Immediate treatment of acute asthma in children 6–11 in the ED

All of:

Can walk, speak whole sentences in one breath (younger children can speak in phrases)

SpO₂ (room air) >94%

Any of:

Unable to complete sentences in one breath due to breathlessness

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 4–12 actuations (100 microg per actuation) via pMDI and spacer (tidal breathing)

Repeat salbutamol 4–12 actuations every 20–30 minutes for the first hour, if needed (sooner if needed)

Start bronchodilators:

Salbutamol 12 actuations (100 microg per actuation) via pMDI and spacer (tidal breathing). If patient cannot use spacer, give 5 mg nebule via nebuliser.

Ipratropium 8 actuations (21 microg/actuation) via pressurised metered-dose inhaler and spacer every 20 minutes for first hour.

Start oxygen supplementation if SpO₂ <92% on room air and titrate to target SpO₂ 92–96%

Repeat bronchodilators 4–6 hourly for 24 hours. If salbutamol delivered via nebuliser, add 500 microg ipratropium to nebulised solution every 20 minutes for first hour. Repeat 4–6 hourly.

Arrange immediate transfer to higher-level care

Start bronchodilators:

Salbutamol 2 x 5 mg nebules via continuous nebulisation driven by oxygen

Ipratropium 500 microg ipratropium added to nebulised solution every 20 minutes for first hour. 

Maintain SpO₂ 92–96%

Repeat bronchodilators 4–6 hourly.

When dyspnoea improves, consider changing to salbutamol via pMDI plus spacer or intermittent nebuliser