Transcript British Guideline on the Management of Asthma

Paediatric asthma
Thorax 2003; 58 (Suppl I): i1-i92
Diagnosis of asthma in children
Presenting features
• wheeze
• dry cough
•
•
breathlessness
noisy breathing
Detailed history and physical examination
• pattern of illness • differential clues
• severity/control
Is it asthma?
Thorax 2003; 58 (Suppl I): i1-i92
Clues to alternative
diagnoses in wheezy children
Clinical clue
Possible diagnosis
Perinatal and family history
• symptoms present from birth or perinatal • cystic fibrosis; chronic lung disease; ciliary dyskinesia;
lung problem
• family history of unusual chest disease
• severe upper respiratory tract disease
developmental anomaly
• cystic fibrosis; developmental anomaly; neuromuscular disorder
• defect of host defence
Symptoms and signs
• persistent wet cough
• excessive vomiting or posseting
• dysphagia
• abnormal voice or cry
• focal signs in the chest
• cystic fibrosis; recurrent aspiration; host defence disorder
• reflux (aspiration)
• swallowing problems (aspiration)
• laryngeal problem
• developmental disease; postviral syndrome; bronchiectasis;
• inspiratory stridor as well as wheeze
• failure to thrive
tuberculosis
• central airway or laryngeal disorder
• cystic fibrosis; host defence defect; gastro-oesophageal reflux
Investigations
• focal or persistent radiological changes
• developmental disorder; postinfective disorder; recurrent
aspiration; inhaled foreign body; bronchiectasis; tuberculosis
Thorax 2003; 58 (Suppl I): i1-i92
Delivery of ß2 agonists
Adults
A
Children Children
5-12
<5
years
years
A

Use pMDI and large volume spacer for adults and
children aged 2-12 years with mild and moderate
exacerbations of asthma
pMDI + spacer preferred delivery method for
children aged 0-5 years
In children aged 5-12 years with chronic asthma, pMDI +
spacer is as effective as any other hand held inhaler
In adults, pMDI ± spacer is as effective as any other hand held
inhaler, but patients may prefer dry powder inhalers
A
A

Base choice of reliever inhaler for stable asthma on patient
preference/ability to use, as many patients will not carry a spacer
A
Salbutamol non-CFC pMDI can be substituted for CFC pMDI at
1:1 dosing
Thorax 2003; 58 (Suppl I): i1-i92
Delivery of inhaled steroids
Adults
Children Children
5-12
<5
years
years

A
A

A
pMDI + spacer preferred delivery method for
children aged 0-5 years
For children aged 5-12 years, pMDI + spacer is as
effective as any dry powder inhaler
In adults, a pMDI ± spacer is as effective as any
dry powder inhaler
HFA-BDP pMDI can be substituted for CFC-BDP
pMDI at 1:2 dosing, but should incorporate period
of close monitoring
Fluticasone non-CFC pMDI can be substituted for
CFC pMDI at 1:1 dosing
Thorax 2003; 58 (Suppl I): i1-i92
Initial assessment of acute asthma in
children aged >2 years in A&E
Moderate
exacerbation
Severe
exacerbation
Life threatening
asthma
• SpO2 92%
• PEF 50% best/
• SpO2 <92%
• PEF <50% best/
• SpO2 <92%
• PEF <33% best/
predicted (>5 years)
• No clinical features of
severe asthma
• Heart rate:
- 130/min (2-5 years)
- 120/min (>5 years)
• Respiratory rate:
- 50/min (2-5 years)
- 30/min (>5 years)
predicted (>5 years)
• Too breathless to talk
or eat
• Heart rate:
- >130/min (2-5 years)
- >120/min (>5 years)
• Respiratory rate:
- >50/min (2-5 years)
- >30/min (>5 years)
• Use of accessory neck
muscles
predicted (>5 years)
• Silent chest
• Poor respiratory effort
• Agitation
• Altered consciousness
• Cyanosis
Thorax 2003; 58 (Suppl I): i1-i92
Management of acute asthma
in children aged >2 years in A&E
Moderate
exacerbation
• ß2 agonist 2-10 puffs via
•
spacer ± facemask
Reassess after 15 minutes
RESPONDING
• Continue inhaled
ß2 agonists
1-4 hourly
• Add soluble oral
prednisolone
- 20mg (2-5 years)
- 30-40mg
(>5 years)
Severe
exacerbation
Life threatening
exacerbation
• Give nebulised ß2 agonist:
•
•
salbutamol (2-5 years: 2.5mg; >5 years: 5mg) or terbutaline
(2-5 years: 5mg; >5 years: 10mg) with oxygen as driving gas
Continue oxygen via facemask/nasal prongs
Give prednisolone (2-5 years: 20mg; >5 years 30-40mg) or
IV hydrocortisone (2-5 years: 50mg; >5 years: 100mg)
NOT RESPONDING
• Repeat inhaled
ß2 agonist every
20-30 minutes
• Add soluble oral
prednisolone
- 20mg (2-5 years)
- 30-40mg (>5 years)
IF LIFE THREATENING FEATURES PRESENT
Discuss with senior clinician, PICU team or
paediatrician. Consider:
• Chest x-ray and blood gases
• Repeat nebulised ß2 agonists plus ipratropium
bromide 0.25mg nebulised every 20-30 minutes
• Bolus IV salbutamol 15g/kg of 200g/ml
solution over 10 minutes
• IV aminophylline
Thorax 2003; 58 (Suppl I): i1-i92
Response to treatment of acute asthma
in children aged >2 years in A&E
Moderate
exacerbation
Severe
exacerbation
Life threatening
exacerbation
RESPONDING TO
TREATMENT
NOT RESPONDING TO
TREATMENT
IF POOR RESPONSE TO
TREATMENT
ARRANGE ADMISSION
(lower threshold if concern
over social circumstances)
ARRANGE IMMEDIATE
TRANSFER TO PICU/HDU
DISCHARGE PLAN
• Continue ß2 agonists 1-4 hourly
prn
• Consider prednisolone
20mg (2-5 years) 30-40mg
(>5 years) daily for up to 3 days
• Advise to contact GP if not
controlled on above treatment
• Provide a written asthma action
plan
• Review regular treatment
• Check inhaler technique
• Arrange GP follow up
Thorax 2003; 58 (Suppl I): i1-i92
Treatment of acute asthma
in children aged >2 years
D

A
A
B
B
Use structured care protocols detailing bronchodilator usage, clinical
assessment, and specific criteria for safe discharge
Children with life threatening asthma or SpO2 <92% should receive
high flow oxygen via a tight fitting face mask or nasal cannula at
sufficient flow rates to achieve normal saturations
Inhaled ß2 agonists are first line treatment for acute asthma *
pMDI and spacer are preferred delivery system in mild to moderate
asthma
Individualise drug dosing according to severity and adjust according
to response
IV salbutamol (15mg/kg) is effective adjunct in severe cases
* Dose can be repeated every 20-30 minutes
Thorax 2003; 58 (Suppl I): i1-i92
Steroid therapy for acute
asthma in children aged >2 years
A
Give prednisolone early in the treatment of acute asthma attacks
• Use prednisolone 20mg (2-5 years), 30-40mg (>5 years)
• Those already receiving maintenance steroid tablets should receive
2 mg/kg oral prednisolone up to a maximum dose of 60 mg

• Repeat the dose of prednisolone in children who vomit and consider
IV steroids
• Treatment up to 3 days is usually sufficient, but tailor to the number

of days for recovery
Do not initiate inhaled steroids in preference to steroid tablets to treat
acute childhood asthma
Thorax 2003; 58 (Suppl I): i1-i92
Other therapies for acute
asthma in children aged >2 years
A
A
C


If poor response to 2 agonist treatment, add nebulised ipratropium
bromide (250mcg/dose mixed with 2 agonist) *
Aminophylline is not recommended in children with mild to
moderate acute asthma
Consider aminophylline for children in high dependency/intensive
care with severe or life threatening bronchospasm unresponsive to
maximal doses of bronchodilators and steroid tablets
Do not give antibiotics routinely in the management of acute
childhood asthma
ECG monitoring is mandatory for all intravenous treatments
* Dose can be repeated every 20-30 minutes
Thorax 2003; 58 (Suppl I): i1-i92
Hospital admission for acute
asthma in children aged >2 years

Children with acute asthma failing to improve after 10 puffs of 2 agonist
should be referred to hospital. Further doses of bronchodilator should be
given as necessary whilst awaiting transfer

Treat with oxygen and nebulised 2 agonists during the journey to
hospital

Transfer children with severe or life threatening asthma urgently to
hospital to receive frequent doses of nebulised 2 agonists (2.5-5mg
salbutamol or 5-10 mg terbutaline)

Decisions about admission should be made by trained physicians after
repeated assessment of the response to further bronchodilator treatment
B
Consider intensive inpatient treatment for children with SpO2 <92% on
air after initial bronchodilator treatment
Thorax 2003; 58 (Suppl I): i1-i92
Treatment of acute asthma
in children aged <2 years
B
A
C

B
Oral 2 agonists are not recommended for acute asthma in infants
For mild to moderate acute asthma, a pMDI with spacer is the
optimal drug delivery device
Consider steroid tablets in infants early in the management of
moderate to severe episodes of acute asthma in the hospital
setting
Steroid tablet therapy (10 mg of soluble prednisolone for up to
3 days) is the preferred steroid preparation
Consider inhaled ipratropium bromide in combination with an
inhaled 2 agonist for more severe symptoms
Thorax 2003; 58 (Suppl I): i1-i92