(C) Managing a Child Under 5yr.

:
Step 1: Mild Intermittent Asthma  Short-acting Beta 2 Agonist to all children for rapid relief PRN

Step 2: Regular Preventive Therapy

- Add ICS (Beclomethasone 200-400mcg/d) OR Leukotriene Receptor Antagonist (Montelukast)

Indications for ICS:

1. Having symptoms 3x weekly or more
2. Awaking 1x night/weekly or more
3. An exacerbation in the last 2 yrs
4. SBA 3x/wk or more

Note: If ICS is not tolerated or contraindicated, start a leukotriene receptor antagonist at Step 2

Step 3: If still symptomatic while using regular ICS consider:

a) <2 = move to stage 4
b) 2-5 = add a trial of leukotriene receptor antagonist; if still uncontrolled move to step 4

Step 4: Refer to pediatrician with knowledge about resp diseases

(D) Managing a Child 5-12 yrs.:

Step 1: Mild Intermittent Asthma  Short-acting Beta 2 Agonist to all children for rapid relief PRN

Step 2: Regular Preventive Therapy

- Add ICS (Beclomethasone 200-400mcg/d) OR Leukotriene Receptor Antagonist (Montelukast)

Indications for ICS:

1. Having symptoms 3x weekly or more
2. Awaking 1x night/weekly or more
3. An exacerbation in the last 2 yrs
4. SBA 3x/wk or more

Note: If ICS is not tolerated or contraindicated, start a leukotriene receptor antagonist at Step 2

Step 3: ADD on therapy

- If still symptomatic while using regular ICS consider: ADD LABA (not in under 5)
- ADD LABA (long acting beta2 agonist) if uncontrolled when using an ICS at 400micrograms/d

LABA:
1. if child has a good response to LABA + ICS, continue
2. If child has a good response with LABA, but still uncontrolled increase the ICS dose to maximum
3. If child doesn’t respond to LABA, stop LABA & start a leukotriene receptor antagonist or a modified
release theophylline

Step 4: Persistent Poor Control Consider increasing the ICS to the maximum recommmeded daily dose
(equivalent to Beclomethasone 800mcg/d)

Step 5: refer to pediatrician with knowledge in resp medicine

Or Continuous / Frequent Use of Oral Steriods

- use daily steroid tablet in lowest dose for adequate control temporarily
- but need to refer
IV. Management of Acute Exacerbations of Asthma:
(A) Assessment of Acute Asthma:
1. Ask about trigger factors ie.: recent URTI
2. Type + duration of symptoms
3. What tx. started & whether the tx. improved the symptoms
4. Assess severity of exacerbation
a) RR
b) O2 sat
c) BP
d) Pulse
- an increased HR = indicates worsening asthma
- a fall of HR = preterminal event

5. Signs of exhaustion:
a) quiet child
b) inability to complete sentences + cyanosis
6. Signs of resp distress:
a) use of accessory muscles
b) intercostal recession, subcostal recession
c) tracheal tug
7. Listen for wheeze which may become biphasic or less apparent with increasing airways obstruction
8. Note degree of agitation: some children in severe asthma = become quiet + don’t appear distressed
9. Examine child’s chest
a) listen for air entry
b) wheeze inspiratory / expiratory (mostly)
c) crepitations
d) silent chest = lifethreatening asthma

10. Record Peak Expiratory Flow (if child is old enough to comply) & use the best of 3 recordings to
grade severity of the attack on the basis of best predicted value

a) Moderate >50-70% = don’t admit

b) Acute severe 33-50%, SPO2 <92%
- can’t complete sentences in 1 breath or too breathless to talk or feed
- pulse >125 (5yrs old) or >140 (2-5yrs)
- breath >30 (>5 yrs) or >40 (2-5yrs)
- admit
c) Acute Life-threatening <33% + O2 sat <92%  Hypotension, exhaustion, confusion, coma, silent chest,
cyanosis, poor resp effect
- admit to hospital

(B) Managing the child who does need hospital admission:

1. Beta-2 agonist= first line tx. (increase dose by 2 puffs every 2 min according to response upto 10
puffs). May use nebulizer
2. High flow O2 if saturation <94%
3. Prednisolone early (20mg for children 2-5yrs; 30-40mg for children >5yrs)
4. Ipratropium Bromide if symptoms are refractory to Beta2 agonist (250mcg/dose mixed with
nebulized beta-2 agonist)
5. Admit Acute severe 33-50% or Acute life threatening (33%)

Management of Acute Asthma Attack in Management of Acute Asthma Attack in < 2

Children >2yrs:
1. Steroid therapy: Prednisolone given early
in tx. of acute asthma attack
- 20mg (2-5yrs) or 30-40 (>5yrs)
- those already receiving maintenance
steroid tablets shoulde receive 2mg/kg
yrs:
- assessment of acute asthma in early
childhood = difficult
- intermittent wheezing attacks = can be
viral infections + the response to
asthma medication can be inconsistent
 prednisolone upto a maximum dose of
60mg Ddx.:
- repeat prednisolone dose in children who
vomit or consider IV steroids
- tx. upto 3 days
2. If symptoms are refractory to initial beta-2
agonist, add ipratropium bromide (250mcg
mixed dose with nebulized beta2 agonist
solution)
3. Repeat doses of ipratropium bromide to tx.
children who respond poorly to beta-2 Tx.:
agonists
4. Antibiotics = If bacterial infection too
5. Aminophylline = LAST RESORT
NOTE:
- Aminophylline = not recommended in
children with mild to moderate acute
asthma
- Consider Aminophylline if in PICU in severe
cases of life threatening bronchospasm
unresponsive to maximal dose of
broncodilators plus steroids
1. aspiration pneumonia
2. pneumonia
3. bronchiolitis
4. tracheomalacia
5. complications of underlying conditions
ie.: congenital anomalies or CF
6. prematurity / LBW = recurrent
wheezing
1. Inhaled Beta-2 agonist bronchiodilators
- note: oral beta-2 agonists not for
children
- add spacer
2. Steroid therapy
- mod to severe asthma in hosp = steroid
tablets (10mg soluble prednisolone for
3d)
3. Consider inhaled ipratropium
bromide in combination with an inhaled
beta-2 agonist for more severe symptoms

(C) Managing Moderate Asthma Attacks that Don’t Warrant Admission:

1. Short course of oral prednisolone (check child’s weight) Dose 1-2mg/kg
2. Give antibiotics only if signs /symptoms of an overlying bacterial infection
3. Advise parent to use SBA via a large volume spacer
4. Give 2 puffs every 2 min according to response upto 10 puffs
5. Each puff should be given 1 at a time and inhaled with 5 tidal breaths
6. Repeat every 10-20min according to clinical response
7. After 10 puffs have been used: return to SBA prn upto 4x/d (not exceeding 4- hrly use) + monitor
PEFR + symptoms (if PEFR decreases + symptoms worsen = seek medical advice)

(D) Follow-up of Acute Exacerbations: 1 wk post attack

1. Assess exacerbation
-duration + severity of exacerbation compared with any previous episodes
- no. of exacerbations + hospital admissions
- triggers: exercise, work, allergens

2. Optimize tx.:
- compliance, review inhaler technique (correcting problems)
- advice on lifestyle, vaccinations, diet, exercise, child or parental smoking
- stepping up tx. by increasing ICS or adding a new preventive therapy

3. Review self-management education + written action plan

- review person’s understanding of how to recognize + management early exacerbation
(increase beta-2 agonist + start oral steroids)
- reinforce understanding by updating the written action plan