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why isn't prednisolone right? he already has salbutamol prescribed, so isn't the assumption that he has already tried salbutamol?
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QuestionComment
Here he has salbutamol prescribed but as an inhaler for at home use, they would need to prescribe it again in the nebulised form as the dose is different. You're right that prednisolone would be used afterwards ( but it wouldn't be once off duration which is the clue)
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# Summary
 

Acute exacerbations of asthma in children are primarily triggered by allergens such as dust, pollution, animal hair, or smoke, leading to a type 1 (IgE-mediated) hypersensitivity reaction. This triggers bronchoconstriction and bronchial oedema. Signs of a severe episode may include respiratory distress, tachycardia, and significantly reduced peak expiratory flow rate. Key differentials include pneumothorax, anaphylaxis, foreign body inhalation, and cardiac arrhythmia. Investigations involve a stepwise approach to managing acute exacerbations according to the British Thoracic Society and Scottish Intercollegiate Guidelines Network, including the use of high-flow oxygen, inhaled and intravenous salbutamol, and steroids.
 

# Definition
 

Acute exacerbations of asthma in children are episodes where symptoms of asthma, a chronic inflammatory disease of the airways, are significantly intensified. This is typically due to triggers such as exposure to certain allergens, leading to a type 1 (IgE-mediated) hypersensitivity reaction, which results in bronchoconstriction and bronchial oedema.
 

# Epidemiology
 

 -  Asthma is a common condition, affecting millions of children globally.
 -  Asthma can start at any age, but it most commonly begins during childhood.
 -  Asthma exacerbations are among the most common reasons for hospitalisation in children.
 

# Aetiology
 

Acute exacerbations of asthma in children can be triggered by a variety of factors including:
 

 -  Allergens: Dust, pollution, animal hair, smoke
 -  Respiratory infections: Viruses such as the common cold
 -  Exercise: Especially in cold weather
 -  Emotional stress: This can lead to hyperventilation and symptoms of an asthma attack.

 
Risk factors for severe acute asthma include:

- Background of severe asthma (previous near-fatal asthma, or admissions to hospital/PICU)
- Exposure to second-hand smoke, air pollution or pollen 
- Inadequately controlled asthma 
 

# Signs and Symptoms
 
 
## Features of moderate acute asthma 

- Peak flow >50% predicted 
- Tachypnoea but respiratory rate less than 40/minute if 1-5 years old or less than 30/minute if over 5 years 
- Tachycardia but <140/minute if 1-5 years old or <125 if over 5 years 
- SpO2 >2%
- The child is still able to speak in complete sentences 

## Features of acute severe asthma
 

 -  Respiratory distress: use of accessory muscles of respiration, breathlessness resulting in an inability to complete sentences, tachypnoea with a respiratory rate > 30/min if over 5yrs, > 40 if under 5yrs
 -  Heart rate > 125/min if over 5yrs, > 140/min if under 5yrs
 -  Peak expiratory flow rate 33-50% of predicted
 

## Features of life-threatening asthma   
 

 -  Peak expiratory flow rate <33% predicted
 -  Oxygen saturations <92%
 -  Silent chest on auscultation
 -  Weak or no respiratory effort
 -  Hypotension
 -  Exhaustion
 -  Confusion/altered conscious level
 

# Differential Diagnosis
 

Important differentials include:
 

 -  **Pneumothorax**: Very sudden onset, chest pain, possible deviation of the trachea
 -  **Anaphylaxis**: Very sudden onset, associated with antigen exposure, may be associated with rash and angioedema
 -  **Inhalation of a foreign body**: Unilateral chest signs
 -  **Cardiac arrhythmia**: Chest pain or palpitations, tachycardia or changes in blood pressure
 

# Investigations

The diagnosis of an acute asthma exacerbation is primarily clinical, based on the presenting symptoms and history. Important investigations may include:
 
 - Peak flow meter: to estimate PEFR 
 -  Spirometry: Reduction in peak expiratory flow rate and FEV1 which improves with treatment confirms the diagnosis
 -  Blood tests: To evaluate the inflammatory response and rule out other causes
 -  Chest X-ray: In severe cases or when the diagnosis is uncertain
 -  ABG may be used if there is a poor response to initial treatment
 

# Management
 

The management of acute exacerbations of asthma in children, according to the British Thoracic Society and Scottish Intercollegiate Guidelines Network, follows a stepwise approach:
 

 -  Maintain oxygen saturations between 94-98% with high flow oxygen if necessary.
 -  Administer inhaled salbutamol with a pressurised metered dose inhaler and spacer 
 -  Proceed to nebulised salbutamol (2.5-5 mg) if necessary
 -  Add nebulised ipratropium bromide
 -  All patients should receive steroids, given IV only if the patient is unable to take the dose orally
     -   20 mg oral prednisolone for children aged 2-5 years
     -  40 mg oral prednisolone for children over 5 years 
     -  If not tolerating oral, IV hydrocortisone 4 mg/kg every 4 hours can be used 
     -  Steroids are given for 3 days 
    -  If the patient is not responding to salbutamol or ipratropium, consult with a senior clinician 
     - For consideration of IV magnesium, IV salbutamol or aminophylline
        
Moderate asthma may be managed using oral prednisolone and beta 2 bronchodilator therapy as an outpatient. 

If there are signs of severe or life-threatening asthma, refer to PICU urgently. 
 
Discharge criteria:

- Child stable on their normal salbutamol inhalers every 3-4 hours 
- Peak Expiratory Flow (PEF) or Forced Expiratory Volume in first second of expiration (FEV1) > 75% best or predicted
- Oxygen saturations >94% on room air


Follow-up after discharge:
 
 - The child should be reviewed by their GP within 2 working days to update or create an asthma action plan, check inhaler technique and adherence
 - The child should be discharged on inhaled corticosteroid-containing controller treatment or on an increased dose compared to their pre-existing dose 
 - If a child has a near-fatal attack, they will require specialist supervision 

# Complications

- Fatigue
- Pneumothorax 
- Aspiration pneumonia 
- Respiratory failure requiring intubation and ventilation 
- Hypokalaemia and cardiac arrhythmias  related to treatment used
- Hypoxic-ischaemic brain injury 

# Prognosis 

Unfortunately, outcomes in the UK are some of the worst in Europe, with approximately 25-30 children per year dying of asthma. 90% of these deaths are thought to be preventable with better care and tackling the deprivation that contributes to poor outcomes. 
 
#  NICE Guidelines
 
 [BNFc Guidelines for Acute Asthma](https://bnfc.nice.org.uk/treatment-summaries/asthma-acute/) 
 

# References
 

 [British Thoracic Society Guidelines](https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&ved=2ahUKEwiL-dbLtOPrAhUXQEEAHbUKAEcQFjACegQIAhAB&url=https%3A%2F%2Fwww.brit-thoracic.org.uk%2Fdocument-library%2Fguidelines%2Fasthma%2Fbtssign-asthma-guideline-quick-reference-guide-2019%2F&usg=AOvVaw0ZD19J5kUP75tRHs2_eoUU)
 
 [Resuscitation Council UK Paediatric emergency algorithms & resources](https://www.resus.org.uk/sites/default/files/2022-03/RCUK%20Paediatric%20emergency%20algorithms%20and%20resources%20Mar%2022%20V1.pdf) 
 
 [Patient Info Acute Severe Asthma and Status Asthmaticus](https://patient.info/doctor/acute-severe-asthma-and-status-asthmaticus) 
 
 [BMJ Best Practice Acute Asthma in Children](https://bestpractice.bmj.com/topics/en-gb/1098/treatment-algorithm#)
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Internal Medicine
# Drug choice feedback

Any short-acting beta-2 agonist is appropriate as first line agent for the treatment of acute asthma. These include salbutamol and terbutaline sulphate, although the former is more commonly prescribed as it is less expensive but no different in efficacy.

# Dose/Route/Frequency/Duration feedback

The correct dose is 2.5mg-5mg for nebulised salbutamol and 5mg-10mg for nebulised terbutaline sulphate respectively. The nebulised route is most preferred in the initial stages of asthma management.
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2.5 mg
PrescribeAnswerData
salbutamol 1 mg/mL nebuliser liquid
PrescribeAnswerData
Once-off
PrescribeAnswerData
once only (STAT)
PrescribeAnswerData
nebulised (NEB)
PrescriptionAnswer
PrescribeAnswerData
5 mg
PrescribeAnswerData
salbutamol 2 mg/mL nebuliser liquid
PrescribeAnswerData
Once-off
PrescribeAnswerData
once only (STAT)
PrescribeAnswerData
nebulised (NEB)
PrescriptionAnswer
PrescribeAnswerData
5 mg
PrescribeAnswerData
salbutamol 1 mg/mL nebuliser liquid
PrescribeAnswerData
Once-off
PrescribeAnswerData
once only (STAT)
PrescribeAnswerData
nebulised (NEB)
PrescriptionAnswer
PrescribeAnswerData
2.5 mg
PrescribeAnswerData
salbutamol 2 mg/mL nebuliser liquid
PrescribeAnswerData
Once-off
PrescribeAnswerData
once only (STAT)
PrescribeAnswerData
nebulised (NEB)
Case Presentation: A 19-year-old gentleman is brought to the Emergency Department with a sudden-onset 2-hour history of shortness of breath and wheezing




## PH


Asthma


## DH


Salbutamol metered dose inhaler 200 mcg/dose INH PRN, Beclometasone inhalation powder 200 mcg/dose INH BD (NKDA)


## On examination


Appears distressed, barely able to answer in full sentences. Wheeze heard throughout both lung fields, no crackles. Use of accessory muscles seen. No cyanosis.


Temperature 36.6°C, HR 105, RR 29, BP 110/78, O2 95% RA, GCS 15, Weight 67kg


## Investigations


||||
|--------------|:-------:|------------------|
|pH|7.41|7.35 - 7.45|
|PaO₂|16 kPa|11 - 15|
|PaCO₂|3.8 kPa|4.6 - 6.4|
|Bicarbonate|25 mmol/L|22 - 30|

CXR normal


# Prescribing Request


Write a prescription for one drug that is most appropriate to treat his bronchospasm.