Treatment algorithm
Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer
nebulised anticholinergic
Additional treatment recommended for SOME patients in selected patient group
Children aged 6-11 years are routinely given a nebulised anticholinergic. Children aged 5 years and younger only receive a nebulised anticholinergic if there is poor response to initial treatment with beta-2 agonists, corticosteroids, and oxygen. The benefits and risks in children <2 years are unclear and anticholinergics are not recommended, except for children with bronchiolitis and chronic lung disease of prematurity.[7][57][86]
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]
Anticholinergics are given by oxygen-driven nebuliser every 20 minutes for the first hour and then reassessed.[7][57] Nebulised anticholinergics produce a weaker bronchodilation response with a slower onset of action (30-90 minutes) than beta-2 agonists (5-15 minutes).[85] Their addition can improve both cholinergic bronchomotor tone and secretions.
Cardiac stimulation occurs but is less marked than that produced by beta-2 agonists.
Primary options
ipratropium inhaled: children ≤5 years of age: 250 micrograms nebulised every 20 minutes for 3 doses; children 6-11 years of age: 250-500 micrograms nebulised every 20 minutes for 3 doses
intravenous bronchodilator or nebulised magnesium sulfate
Additional treatment recommended for SOME patients in selected patient group
Consider intravenous bronchodilator therapy if there is poor response to inhaled bronchodilators and corticosteroids.[7][57][59] Criteria for starting include no response to initial therapies, persistent hypoxaemia, and an FEV₁ <60% predicted at 1 hour.[7]
Intravenous magnesium sulfate is preferred by GINA (children 6-11 years old) and BTS/NICE/SIGN (children 2-11 years old) for exacerbations unresponsive to first-line therapy.[7][57][59][75][76]
[ ]
Its use can reduce the length of hospital stay.[83] However, it does not have an established role in children 5 years and younger due to a lack of evidence.[7] Nebulised magnesium sulfate can be considered if there is no intravenous access, but this offers only modest benefit in severe exacerbations.[7][57][78][79][80]
[ ]
Nebulised magnesium sulfate can be added to a nebulised short-acting beta-2 agonist and anticholinergic in the first hour of treatment for children 2-5 years with severe asthma (e.g., oxygen saturation <92%), particularly if symptoms have lasted <6 hours.[7][57] However, this may not be as effective as intravenous therapy.[7][73][74]
[ ]
Intravenous SABA (salbutamol or subcutaneous terbutaline where intravenous salbutamol is not available) or a methylxanthine (aminophylline or theophylline) are listed as second-line intravenous bronchodilators by the BTS/NICE/SIGN guideline for use in children 2-11 years old, but only under expert supervision and with extreme caution.[57][59] Neither approach is recommended by GINA.[7]
Treatment with intravenous magnesium sulfate requires close monitoring for respiratory depression. During intravenous treatment with beta-2 agonists, monitor and replace potassium levels as required.[57] If patients receive intravenous aminophylline, adverse effects are more likely in those taking sustained-release theophylline as part of their chronic management.[7] Serum theophylline levels should be checked regularly and the dose adjusted accordingly if patients receive continuous therapy.
Primary options
magnesium sulfate: children ≥2 years of age: 40-50 mg/kg intravenously by slow infusion over 20-60 minutes, maximum 2000 mg/dose
Secondary options
salbutamol: consult specialist for guidance on dose
OR
terbutaline: consult specialist for guidance on dose
OR
magnesium sulfate: children ≥2 years of age: 150 mg nebulised every 20 minutes for 3 doses
MoreTertiary options
aminophylline: consult specialist for guidance on dose
nebulised anticholinergic
Additional treatment recommended for SOME patients in selected patient group
Children aged 6-11 years are routinely given a nebulised anticholinergic. Children aged 5 years and younger only receive a nebulised anticholinergic if there is poor response to initial treatment with beta-2 agonists, corticosteroids, and oxygen. The benefits and risks in children <2 years are unclear and anticholinergics are not recommended, except for children with bronchiolitis and chronic lung disease of prematurity.[7][57][86]
[ ]
Anticholinergics are given by oxygen-driven nebuliser every 20 minutes for the first hour and then reassessed.[7][57] Nebulised anticholinergics produce a weaker bronchodilation response with a slower onset of action (30-90 minutes) than beta-2 agonists (5-15 minutes).[85] Their addition can improve both cholinergic bronchomotor tone and secretions.
Cardiac stimulation occurs but is less marked than that produced by beta-2 agonists.
Primary options
ipratropium inhaled: children ≤5 years of age: 250 micrograms nebulised every 20 minutes for 3 doses; children 6-11 years of age: 250-500 micrograms nebulised every 20 minutes for 3 doses
intravenous bronchodilator or nebulised magnesium sulfate
Additional treatment recommended for SOME patients in selected patient group
Consider intravenous bronchodilator therapy if there is poor response to inhaled bronchodilators and corticosteroids.[7][57][59] Criteria for starting include no response to initial therapies, persistent hypoxaemia, and an FEV₁ <60% predicted at 1 hour.[7]
Intravenous magnesium sulfate is preferred by GINA (children 6-11 years old) and BTS/NICE/SIGN (children 2-11 years old) for exacerbations unresponsive to first-line therapy.[7][57][59][75][76]
[ ]
Its use can reduce the length of hospital stay.[83] However, it does not have an established role in children 5 years and younger due to a lack of evidence.[7] Nebulised magnesium sulfate can be considered if there is no intravenous access, but this offers only modest benefit in severe exacerbations.[7][57][78][79][80]
[ ]
Nebulised magnesium sulfate can be added to a nebulised short-acting beta-2 agonist and anticholinergic in the first hour of treatment for children 2-5 years with severe asthma (e.g., oxygen saturation <92%), particularly if symptoms have lasted <6 hours.[7][57]However, this may not be as effective as intravenous therapy.[7][73][74]
[ ]
Intravenous SABA (salbutamol or subcutaneous terbutaline where intravenous salbutamol is not available) or a methylxanthine (aminophylline or theophylline) are listed as second-line intravenous bronchodilators by the BTS/NICE/SIGN guideline for use in children 2-11 years old, but only under expert supervision and with extreme caution.[57][59] Neither approach is recommended by GINA.[7]
Treatment with intravenous magnesium sulfate requires close monitoring for respiratory depression. During intravenous treatment with beta-2 agonists, monitor and replace potassium levels as required.[57] If patients receive intravenous aminophylline, adverse effects are more likely in those taking sustained-release theophylline as part of their chronic management.[7] Serum theophylline levels should be checked regularly and the dose adjusted accordingly if patients receive continuous therapy.
Primary options
magnesium sulfate: children ≥2 years of age: 40-50 mg/kg intravenously by slow infusion over 20-60 minutes, maximum 2000 mg/dose
Secondary options
salbutamol: consult specialist for guidance on dose
OR
terbutaline: consult specialist for guidance on dose
OR
magnesium sulfate: children ≥2 years of age: 150 mg nebulised every 20 minutes for 3 doses
MoreTertiary options
aminophylline: consult specialist for guidance on dose
inhaled short-acting beta-2 agonist
Give an inhaled short-acting beta-2 agonist (SABA) immediately, reassess after 15-20 minutes, and give a further dose if response is inadequate (up to three doses in the first hour). The response to treatment should be immediate and sustained for 3-4 hours.[7]
A metered-dose inhaler plus a spacer is just as effective as a nebuliser for mild to moderate exacerbations.[81]
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Use a face mask for children aged <3 years and a mouthpiece used for older children.[7]
Mild exacerbations do not usually require hospital admission and can be treated appropriately at home using the child's personalised asthma action plan. Some moderate exacerbations may require hospital admission.[7][57][72]
[ ]
Primary options
salbutamol inhaled: (100 micrograms/dose metered-dose inhaler) children ≤5 years of age: 200-600 micrograms (2-6 puffs) every 20 minutes for 3 doses, then adjust dose according to response; children 6-11 years of age: 400-1000 micrograms (4-10 puffs) every 20 minutes for 3 doses, followed by 4-10 puffs every 3-4 hours to 6-10 puffs every 1-2 hours
oral corticosteroid
Additional treatment recommended for SOME patients in selected patient group
Oral corticosteroids are not usually required in a mild exacerbation, but may be needed to prevent deterioration when response to an inhaled short-acting beta-2 agonist (SABA) is incomplete. For children 5 years and younger with mild to moderate exacerbations, a systemic corticosteroid should only be given if symptoms recur within 3-4 hours of treatment with a SABA.[7]
Corticosteroids produce a treatment response by 4-6 hours.[7][82] Early administration within the first hour of arrival reduces admission rates compared with placebo.[82]
A pragmatic approach is to prescribe treatment for 3 days and then review the need for a longer course.[7][57]
Adjusting the ICS dose may be considered on a case-by-case basis to reduce hospitalisations (e.g., adding a short course of daily ICS to a SABA reliever at the onset of a respiratory illness in children aged 0-4 years), but this is not recommended routinely.[7][55][89][90][91][92][94][95]
[ ]
Primary options
prednisolone: 1-2 mg/kg/day orally, maximum 20 mg/day (children <2 years of age) or 30 mg/day (children 2-5 years of age) or 40 mg/day (children 6-11 years of age)
inhaled anticholinergic
Additional treatment recommended for SOME patients in selected patient group
An inhaled anticholinergic can be added to the short-acting beta-2 agonist if there is a poor response to initial treatment in children with a moderate to severe exacerbation.[7][57]
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[ ]
Anticholinergics produce a weaker bronchodilation response with a slower onset of action (30-90 minutes) than beta-2 agonists (5-15 minutes).[85] Give the anticholinergic at 20 minute intervals and reassess response.[7]
The use of spacers with pressurised metered-dose inhalers is recommended, especially for young children (i.e., ≤5 years old).[7] Use a face mask if <3 years old and a mouthpiece if older.
Routine use of an anticholinergic is not recommended in children <2 years of age, except for those with bronchiolitis or chronic lung disease of prematurity.[86]
Cardiac stimulation occurs but is less marked than that produced by beta-2 agonists.
Primary options
ipratropium inhaled: consult specialist for guidance on dose
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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer
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