A 9-year-old boy with known asthma presents to the emergency department with an acute exacerbation. Following administration of oxygen, nebulized salbutamol, ipratropium bromide, and oral prednisolone, he remains in respiratory distress with oxygen saturation 92% on high-flow oxygen, peak flow 30% of predicted, and poor respiratory effort. What is the appropriate dose and route of magnesium sulphate administration in this clinical scenario?

40 mg/kg (maximum 2 g) intravenous infusion over 20 minutes

25 mg/kg (maximum 1 g) intravenous bolus over 5 minutes

40 mg/kg nebulized with salbutamol

50 mg/kg (maximum 2.5 g) intravenous infusion over 30 minutes

150 mg nebulized with ipratropium bromide

A 4-year-old boy presents with sudden onset high fever of 40.2°C, drooling, and severe difficulty swallowing. He is sitting upright, leaning forward with his neck extended, and appears anxious. There is inspiratory stridor and he is reluctant to speak. Oxygen saturation is 96% on air. What is the single most appropriate immediate action?

Contact senior anaesthetist and ENT surgeon urgently without disturbing the child

Examine the throat with tongue depressor to visualize the epiglottis

Obtain blood cultures and commence intravenous antibiotics immediately

Administer nebulized adrenaline and oral dexamethasone

Perform lateral neck X-ray to confirm the diagnosis

A 2-year-old boy with viral-induced wheeze is assessed in the emergency department. He has received salbutamol via spacer but continues to have expiratory wheeze, recession, and a respiratory rate of 50/min. Oxygen saturation is 93% on air. The parents ask whether their child will develop asthma. Which factor most strongly predicts progression from preschool wheeze to persistent childhood asthma?

Eczema or allergic rhinitis in the child

Early onset of wheeze in the first year of life

Parental smoking in the household

History of bronchiolitis requiring hospitalization

A 15-month-old child is brought to the emergency department with fever of 39.6°C for 2 hours. The mother reports the child had a brief generalized tonic-clonic seizure lasting approximately 3 minutes at home which resolved spontaneously. The child is now alert and playful with no focal neurological signs. There are no signs of meningism. The seizure occurred on the way up in fever. What is the most important next step in management?

Undertake thorough clinical examination to identify source of fever

Perform urgent lumbar puncture to exclude meningitis

Administer intravenous antibiotics immediately

Commence regular paracetamol and observe for further seizures

Arrange urgent CT head to exclude intracranial pathology

A 5-year-old girl with poorly controlled asthma on beclometasone 400 micrograms twice daily plus montelukast presents with her fourth exacerbation in 6 months. Her mother reports good adherence but mentions they have a cat at home and the child often plays with it. Skin prick testing confirms cat allergy. Despite advice about allergen avoidance, the family is unable to rehome the pet. What is the most appropriate next step in her asthma management?

Add long-acting beta-agonist to current therapy

Continue current therapy and arrange follow-up in 3 months

Switch to high-dose inhaled corticosteroid monotherapy

Commence allergen-specific immunotherapy for cat allergy

Add oral prednisolone maintenance therapy

Acute wheeze and asthma: High-Yield Child Health Lessons

Quick Overview

Acute wheeze in children is a common paediatric emergency requiring rapid severity assessment and stepwise treatment. NICE NG80 provides evidence-based guidance for managing acute asthma exacerbations. Distinguishing viral-induced wheeze from asthma influences long-term management, though acute treatment protocols overlap significantly.

Core Facts & Concepts

Severity Assessment (NICE NG80)

Severity	Clinical Features	Oxygen Sats	Peak Flow
Moderate	Talking in sentences, SpO₂ ≥92%, HR/RR increased	≥92%	>50% predicted
Severe	Can't complete sentences, SpO₂ <92%, using accessory muscles	<92%	33-50% predicted
Life-threatening	Silent chest, poor respiratory effort, altered consciousness, cyanosis, exhaustion	Variable	<33% predicted

Figure 1: Chest X-ray showing hyperinflated lungs with flattened hemidiaphragms

Age-Specific Inhaler Devices

<3 years: pMDI + spacer with face mask
3-5 years: pMDI + spacer with mouthpiece
>5 years: pMDI + spacer or breath-actuated inhaler

Viral Wheeze vs Asthma

Viral wheeze: Age <3 years, only with viral URTI, no interval symptoms, no atopy
Asthma: Multiple trigger wheeze, interval symptoms, personal/family atopy history

Problem-Solving Approach

Stepwise Acute Management

Oxygen: Target SpO₂ 94-98% (all severities)
First-line bronchodilators:
- Salbutamol: 10 puffs via spacer (moderate) OR nebulised 2.5mg <5yrs/5mg ≥5yrs (severe)
- Repeat every 20 minutes as needed
Add ipratropium bromide (severe/life-threatening):
- Nebulised 250mcg mixed with salbutamol
- Give 3 doses in first hour
Systemic steroids (all severities):
- Prednisolone 20mg (2-5yrs) or 30-40mg (>5yrs) PO for 3 days
- IV hydrocortisone 4mg/kg if vomiting
Magnesium sulphate (severe not responding):
- Single dose IV 40mg/kg (max 2g) over 20 minutes
Aminophylline infusion (life-threatening refractory):
- 5mg/kg loading dose over 20 minutes, then 1mg/kg/hr
- Only if not on oral theophyllines

⚠️ Warning: Silent chest indicates life-threatening asthma-prepare for PICU transfer and consider salbutamol infusion

Analysis Framework

Discharge Criteria (all must be met)

Stable on 3-4 hourly salbutamol for 12-24 hours
SpO₂ >94% in air
Inhaler technique checked and adequate
PEF >75% best/predicted (if age appropriate)
Written asthma action plan provided
GP follow-up within 2 working days

Red Flags Requiring Senior/ICU Input

SpO₂ <92% despite high-flow oxygen
Exhaustion or reduced consciousness
Rising PaCO₂ (hypercapnia indicates respiratory failure)
Poor response to 3 doses of bronchodilators

Visual Aid

Key Points Summary

✓ Severity markers: SpO₂ <92%, silent chest, inability to complete sentences, altered consciousness define severe/life-threatening asthma

✓ Bronchodilator dosing: Salbutamol 10 puffs via spacer equals nebulised dose; add ipratropium for severe cases (3 doses in first hour)

✓ Steroids for all: Prednisolone 20-40mg (age-dependent) for 3 days reduces relapse rates-give early in all acute presentations

✓ Magnesium threshold: Single IV dose (40mg/kg, max 2g) for severe asthma not responding to initial bronchodilators

✓ Device matters: Wrong inhaler technique is a common cause of treatment failure-always check and demonstrate correct use

✓ Discharge safety: Require stability on 3-4 hourly salbutamol, SpO₂ >94%, and confirmed GP follow-up within 48 hours

✓ Viral wheeze distinction: Affects prophylaxis decisions but not acute management-treat acute episodes identically to asthma

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