6 hourly
Add ipratropium 0.25 mg to nebulised B agonist (0.125 mg in very young children)
Pulse oximetry is helpful in assessing response to treatment. An Sao292% may indicat the need for chest radiography
2 Subsequent management
IF PATINT IS IMPROVING CONTINUE
High flow oxygen
Prednisolone 1-2 mg/kg daily (maximum 4 mg/day)
Nebulised B agonist 4 hourly
IF PATIENT IS NOT IMPROVING AFTER 15-30 MINUTES
Continue oxygen and steroids
Give nebulised B agonist more frequently up to every 30 minutes
Add ipratropium to nebuliser and repeat 6 hourly until improvement starts
IF PATIENT IS STILL NOT IMPROVING GIVE
Aminophylline infusion (1 mg/kg/h; monitor blood concentrations if continued for over 24 hours
3 Monitoring treatment
Repeat PEF measurement 15-30 minutes after starting treatment (if appropriate)
Oximetry: maintain Sao2 > 92%
Chart PEF if appropriate before and after the child inhales B agonists and at least 4 times daily throughout hospital stay
4 Transfer to the intensive care unit accompanied by a doctor prepared to intubate if there is:
Deteriorating PEF worsening or persisting hypoxia or hypercapnia
Exhaustion feeble respirations confusion or drowsiness
Coma or respiratory arrest
5 When discharged from hospital patients should have:
Been on discharge medication for 24 hours and have had inhaler technique checked and recorded
If recorded PEF diurnal variability < 25%
Treatment with soluble steroid tablets and inhaled steroids in addition to bronchodilators
Own PEF meter and if appropriate self management plan or written instructions for parents
GP follow up arranged within 1 week
Follow up appointment in clinic within 4 weeks