Astmul Bronsic Infantil in ER

8/11/2019 Astmul Bronsic Infantil in ER

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Reason for this Guideline

Asthma is a common condition in western society and children with it present frequently to

emergency departments. Some asthmatics attend with life-threatening symptoms and require

immediate life-saving intervention, while others come to the ED because the parents are under-

standably very worried about their wheezy childespecially if there are other family members

with asthma. Many lay between these extremes, and the real skill in caring for suffers lies in

rapid and accurate assessment of severity - and therefore urgency of need. This guideline is

designed to ensure that the clinicians in the Emergency Department have a framework that

guides both assessment and therapy, and in particular ensures that children needing resuscita-tion receive it promptly.

When to use this Guideline

This guideline should be used in all children with known asthma who attend the Emergency De-

partment.

How to use this Guideline

The key to successful use of this guideline is an understanding of the clinical risk assessment

that has been derived from the BTS guidelines. The first aim is to identify children with life-

threatening asthma, and then to establish whether they need urgent intubation and ventilation

(after discussion with the Paediatric Team) or whether maximal medical therapy can be tried.Children with severe asthma can also be identified early and treated appropriately, while those

with mild exacerbations can use their normal bronchodilators. Most importantly all children are

reassessed (using the same risk assessment) and treatment is modified as necessary. Those

who continue to have life-threatening features are admitted to the paediatric critical care ar-

eas, while those who have severe symptoms should be admitted to the paediatric wards. Chil-

dren who presented with mild symptoms, and those whose symptoms have improved significantly

with treatment will probably be suitable for discharge, possibly after a pe-

riod of observation and if there is suitable adult supervision. If they do go

home then community follow up should be considered, as should referral to

the paediatric asthma team.

Guideline FAQs

What is asthma?

Asthma is lower airway obstruction caused by bronchospasm.

Which children should this guideline be used for?

This guideline should be used for all patients presenting to the department with symp-

tomatic asthma.

Should I ever give asthmatic children anything to calm them down if they are anx

ious?

No! Sedating patients who are having difficulty breathing is absolutely contraindi-

cated. Treat the underlying cause (asthma).

Special points of inter-

est:

It is important to remem-

ber that normal physio-logical values change with

age

The PEFR can be very

difficult to obtain in

children

Children under the age of

5 (and a significant num-

ber over this age) cannot

use inhalers effectively

without a spacer device

Children under the age of

18 months may wheeze for

a number of other rea-

sonsand may respondpoorly to treatment

intheEmergency

Department

2003-52

CDSG

Asthma in Childhood


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PDI/520: SUITABILITY FOR PROTOCOL DRIVEN INVESTIGATION (ALL YES)

Order: T, P, BP, R, SaO2, PEFR, Weight

CDU/521 / 523: CLINICAL RISK ASSESSMENT OF Asthma CDU/061 CDU/063

Life threatening if any of LT, severe to moderate if none of LTand any of Sor Moand mild if none of LT, Sor Mo. NB PEFRis not usually possible in children aged less than 3 years.

MEDICAL THERAPY ADVICE

CDU/522: Need for immediate review for IPPV (ANY YES)

CDU/524: Need for second review for IPPV (ANY YES)

CDU/524: Suitable for discharge (ALL YES)

Known Asthma YesAcute breathlessness / wheeze is the main complaint Yes

LT S/Mo LT S/Mo

Reduced level of consciousness / agitation

Cyanosis / SaO2< 92% on air

Poor respiratory effort / silent chest

Exhaustion

PEFR < 33% best or predicted

PaO2< 8 kPa / PaCO2 > 4.6 kPa

Dysrhythmia (including bradycardia)

SBP < 90 mm Hg

Unable to talk in sentences or eat

Use of accessory neck muscles

PEFR 33 - 75% best or predicted

RR significantly elevated for age (>50 age 2-5, >30 age > 5)

P significantly elevated for age (>130 age 2-5, >120 age > 5)

Maximal medical therapy: This consists of continuous nebulised salbutamol (2.5mg < 5y, 5mg > 5y) together with steroids IV (hydrocortisone 4 mg/kg max100 mg). IV bronchodilators (salbutamol or aminophylline) may be required.

Medical therapyThis consists of intermittent nebulised salbutamol (2.5mg < 5y, 5mg > 5y) together with steroids orally (prednisolone 1-2 mg/kg max40mg). IV bronchodilators (salbutamol or aminophylline) may be required. Antibiotics may be indicated.

Antiibiotics:Are indicated if there are clinical or radiographic signs of pneumonia. Start with amoxicillin po (erythromycin if allergic to penicillin), or cefu-roxime IV tds if parenteral delivery is required.

Airway compromise Yes

Inadequate breathing Yes

Severe hypoxia (SaO2< 70% on air) Yes

Airway compromise Yes

Inadequate breathing YesSevere hypoxia (SaO2< 70% on air) Yes

Adequate social support YesAble to eat and drink Yes

Able to use inhaler with spacer device Yes

No consolidation or pneumothorax on CXR if indicated Yes

6h of stable observation for all children who have required nebulisers Yes

Alert Yes

Ref/526: Suitable for paediatric referral for admission

Ref/527: Suitable for Discharge and community follow-up


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Evidence Base

This guideline is based primarily on the following sources:

There are 6 relevant Cochrane reviews:

Additional reviews (BestBETs) have been undertaken as follows:

Additional sources of interest include:

Nice guidance is extant / pending / NOTCURRENTLYPLANNED

British Guideline on the Management of Asthma. A national clinical guideline. British Tho-

racic Society and the Scottish Intercollegiate Guidelines Network.http://www.brit-

thoracic.org.uk/docs/asthmafull.pdf

Anticholinergic drugs for wheeze in children under the age of two years. ML Everard, A Bara, M Kurian, TM Elliott, F Ducharme

Combined inhaled anticholinergics and beta2-agonists for initial treatment of acute asthma in children. LH Plotnick, FM Ducharme

Corticosteroids for hospitalised children with acute asthma. M Smith, S Iqbal, TM Elliott, BH Rowe

Interventions for educating children who have attended the emergency room for asthma. MM Haby, E Waters, CF Robertson, PG Gibson, FM

Ducharme

Intravenous aminophylline for acute severe asthma in children over 2 years using inhaled bronchodilators. A Mitra, D Bassler, FM Ducharme

Oral and systemic steroids at different doses for acute asthma in hospitalised children. M Smith, L McLoughlin

BB 43. Oral steroids are as effective as intravenous steroids in acute severe asthma http://www.bestbets.org/cgi-bin/bets.pl?record=00043

BB 212. Beta-agonists with or without anti-cholinergics in the treatment of acute childhood asthma? http://www.bestbets.org/cgi-bin/bets.pl?

record=00212

Bb 235. Lignocaine as a pretreatment to Rapid Sequence Induction in patients with status asthmaticus http://www.bestbets.org/cgi-bin/bets.pl?

record=00235

BB 239. Is IV aminophylline better than IV salbutamol in the treatment of moderate to severe asthma http://www.bestbets.org/cgi-bin/bets.pl?

record=00239

BB 444. Is homeopathy better than placebo in the treatment of bronchial asthma ? http://www.bestbets.org/cgi-bin/bets.pl?record=00444

BB 620. Nebulised magnesium in asthma http://www.bestbets.org/cgi-bin/bets.pl?record=00620

BB 686. Non-steroidal anti-inflammatory drugs and exacerbations of asthma in children http://www.bestbets.org/cgi-bin/bets.pl?record=00686

BB 768. Does magnesium sulphate have a role in the management of paediatric status asthmaticus? http://www.bestbets.org/cgi-bin/bets.pl?

record=00768
http://www.brit-thoracic.org.uk/docs/asthmafull.pdfhttp://www.brit-thoracic.org.uk/docs/asthmafull.pdfhttp://www.brit-thoracic.org.uk/docs/asthmafull.pdfhttp://www.brit-thoracic.org.uk/docs/asthmafull.pdfhttp://www.bestbets.org/cgi-bin/bets.pl?record=00043http://www.bestbets.org/cgi-bin/bets.pl?record=00212http://www.bestbets.org/cgi-bin/bets.pl?record=00212http://www.bestbets.org/cgi-bin/bets.pl?record=00212http://www.bestbets.org/cgi-bin/bets.pl?record=00235http://www.bestbets.org/cgi-bin/bets.pl?record=00235http://www.bestbets.org/cgi-bin/bets.pl?record=00235http://www.bestbets.org/cgi-bin/bets.pl?record=00239http://www.bestbets.org/cgi-bin/bets.pl?record=00239http://www.bestbets.org/cgi-bin/bets.pl?record=00239http://www.bestbets.org/cgi-bin/bets.pl?record=00444http://www.bestbets.org/cgi-bin/bets.pl?record=00620http://www.bestbets.org/cgi-bin/bets.pl?record=00686http://www.bestbets.org/cgi-bin/bets.pl?record=00768http://www.bestbets.org/cgi-bin/bets.pl?record=00768http://www.bestbets.org/cgi-bin/bets.pl?record=00768http://www.bestbets.org/cgi-bin/bets.pl?record=00768http://www.bestbets.org/cgi-bin/bets.pl?record=00239http://www.bestbets.org/cgi-bin/bets.pl?record=00235http://www.bestbets.org/cgi-bin/bets.pl?record=00212http://www.brit-thoracic.org.uk/docs/asthmafull.pdfhttp://www.bestbets.org/cgi-bin/bets.pl?record=00768http://www.bestbets.org/cgi-bin/bets.pl?record=00686http://www.bestbets.org/cgi-bin/bets.pl?record=00620http://www.bestbets.org/cgi-bin/bets.pl?record=00444http://www.bestbets.org/cgi-bin/bets.pl?record=00239http://www.bestbets.org/cgi-bin/bets.pl?record=00235http://www.bestbets.org/cgi-bin/bets.pl?record=00212http://www.bestbets.org/cgi-bin/bets.pl?record=00043http://www.brit-thoracic.org.uk/docs/asthmafull.pdf


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Disclaimer

This guideline has been developed by clinicians and its content has been reviewed by theClinical Effectiveness Committee of the British Association for Emergency Medicine.Guidelines cannot always contain all the information necessary for determining appropriatecare and cannot address all individual situations, therefore individuals using these guidelines

must ensure they have the appropriate knowledge and skills to enable interpretation.Guidelines can never substitute for sound clinical judgement. This guideline may not reflectchanges in clinical practice that have occurred since it was last reviewed.

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Astmul Bronsic Infantil in ER