APPROACH TO A

CHILD WITH
CHILDHOOD ASTHMA
MODERATOR: DR. DHULIKA DHINGRA
PRESENTOR: DR. A.PRAMILA
 Asthma is a common chronic disease that can be controlled but
not cured
 Asthma causes symptoms such as wheezing, shortness of breath,
chest tightness and cough that vary over time in their occurrence,
frequency and intensity
 Symptoms are associated with variable expiratory airflow,
i.e. difficulty breathing air out of the lungs due to
 Bronchoconstriction (airway narrowing)
 Airway wall thickening
 Increased mucus
 Symptoms may be triggered or worsened by factors such as viral
infections, allergens, smoke, exercise and stress
 DIAGNOSIS AND
ASSESSMENT OF
SEVERITY OF ASTHMA

A STEPWISE APPROACH
STEP 1A
SUSPECT ASTHMA IN ALL PATIENTS WITH RECURRENT
AIRFLOW OBSTRUCTION
 RECURRENT WHEEEZE
 RECURRENT ISOLATED COUGH
 RECURRENT BREATHLESSNESS
 NOCTURNAL COUGH
 CHEST TIGHTNESS
 EXEERCISE/ACTIVITY/STRESS INDUCED

RESPONSE TO BRONCHODILATOR- DIAGNOSIS OF ASTHMA LIKELY

STEP1B
SIGNS THAT SUGGEST GENERALISED AIR FLOW
OBSTRUCTION
 Generalised wheeze
 Prolonged expiration
 Chest hyperinflation
TYPICAL FEATURES OF ASTHMA
 Afebrile episodes
 Exercise/ activity/ stress induced
 Seasonality
 Atopy /asthma in parents
 Relief with bronchodilator/ steroids
 Triggers
STEP 2
RULE OUT ALTERNATIVE DIAGNOSIS

 Wet cough/productive cough

 Monophonic wheeze
 Stridor
 Neonatal or early onset symptoms
 Regurgitation
 Clubbing
 Non responsive to bronchodilator therapy
 Persistent unexplained failure to thrive
STEP 3
INVESTIGATIONS
 Complete hemogram
 Chest x-ray
 Serum IgE levels
 Spirometry : low FEV1 and FEV1/FVC(NORMAL:>0.90 in children and
0.75-0.80 in adolescent)
 Excessive variability
 Improvement with bronchodilator
 STEP 4A
 ASSESS THE LEVEL OF CONTROL TO DECIDE INITIAL THERAPY
 Done in children over 5 yrs
 It is assessed in two domains
1. Impairment
2. Risk factors for poor asthma control
 Impairment
A. Characteristics Level of asthma symptom control
Well- Partly Uncontrolled
In the past 4 weeks, has the patient had: controlled controlled

• Daytime asthma symptoms more

than twice a week? Yes No

• Any night waking due to asthma? Yes No

None of 1-2 of 3-4 of
• Reliever needed for symptoms* these these these
more than twice a week? Yes No

• Any activity limitation due to asthma? Yes

No
Risk factors for poor asthma control
(it is assessed at diagnosis and
periodically)
MODIFIABLE UNCONTROLLED ASTHMA SYMPTOMS
• INADEQUATE ICS﴾ not prescribed, poor adherance,
incorrect technique﴿
• LOW FEV -1
• CO-MORBIDITIES: obesity, rhino-sinusities,
confirmed food allergy
• EXPOSURES :smoking,allergen exposures if
sensitized.
• Sputum or blood eosinophlia

NON MODIFIABLE Ever intubated or picu admission

> 1 severe exacerbation in the last 12 months
STEP 4B
GRADING SEVERITY OF DISEASE

CONTROL ACHIEVED AT STEP GRADING OF ASTHMA

STEP 1 INTERMITTENT ASTHMA

STEP2 MILD ASTHMA

STEP3 MODERATE ASTHMA

STEP4 SEVERE ASTHMA

UNDER 5 WHEEZER
(recurrent wheezer i.e. 3 or more episodes)

 EPISODIC VIRAL WHEEZE: Discrete episodes of wheez with clinical evidence

of viral respiratory tract infections
They have anatomically smaller airways
Each infections causes inflamed hyperactive
airways
Improves with age
 MULTI – TRIGGER WHEEZE: in addition to viral infections some children wheez
in response to triggers like cold air, laugh ,exercise.
These group is previously called as WALRI or early
onset asthma
 ATYPICAL WHEEZE
 CAUSES OF ATYPICAL WHEEZ
Condition
 Gastroesophageal reflux
 Foreign body aspiration
 Tracheomalacia or bronchomalacia
 Tuberculosis
 Congenital heart disease
Typical features
Cough when feeding; recurrent chest infections; vomits
easily especially after large feeds; poor response to
asthma medications
Episode of abrupt severe cough and/or stridor during
eating or play; recurrent chest infections and cough;
focal lung signs
Noisy breathing when crying or eating, or during URTIs;
harsh cough; inspiratory or expiratory retraction;
symptoms often present since birth; poor response to
asthma treatment
Persistent noisy respirations and cough; fever
unresponsive to normal antibiotics; enlarged lymph
nodes; poor response to ICS; contact with someone with TB
Cardiac murmur; cyanosis when eating; failure to thrive;
tachycardia; tachypnea or hepatomegaly; poor response
to asthma medications
 Cystic fibrosis
 Primary ciliary dyskinesia
 Vascular ring
 Bronchopulmonary dysplasia
 Immune deficiency
failure to thrive
Cough starting shortly after birth; recurrent chest
infections; failure to thrive (malabsorption); loose
greasy bulky stools
Cough and recurrent mild chest infections;
chronic ear infections and purulent nasal
discharge; poor response to asthma
medications; situs inversus (in ~50% children with
this condition)
Respirations often persistently noisy; poor
response to asthma medications
Infant born prematurely; very low birth weight;
needed prolonged mechanical ventilation or
supplemental oxygen; difficulty with breathing present
from birth
Recurrent fever and infections (including non-respiratory);
 The probability of asthma in under five wheezer is higher in the
presence of one or more of the following
1. Duration of each episode lasts for >10 days
2. Symptomatic between episodes
3. Activity or exercise induced
4. Personal history of atopy
5. Family history of asthma
GOALS OF LONG TERM
MANAGEMENT
 AIM FOR
• FREEDOM FROM
NOCTURNAL COUGH,
ACUTE ATTACKS AND EMERGENCY DOCTOR/HOSPITAL VISITS
FREQUENT SCHOOL ABSENTEEISM
ADVERSE DRUG EFFECTS
• NORMAL
DAILY ACTIVITIES AND SPORTS PARTICIPATION,
GROWTH CHARTS
PULMONARY FUNCTION TESTS
 TOWARDS REACHING THESE GOALS
• PATIENT EDUCATION
• PHARMACOTHERAPY
• DEALING WITH TRIGGERS/PRECIPITANTS
• ADDRESSING SPECIAL SITUATIONS
• FOLLOW UP
• DEALING WITH POOR ASTHMA CONTROL
 Patient education
 Discuss that asthma is a chronic condition with episodic symptoms
and hence the need for continous controller drugs
 Emphasise the drug controls but not cures
 Differentiate between controller and reliever medication
 Usage and maintain the device
 To deal with triggers/ precipitants
 To maintain dairy of events
 Educate regarding the management of acute exacerabation
 Schedule follow up
 Symptom dairy record

Date Cough Breathlessness Sleep School Drugs

Disturbance Absence

22/2/17 - None - None - Slept well + for school B-100

+ sometimes + yes + Wakes up absence S
++frequent Add suffix E if due to cough
+++most of
the time
Add suffix E if
symptom
trigger on
running/cryin
g/laughing
23/2/17

24/2/17
 Children with wheezing < 5yrsO
(r/o atypical cause)

Episodic viral Unclear

wheezer Multitrigger wheezer phenotype

Infrequent
Frequent
No prophylaxis
Consider Trial of
needed
regular ICS/LRTA KEEP UNDER
Treat
LTRA/ICS FOLLOW UP
symptomatically
Good
No or partial
response in 6
No or partial response
weeks
improveme
nt
Continue for 12 weeks Refer for
Stop medication specialist
Watch for symptoms opinion
Stop medication
re-affirm the
diagnosis If symptoms recurs and responds
Try alternative drugs to same therapy again, manage
as asthma in under five
LONG TERM MANAGEMENT OF A
CHILD WITH ASTHMA
 PHARMACOLOGICAL THERAPY
Reliever therapy
Controller therapy
 Add on therapy
 Non pharmacological therapy
 Management of comorbidities
 RELIEVER DRUGS
Drugs Formulations Dose

Salbutamol MDI 100 mcg/dose 2-4 puffs as needed.can be repeated

thrice at 20 mins and then hourly
DPI Rotacaps 1-2 rotacaps as needed. May be used
200mcg/dose frequently as a rescue for mild asthma
Neb respirator 0.15mg/kg; min of 0.25ml
solution 5mgs/ml <6 mon 0.5ml; >6mon 0.5-1ml
>6yrs 1ml
For cont.nebulization 10mg/10ml saline
Neb respule Use equivalent dose as respirator dose
2.5mg/2.5ml
2.5mg/3ml
Syp.2mg/5ml 0.15mg/kg/dose 3-4 times a day
Tab.2mg,4mg,8mg
Levosalbutamol Neb. Respule 0.075mg/kg/ similar as respirator dose
0.31mg/2.5ml
0.63mg/2.5ml
1.25mg/2.5ml
Terbutataline Neb respirator solution 2-5mgs diluted and nebulised
10mg/ml

Syp.1.5mg/5ml 0.075mg/kg/dose thrice daily

Tab.2.5mg,5mg

Inj. 0.5mg/ml 0.01mg/kg sc once

Bolus 5-10mcg/kg over10 mins
followed by 0.1-10mcg/kg/hr
Terbutaline+50ml 5%dextrose
1ml=10 mcg
Adrenaline Inj. 1mg/ml 0.01mg/kg sc
(1:1000) Can be repeated 3times at 20
mins, only if red flag signs+
Ipratropium MDI 20 mcg/dose 2-4 puff9(80-160mcg)thrice at 20
bromide mins and then 6-8 hryl

DPI rotacaps 40 1-2 rotacaps

mcgs/dose

Neb solution 0.25mg/ml 0.5ml<1yr, 1ml>1yr thrice at 20

Neb respule 0.5mg/2ml mins and then 6-8hrly
Prednisolone Tab. 5mg, 1-2 mg/kg/day for 3-7 days
10 mg,20mg,40mg Max 20mg <2yrs
Spy.5mg/5ml,15mg/5ml 30mg 2-5yrs
40mg >5yrs
Hydrocortisne Inj.100mg/vial 4-5mg/kg6hr

Methyl prednisolone Inj. 40mg, 125mg, 1mg/kg/6hr

500mg, 1g.

Aminophylline Inj. 250mg/10ml Bolus: 5mg/kg in 5%D slow iv

Maintenance:0.5-1mg/kg/hr
Continous infusion in 5%D
Magnesium sulfate 1nj.25%(250mg/ml) 25-50mg/kg in NS over 30 mins
50%(500mg/ml)
Controller drugs
Drugs Formulations Dose

Beclomethasone MDI 100,200mcg/puff 100-400 mcg twice a day

diproprionate DPI Rotacaps 100,200,400 100-400 mcg twice a day
mcg/dose
Budesonide MDI 100,200mcg/dose 100-400 mcg twice a day
DPI Rotacaps 100-400 mcg twice a day
100,200,400mcg/dose
Neb respirator solution Initiating dose
0.5ml/2ml 0.5-1mg twice a day
1mg/2ml Maintenance dose
0.25-0.5mg twice a day
Fluticasone diproprionate MDI 125,250mcg/dose 100-200 mcg twice a day
DPI Rotacaps 100,250,500 50-200 mcg twice a day
mcg/dose
Neb respules 1mg twice a day
0.5mg/2ml
2mg/2ml
Ciclosonide MDI 80/160 mcg/dose 1-2 puff OD
Fluticasone (FP) MDI
Salmeterol(SML)  FP 50 mcg +SML 25mcg/dose
 FP 125mcg+SML 25mcg/dose
 FP 250mcg+SML 25 mcg/dose
DPI Rotacaps
 FP 100mcg+SML 50 mcg/dose
 FP 250mcg+SML 50mcg/dose
 FP 500mcg+SML 50mcg/dose
Budesonide (BUD) MDI
Formeterol(FORM) BUD 100/200/400mcg+
FORM 12mcg/dose
DPI Rotacaps
BUD 100/200/400/mcg+
FORM 12mcg/dose
Montelukast 4mg granules
4mg,5mg dispersible tablets
Tab.10 mg
Theophylline Sustained release anhydrous
Tab/Cap 100, 200,300,450mg
Syp. 50mg/ml
1-2 puff twice a day
1-2 puff twice a day
1-2 puff twice a day
1-2 rotacaps twice a day
1 rotacaps twice a day
1 rotacaps twice a day
1 puff twice a day
1-2 Rotacaps twice a day
6mo-5yrs 4 mg/day
6-14yrs 5 mg/day
>14yrs 10mg/day
>1 yr 10mg/kg
<1 yr 0.2×age in weeks+5
Given in mg/kg
 BUTTHE CRUX OF THE MATTER IS TO
TREAT OR NOT TO TREAT
 PHARMACOLOGY THERAPY
SELECTING OPTIMAL CONTROLLER REGIME
 1. STARTING THERAPY IN TREATMENT NAIVE

PRESENTING SYMPTOMS FIRST CHOICE OTHER OPTIONS

INFREQUENT SYMPTOMS( No long term controller

not falling into medication
uncontrolled or partly
controlled and no risk
factors)
Asthma ( even if frequent Low dose ICS + LABA ( > Low/medium dose ICS
symptoms) with any risk 12 years) or medium dose +LTRAS /SR theophylline
factors for exacerbations ICS ( 6-11 Years)
Symptoms like partly
controlled asthma
Severly uncontroled Medium to high dose ics + SHORT COURSE ORAL
symptoms LABA STEROID AND HIGH DOSE
ICS OR MODERATE DOSE
ICS/ LABA
DRUG DOSAGES FOR VARIOUS STEROIDS

DRUG BUDESONID FLUTICASO CICLESONI

E/ NE DE
BECLOMETH
ASONE
AGE < 12 years >12 years < 12 years >12 years > 12
GROUP years

LOW DOSE 100-200 100-400 100-200 100-250 80-160

(µg/d)
Medium >200-400 >400-800 >200-500 > 250-500 160-320
dose(µg/d)

High dose >400 > 800 > 500 >500 >320

﴾µg/d)
Steps to reduce side effects of ICS

 USE LOW TO MODERATE DOSES OF ICS

 TAPER THE DOSE BY 25-50 % AFTER 3 MONTHS OF GOOD CONTROL
 ASSESS MINIMUM DOSE REQUIRED TO ACHIEVE CONTROL
 ALWAYS USE A SPACER
 RINSE MOUTH AND SPIT AFTER TAKING THE DRUG
 MONITOR GROWTH VELOCITY
SELECTING THE OPTIMAL
CONTROLLER REGIME

2. MANAGEMENT OF CASES WHO ARE ALREADY ON CONTROLLER REGIMES BUT

ARE UNDER REVIEWAND THE FURTHER MANAGEMENT IS GUIDED BY ;
The control-based asthma management cycle

Diagnosis
Symptom control & risk factors
(including lung function)
Inhaler technique & adherence
Symptoms Patient preference
Exacerbations
Side-effects
Patient
satisfaction
Lung function Asthma medications
Non-pharmacological strategies
Treat modifiable risk factors
Drug delivery devices
Initiating inhaled therapy
select the appropriate device
MDI, SPACERS
SPACERS+ MASK
DPI- ROTAHALER
NEBULISER
Drug delivery- Inhaled Route

Inhalation device Proportion of drug Proportion of

deposited in the airway orophayrngeal
deposition
MDI with spacer 10-15% < 10%

MDI 5-10% 40-60%

DPI 5-10% 40-70%

NEBULISER 1-5% 50%

OR MORE
Non pharmacological intervention
 ALLERGENS
 IRRITANTS
 PRECIPITANTS
 DRUGS
 DIET
Addressing co-morbid conditions
and concurrent medical conditions
 ALLERGIC RHINOSINUSITIS
 GERD
 SEASONAL ASTHMA
 SURGERY
FOLLOW UP

 Call for the first follow up 1-2 weeks after initiating therapy to check
understanding of the prescription and inhalation technique
 On review visit, review regime prescribed and diary of events since
the past visit. Enquire about bronchodilator usage, school
absenteeism, limitation of activity and sleep disturbance
 Assess if symptoms and signs of asthma are present at the time of
the visit and monitor weight and height
 Check for adverse effects
 Reemphasise the need for continued adherance and clarify doubts
 Assess whether goals of treatment have been achieved
FOLLOW UP
ISSUES THAT CAN BE CORRECTED IN POOR
ASTHMA CONTROL
MANAGING ACUTE EPISODES
ASSESSING SEVERITY
 HISTORY
 Timing of onset and cause
 Severity
 Current medication including doses and devices, response to therapy and
adherence
 PHYSICAL EXAMINATION
 Vital signs, level of consciousness, use of accessory muscle, wheezing
 Complicating factors like pneumonia
 Other causes of breathlessness like CCF, inhaled foreign body,upper airway
dysfunction
 OBJECTIVE MEASUREMENTS
 Pulse oximetry saturation
 Pulmonary index scoring
 Risk of severe exaberations
 IDENTIFY RISK FACTORS
 Previous exacerabations
1. Chronic steroid dependant asthma
2. Prior picu admissions
3. Poor adherence
 Current exacerabations
1. Rapid onset and progression of symptoms
2. Frequent OPD visit in preceding days
3. Visit to ER in 48 hrs
RED FLAG SIGNS TO WATCH OUT
FOR
 ALTERED SENSORIUM
 BRADYCARDIA
 POOR PULSE VOLUME
 CYANOSIS
 EXCESSIVE USE OF ACCESSORY MUSCLES
 VOCALISATION LIMITED TO 1-2 WORDS
 SILENT CHEST ON AUSCULTATION
 SpO2 < 92 %
If red flag signs are absent, grade
the severity based on pulmonary
score
Management
MILD(PS 0-3) SABA
HOME PLAN MDI+SPACER+/-MASK
2-4PUFFS q 20mins for 3
times

Not sustained for

Sustained 4-6 hrs 4-6hrs
Risk factor present

First dose rescue

oral steroid(1 mg
/kg)
Early doctor visit
MODERATE (PS4-6)
EMERGENCY ROOM PLAN
OXYGEN
SABA neb q20mins×3times
Or
SABA MDI+ SPACER±MASK 2 puffs q2-
3min till 4-6 puffs,
Repeat every 20 mins×3 times
Commence rescue steroids
Observe hourly for 3-4hours
SABA nebq1 hrly for 3-4 hrs
Adrenaline
0.01ml/kg sc
Sustained 4-6 hrs q20 mins×3 doses
Reduce SABA q4-6hrs Terbutaline
0.01ml/kg sc
1 dose
DISCHARGE PLAN
 SEVERE(PS>6)
 WARD AND INTENSIFIED WARD PLAN
Start oxygen, IV fluids
IV steroids
Continue SABA q1 hr
Start ipratropium
nebulisationq30mins×3 and then q6hr
for 24 hrs
Monitor spo2,PS, vitals for q15-30min
Observe 1-2 hrs
Discharge plan
Continue SABAq1hr
Magnesium sulfate IV infusion
for 30 mins
Terbutaline iv infusion
Discontinue nebs at higher rate or
toxicity develops
Aminophylline continuous infusion
Monitor potassium
CXR,CBC,ABG
Sustained 4-6 hrs
FED FLAG SIGN
 ICU PLAN

Continue intensified ward plan

Blood gas analysis
A trial of NIV
Possible intubation and mechanical
ventilation with midazolam/fentanyl
infusion
Paralysis with vecuronium if neded

Step down as in
ward plan

Discharge plan
Practices not routinely
recommended
 ANTIBIOTICS
 MUCOLYTICS
 SEDATIVES
 CHEST PHYSIOTHERAPY
Stepping down acute care

 Follow the principle: Last in first out

 Discontinue ipratropium nebulisation within 24 hours

 Reduce short acting BA FIRST 2-4 HOURLY THEN 4-6 HOURLY

 Replace IV steroid with oral steroidFOR 3-7 DAYS(without tapering)

DISCHARGE CRITERIA

 Pulmonary Score less than 3

 Slept well at night
 Eating well
 Appears comfortable
 Not on any continous infusion and receiving less frequent
nebulisations
 Send home with asthma action plan and review of control with
current step of therapy