Acute Asthma

Life-threatening features: Cyanosis, silent chest, exhaustion, poor respiratory effort, agitation, low BCS

Like in all emergencies - approach patient with an ABCDE-assessment!

Important points in history


Acute features

Chronic features

Differential Diagnosis


Definitions of severity of asthma


Moderate Severe


(nota bene: if inhalers and spacers cannot be obtained then start with nebulised Salbutamol at below mentioned doses and switch to inhalers later)

Mild Asthma Moderate Asthma Severe or life-threatening Asthma



If not improving

Continue Salbutamol Nebs meanwhile

Drug dosages

  • 40 mg/kg (diluted to at least 10 %) over 20 min. Monitor BP (see BNF and look at ampoule concentration)
  • Safer than aminophylline
  • Available in oncology or labour ward

Aminophylline - CAUTION

  • loading dose = 5mg/kg (max. 300 mg) diluted (maximum concentration 25mg/mL) and administered over 20mins (maximum rate should not exceed 25mg/min) then 1 mg/kg/hr ONLY WITH SENIOR INPUT (see BNF)
  • If the child has been on maintenance theophylline or has been taking erythromycin, the loading dose of aminophylline should be omitted
  • These children will need very careful monitoring. Signs of potential aminophylline reaction
    • Tachycardia (pulse rate of >180/min) - contact senior if concerned
    • Headache or convulsion
    • Vomiting
    • Flushing

Supportive Care

On discharge

Review in General Clinic (Wednesdays 1:30pm) if needing inhaler >3 times per week or if this is second presentation to hospital

Chronic/ ongoing Asthma


All children (except mildest wheeze) need a Salbutamol inhaler on discharge for when the child is acutely breathless or wheezy If >1 asthma attack, consider daily Beclomethasone inhaler 'Interval Symptoms' (cough/wheeze at night or after exercise, prolonged recovery from URTIs) are guides to poorly controlled asthma. The child should come back to general clinic

Guardian education

Follow up

How to make and use a SOBO Bottle spacer - 2 options of placing inhaler

Steps for use

  1. Shake inhaler
  2. Insert inhaler into the hole in the bottle
  3. Teach the child to form a tight seal around the mouthpiece of the bottle
  4. Apply a puff from the inhaler into the bottle
  5. Count for 10 seconds whilst the child breathes in and out (10 breaths)
  6. Take inhaler out of bottle and shake to mix
  7. Repeat steps 1-6 to give the number of puffs needed.

For children under 3 years

Attach a face mask to the mouth piece of the bottle. If the mask has holes in it, put tape over these. Follow above steps. Needs 2 people.

Spacer care

Wash once a week in soapy water and leave out in the sun to dry. Do not dry inside with a cloth.


Eventually there will be asthma diaries and informative leaflets for the families available in the department.