Raigmore Critical Care Guidelines Paediatric Asthma Guidelines Aim

Raigmore Critical Care Guidelines Paediatric Asthma Guidelines Aim To provide guidance on initial management of asthma Scope All critically ill paediatric patients Child with Asthma referred to Critical Care • A child with severe / deteriorating asthma is at significant danger. The role of the clinician is to appropriately judge the level of severity for the asthma attack and instigate treatment that results in a prolonged period of stable control (not merely chasing deteriorating symptoms). • Children with severe acute asthma may require rapid escalation of treatment with a significant proportion of these patients requiring intensive treatment and monitoring in a HDU/ ITU setting. Assessment Acute severe asthma • Can’t complete sentences in one breath or too breathless to talk or feed. • Sp. O 2 <92% • PEF 33 -50% best or predicted • Pulse: >140 bpm in children aged 2 -5 years OR >125 in children aged >5 years • Use of accessory muscles of respiration and rate >40 breaths/min aged 2 -5 years OR >30 breaths/min aged 7 -15 years Life threatening asthma Any one of the following in a child with severe asthma: Clinical signs Measurements Silent chest Sp. O 2 <92% Cyanosis PEF <33% best or predicted Poor respiratory effort Hypotension Use of accessory muscles of respiration Exhaustion Confusion Initial Management • High flow oxygen via a tight fitting facemask. • Nebulised salbutamol (2. 5 mg if <4 yrs, 5 mg if >4 yrs) “back to back “ if required • Ipratropium bromide 250 micrograms 20 to 30 minutes for 1 st hr. (Nebuliser driven by 6 -10 l/min O 2). • Steroids: Oral prednisolone: < 1 year of age = 2 mg/kg 1 -2 years of age = 20 mg 3 -4 years of age = 30 mg 5+ years of age = 40 mg OR iv hydrocortisone 4 mg/kg if oral route not possible (Max dose 100 mg). • CXR - Rule out pneumothorax • Blood gas – capillary (normal values) • IV access – check U&Es, FBC, and Glucose. • IV Magnesium sulphate bolus – 50 mg/kg over 20 minutes (max 2 g) (0. 1 ml/kg of 50% Magnesium sulphate – dilute dose 5 times before giving). Can be repeated if necessary. • IV Salbutamol (make up to concentration = 200 microgram/ml so 0. 3 ml/kg/hr=1 microgram/kg/min) Loading dose of 15 micrograms/kg over 10 minutes Maintenance dose 2 -5 micrograms/kg/min Adapted from Scotstar Website M Mac. Kinnon 22. 11. 2016

Raigmore Critical Care Guidelines Paediatric Asthma Guidelines Further Medical Management • 2 nd IV access – regular blood gas, electrolyte and glucose monitoring. • Once on IV salbutamol, nebulised salbutamol should continue every 30 minutes with nebulised ipratropium bromide every 4 -6 hrs. • IV Aminophylline – if not on long term theophyllines (not to be given via same IV cannula as Salbutamol) Loading dose 5 mg/kg over 20 minutes Maintenance dose 1 mg/kg/hr • Consider IV ondansetron 0. 1 mg/kg – max dose 4 mg • Care should be taken to identify signs of salbutamol toxicity particularly in the older age group • Acidosis • Lactataemia • Tachycardia/tachyarrhythmias Critical Care Intervention • Ensure adequate monitoring is in place • If intubation and ventilation likely, transfer to theatre • Consider using ketamine as induction agent (2 mg/kg iv, 5 -10 mg/kg im) • Repeat CXR as soon as appropriate following ventilation • d/w mike re NIV Ventilation Strategies • Consider using SIMV without autoflow as ventilation mode • Set extended I: E ratio with relatively low respiratory rate • Monitor expiratory flow • Monitor intrinsic PEEP to aid setting extrinsic PEEP • If severe air-trapping consider prolonged disconnection from ventilator • Consider ketamine infusion 1 -2 mg/kg bolus; 0. 5 -2. 5 mg/kg/hr (20 mg/ml solution saline or dextrose) • Consider infusion of muscle relaxant e. g Rocuronium see trolley folder • Consider volatile anaesthetic agent (note scavenging issues) Adapted from Scotstar Website M Mac. Kinnon 22. 11. 2016