PRAM severity (0–12) (Mild 0–3 · Moderate 4–7 · Severe 8–11 · Impending respiratory failure 12 — use PRAM or clinical features together; reassess after each bronchodilator dose (GINA 2025, BTS/SIGN 158, RCH Melbourne))
Moderate clinical features (Speaks phrases (not full sentences), increased work of breathing, accessory muscle use, audible wheeze, SpO2 typically ≥92% on room air, PEF 50–80% best/predicted if measurable (BTS/SIGN 158, NICE NG51))
Max 1 mg/dose · Duration: PRN · 1 puff/kg (100 mcg/puff) — max 10 puffs (1 mg)/dose; repeat q20–30 min PRN first hour; then q1–4 h when improving
• pMDI + spacer first-line: at least as effective as nebulizer with fewer side effects and lower infection transmission risk — deliver 1 puff at a time with 5 tidal breaths per puff; mask if age <4 years (BTS/SIGN 158, GINA 2025, Australian Asthma Handbook).
• Mild attack (PRAM 0–3): 2–4 puffs (200–400 mcg) may suffice; reassess at 20 min — if incomplete relief give additional puffs up to 10 total (BTS/SIGN 158).
• Moderate attack (PRAM 4–7): up to 10 puffs (1 mg) per dose via spacer; repeat q20–30 min in first hour if persistent symptoms — typical total first-hour need 2–3 doses (BTS/SIGN 158, WHO Pocket Book).
• Switch to nebulizer only if child cannot use spacer (e.g. poor mask seal, pre-arrest, SpO2 <92% needing oxygen-driven nebs) — see nebulizer dose tier (BTS/SIGN 158, RCH).
• Do NOT use oral or IV salbutamol for acute exacerbation — inhaled route preferred; monitor for salbutamol toxicity (tachycardia, tremor, hypokalaemia, metabolic acidosis) with repeated doses (GINA 2025, RCH).
Enter weight on Kids to calculate doses
Ipratropium bromide • inhaled (nebulized)
Duration: PRN · 250 mcg (0.25 mg) per nebulizer dose mixed with salbutamol — repeat q20–30 min up to 3 doses in first hour if poor β2 response; ≥20 kg use 500 mcg (0.5 mg)/dose; not routine in mild attacks (BTS/SIGN 158, GINA 2025, Nationwide Children's ED pathway)
• Ipratropium: add when poor response to initial salbutamol (persistent moderate symptoms after 1–2 bronchodilator doses) — reduces admissions in severe airflow obstruction; up to 3 doses q20–30 min in first hour, then taper to q4–6 h or stop (BTS/SIGN 158, GINA 2025).
• Prednisolone: give early in moderate exacerbation — within 1 h of presentation reduces admission and relapse; essential for any child requiring hospitalization; already on maintenance steroids → give 2 mg/kg prednisolone (max 60 mg) (BTS/SIGN 158, GINA 2025).
• Dexamethasone preferred when: vomiting risk, compliance concerns, palatability issues, or outpatient/ED discharge — single or two-dose regimen; NOT for courses >2 days (mineralocorticoid effects) (BTS/SIGN 158, Paniagua 2017, Cronin 2016).
• Preschool wheeze (1–5 yr): systemic steroids only if episode severe enough to require admission — not routine for mild viral wheeze (Australian Asthma Handbook, GINA 2025).
• If unable to retain oral steroids: IV hydrocortisone 4 mg/kg q6h or IM methylprednisolone 1–2 mg/kg — reserve for severe vomiting or life-threatening asthma (BTS/SIGN 158, RCH).
Ipratropium bromide (≥20 kg dose) • inhaled (nebulized)
Duration: PRN · 500 mcg (0.5 mg) per nebulizer dose for children ≥20 kg — mixed with salbutamol nebulizer solution
Clinical notes
• Severity assessment: use PRAM (0–12) and clinical features together — mild (speaks sentences, no distress, PEF >80%), moderate (phrases, accessory muscles, PEF 50–80%), severe (words only, prominent accessory muscles, SpO2 <92%, PEF <50%), life-threatening (silent chest, cyanosis, exhaustion, confusion, poor respiratory effort, hypotension) — reassess after every bronchodilator dose (BTS/SIGN 158, GINA 2025, RCH).
• Oxygen: give controlled supplemental O2 to hypoxaemic children — target SpO2 **94–98%** when receiving oxygen (BTS/SIGN 158, NICE); start O2 if SpO2 <92% on room air and titrate to 92–96% per Australian Asthma Handbook; life-threatening asthma or SpO2 <94% → high-flow O2 via tight mask/nasal cannula; do not delay bronchodilator for O2 setup — mask/spacer can be applied over nasal prongs (BTS/SIGN 158, RCH).
• Repeated salbutamol: repeat q20–30 min in first hour while symptoms persist — typical moderate case needs 2–3 doses; continuous nebulization offers no benefit over intermittent same hourly dose; when improving on q2–4 h nebs, switch to pMDI + spacer; discharge criteria include stable on q3–4 h bronchodilator and SpO2 >94% (BTS/SIGN 158).
• Systemic steroid indications: all moderate, severe, and life-threatening exacerbations — give within 1 h of presentation; prednisolone 1 mg/kg (max 40 mg) × 3 days OR dexamethasone 0.6 mg/kg × 1–2 doses; steroids at discharge reduce relapse; ipratropium indications: poor initial β2 response, moderate–severe obstruction — not for mild attacks (BTS/SIGN 158, GINA 2025).
• Hospital admission: poor response after 2–3 bronchodilator doses, SpO2 <92% despite O2, inability to maintain oral fluids, social concerns, previous ICU, or parental anxiety; PICU/HDU referral: life-threatening features, altered consciousness, exhaustion/silent chest, need for IV β2 agonist or IV magnesium, rising PaCO2/acidosis, or failure to improve on maximal inhaled therapy — urgent senior/paediatric respiratory review (BTS/SIGN 158, GINA 2025, RCH).
• GINA — Global Strategy for Asthma Management and Prevention (pediatric exacerbations) (2025)
• BTS/SIGN — British Guideline on the Management of Asthma (SIGN 158) (2019)
• AAP Clinical Report — Management of Asthma Exacerbations (2023)
+ 3 more
• NICE NG51 — Croup and Acute Upper Airway Obstruction (oxygen and severity principles) (2017)
• RCH Melbourne — Clinical Practice Guideline: Acute Asthma (2024)
• ERC — European Resuscitation Council Guidelines (pediatric emergency care) (2021)
