Paediatric Acute Wheeze & Asthma — Ward Management

Assess → classify severity → treat to tier → reassess frequently → wean or escalate. A decision-support flow for the inpatient paediatric ward.

Adapted from CHQ / QPEC guidelines Asthma CHQ-GDL-60002 v5.0 Pre-school wheeze CHQ-GDL-60009 v5.0

Read first. The statewide guidelines are written for the ED; this reflows them for ward use but does not replace them or your local Metro South / Logan policy. Escalation on the ward is triggered by your CEWT (Children's Early Warning Tool) and local CERS/MET criteria as well as the clinical thresholds below. Confirm every dose against the current CHQ guideline / CREDD / local formulary before prescribing. Frequent senior review is expected — this is support, not a substitute for it.

First fork — which pathway?

age drives the whole plan

Under 1 year

Think bronchiolitis

First wheeze in an infant is usually bronchiolitis — a different guideline and a different approach (supportive care; bronchodilators/steroids not indicated).

Use the Bronchiolitis guideline, not this flow.

1–5 years

Pre-school wheeze (“reactive airways disease”)

Heterogeneous, usually viral-triggered. This is the group where the common ward errors happen.

Steroids & ipratropium are not reflexive — see the age-split boxes in each tier.

Over 5 years

Asthma

Salbutamol and corticosteroid are first-line for moderate–severe / persistent symptoms.

Give steroid early — admission rates drop when given within 1 hour.

Always exclude mimics: Anaphylaxis Inhaled foreign body Pneumonia Cardiac failure DKA Tracheo/bronchomalacia

Assessment — what to look for

general appearance + work of breathing are the most important markers

Marker	Mild	Moderate	Severe	Life-threatening
Mental state	Normal	Normal	Agitated, restless, distressed	Exhausted, confused, ↓ consciousness
Work of breathing	No accessory muscle use	Minimal accessory use	Moderate use, nasal flare, tracheal tug, hyperinflation	Excessive use → or poor effort / tiring
Respiratory rate	Normal / mild ↑	Tachypnoea	Tachypnoea, prolonged expiration	Falling RR — may only gasp
Heart rate	Normal	Tachycardia	Tachycardia	Falling HR — pulse hard to feel
Speech	Sentences	Phrases	1–2 word gasps	Unable to talk
Colour / SpO₂	No cyanosis · SpO₂ >94%	No cyanosis · SpO₂ 90–94%	Cyanosis likely · SpO₂ <90%	Cyanosis · SpO₂ <90%
Auscultation	Variable wheeze	Moderate–loud wheeze	Often quiet wheeze	Silent chest — sign of near-arrest

Do not be reassured by a quiet chest.

A silent chest, exhaustion, or altered conscious state = life-threatening → call for help & move to resus now.
Wheeze may vanish because airflow has collapsed, not because the child is better. Trend the whole picture, not the wheeze alone.
History that raises the stakes: previous PICU/critical care admission, previous sudden deterioration, poor response to home salbutamol.

Management by severity

MDI + spacer preferred; nebulise if hypoxic, severe, or unable to seal on spacer

MildSpO₂ >94%

Salbutamol via MDI + spacer, age-dosed (see §6). Reassess response.
If good response → stretch the interval (see §4) and observe.

1–5 yr (pre-school)

Salbutamol only. No steroid for a first/infrequent mild episode.

Over 5 yr (asthma)

Add oral steroid if moderate features emerge or symptoms persist after salbutamol.

Reassess before each dose — wheeze alone is not a reason to re-dose salbutamol.

ModerateSpO₂ 90–94%

Salbutamol burst — 3 doses at 20-min intervals via MDI + spacer.
Ipratropium with the first 3 salbutamol doses (best evidence is in the first 2 hours).
Corticosteroid — dexamethasone 0.6 mg/kg (max 16 mg) single dose, or prednisolone 2 mg/kg.
Reassess after the burst → wean if improving; step up if not.

1–5 yr (pre-school)

Steroid if: frequent episodes, salbutamol needed > every 2 h, or atopic/asthma phenotype. Ipratropium is indicated for moderate–severe.

Over 5 yr (asthma)

Steroid + ipratropium both indicated. Give steroid early.

Medical review no later than 1 hour after salbutamol.

SevereSpO₂ <90%

Call senior / paediatric registrar now. Continuous cardiorespiratory monitoring.
Continuous / frequent nebulised salbutamol + ipratropium (nebulise — child is hypoxic).
Oxygen to correct hypoxia (guideline threshold: give O₂ if SpO₂ <90%; many units target ≥92%).
Corticosteroid — oral dexamethasone/prednisolone, or IV (hydrocortisone / methylprednisolone) if not tolerating oral.
IV access. Consider VBG (K⁺, lactate, glucose — salbutamol toxicity markers) & consider CXR only if alternate diagnosis / complication suspected.
Not responding in the first hour → IV magnesium sulphate (senior-led, see §6).

Frequent repeated clinical assessment is the best guide — reassess continuously.

Life-threateningsilent chest / ↓ LOC

Resus. Call the most senior help onsite + paediatric critical care immediately. RSQ 1300 799 127.
High-flow oxygen. Continuous nebulised salbutamol + ipratropium.
IV magnesium sulphate. IV corticosteroid.
IV salbutamol bolus ± infusion — critical-care directed.
Consider IM adrenaline (especially if any suggestion of anaphylaxis).
Aminophylline — only after discussion with critical care. Consider HFNC / NIV; prepare for intubation.

Notify the receiving service early — a child at this tier is likely to need transfer.

Weaning (“stretching”) salbutamol

the core of the ward job

1 hourly→ 2 hourly→ 3 hourly→ 4 hourly→ off / discharge

Stretch when these improve

WOB — recession, tracheal tug, nasal flaring settling
Activity — more alert, more active
RR & HR — trending toward normal for age
Speech — back to sentences
Air entry — improved; wheeze reduced
Cough — looser / easing
SpO₂ — rising, O₂ requirement falling

Judge the child, not the clock

Assess against the markers above before every stretch — decide with the child and caregiver.
A child may jump from hourly straight to 3-hourly, or need to go back up a step. Both are fine.
Wheeze alone is not an indication for salbutamol — and its reappearance in a previously quiet chest can be a good sign (airflow returning).
Monitor SpO₂ continuously if dosing more often than every 2 h.

Salbutamol toxicity: cumulative doses cause tremor, agitation, tachycardia, tachypnoea. Raised lactate, hypokalaemia and hyperglycaemia on VBG are the markers — use steroid/ipratropium/magnesium as salbutamol-sparing measures rather than simply pushing more salbutamol.

When to escalate

plus your CEWT / local CERS triggers

Escalate immediately if — severe & not responding · needs respiratory support (HFNC/NIV) · needs IV salbutamol · considering aminophylline / IM adrenaline / intubation

Clinical thresholds flagging a critically unwell / rapidly deteriorating child (a guide — treat the child, and follow your CEWT):

Age band	RR	HR	Systolic BP	SpO₂	GCS
1–4 yr	>40	<80 or >160	<70	<93% in O₂ or <85% in air	≤12
5–11 yr	>40	<70 or >150	<75	<93% in O₂ or <85% in air	≤12
≥12 yr	>30	<50 or >130	<85	<93% in O₂ or <85% in air	≤12

Step 1 · onsite

Paediatric registrar / SMO

Most senior resource onsite. Bedside review, escalate treatment tier.

Step 2 · onsite

Critical care / anaesthetics

For airway concern, HFNC/NIV, IV salbutamol, deteriorating LOC.

Step 3 · advice

RSQ

1300 799 127

Paediatric critical care advice + retrieval of a critically unwell child. Notify early.

Advice / transfer

CATCH · TEMSU

13 22 82

QCH advice, disposition, non-critical transfer. TEMSU video 1800 11 44 14.

Medication quick-reference

verify against CREDD / current guideline before prescribing

Drug	Dose	Notes
Salbutamol — MDI	1–5 yr & 5 yr: 6 puffs · ≥6 yr: 12 puffs (100 µg/puff, via spacer)	Burst = 3 doses q20min. MDI+spacer preferred over neb.
Salbutamol — neb	1–5 yr & 5 yr: 2.5 mg · ≥6 yr: 5 mg	Continuous = neat 5 mg/mL, replenish reservoir. Neb if hypoxic/severe.
Ipratropium	≤5 yr: 4 puffs (84 µg) or 250 µg neb · ≥6 yr: 8 puffs (168 µg) or 500 µg neb — q20min ×3	With first 3 salbutamol doses. Moderate–severe. Can mix in neb with salbutamol.
Dexamethasone	0.6 mg/kg (max 16 mg) single dose day 1 — oral / IM / IV	IV prep can be given orally (tasteless). Single dose = no discharge script.
Prednisolone	2 mg/kg (max 50 mg) day 1, then 1 mg/kg days 2–3	Extend to 5 days if still symptomatic.
Hydrocortisone IV	4 mg/kg (max 100 mg) then q6h day 1	If not tolerating oral. senior
Methylprednisolone IV	1 mg/kg (max 60 mg) then q6h day 1	Alternative to hydrocortisone. senior
Magnesium sulphate IV	0.2 mmol/kg (= 50 mg/kg) over 20 min · max 10 mmol (2500 mg)	Prescribe in mmol. Safety-software syringe driver @ 0.5 mmol/mL. Full cardiac monitor, BP q5min. senior
Salbutamol IV	Bolus 15 µg/kg over 10 min (max 300 µg) → infusion 0.5–1 µg/kg/min (max 40 µg/min)	Monitor K⁺, full cardiac monitor. critical care
Adrenaline IM	0.01 mg/kg (max 0.5 mg) = 0.01 mL/kg of 1:1000, repeat q5min prn	Life-threatening / ?anaphylaxis. critical care
Aminophylline IV	See CREDD for dosing	Not if already on oral theophylline. discuss with critical care first

Ongoing ward course & disposition

Keep on the ward / step up if

Clinical deterioration needing escalation of treatment.
Asthma: failure to wean to 3-hourly salbutamol within 12–24 h.
Pre-school wheeze: still needing salbutamol every 1–2 h at 24 h, or no improvement after 12 h of care.
Persisting or increasing supplemental oxygen requirement.
Failure to progress → reconsider: poor bronchodilator responder, suboptimal inhaler technique/frequency, or an alternative diagnosis.

Consider discharge when ALL of

SpO₂ ≥ 90% in room air.
Not tachypnoeic; no / mild work of breathing.
Good air entry with minimal wheeze.
Stable on salbutamol no more often than every 3–4 h.
Caregiver can manage at home, recognise deterioration, return, and access medication.
Longer observation if: previous critical-care admission / sudden deterioration, >30 min from hospital, or social concerns.

Discharge bundle

Written Asthma / Wheeze Action Plan (copies: family, GP, chart)
Check spacer & inhaler technique before leaving
Steroid complete (dex given) or prednisolone script
Consider preventer trial (e.g. fluticasone) if recurrent flares
GP / paediatric follow-up — within a week if the episode was severe
Preventer-trial review at 4–6 weeks (pre-school: ~3 months)
Asthma / puffers & spacers factsheets
Disease-education checklist completed