Criteria

GINA criteria for the severity of asthma exacerbations[7]​​

For children 5 years or younger

Mild or moderate:

  • Breathless, agitated

  • Pulse rate ≤180 beats per minute (bpm) (0-3 years) or ≤150 bpm (4-5 years)

  • Oxygen saturation (on air) ≥92%

Severe or life-threatening:

  • Unable to speak or drink

  • Central cyanosis

  • Confusion or drowsiness

  • Respiratory rate >40/minute

  • Oxygen saturation (on air) <92%

  • Silent chest on auscultation

  • Pulse rate >180 bpm (0-3 years) or >150 bpm (4-5 years)

For children 6-11 years

Mild or moderate:

  • Talks in phrases, prefers sitting to lying, not agitated

  • Respiratory rate increased

  • Accessory muscles not used

  • Pulse rate 100-120 bpm

  • Oxygen saturation (on air) 90% to 95%

  • PEF >50% predicted or best

Severe:

  • Talks in words, sits hunched forwards, agitated

  • Respiratory rate >30/minute

  • Accessory muscles in use

  • Pulse rate >120 bpm

  • Oxygen saturation (on air) <90%

  • PEF ≤50% predicted or best

Life-threatening:

  • Drowsy, confused, or with silent chest

NAEPP/NHLBI criteria for the severity of asthma exacerbations[50]

These criteria cover all ages (including adults).

Mild:

  • Dyspnoea only with activity; patient talks in sentences

  • Increased respiratory rate; no increase in heart rate

  • Usually no accessory muscle use or suprasternal retractions

  • Moderate wheeze (often only end expiratory)

  • Absent pulsus paradoxus (<10 mmHg)

  • Oxygen saturation on air >95%

  • Peak expiratory flow (PEF) (or forced expiratory volume in the first second of expiration [FEV₁]) 70% or more of predicted or percentage of personal best.

Moderate:

  • Dyspnoea interferes with or limits usual activity; patient talks in phrases

  • Increased respiratory rate and heart rate

  • Often has accessory muscle use and suprasternal retractions

  • Loud wheeze (throughout exhalation)

  • Pulsus paradoxus may be present (10-25 mmHg)

  • Oxygen saturation (on air) 90% to 95%

  • PEF (or FEV₁) 40% to 69% predicted or percentage of personal best.

Severe and life-threatening:

  • Dyspnoea at rest; cessation of feeding in infants; agitation or drowsiness; speaking in single words or inability to speak

  • Increased respiratory rate and heart rate

  • Accessory muscle use and suprasternal retractions; may have thoraco-abdominal movement

  • Usually loud wheeze (throughout inhalation and exhalation), but wheeze may be absent (silent chest)

  • Pulsus paradoxus often present in severe exacerbations (20-40 mmHg in a child); in a severe exacerbation, the absence of pulsus paradoxus suggests respiratory muscle fatigue and imminent respiratory arrest

  • Oxygen saturation (on air) <90%

  • Cyanosis may be present

  • Partial pressure of oxygen (PaO₂) (on air) <60 mmHg; partial pressure of carbon dioxide (PaCO₂) ≥42 mmHg

  • PEF (or FEV₁) 25% to 39% (severe) or <25% (life-threatening) predicted or percentage of personal best.

BTS/NICE/SIGN criteria for the severity of asthma exacerbations[57]​​

If a patient has signs and symptoms across categories, always treat according to their most severe features.

For children aged <2 years

Moderate asthma:

  • Oxygen saturation measured by pulse oximetry (SpO₂) (on air) ≥92%

  • Audible wheeze and using accessory muscles

  • Still feeding

  • No clinical features of acute severe asthma

Acute severe asthma:

  • SpO₂ (on air) <92%

  • Cyanosis

  • Marked respiratory distress

  • Too breathless to feed

For children aged 2-5 years:

Moderate asthma:

  • Oxygen saturation measured by pulse oximetry (SpO₂) (on air) ≥92%

  • No clinical features of acute severe asthma

Acute severe asthma:

  • SpO₂ (on air) <92%

  • Too breathless to talk or eat

  • Heart rate >140/minute

  • Respiratory rate >40/minute

  • Use of accessory neck muscles

Life-threatening asthma:

  • SpO₂ (on air) <92% plus any of:

    • Silent chest

    • Poor respiratory effort

    • Agitation

    • Confusion

    • Cyanosis

For children aged over 5 years

Moderate asthma:

  • SpO₂ (on air) ≥92%

  • PEF ≥50% best or predicted

  • No clinical features of severe asthma

Acute severe asthma:

  • SpO₂ (on air) <92%

  • PEF 33% to 50% best or predicted

  • Heart rate >125/minute

  • Respiratory rate >30/minute

  • Use of accessory neck muscles

Life-threatening asthma:

  • SpO₂ (on air) <92% plus any of:

    • PEF <33% best or predicted

    • Silent chest

    • Poor respiratory effort

    • Altered consciousness

    • Cyanosis

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