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Update on asthma management


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The Royal Children’s Hospital in Melbourne have released an update on their asthma management. There are some great points here around the use of steroids and planning for discharge. Thanks to Mike Starr and RCH for allowing us to reproduce the update here…


  • A child can be discharged one hour after initial therapy if he/she has improved and has adequate follow-up plans in place; it is not always necessary to observe a child for longer than this to demonstrate that salbutamol “can be stretched”. (Note that discharge at 1 hour should only apply to those with mild exacerbations who are clinically well).
  • Oxygen saturations in the low 90s need not preclude discharge if a child is clinically well and has responded well to treatment.  

Editor addendum – the RCH have released some more advice about discharge. The following is an excerpt from their guidelines.

Consider discharge when:

  • Assess patient for clinical improvement 1 hour following initial therapy and discharge if clinically well. If necessary, reassess again after 30 minutes.
  • Adequate oxygenation – oxygen saturation of less than 92% should not preclude discharge if patient is clinically well and has responded well to treatment
  • Adequate oral intake
  • Adequate parental education and ability to administer salbutamol via spacer

Avoid steroids for preschool children

  • Wheeze in preschool children is often not caused by reversible bronchospasm – this age group may not respond well to bronchodilators and steroids may be less effective. 
  • Steroids should only be given to preschool aged children if they’re admitted (or have had previous ICU admissions) with bronchodilator-responsive wheeze.
  • In preschool children with wheeze, steroids do not appear to reduce the severity of symptoms, nor the need for treatment in an Emergency Department or hospitalisation.

Steroid dose

  • An initial dose of 2 mg/kg (max 60 mg) of prednisolone is now recommended for children, and subsequently, daily doses of 1mg/kg if required.  The majority of studies have used 2mg/kg of oral prednisolone (maximum 60 mg) given initially then 1mg/kg per day if required.  This regimen is also recommended by the national asthma guidelines (Australian Asthma Handbook). Some guidelines recommend a maximum dose of 50 mg for children, purely for practical reasons. 

About the authors

  • Tessa Davis is a Consultant in Paediatric Emergency Medicine at the Royal London Hospital and a Senior Lecturer at Queen Mary University of London.


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