The video version of this podcast can be found here: ·      https://youtu.be/LxlmAeHzjsgThis channel may make reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by NICE. My name is Fernando Florido (also known as Juan Fernando Florido Santana), a GP in the UK. In this episode, I will go through the new NICE guideline on acute asthma, NG244, focusing on what is relevant in Primary Care only. Given how extensive the guidance is, in this episode I will just focus on the treatment of acute asthma in children. In the last three episodes I covered the initial assessment in adults and children and the treatment in adults and in the next episode, I will cover:·      Lessons from asthma deaths and near-fatal asthma as well as reviewing the concept of difficult asthmaJust like the NICE guideline on the management of chronic asthma, which was updated in November 2024, the NICE guideline on acute asthma is also a collaborative initiative developed by NICE, the British Thoracic Society (BTS), and the Scottish Intercollegiate Guidelines Network (SIGN). It replaces previous guidance, and you can find a link to it in the episode description.I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.  Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release] Music provided by Audio Library Plus Watch: https://youtu.be/aBGk6aJM3IU Free Download / Stream: https://alplus.io/halfway-through  There is a podcast version of this and other videos that you can access here:Primary Care guidelines podcast: ·      Redcircle: https://redcircle.com/shows/primary-care-guidelines·      Spotify: https://open.spotify.com/show/5BmqS0Ol16oQ7Kr1WYzupK·      Apple podcasts: https://podcasts.apple.com/gb/podcast/primary-care-guidelines/id1608821148 There is a YouTube version of this and other videos that you can access here: The Practical GP YouTube Channel: https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk The link to the new NICE guideline on acute asthma can be found here:·      https://www.nice.org.uk/guidance/ng244/chapter/Managing-acute-asthmaBased on recommendations on managing acute asthma in the BTS/SIGN British guideline on the management of asthma:·      https://rightdecisions.scot.nhs.uk/bts-nice-and-sign-asthma-pathway/managing-acute-asthma/Disclaimer:The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions. In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.TranscriptIf you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description.Hello and welcome, I am Fernando, a GP in the UK. Today, we will go through the new NICE guideline on acute asthma, or NG244, focusing on what is relevant in Primary Care only. Just like in chronic asthma, the NICE guideline on acute asthma is a joint effort by NICE, BTS and SIGN. A link to it is in the episode description.In this episode we will just focus on the treatment of acute asthma in children.In the last three episodes we have covered the initial assessment in adults and children and the treatment in adults and in the next episode, I will cover lessons from asthma deaths. So, stay tuned for that!Right, let’s jump into it.When managing acute asthma in children, it helps to follow a structured approach to ensure effective and timely treatment. And let’s start by looking at the various therapeutic interventions, starting withOxygen: For children with life threatening asthma or oxygen saturation below 94%, we should immediately administer high-flow oxygen using a tight-fitting face mask or nasal cannula to maintain saturations between 94 and 98%.The next step is Inhaled short-acting β2 agonists: They are the first-line treatment for acute asthma in children. We need to bear in mind that when children require short-acting β2 agonists more frequently than every four hours, we should discontinue any long-acting β2 agonists.For mild to moderate asthma, a pMDI with a spacer is the preferred delivery method. We will need to adjust the dose based on severity and response, administering one puff every 30 to 60 seconds, up to a maximum of ten puffs.Children under three will often require a face mask attached to the spacer for effective drug delivery. The inhaler should be actuated into the spacer one puff at a time, with the child inhaling immediately through tidal breathing for five breaths.Frequent β2 agonist doses are safe in acute asthma, though children with milder symptoms benefit from lower doses. So, For mild attacks, two to four puffs of salbutamol (100 micrograms via pMDI and spacer) may be sufficient, while more severe attacks might require up to 10 puffs. Bronchodilators should provide symptom relief for 3–4 hours. If symptoms return sooner, a further or larger dose—up to 10 puffs—should be administered, and parents or carers should seek urgent medical advice.Equally, If the child at home does not improve after 10 puffs of salbutamol via pMDI and spacer, parents or carers should also seek urgent medical advice. While waiting for help, additional bronchodilator doses can be given if symptoms are severe. Healthcare professionals attending to children with acute asthma in these situations should administer nebulised salbutamol, ideally using an oxygen-driven nebuliser, and transfer the child to the emergency department as soon as possible, particularly in cases of acute severe or life-threatening asthma.In children aged two years and older, we should monitor the response to β2 agonists through repeat clinical observations and oxygen saturation measurements. Children receiving β2 agonists via a pMDI + spacer are less likely to have tachycardia and hypoxia than when the same drug is given via a nebuliser.For children under two who show a poor initial response to β2 agonists, despite proper administration technique, we need to consider alternative diagnoses and treatment options.Children with severe or life-threatening asthma (for example when the SpO2 <92%) should receive frequent doses of nebulised bronchodilators driven by oxygen while waiting for hospital admission. This involves administering 2.5–5 mg of salbutamol in the nebuliser. If the initial β2 agonist dose has a poor response, we should combine subsequent doses with nebulised ipratropium. Continuous nebulisation offers no added benefit over frequent intermittent dosing at the same total hourly dosage.Schools can hold a generic reliever inhaler, which allows them to treat children having an acute asthma attack while waiting for medical assistance. This practice is both safe and potentially life-saving.Let’s now look at Ipratropium: When symptoms do not respond adequately to β2 agonists, we should add ipratropium. This involves using 250 micrograms per dose mixed with the nebulised β2 agonist solution, while we arrange referral to the emergency department.Then we have Steroid therapy: We need to introduce oral steroids early in the treatment of acute asthma attacks and Oral prednisolone is the preferred steroid unless the child is unable to tolerate it. Early use of steroids reduces hospital admissions and lowers the risk of relapse. Benefits typically become evident within three to four hours.In the acute situation, it is often difficult to determine whether a preschool child has asthma or episodic viral wheeze. For preschool children with severe symptoms requiring hospitalisation, we should administer oral steroids, even if we are unsure whether the cause is asthma or episodic viral wheeze. Therefore, in children with moderate to severe wheeze and no prior asthma diagnosis, oral steroids are still recommended. However, for children with frequent viral-associated wheeze episodes, we should be cautious with multiple courses of oral steroids.We should use the following prednisolone doses based on age:10 mg for children under two years20 mg for children aged 2–5 years30–40 mg for children older than five years For children already on maintenance steroid tablets, we should give 2 mg/kg of prednisolone, up to a maximum of 60 mg. If the child vomits, we should repeat the dose or consider intravenous steroids if oral administration is not feasible.Treatment courses of up to three days are usually sufficient, but we should tailor the duration based on the child's recovery. Tapering is unnecessary unless the course exceeds 14 days. Oral and intravenous steroids have similar efficacy, so intravenous hydrocortisone should be reserved for children with severe symptoms who cannot tolerate oral medication. Larger steroid doses generally do not provide additional benefit for the majority of children.Next we have Inhaled corticosteroids: And There is currently insufficient evidence to support inhaled corticosteroids as an alternative or add-on treatment to oral steroids in acute asthma, so we should not use inhaled corticosteroids in place of oral steroids during an asthma attack. However, it is good practice for children already on inhaled corticosteroids to continue their regular maintenance dose during the attack while receiving additional treatment.Children with chronic asthma who are not on regular preventative treatment will benefit from starting inhaled corticosteroids as part of their long-term management plan. There is no evidence that increasing the dose of inhaled corticosteroids is effective for acute symptoms, but we should ensure children already on them continue their maintenance dose, adjusting the dose to achieve good asthma control of symptoms.IN respect of Antibiotics: We should not routinely prescribe them for children with acute asthma. Most acute asthma attacks are triggered by viral infections, and there is no clear evidence to support the role of antibiotics in this context.And finally, In primary care, starting a Leukotriene receptor antagonist such as oral montelukast early during a mild asthma attack may reduce symptoms and the need for follow-up healthcare visits.We also need to bear in mind that many children who have recurrent wheezing episodes triggered by viruses do not go on to develop atopic asthma. The need for regular preventer treatment depends on the severity and frequency of these episodes. Many may not require inhaled corticosteroids.In terms of admission to hospital, We should admit to hospital children who present with acute severe asthma that does not resolve after initial treatment and those children presenting with Life-threatening asthma, defined by SpO2 below 92%, along with any of the following features:Silent chestPoor respiratory effortAgitationConfusion andCyanosis.However, We should also consider a lower threshold for hospital admission if:The attack occurs late in the afternoon or at nightThe child has had a recent hospital admission or a previous severe attack orThere are concerns about social circumstances or the family’s ability to manage the condition at home.Before discharging a child from hospital after an asthma attack, they need to be stable on inhaled bronchodilators, peak expiratory flow or FEV1 should be above 75% of their best or predicted value, and oxygen saturation should be greater than 94%.The discharge plan should cover the following key points:Diagnosis.Inhaler technique.Preventer treatment.Personal Asthma Action Plan (PAAP).Exposure to smoke: for example Assessing for environmental tobacco smoke or actual smoking in older children, Trigger identification:  trying to Identify the cause of the acute attack and discussing strategies to manage future exposures.Follow-up: Arranging a follow-up appointment within two working days.And finally, Specialist review: approximately one month after admission.So that is it, a review of the treatment of acute asthma in children. We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement.Thank you for listening and goodbye.

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