Print Print
CKS is no longer commissioned by the National Institute for Health and Clinical Excellence (NICE). NICE remains committed to providing a replacement service for CKS and is currently reviewing its options. In the meantime, although CKS content is now not being maintained, it still remains relevant and will continue to be made available. CKS content was generated under a programme of topic creation and update. To check if the topic you are viewing is current or out of date, please refer to the topic publication details by clicking on the 'How up-to-date is this topic?' link in the left hand menu on individual topic pages.

Asthma - Management
Children and adults not needing admission to hospital: How do I manage?

  • Prescribe a short course of oral prednisolone (see Table 1 for doses).
  • Do not prescribe antibiotics routinely, unless symptoms and signs suggest a bacterial infection.
  • Advise the person (or parent of a child) to use their short-acting beta2-agonist via a large-volume spacer.
    • For an adult, give 4 puffs initially, followed by 2 puffs every 2 minutes according to response, up to 10 puffs.
    • For a child, give 2 puffs every 2 minutes according to response, up to 10 puffs.
    • Each puff should be given one at a time and inhaled with five tidal breaths.
  • After the short-acting beta2-agonist has been given (up to 10 puffs), advise the person (or parent of a child):
    • To return to using their short-acting beta2-agonist as-required, up to four times a day (not exceeding 4-hourly use).
    • To monitor their peak expiratory flow rate (PEFR) and symptoms. If symptoms worsen, or PEFR decreases after starting treatment, they should seek further medical advice.
  • Follow up a person (ideally) within 24 hours, or sooner if they deteriorate, and within 1 week after an exacerbation.
Clarification / Additional information
  • People whose condition deteriorates despite treatment normally need admission to hospital. Ideally, all people should be followed up after an exacerbation by telephone or, preferably, in person.
  • Inhaled beta2-agonists can be used on a regular basis to alleviate persistent symptoms during an exacerbation. Many people may have already implemented this procedure as part of their action plan.
  • Oral corticosteroids should be given for at least 5 days in adults, whilst 3 days is usually sufficient for children. Nevertheless, the length of a course should be tailored to the number of days necessary to bring about recovery. The benefits of corticosteroids can occur within 3–4 hours, and most people do not need tapering of the dose at the end of such a short course.
  • The dose of inhaled corticosteroids (ICS) does not need to be increased during an exacerbation, and people should remain on their usual dose. Treatment with ICS should not be used as an alternative to oral corticosteroids.
  • Antibiotics: explain to the individual that most exacerbations of asthma are not caused by a bacterial infection and antibiotics will not hasten recovery. If a person has a productive cough and elevated body temperature, consider an alternative diagnosis — see Differential diagnosis.
Table 1. Dose of oral prednisolone used in acute severe exacerbation of asthma.
Dose of oral prednisolone (once daily)
< 2 years old
2–5 years old
6–12 years old
> 12 years old
People not taking regular oral corticosteroid
10 mg
20 mg
30–40 mg
40–50 mg*
People taking regular oral corticosteroid
2 mg/kg (maximum 40 mg)
2 mg/kg
(maximum 60 mg)
2 mg/kg
(maximum 60 mg)
2 mg/kg
(maximum 60 mg)
* In practice, many healthcare professionals prescribe 30 mg/day.
Data from: [BNF 53, 2007; BNF for Children, 2007; SIGN and BTS, 2009]
Basis for recommendation
  • These recommendations are based on the British Guideline on the Management of Asthma: a national clinical guideline [SIGN and BTS, 2009]:
    • Oral corticosteroids: the evidence shows that oral corticosteroids reduce mortality, relapse, subsequent hospital admission, and requirement for beta2-agonist therapy. The earlier oral corticosteroids are given in an acute attack, the better the outcome. Larger doses than those stated in the recommendation do not appear to provide any additional benefit.
    • Inhaled corticosteroids: no evidence indicates that doubling the dose of inhaled corticosteroids is effective in treating acute symptoms of asthma [SIGN and BTS, 2009].
    • Antibiotics: the evidence suggests that when an infection precipitates an exacerbation of asthma, it is likely to be viral. The role of bacterial infections has been overestimated [SIGN and BTS, 2009].

© NHS Institute for Innovation and Improvement