some useful telephone numbers: bronchiolitis advice sheet...bronchiolitis advice sheet advice for...

If you are worried about your child, trust your instincts.

Contact your GP or dial NHS 111.

If you need advice please try:Your local pharmacy can be found at www.nhs.uk

Health Visitor: ..........................................................

Your GP Surgery: ......................................................

Please contact your GP when the surgery is open or call NHS 111 when the GP surgery is closed.

NHS 111 provides advice for urgent care needs. NHS 111 is available 24 hours a day, 365 days a year.

Calls from landlines and mobile phones are free. NHS Choices: www.nhs.uk

for online advice and information Bucks:

Family Information Service Tel: 0845 688 4944 or www.bucksfamilyinfo.org

For common childhood illness advice see:www.childhealthbucks.com

Berks: Family Information Service - Slough

Tel: 01753 476589 or www.servicesguide.slough.gov.uk Windsor, Ascot and Maidenhead Tel: 01628 685632

or www.rbwm.gov.uk/web/cis.htm

For common childhood illness advice see:www.childhealthslough.com www.childhealthwam.com

Some useful telephone numbers:

If they have or were:

• a premature baby• are less than 6 weeks old• alungproblem•aheartproblem• a problem with your child’s immune system• or any other pre-existing medical condition that may

affect your child’s ability to cope with this illnessPlease contact your Practice Nurse or Doctor

Below are some other conditions that could affect your child’s ability to cope:

Bronchiolitis Advice SheetAdvice for parents and carers of children aged 2 years old and under

• Most children with bronchiolitis will seem to worsen during the first 1-3 days of the illness before beginning to improve over the next two weeks. The cough may go on for a few more weeks.

• As a parent / carer, you may find this useful to know as it lasts longer then the normal coughs / colds that children get.

• Your child can go back to nursery or day care as soon as he or she is well enough ( feeding normally and with no difficulty in breathing).

• There is usually no need to see your doctor if your child is recovering well. If you are worried about your child’s progress, discuss this with your Health Visitor, Practice Nurse or Doctor.

How long does bronchiolitis last?

Bronchiolitis is when the smallest air passages in a child’s lungs become swollen.

This can make it more difficult for your child to breathe. Usually, bronchiolitis is caused by a virus called respiratory syncytial virus (known as RSV).

Almost all children will have had an infection caused by RSV by the time they are two years old. It is most

common in the winter months and usually only causes mild “cold-like” symptoms.

Most children get better on their own.Some children, especially very young ones, can

have difficulty with breathing or feeding and may need to go to hospital.

Most children with bronchiolitis get better within about two weeks. The cough may go on for

a few more weeks.

What is bronchiolitis?

• Your child may have a runny nose and sometimes have a temperature and a cough.

• After a few days your child’s cough may become worse.• Your child’s breathing may be faster than normal and it

may become noisy. He or she may need to make more effort to breathe.

• Sometimes, in the very young children, bronchiolitis may cause them to have brief pauses in their breathing.

• Sometimes their breathing can become more difficult, and your child may not be able to take their usual amount of milk by breast or bottle or may want to feed more frequently but take a smaller amount.

• You may notice fewer wet nappies than usual.• Your child may vomit after feeding and become irritable.

What are the symptoms?

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Update approved by Children and Young People Urgent Care Board

This guidance is written in the following context:

This document was arrived at after careful consideration of the evidence available including but not exclusively NICE, SIGN, EBM data and NHS evidence, as applicable.

Healthcare professionals are expected to take it fully into account when exercising their clinical judgement. The guidance does not, however, override the individual responsibility

of healthcare professionals to make decisions appropriate to the circumstances of the individual patient in consultation with the patient and / or carer.

For more copies of this document please email: [email protected] you need an interpreter or need a document in another language, large print, Braille or audio

version, please contact Family Information Service web links as above.

ChilternClinical Commissioning Group

Aylesbury ValeClinical Commissioning Group

SloughClinical Commissioning Group

Windsor, Ascot and MaidenheadClinical Commissioning Group

Published November 2013 To be reviewed November 2014

www.chilternccg.nhs.uk www.aylesburyvaleccg.nhs.uk www.sloughccg.nhs.uk www.windsorascotmaidenheadccg.nhs.uk

RED

If your child has any one of these below:

•Has blue lips• or is unresponsive or very irritable• or is struggling to breathe• or has unusually long pauses in breathing• or has an irregular breathing pattern

You need EMERGENCY helpCall 999 or go straight to the nearest

Hospital Emergency (A&E) Department

Nearest Hospitals (open 24 hours 7 days a week):•Frimley Park, Surrey•Hillingdon Hospital•John Radcliffe, Oxford•Milton Keynes Hospital •Royal Berkshire, Reading

•Stoke Mandeville Hospital, Aylesbury

•Wexham Park Hospital, Slough

Bring your child’s Red Book with you.

AMBER

If your child has any one of these below:

• If your child’s health gets worse or you are worried

• or has decreased feeding by 50% (half)• or is passing less urine than normal• or is vomiting• or temperature is above 38°C• or is finding it difficult to breathe•Please see box “conditions that could affect

your child’s ability to cope”overleaf

You need to contact a nurse or doctor todayPlease ring your GP surgery during the day or when your GP surgery is closed,

please call NHS 111

Bring your child’s Red Book with you.

GREEN

If none of the features in the red or amber boxes above are present.

Self careUsing the advice on this leaflet you can care for

your child at home.If you feel you need advice please contact your

Health Visitor or GP Surgery or your local pharmacy

(follow the links at www.nhs.uk)

You can also call NHS 111

Most children with bronchiolitis get better over time, but some children can get worse. You need to regularly check your child and follow the advice below.

What do I do if my child has bronchiolitis? (traffic light advice)• If your child is not feeding as normal, offer smaller

feeds more frequently.• If your child is distressed or you feel they are in

discomfort you may use medicines (Paracetamol or Ibuprofen) to help them feel more comfortable. However, you may not need to use these medicines.

•At home, we do not recommend giving both Paracetamol and Ibuprofen at the same time together. If your child has not improved after 2-3 hours you may want to give them the other medicine. Never exceed the dose on the bottle.

•Please read and follow the instructions on the medicine container. Over the counter (OTC) medicines may not be available to purchase for all age groups. Ask your pharmacist.

• If your child is already taking medicines or inhalers, you should carry on using these. If you find it difficult to get your child to take them, ask your Pharmacist, Health Visitor or Doctor for advice.

• Bronchiolitis is caused by a virus so antibiotics will not help.

How can I help my baby?

•Make sure your child is never exposed to tobacco smoke. Passive smoking can seriously damage your child’s health. It can make breathing problems like bronchiolitis worse. Remember smoke remains on your clothes when you smoke anywhere including outside.

• If you would like help to stop smoking, please contact:

Passive smoking affects your baby - if you would like help to stop smoking:

Buckinghamshire

Stop Smoking Bucks – Tel: 0845 2707222 Email: [email protected]

Berkshire

SmokefreelifeBerkshire - Tel: 0800 6226360 or send a SMS QUIT to 66777 Email: [email protected]

All green and no amber or red

Send home with Bronchiolitis Advice Sheet

Any amber Signs / Symptoms and no red

Needs further assessment by doctor. Consider admission

Any red Signs / Symptoms

Immediate medical assessment and resuscitation

Nurse to monitor and document observations at least every hour until child can be seen by a doctor and a plan made.

If presenting on day 1 – 3 of illness and amber, condition is likely to deteriorate. This needs to be considered - may need to admit.

* Oxygen saturation to be measured using relevant paediatric probe. ** Apnoea – for 10-15 secs or shorter if accompanied by a sudden decrease in saturations / central cyanosis or bradycardia.

Immediate resuscitation if required. Seek input of Senior A&E +

Paediatrician-On-Call

Child presenting with bronchiolitis:Assess and look for life threatening signs and symptoms

(see Table 1, Table 2 and Table 3)

Consider differential diagnosis if temperature is greater than 39°C or unusual features of illness. It is unusual for infants with bronchiolitis to appear “toxic”. A “toxic” infant who is drowsy, lethargic or irritable, pale, mottled and tachycardic requires immediate treatment. Careful evaluation for other causes should be undertaken before making a diagnosis of bronchiolitis.

Table 1 : Traffic light system of signs and symptoms for identifying severity of illness

Green – low risk Amber - intermediate risk Red – high risk

Behaviour

• Alert• Normal

• Miserable• Not responding normally to social cues• Decreased activity• No smile

• Unable to rouse• Wakes only with prolonged stimulation• No response to social cues• Weak or continuous cry• Appears ill to a healthcare professional

Skin

• CRT < 2 secs• Normal colour skin, lips and

tongue• Moist mucous membranes

• CRT 2–3 secs• Pale / mottled• Pallor colour reported by parent / carer• Cool peripheries

• CRT > 3 secs• Pale / Mottled / Ashen blue• Cyanotic lips and tongue

Respiratory Rate• < 12 mths < 50 breaths / min• > 12 mths < 40 breaths / min• No respiratory distress

• Tachypnoea• < 12 mths 50-60 breaths / min• > 12 mths 40-60 breaths / min

• Tachypnoea• All ages > 60 breaths / min

Oxygen sats in air*

• 95% or above • 92 – 94% • < 92%

Chest recession • None • Moderate • Severe

Nasal Flaring • Absent • May be present • Present

Grunting • Absent • Absent • Present

Feeding Hydration

• Normal• Tolerating 75% of fluid

• Occasional cough induced vomiting

• Tolerating 50-75% fluid intake over 3-4 feeds

• + / - vomiting. • Reduced urine output

• Tolerating < 50% fluid intake over 2-3 feeds + / - vomiting.

• Significantly reduced urine output

Apnoeas • Absent • Absent • Yes**

Other

• Pre-existing lung disease

• Congenital heart disease

• Age < 12 weeks (corrected)

• Immuno-compromised

• Prematurity• Family anxiety• Re-attendance

BRONCHIOLITIS PATHWAY– CLINICAL ASSESSMENT / MANAGEMENT TOOL FOR THE CHILD YOUNGER THAN 2 YEARS WITH SUSPECTED BRONCHIOLITIS

Management - within Hospital Setting


This document was arrived at after careful consideration of the evidence available including but not exclusively NICE, SIGN, EBM data and NHS evidence, as applicable. Healthcare professionals are expected to take it fully into account when exercising their clinical judgement. The guidance does not, however, override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient in consultation with the patient and / or carer.


ChilternClinical Commissioning Group

Aylesbury ValeClinical Commissioning Group

SloughClinical Commissioning Group

Windsor, Ascot and MaidenheadClinical Commissioning Group

• Rhinorrhoea (runny / snuffly nose)

• Cough• Poor feeding

• Bronchiolitis season• Vomiting• Pyrexia• Respiratory distress

• Chesty cough• Increased work of breathing• Apnoea

• Inspiratory crackles + / - wheeze

• Cyanosis• Head bobbing

Table 2 : Signs and Symptoms can include:

If the child does not need admission provide a safety net for the parents / carers ie. provide parent / carer with written and verbal information on warning symptoms (see Bronchiolitis Advice Sheet) and accessing further health care; Arrange appropriate follow up; Liaise with other professionals to ensure parent / carer has direct access to further assessment; Manage the parents expectations about the length of the illness. Remind them that the peak of the illness lasts 1 - 3 days; Most babies get better within 7-14 days but the coughing could go on for 4 weeks.

• Pre-existing lung disease• Congenital heart disease• Age < 12 weeks (corrected)• Immuno-compromised

• Prematurity• Family anxiety• Re- attendance

Table 3 : High Risk Factors - Healthcare professionals should be aware of the increased need for hospital

admission in infants with the following:• Chest physiotherapy using

vibration and percussion• Nebulised Ribavirin• Antibiotic therapy• Nebulised Epinephrine• Inhaled corticosteroids

• Inhaled beta 2 agonist bronchodilators (may work if atopic background)

• Nebulised Ipratropium Bromide

• Oral systemic corticosteroids

Table 4 : The following treatments are NOT recommended for infants with acute bronchiolitis

Update approved by Children and Young People Urgent Care Board Published November 2013 To be reviewed November 2014

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Seek advice of Senior A&E + Paediatrician-On-Call

If any red features (from Table 1)

Commence high flow oxygen support.

If any amber features and no red

(from Table 1)

Oxygen support required?

Is feeding sufficient to maintain hydration?

Is feeding sufficient to maintain hydration?

No

No

If all green features and no amber or red

(from Table 1)

Send Home

Prior to sending home please see Tables 3 and 4 below.

Give appropriate and clear guidance to the parent / carer

and hand them the Bronchiolitis Advice Sheet (includes useful

telephone numbers)

Yes

No

Yes O2 alone

Refer to Paediatrics if not Already Done

ADMIT

Appears ill to a healthcare professional

Yes

Consider NPAThe following investigations are not routinely recommended but may be considered where there is diagnostic uncertainty or an atypical disease course: •ChestXray •FullBloodCount;BloodCulture •Measurementofureaandelectrolytes•Bloodgas

No

Give Oxygen if required to maintain saturations >92%

Consider NG feeding at 75% of maintenance.

Assess for Respiratory Distress

If there is continuing clinical deterioration:

Discuss with Consultant ASAP & consider informing PICU (also follow any appropriate local protocols)

Continue with Regular Assessment

For Senior Paediatric Review

Continue NG Feeds

with regular reassessment

NBM

IV fluids

Stable + <40% Oxygen

Increased + Oxygen >40%

Stable Increased

Refer to Paediatrician-

On-Call

Update approved by Children and Young People Urgent Care Board


This document was arrived at after careful consideration of the evidence available

including but not exclusively NICE, SIGN, EBM data and NHS evidence, as applicable.

Healthcare professionals are expected to take it fully into account when exercising their

clinical judgement. The guidance does not, however, override the individual responsibility

of healthcare professionals to make decisions appropriate to the circumstances of the

individual patient in consultation with the patient and / or carer.

If you need an interpreter or need a document in another language, large print, Braille or audio

version, please contact Family Information Service web links as above.

If you are worried about your

child, trust your instincts.

Contact your GP or dial NHS 111.

Chiltern

Clinical Commissioning Group

Aylesbury Vale


Slough


Windsor, Ascot and Maidenhead


If you need advice please try

Your local pharmacy can be found at www.nhs.uk

Health Visitor: ......................

..........................

..........

Your GP Surgery: ........................

..........................

....

Please contact your GP when the surgery is open or

call NHS 111 when the GP surgery is closed.

NHS 111 provides advice for urgent care needs.

NHS 111 is available 24 hours a day, 365 days a year.

Calls from landlines and mobile phones are free.

NHS Choices: www.nhs.uk

for online advice and information

Bucks:

Family Information Service

Tel: 0845 688 4944 or www.bucksfamilyinfo. org.uk;

For common childhood illness advice see:

www.childhealthbucks.com

Berks:

Family Information Service - Slough

Tel: 01753 476589 or www.servicesguide.slough.gov.uk;

Windsor, Ascot and Maidenhead Tel: 01628 685632

or www.rbwm.gov.uk/web/cis.htm

For common childhood illness advice see:

www.childhealthslough.com

www.childhealthwam.com;

Some useful telephone numbers:

If they have or were:

• a premature baby

• are less than 6 weeks old

• a lung problem • a heart problem

• a problem with your child’s immune system

• or any other pre-existing medical condition that may

affect your child’s ability to cope with this illness

Please contact your Practice Nurse or Doctor

Below are some other conditions that could

affect your child’s ability to cope:

Bronchiolitis

Advice Sheet

Advice for parents and carers of

children aged 2 years old and under

• Most children with bronchiolitis will seem to worsen

during the first 1-3 days of the illness before beginning

to improve over the next two weeks. The cough may go

on for a few more weeks.

• As a parent / carer, you may find this useful to know as

it lasts longer then the normal coughs / colds that

children get.

• Your child can go back to nursery or day care as soon as

he or she is well enough ( feeding normally and with no

difficulty in breathing).

• There is usually no need to see your doctor if your child

is recovering well. If you are worried about your child’s

progress, discuss this with your Health Visitor, Practice

Nurse or Doctor.

How long does bronchiolitis last?

Bronchiolitis is when the smallest air passages in a

child’s lungs become swollen.

This can make it more difficult for your child to

breathe. Usually, bronchiolitis is caused by a virus

called respiratory syncytial virus (known as RSV).

Almost all children will have had an infection caused

by RSV by the time they are two years old. It is most

common in the winter months and usually only

causes mild “cold-like” symptoms.

Most children get better on their own.

Some children, especially very young ones, can

have difficulty with breathing or feeding and may

need to go to hospital.

Most children with bronchiolitis get better

within about two weeks. The cough may go on for

a few more weeks.

What is bronchiolitis?

• Your child may have a runny nose and sometimes

have a temperature and a cough.

• After a few days your child’s cough may become worse.

• Your child’s breathing may be faster than normal and it

may become noisy. He or she may need to make more

effort to breathe.

• Sometimes, in the very young children, bronchiolitis may

cause them to have brief pauses in their breathing.

• Sometimes their breathing can become more difficult,

and your child may not be able to take their usual amount

of milk by breast or bottle or may want to feed more

frequently but take a smaller amount.

• You may notice fewer wet nappies than usual.

• Your child may vomit after feeding and become irritable.

What are the symptoms?

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Published November 2013 To be reviewed November 2014

Name: ...................................................................

Date: ...................................

Smoking even outdoors will make asthma worseNational Smoking Helpline: 0800 022 4332

http://www.smokefree.nhs.uk

How to Treat yourWheeze/Asthma

Useful Websites:

Asthma UK: www.asthma.org.uk

Teenage Health Freak: www.teenagehealthfreak.com

www.childhealthbucks.com

Spacers

One puff every five breaths using the spacer (Tidal Breathing)

Aero ChamberVolumatic

Treatment Plan once you are homeOral Soluble Prednisolone (Dose) ...............................................................................

Length of treatment (in days) ..............................................................................................

Start date: ..................................................... End date: ......................................................

Salbutamol (Blue Reliever Inhaler)

Dose.................................................. Start Date....................... ..........................................

Other Medication ................................................................................................................This should be reduced using the Six Steps to reducing your inhaler usage guide below

Steroids (Preventer Inhaler) ......................................................................................Dose.................................................. Start Date.................................................................

Other Medication ..........................................................................................................

A follow up review should be undertaken by your GP/nurse within the next .................... days.

Always take your inhalers via a spacer as this is a much more effective way of getting medicines into the lungs● Smaller children (generally under 3 years)

to use spacer with face mask● Older children (generally over 3 years) to

use spacer with mouth piece

This is my Blue Reliever Inhaler.

This is used to relieve the wheeze/cough and can be used before exercise if necessary - it is best used with a spacer.

This helps me when I am coughing or wheezing by opening up and relaxing my lungs.

If I am using this more frequently than normal, I should see my doctor or nurse to have my asthma checked.

When my asthma is well controlled I should not need to use my blue inhaler regularly.

Reliever (Blue Inhaler)

Preventer Inhalers (Brown, Orange, Purple, Green or White)

My Preventer Inhaler is ..................... (colour)

This inhaler prevents my lungs becoming irritated and inflamed.

I must use this every day even when I am well to keep my asthma under control.

Spacer prescribed? YES NO

Health Care Professional has checked technique?

YES NO

● Organise a review with your GP or Asthma Nurse

● Keep your blue inhaler with you at all times

● Get a new inhaler when you start your last full one

● Ask your Health Care Professional how to use your inhaler and spacer properly and check your technique at every appointment

● If you run out, in an emergency a pharmacist may be able to supply salbutamol (there may be a charge for this)

● Avoid trigger factors for your asthma/wheeze eg. pollen/dust

● Remember to rinse your mouth out after using your preventer

● Wash your spacer monthly with warm soapy water, leaving it to drip dry

● Smoking even outdoors will make asthma worse

When my asthma is back under control this is what I should do

If your child gets more wheezy or breathless, go back up a step and contact your GP as soon as possible

(If your child is sleeping and breathing comfortably you do not need to wake them to give them their inhalers overnight).

1 Inhale 10 puffs every 4 hours for 24 hours

2 Then inhale 8 puffs every 4 hours for 24 hours



5 Then inhale 2 puffs every 6-8 hours for 24 hours

6 Then inhale 2 puffs as and when required

GIVING YOUR INHALER Steps 1-3 needs to be followed for each puff e.g. if asked to give 2 puffs; repeat the whole process twice. You may be given different coloured inhalers or chambers. The process is the same for all colours. Below are some examples of different coloured inhalers and chambers.

Top TipsSix Steps to reducing your salbutamol (Blue Reliever Inhaler) usage

Reassess and monitor your child regularly (symptoms may start or get worse in the evening ) - please follow traffic light advice above.

REMEMBER ALWAYS HAVE YOUR BLUE INHALER AND SPACER WITH YOUIMPORTANT: ASTHMA/WHEEZE CAN BE LIFE THREATENING

LIFE THREAT

If your child:● becomes unresponsive● becomes blue● is having severe difficulty breathing - using tummy muscles - ribs are sinking in● unable to complete sentences● is unable to take fluids and is

getting tired ● is pale, drowsy, weak or quiet

MODERATE

If your child is:● having some difficulty in breathing /

noisy breathing● Mild wheeze and has breathless-

ness that is not responding to the usual reliever (blue inhaler) treatment

● Using their blue reliever inhaler – more than 2 puffs every 4 hours

● Breathing more quickly than normal

You need to contact a nurse or doctor today

Increase blue inhaler 10 puffs over 20 min-utes and repeat every 4 hours via spacer and

Please ring your GP surgery during the day or when your GP surgery is closed, please call NHS 111 by dialling 111.

MILD

If your child is:Using their reliever more than usual but is not breathing quickly and is able to continue doing day to day activities and is able to talk in full sentences

Needs doctor / nurse review over the next few days, unless deteriorating. Continue to use blue inhaler as required. Read this leaflet about how to help with your wheeze / Asthma symptom control.

What do I do if my child is Wheezy / has Asthma? (traffic light advice)

Warning signs that your asthma is not well controlled include:● Waking up regularly to cough, feeling tight / wheezy during the night ● Early morning tightness wheeze or cough● Frequently needing your blue inhaler● Frequent exercise induced cough or wheeze

You need EMERGENCY helpRing 999 - you need help immediately

If you have a blue inhaler use it now - 1 puff per minute via Spacer

UNTIL AMBULANCE ARRIVES

Nearest Hospitals (open 24 hours 7 days a week):

▲▲

▲

Frimley Park, SurreyHillingdon HospitalJohn Radcliffe, OxfordMilton Keynes Hospital

Royal Berkshire, ReadingStoke Mandeville Hospital, AylesburyWexham Park Hospital, Slough

Produced by the Children and Young People Urgent Care Board

Published August 2014 To be reviewed August 2015. This guidance is written in the following context:

This document was arrived at after careful consideration of the evidence available including but not exclusively NICE Quality Standard for Asthma QS25- February 2013, BTS/SIGN Asthma Guidelines 2009, as applicable. Healthcare professionals are expected to take it fully into account when exercising their clinical judgement. The guidance does not, however, override the

individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient in consultation with the patient and / or carer.


Produced by the Children and Young People Urgent Care Board Published August 2014 To be reviewed August 2015. This guidance is written in the following context:

This document was arrived at after careful consideration of the evidence available including but not exclusively NICE Quality Standard for Asthma QS25- February 2013, BTS/SIGN Asthma Guidelines 2009, as applicable. Healthcare professionals are expected to take it fully into account when exercising their clinical judgement. The guidance does not, however, override the individual responsibility of

healthcare professionals to make decisions appropriate to the circumstances of the individual patient in consultation with the patient and / or carer.


Dose of Soluble Prednisolone (orally) < 2 yrs 10mg; 2-5 yrs 20 mg; >5 yrs 30 – 40 mg

Dose Hydrocortisone (IV) < 2 yrs 25mg QDS; 2-5 yrs 50 mg QDS; >5-18 yrs 100mg QDS

Dose Salbutamol nebulisers <5 yrs 2.5 mg; >5yrs 5mg

Dose Ipratropium Bromide 250 mcg all ages (or up to 500mcg via nebuliser for over 12 years)

Table 5 : Drug Doses

Moderate Exacerbation• Give 10 puffs of salbutamol stat via spacer

(Tidal breathing, 1 puff to every 5 breaths)• Reassess 15-30 minutes post intervention• Consider a 3 day course of soluble

prednisolone - 1st dose now (See Table 5)

Assess response after one hour

Send Home:• Customise the ‘How to Treat Your Asthma/

Wheeze’ booklet for the patient• Highlight safety netting and red flags• Check the patient has enough inhaler and

appropriate spacer and check their technique• Advise parents to contact their GP surgery

the next day to arrange a follow up within 48 - 72 hours

• Send home with correct dosage of salbutamol tailored according to response

• Discuss further management with Paediatrician-On-Call

• Consider lower threshold for admission circumstances

•Repeat salbutamol up to every 20-30 minutes

•Give nebulised ipratropium at an appropriate dose driven by oxygen (Ref Table 5)

•Bleep Paediatrician-on-call urgently to arrange a quick review and admit to ward

Severe Exacerbation• Give O

2 to achieve SpO

2 in air 94-98%

• Nebulised salbutamol driven by O2 (Ref Table 5)

• Oral prednisolone or IV hydrocortisone (Ref Table 5)

• Continue oxygen, salbutamol therapy as appropriate (Ref Table 5)

• If poor response give nebulised ipratropium bromide driven by O

2 (Ref Table 5)

Reassess after each treatment

Life threatening• Give O

2 via a face mask to achieve SpO

2 in air

94-98%• Contact Anaesthetic Registrar/Paediatrician-On-Call

• Nebulised salbutamol driven by O2 (Ref Table 5)

• Give oral prednisolone (Ref Table 5) or IV hydrocortisone

• Repeat salbutamol up to every 2- -30 minutes

• Use hospital Asthma Guidelines for further management including IV medications

Assess after each intervention

Admit

If all green features and no amber or red

If any amber features and no red

If any red features

(Adapted from APLS†) Respiratory Rate at rest: Heart Rate Systolic BP mmHg

Pre-school 2 - 5 years 25 - 30 95 - 140 85 - 100

School 5 - 11 years 20 - 25 80 - 120 90 - 110

Adolescent 12-16 years 15 - 20 60 - 100 100 - 120

Table 4 : Normal paediatric values:

† Adapted from Advanced Paediatric Life Support The Practical Approach Fifth Edition Advanced Life Support Group Edited by Martin Samuels; Susan Wieteska Wiley-Blackwell / 2011 BMJ Books.

Table 3 : Traffic Light system for identifying severity of acute wheeze/asthma

Green - moderate Amber - Severe Red – Life ThreateningTalking In sentences Not able to complete a sentence in one breath

Too breathless to talk or feed

Not able to talk / Not responding

Confusion / Agitation Auscultation

of chestGood air entry, mild - moderate wheeze Decreased air entry with marked wheeze Silent chest

Respiratory Rate Within normal range •≤ 40 breaths / min (2-5 yrs)

•≤ 30 breaths / min (> 5 yrs)

> 40 breaths p/min (2-5 yrs) > 30 breaths p/ min (> 5 yrs)

Cyanosis Poor respiratory effort Exhaustion

Heart Rate ≤140 beats p/min (2-5 yrs) ≤125 beats p/ min (> 5 yrs)

>140 beats p/min (2-5 yrs) >125 beats p/ min (> 5 yrs)

Tachycardic or Bradycardic

Hypotension Oxygen Saturation in air Greater than or equal to 92% in air <92% in air <92% in air

PEFR (if possible)

>50% of predicted 33-50% of predicted <33% predicted

Feeding Still feeding Struggling Unable to feed

•Fever(pneumonia)•Dysphagia(epiglottis)•Productivecough(pneumonia)•Inspiratorystridor(croup)•Breathlessness with light headedness and peripheral tingling (hyperventilation) •Asymmetry on auscultation (pneumonia or a foreign body etc)•Excessivevomiting(GORD)

Immediate resuscitation if required.

Child presenting with wheeziness / asthma:Assess and look for life threatening signs and symptoms

(see Table 1, Table 2 and Table 3)

• Attack in late afternoon or night

• Recent hospital admission

• Previous severe attack

• Young age

• Previous cardio-respiratory illness

Table 1 : High Risk Factors – Healthcare professionals should be aware of the increased need for hospital admission in children with the following:

Table 2 : Consider other diagnoses if any of the following are present:

MANAGEMENT OF ACUTE WHEEzE IN SECONDARY CARE– CLINICAL ASSESSMENT / MANAGEMENT TOOL for 2 - 16 years

Management - In Hospital Setting acute wheeze /asthma

Good response clinically better

Moderate response

Poor response Consider if now amber/red

Name: ...................................................................

Date: ...................................

Smoking even outdoors will make asthma worse

National Smoking Helpline: 0800 022 4332

http://www.smokefree.nhs.uk

How to Treat yourWheeze/Asthma

Useful Websites:Asthma UK: www.asthma.org.ukTeenage Health Freak: www.teenagehealthfreak.comwww.childhealthbucks.com

Response





Dose of soluble prednisolone (orally) 2-5 yrs 20 mg; >5 yrs 30 – 40 mg

Dose salbutamol nebulisers <5 yrs 2.5 mg; >5yrs 5mg

Dose ipratropium bromide 250 mcg all ages (or up to 500mcg via nebuliser for over 12 years)

Table 4 : Drug Doses

• Consider hospital admission/999

• Oxygen if SpO2 < 94%.

• Continue with further doses of salbutamol while awaiting transfer.

• Add ipatropium dose mixed with salbutamol nebuliser

• Send home with personalised written action plan.

• 3 days of oral prednisolone if asthmatic (See Table 4 : Drug Doses)

• Antibiotics should not be routinely given.• Check inhaler technique• Safety net • Advise parents to contact GP surgery next

day to arrange a follow up within 48-72 hrs.• Remember to check they have enough

inhaler and appropriate spacer

Good Response Poor Response

Table 6 : Predicted Peak Flow: For use with EU / EN13826 scale PEF metres only

Height (m)

Height (ft)

Predicted EU PEFR

Height (m) (L/min)

Height (ft)

Predicted EU PEFR (L/min)

1.00 3’ 3” 115 1.45 4’9” 276

1.05 3’ 5“ 127 1.50 4’11” 299

1.10 3’ 7” 141 1.55 5’1” 323

1.15 3’ 9” 157 1.60 5’3” 346

1.20 3’ 11” 174 1.65 5’5” 370

1.25 4’ 1” 192 1.70 5’7” 393

(Adapted from APLS†)

Respiratory Rate at rest:

Heart Rate Systolic BP mmHg

Pre-school 2 - 5 years 25 - 30 95 - 140 85 - 100

School 5 - 11 years 20 - 25 80 - 120 90 - 110

Adolescent 12-16 years 15 - 20 60 - 100 100 - 120

Table 5 : Normal paediatric values:

† Adapted from Advanced Paediatric Life Support The Practical Approach Fifth Edition Advanced Life Support Group Edited by Martin Samuels; Susan Wieteska Wiley-Blackwell / 2011 BMJ Books.

• Refer to Hospital Urgently (999)• High flow oxygen via face mask if available• Give salbutamol nebuliser, oxygen driven if available (See Table 4 : Drug Doses) • If poor response add ipatropium bromide dose mixed with the nebulised salbutamol

(See Table 4 : Drug Doses)• Continue with further doses of bronchodilator while awaiting transfer• Give stat dose of soluble prednisolone (See Table 4 : Drug Doses)

• Give 10 puffs of salbutamol stat via spacer (tidal breathing,1 puff to every 5 breaths). If nebulising this should be oxygen driven but if necessary compressor driven is acceptable.

• Reassess 15-30 minutes post intervention• Consider a 3 day course of soluble prednisolone -

1st dose now. (See Table 4 : Drug Doses)

Table 3 : Traffic Light system for identifying severity of acute wheeze

Green - moderate Amber - Severe Red – Life ThreateningTalking In sentences Not able to complete a sentence in one breath

Too breathless to talk or feed

Not able to talk / Not responding

Confusion / Agitation Auscultation

of chestGood air entry, mild - moderate wheeze Decreased air entry with marked wheeze Silent chest

Respiratory Rate Within normal range •≤ 40 breaths / min (2-5 yrs)

•≤ 30 breaths / min (> 5 yrs)

> 40 breaths p/min (2-5 yrs) > 30 breaths p/ min (> 5 yrs)

Cyanosis Poor respiratory effort Exhaustion

Heart Rate ≤140 beats p/min (2-5 yrs) ≤125 beats p/ min (> 5 yrs)

>140 beats p/min (2-5 yrs) >125 beats p/ min (> 5 yrs)

Tachycardic or Bradycardic

Hypotension Oxygen Saturation in air Greater than or equal to 92% in air <92% in air <92% in air

PEFR (if possible)

>50% of predicted 33-50% of predicted <33% predicted

Feeding Still feeding Struggling Unable to feed

•Fever(pneumonia)•Dysphagia(epiglottis)•Productivecough(pneumonia)•Inspiratorystridor(croup)•Breathlessness with light headedness and peripheral tingling (hyperventilation) •Asymmetry on auscultation (pneumonia or a foreign body etc)•Excessivevomiting(GORD)

Immediate resuscitation if required. Dial 999Child presenting with acute wheeze

• Attack in late afternoon or night

• Recent hospital admission

• Previous severe attack

• Young age

• Previous cardio-respiratory illness

Table 1 : High Risk Factors – Healthcare professionals should be aware of the increased need for hospital admission in infants with the following:

Table 2 : Consider other diagnoses if any of the following are present:

MANAGEMENT OF ACUTE WHEEzE IN PRIMARY CARE– CLINICAL ASSESSMENT / MANAGEMENT TOOL for 2 - 16 years

Management - Out of Hospital Setting





Alarming Signs

• SpO2 < 92%, Cyanosis• Bradycardia < 100 beats/minute• RR < 20/Apnoea• Marked Sternal recessions• Worsening SOB• Poor air entry

• < 3/12

• Exprem, low birth weight

• Prolonged NICU/SCBU

• CHD, pre-existing lung condition

• Reduced feeding < 50%

• Previous severe episodes

• Antibiotics should not be routinely given

• Oral beta 2 agonist not recommended

• Personalised written action plan

• Check inhaler technique

• Safety net and review by 48-72 hrs

• Alert

• Still Feeding

• SpO2 > 92%

• Bilateral wheeze on Auscultation

• Good air entry

• Refer to Paediatricians urgently

• Oxygen if SpO2 < 94%

High Risk Children

Mild - Moderate

Prompt recognition of respiratory failure

MANAGEMENT oF ACUTE WHEEzE IN PRIMARY CARE– ClINICAl ASSESSMENT / MANAGEMENT Tool FoR UNDER 2 YEARS

Management - out of Hospital Setting

Refer to hospital urgently (999).

oxygen via face mask

oxygen driven salbutamol nebuliser

First line treatment: 10 puffs of beta 2 agonist via MDI via spacer and face mask (preferred route). O2 driven is

the recommended method of nebulisation.

(Compressor driven nebuliser treatment is acceptable if oxygen not available)

Re-assess after 15-30 minutes

Good Response Poor Response

some useful telephone numbers: bronchiolitis advice sheet...bronchiolitis advice sheet advice for...

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