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