1 Children & Young People s Directorate Paediatric-Neonatal Guidelines Checklist & Version Control Sheet 1 Name of Guideline / Policy/ Procedure MANAGEMENT OF ACUTE PAEDIATRIC ASTHMA Purpose of Procedure/ Guidelines/ Protocol: 3 Replaces: Previous guideline/management (NICE) 4 Professionals consulted during development Prepared by: M Smith Checked by: R. Clements Review date: November 2018 5 Applicable to which staff: 6 Name & Title of Author: Dr M Smith, Consultant Paediatrician Dr Aljarad, CD, Consultant Paediatrician 7 Proposals for dissemination: Southern Trust Web Portal 8 Proposals for implementation: n/a 9 Training Implications: n/a 10 Date Procedure/Guideline/ Protocol submitted to Procedures Committee: 11 Outcome : Approved Approved/Minor amendments Not approved Deferred 12 Date of CYP SMT approval Comments: CYP Clinical Governance Oversight Committee 13 Date of approval by Trust SMT (if n/a required): 14 Date for further review (3 year November 2018 default) 15 Date added to repository: 16 Clinical Guidelines ID: CG0528 (Note: Guideline author to complete parts 1-10)
2 MANAGEMENT OF ACUTE PAEDIATRIC ASTHMA Version 09 November 2016 Exacerbation of Asthma Early warning score > 94% OR signs of mild to moderate asthma 4-10 puffs salbutamol (MDI + spacer) up to 3 times. Reassess. BETTER NO BETTER Sp02 on arrival (in room air) SpO2 <94% indication for O2 in acute asthma SpO2 < 92% post bronchodilator = admit BETTER < 94% OR signs of moderate to severe asthma Nebulised salbutamol + Ipratropium bromide + MgSO4 x3 followed by continuous salbutamol nebulization O 2 to keep saturation 94% Oral steroids (if vomiting IV) NO BETTER Clinically improved a) Discharge Education on use of 2 agonist Oral corticosteroid therapy (add early) Consider increased preventive therapy b) Written action plan and letter to GP c) Check inhaler technique d) Follow-up GP or refer to asthma clinic e) No CXR or antibiotic required unless clinically indicated Slow or moderate response a) Admit b) give 3 X nebulized salbutamol/ipratropium bromide immediately in first 60 min (if not given already) thereafter ONLY nebulized salbutamol every 1-4 hours c) Frequent assessment over 6-12 hours d) No CXR or antibiotic required unless clinically indicated Severe life threatening asthma or no response (involve senior clinician or PICU team) Give continuous nebulized bronchodilators Consider: a) IV MgSO4 (avoid in <2 y) or b) IV Salbutamol or c) IV Aminophylline and d) CXR e) Venous blood gas f) Electrolyte levels High dependency care and consider transfer to PICU if child seriously ill or requiring both IV salbutamol and IV aminophylline
3 Pharmacotherapy of acute asthma (This should be read in conjunction with BTS Guidelines for the management of acute asthma and current BNF for Children) 2 Agonist Bronchodilators Individualise drug dosing according to severity and adjust according to the patient s response Salbutamol 100 microgram/dose MDI inhaler + spacer device 4 puffs (400 micrograms) repeated every 20-30 minutes according to clinical response might be sufficient for mild attacks although up to 10 puffs (1000 micrograms) might be needed for more severe asthma. Doses can be repeated every 20 30 minutes. For patients with moderate to severe asthma, use nebulised 2 agonists with oxygen (2.5-5mg salbutamol). Ipratroprium bromide If symptoms are refractory to initial 2 agonist treatment, add ipratropium bromide (250 500 microgram ( 5yrs)/dose mixed with the nebulised 2 agonist solution) in back to back treatment. Frequent doses up to every 20-30 minutes (250 500 microgram/dose mixed with the 2 agonist solution (5mg salbutamol neb) in the same nebulizer) should be used early. The dose frequency should be reduced as clinical improvement occurs. There is NO benefit given after 1-2 hours of initial therapy. Nebulised Magnesium sulphate Consider adding 150mg of magnesium sulphate to each nebulized salbutamol/ipratropium in the first hour in children with short duration of acute severe asthma symptoms presenting with an oxygen saturation < 92% Steroid Therapy Give prednisolone early in the treatment of acute asthma attack Use a dose of 20mg for children 2-5 years and 30-40mg for children > 5 years. Those already receiving maintenance steroid tablets should receive 2mg/kg prednisolone up to a maximum dose of 60mg. Use a dose of 10mg of soluble prednisolone for children below 2 years for up to three days. Treatment for up to three days is usually sufficient, but the length of course should be tailored to the number of days necessary to bring about recovery. Dose of IV hydrocortisone 4mg/kg- 6 hourly
4 Intravenous therapy 1. IV Magnesium in children with severe / life threatening asthma Use Prescribing Form Dose In children of 5 years and over who have been assessed by the pathway as having severe/life threatening asthma and who do not improve after 3 nebulised treatments. All children who receive intravenous magnesium sulphate must be admitted. Intravenous magnesium sulphate must be prescribed by, or under the supervision of, appropriately experienced Medical, A&E or PICU staff (middle grade staff should always be involved with these children). Magnesium sulphate 50% injection containing 500mg/ml of magnesium sulphate (2mmol/ml of magnesium). This is available in 10ml ampoules. Infuse 40mg/kg (0.16mmol/kg) over 20 minutes. The maximum dose is 2g (8mmol). Use the appropriate volume of magnesium sulphate 500mg/ml (2mmol/ml) from the table below and make up to 20ml with sodium chloride 0.9%. Prepare and use immediately. Administer via an infusion pump. Dose Weight (kg) Dose of magnesium sulphate (mg)(mmol) Dose Volume of 50% magnesium sulphate (ml) 15-16kg 600mg (2.4mmol) 1.2ml 17-18kg 700mg (2.8mmol) 1.4ml 19-23kg 800mg (3.2mmol) 1.6ml 24-28kg 1000mg (4mmol) 2ml 29-33kg 1200mg (4.8mmol) 2.4ml 34-38kg 1400mg (5.6mmol) 2.8ml 39-43kg 1600mg (6.4mmol) 3.2ml 44-48kg 1800mg (7.2mmol) 3.6ml 49kg 2000mg (8mmol) 4ml Contraindications Side Effects Children less than 2 years of age Children with severe renal impairment Children with myasthenia gravis Mild discomfort has been reported at the infusion site during the infusion in approximately half of patients. This is not usually an indication to stop the infusion. A clinically non-significant fall in blood pressure (~5mmHg) may occur. This is not usually an indication to stop the infusion. Overdose Hypermagnesaemia. Dependent on the size of the overdose, progressive muscle weakness, significant hypotension and ultimately respiratory failure have been reported. Repeat doses The clinical state of the patient should be reviewed 20 minutes after the magnesium sulphate infusion is completed. IV magnesium sulphate should NOT be repeated (except by PICU team). If the patient fails to improve, further intravenous therapy with aminophylline/salbutamol should be considered see asthma pathway.
5 2. IV Salbutamol in children with severe/ life threatening asthma Involve senior clinician and PICU team Salbutamol 5ml ampoules contain 5mg (1mg/ml) DOSAGE FOR A SINGLE BOLUS By intravenous injection over 5 minutes Child 1 month 2 years 5 micrograms/kg as a single dose Child 2 17 years 15 micrograms/kg (max. 250 micrograms) as a single dose This may be followed up with a continuous infusion in refractory asthma DOSAGE FOR CONTINUOUS INFUSION SEE TABLE Child 1 month 18 years 60 300 micrograms/kg/hour, dose adjusted according to response and heart rate (doses above 120 micrograms/kg/hour with close monitoring) SALBUTAMOL INFUSION - FOR USE IN PERIPHERAL OR CENTRAL LINE PREPARATION 1. A 50ml bag of NaCl 0.9% should be used. 2. Withdraw 10ml from the bag. 3. Add 10ml (10 mg) of salbutamol for intravenous infusion (two 5ml ampoules) 4. This will produce a final concentration of 200 micrograms per ml 5. More than one 50ml bag can be made up and kept in the fridge 6. Discard 24 hours after preparation. INFUSION RATE PRESCRIPTION TO CALCULATE INFUSION RATE 60 micrograms/kg/hour 0.3ml x wt (kg) per hour 120 micrograms/kg/hour 0.6ml x wt(kg) per hour 180 micrograms/kg/hour 0.9ml x wt(kg) per hour 240 micrograms/kg/hour 1.2ml x wt(kg) per hour 300 micrograms/kg/hour 1.5ml x wt(kg) per hour MONITORING Patients on intravenous salbutamol should have continuous ECG monitoring linked to the central station. Reduce infusion rate if arrhythmia occurs. Serum potassium should be checked 6 hours after commencing infusion and at least 12 hourly thereafter If salbutamol infusion is running for more than 24 hours check serum phosphate and blood sugar.
6 3. IV Aminophylline in children with severe/ life threatening asthma Packaging Aminophylline 250mg/10ml solution for injection, ampoules. PREPARATION 1. A 500ml bag of 0.9% Sodium chloride should be used 2. Withdraw 20ml of 0.9% sodium chloride and add 20ml (500mg) of Aminophylline for intravenous infusion (two 10ml ampoules) 3. This will produce a final concentration of 1mg per ml This is a two stage procedure with both loading and maintenance are given in separate syringes First, prepare and label the LOADING dose syringe Give 5mg/kg over 20 minutes - (if on theophylline, commence maintenance only) Calculation:- e.g., for 20kg child, dose is 100mg=100ml. Therefore, give 100ml over 20 minutes = 300ml per hour. Draw up required amount for loading dose from 500ml bag in a syringe and administer first over 20 minutes. Dilute and give slowly over at least 20 minutes, using an infusion pump, at a rate not exceeding 25mg per minute. If acute adverse effects occur, slow the rate or stop the infusion for 5-10 minutes Discard syringe. Second, prepare and label the MAINTENANCE INFUSION using a separate syringe Maintenance dose by continuous IV infusion: CHILD 1 month 12 years Dilute and administer using an infusion pump at an initial rate of 1mg/kg/hour. CHILD 12 18 years Dilute and administer using an infusion pump at an initial rate of 500-700micrograms/kg/hour Age: 1-9 years - 1 mg/kg/hour Age: 9-16 years 800 microgram/kg/hr Calculation: e.g. for 20kg child, dose is 20mg=20ml. Therefore, give 20mls per hour. Do not mix with IV salbutamol Monitor blood glucose and potassium. Patients should have continuous ECG monitoring linked to the central station. If aminophylline is given intravenously, a blood sample should be taken 4-6 hours after starting treatment; in a child already taking theophylline, plasma-theophylline concentration should be determined before giving the intravenous dose. Prepared by: M Smith Checked by: R. Clements Review date: November 2018 References: 1. SIGN 153 British guideline on the management of asthma, A national clinical guideline September 2016 (https://www.britthoracic.org.uk/document-library/clinical-information/asthma/btssign-asthma-guideline-2016/). 2. BNFC on line (https://www.medicinescomplete.com/mc/bnfc/current/) 3. Medicines for Children 2003, Royal College of Paediatrics and Child Health/NPPG. 4. Medusa (http://medusa.wales.nhs.uk/ivguidedisplay.asp). Accesed 17/11/16.