Asthma/wheeze management plan Name of Patient Date of Birth NHS Number GP surgery Telephone Next appointment Children s Assessment unit/ward telephone Out of hours call 111 Open access Y/N Until date Some areas may instruct you to take your child to the Children s Emergency Department. Make sure you know what to do in your area This is your child s discharge plan and treatment until their next review. Make an appointment with a GP or asthma nurse within 48hrs of discharge Symptoms of asthma include: Cough, wheeze, shortness of breath, chest tightness that may cause difficulty in speaking or feeding. Not everyone with asthma will wheeze Please note how much treatment your child is requiring and how this helps When asthma is fully controlled your child should be symptom free and not require any reliever inhaler (salbutamol.) Preventer medication should be used even when well Treatment Medication When to use Name and strength of medication No. of puffs/dose Times per day Reliever inhaler usually Salbutamol and blue Preventer inhaler Often brown, orange or purple Prednisolone (steroids) Preventer tablet or granules. Use every day Other treatments: Use when your child is coughing or wheezing or their chest feels tight. Your child should use their ( ) inhaler every day even when well Short course when unwell, usually 3-5 days Use every day Remember Your child should use their Preventer inhaler ( ) every morning and evening and only stop if their doctor or asthma nurse tells them to. Salbutamol is a reliever. When you child is well they will not need to use this at all Keep a salbutamol inhaler with you at all times. Start salbutamol as soon as your child gets symptoms and continue until symptoms have resolved. Using salbutamol Give 2 puffs. I puff at a time, wait for 2 minutes and assess the response, repeat if necessary continuing up to 10 puffs. If your child does not respond to 10 puffs call 999 & repeat If your child needs to use their blue inhaler more often than every 4 hours you should take them to see their doctor or use the out of hours services. (Call 111) If your child repeatedly needs doses of 6-10 puffs every 4 hours you should take them to see their doctor or use the out of hours services. (Call 111) they are likely to need a course of steroids
How to use an MDI with a small volume spacer and mask (spacer may be yellow, orange or blue.) How to use an MDI with a small volume spacer 1. Remove the cap from the inhaler. Shake the inhaler and insert into the back of the spacer. 2. Place the mask of the spacer over the mouth and nose of the child and ensure there is a good seal. 3. Keeping the spacer level press the inhaler canister. 1. Remove caps from the inhaler and spacer. Shake the inhaler and insert into the back of the spacer. 2. Breathe out gently as far as is comfortable. Put the mouthpiece of the spacer into your mouth and seal your lips around it. 3. Press the canister once to release a dose of medicine. Breathe in slowly and 4. Encourage the child to breathe in and out slowly and gently for 5 breaths, (if you hear a whistling sound they are breathing in to quickly). 5. Remove the mask from the child s face. 6. If taking another dose, wait 30 seconds and repeat steps 1-4. Replace mouthpiece cover after use. steadily (if you hear a whistling sound you are breathing in too quickly). 4. Remove spacer from your mouth and hold your breath for 10 seconds, or as long as is possible, then breathe out slowly. 5. If taking another dose, wait for 30 seconds and repeat steps 1-4. Replace the mouthpiece covers after use. How to use an MDI with a large volume spacer and mask for infant/small child 1. Remove the cap. 2. Attach the mask to the spacer mouthpiece. 3. Shake the inhaler and insert into back of spacer. 4. Tip the spacer to an angle of 45 or more to allow the valve to remain open. 5. Place the mask over the mouth and nose of the child to ensure there is a good seal. 6. Press the inhaler canister and keep the mask on the child s face for 5 breaths. 7. Remove the mask from the child s face. 8. For a further dose wait 30 seconds and repeat steps 3 to 7. Not all types of inhaler are shown here. Ask the doctor or nurse if you are unsure how to use the inhalers you have been given. The type of inhaler and spacer with or without a mask you are given will depend on your child. For more information see http://www.asthma.org.uk/sites/healthcare-professionals/pages/inhaler-demos Medications reviewed by Name: Signature:: Date Inhaler technique checked by Name: Signature:: Date Information/education received by: Name: Signature:: Date Copy of this plan sent to GP Name: Signature:: Date Get help day or night. Do not worry about making a fuss Life threatening Severe Moderate Mild If your child is: Drowsy Has a severe wheeze Is unable to speak in sentences Is unable to respond If your child is: Frightened Breathless with a heaving chest Unable to speak in sentences/take fluids and is getting tired If your child is: Wheezing and breathless and not responding to usual reliever treatment Monitor your child closely and look for signs to see if they are getting worse If your child is: Requiring their reliever regularly throughout the day/night for cough or wheeze but is not working hard with their breathing and is able to continue day to day activities Ring 999 You need immediate help Give 2 puffs (1 at a time) every 2 minutes of salbutamol via a spacer until the ambulance arrives Ring 999 You need immediate help Give 2 puffs (1 at a time) every 2 minutes of salbutamol via a spacer until the ambulance arrives Contact your GP to make an appointment for your child to be seen immediately. Out of hours call 111 Continue to give salbutamol as described earlier Arrange an appointment to see your GP as soon a possible/preferably the same day or call 111 if it is out of hours Continue to give salbutamol as described earlier and watch them closely For more information about asthma http://www.asthma.org.uk T 0800 1216244 Smoking, even outside can affect your child s health & asthma. Ask at your surgery for help to quit. For more information www.smokefree.nhs.uk
Management of Acute Exacerbation of Asthma / Wheeze Primary Care Clinical Assessment Tool for Children Under 2 Years Assessment History Breathless/wheeze/cough Viral or allergic trigger Previous episodes or interval symptoms FH or personal history asthma, eczema or atopy Current/Previous treatment and response Examination Feeding and speech Respiratory rate Chest wall expansion and movement Use of accessory Auscultation of chest reduced air entry, wheeze, prolonged expiration Oxygen Saturation (Sats) Consider other diagnosis Pneumonia Bronchiolitis in under 1yr old Croup Foreign body No treat as below Yes It may not be asthma. Seek expert help Treat according to most severe feature Moderate Able to feed or talk Moderate use of accessory Audible wheeze Sats>92% in air <1 year RR<40/min HR 120-170/min 1-2 yrs R<35/min HR 80-110/min Severe Previous attack within last 2 weeks Too breathless to feed or talk Marked use of accessory and wheeze Sats< 92 % in air <1 yr: RR >40/min HR>170/min 1-2yrs: RR >35/min HR >110/min Life Threatening Sats <92% in air plus any of the following: Silent chest Poor respiratory effort Exhausted and unresponsive Coma/agitation Cyanosis Bradycardia Apnoea Respiratory arrest Give salbutamol 2-10 puffs via spacer+facemask (one puff at a time.) Increase by 2 puffs every 2 minutes up to 10 puffs according to response Assess response and repeat if necessary prednisolone 10mg Good response Reassess within 1 hour Subtle or no use of accessory Minimum wheeze Sats >92% in air Poor Response Reconsider diagnosis or severe & life threatening episode Call 999 Give high flow oxygen via fitted mask aim for Sats 94-98% Give nebulised Salbutamol 2.5mg (using 6L-8L oxygen) Reassess and repeat at 20-30 minute intervals or as necessary Prednisolone 10mg Consider nebulised Ipratropium Bromide 250mcg (using 6L-8L oxygen). Repeat every 20-30 minutes Commence resuscitation Call 999 Give high flow Oxygen via fitted mask Give back to back nebulised Salbutamol 2.5mg (using 6L-8L oxygen) Prednisolone 10mg Give nebulised Ipratropium Bromide 250mcg (using 6L-8L oxygen). Repeat every 20-30 minutes Ensure a health professional stays with child Contact duty paediatric registrar or consultant to arrange admission Ambulance transfer pathway Continue to administer oxygen driven nebulised salbutamol if symptoms are severe whilst transferring the child to the emergency department
Discharge from hospital and GP Patient must be stable have minimal recession with Sats >92% and manage 3-4 hourly between doses of inhaler Discharge on salbutamol 2-10 puffs up to 4 hourly via spacer + facemask Complete a 3 day course of Prednisolone 10mg or 2mg/kg/dose Give acute asthma management plan Check inhaler technique and regular medication Review overall asthma control and consider need to step up medication Arrange a review at GP practice within 48 hours and give advice on re-accessing medical care if condition worsens e.g. OOH service (or open access to Children s Assessment unit if an option.) Full Respiratory assessment in 7-14 days in primary care THINK TTT consider compliance with existing Therapy, Inhaler Technique and Triggers before stepping up treatment Ref: The British Thoracic Society (BTS) and SIGN Guideline on the Management of Asthma (Revised Jan 2012) and thanks to The Suffolk Respiratory Pathway Group July 2013
Management of Acute Exacerbation of Asthma / Wheeze Primary Care Clinical Assessment Tool for Children Over 2 Years Assessment History Breathless/wheeze/cough/chest tightness Viral or allergic trigger Previous episodes or interval symptoms Family or personal history asthma, eczema or atopy Current/Previous treatment and responses Examination Speech Respiratory rate Chest wall expansion and movement Use of accessory Auscultation of chest reduced air entry, wheeze, prolonged expiration Oxygen Saturation (Sats) Peak flow measurement (>5yrs but often unreliable in younger age) Consider other diagnosis Pneumonia Bronchiolitis in under 1yr old Croup Foreign body No treat as below Yes It may not be asthma. Seek expert help Treat according to most severe feature Moderate Exacerbation Able to talk Moderate respiratory distress/wheeze Sats 92% PEF >50% predicted or best (>5yrs) 2-5 yrs: RR 40/min HR 140/min 5-12yrs: RR 30/min HR 125/min 12-18yrs: RR <25/min HR 110/mn Severe Previous attack within last 2 weeks Too breathless to talk or complete sentence Marked respiratory distress/wheeze Sats <92% PEF 33-50% predicted or best 2-5yrs RR>40/min HR > 140/min 5-12yrs RR>30/min HR > 125/min 12-18yrs RR 25/min HR >110/min Life Threatening Sats <92% plus any of the following: Silent chest Poor respiratory effort Exhausted and unresponsive Confusion/coma/agitation Cyanosis Bradycardia Respiratory arrest PEF not recordable or <33% predicted or best Give Salbutamol 2-10 puffs via spacer+facemask (one puff at a time.) Increase by 2 puffs every 2 minutes up to 10 puffs according to response Assess response and repeat if necessary Prednisolone 20mg 2-5yrs and 30-40 mg > 5yrs or 2mg/Kg dose (maximum 40mg) Good response Reassess within 1 hour Subtle or no use of accessory Minimum wheeze Sats >92% in air Rising PEF in >5 yrs Poor Response Reconsider diagnosis or severe & life threatening episode Call 999 Give high flow oxygen via fitted face mask aim for Sats 94-98% Give nebulised Salbutamol (using 6L-8L oxygen):<5yrs 2.5mg and > 5yrs 5mg Reassess and Repeat at 20-30min intervals or as necessary Prednisolone 20mg 2-5yrs and 30-40 mg > 5yrs or 2mg/Kg dose (maximum 40mg) Consider nebulised Ipratropium Bromide (using 6L oxygen): <12yrs 250mcg;12-18yrs 500mcg repeated every 20-30 minutes Commence resuscitation - ABC Call 999 Give high flow oxygen via fitted facemask Give back to back nebulised Salbutamol (using 6L- 8L oxygen): <5yrs 2.5mg; >5yrs 5mg Prednisolone 20mg 2-5yrs and 30-40 mg > 5yrs or 2mg/Kg dose (maximum 40mg) Give nebulised Ipratropium Bromide (using 6L oxygen): <12yrs 250mcg; 12-18yrs 500mcg repeated every 20-30 mins Ensure a health professional stays with child Contact duty paediatric registrar or consultant to arrange admission Ambulance transfer pathway Continue to administer oxygen driven nebulised salbutamol if symptoms are severe whilst transferring the child to the emergency department
Discharge from hospital and GP Patient must be stable have minimal recession with Sats >92% and manage 3-4 hourly between doses of inhaler Discharge on salbutamol 2-10 puffs up to 4 hourly via spacer + facemask Complete a 3 day course of Prednisolone; child < 5 yrs 20mg; 5-12 yrs 30-40mg for 3 days; 12-18 yrs 40mg for 3-5 days(or 2mg/kg dose up to 40mg ) Give Acute Asthma Management Plan Check inhaler technique and regular medication Review overall asthma control and consider need to step up medication Arrange a review at GP practice within 48 hours and give advice on re-accessing medical care if condition worsens e.g. OOH service (or open access to Children s Assessment Unit if an option.) Full Respiratory assessment in 7-14 days in primary care THINK TTT consider compliance with existing Therapy, Inhaler Technique and Triggers before stepping up treatment Table 1: Normal Paediatric Values Respiratory Rate at Rest: <2-5yrs 25-30 breaths/min 5-12yrs 20-25 breaths/min >12yrs 15-20 breaths/min Heart Rate <2-5yrs 95-140 bpm 5-12yrs 80-120 bpm >12yrs 60-100 bpm Table 2: Predicted Peak flow: for use with EU/EN13826 scale PEF metres only Height (m) Height (ft) Predicted EU PEFR (L/min) 0.85 2 9 87 0.90 2 11 95 0.95 3 1 104 1.00 3 3 115 1.05 3 5 127 1.10 3 7 141 1.15 3 9 157 1.20 3 11 174 1.25 4 1 192 1.30 4 3 212 1.35 4 5 233 1.40 4 7 254 1.45 4 9 276 1.50 4 11 299 1.55 5 1 323 1.60 5 3 346 1.65 5 5 370 1.70 5 7 393 Ref: The British Thoracic Society (BTS) and SIGN Guideline on the Management of Asthma (Revised Jan 2012) and thanks to The Suffolk Respiratory Pathway Group
Management of Acute Exacerbation of Asthma / Wheeze Secondary Care Clinical Assessment Tool for Children Under 2 Years Assessment History Breathless/wheeze/cough Viral or allergic trigger Previous episodes or interval symptoms FH or personal history asthma, eczema or atopy Current/Previous treatment and response Examination Feeding and speech Respiratory rate Chest wall expansion and movement Use of accessory Auscultation of chest reduced air entry, wheeze, prolonged expiration Oxygen Saturation (Sats) Consider other diagnosis Pneumonia Bronchiolitis in under 1yr old Croup Foreign body No treat as below Yes It may not be asthma. Seek expert help Treat according to most severe feature Moderate Exacerbation Able to feed or talk Moderate use of accessory Audible wheeze Sats >92% in air < 1 yr: RR 40/min HR 120-170/min 1-2yrs: RR 35/min HR 80-110/min Severe Previous attack within last 2 weeks Too breathless to feed or talk Marked use of accessory and wheeze Sats< 92 % in air <1 yr: RR >40/min HR>170/min 1-2yrs: RR >35/min HR >110/min Life Threatening Sats <92% in air plus any of the following: Silent chest Poor respiratory effort Exhausted and unresponsive Coma/agitation Cyanosis Bradycardia Apnoea Respiratory arrest Give Salbutamol 2-10 puffs via spacer+facemask (one puff at a time. Increase by 2 puffs every 2 minutes up to 10 puffs according to response Assess response and repeat if necessary Prednisolone 10mg Good response Reassess within 1 hour Subtle or no use of accessory Minimum wheeze Sats >92% in air Poor Response Reconsider diagnosis: Severe or Life Threatening episode Give high flow Oxygen via fitted mask aim for sats 94-98% Give nebulised Salbutamol 2.5mg (using 6L-8L oxygen) Reassess and Repeat at 20-30 minute intervals or as necessary Prednisolone 10mg Repeat dose if patient vomits, or consider IV Hydrocortisone 4mg/Kg If Poor response Ipatropium Bromide 250 micrograms via oxygen driven nebuliser repeated every 20-30minutes Poor response see life-threatening Discuss with senior clinician or Paediatrician or PICU team Good response Continue salbutamol 1-4 hourly Re-Assess regularly Admit/further observation on Children s Assessment unit for all cases if severe symptoms after initial treatment Commence resuscitation - ABC Give high flow Oxygen via mask PAEDIATRIC CARDIAC ARREST CALL Give back to back nebulised Salbutamol 2.5mg (using 6L- 8L oxygen) Prednisolone 10mg Repeat dose if patient vomits, or consider IV Hydrocortisone 4mg/Kg Give nebulised Ipratropium Bromide 250mcg (using 6L- 8L oxygen). Repeat every 20-30 minutes POOR RESPONSE Consider IV Salbutamol and Magnesium Consider Chest X-Ray Arrange PICU/ITU admission
Discharge from hospital and GP Patient must be stable have minimal recession with Sats >92% and manage 3-4 hourly between doses of inhaler Discharge on salbutamol 2-10 puffs up to 4 hourly via spacer + facemask Complete a 3 day course of Prednisolone10 mg or 2mg/kg/dose Give Acute Asthma Management Plan Check inhaler technique and regular medication Review overall asthma control and consider need to step up medication Arrange review at GP practise 48hrs Open access to Children s Assessment Unit for 48hours Full respiratory review at GP practise in 7-14 days Arrange FU in clinic with Asthma Consultant/nurse THINK TTT consider compliance with existing Therapy, Inhaler Technique and Triggers before stepping up treatment Ref: The British Thoracic Society (BTS) and SIGN Guideline on the Management of Asthma (Revised Jan 2012) and thanks to The Suffolk Respiratory Pathway Group. July 2013
Management of Acute Exacerbation of Asthma / Wheeze Secondary Care Clinical Assessment Tool for Children Over 2 Years Assessment History Breathless/wheeze/cough/chest tightness Viral or allergic trigger Previous episodes or interval symptoms Family or personal history asthma, eczema or atopy Current/Previous treatment and responses Examination Able to speak in sentences Respiratory rate Chest wall expansion and movement Use of accessory Auscultation of chest reduced air entry, wheeze, prolonged expiration Oxygen Saturation Peak flow measurement (>5yrs but often unreliable in younger age) Consider other diagnosis Pneumonia Croup Foreign body Hyperventilation/panic attack No treat as below Yes It may not be asthma. Seek expert help Treat according to most severe feature Moderate Exacerbation Able to talk Moderate respiratory distress/wheeze Oxygen Sats 92% PEF >50% predicted or best (>5yrs) 2-5 yrs: RR 40/min HR 140/min 5-12yrs: RR 30/min HR 125/min 12-18yrs: RR <25/min HR 110/mn Severe Previous attack within last 2 weeks Too breathless to talk or complete sentence Marked respiratory distress/wheeze Sats <92% PEF 33-50% predicted or best 2-5yrs RR>40/min HR > 140/min 5-12yrs RR>30/min HR > 125/min 12-18yrs RR 25/min HR >110/min Life Threatening Oxygen sats <92% plus any of the following: Silent chest Poor respiratory effort Exhausted and unresponsive Confusion/coma/agitation Cyanosis Bradycardia Respiratory arrest PEF not recordable or <33% predicted or best Give Salbutamol 2-10 puffs via spacer+facemask (given one at a time) Increase by 2 puffs every 2 minutes up to 10 puffs according to response Assess response and repeat if necessary Prednisolone 20mg 2-5yrs and 30-40 mg > 5yrs or 2mg/Kg dose (maximum 40mg) Good response Reassess within 1 hour Subtle or no use of accessory Minimum wheeze Sats >92% in air Rising PEF in >5 yrs Poor Response Reconsider diagnosis: Severe or Life Threatening episode Give high flow oxygen via fitted face mask aim for Sats 94-98% Give nebulised Salbutamol (using 6L oxygen). <5yrs 2.5mg and > 5yrs 5mg Reassess and Repeat at 20-30min intervals or as necessary Prednisolone 20mg 2-5yrs and 30-40 mg > 5yrs or 2mg/Kg dose (maximum 40mg) Or IV Hydrocortisone 4mg/Kg If poor response nebulised Ipratropium Bromide (using 6L oxygen): <12yrs 250mcg;12-18yrs 500mcg repeated every 20-30 minutes Poor response see life-threatening Discuss with senior clinician or Paediatrician or PICU team Good response Continue salbutamol 1-4 hourly Re-Assess regularly Admit/further observation on Children s Assessment unit for all cases if severe symptoms after initial treatment Commence resuscitation - ABC Give high flow oxygen via a facemask to achieve Sp0₂ 94-98% PAEDIATRIC CARDIAC ARREST CALL Give back to back nebulised Salbutamol (using 6L-8L oxygen). <5yrs 2.5mg, >5yrs 5mg Give oral prednisolone 20mg 2-5yrs and 30-40 mg > 5yrs or 2mg/Kg dose (maximum 40mg) Or Hydrocortisone 4mg/Kg Give nebulised Ipratropium Bromide (using 6L-8L oxygen). <12yrs 250mcg 12-18yrs 500mcg repeated every 20-30 minutes POOR RESPONSE Ensure consultant paediatrician present IV Salbutamol 15mcg/Kg bolus over 10 minutes followed by continuous infusion 1-5mcg/Kg/min (dilute to 200mcg/ml) IV Aminophylline 5mg/Kg loading dose over 20 minutes followed by continuous infusion 1 mg/kg/hour Bolus IV infusion of Magnesium Sulphate 40mg/Kg (max 2g) over 20 mins Consider CXR and blood gases Arrange PICU/HDU admission
Discharge from hospital and GP Patient must be stable have minimal recession with Sats >92% and manage 3-4 hourly between doses of inhaler Discharge on salbutamol 2-10 puffs up to 4 hourly via spacer + facemask Complete a 3 day course of Prednisolone; child < 5 yrs 20mg; 5-12 yrs 30-40mg for 3 days; 12-18 yrs 40mg for 3-5 days(or 2mg/kg dose up to 40mg ) Give acute asthma management plan Check inhaler technique and regular medication Review overall asthma control and consider need to step up medication Arrange a review at GP practice within 48 hrs Open access to Children s Assessment Unit for 48hours Full respiratory review at GP practise in 7-14 days Arrange FU in clinic with Asthma Consultant/nurse THINK TTT consider compliance with existing Therapy, Inhaler Technique and Triggers before stepping up treatment Table 1: Normal Paediatric Values metres only Respiratory Rate at Rest: <2-5yrs 25-30 breaths/min 5-12yrs 20-25 breaths/min >12yrs 15-20 breaths/min Heart Rate <2-5yrs 95-140 bpm 5-12yrs 80-120 bpm >12yrs 60-100 bpm Systolic Blood Pressure <2-5yrs 80-100 mmhg 5-12yrs 90-110 mmhg >12yrs 100-120 mmhg Table 2: Predicted Peak flow: for use with EU/EN13826 scale PEF Height (m) Height (ft) Predicted EU PEFR (L/min) 0.85 2 9 87 0.90 2 11 95 0.95 3 1 104 1.00 3 3 115 1.05 3 5 127 1.10 3 7 141 1.15 3 9 157 1.20 3 11 174 1.25 4 1 192 1.30 4 3 212 1.35 4 5 233 1.40 4 7 254 1.45 4 9 276 1.50 4 11 299 1.55 5 1 323 1.60 5 3 346 1.65 5 5 370 1.70 5 7 393 Ref: The British Thoracic Society (BTS) and SIGN Guideline on the Management of Asthma (Revised Jan 2012) and thanks to The Suffolk Respiratory Pathway Group July 2013