Aim At present there is not sufficient evidence to suggest the optimal choice, or order, of intravenous bronchodilator in the management of life threatening wheeze or asthma in children. As a result, recent BTS guidelines are unable to give clear advice. This has led to variation at a national and also led to confusion within many departments. We set out to review variations within a group of children aged >1 year of age admitted from a busy Paediatric Emergency Department (PED) to a co-located Paediatric HDU.

Methods All admissions from PED to Paediatric HDU with wheeze or an acute exacerbation of asthma requiring intravenous bronchodilators over a 7 month period running from April to November 2014 were identified by review of electronic records. Those <1 year of age were excluded from analysis.

Each patient’s electronic and paper notes were reviewed to identify choice and order of intravenous bronchodilator alongside need for ventilatory support as a marker of severity.

These results were reviewed in the context of a local guideline suggesting salbutamol as the first line, magnesium sulphate as the second line and aminophylline as third line.

Results 37 cases of children requiring intravenous bronchodilator were identified. Of these 12 (32%) of children received a single intravenous bronchodilator, 15 (40%) received two bronchodilators and 10 (27%) received three different bronchodilators.

In contrast to the guideline, magnesium sulphate was the first choice in 35 (95%) of cases, with salbutamol chosen first in only 2 (5%) of cases. Aminophylline was only ever used after both magnesium and salbutamol had been commenced.

Of this group 5 (13.5%) received ventilatory support beyond simple oxygen delivery with 3 receiving Optiflow, 1 CPAP, 1 BiPAP and none requiring intubation.

Discussion Variation and uncertainty at national level is reflected in local practice. Use of magnesium sulphate is far higher than suggested by our local guidelines and appears to be driven by individual clinicians’ experiences.

This study identifies the need for further work to develop an evidence based approach to managing the child with life threatening wheeze or asthma to limit variation and, it is hoped, improve outcomes.