Training of Inhalation Therapy

& Pediatric Asthma Management

Module 6

Acute Asthma
Management
Departemen IKA FKUI-RSCM
UKK Respirologi PP IDAI

Prof. Dr. Mardjanis Said, Sp.A(K)

Born: Payakumbuh, 1 September 1945
Education:
1. Faculty medicine, University Indonesia, 1970
2. Medical Post Graduate (Pediatrics), Faculty of
Medicine Universitas Indonesia, 1976
3. Pediatric Pulmonology Subspecialty, Faculty of
Indonesia 1987
Recent position :

Staff member of Division of Respirology

Lecturer on Pediatric Pulmonology and
Respirology,Dept of Child Health, Faculty of
Medicine University of Indonesia
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Asthma, 2 aspects
Asthma : chronic respiratory disease that
can have acute attack (two in one
disease)

Chronic Asma

Asthma
Acute Asthma

Classification of pediatric asthma

Chronic asthma

Acute asthma

1. Infrequent
episodic asthma
2. Frequent
episodic asthma

1. Mild attack
2. Moderate
attack
3. Severe attack

3. Persistent
asthma

Asthma managements
Chronic asthma
Long term
management
Algorithm diagnosis
& treatment

Acute asthma
Attack
management
Algorithm attack
management

Asthma managements
Chronic asthma
Long term
management
Reliever &
Controller

Acute asthma
Attack
management
Reliever

Asthma medication
Controller
drug to control
asthma ie attack
or symptom not
easily emerge
Inhaled steroid
LABA, ALTR

Reliever
drug to relieve
asthma attack
or symptoms
-agonist
Xanthine
anticholinergic

Definition
Acute asthma = asthma attack
= asthma excacerbation
Rapid progressive worsening
episode of cough, dyspnea,
wheezing, chest tightness etc

Type of asthma attacks

in Cipto Mangunkusumo hospital
Mild
Moderate
11.7%

3.9%
Severe

84.4%

Asthma
Triggers
Inhalant
house dustmite
Smoke
Food

Failed of
long term
management

Acute attacks

Pathophysiology of acute asthma

triggers
bronchoconstriction, edema, secretion
Airway obstruction

Atelectasis
surfactant

non-uniform
ventilation

Lung
hyperinflation

Ventilation-perfusion
mismatch

Compliance
disturbances

Alveolar hypoventilation

breathing

acidosis
Pulmonary
vasoconstriction

work of

PaCO2
PaO2

Michael Sly. Nelson Textbook, 1996

Respiratory track of healthy children

Triggers
(dust, animal danders, smoke, etc)

Keep on wide, opened

(not hypersensitive,
not easily constricted)

Bronchus

Bronchus

Respiratory track of asthmatic children

triggers
(dust, animal danders, smoke, etc)

no symptoms

very fragile
very sensitive
constrict easily

attack

muscle spasm
wall oedema
hyper secretions
Bronchus

Bronchus

Triggers of asthma
Respiratory infection (viral, mycoplasma)
Exercise
Allergens : - inhaled
- ingested (rare)
Irritants (cigarette smoke, air pollution)
Weather changes
Medications (ASA)
Chemical (tartrazine, sulfites, menosodium
glutamate)
Emotional stress
Gastroesophageal reflux

Symptoms of asthma attack:

Rigorous cough/without stopping

Dyspnea, difficult breathing
Wheezing
Tachypnea, fast breathing
Chest pain
Difficult to speak
Cyanosis

Asthma management principles

1.Avoidance
2.Avoidance
3.Avoidance
4.Drugs
inhalation therapy
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Goal of acute asthma management

Rapid resolution of acute symptoms
To reduce hypoxemia
Normal lung function as soon as
possible
Reevaluation to prevent asthma
attacks
Lenfant C et al, GINA 2002

Acute asthma management

Asthma attack / symptoms present:
First line therapy
-agonist : terbutaline, salbutamol
anticholinergic: ipratropium bromida

Chronic asthma (long term management)

First line therapy
Inhaled steroid
Long-acting beta-2 agonist (LABA)
22

Assessment of severity
Mild

Moderate

Severe

Breathless

Walking
Can lie down

Talking
Infant-softer
Shorter cry
Difficult
feeding
Prefers
sitting

At rest
Infant stops
feeding
Hunched
forward

Talks in

Sentences

Phrases

Words

Alertness

Maybe
agitated

Usually
agitated

Usually
agitated

Respiratory
rate

Increased

Increased

Often
>30x/min

Respiratory
arrest
imminent

Drowsy or
confused

Normal rates of breathing in awake children:

Age

Normal rates

<2 months
2-12 months
1-5 years
6-8 years

<60/min
<50/min
<40/min
<30/min

Accessory
muscles and
suprasternal
retractions

Usually not

Usually

Usually

Paradoxal
thoracoabdominal
movement

Wheeze

Moderate,
often only
end
expiratory

Loud

Usually loud

Absence of
wheeze

Pulse/min

<100

100-200

>120

Bradycardia

Infants
Preschool age
School age
Pulsus
paradoxus

Absent
<10 mmHg

2-12 months <160/min

1-2 years
<120/min
2-8 years
<110/min

Maybe
present
10-25 mmHg

Often present
20-40 mmHg

Absence
suggests

Pulsus
paradoxus

Maybe
present
10-25 mmHg

Often present
20-40 mmHg

PEF after
Over 80%
initial ronchodilator,
%predicted
or %personal
best

Approx. 6080%

<60%
predicted or
personal best
or response
lasts <2 hrs

PaO2 (on air)

Normal
Test not
usually
necessary
<45 mmHg

>60 mmHg

<60 mmHg
possible
cyanosis

>95%

91-95%

and/or
PaCO2

SaO2%

Absent
<10 mmHg

<45 mmHg

>45 mmHg
<90%

Absence
suggests

Acute asthma algorithm

Clinic/ER
Asses attack severity
1st management
nebulitation -agonis 3x, 20 min interval
3rd nebulitation + anticholinergic

Mild attack
(nebulization 1x,
complete response)
persist 1-2 hr:
discharge
symptom reappear:
Moderate attack

Moderate attack
(nebulization 2-3x,
partial response)
give O2

asses: Moderate
ODC
IV line

Severe attack
(nebulization 3x,
no response)
O2 from the start
IV line
asses: Severe hospitalized
CXR

Discharge
give -agonist
(inhaled/oral)
routine drugs
viral infection:
oral steroid
Outpatient clinic in
24-48 hours

One Day Care (ODC)

Oxygen therapy
Oral steroid
Nebulized / 2 hour
Observe 8-12 hours,
if stable discharge
Poor response in 12h,
admission

Admission room
Oxygen therapy
Treat dehydration and
acidosis
Steroid IV / 6-8 hours
Nebulized / 1-2 hours
Initial aminophylline IV,
then maintenance
Nebulized 4-6x
good response per 4-6 h
If stable in 24 hours
discharge
Poor response ICU

Notes:
In severe attack, directly use -agonist + anticholinergic
If nebulizers not available, use adrenalin SC 0.01 ml/kg/times with maximal dose 0.3 ml/times
Oxygen therapy 2-4 l/min should be early treatment in moderate
and severe attack

At home
Known of asthma symptoms
Nebulized 2 agonist
If not available: MDI with/without
spacer or orally
In Indonesia: not popular
Be careful with OTC

Early management

Initial assessment of severity asthma attacks

Nebulized 2-agonist, interval 20 minute
3rd nebulization: anticholinergic agent
Severe attacks: directly with anticholinergic agent
If nebulizer not available:
 MDI with Spacer
 Adrenalin SC

MDI with Spacer Vs Nebulizer

2 agonist: bronchodilator
Mild-moderate attacks
MDI with spacer: as effective as nebulizer

Severe attacks:
Nebulizer is recommended

MDI with spacer vs nebulizer

Take less time

Fewer side effects
More portable
Cheaper
Easier use

2 agonist + ipratropium bromide.

Symptoms score decrease

Lung function better than alone
Hospitalized 
Activity: longer

Mild attacks

Good response post nebulization

Observe: 1-2 hours
Discharge if the response is good
Treat as moderate attacks if symptoms still
remain
Use routine drugs
Out patient clinics

Management of asthma attacks

Mild
Nebulization
Observe 11-2 hours

DISCHARGE
Routine drugs
Outpatient clinic

Moderate

Moderate attacks

Partial response post nebulization

ODC admission
Oxygen therapy
Oral steroid
IV line
Repeated nebulization
Good response: discharge
Poor response: admission

Management of Asthma Attack

MILD
Nebulization
Observe: 1-2 hours

MODERATE

???

DISCHARGE

ODC
Oxygen
Nebulization
IVFD
Oral steroid

SEVERE

Why is not response?

Dehydration
Metabolic acidosis
Atelectasis

Severe attacks

Poor response postnebulization

Oxygen therapy
IV line: rehydration and treat acidosis
Corticosteroids (IV)
Initial Aminophylline (IV), then
maintenance
Repeated nebulization
Chest X-ray
Good response : Discharge
Poor response : Intensive care

Management of asthma attack

MILD
Nebulization
Observe 1-2 hours

DISCHARGE

MODERATE

ODC
Oxygen
Nebulization
IVFD
Oral steroid

SEVERE
O
O2, steroid
Nebulization
Hydration
Aminophylline
Aminophylline
R
ICU
ICU (?)

Others drugs (asthma attacks)

Adrenalin: maximal dose, and b effects

Salbutamol SC: be careful
MgSO4: not significant
Inhaled steroid : high dose (1600 mg)

Asthma attacks
Assess the severity
of attacks
Stable asthma
(No attack)
Assess class of
disease

Infrequent
episodic

Frequent
episodic

Persistent

Educations and AVOIDANCE

Reliever (+)
Controller ((-)

Reliever (+)
Controller (+)

Reliever (+)
Controller (+)

Acute asthma attacks

Nebulization 1-2 x
Good response

-Agonist

Partially response

One Day Care

Discharge
Bronchodilator

Good response
Discharge

Oxygen
Nebulization
Oral steroid
IVFD

Poor response

Hospitalization
Oxygen
Nebulization
IVFD: rehydration
Systemic steroid
Aminophylline

Oxygen therapy
Reduce hypoxemia
To achieve saturation > 95%
Should be titrated according to oximetry

Inhalation therapy
2 agonist and ipratropium bromide Vs
2 agonist alone:
Hospitalization 
Symptoms score 
Lung function 
Duration of action: 

Mucolytics: worsen
Schuh et al. J Pediatr 1995; 126:639-45.

IVFD
Replacement therapy for dehydration
Intake  because dyspnea
Vomiting

Treat acid-base and electrolyte imbalance

Parenteral medications

Steroids
Intravenous or oral
Anti-inflammations
Inhaled steroids: controversial

Aminophylline
Initial: 6-8 mg/kgBW IV in 10-20
minute
Maintenance dose 0.5 - 1
mg/kgBW/hour
Monitoring: aminophylline serum level
Narrow safety margin

National guidelines for childhood asthma, 2004

Other drugs
Adrenalin: maximal dose !!!, and effects
Salbutamol SC: be careful
MgSO4: not significant than salbutamol
Inhaled Steroid : high dose (1600-2000
mg)
LABA: Nocturnal asthma, EIA
Antibiotics: Not necessary except sinusitis

Lenfant C et al, GINA 2002

Inhaled steroid
 Controversial (limited literature)
 High dose (1600-2000 mg)
 Reduced asthma attacks
 Not effective in severe attacks
 Alternative therapy

Management of acute asthma

MILD
Nebulization
Observe 1-2 hours

DISCHARGE

MODERATE

ODC
Oxygen
Nebulization
IVFD
Oral steroid

SEVERE
O2, steroid
Nebulization
Hydration
Aminophylline
R
ICU (?)

Severe acute asthma

No response after initial serial nebulization
Oxygen
IV line: dehydration and acidosis
Systemic steroid: oral or IV
Frequent nebulization
Aminophylline IV drip: initial +
maintenance
Chest X ray

Non responsive
Dehydration:
inadequate intake, the longer the more
evaluate: clinically, laboratory;
overcome

Acidosis: correction
Atelectasis & mucus plug:
CXR mandatory; physiotherapy

Monitoring
Vital sign: consciousness, RR, HR,
temperature
Cyanosis, retraction, wheezing
Hydration state and acid base, electrolite
Complication: pneumothorax, atelectasis,
encephalopathy

Nonresponsive
Excessive use of -agonist  down
regulation of -agonist receptors 
tachyphylaxis, subsensitivity
Systemic steroid
reduce the edema
up regulates  more -agonist
receptors  sensitive again to agonist drugs

Conclusion

Asthma labelling
Acute asthma: mild, moderate, and severe
Avoidance is a very important prevention
Initial management is important to prevent
mortality
Nebulisation in severe acute asthma:
agonist + ipratropium bromida

Pedoman Nasional Asma Anak

Thanks for
your attention
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