Acute asthma, child 6–11 years
For ages 6–11. Age 5 or under, or first wheeze under 12 months (bronchiolitis): do not use this pathway. Age 12+: use the adult and adolescent acute asthma pathway.
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Pediatric Acute Asthma Exacerbation, 6–11 Years (GINA 2026)
Pediatric Acute Asthma Exacerbation, 6–11 Years (GINA 2026): Acute asthma, child 6–11 years → First: anaphylaxis? Give IM adrenaline before salbutamol →...
Pathway Overview
16 steps
Algorithm Steps
16 total
01Start 02Warning First: anaphylaxis? Give IM adrenaline before salbutamol
Ages 6–11 only (age 5 or under, or bronchiolitis: use a different pathway). Check for anaphylaxis and other causes first.
- Anaphylaxis (wheeze with hives, lip swelling, hypotension or allergen exposure): IM adrenaline 1 mg/mL, 0.01 mg/kg (max 0.5 mg), then start salbutamol
- Other causes: inhaled foreign body, pneumothorax, pneumonia, inducible laryngeal obstruction
- Do not give sedatives. Sedation in acute asthma is linked to avoidable deaths
03Decision Any life-threatening feature?
Drowsy, confused or exhausted; cyanosis; silent chest or poor respiratory effort; SpO2 below 90%; PRAM 11–12.
- If Yes
04Warning Life-threatening: call PICU or anaesthesia now; continuous nebulised salbutamol
No sedation. Arrange immediate transfer to higher-level care. Monitor continuously.
- Continuous nebulised salbutamol (2 × 5 mg nebules) driven by oxygen, plus nebulised ipratropium 500 microgram every 20 min in hour 1 (AAH). Keep SpO2 92–95%
- IV magnesium sulfate 0.1–0.2 mmol/kg (25–50 mg/kg), max 8 mmol (2 g), over 20 min. Renal impairment: check serum magnesium
- IV methylprednisolone 1 mg/kg (max 60 mg) or IV hydrocortisone 4 mg/kg (max 100 mg) every 6 hours
05Action Life-threatening: monitoring, tests and airway plan
Do this while bronchodilators run. The PICU or anaesthesia team leads the airway.
- IV access; blood gas; chest X-ray (do not delay treatment for it)
- Monitor for salbutamol toxicity: potassium, lactate, heart rhythm
- Poor effort, cannot inhale or peri-arrest: IM adrenaline 1 mg/mL, 0.01 mg/kg (max 0.5 mg), lateral thigh; repeat every 5 min if needed
- NIV or intubation only by the PICU or anaesthesia team. Do not sedate to allow NIV
06Outcome Admit to PICU or retrieve to paediatric critical care
Continue continuous bronchodilator, oxygen, IV steroid and monitoring until the PICU or retrieval team takes over.
If No07Action No life-threatening feature: assess severity
Assess speech, work of breathing, SpO2 on room air, and PEF or FEV1 if the child can do it. Use a clinical score (PRAM).
- Severe (any): cannot complete a sentence in one breath; accessory muscle use, tracheal tug or subcostal recession; cannot lie flat or sits hunched forward; SpO2 on room air 94% or less; PEF or FEV1 50% predicted or less; PRAM 8–10
- Mild–moderate (all): talks in sentences or phrases; can lie flat or sit up; no severe distress; SpO2 on room air above 94%; PRAM 1–7
- SpO2 thresholds follow the Australian Asthma Handbook (AAH) v3.0. GINA 2026 uses SpO2 below 92% for severe
- Pulse oximetry can overestimate SpO2 in children with dark skin
08Decision Any severe feature?
Severe if any severe feature in the step above. Mild–moderate only if all mild–moderate features are present.
- If Yes
09Action Severe: salbutamol + ipratropium, oxygen, steroid now
Start bronchodilators at once. Monitor continuously.
- Salbutamol 100 microgram/puff via pMDI + spacer, 1 puff at a time: 6–10 puffs (GINA) or 12 puffs (AAH). Cannot use spacer: nebulised salbutamol 5 mg
- Ipratropium with each salbutamol dose, every 20 min in hour 1: pMDI 21 microgram/puff, 8 puffs (AAH) or 20 microgram/puff, 4 puffs (GINA). Nebulised: 250 microgram (GINA) or 500 microgram (AAH)
- Oxygen only if SpO2 below 92%; target SpO2 92–95%
- Within 1 hour: prednisolone 1–2 mg/kg orally once daily (max 40 mg). Cannot take oral: IV methylprednisolone 1 mg/kg (max 60 mg) or IV hydrocortisone 4 mg/kg (max 100 mg) every 6 hours
- Repeat salbutamol every 20–30 min, up to 3 doses in hour 1, only if needed. Review after each dose
- Consider IV magnesium sulfate (dose in the escalation step)
- Watch for salbutamol toxicity: tachycardia, low potassium, lactic acidosis, fast breathing that looks like worse asthma
10Decision Marked improvement at 1 hour or earlier?
Reassess SpO2, respiratory rate, accessory muscle use, air entry, PEF or FEV1 and PRAM. Less wheeze alone can mean worse asthma, not better.
- If Yes
11Action Marked improvement: assess for discharge
Discharge only if stable for at least 1–2 hours after the last salbutamol (GINA). AAH: observe at least 4 hours after distress settles.
- SpO2 on room air 92% or more (GINA 2026); no increased work of breathing; PEF or FEV1 above 70% predicted or personal best
- Start or step up ICS-containing maintenance treatment. Do not discharge on salbutamol alone
- Complete prednisolone 1–2 mg/kg once daily (max 40 mg) for 3–5 days in total (GINA). AAH: 1 mg/kg (max 50 mg) for 3 days. If dexamethasone was given: 1–2 days in total (max 12 mg a dose); switch to prednisolone if relapse
- Written asthma action plan; check spacer technique; salbutamol only as needed
- Follow-up with GP in 2–5 days (GINA); AAH: within 3 days. Full review in 2–4 weeks
12Outcome Discharge home with ICS, action plan and GP review in 2–5 days
Return at once if symptoms worsen or come back. Dispense one steroid course only.
If No13Action No marked improvement: escalate and review at least every hour
Look for other causes. Salbutamol toxicity (lactic acidosis, low potassium) can look like worse asthma: check before you give more.
- Extra salbutamol and ipratropium if needed; systemic corticosteroid if not yet given
- IV magnesium sulfate: 0.1–0.2 mmol/kg (25–50 mg/kg), max 8 mmol (2 g), diluted, as one IV infusion over 20 min. Check mmol or g on the ampoule
- Magnesium can cause low blood pressure: monitor BP. Renal impairment: risk of magnesium toxicity; senior advice and check serum magnesium
- Do not use IV aminophylline or theophylline
14Decision Worsening, or any life-threatening feature?
Drowsy, exhausted, cyanosis, silent chest, poor effort, SpO2 below 90%, or rising oxygen need. Yes: treat as life-threatening now (call PICU or anaesthesia; continuous nebulised salbutamol; see the life-threatening step).
- If Yes
- Path rejoins step 04Shared downstream outcome
If No15Outcome Partial response: admit to hospital
Review at least every hour. If the child now meets the discharge criteria, assess for discharge. Admit if not improving, or any of: SpO2 below 92% on room air; salbutamol needed more often than every 1–2 hours; breathless 4–6 hours after steroid; concerns about adherence, follow-up or risk factors for fatal asthma. On the ward: salbutamol every 4–6 hours for 24 hours, or sooner if needed; severe: add ipratropium every 4–6 hours for 24 hours if needed (AAH).
If No16Action Mild–moderate: salbutamol via pMDI + spacer
Give salbutamol, then review the child after each dose.
- Salbutamol 100 microgram/puff via pMDI + spacer, 1 puff at a time with 4 tidal breaths: 4–6 puffs (GINA 2026). AAH v3.0 allows 4–12 puffs
- Repeat every 20–30 min, up to 3 doses in hour 1, only if needed
- Moderate or slow response: add ipratropium with each salbutamol dose (pMDI 21 microgram/puff, 8 puffs; or nebulised 250–500 microgram)
- Unless mild: prednisolone 1–2 mg/kg orally once daily (max 40 mg) within 1 hour (GINA). AAH: 1 mg/kg (max 50 mg). Or dexamethasone 0.3–0.6 mg/kg orally once daily (max 12 mg) for 1–2 days
- Cannot use spacer: nebulised salbutamol 2.5 mg
- Oxygen only if SpO2 below 92%; target SpO2 92–95%
- Path rejoins step 10Shared downstream outcome
Guideline Source
GINA 2026 Global Strategy for Asthma Management and Prevention
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- For children 6–11 years only. Age 5 and under (preschool wheeze) and infants with bronchiolitis need different care; age 12 and over: use the adult and adolescent pathway.
- Doses follow GINA 2026 with Australian Asthma Handbook v3.0 alternatives. Follow local paediatric protocols for oxygen targets, IV infusions and PICU criteria.
- Does not cover long-term asthma management, PICU ventilation or IV salbutamol infusions (specialist only).
Contraindicated Populations
Infants under 12 months with first wheeze (bronchiolitis)Children 5 years and under (use the GINA preschool wheeze approach)Adolescents 12 years and over (use the adult and adolescent pathway)
Applicable Regions
USEUAU
AU: Australian Asthma Handbook v3.0 (NAC 2025), children 6–11 in the ED: salbutamol 4–12 puffs (mild–moderate) or 12 puffs (severe) of 100 microgram; ipratropium 21 microgram/puff, 8 puffs; prednisolone 1 mg/kg (max 50 mg) daily for 3 days; SpO2 94% or less = severe; oxygen target 92–96%; GP review within 3 days.
Version 2Next review: 2027-09-30
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Related Resources
Frequently Asked Questions
What is the Pediatric Acute Asthma Exacerbation, 6–11 Years (GINA 2026)?
The Pediatric Acute Asthma Exacerbation, 6–11 Years (GINA 2026) is a emergency clinical algorithm for Pediatrics. It provides a structured decision tree to guide clinical decision-making, based on GINA 2026 Global Strategy for Asthma Management and Prevention.
What guideline is the Pediatric Acute Asthma Exacerbation, 6–11 Years (GINA 2026) based on?
This algorithm is based on GINA 2026 Global Strategy for Asthma Management and Prevention.
What are the limitations of the Pediatric Acute Asthma Exacerbation, 6–11 Years (GINA 2026)?
Known limitations include: For children 6–11 years only. Age 5 and under (preschool wheeze) and infants with bronchiolitis need different care; age 12 and over: use the adult and adolescent pathway.; Doses follow GINA 2026 with Australian Asthma Handbook v3.0 alternatives. Follow local paediatric protocols for oxygen targets, IV infusions and PICU criteria.; Does not cover long-term asthma management, PICU ventilation or IV salbutamol infusions (specialist only).. Individual patient factors may require deviation from these recommendations.
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