Acute asthma in children - emergency department
A concise ED‑focused guide to assessment, initial treatment, escalation and discharge for children with acute asthma. Aligns with NICE acute‑asthma pathway and Resuscitation Council / RCEM acute care recommendations. See NICE NG244 and Resuscitation Council UK for full pathways and BTS/SIGN acute‑attack algorithms.
Key principles
- Rapid ABCDE assessment and early recognition of life‑threatening features.
- Start bronchodilator therapy promptly; use pMDI + spacer when effective and nebuliser (oxygen‑driven) when required.
- Give systemic corticosteroid early (ideally within the first hour).
- Escalate early for poor response; involve senior paediatrics/PICU for refractory or life‑threatening disease.
- Document response and safety‑monitoring throughout.
Why attacks occur
- Most exacerbations are triggered by viral URIs, allergens, irritants or poor adherence to inhaled corticosteroids.
- Pathology: acute bronchoconstriction, mucosal oedema and excess secretions → increased airway resistance, V/Q mismatch and, in severe cases, respiratory muscle fatigue with hypercapnic respiratory failure.
Initial assessment - ED priorities
- Use an ABCDE approach. Identify immediately life‑threatening features: silent chest, poor respiratory effort, cyanosis, altered consciousness.
- Record baseline observations: respiratory rate (RR), heart rate (HR), SpO2, work of breathing (recession, accessory muscle use), speech/feeding, conscious level.