British guideline on the management of asthma in children continued

Non-pharmacological management

Primary prevention

• Breast feeding should be encouraged
• Parents and parents-to-be who smoke should be advised of the many adverse effects of smoking on their children

Secondary prevention

• In committed families, with evidence of house dust mite allergy, multiple approaches to reduce exposure to house dust mite may help
• Parents who smoke and who have asthma should be advised about the dangers to themselves and their children with asthma and offered appropriate support to stop smoking
• Immunotherapy can be considered in patients with asthma where a clinically significant allergen cannot be avoided. The potential for severe allergic reactions to the therapy must be fully discussed with patients

Complementary and alternative medicines

• In difficult childhood asthma, there may be a role for family therapy as an adjunct to pharmacotherapy
• Air ionisers are not recommended for the treatment of asthma

Pharmacological management

• The aim of asthma management is control of the disease. Control is defined as:
  • no daytime symptoms
  • no night time awakening due to asthma
  • no need for rescue medication
  • no exacerbations
  • no limitations on activity including exercise
  • normal lung function (in practical terms FEV1 and/or PEF >80% predicted or best) with minimal side-effects
  • minimal side-effects from medication

The stepwise approach

• Start treatment at the step most appropriate to initial severity
• Achieve early control
• Maintain control by:
  • stepping up treatment as necessary
  • stepping down when control is good
• Before initiating a new drug therapy practitioners should check compliance with existing therapies and inhaler technique, and eliminate trigger factors
• Until May 2009 all doses of inhaled steroids in this section have been referenced against beclometasone (BDP) given via CFC-MDIs (metered dose inhaler). As BDP CFC is now unavailable, the reference inhaled steroid will be the BDP-HFA (hydrofluroalkane) product, which is available at the same dosage as BDP-CFC. Note that some BDP-HFA products are more potent and all should be prescribed by brand. Adjustments to doses will have to be made for other devices and other corticosteroid molecules

Stepping down

• Regular review of patients should be carried out as treatment is stepped down is important. When deciding which drug to step down first and at what rate, the severity of asthma, the side-effects of the treatment, the beneficial effect achieved, and the patient’s preference should all be taken into account
• Patients should be maintained at the lowest possible dose of inhaled steroid. Reduction in inhaled steroid dose should be slow as patients deteriorate at different rates. Reductions should be considered every three months, decreasing the dose by approximately 25–50% each time

Exercise-induced asthma

• For most patients exercise-induced asthma is an expression of poorly controlled asthma and regular treatment including inhaled steroids should be reviewed
• If exercise is a specific problem in patients taking inhaled steroids who are otherwise well controlled, consider the following therapies:
  • leukotriene receptor antagonists
  • LABAs
  • chromones
  • oral β2-agonists
  • theophyllines
• Immediately prior to exercise, inhaled short-acting β2-agonists are the drug of choice

British guideline on the management of asthma in children continued

Summary of stepwise management in children aged 5–12 years

Summary of stepwise management in children less than 5 years of age

Inhaler devices

British guideline on the management of asthma in children continued

Technique and training

• Prescribe inhalers only after patients have received training in the use of the device and have demonstrated satisfactory technique

β2-agonist delivery

• Acute asthma
  • children and adults with mild and moderate exacerbations of asthma should be treated by pMDI + spacer with doses titrated according to clinical response
• Stable asthma
  • in children aged 5–12 years, pMDI + spacer is as effective as any other hand held inhaler

Inhaled steroids for stable asthma

• In children aged 5–12 years, pMDI + spacer is as effective as any DPI

CFC vs HFA propellant inhalers

• Salbutamol HFA can be substituted for salbutamol CFC at 1:1 dosing
• HFA-BDP pMDI may be substituted for CFC-BDP pMDI at 1:2 dosing. This ratio does not apply to reformulated HFA-BDP pMDIs
• Fluticasone HFA can be substituted for fluticasone CFC at 1:1 dosing

Prescribing devices

• The choice of device may be determined by the choice of drug
• If the patient is unable to use a device satisfactorily, an alternative should be found
• The patient should have their ability to use an inhaler device assessed by a competent healthcare professional
• The medication needs to be titrated against clinical response to ensure optimum efficacy
• Reassess inhaler technique as part of structured clinical review

Inhaler devices in children under 5

• In children aged 0–5 years, little or no evidence is available on which to base recommendations
• In children aged 0–5 years, pMDI and spacer are the preferred method of delivery of β2-agonists or inhaled steroids. A face mask is required until the child can breathe reproducibly using the spacer mouthpiece. Where this is ineffective a nebuliser may be required

British guideline on the management of asthma in children continued

Management of acute asthma in children aged over 2 years

• Acute severe:
  • can't complete sentences in one breath or too breathless to talk or feed
  • SpO₂ <92%
  • PEF 33–50% best or predicted
  • pulse >140 in children aged 2–5 years; >125 in children aged >5 years
  • respiration >40 breaths/min aged 2–5 years; >30 breaths/min aged 2–5 years
  • Life threatening:
    • hypotension
    • silent chest
    • exhaustion
      
    • cyanosis
    • confusion
    • poor respiratory effort
    • coma
    • SpO₂ <92%
    • PEF <33% best or predicted

  Criteria for admission

  • Transfer children with severe or life threatening asthma urgently to hospital to receive frequent doses of nebulised β2-agonists (2.5–5 mg salbutamol or 5–10 mg terbutaline)
  • Children with acute asthma in primary care who have not improved after receiving up to 10 puffs of β2-agonist should be referred to hospital. Further doses of bronchodilator should be given as necessary whilst awaiting transfer
  • Treat children transported to hospital by ambulance with oxygen and nebulised β2-agonists during the journey
  • Consider intensive inpatient treatment for children with SpO2 <92% on air after initial bronchodilator treatment
  • Attempt to measure PEF or FEV1 in all children aged >5 years
  • The following clinical signs should be recorded:
    • pulse rate – increasing tachycardia generally denotes worsening asthma; a fall in heart rate in life threatening asthma is a pre-terminal event
    • respiratory rate and degree of breathlessness – i.e. too breathless to complete sentences in one breath or to feed
    • use of accessory muscles of respiration – best noted by palpation of neck muscles
    • amount of wheezing – which might become biphasic or less apparent with increasing airways obstruction
    • degree of agitation and conscious level – always give calm reassurance

  • N.B. Clinical signs correlate poorly with the severity of airways obstruction. Some children with acute asthma do not appear distressed

  Treatment of acute asthma

  • Oxygen
    • 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
  • β2-agonist bronchodilators
    • inhaled β2-agonists are the first line treatment
    • a pMDI + spacer are the preferred option in mild to moderate asthma
    • individualise drug dosing according to severity and the patient’s response
    • the early addition of a bolus dose of IV salbutamol (15 µg/kg) can be an effective adjunct to treatment in severe cases
  • Steroid therapy
    • give prednisolone early in the treatment of acute asthma attacks
    • use a dose of 20 mg prednisolone for children aged 2 to 5 years and a dose of 30–40 mg for children aged >5 years. Those already receiving maintenance steroid tablets should receive 2 mg/kg prednisolone up to a maximum dose of 60 mg
    • repeat the dose of prednisolone in children who vomit and consider IV steroids
    • treatment for up to three days is usually sufficient, but tailor length of course to the number of days necessary to bring about recovery
  • Other therapies
    • if symptoms are refractory to initial β2-agonist treatment, add ipratropium bromide (250 µg/dose mixed with the nebulised β2-agonist solution)
    • repeated doses of ipratropium bromide should be given early to treat children poorly responsive to β2-agonists
    • aminophylline is not recommended in children with mild to moderate acute asthma
    • consider aminophylline in a high dependency unit or pediatric intensive care unit setting for children with severe or life threatening bronchospasm unresponsive to maximal doses of bronchodilators plus steroids
    • do not give antibiotics routinely in the management of acute childhood asthma

  Management of acute asthma in children aged under 2 years

  • The assessment of acute asthma in early childhood can be difficult
  • Intermittent wheezing attacks are usually due to viral infection and the response to asthma medication is inconsistent
  • The differential diagnosis of symptoms includes:
    • aspiration pneumonitis
    • pneumonia
    • bronchiolitis
    • tracheomalacia
    • complications of underlying conditions such as congenital anomalies and cystic fibrosis
  • Prematurity and low birth weight are risk factors for recurrent wheezing

  Treatment of acute asthma

  • β2-agonist bronchodilators:
    • oral β2-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
  • Steroid therapy:
    • 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 three days) is the preferred preparation for use in this age group
    • consider inhaled ipratropium bromide in combination with an inhaled β2-agonist for more severe symptoms

full guidelines available from…
Scottish Intercollegiate Guidelines Network, Elliott House, 8–10 Hillside Crescent, Edinburgh EH7 5EA Tel – 0131 623 4720 ) http://www.sign.ac.uk/guidelines/fulltext/101/index.html
The British Thoracic Society, 17 Doughty Street, London EC1N 2PL (Tel – 020 7831 8778)
http://www.brit-thoracic.org.uk/

British Thoracic Society, Scottish Intercollegiate Guideline Network. British guideline on the management of asthma: a national clinical guideline. 4th ed. Edinburgh: SIGN; 2011. (SIGN Guideline No. 101).