Diagnosis and management of asthma
PART C. MANAGEMENT OF WORSENING ASTHMA AND EXACERBATIONS IN CHILDREN 5 YEARS AND YOUNGER
KEY POINTS
• Early symptoms of exacerbations in young children may include increased symptoms; increased coughing, especially at night; lethargy or reduced exercise tolerance; impaired daily activities including feeding; and a poor response to reliever medication.
• Give a written asthma action plan to parents/carers of young children with asthma so they can recognize a severe attack, start treatment, and identify when urgent hospital treatment is required.
o Initial treatment at home is with inhaled short-acting beta2-agonist (SABA), with review after 1 hour or earlier.
o Parents/carers should seek urgent medical care if the child is acutely distressed, lethargic, fails to respond to initial bronchodilator therapy, or is worsening, especially in children <1 year of age.
o Medical attention should be sought on the same day if inhaled SABA is needed more often than 3-hourly or for more than 24 hours.
o There is only weak evidence to support parent-initiated oral corticosteroids.
• In children presenting to primary care or an acute care facility with an asthma exacerbation:
o Assess severity of the exacerbation while initiating treatment with SABA (2–6 puffs every 20 minutes for first hour) and oxygen (to maintain saturation 94–98%).
o Recommend immediate transfer to hospital if there is no response to inhaled SABA within 1–2 hours; if the child is unable to speak or drink or has subcostal retractions or cyanosis; if resources are lacking in the home;
or if oxygen saturation is <92% on room air.
o Give oral prednisone/prednisolone 1–2 mg/kg/day for up to 5 days, up to a maximum of 20 mg/day for 0–2 years, and 30 mg/day for 3–5 years.
• Children who have experienced an asthma exacerbation are at risk of further exacerbations. Follow up should be arranged within 1 week of an exacerbation to plan ongoing asthma management.
DIAGNOSIS OF EXACERBATIONS
A flare-up or exacerbation of asthma in children 5 years and younger is defined as an acute or sub-acute deterioration in symptom control that is sufficient to cause distress or risk to health, and necessitates a visit to a health care provider or requires treatment with systemic corticosteroids. They are sometimes called ‘episodes’.
Early symptoms of an exacerbation may include any of the following:
• An acute or sub-acute increase in wheeze and shortness of breath
• An increase in coughing, especially while the child is asleep
• Lethargy or reduced exercise tolerance
• Impairment of daily activities, including feeding
• A poor response to reliever medication.
In a study of children aged 2–5 years, the combination of increased daytime cough, daytime wheeze, and night-time beta2-agonist use was a strong predictor at a group level of an imminent exacerbation (1 day later). This combination predicted around 70% of exacerbations, with a low false positive rate of 14%. In contrast, no individual symptom was predictive of an imminent asthma exacerbation.472
Upper respiratory symptoms frequently precede the onset of an asthma exacerbation, indicating the important role of viral URTI in precipitating exacerbations in many, although not all, children with asthma.
INITIAL HOME MANAGEMENT OF ASTHMA EXACERBATIONS
Initial management includes an action plan to enable the child’s family members and carers to recognize worsening asthma and initiate treatment, recognize when it is severe, identify when urgent hospital treatment is necessary, and provide recommendations for follow up (Evidence D). The action plan should include specific information about medications and dosages and when and how to access medical care.
Need for urgent medical attention
Parents/carers should know that immediate medical attention should be sought if:
• The child is acutely distressed
• The child’s symptoms are not relieved promptly by inhaled bronchodilator
• The period of relief after doses of SABA becomes progressively shorter
• A child younger than 1 year requires repeated inhaled SABA over several hours.
Initial treatment at home
Inhaled SABA via a mask or spacer, and review response
The parent/carer should initiate treatment with two puffs of inhaled SABA (200 mcg salbutamol or equivalent), given one puff at a time via a spacer device with or without a facemask (Evidence D). This may be repeated a further two times at 20 minute intervals, if needed. The child should be observed by the family/carer and, if improving, maintained in a restful and reassuring atmosphere for an hour or more. Medical attention should be sought urgently if any of the features listed above apply; or on the same day if more than 6 puffs of inhaled SABA are required for symptom relief within the first 2 hours, or if the child has not recovered after 24 hours.
Family/carer-initiated corticosteroids
Although practiced in some parts of the world, the evidence to support the initiation of oral corticosteroid (OCS) treatment by family/carers in the home management of asthma exacerbations in children is weak.473-477 Because of the high potential for side-effects, especially if the treatment is continued inappropriately or is given frequently, family-administered OCS or high dose ICS should be considered only where the health care provider is confident that the medications will be used appropriately, and the child is closely monitored for side-effects (see p.116. Emergency treatment and initial pharmacotherapy).
Leukotriene receptor antagonists
In children aged 2–5 years with intermittent viral wheezing, one study found that a short course of an oral LTRA (for 7–
20 days, commenced at the start of an URTI or the first sign of asthma symptoms) reduced symptoms, health care utilization and time off work for the carer.478 In contrast another study found no significant effect on episode-free days (primary outcome), OCS use, health care utilization, quality of life or hospitalization in children with or without a positive Asthma Predictive Index (API). However, activity limitation and a symptom trouble score were significantly improved, particularly in children with a positive API.479
Box 6-8. Primary care management of acute asthma or wheezing in children 5 years and younger
PRIMARY CARE OR HOSPITAL MANAGEMENT OF ACUTE ASTHMA EXACERBATIONS