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Asthma, life threatening - management in intensive care setting

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This guideline is intended to be used for the management of life threatening asthma in the Paediatric Intensive Care Unit. Other guidelines for managing asthma can be found in the Starship Clinical Guidelines - see related documents above.

General notes

  • The need for ICU admission should be decided on clinical state and response to treatment and not by blood gases.
  • Asthma is life threatening when associated with cyanosis, exhaustion, confusion/drowsiness and/or failure to respond to maximal therapy.
  • Consider diagnoses other than asthma, especially in infants with poorly responsive respiratory distress.
  • No infant (< 1 year) should be started on intravenous bronchodilators without discussion with a consultant.
  • High doses of salbutamol can be toxic if the child does not have small airways obstruction. Always consider this if a child is persistently tachycardic,  tachypnoeic, minimal or absent wheeze, ±hypokalaemia, ±lactic acidosis.
  • Admission from CED is appropriate if there is life threatening asthma or there is a failure to respond to maximal therapy by 6 hours. The PICU registrar should be called to see all children prior to starting an IV salbutamol infusion in CED.


  • Oxygen. High flow via a mask.
  • Continuous nebulised salbutamol. 5mg/dose for all ages.
  • Ipratroprium 0.25mg/ml. Add 1ml to the salbutamol, repeat every 20min for 3 doses, then every 4 hours.
  • Methylprednisolone 1mg/kg 6hrly IV for 24 hours, then 12hrly for 24 hours then daily.
  • IV aminophylline. If not on a theophylline, give 10mg/kg over 1 hour and then a continuous infusion. Measure theophylline concentration one hour after infusion started and then every 12 hours.
Aged 1-9 years
• 1.1mg/kg/hr
• 55mg/kg aminophylline in 50ml 5% glucose at 1ml/hr
Aged ≥ 10 years and <35kg
• 0.7mg/kg/hr
• 35mg/kg aminophylline in 50ml 5% glucose at 1 ml/hr
Aged ≥ 10 years and >35kg
• 0.7mg/kg/hr
• neat aminophylline (25mg/ml) at 0.028ml/kg/hr
  • IV magnesium sulphate 49.3%. Give 0.1ml/kg (approx 50mg/kg) in 20mls 5% glucose over 20 mins. Maximum dose 5ml. This may be repeated 1-2 times.
  • IV salbutamol. Bolus doses of 10mcg/kg (maximum 500mcg) in 5ml 5% glucose over 2 minutes may rarely be needed for life threatening asthma. Salbutamol infusion made up as per "Paediatric Drug Infusion Chart". Give 5mcg/kg/min over 1 hour and then 1mcg/kg/min. Check for hypokalaemia and lactic acidosis 6 hourly. Give in addition to nebulised salbutamol.

If continued deterioration despite above measures:

  1. Magnesium infusion - 0.06ml/kg/hr to keep Mg 1.5-2.5mmol/L.
  2. BiPAP
  3. Intubation and ventilation. Always ensure ICU consultant has been called. Basic principles: cuffed tube, ventilate with low rate (aged 1-9 yr 15-20/min, >10 yr 6-15/min), IT 0.8sec, PEEP 5 or < autoPEEP, use pressure control ventilation. Reduce breath rate so that expiration completed before next breath starts if possible. Aim for PaCO2 8-13, pH 7.10-7.20. Sedate with ketamine 10-20mcg/kg/min.
  4. If deterioration with hypoxaemia on mechanical ventilation, other treatments are volatile agents (isofluorane), VV ECMO.

Once improving:

  1. Wean salbutamol infusion off.
  2. Stop aminophylline infusion.
  3. Reduce nebulised salbutamol from continuous to intermittent, with progressive reduction in frequency.
  4. Change steroids to oral.

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Document Control

  • Date last published: 16 June 2011
  • Document type: Clinical Guideline
  • Services responsible: Paediatric Intensive Care Unit
  • Owner: Gabrielle Nuthall
  • Editor: John Beca
  • Review frequency: 2 years