Clinical Features

This is a clinical diagnosis defined as increasingly severe asthma not responsive to usual drugs. Child is too breathless to feed or talk; there is severe chest retraction; tachypnoea.

  • May have features of respiratory failure:
    • Altered consciousness
    • Poor respiratory effort
    • Silent chest
    • Cyanosis
  • Admit: Child may need ICU care
    • Monitor vital signs every 15–30 minutes.
    • Keep propped up in bed.
    • Administer oxygen by intranasal catheter flow rate of 1–2 litres per minute.
    • Treat as per acute attack of asthma (see section on asthma above).
    • Look for and correct dehydration.
    • Avoid antibiotics unless specifically indicated.
    • Ventilate if necessary using bag and mask


This depends on severity

  • Mild intermittent: Daytime symptoms <2 per week and night <2 per month.
    • Care: short/rapid acting bronchodilators as needed.
  • Mild persistent: Daytime symptoms >2 per week and <1 per day; night >2 per month.
    • Care: Long-term medication – low dose inhaled corticosteroids daily.
    • Attacks – Short/rapid acting bronchodilators
  • Moderate persistent: Daily symptoms and night >1 per week
    • Care: Long-term medication – low to medium dose inhaled corticosteroids daily with or without long acting bronchodilator.
    • Attacks – Short/rapid acting bronchodilators.
  • Severe persistent: symptoms continuous during day and frequent at night.
    • Care: Long-term medication – daily high dose inhaled corticosteroids and long acting bronchodilators with systemic steroids if needed.
    • Attack: Short acting bronchodilators.

Important to note:

  • Clear and preferably written instructions on how and when to use the inhaler at home.
  • Report immediately to a health facility when home treatment is ineffective.
  • Avoidance or reduction of triggers/allergens in the home.
  • Child in school with exercise induced attacks should use the inhaler before exercise.