Synopsis
Recognise age-specific severe and life-threatening asthma from the worst feature, start oxygen and inhaled bronchodilator immediately, add anticholinergic and systemic corticosteroid, reassess repeatedly, and escalate safely to intravenous therapy and paediatric intensive care without sedation.
- Grade severity from the most dangerous feature. A child does not need every criterion, and falling tachycardia or respiratory rate with exhaustion is deterioration.
- First line: give oxygen to target 94–98% and salbutamol immediately. Mild-to-moderate attacks can use a pressurised metered-dose inhaler and spacer; severe or hypoxaemic attacks use an oxygen-driven nebuliser.
- Spacer regimen: give one salbutamol 100-microgram puff at a time with tidal breaths, repeating up to 10 puffs and reassessing; use a mask when a mouthpiece seal is unreliable.
Key red flags
Silent chest, cyanosis, poor effort, exhaustion, confusion, drowsiness, hypotension or arrhythmia is life-threatening irrespective of respiratory rate.
Investigation priorities
Grade response and identify hypoxaemia or fatigue while treatment proceeds.
Management branches
A child presents with a current asthma attack.
- Give oxygen for hypoxaemia and salbutamol by spacer or oxygen-driven nebuliser according to severity.
- Give systemic corticosteroid early and add ipratropium for severe or life-threatening disease.
Key medicines
SalbutamolSpacer: 100 micrograms per puff, one puff at a time up to 10 puffs with reassessment. Severe attack by oxygen-driven nebuliser: 2.5 mg under 5 years or 5 mg age 5 and over, repeated according to response and protocol.
PrednisoloneCommon UK acute regimen: age 2–5 years 20 mg orally once daily; age over 5 years 30–40 mg once daily, usually for at least 3 days. Verify current BNF-C, weight and local protocol.