Paediatric asthma Thorax 2003; 58 (Suppl I): i1-i92

Paediatric asthmaPaediatric asthma

Thorax 2003; 58 (Suppl I): i1-i92

Diagnosis of asthma in childrenDiagnosis of asthma in children


Detailed history and physical examination• pattern of illness• severity/control

• differential clues

Presenting features• wheeze• dry cough

• breathlessness• noisy breathing

Is it asthma?

Clues to alternativeClues to alternativediagnoses in wheezy childrendiagnoses in wheezy children


Clinical clueClinical clue Possible diagnosisPossible diagnosis

Perinatal and family history

• symptoms present from birth or perinatal lung problem

• family history of unusual chest disease• severe upper respiratory tract disease

• cystic fibrosis; chronic lung disease; ciliary dyskinesia; 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

• inspiratory stridor as well as wheeze• failure to thrive

• cystic fibrosis; recurrent aspiration; host defence disorder• reflux (aspiration)• swallowing problems (aspiration)• laryngeal problem• developmental disease; postviral syndrome; bronchiectasis;

tuberculosis• central airway or laryngeal disorder• cystic fibrosis; host defence defect; gastro-oesophageal reflux

InvestigationsInvestigations

• focal or persistent radiological changesfocal or persistent radiological changes • developmental disorder; postinfective disorder; recurrent developmental disorder; postinfective disorder; recurrent aspiration; inhaled foreign body; bronchiectasis; tuberculosisaspiration; inhaled foreign body; bronchiectasis; tuberculosis

AA AAUse pMDI and large volume spacer for adults and Use pMDI and large volume spacer for adults and children aged 2-12 years with mild and moderate children aged 2-12 years with mild and moderate exacerbations of asthmaexacerbations of asthma

pMDI + spacer preferred delivery method for pMDI + spacer preferred delivery method for children aged 0-5 yearschildren aged 0-5 years

AAIn children aged 5-12 years with chronic asthma, pMDI + In children aged 5-12 years with chronic asthma, pMDI + spacer is as effective as any other hand held inhalerspacer is as effective as any other hand held inhaler

AAIn adults, pMDI ± spacer is as effective as any other hand held In adults, pMDI ± spacer is as effective as any other hand held inhaler, but patients may prefer dry powder inhalersinhaler, but patients may prefer dry powder inhalers

Base choice of reliever inhaler for stable asthma on patient Base choice of reliever inhaler for stable asthma on patient preference/ability to use, as many patients will not carry a spacerpreference/ability to use, as many patients will not carry a spacer

AASalbutamol non-CFC pMDI can be substituted for CFC pMDI atSalbutamol non-CFC pMDI can be substituted for CFC pMDI at1:1 dosing1:1 dosing

Delivery of ßDelivery of ß22 agonists agonists


AdultsAdults Children Children 5-12 5-12 yearsyears

Children Children <5 <5

yearsyears

pMDI + spacer preferred delivery method for pMDI + spacer preferred delivery method for children aged 0-5 yearschildren aged 0-5 years

AA For children aged 5-12 years, pMDI + spacer is as For children aged 5-12 years, pMDI + spacer is as effective as any dry powder inhalereffective as any dry powder inhaler

AAIn adults, a pMDI ± spacer is as effective as any In adults, a pMDI ± spacer is as effective as any dry powder inhalerdry powder inhaler

HFA-BDP pMDI can be substituted for CFC-BDP HFA-BDP pMDI can be substituted for CFC-BDP pMDI at 1:2 dosing, but should incorporate period pMDI at 1:2 dosing, but should incorporate period of close monitoringof close monitoring

AAFluticasone non-CFC pMDI can be substituted for Fluticasone non-CFC pMDI can be substituted for CFC pMDI at 1:1 dosingCFC pMDI at 1:1 dosing

Delivery of inhaled steroidsDelivery of inhaled steroids


AdultsAdults Children Children 5-12 5-12 yearsyears

Children Children <5 <5

yearsyears

Initial assessment of acute asthma in Initial assessment of acute asthma in children aged >2 years in A&Echildren aged >2 years in A&E


ModerateModerateexacerbationexacerbation

SevereSevereexacerbationexacerbation

Life threateningLife threateningasthmaasthma

• SpOSpO22 92%92%

• PEF PEF 50% best/ 50% best/ predicted (>5 years)predicted (>5 years)

• No clinical features of No clinical features of severe asthmasevere asthma

• Heart rate:Heart rate: - - 130/min (2-5 years)130/min (2-5 years) - - 120/min (>5 years)120/min (>5 years)• Respiratory rate:Respiratory rate: - - 50/min (2-5 years)50/min (2-5 years) - - 30/min (>5 years)30/min (>5 years)

• SpOSpO22 <92% <92%

• PEF <50% best/ PEF <50% best/ predicted (>5 years)predicted (>5 years)

• Too breathless to talkToo breathless to talkor eator eat

• Heart rate:Heart rate: - >130/min (2-5 years)- >130/min (2-5 years) - >120/min (>5 years)- >120/min (>5 years)• Respiratory rate:Respiratory rate: - >50/min (2-5 years)- >50/min (2-5 years) - >30/min (>5 years)- >30/min (>5 years)• Use of accessory neck Use of accessory neck

musclesmuscles

• SpOSpO22 <92% <92%

• PEF <33% best/ PEF <33% best/ predicted (>5 years)predicted (>5 years)

• Silent chestSilent chest• Poor respiratory effortPoor respiratory effort• AgitationAgitation• Altered consciousnessAltered consciousness• CyanosisCyanosis

Management of acute asthmaManagement of acute asthmain children aged >2 years in A&Ein children aged >2 years in A&E




Life threateningLife threateningexacerbationexacerbation

• ßß22 agonist 2-10 puffs via agonist 2-10 puffs via

spacer spacer ±± facemask facemask• Reassess after 15 minutesReassess after 15 minutes

• Give nebulised ßGive nebulised ß22 agonist: agonist:

salbutamol (2-5 years: 2.5mg; >5 years: 5mg) or terbutalinesalbutamol (2-5 years: 2.5mg; >5 years: 5mg) or terbutaline(2-5 years: 5mg; >5 years: 10mg) with oxygen as driving gas(2-5 years: 5mg; >5 years: 10mg) with oxygen as driving gas

• Continue oxygen via facemask/nasal prongsContinue oxygen via facemask/nasal prongs• Give prednisolone (2-5 years: 20mg; >5 years 30-40mg) orGive prednisolone (2-5 years: 20mg; >5 years 30-40mg) or

IV hydrocortisone (2-5 years: 50mg; >5 years: 100mg)IV hydrocortisone (2-5 years: 50mg; >5 years: 100mg)

RESPONDINGRESPONDING• Continue inhaledContinue inhaled

ßß22 agonists agonists

1-4 hourly1-4 hourly• Add soluble oral Add soluble oral

prednisoloneprednisolone- 20mg (2-5 years)- 20mg (2-5 years)- 30-40mg- 30-40mg (>5 years) (>5 years)

NOT RESPONDINGNOT RESPONDING• Repeat inhaledRepeat inhaled

ßß22 agonist every agonist every

20-30 minutes20-30 minutes• Add soluble oral Add soluble oral

prednisoloneprednisolone- 20mg (2-5 years)- 20mg (2-5 years)- 30-40mg (>5 years)- 30-40mg (>5 years)

IF LIFE THREATENING FEATURES PRESENTIF LIFE THREATENING FEATURES PRESENTDiscuss with senior clinician, PICU team or Discuss with senior clinician, PICU team or paediatrician. Consider:paediatrician. Consider:• Chest x-ray and blood gasesChest x-ray and blood gases• Repeat nebulised ßRepeat nebulised ß22 agonists plus ipratropium agonists plus ipratropium

bromide 0.25mg nebulised every 20-30 minutes bromide 0.25mg nebulised every 20-30 minutes• Bolus IV salbutamol 15Bolus IV salbutamol 15g/kg of 200g/kg of 200g/mlg/ml solution over 10 minutes solution over 10 minutes• IV aminophyllineIV aminophylline


Response to treatment of acute asthmaResponse to treatment of acute asthmain children aged >2 years in A&Ein children aged >2 years in A&E



Life threatening Life threatening exacerbationexacerbation

RESPONDING TO RESPONDING TO TREATMENTTREATMENT

NOT RESPONDING TO NOT RESPONDING TO TREATMENTTREATMENT

IF POOR RESPONSE TO IF POOR RESPONSE TO TREATMENTTREATMENT

DISCHARGE PLANDISCHARGE PLAN• Continue ßContinue ß22 agonists 1-4 hourly agonists 1-4 hourly

prnprn• Consider prednisoloneConsider prednisolone

20mg (2-5 years) 30-40mg20mg (2-5 years) 30-40mg(>5 years) daily for up to 3 days(>5 years) daily for up to 3 days

• Advise to contact GP if not Advise to contact GP if not controlled on above treatmentcontrolled on above treatment

• Provide a written asthma action Provide a written asthma action planplan

• Review regular treatmentReview regular treatment• Check inhaler techniqueCheck inhaler technique• Arrange GP follow upArrange GP follow up

ARRANGE ADMISSIONARRANGE ADMISSION(lower threshold if concern (lower threshold if concern over social circumstances)over social circumstances)

ARRANGE IMMEDIATE ARRANGE IMMEDIATE TRANSFER TO PICU/HDUTRANSFER TO PICU/HDU

Treatment of acute asthmaTreatment of acute asthmain children aged >2 yearsin children aged >2 years


DDUse structured care protocols detailing bronchodilator usage, clinical Use structured care protocols detailing bronchodilator usage, clinical assessment, and specific criteria for safe dischargeassessment, and specific criteria for safe discharge

Children with life threatening asthma or SpOChildren with life threatening asthma or SpO

22 <92% should receive <92% should receive high flow oxygen via a tight fitting face mask or nasal cannula at high flow oxygen via a tight fitting face mask or nasal cannula at sufficient flow rates to achieve normal saturationssufficient flow rates to achieve normal saturations

AA Inhaled ßInhaled ß22 agonists are first line treatment for acute asthma * agonists are first line treatment for acute asthma *

AApMDI and spacer are preferred delivery system in mild to moderate pMDI and spacer are preferred delivery system in mild to moderate asthmaasthma

BB Individualise drug dosing according to severity and adjust according Individualise drug dosing according to severity and adjust according to responseto response

BB IV salbutamol (15IV salbutamol (15mmg/kg) is effective adjunct in severe casesg/kg) is effective adjunct in severe cases

* Dose can be repeated every 20-30 minutes

Steroid therapy for acuteSteroid therapy for acuteasthma in children aged >2 yearsasthma in children aged >2 years


AA Give prednisolone early in the treatment of acute asthma attacksGive prednisolone early in the treatment of acute asthma attacks

• Use prednisolone 20mg (2-5 years), 30-40mg (>5 years)Use prednisolone 20mg (2-5 years), 30-40mg (>5 years)

• Those already receiving maintenance steroid tablets should receive Those already receiving maintenance steroid tablets should receive 2 mg/kg oral prednisolone up to a maximum dose of 60 mg2 mg/kg oral prednisolone up to a maximum dose of 60 mg

• Repeat the dose of prednisolone in children who vomit and consider Repeat the dose of prednisolone in children who vomit and consider IV steroidsIV steroids

• Treatment up to 3 days is usually sufficient, but tailor to the number Treatment up to 3 days is usually sufficient, but tailor to the number of days for recoveryof days for recovery

Do not initiate inhaled steroids in preference to steroid tablets to treat Do not initiate inhaled steroids in preference to steroid tablets to treat acute childhood asthmaacute childhood asthma

Other therapies for acuteOther therapies for acuteasthma in children aged >2 yearsasthma in children aged >2 years


AAIf poor response to If poor response to 22 agonist treatment, add nebulised ipratropium agonist treatment, add nebulised ipratropium bromide (250bromide (250mcgmcg/dose mixed with /dose mixed with 22 agonist) * agonist) *

AAAminophylline is not recommended in children with mild to Aminophylline is not recommended in children with mild to moderate acute asthmamoderate acute asthma

CCConsider aminophylline for children in high dependency/intensive Consider aminophylline for children in high dependency/intensive care with severe or life threatening bronchospasm unresponsive to care with severe or life threatening bronchospasm unresponsive to maximal doses of bronchodilators and steroid tabletsmaximal doses of bronchodilators and steroid tablets

Do not give antibiotics routinely in the management of acute Do not give antibiotics routinely in the management of acute childhood asthmachildhood asthma

ECG monitoring is mandatory for all intravenous treatmentsECG monitoring is mandatory for all intravenous treatments* Dose can be repeated every 20-30 minutes

Hospital admission for acuteHospital admission for acuteasthma in children aged >2 yearsasthma in children aged >2 years


Children with acute asthma failing to improve after 10 puffs of Children with acute asthma failing to improve after 10 puffs of 22 agonist agonist should be referred to hospital. Further doses of bronchodilator should be should be referred to hospital. Further doses of bronchodilator should be given as necessary whilst awaiting transfergiven as necessary whilst awaiting transfer

Treat with oxygen and nebulised Treat with oxygen and nebulised 22 agonists during the journey to agonists during the journey to hospitalhospital

Transfer children with severe or life threatening asthma urgently to Transfer children with severe or life threatening asthma urgently to hospital to receive frequent doses of nebulised hospital to receive frequent doses of nebulised 22 agonists (2.5-5mg agonists (2.5-5mg salbutamol or 5-10 mg terbutaline)salbutamol or 5-10 mg terbutaline)

Decisions about admission should be made by trained physicians after Decisions about admission should be made by trained physicians after repeated assessment of the response to further bronchodilator treatmentrepeated assessment of the response to further bronchodilator treatment

BBConsider intensive inpatient treatment for children with SpOConsider intensive inpatient treatment for children with SpO

22 <92% on air <92% on air after initial bronchodilator treatmentafter initial bronchodilator treatment

Treatment of acute asthmaTreatment of acute asthmain children aged <2 yearsin children aged <2 years


BB Oral Oral 22 agonists are not recommended for acute asthma in infants agonists are not recommended for acute asthma in infants

AAFor mild to moderate acute asthma, a pMDI with spacer is the For mild to moderate acute asthma, a pMDI with spacer is the optimal drug delivery deviceoptimal drug delivery device

CCConsider steroid tablets in infants early in the management of Consider steroid tablets in infants early in the management of moderate to severe episodes of acute asthma in the hospital moderate to severe episodes of acute asthma in the hospital settingsetting

Steroid tablet therapy (10 mg of soluble prednisolone for up toSteroid tablet therapy (10 mg of soluble prednisolone for up to3 days) is the preferred steroid preparation3 days) is the preferred steroid preparation

BBConsider inhaled ipratropium bromide in combination with an Consider inhaled ipratropium bromide in combination with an inhaled inhaled 22 agonist for more severe symptoms agonist for more severe symptoms

Documents

Paediatric asthma Thorax 2003; 58 (Suppl I): i1-i92