LRI Children s Hospital

LRI Children s Hospital Asthma Management in Children On-going Care after Admission to Ward Staff relevant to: Medical & Nursing staff providing asthma management care to Children within UHL Children s Hospital Team approval date: November 2018 Version: 2 Revision due: November 2021 Written by: Reviewed by: H Kulkarni, H Pandya, E Gaillard D Lo Trust Ref: C148/2016 1. Introduction and Who Guideline applies to This guideline is intended for those children who are thought to have asthma causing acute wheeze. This guideline is based on BTS/SIGN guidelines on asthma management. The initial management acute exacerbation of asthma could be based on the SOP for Management of Wheeze and Asthma in Children approved by Emergency department UHL NHS trust via the policy & guideline library Trust ref: C135/2016 http://insitetogether.xuhltr.nhs.uk/pag/pagdocuments/asthma%20uhl%20paediatric%20emergency%20depar tment%20guideline.pdf British guideline on the management of Acute asthma (BTS/SIGN) (Please refer to the Quick reference Guide: Pages 17, 18) URL: https://www.brit-thoracic.org.uk/document-library/clinical-information/asthma/btssignasthma-guideline-quick-reference-guide-2016/ For the full BTS/SIGN guideline on and Chronic Asthma management URL: https://www. b rit -thoracic.or g.uk /document -librar y/clin icalinf ormation/asthma/btssig n -asthma-guideline-2016/ (please refer to Pages 102 to 112 for Acute Management) (If links do not open directly, please copy-paste to Google Chrome) Page 1 of 15

Discharge care bundle (see appendix 6): Ensure that ALL aspects of the patient s asthma care are considered by completing the bundle at the time of discharge for ALL patients with asthma exacerbations.url: https://www.brit thoracic.org.uk/document library/audit andquality improvement/asthma care bundle 2016/annex 1 bts asthma discharge carebundle/ 2. HISTORY: Children with asthma may suffer from a variety of symptoms, none of which is specific for asthma. The common symptoms include cough, wheeze, shortness of breath, chest tightness, exercise induced cough/wheeze, nocturnal cough/wheeze. The hallmark of asthma is that these symptoms tend to be: variable, intermittent, worse at night, provoked by triggers including exercise. The diagnosis of asthma is based on the recognition of a characteristic pattern of symptoms and signs and the absence of an alternative explanation for them. The key is to take a careful clinical history. Additional information which may contribute towards a clinical suspicion of asthma includes: Personal or family history of asthma or other atopic condition (eczema, allergic rhinitis), previous episode of bronchiolitis Worsening of symptoms after exposure to recognised triggers such as pollens, dust, feathered or furry animals, exercise, viral infections, chemicals, and environmental tobacco smoke Background asthma history: Regular asthma medication and frequency of preventer use when well Previous A&E and GP attendances Previous hospital and ITU admissions Frequency of and last course of oral steroids Social Impact (days of school/ day care etc.) Patients at risk of severe asthma: Previous near fatal asthma Previous admissions for asthma especially in the last year Patients requiring three or more classes of asthma medications Increased use of Beta 2 agonist Repeated attendances at A/E for asthma especially in the last year Brittle asthma On admission to HDU/ CICU/wards, the following clinical signs should be recorded: Pulse rate, Respiratory rate and degree of breathlessness, Use of accessory muscles of respiration, Amount of wheezing, Breath sounds: danger signs unequal air entry/silent chest!!! Degree of agitation and consciousness, BP, Oxygen saturations in air Page 2 of 15

Some children with acute severe asthma do not appear distressed. Clinical signs can correlate poorly with the severity of airways obstruction. Chest X rays rarely provide additional useful information and are not routinely indicated. A chest X ray should be performed if there is subcutaneous emphysema, persisting unilateral signs suggesting pneumothorax, lobar collapse or consolidation and/or life threatening asthma not responding to treatment. Table 1: Algorithm for Asthma Management after admission to Childrens hospital >2yrs ASSESS RESPONSE TO INITIAL TREATMENT Record RR, HR, severity of respiratory distress and oxygen saturation every 1 4 hours Children aged 5 years or older presenting with a severe or life threatening acute exacerbation of asthma should receive steroids within 1 hour of presentation (NICE Asthma QS25 no 8) See appendix 1 for steroid doses RESPONDING Continue bronchodilators 1 4 hours & PRN If the patient has been on nebulised salbutamol, they can be switched to pmdi and spacer treatment as tolerated once maintaining their oxygen saturations 92% in air See appendix 1 and 2 for duration of steroids At discharge NOT RESPONDING Back to back O 2 driven nebulised Salbutamol and Ipratropium are first choice Treatments (See Appendix 1) Continue Nebs if showing clinical improvement If still no improvement: Arrange urgent senior review (ST4+) Obtain IV access Send UE, FBC, CRP, Bone, Mg, cap gas Ensure IV Hydrocortisone 4mg/kg given Oxygen via close fitting face mask or nasal prongs to achieve normal saturation. Discharge when stable on 4 hourly inhaled treatment that can be continued at home, and maintaining oxygen saturations 92% in air BTS guidance would also recommend that PEF and/or FEV1 should be >75% of best or predicted at discharge SEE DISCHARGE CHECK LIST (APPENDIX 6) Consider (after discussion with senior): Chest x ray and cap gas IV salbutamol 15 mcg/kg bolus (max 250 micrograms) over 10 minutes followed by continuous infusion (Appendix 1) Salbutamol bolus can be omitted if already given in ED within last 24 hours Bolus IV injection of Magnesium sulphate 40mg/kg (max 2g) over 20 minutes (Appendix 3) Aminophylline if unresponsive to maximal doses of bronchodilators plus steroids (Appendix 1) Arrange HDU/CICU transfer Review patient regularly to assess response to therapy and aim to discontinue intravenous drugs as soon as clinically possible Page 3 of 15

Table 2: Management of acute asthma in children aged < 2 years These guidelines are intended for those who are thought to have asthma causing acute wheeze and should not be used as a guide for treating acute bronchiolitis. ASSESS ASTHMA SEVERITY NB: If a patient has signs and symptoms across categories, always treat according to their most severe features Moderate Sp02 > 92%, Audible wheezing Using accessory muscles, Still feeding Most infants are audibly wheezy with intercostal recession but not distressed Give trial of Salbutamol up to 10 puffs via spacer & face mask or Nebulised Salbutamol 2.5 mg. Repeat every 1 4 hours if responding If poor response: Add nebulised ipratropium 250 micrograms Consider: Oral steroids At discharge Discharge when stable on 4 hourly inhaled treatment that can be continued at home, and maintaining oxygen saturations 92% in air SEE DISCHARGE CHECK LIST (APPENDIX 6) Severe Sp02 <92%, Marked respiratory distress, Too breathless to feed, Cyanosis Earlier recognition and management of potential respiratory failure. Assess A B C D, continuous close monitoring. Follow APLS algorithm. Blood gas. Site 2 peripheral lines Send UE, FBC, CRP, Bone, Mg, blood gas Consider chest x ray Oxygen via close fitting face mask or nasal prongs to achieve normal saturations. Neb salbutamol 2.5 mg and Neb Ipratropium Bromide 250 micrograms. Repeat 3 4 back to back nebs. Continue Nebs if showing clinical improvement If no response, consider IV Salbutamol 5mcg/kg bolus (Max 250 micrograms) over 10 min followed by continuous intravenous infusion (see Appendix 1) IV Hydrocortisone (4mg/kg) initially and change to Oral Prednisolone when stable. Arrange HDU/CICU transfer HR, RR, pulse oximetry, supportive nursing care with adequate hydration. If not responding or any life threatening features, discuss with on call Consultant and CICU team Page 4 of 15

3. Education and Training No further training is required to implement this guideline. 4. Monitoring Compliance What will be measured to monitor compliance Completion of discharge bundle for each child admitted with an asthma attack Proportion of children presenting with an asthma attack to receive oral corticosteroids within one hour of presentation Proportion of children who received intravenous bronchodilator to have been given back-to-back nebulisers first How will compliance be monitored As part of BTS asthma audit As part of BTS asthma audit As part of BTS asthma audit Monitoring Lead D Lo/E Gaillard D Lo/E Gaillard D Lo/E Gaillard Frequency Annual Annual Annual Reporting arrangements Central national/regional database results reported at local departmental audit meetings 5. Supporting References 1. BTS/SIGN guidelines on management of Acute asthma in children: (http://www.britthoracic.org.uk/guidelines/asthma guidelines.aspx) 2. Carroll CL, Schramm CM: Noninvasive positive pressure ventilation for the treatment of status asthmaticus in children. Ann Allergy Asthma Immunol 2006, 96(3):454 459. 3. Levine DA: Novel therapies for children with severe asthma. Curr Opin Pediatr 2008, 20:261 4. Global Intitiave for Asthma. Revision. 2009 (http://www.nhlbi.nih.gov/guidelines/asthma/asthsumm.pdf ) 5. http://www.medicinesforchildren.org.uk/search for a leaflet/prednisolone for asthma/ 6. NICE Asthma Quality standard (QS25), February 2013 (http://guidance.nice.org.uk/qs25) 6. Key Words Asthma, Acute wheeze, Bronchodilators, Salbutamol, Nebuliser, Inhaler Guideline Lead (Name and Title) Lorraine Taylor - Clinical Risk & Quality Standards RM CONTACT AND REVIEW DETAILS Executive Lead Chief Nurse UHL Page 5 of 15

Details of Changes made during review: Reviewed by D Lo - Consultant Adapted from Asthma Guideline, Policy No. C124/2006, UHL NHS Trust Updated WEB addresses and links Table 1: Added Under responding to treatment - maintaining their oxygen saturations 92% in air Discharge when stable on 4 hourly inhaled treatment that can be continued at home. BTS guidance would also recommend that PEF and/or FEV1 should be >75% of best or predicted at discharge Removed Oral prednisolone dosing from table Added - Under Not responding to treatment Arrange urgent senior review (ST4+) Obtain IV access instead of site 2 peripheral lines Consider (after discussion with senior) Salbutamol bolus can be omitted if already given in ED within last 24 hours Removed reference to maintenance of IV fluids and Aminophylline dosing Table 2: Under moderate - Changed consider prednisolone to consider steroids. Added discharge when stable on 4 hourly inhaled treatment that can be continued at home, and maintaining oxygen saturations 92% in air. Added Monitoring compliance Appendix 1 - Added side effects to IV salbutamol Changed frequency of Ipatropium Bromide nebulisers from every 20 to 30 minutes to 20 minutes Added dosing of dexamethasone Added in children who were commenced on IV hydrocortisone (regardless of whether they received oral dexamethasone or prednisolone beforehand) due to clinical need, switch to oral prednisolone at 1mg/kg/day once they are ready to come off IV medications for a 3 to 5 day course Added Appendix 2: Continuing Oral Corticosteroids after First Dose of Dexamethasone Page 6 of 15

APPENDIX 1: MEDICATIONS IN ACUTE ASTHMA Salbutamol i. Salbutamol inhaler up to 10 puffs pmdi + spacer is the preferred option in mild to moderate asthma. Children aged <3 years are likely to require a face mask connected to the mouthpiece of a volumatic spacer for successful drug delivery. Inhalers should be actuated into the spacer in individual puffs and inhaled immediately by tidal breathing for minimum five breaths. ii. Salbutamol nebuliser driven by oxygen < 2yrs; 2.5mg, >2yrs; 2.5 5mg Doses can be repeated every 20 30 minutes. Continuous nebulised β2 agonists are of no greater benefit than the use of frequent intermittent doses in the same total hourly dosage. If there is poor response to the initial dose of β2 agonists, subsequent doses should be given in combination with nebulised ipratropium bromide. iii. IV Salbutamol requires close monitoring of HR, RR, BP, ECG, Electrolytes, saturations and neurological status. Side effects Common: arrhythmias; dizziness; headache; hypokalaemia (with high doses); nausea; palpitations; tremors; and lactic acidosis (which may worsen tachypnoea) Loading dose: 5mcg/kg bolus over 10 min for children < 2 years. If >2 years of age, 15 micrograms/kg (max. 250 micrograms) as a single loading dose over 10 min. Followed by continuous intravenous infusion: 1 5 micrograms/kg/min for both age groups Note: After 2 micrograms/kg/min, the infusion rate MUST be increased gradually with close monitoring of RR, HR, BP, ECG, oxygen sats and neurological status. The HDU/PICU team must be informed if a patient needs more than 2 micrograms/kg/min infusion rate. Nebulised bronchodilators should be continued while the patient is receiving intravenous bronchodilators. For Initial bolus dose: Dilute to 50micrograms/ml Dilute 1mg (1ml) to 20ml with sodium chloride 0.9% to give 50micrograms/ml. Administer calculated dose over 10 minutes. Flush with sodium chloride 0.9%. For Continuous Intravenous infusion: Dilute to 200micrograms/ml Patient s Weight Up to 10kg Dilution to prepare 20mg in 100ml Bag size 100ml to bag Volume to remove from bag before adding salbutamol 20ml 10 25kg 50mg in 250ml 250ml bag 50ml > 25kg 100mg in 500ml 500ml bag 100ml Rates: At a concentration of 200microgram/ml Page 7 of 15

Syringe for URGENT Cases in ED/ CAU for PERIPHERAL USE: Take 10ml (10mg) of 5mg/5ml solution and dilute to 50ml with sodium chloride 0.9% giving a solution of 200microgram/ml. Calculate rate as above e.g. 0.3ml x patient weight (kg) = ml/hr for 1microgram/kg/min Worked example of how to set the infusion rate to provide 1 and 5 microgram/kg/min to a child weighing 27kg (peripheral use): 1microgram/kg/min =0.3ml/kg/hour (see above) 1microgram/kg/min for a 27kg child =0.3 x 27 = 8.1 ml/hr 5microgram/kg/min for a 27kg child =0.3ml/hour x 27 x 5 = 40.5 ml/hr Ipratropium Bromide There is good evidence for the safety and efficacy of frequent doses of ipratropium bromide (every 20 30 minutes) used in addition to β2 agonists for the first two hours of a severe asthma attack. Benefits are more apparent in the most severe patients. Repeated doses of ipratropium bromide should be given early to treat children who are poorly responsive to β2 agonists. Atrovent (Ipratropium Bromide) nebuliser can be given every 20 minutes then 4 6 hourly. <12 years - 250 micrograms >12 years - 500 micrograms Steroids The early use of steroids can reduce the need for hospital admission and prevent a relapse in symptoms after initial presentation. Benefits can be apparent within three to four hours. Give steroids early in the treatment of acute asthma attacks. Oral prednisolone is the steroid of choice for asthma attacks in children unless the patient is unable to tolerate the dose (BTS 2016) in which case oral dexamethasone can be considered There is no evidence that increasing the dose of inhaled steroids is effective in treating acute symptoms, but it is good practice for children already receiving inhaled steroids to continue with their usual maintenance doses. There is limited evidence for the use of oral steroids in pre-school viral wheeze. The use of oral corticosteroids in acute preschool wheeze remains in equipoise, but should be considered in those admitted who fall into the moderate severe category. [Bush A, Grigg J, Saglani S. Managing wheeze in preschool children. BMJ 2014;348:g15] Page 8 of 15

Steroid Route Dose Frequency Prednisolone Oral <2yrs 10mg Once per day for 3 2-5yrs 20mg to 5 days >5yrs 30-40mg Dexamethasone Oral 0.6mg/kg Usually a single (Max 16mg) dose (see appendix Hydrocortisone Intravenous 4mg/kg (Max 100mg) 2) 6 hourly In children who were commenced on IV hydrocortisone (regardless of whether they received oral dexamethasone or prednisolone beforehand) due to clinical need, switch to oral prednisolone at 1mg/kg/day once they are ready to come off IV medications for a 3 to 5 day course. IV Aminophylline Consider aminophylline in a HDU or PICU setting for children with severe or life threatening bronchospasm unresponsive to maximal doses of bronchodilators plus steroids. Loading dose; Child 1 month 18 years: 5 mg/kg (max. 500 mg) by intravenous infusion over at least 20 minutes (If not previously treated with theophylline), followed by continuous infusion at 1 mg/kg/hour adjusted according to plasmatheophylline concentration Note: Plasma theophylline concentration for optimum response in asthma 10 20 mg/l (55 110 micromol/litre); narrow margin between therapeutic and toxic dose. Avoid loading dose in children taking oral theophylline or who have received theophylline in the previous 24 hours and monitor plasma theophylline levels regularly (4 6 hours starting or dose change). Discuss with pharmacist if the level is low. To avoid excessive dosage in obese children, dose should be calculated on the basis of ideal weight for height Page 9 of 15

APPENDIX 2: Continuing Oral Corticosteroids after First Dose of Dexamethasone SCOPE This section relates to the prescription of on-going oral corticosteroids for children who are admitted to the children s hospital with an acute exacerbation of asthma, having already been given one dose of 0.6mg/kg oral dexamethasone by the emergency department (instead of oral prednisolone). Child: 1) With Acute Asthma 2) Admitted to Ward 3) Already received one dose of 0.6mg/kg Dexamethasone on admission If good response: 1) Weaning frequency of bronchodilators 2) Minimal/no oxygen requirmement NO FURTHER STEROID DOSES NEEDED If slow response: 1) Still needing 1-2 hourly bronchodilators after 24 hours GIVE ONE FURTHER 0.6MG/KG ORAL DOSE OF DEXAMETHASONE (MAX. 16MG) If good response: 1) Weaning frequency of bronchodilators 2) Minimal/no oxygen requirmement NO FURTHER STEROID DOSES NEEDED If response is still slow/suboptimal AND diagnosis is still most likely asthma, as determined by a Consultant CAN BE PRESCRIBED FURTHER 3-5 DAYS COURSE OF ORAL PREDNISOLONE AT 1MG/KG OD, TO COMMENCE 48 HOURS AFTER LAST DOSE OF DEXAMETHASONE What about at re-presentation? In children re-presenting to hospital with worsening asthma symptoms soon after discharge, further courses or steroids can be considered if felt to be of clinical benefit after discussion with SpR/Consultant 1. If a child presents more than 7 days following their last course of oral dexamethasone with asthma, then they can be given a further 1-2 day course of oral dexamethasone IF steroids are thought to be needed 2. If a child presents within 7 days following their last course of oral dexamethasone with asthma, then they can be given a course of prednisolone IF steroids are thought to be needed Page 10 of 15

APPENDIX 3: INTRAVENOUS MAGNESIUM SULPHATE FOR ACUTE ASTHMA IN CHILDREN Intravenous magnesium sulphate: Key Points: The available evidence to support the use of intravenous Magnesium in asthmatic children at any age is not robust Particular caution should be exercised in children under the age of 5 Its place in acute management is not yet established although it is a safe treatment for acute asthma. The mechanism of action of magnesium sulphate is not clearly defined. Studies of efficacy for severe childhood asthma unresponsive to more conventional therapies have been inconsistent in providing evidence of benefit. However, the recent GINA guidelines suggest that intravenous magnesium may be considered in acute moderate and severe asthma with incomplete response to initial treatment during the first 1 2 hours 50% Magnesium Sulphate to be used intravenously for this purpose (as this is available in UHL) Oral magnesium is poorly absorbed hence not indicated. 1 ml of 50% MgSO4 contains 2mmols of Mg2+ 40mg/kg =0.08ml/kg = 0.16mmols/kg of 50% MgSO4 Maximum Dose per day will be 2gms = 4mls = 8 mmols of 50% MgSO4 Initial Dose: 0.08 mls/kg of 50% MgSO4 (max of 4 mls) via intravenous route over 20 minutes (Please remember the maximum dose) with a syringe pump. Monitor for blood pressure, respiratory rate, urine output and signs of over dosage (loss of tendon reflexes, weakness, double vision and rarely paralysis & arrhythmias) Further Doses: To be given after discussing with HDU/PICU team, the aim is to maintain level of serum Mg2+ between 1.5 and 2. Monitor for blood pressure, respiratory rate, urine output and signs of over dosage (loss of tendon reflexes, weakness, double vision and rarely paralysis & arrhythmias) Bloods: U&E & bone profile along with magnesium levels needs monitoring. Duration of treatment with IV magnesium to be decided by HDU/PICU consultant PLEASE NOTE MAGNESIUM IS NOT COMPATIBLE WITH: Ketamine, Salbutamol and Aminophylline. Please site a new cannula for IV magnesium. Page 11 of 15

APPENDIX 4: NON INVASIVE POSITIVE PRESSURE VENTILATION FOR THE TREATMENT OF STATUS ASTHMATICUS IN CHILDREN Recent studies suggest that bilevel positive airway pressure (BiPAP) in children with severe asthma may improve symptoms and ventilation without significant adverse events and reduce the need for intubation and mechanical ventilation. Intubation and positive pressure ventilation of an asthmatic child may increase bronchoconstriction, increase the risk of airway leakage and has disadvantageous effects on circulation and cardiac output. Therefore, intubation should be avoided unless respiratory failure is imminent despite adequate institution of all available treatment measures. Consider BiPAP early in severe Asthma and discuss with HDU/PICU consultant. BiPAP also improves drug delivery of neublised medication. APPENDIX 5: ASTHMA MANAGEMENT: KEY PRINCIPLES Patients requiring oxygen should have nebulised B2 bronchodilator Children not requiring oxygen therapy should have their bronchodilator therapy via a metered dose inhaler and large volume spacer. PRN bronchodilator therapy should be prescribed, both via a nebuliser and via a large volume spacer. Any current home asthma treatment should also be prescribed during admission and reviewed at discharge. The child s inhaler technique and usual medication should be reviewed during admission. Discuss with respiratory team if difficult asthmatic or unusual presentation At discharge patients should be stable on inhaled Salbutamol 4 hourly. On discharge, prescribe Salbutamol pmdi via spacer 2 6 puffs, 4 6 hourly for up to 5 7 days, then reduce to PRN. Ensure Discharge bundle completed and follow up plans made Ensure patient/parents aware of Emergency management plan (All children should be provided with a written Personalised Asthma action plan which includes advice on treating future asthma attacks) Ensure Smoking issues discussed Always ask about the child s exposure to smoking Offer smoking cessation advice to patients/parents/carers Always advocate a smoke free home & car THIS INFORMATION IS FOR GUIDANCE, YOU SHOULD ALWAYS USE YOUR CLINICAL JUDGEMENT. If it is clinically appropriate to vary from the guidelines in this pathway it is essential that you record the reasons for your management Asthma Action plan, Inhaler technique leaflets and Asthma discharge care bundle are attached below: Every admission should have these 3 appendices completed (Appendices 6, 7, and 8) Page 12 of 15

Appendix 6: Page 13 of 15

Appendix 7: Page 14 of 15

Appendix 8: Page 15 of 15