Acute wheezing in children aged over 2 years (asthma and viral wheeze)

A clinical assessment will help to assess the urgency of the child’s condition.  Oxygen saturations in young children should only be measured if a paediatric saturation probe is available.

An attempt to measure peak expiratory flow should be made in all children aged 6 years and over. The normal values can be found here:

http://www.peakflow.com/paediatric_normal_values.pdf

A guide on how to perform peak expiratory flow can be found here:

https://www.asthma.org.uk/advice/manage-your-asthma/peak-flow/#howtouseaPFM

*Prednisolone

1. Try to avoid in < 2 years old and episodic wheeze, i.e. distinct episodes of wheeze with upper respiratory tract infections only; especially if there is no history of interval symptoms and no other triggers.
2. Give prednisolone 1mg/kg (max 40mg) as early as possible in multi trigger wheeze / asthma or if there is a history of atopy or family history of asthma/atopy.  A standard course is 3 days. If still significant symptoms after 3 days, further steroids and review in secondary care paediatrics should be considered.

Please consider whether an alternative diagnosis is likely, such as:

1. Chest infection – high fevers, wet cough, focal signs on chest auscultation
2. Foreign body aspiration – usually from history, focal chest signs
3. Croup – inspiratory stridor, sudden onset
4. Bronchiolitis in < 12 months old – especially if widespread wheeze and crackles

Things to consider at phone/in person review:

Following an acute attack:

1. Check if improving – if child is unable to progress through the salbutamol weaning plan, or has deteriorated/’gone backwards’, please refer to Paediatrics for same day assessment.
2. Check need for further steroids
3. Review triggers leading to attack i.e. (allergens / compliance with meds / anxiety / weather/ exercise or exertion)
4. Check need for preventer inhaler – interval symptoms between attacks / use of Salbutamol > 2 – 3 times per week or > 2 attacks per year (see ‘chronic asthma’)
5. Check the child has sufficient salbutamol and an appropriate spacer available for future episodes
6. Check inhaler technique. 

Ongoing management

1. If using short acting B2 agonist more than three times a week consider regular preventer therapy- In the under 5 age group this can be either an inhaled low dose corticosteroid or leukotriene receptor antagonist (Montelukast)
2. Consider referral to Paediatrics if the child has required an inpatient admission or there are recurrent episodes over a several month period. Similarly, also consider referral if concerns over compliance with treatment or parental anxiety.

Here are some useful videos to guide parents:

https://www.asthma.org.uk/advice/inhaler-videos/single-breath-and-hold/

https://www.asthma.org.uk/advice/inhaler-videos/tidal-breathing/

• Check wheeze action plan in place

This is the one we recommend:

https://www.monkeywellbeing.com/wp-content/uploads/2020/03/MonkeyMyAsthmaPlanColourv2-1.pdf

• Check if any ‘Red Flags’ are present which would trigger a referral to Paediatric Outpatients.