This section is intended for clinicians caring for children with asthma in a hospital or tertiary care setting. It outlines examples of best practice in the assessment, treatment and ongoing management of children and young people with asthma in an acute setting.
Asthma management in emergency departments
Acute asthma is a relatively common emergency in children and young people and should be treated as severe until proven otherwise. Severe asthma in children is the third most common cause of hospital admission and the most common cause of admission to paediatric intensive care units (PICU). Asthma exacerbations can be classified as mild, moderate, severe, or life threatening. In the ambulatory, urgent care and emergency department settings, the treatment goals are correction of severe hypoxemia, rapid reversal of airflow obstruction and preventing relapse. It is essential to recognise the severity of an acute asthma attack by observing the degree of a child’s breathlessness and whether they are using their accessory muscles, if they have a wheeze, what their pulse and respiratory rate is and their level of distress.
There is evidence that pulse oximetry in people with brown or black skin tones may underestimate the level of hypoxia; the oximeter companies are aware of this and working on possible solutions. Therefore, clinicians should not rely on oximetry alone and assessments of people with asthma should include a thorough assessment including respiratory and pulse rate and lung function. Please find a statement on the use of oximetry for people with brown or black skin tones which has been agreed for London.
Prompt action to manage asthma exacerbations is required with the right care, in the right place, at the right time by clinicians that are trained in asthma. Rapid access to specialist care when needed is required.
- The department should have an identified lead for asthma who helps to develop excellent streamlined processes and best practice for admission and discharge.
- Access to short acting bronchodilators via metered dose inhalers via a spacer will prevent over reliance on hospital care. If nebuliser therapy is required assessment should be by a consultant and it should be administered by an oxygen device not air driven.
- Systemic steroids within 1 hour of presentation.
The National Bundle of Care for CYP with asthma has a section on management of exacerbations with standards on acute presentation and discharge.
Examples of London Hospital Guidelines (more are available in the Guidelines and Pathways section)
- Guidelines and pathways – Transformation Partners in Health and Care
- Clinical assessment of acute asthma for a child aged 2-16 years
As outlined in NICE quality standards, a structured assessment and review should be undertaken before discharge. The British Thoracic Society (BTS) have developed an asthma care bundle which can be used for patients discharged from ED following an acute asthma attack, but can also be used in admissions wards.
A ward round discharge checklist can be useful. London’s clinical leadership group have made a clinical recommendation on the use of salbutamol post acute asthma attack, related to the use of salbutamol weaning plans which are not recommended. These resources on symptom management after an asthma attack have been developed by beat asthma. Your patients and families may find this video, developed by the CYP asthma team at Addenbrooke’s Hospital and Cambridge University Hospitals, useful.
All children and young people who have attended ED or been admitted to hospital with wheeze or asthma should have a review in primary care within 48 hours. This leaflet from from St George’s can be used to explain this to patients and their families. This list of mental health resources may be useful to signpost children and young people who have anxiety associated with their asthma.