Australian Asthma Handbook
The National Guidelines for Health Professionals
Australian Asthma Handbook
The National Guidelines for Health Professionals
Table
| Mild–moderate | Severe | Life-threatening | |
| Description | All of: Can walk (for younger children, can move about) Can speak in phrases (for younger children, can vocalise) Moderate use of accessory muscles of neck or intercostal muscles/tracheal tug/subcostal recession SpO2 (room air) >94% | Any of: Unable to complete sentences in one breath due to breathlessness Significant use of accessory muscles of neck or intercostal muscles/tracheal tug/subcostal recession during inspiration Obvious respiratory distress SpO2 (room air) ≤94% | Any of: Reduced consciousness/collapse, exhaustion Cyanosis Poor respiratory effort SpO2 (room air) <90% Poor respiratory effort, soft/absent breath sounds
|
Immediate treatment | Give salbutamol 2–6 actuations (100 microg per actuation) via pMDI and spacer (tidal breathing), plus mask if needed
| Arrange transfer to acute care Give salbutamol 6 actuations (100 microg per actuation) via pMDI and spacer (tidal breathing), plus mask if needed If patient cannot breathe through spacer with mask, give 2.5 mg nebule via nebuliser Start oxygen supplementation if SpO2<92% on room air Titrate to target 92–96% | Arrange transfer to ICU Give salbutamol 2 x 2.5 mg nebules via continuous nebulisation driven by oxygen Maintain SpO2 to target 92–96% |
| Continued treatment | Repeat salbutamol 4–6 actuations every 20–30 minutes for the first hour, if needed (sooner if needed) | Repeat salbutamol 6 actuations at least every 20 minutes for first hour (3 doses) and as needed |
Additional information
pMDI: pressurised metered-dose inhaler; SpO2: oxygen saturation
Table
| Mild–moderate (all of): | Severe (any of): | Life-threatening (any of): | |
| Consciousness | Alert | N/A | Drowsy or unconscious |
| Speech | Can talk or vocalise | Can only speak a few words in one breath | Cannot vocalise due to dyspnoea |
| Posture | Can walk or crawl | Lethargic | Collapsed or exhausted |
| Breathing | Respiratory distress is not severe | Paradoxical chest wall movement: inward movement on inspiration and outward movement on expiration (chest sucks in when person breathes in) or Use of accessory muscles of neck or intercostal muscles or ‘tracheal tug’ during inspiration or Subcostal recession (‘abdominal breathing’) | Severe respiratory distress or Poor respiratory effort |
| Skin colour | Normal | N/A | Cyanosis |
| Respiratory rate | Normal | Tachypnoea | Bradypnoea (indicates respiratory exhaustion) |
| Heart rate | Normal | Tachycardia | Cardiac arrhythmia or Bradycardia (may occur just before respiratory arrest) |
| Chest auscultation | Wheeze or Normal lung sounds
| N/A | Silent chest or Reduced air entry |
| Oxygen saturation | >94% | 90–94% | <90% or Clinical cyanosis |
Additional information
N/A: Not applicable – may be the same as moderate and does not determine severity category
Table
| Active ingredient | Total daily dose (microg) | |
| Low | Medium/high | |
| Fluticasone propionate | 100 (50 twice daily) | 200 (100 twice daily) |
Additional information
ICS: inhaled corticosteroid
Medium/high doses should be avoided except under specialist supervision
Recommendation type: Consensus recommendation
Shi C, Goodall M, Dumville J, et al. The accuracy of pulse oximetry in measuring oxygen saturation by levels of skin pigmentation: a systematic review and meta-analysis. BMC Med 2022; 20: 267.
Pulse oximetry may overestimate oxygen saturation in people with higher levels of skin pigmentation.[Shi 2022]
Recommendation type: Consensus recommendation
In children aged 5 and younger with acute asthma symptoms or acute wheeze, salbutamol improves symptoms, reduces work of breathing, and increases oxygen saturation.[Storgaard 2025]
In older children and adults, repeated administration of inhaled SABA every 20 minutes for the first hour is effective for rapidly achieving bronchodilation in mild-to-moderate asthma exacerbations.[GINA 2025]
Salbutamol delivered via a pMDI with spacer is at least as effective as salbutamol delivered via nebuliser in preschool children with viral-induced wheezing or acute asthma who do not require mechanical ventilation.[Mitselou 2016]
The use of nebulisers may increase the risk of viral transmission.[Hui 2009, Biney 2024, Goldstein 2021]
Oral salbutamol or intravenous salbutamol are not recommended.
Biney IN, Ari A, Barjaktarevic IZ, et al. Guidance on mitigating the risk of transmitting respiratory infections during nebulization by the COPD Foundation Nebulizer Consortium. Chest 2024; 165: 653-668.
Global Initiative for Asthma (GINA). Global Strategy for Asthma Management and Prevention, 2025. Available from: www.ginasthma.org
Goldstein KM, Ghadimi K, Mystakelis H, et al. Risk of transmitting coronavirus disease 2019 during nebulizer treatment: a systematic review. J Aerosol Med Pulm Drug Deliv 2021; 34: 155-170.
Hui DS, Chow BK, Chu LC, et al. Exhaled air and aerosolized droplet dispersion during application of a jet nebulizer. Chest 2009; 135: 648-654.
Mitselou N, Hedlin G, Hederos CA. Spacers versus nebulizers in treatment of acute asthma – a prospective randomized study in preschool children. J Asthma 2016; 53: 1059-62.
Storgaard Petersen R, Hallas H, Brustad N, Chawes B. Short-term efficacy of inhaled short-acting beta-2-agonists for acute wheeze/asthma symptoms in preschool-aged children: a systematic review and meta-analysis. Thorax 2025; 80: 349-357.
National Asthma Council’s video on how to use a metered dose inhaler (puffer) with a spacer for children
National Asthma Council Australia’s fact sheet on spacers for pressurised metered-dose inhalers
Tidal breathing method:
1. Connect spacer to pMDI plus tightly fitting mask connected to the spacer mouthpiece.
2. Release 1 actuation of salbutamol into the spacer.
3. Watch the child breathe in and out for 4 breaths.
4. Release 1 more actuation of salbutamol into the spacer and repeat until all required actuations delivered.
If the child cannot breathe through a spacer using either the mouthpiece or a mask, use a nebuliser with mask.
Recommendation type: Consensus recommendation
There is very little evidence available to inform recommendations for oxygen saturation targets in children with asthma. Recommended targets differ between major Australian paediatric teaching hospitals.
Delivery methods include simple mask (flow rate 5 L/min) or nasal prongs (flow rate 3 L/min).[GWACAHS 2023]
The normal range oxygen saturation levels measured by pulse oximetry in children is generally stated as 95–100%, one study reported a normal range of 97–100% in healthy children without asthma aged approximately 5–13 years.[Elder 2015]
Some guidelines recommend pulse oximetry alarms to be set at 92% low and 99% high when a child is receiving oxygen therapy.[SCHN 2024] Others recommend targets of 94–98% [RCHM 2020] or >95% for children. Saturations of 100% should be avoided in patients receiving supplemental O2 (acceptable in a child breathing room air).[SCHN 2024]
Some guidelines suggest that, in a child recovering after acute asthma, SpO2 in the low nineties due to ventilation/perfusion mismatch is acceptable if the child is clinically improving.[RCHM 2020, RCHM 2023]
There is no physiological basis for the application of low flow oxygen therapy to a child with normal SpO2 while breathing room air and increased work of breathing.[SCHN 2024]
Elder JW, Baraff SB, Gaschler WN, et al. Pulse oxygen saturation values in a healthy school-aged population. Pediatr Emerg Care 2015; 31: 645-647.
Government of Western Australia Child and Adolescent Health Service. Community Health clinical nursing manual. Oxygen administration. [Reviewed 26 October 2023].
The Royal Children’s Hospital Melbourne. Nursing guidelines. Oxygen delivery [webpage] [Approved December 2020].
The Royal Children’s Hospital Melbourne. Acute asthma. [webpage] [last updated July 2023]
The Sydney Children's Hospitals Network. Oxygen therapy and delivery devices. Practice guideline. Guideline No: 2015-9085 v5. 15 November 2024.
Shi C, Goodall M, Dumville J, et al. The accuracy of pulse oximetry in measuring oxygen saturation by levels of skin pigmentation: a systematic review and meta-analysis. BMC Med 2022; 20: 267.
The Royal Children’s Hospital Melbourne’s guidance on oxygen delivery
The Sydney Children's Hospitals Network’s practice guideline on oxygen therapy and delivery devices
Mask and spacer can be applied over nasal prong oxygen to deliver inhaled bronchodilator [RCHM 2023]
Pulse oximetry may overestimate oxygen saturation in people with higher levels of skin pigmentation.[Shi 2022]
Local policy for oxygen supplementation thresholds and targets may differ.
Perform a physical examination including auscultation, vital signs, and repeated pulse oximetry.
Complete a brief history, including:
Recommendation type: Consensus recommendation
The association of asthma and food allergy is a risk factor for fatal and near-fatal allergic reactions to food allergens.[Burks 2012]
Burks AW, Tang M, Sicherer S, et al. ICON: food allergy. J Allergy Clin Immunol 2012; 129: 906-920.
Children 1–5: prednisone/prednisolone 1 mg/kg orally each morning for 3 days
Recommendation type: Consensus recommendation
For children aged 1–5 years, systemic corticosteroids should generally be limited to those with severe acute wheezing. The Thoracic Society of Australia and New Zealand 2010 position statement on the use of corticosteroids in children [van Asperen 2010] recommended that the use of systemic corticosteroids in preschool children, particularly those with intermittent viral induced wheezing, should be limited to those with wheeze severe enough to need admission to hospital.
Evidence
In preschool children with acute viral-induced wheezing, there is inconsistent evidence for the benefits of systemic corticosteroids.[Foster 2018, Panickar 2009] Oral corticosteroids may be beneficial in children younger than 6 years with frequent acute wheezing or asthma, but evidence does not strongly support their use in this age group.[Castro-Rodriguez 2016]
After an acute asthma episode, treatment with systemic corticosteroids (intramuscular corticosteroids, oral prednisone/prednisolone, or oral dexamethasone) at discharge from the emergency department reduces the risk of relapse in children.[Castro-Rodriguez 2015, Kirkland 2018] However, systemic corticosteroid is not recommended for children 1–5 years unless the acute episode does not respond well to initial bronchodilator treatment or is severe enough to require hospital admission.
Doses
In children the majority of studies in children have used 1–2 mg/kg of oral prednisolone (maximum 60 mg) given initially then 1 mg/kg per day. Current evidence does not support the use of higher doses.[Normansell 2016]
In children, a 3-day course of prednisone/prednisolone is generally as effective as a 5-day course.[Chang 2008]
Most studies evaluating oral dexamethasone in children have used 0.6 mg/kg per dose on one or two consecutive days.[Paniagua 2017] Dexamethasone has a longer half-life than prednisone/prednisolone. Longer courses may more pronounced mineralocorticoid adverse effects. Oral dexamethasone treatment should not exceed 2 days. In children it may be associated with less vomiting than prednisone/prednisolone.[Paniagua 2017, Bravo-Soto 2017, Meyer 2014, Keeney 2014, Cronin 2016]
Safety
Short-term use of oral corticosteroids to treat acute asthma is often well tolerated in children,[Rowe 2001, Smith 2003, Rowe 2007] but may be associated with mood changes, nocturia, and difficulty sleeping.
In the long term, short courses of oral corticosteroids to manage asthma exacerbations are associated with increased lifetime risk of osteoporosis, pneumonia, cardiovascular or cerebrovascular diseases, cataract, sleep apnoea, renal impairment, depression/anxiety, type 2 diabetes, and weight gain.[Price 2018]
Bravo-Soto GA, Harismendy C, Rojas P et al. Is dexamethasone as effective as other corticosteroids for acute asthma exacerbation in children? Medwave 2017; 17: e6931.
Castro-Rodriguez, J. A., Rodrigo, G. J., Rodriguez-Martinez, C. E.. Principal findings of systematic reviews for chronic treatment in childhood asthma. J Asthma 2015; 52: 1038-45.
Castro-Rodriguez JA, Beckhaus AA, Forno E. Efficacy of oral corticosteroids in the treatment of acute wheezing episodes in asthmatic preschoolers: Systematic review with meta-analysis. Pediatric pulmonology 2016; 51: 868-76.
Chang, A B, Clark, R, Sloots, T P, et al. A 5- versus 3-day course of oral corticosteroids for children with asthma exacerbations who are not hospitalised: a randomised controlled trial. Med J Aust 2008; 189: 306-310.
Cronin JJ, McCoy S, Kennedy U et al. A randomized trial of single-dose oral dexamethasone versus multidose prednisolone for acute exacerbations of asthma in children who attend the emergency department. Ann Emerg Med 2016; 67: 593-601.e3.
Foster SJ, Cooper MN, Oosterhof S, Borland ML. Oral prednisolone in preschool children with virus-associated wheeze: a prospective, randomised, double-blind, placebo-controlled trial. Lancet Respir Med 2018; 6: 97-106.
Keeney GE, Gray MP, Morrison AK et al. Dexamethasone for acute asthma exacerbations in children: a meta-analysis. Pediatrics 2014; 133: 493-9.
Kirkland SW, Vandermeer B, Campbell S et al. Evaluating the effectiveness of systemic corticosteroids to mitigate relapse in children assessed and treated for acute asthma: A network meta-analysis. J Asthma 2018: 1-12.
Meyer JS, Riese J, Biondi E. Is dexamethasone an effective alternative to oral prednisone in the treatment of pediatric asthma exacerbations? Hosp Pediatr 2014; 4: 172-80.
Normansell R, Kew KM, Mansour G. Different oral corticosteroid regimens for acute asthma. Cochrane Database Syst Rev 2016; Issue 5: CD011801.
Paniagua N, Lopez R, Muñoz N, et al. Randomized trial of dexamethasone versus prednisone for children with acute asthma exacerbations. J Pediatr 2017;191:190-196.e1.
Panickar J, Lakhanpaul M, Lambert PC, et al. Oral prednisolone for preschool children with acute virus-induced wheezing. N Engl J Med 2009; 360: 329-328.
Price DB, Trudo F, Voorham J, et al. Adverse outcomes from initiation of systemic corticosteroids for asthma: long-term observational study. J Asthma Allergy 2018; 11: 193-204.
Rowe BH, Spooner C, Ducharme F, et al. Early emergency department treatment of acute asthma with systemic corticosteroids. Cochrane Database Syst Rev 2001; Issue 1: CD002178.
Rowe BH, Spooner C, Ducharme F, et al. Corticosteroids for preventing relapse following acute exacerbations of asthma. Cochrane Database Syst Rev 2007; Issue 3: CD000195.
Smith M, Iqbal S, Elliot TM et al. Corticosteroids for hospitalised children with acute asthma. Cochrane Database Syst Rev 2003; Issue 2: CD002886.
van Asperen PP, Mellis CM, Sly PD, et al. The role of corticosteroids in the management of childhood asthma. The Thoracic Society of Australia and New Zealand, 2010. Available from: https://thoracic.org.au/clinical-documents/asthma
Dispense only one course, to avoid overuse or inappropriate use of systemic corticosteroids.
If dyspnoea/increased work of breathing is partially relieved within first 5 minutes, reassess the need for repeated bronchodilator at 15 minutes.
If dyspnoea/increased work of breathing is not relieved, or condition deteriorates, repeat bronchodilator dose and consider adding inhaled ipratropium bromide (if not part of initial treatment) or IV magnesium sulfate:
Recommendation type: Consensus recommendation
Inhaled ipratropium bromide
Ipratropium is recommended as a first-line bronchodilator for patients with severe or life-threatening acute asthma, and as a second-line bronchodilator if inadequate response to salbutamol. The combination of ipratropium and short-acting beta2 agonist appears to be well tolerated in children.[Griffiths 2013]
Intravenous MgSO4
Intravenous magnesium sulfate can be considered as a second-line bronchodilator in severe or life-threatening acute asthma, or when poor response to repeated maximal doses of other bronchodilators. It should not be used as a substitute for inhaled beta2 agonists.[Knightly 2017]
Intravenous magnesium sulfate may reduce hospitalisation rates and improve lung function among children with acute asthma in presenting to the emergency department,[Goodacre 2013, Griffiths 2016] but clinical trial evidence is limited.[Griffiths 2016]
A small randomised controlled trial reported that IV magnesium sulfate was ineffective in reducing respiratory distress in very young children (6 months to 4 years) with acute virus-induced wheezing.[Pruikkonen 2018]
The optimal dose and infusion regimen has not been identified.[Green 2016]
IV magnesium sulfate is generally well tolerated.[Griffiths 2016, Irazuzta 2017]
Nebulised MgSO4
A 2024 systematic review reported that nebulised MgSO4 as an add-on second-line therapy for children with acute asthma may slightly improve lung function but does not reduce hospitalisation rates, based on low-certainty evidence.[Kumar 2024]
Nebulised magnesium sulfate is well tolerated in children.[Powell 2013a, Powell 2013b]
Goodacre S, Cohen J, Bradburn M et al. Intravenous or nebulised magnesium sulphate versus standard therapy for severe acute asthma (3Mg trial): a double-blind, randomised controlled trial. Lancet Respir Med 2013; 1: 293-300.
Griffiths B, Kew KM. Intravenous magnesium sulfate for treating children with acute asthma in the emergency department. Cochrane Database Syst Rev 2016; 4: CD011050.
Irazuzta JE, Chiriboga N. Magnesium sulfate infusion for acute asthma in the emergency department. J Pediatr (Rio J) 2017; 93 Suppl 1: 19-25.
Kumar J, Kumar P, Goyal JP, et al. Role of nebulised magnesium sulfate in treating acute asthma in children: a systematic review and meta-analysis. BMJ Paediatr Open 2024; 8: e002638.
Knightly R, Milan SJ, Hughes R et al. Inhaled magnesium sulfate in the treatment of acute asthma. Cochrane Database Syst Rev 2017; 11: CD003898.
Powell C, Kolamunnage-Dona R, Lowe J, et al. MAGNEsium Trial In Children (MAGNETIC): a randomised, placebo-controlled trial and economic evaluation of nebulised magnesium sulphate in acute severe asthma in children. Health Technol Assess 2013; 17: 1-216.
Powell C, Kolamunnage-Dona R, Lowe J et al. Magnesium sulphate in acute severe asthma in children (MAGNETIC): a randomised, placebo-controlled trial. Lancet Respir Med 2013; 1: 301-308.
Pruikkonen H, Tapiainen T, Kallio M et al. Intravenous magnesium sulfate for acute wheezing in young children: a randomised double-blind trial. Eur Respir J 2018; 51.
Su Z, Li R, Gai Z. Intravenous and nebulized magnesium sulfate for treating acute asthma in children: a systematic review and meta-analysis. Pediatr Emerg Care 2018; 34: 390-395.
Recommendation type: Consensus recommendation
If the child’s asthma has been managed with a reliever alone (e.g. as-needed salbutamol), prescribe maintenance ICS treatment or arrange urgent review for reassessment of treatment.
Recommendation type: Consensus recommendation
A child with asthma who has an exacerbation severe enough to necessitate an ED visit needs maintenance ICS treatment, even if the child has been prescribed a short course of systemic corticosteroid. ICS should be started before the end of the systemic corticosteroid course, and the dose reviewed by the GP at follow-up.
Recommendation type: Consensus recommendation
Warraich S, Bush A, Levy ML, Fleming L. Regular (up to 10 puffs 4-hourly) inhaled salbutamol should be prescribed at discharge after an asthma attack: myth or maxim? Breathe (Sheff) 2023; 19: 230054.
‘Weaning plans’ for salbutamol are not recommended.[Warraich 2023]
Recheck within 3 days with the child’s usual GP.
Comprehensive assessment in 2–4 weeks to reassess risk factors and review the treatment regimen (GP, paediatric respiratory physician, allergist, or paediatrician)
Recommendation type: Consensus recommendation
ASCIA 2024 doses:
Auto-injector
ASCIA 2024 recommended dose for child 7.5–20 kg: adrenaline 150 microg IM via auto-injector
IM via needle and syringe using adrenaline 1:1,000 ampoules (1 mg per 1 mL)
Children: 0.01 mg per kg up to 0.5 mg (0.5 mL) per dose
Recommendation type: Adapted from ASCIA 2024
Anaphylaxis should be suspected when asthma-like respiratory symptoms are accompanied by either of the following features:[ASCIA 2024]
ASCIA. Acute management of anaphylaxis. 2024, Australasian Society of Clinical Immunology and Allergy.
ASCIA Guidelines: Acute management of anaphylaxis
Adrenaline should be given before considering salbutamol when anaphylaxis is suspected.[ASCIA 2024]
When breathing improves, consider changing to a pressurised metered-dose inhaler plus spacer or intermittent nebuliser.
Recommendation type: Consensus recommendation
The use of nebulisers may carry a higher risk of viral transmission.[GINA 2025]
Biney IN, Ari A, Barjaktarevic IZ, et al. Guidance on mitigating the risk of transmitting respiratory infections during nebulization by the COPD Foundation Nebulizer Consortium. Chest 2024; 165: 653-668.
Global Initiative for Asthma (GINA). Global Strategy for Asthma Management and Prevention, 2025. Available from: www.ginasthma.org
Goldstein KM, Ghadimi K, Mystakelis H, et al. Risk of transmitting coronavirus disease 2019 during nebulizer treatment: a systematic review. J Aerosol Med Pulm Drug Deliv 2021; 34: 155-170.
Hui DS, Chow BK, Chu LC, et al. Exhaled air and aerosolized droplet dispersion during application of a jet nebulizer. Chest 2009; 135: 648-654.
To deliver intermittent nebulised bronchodilators in a patient receiving oxygen therapy, use an air-driven compressor nebuliser and administer oxygen by nasal cannulae.
Titrate oxygen to target SpO2 92–96% in children (or according to local policy).
If nebulised salbutamol is needed for a patient receiving supplemental oxygen, the nebuliser can be driven by piped (wall) oxygen or an oxygen cylinder fitted with a high-flow regulator capable of delivering >6 L/min. The patient should be changed back to their original oxygen mask when nebulisation is completed.
The use of nebulisers may increase the risk of viral transmission.[Hui 2009, Biney 2024, Goldstein 2021]
Recommendation type: Consensus recommendation
Adrenaline is not used routinely in the management of severe acute asthma.
Its use should be reserved for situations where inhaled salbutamol cannot be given in a patient with respiratory arrest or pre-arrest status, or when anaphylaxis is suspected.
Consider admission if any of the following:
For most children with an acute episode requiring an ED visit, ICS should be started at (or increased to) medium doses, with review scheduled for 2–3 months later.
Acute wheezing in this age group is most commonly due to acute viral bronchiolitis.
Follow bronchiolitis guidelines.