retain oral medication.

Nebulised ipratropium bromide can be combined with

beta2 agonist treatment for children with severe or lifethreatening acute asthma or in those with a poor initial

response to beta2 agonist therapy to provide greater

bronchodilation. Consider adding magnesium sulfate to

nebulised salbutamol and ipratropium bromide in the first

hour in children with a short duration of acute severe asthma

symptoms presenting with an oxygen saturation less than

92%.

Children with continuing severe asthma despite frequent

nebulised beta2 agonists and ipratropium bromide plus oral

corticosteroids, and those with life-threatening features,

need urgent review by a specialist with a view to transfer to a

high dependency unit or paediatric intensive care unit

(PICU) to receive second-line intravenous therapies.

In a severe asthma attack where the child has not

responded to initial inhaled therapy, early addition of a

single bolus dose of intravenous salbutamol may be an

option. Continuous intravenous infusion of salbutamol,

administered under specialist supervision with continuous

ECG and electrolyte monitoring, should be considered in

children with unreliable inhalation or severe refractory

asthma. Aminophylline may be considered in children with

severe or life-threatening acute asthma unresponsive to

maximal doses of bronchodilators and corticosteroids.

Aminophylline is not recommended in children with mild to

moderate acute asthma. Intravenous magnesium sulfate

p. 1051 has been used for acute asthma [unlicensed use]

although its place in management is not yet established. h

Child under 2 years

g Inhaled short-acting beta2 agonists are the initial

treatment of choice for acute asthma in children under

2 years. For mild to moderate acute asthma attacks, a

metered-dose inhaler with a spacer and mask is the optimal

drug delivery device. In a hospital setting, consider oral

prednisolone daily for up to 3 days, early in the management

of severe asthma attacks. For more severe symptoms,

inhaled ipratropium bromide p. 246 in combination with an

inhaled beta2 agonist is also an option. h

Follow up in all cases

g Episodes of acute asthma may be a failure of

preventative therapy, review is required to prevent further

episodes. A careful history should be taken to establish the

reason for the asthma attack. Inhaler technique should be

checked and regular treatment should be reviewed. Patients

should be given a written asthma action plan aimed at

preventing relapse, optimising treatment, and preventing

delay in seeking assistance in future attacks. It is essential

that the patient’s GP practice is informed within 24 hours of

discharge from the emergency department or hospital

following an asthma attack. Patients who have had a nearfatal asthma attack should be kept under specialist

supervision indefinitely. A respiratory specialist should

follow up all patients admitted with a severe asthma attack

for at least one year after the admission. h

Bronchodilators 29-Nov-2017

Adrenoceptor agonists (sympathomimetics)

Selective beta2 agonists produce bronchodilation. A shortacting beta2 agonist (such as salbutamol p. 252 and

terbutaline sulfate p. 255) is used for immediate relief of

asthma symptoms while some long-acting beta2 agonists are

added to an inhaled corticosteroid in patients requiring

prophylactic treatment.

Adrenaline/epinephrine p. 222 (which has both alpha-and

beta-adrenoceptor agonist properties) is used in the

emergency management of acute allergic and anaphylactic

reactions, in angioedema, in cardiopulmonary resuscitation,

and in the management of severe croup.

Long-acting beta2 agonists

Formoterol fumarate p. 250 and salmeterol p. 252 are longeracting beta2 agonists which are administered by inhalation.

They should be used for asthma only in patients who

regularly use an inhaled corticosteroid.

BNF 78 Airways disease, obstructive 241

Respiratory system