Paeds Acute Asthma Algorithm
Source: Paediatric Protocols for Malaysian Hospitals, 5th Edition. Ministry of Health Malaysia.
Source: Paediatric Protocols for Malaysian Hospitals, 5th Edition. Ministry of Health Malaysia.
Mild · PAS 5-7
MDI Salbutamol now and every 60min PRN (via MDI and spacer)
or
Nebulised Salbutamol
Give systemic corticosteroid (oral)
Complete all of the above within 60min of triage
VITAL SIGNS & PAS q 60min
If PAS increase (8-11) — Move to "Moderate pathway"
If PAS remained the same or less (PAS 5-7) — Consider discharge; Provide discharge plan; Short course prednisolone
Moderate · PAS 8-11
MDI Salbutamol now and every 20min (via spacer) X 3
or
Oxygen driven Nebulised Salbutamol
Administer oxygen to maintain SpO2 94-98%
Give oral corticosteroid AS SOON AS POSSIBLE after 1st salbutamol dose (within 60 min of triage)
Complete all of the above within 60min of triage
VITAL SIGNS & PAS q 30-60 min
If PAS increase (12-15) — Move to "Severe pathway"
If PAS remained the same (PAS 8-11) — Consider admission; Move to "Severe pathway"
If PAS reduced (5-7) — Consider discharge; Provide discharge plan; Short course prednisolone
Severe · PAS 12-15
Administer oxygen to maintain SpO2 94-98%
Oxygen driven Nebulised Salbutamol + Ipratropium Bromide + Steroid now and every 20min X 3
Give oral/IV corticosteroid AS SOON AS POSSIBLE (within 20 min of triage)
Consider IV access or ABG
Complete all of the above within 60min of triage
VITAL SIGNS & PAS q 20-30 min
If PAS increase — Move to "Life-threatening respiratory failure pathway"
If PAS remained the same — Repeat the same with oxygen driven nebulised Salbutamol + Ipratropium every 20min X 3; IV MgSO4 / SC Terbutaline
If PAS improving (8-11) — Move to "Moderate pathway"
Life-threatening respiratory failure
To assess STATLethargy, cyanosis, decreasing respiratory effort and/or rising pCO2
Administer 100% oxygen
Support ventilation (DO NOT OVERVENTILATE)
Continuous cardiopulmonary monitoring
Oxygen driven Nebulised Salbutamol + Ipratropium Bromide + Steroid now and back to back/continuous every 20min X 3
Give systemic corticosteroid AS SOON AS POSSIBLE
IV MgSO4 (caution: can cause low BP) or SC Terbutaline
Obtain IV access & ABG
VITAL SIGNS & PAS q 20
If no improvement — Add IV Salbutamol (slow bolus +/- infusion, need continuous ECG monitor for infusion); IV fluid; CXR; PICU/PHDU admission
| Drug | Formulation | Dosage |
|---|---|---|
| SABA: Short Acting β₂-agonists | ||
| Salbutamol | MDI + spacer | ≤ 6 years: 4-6 puffs > 6 years: 8-10 puffs¹ may administer every 20min x 3 |
Nebuliser solution 5mg/ml | 0.15 mg/kg ≤ 5 years: 2.5 mg¹,³ > 5 years : 5 mg Consider neat nebulised salbutamol in life threatening asthma | |
Intravenous | Single bolus 5-15 mcg/kg over 10 min then 1-5 mcg/kg/min thereafter³ | |
| Terbutaline | Nebuliser solution 10 mg/ml, 2.5 mg/ml or 5mg/ml respule | 0.2-0.3 mg/kg/dose or < 20 kg: 2.5 mg/dose ≥ 20 kg: 5.0 mg/dose |
subcutaneous | 5-10 mcg/kg/dose (max 0.5 mg) | |
| SAMA: short acting muscarinic antagonist (anti-cholinergic) | ||
| Ipratopium bromide (used in combination with SABA) | Nebuliser solution 250mcg/ml | < 6 years: 125-250 mcg 6 hourly ≥6 years: 250-500 mcg 6 hourly May administer every 20 min (q20min) x3 in the first hour of nebulised ipratropium. Can repeat during 2nd hour then 6 hourly |
MDI + spacer (inhaler) | <6 years: 2 puffs q20min x 3 ≥6 -12 years: 4-8 puffs q20min x 3 ≥12 years: 8 actuations q20 doses x3 in the first hour (1 puff= 20 mcg/puff) | |
| Magnesium sulphate (MgSO4) | Intravenous | Magnesium sulphate 50%, 0.1 mL/kg (50 mg/kg) IV over 20 mins |
| Corticosteroids | ||
| Prednisolone | Oral | 1-2 mg/kg/day (for 3-7 days) Maximum daily dose: • 10 mg prednisolone for children under 2 years of age • 20 mg for children aged 2–5 years • 30–40 mg for children 6-11years • 40-50 mg for 12 years and older for 5-7 days |
| Hydrocortisone | Intravenous | 4-5 mg/kg/dose 6 hourly (max 100mg) |
| Methylprednisolone | Intravenous | 1 mg/kg 6 hourly day 1, then 12 hourly day 2, then 24 hourly |
| Budesonide | Nebulised | 0.5 mg /dose x 3 doses within first 1 hour (max daily dose is 2 mg). It can be mixed with SABA and SAMA solutions |
| Dexamethasone | PO intramuscular | 0.6 mg/kg/dose (max 16 mg) OD for 1-2/7. 0.3-0.6 mg/kg/dose (max 15 mg) stat dose. |