What are the symptoms?
Some useful telephone numbers:
• 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.
Based on Scottish Intercollegiate Guidelines (SIGN) 2006 Guideline No. 91 Bronchiolitis in children - http://www.sign.ac.uk/guidelines/fulltext/91/index.html
• Your child may vomit after feeding and become irritable.
Below are some other conditions that could
affect your child’s ability to cope:
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
How long does bronchiolitis last?
• 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.
If you need an interpreter or need a document in another language, large print, Braille or audio
• 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
Clinical Commissioning Group
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
clinical judgement. The guidance does not, however, override the individual responsibility
progress, discuss this with your Health Visitor, Practice
Nurse or Doctor.
Bronchiolitis
If you need advice please try:
Your local pharmacy can be found at www.nhs.uk Advice Sheet
Health Visitor: .......................................................... Advice for parents and carers of
Your GP Surgery: ...................................................... children aged 2 years old and under
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
What is bronchiolitis?
Bronchiolitis is when the smallest air passages in a
If you are worried about your child’s lungs become swollen.
child, trust your instincts. This can make it more difficult for your child to
breathe. Usually, bronchiolitis is caused by a virus
Contact your GP or dial NHS 111. called respiratory syncytial virus (known as RSV).
Almost all children will have had an infection caused
For more copies of this document please email: chilternccg@nhs.net
by RSV by the time they are two years old. It is most
version, please contact Family Information Service web links as above. common in the winter months and usually only
Published November 2013 To be reviewed November 2014 causes mild “cold-like” symptoms.
Update approved by Children and Young People Urgent Care Board
Most children get better on their own.
Chiltern
Aylesbury Vale
Clinical Commissioning Group
Slough
Clinical Commissioning Group
Windsor, Ascot and Maidenhead
Clinical Commissioning Group Some children, especially very young ones, can
This guidance is written in the following context: have difficulty with breathing or feeding and may
This document was arrived at after careful consideration of the evidence available need to go to hospital.
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 Most children with bronchiolitis get better
of healthcare professionals to make decisions appropriate to the circumstances of the within about two weeks. The cough may go on for
individual patient in consultation with the patient and / or carer. a few more weeks.
www.chilternccg.nhs.uk www.aylesburyvaleccg.nhs.uk
www.sloughccg.nhs.uk www.windsorascotmaidenheadccg.nhs.uk
 How can I help my baby? 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. Most children with bronchiolitis get better over time, but some children can get worse.
• If your child is distressed or you feel they are in
You need to regularly check your child and follow the advice below.
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
You need EMERGENCY help
together. If your child has not improved after Call 999 or go straight to the nearest
If your child has any one of these below: Hospital Emergency (A&E) Department
2-3 hours you may want to give them the other


medicine. Never exceed the dose on the bottle. • Has blue lips Nearest Hospitals (open 24 hours 7 days a week):
• Please read and follow the instructions on the • or is unresponsive or very irritable • Frimley Park, Surrey • Stoke Mandeville
medicine container. Over the counter (OTC) • or is struggling to breathe • Hillingdon Hospital Hospital, Aylesbury
medicines may not be available to purchase for all • or has unusually long pauses in breathing • John Radcliffe, Oxford • Wexham Park Hospital,
age groups. Ask your pharmacist. RED • or has an irregular breathing pattern • Milton Keynes Hospital Slough
• If your child is already taking medicines or inhalers,
• Royal Berkshire, Reading
you should carry on using these. If you find it
difficult to get your child to take them, ask your Bring your child’s Red Book with you.
Pharmacist, Health Visitor or Doctor for advice.
• Bronchiolitis is caused by a virus so antibiotics will
not help.
If your child has any one of these below:
• If your child’s health gets worse or you are You need to contact a
worried
nurse or doctor today


• or has decreased feeding by 50% (half)
Passive smoking affects your baby - if you • or is passing less urine than normal
would like help to stop smoking: Please ring your GP surgery during the
• or is vomiting day or when your GP surgery is closed,
• or temperature is above 38°C please call NHS 111
• Make sure your child is never exposed to tobacco
smoke. Passive smoking can seriously damage your
AMBER • or is finding it difficult to breathe
• Please see box “conditions that could affect Bring your child’s Red Book with you.
child’s health. It can make breathing problems like your child’s ability to cope”overleaf
bronchiolitis worse. Remember smoke remains on
your clothes when you smoke anywhere including
outside.
• If you would like help to stop smoking, please
contact:
Self care
Using the advice on this leaflet you can care for
Buckinghamshire your child at home.
Stop Smoking Bucks – Tel: 0845 2707222
Email: stopsmoking@buckshealthcare.nhs.uk
Berkshire
GREEN
If none of the features in the red or amber
boxes above are present.
 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)
SmokefreelifeBerkshire - Tel: 0800 6226360
or send a SMS QUIT to 66777 You can also call NHS 111
Email: info@smokefreelifeberkshire.co.uk
BRONCHIOLITIS PATHWAY
– CLINICAL ASSESSMENT / MANAGEMENT TOOL FOR THE CHILD
YOUNGER THAN 2 YEARS WITH SUSPECTED BRONCHIOLITIS

Management - within Hospital Setting

Child presenting with bronchiolitis: Immediate resuscitation if required.

Assess and look for life threatening signs and symptoms Seek input of Senior A&E +
(see Table 1, Table 2 and Table 3) Paediatrician-On-Call

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

• Alert • Miserable • Unable to rouse
• Normal • Not responding normally to social cues
• Wakes only with prolonged stimulation
Behaviour • Decreased activity • No response to social cues
• No smile • Weak or continuous cry
• Appears ill to a healthcare professional
• CRT < 2 secs • CRT 2–3 secs • CRT > 3 secs
• Normal colour skin, lips and • Pale / mottled • Pale / Mottled / Ashen blue
Skin tongue • Pallor colour reported by parent / carer • Cyanotic lips and tongue
• Moist mucous membranes • Cool peripheries
• < 12 mths < 50 breaths / min • Tachypnoea • Tachypnoea
Respiratory Rate • > 12 mths < 40 breaths / min • < 12 mths 50-60 breaths / min • All ages > 60 breaths / min
• No respiratory distress • > 12 mths 40-60 breaths / min
Oxygen sats in • 95% or above • 92 – 94% • < 92%
air*
Chest recession • None • Moderate • Severe
Nasal Flaring • Absent • May be present • Present
Grunting • Absent • Absent • Present
• Normal
• Tolerating 75% of fluid • Tolerating 50-75% fluid intake • Tolerating < 50% fluid intake over
Feeding over 3-4 feeds 2-3 feeds + / - vomiting.
Hydration • Occasional cough induced • Significantly reduced urine output
vomiting • + / - vomiting.
• Reduced urine output
Apnoeas • Absent • Absent • Yes**
• Pre-existing lung • Immuno-
disease compromised
• Congenital heart • Prematurity
Other disease • Family anxiety
• Age < 12 weeks • Re-attendance
(corrected)

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.

All green and no Any amber Signs / Symptoms

amber or red Any red Signs / Symptoms
and no red
Send home with Bronchiolitis Immediate medical assessment
Needs further assessment by
Advice Sheet and resuscitation
doctor. Consider admission

* 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.
 If all green features If any amber features
If any red features
and no amber or red and no red
(from Table 1)
(from Table 1) (from Table 1)

Send Home Oxygen support required? Commence high flow

oxygen support.
Prior to sending home please see
Tables 3 and 4 below.
No Yes
iolitis Give appropriate and clear Seek advice of Senior A&E
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Based on Scottish Intercollegiate Guidelines (SIGN) 2006 Guideline No. 91 Bronchiolitis in children - http://www.sign.ac.uk/guidelines/fulltext/91/index.html

Give Oxygen if required to Consider NG feeding Consider NPA

maintain saturations >92% at 75% of maintenance. The following investigations are not
routinely recommended but may be
considered where there is diagnostic
Assess for Respiratory Distress uncertainty or an atypical disease course:
• Chest Xray
• Full Blood Count; Blood Culture
Increased + Stable Increased • Measurement of urea and electrolytes
Stable + <40% • Blood gas
Oxygen
Oxygen
>40%
If the child does not need admission provide
Continue NBM a safety net for the parents / carers ie. provide
parent / carer with written and verbal information
Continue For Senior NG Feeds
on warning symptoms (see Bronchiolitis Advice
with Regular Paediatric with regular IV fluids Sheet) and accessing further health care;
Assessment Review reassessment 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
If there is continuing clinical deterioration: illness. Remind them that the peak of the illness
lasts 1 - 3 days; Most babies get better within
Discuss with Consultant ASAP & consider informing PICU 7-14 days but the coughing could go on for 4
(also follow any appropriate local protocols) weeks.

Table 2 : Signs and Symptoms can include:

• Rhinorrhoea • Bronchiolitis season • Chesty cough • Inspiratory crackles + / -

(runny / snuffly nose) • Vomiting • Increased work of breathing wheeze
• Cough • Pyrexia • Apnoea • Cyanosis
• Poor feeding • Respiratory distress • Head bobbing

Table 3 : High Risk Factors - Healthcare professionals Table 4 : The following treatments are NOT
should be aware of the increased need for hospital recommended for infants with acute bronchiolitis
admission in infants with the following:
• Chest physiotherapy using • Inhaled beta 2 agonist
• Pre-existing lung disease • Prematurity vibration and percussion bronchodilators (may work
• Nebulised Ribavirin if atopic background)
• Congenital heart disease • Family anxiety
• Antibiotic therapy • Nebulised Ipratropium
• Age < 12 weeks (corrected) • Re- attendance Bromide
• Nebulised Epinephrine
• Immuno-compromised • Oral systemic corticosteroids
• Inhaled corticosteroids

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

Chiltern Aylesbury Vale Slough Windsor, Ascot and Maidenhead

Clinical Commissioning Group Clinical Commissioning Group Clinical Commissioning Group Clinical Commissioning Group

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.
www.chilternccg.nhs.uk www.aylesburyvaleccg.nhs.uk www.sloughccg.nhs.uk www.windsorascotmaidenheadccg.nhs.uk
 How to Treat your
Wheeze/Asthma
Name:....................................................................

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

Useful Websites:
Asthma UK: www.asthma.org.uk

Teenage Health Freak:

www.teenagehealthfreak.com

www.childhealthbucks.com

Smoking even outdoors will make asthma worse

National Smoking Helpline: 0800 022 4332
http://www.smokefree.nhs.uk
 GIVING YOUR INHALER
Treatment Plan once you are home When my asthma is back under Steps 1-3this
control needs
is towhat I shouldfordoeach
be followed
puff e.g. if asked to give 2 puffs; repeat the
Oral Soluble Prednisolone (Dose)................................................................................ whole process twice.
You may be given different coloured
Length of treatment (in days)............................................................................................... Reliever Preventer Inhalers
inhalers or chambers. The process is the
(Blue Inhaler) (Brown,
same for Orange, Purple, Green or White)
all colours.
Start date:...................................................... End date:.......................................................
Salbutamol (Blue Reliever Inhaler) Below are some
My Preventer examples
Inhaler of different
is...................... (colour)
coloured inhalers and chambers.
Dose.................................................. Start Date....................... ..........................................
Other Medication.................................................................................................................
This should be reduced using the Six Steps to reducing your inhaler usage guide below This is my Blue
Reliever Inhaler.
Steroids (Preventer Inhaler).......................................................................................
Dose.................................................. Start Date................................................................. This is used to relieve the wheeze/cough and
Other Medication........................................................................................................... can be used before exercise if necessary - it
is best used with a spacer.
A follow up review should be undertaken by your GP/nurse within the next ..................... days.
This helps me when I am coughing or This inhaler prevents my lungs becoming
Spacers wheezing by opening up and relaxing my irritated and inflamed.
Always take your inhalers via a spacer as this is a much more effective lungs. I must use this every day even when I am
way of getting medicines into the lungs If I am using this more frequently than normal, well to keep my asthma under control.
Volumatic Aero Chamber
I should see my doctor or nurse to have my
● S maller children (generally under 3 years) Spacer prescribed? YES NO
asthma checked.
to use spacer with face mask
● Older children (generally over 3 years) to When my asthma is well controlled I should
Health Care Professional has checked technique?
use spacer with mouth piece not need to use my blue inhaler regularly.
YES NO

Six Steps to reducing your salbutamol (Blue Reliever Inhaler) usage Top Tips
(If your child is sleeping and breathing comfortably you do not need to wake them to give them their
inhalers overnight). ● Organise a review with your GP or Asthma Nurse
One puff every five breaths using the spacer (Tidal Breathing) ● Keep your blue inhaler with you at all times
1 Inhale 10 puffs every 4 hours for 24 hours ● Get a new inhaler when you start your last full one
2 Then inhale 8 puffs every 4 hours for 24 hours ● Ask your Health Care Professional how to use your inhaler and spacer properly
and check your technique at every appointment
3 Then inhale 6 puffs every 6 hours for 24 hours
● If you run out, in an emergency a pharmacist may be able to supply
4 Then inhale 4 puffs every 6 hours for 24 hours salbutamol (there may be a charge for this)
5 Then inhale 2 puffs every 6-8 hours for 24 hours ● Avoid trigger factors for your asthma/wheeze eg. pollen/dust
6 Then inhale 2 puffs as and when required ● Remember to rinse your mouth out after using your preventer
● Wash your spacer monthly with warm soapy water, leaving it to drip dry
If your child gets more wheezy or breathless, go back up
a step and contact your GP as soon as possible ● Smoking even outdoors will make asthma worse
 What do I do if my child is Wheezy / has Asthma? (traffic light advice)

You need EMERGENCY help

If your child:
Ring 999 - you need help immediately
● becomes unresponsive

▲
● becomes blue If you have a blue inhaler use it now -
1 puff per minute via Spacer
● is having severe difficulty breathing
- using tummy muscles UNTIL AMBULANCE ARRIVES
- ribs are sinking in Nearest Hospitals (open 24 hours 7 days a week):
Life ● unable to complete sentences
● is unable to take fluids and is Frimley Park, Surrey Royal Berkshire, Reading
Threat Hillingdon Hospital Stoke Mandeville Hospital, Aylesbury
getting tired
● is pale, drowsy, weak or quiet John Radcliffe, Oxford Wexham Park Hospital, Slough
Milton Keynes Hospital

If your child is:

● having some difficulty in breathing / You need to contact a
●
noisy breathing
Mild wheeze and has breathless-
▲ ▲ nurse or doctor today
Increase blue inhaler 10 puffs over 20 min-
ness that is not responding to
the usual reliever (blue inhaler) utes and repeat every 4 hours via spacer and
treatment Please ring your GP surgery during the
Moderate ● Using their blue reliever inhaler – day or when your GP surgery is closed,
more than 2 puffs every 4 hours please call NHS 111 by dialling 111.
● Breathing more quickly than normal

If your child is:

Needs doctor / nurse review over the next few
Using their reliever more than usual
days, unless deteriorating. Continue to use blue
but is not breathing quickly and is able
inhaler as required. Read this leaflet about how to
to continue doing day to day activities
help with your wheeze / Asthma symptom control.
and is able to talk in full sentences
Mild
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
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 YOU
IMPORTANT: ASTHMA/WHEEZE CAN BE LIFE THREATENING
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.

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

Management of Acute Wheeze in Secondary Care
– Clinical Assessment / Management Tool for 2 - 16 years

Management - In Hospital Setting acute wheeze /asthma

Child presenting with wheeziness / asthma:
Immediate resuscitation
Assess and look for life threatening signs and symptoms
(see Table 1, Table 2 and Table 3) if required.

Table 1 : High Risk Factors – Healthcare professionals should be aware of the Table 2 : Consider other diagnoses if any of the following are present:
increased need for hospital admission in children with the following:
• Fever (pneumonia)
• Attack in late afternoon or night • Dysphagia (epiglottis)
• Productive cough (pneumonia)
• Recent hospital admission
• Inspiratory stridor (croup)
• Previous severe attack • Breathlessness with light headedness and peripheral tingling (hyperventilation)
• Young age • Asymmetry on auscultation (pneumonia or a foreign body etc)
• Previous cardio-respiratory illness • Excessive vomiting (GORD)

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

Green - moderate Amber - Severe Red – Life Threatening

Talking In sentences Not able to complete a sentence in one breath Not able to talk / Not responding
Too breathless to talk or feed Confusion / Agitation
Auscultation Good air entry, mild - moderate wheeze Decreased air entry with marked wheeze Silent chest
of chest
Respiratory Rate Within normal range > 40 breaths p/min (2-5 yrs) Cyanosis
• ≤ 40 breaths / min (2-5 yrs) > 30 breaths p/ min (> 5 yrs) Poor respiratory effort
Exhaustion
• ≤ 30 breaths / min (> 5 yrs)
Heart Rate ≤140 beats p/min (2-5 yrs) >140 beats p/min (2-5 yrs) Tachycardic or Bradycardic
≤125 beats p/ min (> 5 yrs) >125 beats p/ min (> 5 yrs) Hypotension
Oxygen Saturation in air Greater than or equal to 92% in air <92% in air <92% in air
PEFR >50% of predicted 33-50% of predicted <33% predicted
(if possible)
Feeding Still feeding Struggling Unable to feed

If all green features and If any amber features

If any red features
no amber or red and no red

Moderate Exacerbation Severe Exacerbation Life threatening

• Give 10 puffs of salbutamol stat via spacer • Give O2 to achieve SpO2 in air 94-98%
(Tidal breathing, 1 puff to every 5 breaths) • Nebulised salbutamol driven by O2 (Ref Table 5)
• Reassess 15-30 minutes post intervention • Oral prednisolone or IV hydrocortisone
• Consider a 3 day course of soluble (Ref Table 5)
prednisolone - 1st dose now (See Table 5) • Continue oxygen, salbutamol therapy
as appropriate (Ref Table 5)
Assess response after one hour
• If poor response give nebulised ipratropium
bromide driven by O2 (Ref Table 5)
Reassess after each treatment
• Give O2 via a face mask to achieve SpO2 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

Response

Good response Moderate Poor response

Admit
clinically better response Consider if now amber/red

Send Home: • Discuss further • Repeat salbutamol up to every 20-30 minutes

• Customise the ‘How to Treat Your Asthma/ management with
• Give nebulised ipratropium at an appropriate dose
Wheeze’ booklet for the patient Paediatrician-On-Call
How to driven by oxygen (Ref Table 5)
T
• Highlight safety netting and red flags Wheez reat your • Consider lower
e/Asth threshold for admission • Bleep Paediatrician-on-call urgently to arrange a
• Check the patient has enough inhaler and ma
Name:
............
............ circumstances quick review and admit to ward
appropriate spacer and check their technique ............

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

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Table 4 : Normal paediatric values: Table 5 : Drug Doses

(Adapted from APLS†) Respiratory Rate at rest: Heart Rate Systolic BP mmHg Dose of Soluble Prednisolone (orally) < 2 yrs 10mg; 2-5 yrs 20 mg; >5 yrs 30 – 40 mg
Pre-school 2 - 5 years 25 - 30 95 - 140 85 - 100 Dose Hydrocortisone (IV) < 2 yrs 25mg QDS; 2-5 yrs 50 mg QDS; >5-18 yrs 100mg QDS
School 5 - 11 years 20 - 25 80 - 120 90 - 110 Dose Salbutamol nebulisers <5 yrs 2.5 mg; >5yrs 5mg
Adolescent 12-16 years 15 - 20 60 - 100 100 - 120
Dose Ipratropium Bromide 250 mcg all ages (or up to 500mcg via nebuliser for over 12 years)
† 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.

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.

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

Management of Acute Wheeze in Primary Care
– Clinical Assessment / Management Tool for 2 - 16 years

Management - Out of Hospital Setting

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

Table 1 : High Risk Factors – Healthcare professionals should be aware of the Table 2 : Consider other diagnoses if any of the following are present:
increased need for hospital admission in infants with the following:
• Fever (pneumonia)
• Attack in late afternoon or night • Dysphagia (epiglottis)
• Productive cough (pneumonia)
• Recent hospital admission
• Inspiratory stridor (croup)
• Previous severe attack
• Breathlessness with light headedness and peripheral tingling (hyperventilation)
• Young age • Asymmetry on auscultation (pneumonia or a foreign body etc)
• Previous cardio-respiratory illness • Excessive vomiting (GORD)

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

Green - moderate Amber - Severe Red – Life Threatening

Talking In sentences Not able to complete a sentence in one breath Not able to talk / Not responding
Too breathless to talk or feed Confusion / Agitation
Auscultation Good air entry, mild - moderate wheeze Decreased air entry with marked wheeze Silent chest
of chest
Respiratory Rate Within normal range > 40 breaths p/min (2-5 yrs) Cyanosis
• ≤ 40 breaths / min (2-5 yrs) > 30 breaths p/ min (> 5 yrs) Poor respiratory effort
Exhaustion
• ≤ 30 breaths / min (> 5 yrs)
Heart Rate ≤140 beats p/min (2-5 yrs) >140 beats p/min (2-5 yrs) Tachycardic or Bradycardic
≤125 beats p/ min (> 5 yrs) >125 beats p/ min (> 5 yrs) Hypotension
Oxygen Saturation in air Greater than or equal to 92% in air <92% in air <92% in air
PEFR >50% of predicted 33-50% of predicted <33% predicted
(if possible)
Feeding Still feeding Struggling Unable to feed

• 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)
• 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)

Good Response Poor Response

• Send home with personalised written • Consider hospital admission/999

action plan. • Oxygen if SpO2 < 94%.
• 3 days of oral prednisolone if asthmatic • Continue with further doses of salbutamol
(See Table 4 : Drug Doses) while awaiting transfer.
• Antibiotics should not be routinely given.
• Add ipatropium dose mixed with
• Check inhaler technique salbutamol nebuliser
• 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 Table 4 : Drug Doses

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

(Adapted from Respiratory Rate at Heart Rate Systolic BP mmHg Predicted EU

APLS†) rest: Height Height Height Height Predicted EU
PEFR
(m) (ft) (m) (L/min) (ft) PEFR (L/min)
Pre-school 2 - 5 years 25 - 30 95 - 140 85 - 100
School 5 - 11 years 20 - 25 80 - 120 90 - 110 1.00 3’ 3” 115 1.45 4’9” 276
Adolescent 12-16 years 15 - 20 60 - 100 100 - 120 1.05 3’ 5“ 127 1.50 4’11” 299
1.10 3’ 7” 141 1.55 5’1” 323
† 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. 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

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.

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

Management of Acute Wheeze in Primary Care
– Clinical Assessment / Management TOOL FOR UNDER 2 YEARS

Management - Out of Hospital Setting

High Risk Children Prompt recognition of respiratory failure

• < 3/12 Alarming Signs
• Exprem, low birth weight • SpO2 < 92%, Cyanosis
• Prolonged NICU/SCBU • Bradycardia < 100 beats/minute
• CHD, pre-existing lung condition • RR < 20/Apnoea
• Marked Sternal recessions
• Reduced feeding < 50%
• Worsening SOB
• Previous severe episodes • Poor air entry

Refer to hospital urgently (999).

Oxygen via face mask
oxygen driven salbutamol nebuliser

Mild - Moderate
First line treatment: 10 puffs of beta 2 agonist via MDI
• Alert
via spacer and face mask (preferred route). O2 driven is
• Still Feeding
the recommended method of nebulisation.
• SpO2 > 92%
• Bilateral wheeze on Auscultation (Compressor driven nebuliser treatment is acceptable
• Good air entry if oxygen not available)
Re-assess after 15-30 minutes

Good Response Poor Response

• Antibiotics should not be routinely given

• Oral beta 2 agonist not recommended
• Personalised written action plan • Refer to Paediatricians urgently
• Check inhaler technique • Oxygen if SpO2 < 94%
• Safety net and review by 48-72 hrs

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.

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