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Acute wheeze in children 2 years and older: assessment and management

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This guidance replaces the previous guidelines "Acute asthma in children aged between 2 and 5 years" and "Acute asthma in children > 5 years"

Separate guidance is available for Acute asthma in children aged < 2 years.

November 2023: This guidance is currently under review as it has gone beyond the standard review date. It reflects best practice at the time of authorship / last review and remains safe for use. If there are any concerns regarding the content then please consult with senior clinical staff to confirm.

Initial assessment

Wheeze severity assessment



  • Normal mental state
  • Able to talk normally
  • Subtle or No ⇧ WOB
    (work of breathing)
    • No accessory muscle use or chest wall recession
  • No ⇧ Heart Rate (HR) or ⇧ Respiratory Rate (RR)




  • Normal mental state
  • Dyspnoea resulting in limitation of full sentences
  • Moderate ⇧ WOB
    • Moderate accessory muscle use & chest wall recession
  • HR - PEWS <2
  • RR - PEWS <2
  • PEF >50% of best or predicted



  • Agitated/distressed state
  • Marked dyspnea resulting in <3 word sentences
  • Severe ⇧ WOB
  • Marked accessory muscle use and chest wall recession
  • HR - PEWS >2
  • RR - PEWS >2
  • PEF 33-50% of best or predicted



  • Confused / drowsy
  • Unable to talk due to dyspnoea
  • Beware exhaustion may = poor respiratory effort
  • SILENT CHEST (exclude upper airway obstruction)
  • PEF <33% of best or predicted
'Red Flag' features
  • Has the patient previously received IV therapy for wheeze management?

  • Has the patient been admitted to the PICU previously for respiratory illness?

If YES to any of the above then patient should be discussed with on call Paediatric Registrar prior to discharge.


Salbutamol MDI + Spacer – Initial therapy = 10 puffs.  (100mcg per puff)

Oxygen – minimum 6 l/min via non-rebreather mask


2 -4yrs       20mg OD

>5yrs      40mg OD


Nebulised medication for Severe Wheeze

2 -4yrs  

Salbutamol 2.5mg
Ipratropium bromide 250mcg
Magnesium sulphate 154mg (2.5mls)


Salbutamol 5mg
Ipratropium bromide 250mcg (>12yrs 500 mcg)
Magnesium sulphate 154mg (2.5mls)

(To be prescribed as per the Escalation to IV therapy care pathway)

1. Magnesium sulphate injection 

40mg/kg over 20 minutes (max 2gram)

2. Aminophylline 

Loading dose    


5mg/kg* for all ages
(*unless on long-acting theophylline)

Continuous dose

<12 years 1mg/kg/hr 

≥12 years 500 mcg/kg/hr

3. Salbutamol

Bolus dose

Infusion dose

15µg/kg over 10mins


- Hydrocortisone              

- Ondansetron      

4mg/kg QDS (max 100mg)

100micrograms/kg (max 4mg)

Discharge criteria and checklist
  • Patient maintaining saturations > 94% in air
  • Tolerating 3hrly multidosing        

Patients with MILD asthma at 1st assessment can be discharged after Salbutamol without being monitored for 4 hours

  • Discharge Checklist Completed
  • No red flag features
  • If presenting with interval symptoms medication reviewed and consideration given to starting Clenil Modulite 100mcg BD
  • Follow-Up arranged as below
Escalation to intravenous therapy for acute wheeze integrated care pathway (ICP) - for patients over 2 years old
  1. BTS/SIGN British guideline on the management of Asthma; 2019.
  2. Mechanism of lactic acidosis in children with acute severe asthma; Meert KL, McCaulley L, Sarnaik AP. Paediatric Critical Care Medicine. 2012 Jan;13(1):28-31
  3. A Clinical Guideline for the use of Aminophylline in Acute Severe Asthma in Children; Norfolk and Norwich University Trust. Dr Caroline Kavanagh; 5th April 2017
  4. Aminophylline Dosage in Children Asthma Exacerbations in Children: A Systematic Review; Cooney L, Sinha I, Hawcutt D. PLoS One. 2016.
  5. Standards for Level of Asthma Intervention; Greater Glasgow and Clyde Health Board
  6. Aminophylline Hydrate; December 2015.
  7. BNF for Children. Aminophylline.
  8. BNF for Children. Hydrocortisone
  9. BNF for Children. Prescribing for children: weight, height and gender.
  10. Clinical Practice Guidelines: Asthma Acute. The Royal Hospital for Children, Melbourne. May 2015
Editorial Information

Last reviewed: 11 June 2020

Next review: 31 October 2024

Author(s): Dr Steve Foster (Consultant in Paediatric Emergency – Paediatric Emergency Department), Dr Morag Wilson (Consultant in General Paediatrics – Acute Paediatrics)

Approved By: Clinical Effectiveness

Document Id: 623