Paediatric ECAT protocol

Wheeze (including viral-induced or suspected asthma)

P2.2 Published: December 2023 Printed on 19 May 2024

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Any person, 1 to 15 years, presenting with a diagnosis of asthma or patients with cough, wheeze and difficulty breathing.

Children less than 12 months, switch to bronchiolitis (suspected) protocol.

This protocol is intended to be used by registered and enrolled nurses within their scope of practice and as outlined in The Use of Emergency Care Assessment and Treatment Protocols (PD2024_011). Sections marked triangle or diamond indicate the need for additional prerequisite education prior to use. Check the medication table for dose adjustments and links to relevant reference texts.

Follow the patient's own management plan if available.
If there are signs of anaphylaxis, switch to anaphylaxis protocol.

History prompts, signs and symptoms

These are not exhaustive lists. Maintain an open mind and be aware of cognitive bias.

History prompts

Presenting complaint
Onset of symptoms
Frequency of episodes, i.e. recurrence of wheeze
Triggers, including allergies, exercise or thunderstorm asthma
Recent illness
Pain assessment
Pre-hospital treatment, including frequency of salbutamol, delivery method and time of last dosing
Past admissions
Medical and surgical history, hospital or ICU admission
Current medications
Known allergies
Immunisation status
Current weight

Signs and symptoms

Respiratory distress
Difficulty talking
Prolonged expiratory phase
Increased work of breathing
Persistent cough
Wheeze
Tachycardia

Red flags

Recognise: identify indicators of actual or potential clinical severity and risk of deterioration.

Respond: carefully consider alternative ECAT protocol. Escalate as per clinical reasoning and local CERS protocol, and continue treatment.

Historical

Previous HDU or ICU admission
Pre-existing cardiac and respiratory conditions
Not responding to pre-hospital treatment
Recurrent admission for asthma
History of anaphylaxis

Clinical

Altered level of consciousness
Tripod positioning
Hypoxia
Cyanosis
Exhaustion, lethargy or fatigue
Silent chest
Talking in words only
Marked accessory muscle use
Severe respiratory distress
Tachycardia
Pre-syncope

Remember child or adolescent at risk: patient or carer concern, suspected non-accidental injury or neglect, multiple comorbidities or unplanned return.

Clinical assessment and specified intervention (A to G)

If the patient has any Yellow or Red Zone observations or additional criteria (as per the relevant NSW Standard Emergency Observation Chart), refer and escalate as per local CERS protocol and continue treatment.

Position

Assessment	Intervention
General appearance/first impressions	Position of comfort, aim for sitting Minimal handling recommended

Assessment

Intervention

General appearance/first impressions

Position of comfort, aim for sitting

Minimal handling recommended

Airway

Assessment	Intervention
Patency of airway	Maintain airway patency Consider airway opening manoeuvres and positioning If anaphylaxis is suspected, switch to anaphylaxis protocol

Assessment

Intervention

Patency of airway

Maintain airway patency

Consider airway opening manoeuvres and positioning

If anaphylaxis is suspected, switch to anaphylaxis protocol

Breathing

Assessment	Intervention
Life-threatening or critical asthma (suspected): Confused or drowsy Maximal work of breathing, accessory muscle use or recession Exhaustion Marked tachycardia Unable to talk Silent chest: wheeze may be absent if there is poor air entry	Immediately escalate as per local CERS protocol Assist ventilation, as clinically indicated Apply oxygen Continual cardiorespiratory monitoring required Auscultate chest Give with 8–10 L of oxygen via nebuliser: Continuous nebulised salbutamol Place 2 nebules at a time into the nebuliser chamber and give via continuous nebulisation – repeat as required 1–6 years: 2.5 mg nebules 6 years and over: 5 mg nebules And nebulised ipratropium (added to salbutamol) every 20 minutes, for 3 doses only 1–6 years: 250 microg 6 years and over: 500 microg Insert IV cannula, if trained If unable to obtain IV access, consider intraosseous, if trained Give methylprednisolone 1 mg/kg IV, once only, maximum dose 60 mg If there is no improvement, give: adrenaline (epinephrine) IM injection, into the lateral thigh, 10 microg/kg (0.01 mL/kg of 1:1000), maximum dose 500 microg (0.5 mL of 1:1000), once only. If unable to calculate exact dose, see specific treatment section for adrenaline dosing chart
Severe asthma (suspected): Agitated or distressed Moderate–marked increased work of breathing, accessory muscle use/recession Tachycardia Marked limitation of ability to talk Wheeze is a poor predictor of severity	Immediately escalate as per local CERS protocol Assist ventilation, as clinically indicated Apply oxygen to maintain SpO₂ over 93% Auscultate chest Select: Able to breathe via spacer Unable to breathe adequately via spacer Able to breathe via spacer Give salbutamol by MDI via spacer with mask, every 20 minutes for 3 doses: 1–6 years: 6 puffs (100 microg/puff) 6 years and over: 12 puffs (100 microg/puff) and give ipratropium MDI via spacer with mask, every 20 minutes for 3 doses: 1–6 years: 4 puffs (21 microg/puff) 6 years and over: 8 puffs (21 microg/puff) Unable to breathe adequately via spacer Give with 8–10 L oxygen via nebuliser: nebulised salbutamol, every 20 minutes for 3 doses: 1–6 years: one 2.5 mg nebule 6 years and over: one 5 mg nebule and nebulised ipratropium (added to salbutamol) every 20 minutes for 3 doses: 1–6 years: 250 microg 6 years and over: 500 microg And give: prednisolone 1 mg/kg orally once only, maximum dose 50 mg or methylprednisolone 1 mg/kg IV once only, maximum dose 60 mg or hydrocortisone 4 mg/kg IV once only, maximum dose 100 mg Document observations every 20 minutes before the salbutamol dose Continual cardiorespiratory monitoring is required If patient deteriorates at any stage, treat it as life-threatening/critical asthma
Moderate asthma (suspected): Normal mental state Some increased work of breathing Tachycardia Some limitation of ability to talk	Apply oxygen to maintain SpO₂ over 93% Auscultate chest Give salbutamol by MDI via spacer with mask: 1–6 years: 6 puffs (100 microg/puff) 6 years and over: 12 puffs (100 microg/puff) Reassess after 20 minutes If no response to salbutamol: repeat the salbutamol dose every 20 minutes for 2 further doses 1–6 years: await medical or nurse practitioner review for advice regarding prednisolone 6 years and over: give prednisolone 1 mg/kg orally once only, maximum dose 50 mg Document observations every 20 minutes before the salbutamol dose
Mild asthma or wheeze: Normal mental state Subtle or no increased work of breathing Able to talk normally	Give salbutamol by MDI via spacer with mask: 1–6 years: 6 puffs (100 microg/puff) 6 years and over: 12 puffs (100 microg/puff) Reassess after 20 minutes If there is an inadequate response to the treatment, manage as per the next severity box

Assessment

Intervention

Life-threatening or critical asthma (suspected):

Confused or drowsy
Maximal work of breathing, accessory muscle use or recession
Exhaustion
Marked tachycardia
Unable to talk
Silent chest: wheeze may be absent if there is poor air entry

Immediately escalate as per local CERS protocol

Assist ventilation, as clinically indicated

Apply oxygen

Continual cardiorespiratory monitoring required

Auscultate chest

Give with 8–10 L of oxygen via nebuliser:

Continuous nebulised salbutamol
- Place 2 nebules at a time into the nebuliser chamber and give via continuous nebulisation – repeat as required
- 1–6 years: 2.5 mg nebules
- 6 years and over: 5 mg nebules

And nebulised ipratropium (added to salbutamol) every 20 minutes, for 3 doses only
- 1–6 years: 250 microg
- 6 years and over: 500 microg

Insert IV cannula, if trained

If unable to obtain IV access, consider intraosseous, if trained

Give methylprednisolone 1 mg/kg IV, once only, maximum dose 60 mg

If there is no improvement, give:

adrenaline (epinephrine) IM injection, into the lateral thigh, 10 microg/kg (0.01 mL/kg of 1:1000), maximum dose 500 microg (0.5 mL of 1:1000), once only. If unable to calculate exact dose, see specific treatment section for adrenaline dosing chart

Severe asthma (suspected):

Agitated or distressed
Moderate–marked increased work of breathing, accessory muscle use/recession
Tachycardia
Marked limitation of ability to talk
Wheeze is a poor predictor of severity

Immediately escalate as per local CERS protocol

Assist ventilation, as clinically indicated

Apply oxygen to maintain SpO₂ over 93%

Auscultate chest

Select:

Able to breathe via spacer
Unable to breathe adequately via spacer

Able to breathe via spacer

Give salbutamol by MDI via spacer with mask, every 20 minutes for 3 doses:

1–6 years: 6 puffs (100 microg/puff)
6 years and over: 12 puffs (100 microg/puff)

and give ipratropium MDI via spacer with mask, every 20 minutes for 3 doses:

1–6 years: 4 puffs (21 microg/puff)
6 years and over: 8 puffs (21 microg/puff)

Unable to breathe adequately via spacer

Give with 8–10 L oxygen via nebuliser:

nebulised salbutamol, every 20 minutes for 3 doses:
- 1–6 years: one 2.5 mg nebule
- 6 years and over: one 5 mg nebule
and nebulised ipratropium (added to salbutamol) every 20 minutes for 3 doses:
- 1–6 years: 250 microg
- 6 years and over: 500 microg

And give:

prednisolone 1 mg/kg orally once only, maximum dose 50 mg
or methylprednisolone 1 mg/kg IV once only, maximum dose 60 mg
or hydrocortisone 4 mg/kg IV once only, maximum dose 100 mg

Document observations every 20 minutes before the salbutamol dose

Continual cardiorespiratory monitoring is required

If patient deteriorates at any stage, treat it as life-threatening/critical asthma

Moderate asthma (suspected):

Normal mental state
Some increased work of breathing
Tachycardia
Some limitation of ability to talk

Apply oxygen to maintain SpO₂ over 93%

Auscultate chest

Give salbutamol by MDI via spacer with mask:

1–6 years: 6 puffs (100 microg/puff)
6 years and over: 12 puffs (100 microg/puff)

Reassess after 20 minutes

If no response to salbutamol:

repeat the salbutamol dose every 20 minutes for 2 further doses
1–6 years: await medical or nurse practitioner review for advice regarding prednisolone
6 years and over: give prednisolone 1 mg/kg orally once only, maximum dose 50 mg

Document observations every 20 minutes before the salbutamol dose

Mild asthma or wheeze:

Normal mental state
Subtle or no increased work of breathing
Able to talk normally

Give salbutamol by MDI via spacer with mask:

1–6 years: 6 puffs (100 microg/puff)
6 years and over: 12 puffs (100 microg/puff)

Reassess after 20 minutes

If there is an inadequate response to the treatment, manage as per the next severity box

Circulation

Assessment	Intervention
Perfusion (capillary refill, skin warmth and colour) Heart rate Blood pressure Cardiac rhythm	Assess circulation Attach cardiac monitor if BP/HR are within the Yellow or Red Zones, or where clinically relevant, e.g. irregular pulse, palpitations, syncope, shock, respiratory compromise, cardiac history or clinical concern Consider 12 lead ECG
IVC and/or pathology	Insert IV cannula, if trained and critical or severe illness, or if clinically concerned If unable to obtain IV access, consider intraosseous, if trained See pathology section
Signs of shock: tachycardia and CRT 3 seconds and over and/or abnormal skin perfusion and/or hypotension	If signs of shock present, give sodium chloride 0.9% at 20 mL/kg IV/intraosseous bolus once only, maximum dose 1000 mL

Assessment

Intervention

Perfusion (capillary refill, skin warmth and colour)

Heart rate

Blood pressure

Cardiac rhythm

Assess circulation

Attach cardiac monitor if BP/HR are within the Yellow or Red Zones, or where clinically relevant, e.g. irregular pulse, palpitations, syncope, shock, respiratory compromise, cardiac history or clinical concern

Consider 12 lead ECG

IVC and/or pathology

Insert IV cannula, if trained and critical or severe illness, or if clinically concerned

If unable to obtain IV access, consider intraosseous, if trained

See pathology section

Signs of shock:

tachycardia and CRT 3 seconds and over

and/or abnormal skin perfusion

and/or hypotension

If signs of shock present, give sodium chloride 0.9% at 20 mL/kg IV/intraosseous bolus once only, maximum dose 1000 mL

Disability

Assessment	Intervention
AVPU	If AVPU shows reduced level of consciousness, continue to assess GCS, pupillary response and limb strength
GCS, pupillary response and limb strength	Obtain baseline and repeat assessment as clinically indicated
Pain	Assess pain. If indicated, give early analgesia as per analgesia section then resume A to G assessment

Exposure

Assessment	Intervention
Temperature	Measure temperature
Head-to-toe inspection, including posterior surfaces	Check and document any abnormalities

Fluids

Assessment	Intervention
Hydration status	Assess fluids, in and out. Document on fluid balance chart. Include gastrointestinal losses

Glucose

Assessment	Intervention
BGL	Measure BGL, where clinically relevant or of concern. See medication table for 40% glucose gel dosing If BGL between 2 mmol/L and 3 mmol/L and NOT symptomatic (Yellow Zone criteria): give quick-acting carbohydrate: Up to 12 months: milk feed and/or 40% glucose gel, buccal 12 months and over: sugary soft drink or fruit juice or 40% glucose gel, buccal reassess BGL in 15–30 minutes and repeat treatment until BGL over 3 mmol/L If BGL less than 2 mmol/L OR symptomatic (Red Zone criteria) OR unable to tolerate oral glucose: give 40% glucose gel buccally in incremental doses, as tolerated, while establishing IV access escalate as per local CERS protocol

Assessment

Intervention

BGL

Measure BGL, where clinically relevant or of concern. See medication table for 40% glucose gel dosing

If BGL between 2 mmol/L and 3 mmol/L and NOT symptomatic (Yellow Zone criteria):

give quick-acting carbohydrate:
- Up to 12 months: milk feed and/or 40% glucose gel, buccal
- 12 months and over: sugary soft drink or fruit juice or 40% glucose gel, buccal
reassess BGL in 15–30 minutes and repeat treatment until BGL over 3 mmol/L

If BGL less than 2 mmol/L OR symptomatic (Red Zone criteria) OR unable to tolerate oral glucose:

give 40% glucose gel buccally in incremental doses, as tolerated, while establishing IV access
escalate as per local CERS protocol

Repeat and document assessment and observations to monitor responses to interventions, identify developing trends and clinical deterioration. Escalate care as required according to the local CERS protocol.

Focused assessment

Complete a respiratory focused assessment.

Precautions and notes

Episodic respiratory symptoms such as wheeze are very common in children aged 1–5 years, making it difficult to diagnose asthma.
Spacers should be fitted with a well-sealing face mask for younger children who cannot reliably use the spacer mouthpiece.

Interventions and diagnostics

Specific treatment

Life-threatening or critical and severe asthma (suspected)

If ineffective respiratory effort, consider non-invasive ventilation (NIV) where available.
Aminophylline, magnesium sulfate and IV salbutamol are additional medications used to treat critical and severe asthma. Use of these medications requires a medical review and order.
Escalate as per local CERS protocol regarding further management of critically ill patients.

Adrenaline dosing

Use this table as a reference for IM adrenaline dosing for life-threatening asthma in A to G assessment if unable to obtain exact weight.

Age (years)	Weight (kg)	Volume (mL) of adrenaline 1:1000 ampoules
Up to 2	Up to 10	0.1 mL
2–3	15	0.15 mL
4–6	20	0.2 mL
7–10	30	0.3 mL
10–12	40	0.4 mL
12 and over	50 and over	0.5 mL

Analgesia

If pain score 1–6 (mild–moderate): give paracetamol 15 mg/kg orally once only, maximum dose 1000 mg

If severe pain present, give analgesia and escalate as per local CERS protocol.

Consider non-pharmacological pain relief (appendix).

Radiology

Radiology will depend on the working diagnosis. It needs to be requested by a medical or nurse practitioner. If there is concern for urgent radiology, escalate as per local CERS protocol.

Pathology

Not usually indicated. If there is concern for urgent pathology, escalate care as per local CERS protocol.

Medications

The patient’s weight is mandatory for calculating fluid and medication doses.

The Broselow Tape or APLS weight table (appendix) can be used only in circumstances where the patient cannot be weighed.

The shaded sections in this protocol are only to be used by registered nurses who have completed the required education.

Drag the table right to view more columns or turn your phone to landscape

Drug	Dose	Route	Frequency
Adrenaline (epinephrine)	10 microg/kg (0.01 mL/kg of 1:1000) Maximum dose 500 microg (0.5 mL of 1:1000) per dose	IM (lateral thigh)	Once only
Glucose 40% gel (0.4 g/mL)	4 weeks–1 year: 200 mg/kg (=0.5 mL/kg) 1–5 years: 5 g 6–11 years: 10 g 12 years and over : 15 g	Buccal	Repeat after 15 minutes if required
Hydrocortisone	4 mg/kg Maximum dose 100 mg	IV	Life-threatening/critical/severe asthma Once only
Ipratropium	1–5 years: 250 microg nebule 6 years and over: 500 microg nebule	Inhalation via nebuliser	Life-threatening/critical/severe asthma Repeat every 20 minutes to a total of 3 doses
	OR
	1–5 years: 4 puffs (21 microg/puff MDI) 6 years and over: 8 puffs (21 microg/puff MDI)	Inhalation via spacer	Life-threatening/critical/severe asthma Repeat every 20 minutes to a total of 3 doses
Methylprednisolone	1 mg/kg Maximum dose 60 mg	IV	Life-threatening/critical/severe asthma Once only
Oxygen	0.25–15 L/min, device dependent	Inhalation	Continuous
Paracetamol ^H	15 mg/kg Maximum dose 1000 mg	Oral	Pain score 1–10 Once only
Prednisolone	1 mg/kg Maximum dose 50 mg	Oral	Severe/moderate asthma and if no IV access Once only
Salbutamol	1–6 years: 5 mg (use two 2.5 mg nebules) 6 years and over: 10 mg (use two 5 mg nebules)	Inhalation via nebuliser	Life-threatening/critical asthma (suspected) Continuous nebulisation
	1–6 years: 2.5 mg nebule 6 years and over: 5 mg nebule	Inhalation via nebuliser	Severe asthma (suspected) Repeat every 20 minutes to a total of 3 doses
	OR
	1–6 years: 6 puffs (100 microg/puff MDI) 6 years and over: 12 puffs (100 microg/puff MDI)	Inhalation via spacer	Mild, moderate or severe asthma (suspected) Repeat every 20 minutes up to a total of 3 doses
Sodium chloride 0.9%	20 mL/kg Maximum dose 1000 mL	IV/intraosseous	Bolus Once only

Medications with contraindications or requiring dose adjustment are marked:

^H for patients with known hepatic impairment
^R for patients with known renal impairment.

Escalate to medical or nurse practitioner.

References

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Castro-Rodriguez JA, Beckhaus AA, Forno E. Efficacy of oral corticosteroids in the treatment of acute wheezing episodes in asthmatic preschoolers: Systematic review with meta-analysis. Pediatr Pulmonol. 2016;51(8):868-76. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5007060/
The Royal Children's Hospital Melbourne. Oxygen delivery. Melbourne: Victoria Health; 2017 [cited 23 Feb 2023]. Available from: https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Oxygen_delivery/
Craig SS, Dalziel SR, Powell CV, et al. Interventions for escalation of therapy for acute exacerbations of asthma in children: an overview of Cochrane Reviews. Cochrane Database Syst Rev. 2020 Aug 5;8(8):Cd012977. DOI: 10.1002/14651858.CD012977.pub2
MIMS Australia. Clinical Resources. Australia: MIMS Australia Pty Ltd; 2022 [cited 2 Feb 2023]. Available from: https://www.mimsonline.com.au.acs.hcn.com.au/Search/Search.aspx
Murphy KR, Hong JG, Wandalsen G, et al. Nebulized Inhaled Corticosteroids in Asthma Treatment in Children 5 Years or Younger: A Systematic Review and Global Expert Analysis. J Allergy Clin Immunol Pract. 2020 Jun;8(6):1815-27. DOI: 10.1016/j.jaip.2020.01.042
National Asthma Council Australia. Australian Asthma Handbook. Melbourne: National Asthma Council Australia; 2023 [cited 24 Feb 2023]. Available from: https://www.asthmahandbook.org.au/
Australian Medicines Handbook. Adelaide: AMH; c2023 [cited 28 Feb 2023]. Available from: https://amhonline.amh.net.au.acs.hcn.com.au/
Australian Medicines Handbook Children's Dosing Companion. Adelaide: AMH; c2023 [cited 03 May 2023]. Available from: https://childrens.amh.net.au.acs.hcn.com.au/
Normansell R, Kew KM, Mansour G. Different oral corticosteroid regimens for acute asthma. Cochrane Database Syst Rev. 2016 (5). Available from: https://doi.org//10.1002/14651858.CD011801.pub2
Scarfone R. Acute asthma exacerbations in children younger than 12 years: Emergency department management. UpToDate; 2022 [cited 24 Feb 2023]. Available from: https://www.uptodate.com/contents/acute-asthma-exacerbations-in-children-younger-than-12-years-emergency-department-management
The Royal Children's Hospital Melbourne. Clinical practice guidelines Acute asthma. Melbourne: Victoria Health; 2020 [cited 24 Feb 2023]. Available from: https://www.rch.org.au/clinicalguide/guideline_index/Asthma_acute/
Agency for Clinical Innovation. Rural paediatric emergency clinical guidelines 3rd edition. Sydney: NSW Health; 2021 [cited 24 Feb 2023]. Available from: https://www1.health.nsw.gov.au/pds/Pages/doc.aspx?dn=GL2021_011
The Sydney Children's Hospital Network. Meds 4 Kids Dosing Guide. Australia: NSW Health; 2023 [cited 23 Feb 2023]. Available from: https://webapps.schn.health.nsw.gov.au/meds4kids/
The Sydney Children's Hospitals Network. Asthma - Acute management practice guideline. Sydney: NSW Health; 2019 [cited 24 Feb 2023]. Available from: https://www.schn.health.nsw.gov.au/_policies/pdf/2007-8358.pdf

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Evidence informed	Information was drawn from evidence-based guidelines and a review of latest available research. For more information, see the development process.
Collaboration	This protocol was developed by the ECAT Working Group, led by the Agency for Clinical Innovation. The group involved expert medical, nursing and allied health representatives from local health districts across NSW. Consensus was reached on all recommendations included within this protocol.
Currency	Due for review: Jan 2026. Based on a regular review cycle.
Feedback	Email ACI-ECIs@health.nsw.gov.au

ECAT home page Glossary

Accessed from the Emergency Care Institute website at https://aci.health.nsw.gov.au/ecat/paediatric/wheeze

Wheeze (including viral-induced or suspected asthma)

On this page

History prompts, signs and symptoms

History prompts

Signs and symptoms

Red flags

Historical

Clinical

Clinical assessment and specified intervention (A to G)

Position

Airway

Breathing

Able to breathe via spacer

Unable to breathe adequately via spacer

Circulation

Disability

Exposure

Fluids

Glucose

Focused assessment

Precautions and notes

Interventions and diagnostics

Specific treatment

Life-threatening or critical and severe asthma (suspected)

Adrenaline dosing

Analgesia

Radiology

Pathology

Medications

References