asthma should preferably be administered by inhalation

to minimise fetal drug exposure. Inhaled drugs, theophylline, and prednisolone c

an be taken as normal
during pregnancy and breast-feeding. For the use of
leukotriene receptor antagonists during pregnancy see
section 3.3.2. Women planning to become pregnant
should be counselled about the importance of taking
their asthma medication regularly to maintain good
control.
Severe acute exacerbations of asthma can have an
adverse effect on pregnancy and should be treated
promptly in hospital with conventional therapy, including nebulisation of a beta
2 agonist, and oral or parenteral administration of a corticosteroid; prednisolo
ne
is the preferred corticosteroid for oral administration
since very little of the drug reaches the fetus. Oxygen
should be given immediately to maintain an arterial
oxygen saturation of 94 98% and prevent maternal
and fetal hypoxia. An intravenous beta2 agonist, aminophylline, or magnesium sul
fate can be used during
pregnancy if necessary; parenteral beta2 agonists can
affect the myometrium, see BNF section 7.1.3.
Management of acute asthma1
Impor tant
Regard each emergency consultation as being for
sever e acute asthma until shown otherwise.
Failure to respond adequately at any time requires
immediate transfer to hospital.
Severe acute asthma can be fatal and must be treated
promptly. Treatment of severe acute asthma is safer in
hospital where resuscitation facilities are immediately
available. Treatment should never be delayed for investigations, children should
never be sedated, and the
possibility of a pneumothorax should be considered. If
the child s condition deteriorates despite pharmacological treatment, urgent trans
fer to a paediatric intensive care unit should be arranged. For a table outlinin
g
the management of severe acute asthma, see Management of acute asthma table, p.
134.
Mild to moderate acute asthma Administer a
short-acting beta2 agonist using a pressurised
metered-dose inhaler with a spacer device; for a child
under 3 years use a close-fitting facemask. Give 1 puff
every 15 30 seconds up to a maximum of 10 puffs;
repeat dose after 10 20 minutes if necessary.
Give prednisolone by mouth, child under 12 years 1
2 mg/kg (max. 40 mg) once daily for up to 3 days, or
longer if necessary; if the child has been taking an oral
corticosteroid for more than a few days, give prednisolone 2 mg/kg (max. 60 mg)
once daily. For children 12
18 years, give prednisolone 40 50 mg daily for at least 5
days.
If response is poor or if a relapse occurs within 3 4
hours, transfer child immediately to hospital for assessment and further treatme
nt.
Children under 18 months often respond poorly to
bronchodilators; nebulised beta2 agonists have been
associated with mild (but occasionally severe) paradoxical bronchospasm and tran
sient worsening of oxygen
saturation; response to prednisolone may also be poor

in this age group.

Severe or life-threatening acute asthma Start
treatment below and transfer immediately to hospital.
Administer high-flow oxygen (section 3.6) using a closefitting face mask or nasa
l prongs.
Treat severe or life-threatening acute exacerbations of
asthma with an inhaled short-acting beta2 agonist (as
above). Treatment of life-threatening asthma should be
initiated with nebulised salbutamol 2.5 mg or terbutaline
5 mg (via an oxygen-driven nebuliser if available); nebulised doses may be doubl
ed for children over 5 years.
Repeat the dose every 20 30 minutes or as necessary,
then reduce the frequency on improvement.
Give prednisolone by mouth, child under 12 years 1
2 mg/kg (max. 40 mg) once daily for up to 3 days, or
longer if necessary; if the child has been taking an oral
corticosteroid for more than a few days, give prednisolone 2 mg/kg (max. 60 mg)
once daily. For children 12
18 years, give prednisolone 40 50 mg daily for at least 5
days. If oral administration is not possible, use intravenous hydrocortisone (pr
eferably as sodium succinate) 4 mg/kg (max. 100 mg) every 6 hours (alternatively
,
if weight unavailable, child under 2 years 25 mg every 6
hours, 2 5 years 50 mg every 6 hours, 5 18 years
100 mg every 6 hours).
If response is poor, add nebulised ipratropium
bromide, child under 12 years give 250 micrograms
every 20 30 minutes for the first 2 hours, then every
4 6 hours as necessary. For children 12 18 years, give
ipratropium bromide 500 micrograms every 4 6 hours
as necessary.
If the condition does not respond or is life-threatening,
transfer the child to an intensive care unit and treat with
a parenteral short-acting beta2 agonist (e.g. salbutamol, section 3.1.1.1) or pa
renteral aminophylline (section 3.1.3). Children over 2 years with severe acute
asthma may be helped by intravenous infusion of
magnesium sulfate injection 40 mg/kg, max. 2 g,
(equivalent to approx. 0.16 mmol/kg Mg2+, max.
8 mmol Mg2+) over 20 minutes (section 9.5.1.3), but
evidence of benefit is limited.
Follow-up in all cases Episodes of acute asthma
should be regarded as a failure of preventive therapy. A
careful history should be taken to establish the reason
for the exacerbation. Inhaler technique should be
checked and regular treatment should be reviewed in
accordance with the Management of Chronic Asthma
table, p. 133. Children or their carers should be given an
asthma action plan aimed at preventing relapse, optimising treatment, and preven
ting delay in seeking assistance in future exacerbations. If possible, follow-up
within 48 hours should be arranged with the general
practitioner or appropriate primary care health professional. Children should al
so be reviewed in a paediatric
asthma clinic within 1 2 months of the exacerbation,
and referred to a paediatric respiratory specialist if the
exacerbation included life-threatening features.