1. 1 Paediatric asthma The British Thoracic Society Scottish Intercollegiate Guidelines Network Thorax 2003; 58 (Suppl I): i1-i92

2. 2 Diagnosis of asthma in children Thorax 2003; 58 (Suppl I): i1-i92 Suspect asthma in any child with wheezing on auscultation (distinguished from upper airway noises) D Base the diagnosis of asthma in children on: presence of key features and alternative diagnoses presence of key features and alternative diagnoses response to trials of treatment with ongoing assessment response to trials of treatment with ongoing assessment question the diagnosis if management is ineffective question the diagnosis if management is ineffective  Record the criteria on which the diagnosis has been made

3. 3 Diagnosis of asthma in children Thorax 2003; 58 (Suppl I): i1-i92 Presenting features wheeze wheeze dry cough dry cough breathlessness breathlessness noisy breathing noisy breathing

4. 4 Clues to alternative diagnoses in wheezy children Thorax 2003; 58 (Suppl I): i1-i92 Clinical clue Possible diagnosis Perinatal and family history symptoms present from birth or perinatal lung problem symptoms present from birth or perinatal lung problem family history of unusual chest disease family history of unusual chest disease severe upper respiratory tract disease severe upper respiratory tract disease cystic fibrosis; chronic lung disease; ciliary dyskinesia; developmental anomaly cystic fibrosis; chronic lung disease; ciliary dyskinesia; developmental anomaly cystic fibrosis; developmental anomaly; neuromuscular disorder cystic fibrosis; developmental anomaly; neuromuscular disorder defect of host defence defect of host defence

5. 5 Clues to alternative diagnoses in wheezy children Thorax 2003; 58 (Suppl I): i1-i92 Clinical clue Possible diagnosis Perinatal and family history symptoms present from birth or perinatal lung problem family history of unusual chest disease severe upper respiratory tract disease cystic fibrosis; chronic lung disease; ciliary dyskinesia; developmental anomaly cystic fibrosis; developmental anomaly; neuromuscular disorder defect of host defence Symptoms and signs persistent wet cough persistent wet cough excessive vomiting or posseting excessive vomiting or posseting dysphagia dysphagia abnormal voice or cry abnormal voice or cry focal signs in the chest focal signs in the chest inspiratory stridor as well as wheeze inspiratory stridor as well as wheeze failure to thrive failure to thrive cystic fibrosis; recurrent aspiration; host defence disorder cystic fibrosis; recurrent aspiration; host defence disorder reflux (  aspiration) reflux (  aspiration) swallowing problems (  aspiration) swallowing problems (  aspiration) laryngeal problem laryngeal problem developmental disease; postviral syndrome; bronchiectasis; tuberculosis developmental disease; postviral syndrome; bronchiectasis; tuberculosis central airway or laryngeal disorder central airway or laryngeal disorder cystic fibrosis; host defence defect; gastro-oesophageal reflux cystic fibrosis; host defence defect; gastro-oesophageal reflux

6. 6 Clues to alternative diagnoses in wheezy children Thorax 2003; 58 (Suppl I): i1-i92 Clinical clue Possible diagnosis Perinatal and family history symptoms present from birth or perinatal lung problem family history of unusual chest disease severe upper respiratory tract disease cystic fibrosis; chronic lung disease; ciliary dyskinesia; developmental anomaly cystic fibrosis; developmental anomaly; neuromuscular disorder defect of host defence Symptoms and signs persistent wet cough excessive vomiting or posseting dysphagia abnormal voice or cry focal signs in the chest inspiratory stridor as well as wheeze failure to thrive cystic fibrosis; recurrent aspiration; host defence disorder reflux (  aspiration) swallowing problems (  aspiration) laryngeal problem developmental disease; postviral syndrome; bronchiectasis; tuberculosis central airway or laryngeal disorder cystic fibrosis; host defence defect; gastro-oesophageal reflux Investigations focal or persistent radiological changes focal or persistent radiological changes developmental disorder; postinfective disorder; recurrent aspiration; inhaled foreign body; bronchiectasis; tuberculosis developmental disorder; postinfective disorder; recurrent aspiration; inhaled foreign body; bronchiectasis; tuberculosis

7. 7 Indications for referral of children with suspected asthma Thorax 2003; 58 (Suppl I): i1-i92 Diagnosis unclear or in doubt Symptoms present from birth or perinatal lung problem Excessive vomiting or posseting Severe upper respiratory tract infection Persistent wet cough Family history of unusual chest disease Failure to thrive Unexpected clinical findings e.g. focal signs in the chest, abnormal voice or cry, dysphagia, inspiratory stridor Failure to respond to conventional treatment (particularly inhaled corticosteroids above 400mcg/day or frequent use of steroid tablets) Parental anxiety or need for reassurance

8. 8 Stepwise management of asthma in children aged 5-12 years Thorax 2003; 58 (Suppl I): i1-i92 Step 1: Mild intermittent asthma Inhaled short acting ß 2 agonist as required

9. 9 Stepwise management of asthma in children aged 5-12 years Thorax 2003; 58 (Suppl I): i1-i92 Step 2: Regular preventer therapy Add inhaled steroid 200-400mcg/day * (other preventer drug if inhaled steroid cannot be used) 200mcg is an appropriate starting dose for many patients Step 1: Mild intermittent asthma Start at dose of inhaled steroid appropriate to severity of disease. * BDP or equivalent

10. 10 Stepwise management of asthma in children aged 5-12 years Thorax 2003; 58 (Suppl I): i1-i92 Step 3: Add-on therapy 1. Add inhaled long-acting ß 2 agonist (LABA) 2. Assess control of asthma: good response to LABA – continue LABA. good response to LABA – continue LABA. benefit from LABA but control still inadequate – continue LABA and increase inhaled steroid dose to 400mcg/day * (if not already on this dose). benefit from LABA but control still inadequate – continue LABA and increase inhaled steroid dose to 400mcg/day * (if not already on this dose). no response to LABA – stop LABA and increase inhaled steroid to 400mcg/day *. If control still inadequate, institute trial of other therapies (e.g. leukotriene receptor antagonist or SR theophylline). no response to LABA – stop LABA and increase inhaled steroid to 400mcg/day *. If control still inadequate, institute trial of other therapies (e.g. leukotriene receptor antagonist or SR theophylline). Step 1: Mild intermittent asthma Step 2: Regular preventer therapy Start at dose of inhaled steroid appropriate to severity of disease. * BDP or equivalent

11. 11 Stepwise management of asthma in children aged 5-12 years Thorax 2003; 58 (Suppl I): i1-i92 Step 4: Persistent poor control Increase inhaled steroid up to 800mcg/day * Step 1: Mild intermittent asthma Step 3: Add-on therapy Step 2: Regular preventer therapy Start at dose of inhaled steroid appropriate to severity of disease. * BDP or equivalent

12. 12 Stepwise management of asthma in children aged 5-12 years Thorax 2003; 58 (Suppl I): i1-i92 Step 5: Continuous or frequent use of oral steroids Use daily steroid tablet in lowest dose providing adequate control Maintain high dose inhaled steroid at 800mcg/day * Refer patient to respiratory paediatrician Step 1: Mild intermittent asthma Step 3: Add-on therapy Step 2: Regular preventer therapy Start at dose of inhaled steroid appropriate to severity of disease. * BDP or equivalent Step 4: Persistent poor control

13. 13 Stepwise management of asthma in children aged 5-12 years Thorax 2003; 58 (Suppl I): i1-i92 Step 1: Mild intermittent asthma Step 5: Continuous or frequent use of oral steroids Step 4: Persistent poor control Step 3: Add-on therapy Step 2: Regular preventer therapy

14. 14 Stepwise management of asthma in children under 5 years Thorax 2003; 58 (Suppl I): i1-i92 Step 1: Mild intermittent asthma Inhaled short acting ß 2 agonist as required

15. 15 Stepwise management of asthma in children under 5 years Thorax 2003; 58 (Suppl I): i1-i92 Step 2: Regular preventer therapy Add inhaled steroid 200-400mcg/day * † (leukotriene receptor antagonist if inhaled steroid cannot be used) Step 1: Mild intermittent asthma Start at dose of inhaled steroid appropriate to severity of disease. * BDP or equivalent † Higher nominal doses may be required if drug delivery is difficult required if drug delivery is difficult

16. 16 Stepwise management of asthma in children under 5 years Thorax 2003; 58 (Suppl I): i1-i92 Step 3: Add-on therapy In children aged 2-5 years consider addition of leukotriene receptor antagonist In children under 2 years consider proceeding to step 4 Step 1: Mild intermittent asthma Step 2: Regular preventer therapy

17. 17 Step 3: Add-on therapy Step 2: Regular preventer therapy Stepwise management of asthma in children under 5 years Thorax 2003; 58 (Suppl I): i1-i92 Step 4: Persistent poor control Refer to respiratory paediatrician Step 1: Mild intermittent asthma

18. 18 Stepwise management of asthma in children under 5 years Thorax 2003; 58 (Suppl I): i1-i92 Step 1: Mild intermittent asthma Step 4: Persistent poor control Step 3: Add-on therapy Step 2: Regular preventer therapy

19. 19 Case discussion Jessica

20. 20 Step 2: Introduction of regular preventer therapy (practice points)  Inhaled steroids should be prescribed for patients with recent exacerbations, nocturnal asthma, impaired lung function or using inhaled  2 agonists more than once a day Start patients at inhaled steroid dose appropriate to disease severity (e.g. adults: 400mcg per day; children 5-12 years: 200mcg per day; children under 5 years: higher doses may be required to ensure consistent drug delivery) Use lowest dose at which effective control of asthma is maintained Monitor children’s height on a regular basis In children on inhaled steroids with decreased consciousness, check blood glucose levels urgently and consider IM hydrocortisone Thorax 2003; 58 (Suppl I): i1-i92

21. 21 Initial assessment of acute asthma in children aged >2 years in general practice Thorax 2003; 58 (Suppl I): i1-i92 Moderate exacerbation Severe exacerbation Life threatening exacerbation SpO 2  92% SpO 2  92% PEF  50% best/ predicted (>5 years) PEF  50% best/ predicted (>5 years) Able to talk Able to talk Heart rate: Heart rate: -  130/min (2-5 years) -  130/min (2-5 years) -  120/min (>5 years) -  120/min (>5 years) Respiratory rate: Respiratory rate: -  50/min (2-5 years) -  50/min (2-5 years) -  30/min (>5 years) -  30/min (>5 years) SpO 2 <92% SpO 2 <92% PEF 5 years) PEF 5 years) Too breathless to talk Too breathless to talk Heart rate: Heart rate: - >130/min (2-5 years) - >130/min (2-5 years) - >120/min (>5 years) - >120/min (>5 years) Respiratory rate: Respiratory rate: - >50/min (2-5 years) - >50/min (2-5 years) - >30/min (>5 years) - >30/min (>5 years) Use of accessory neck muscles Use of accessory neck muscles SpO 2 <92% SpO 2 <92% PEF 5 years) PEF 5 years) Silent chest Silent chest Poor respiratory effort Poor respiratory effort Agitation Agitation Altered consciousness Altered consciousness Cyanosis Cyanosis  Measure PEF or FEV 1 in all children aged >5 years

22. 22 Management of acute asthma in children aged >2 years in general practice Thorax 2003; 58 (Suppl I): i1-i92 Moderate exacerbation Severe exacerbation Life threatening exacerbation ß 2 agonist 2-4 puffs via spacer ± facemask ß 2 agonist 2-4 puffs via spacer ± facemask Consider soluble prednisolone: - 20mg (2-5 years) - 30-40mg (>5 years) Consider soluble prednisolone: - 20mg (2-5 years) - 30-40mg (>5 years) Increase ß 2 agonist dose by 2 puffs every 2 minutes up to 10 puffs according to response Oxygen via facemask Oxygen via facemask ß 2 agonist 2-4 puffs via spacer ± facemask or nebulised salbutamol (2-5 years: 2.5mg; >5 years: 5mg) or terbutaline (2-5 years: 5mg; >5 years: 10mg) Soluble prednisolone: - 20mg (2-5 years) - 30-40mg (>5 years) ß 2 agonist 2-4 puffs via spacer ± facemask or nebulised salbutamol (2-5 years: 2.5mg; >5 years: 5mg) or terbutaline (2-5 years: 5mg; >5 years: 10mg) Soluble prednisolone: - 20mg (2-5 years) - 30-40mg (>5 years) Assess response to treatment 15 minutes after ß 2 agonist Oxygen via facemask Oxygen via facemask Nebulised salbutamol (2-5 years: 2.5mg; >5 years: 5mg) or terbutaline (2-5 years: 5mg; >5 years: 10mg) Nebulised salbutamol (2-5 years: 2.5mg; >5 years: 5mg) or terbutaline (2-5 years: 5mg; >5 years: 10mg) Ipratropium 0.25mg Ipratropium 0.25mg Soluble prednisolone (2-5 years: 20mg; >5 years: 30-40mg) or IV hydrocortisone (2-5 years: 50mg; >5 years: 100mg) Soluble prednisolone (2-5 years: 20mg; >5 years: 30-40mg) or IV hydrocortisone (2-5 years: 50mg; >5 years: 100mg)

23. 23 Moderate exacerbation Severe exacerbation Life threatening exacerbation IF POOR RESPONSE ARRANGE ADMISSION IF POOR RESPONSE REPEAT ß 2 AGONIST AND ARRANGE ADMISSION REPEAT ß 2 AGONIST VIA OXYGEN-DRIVEN NEBULISERS WHILST ARRANGING IMMEDIATE HOSPITAL ADMISSION Thorax 2003; 58 (Suppl I): i1-i92 Response to treatment of acute asthma in children aged >2 years in general practice GOOD RESPONSE Continue up to 10 puffs or nebulised ß 2 agonist as needed, not exceeding 4 hourly Continue up to 10 puffs or nebulised ß 2 agonist as needed, not exceeding 4 hourly If symptoms are not controlled, repeat ß 2 agonist and refer to hospital If symptoms are not controlled, repeat ß 2 agonist and refer to hospital Continue prednisolone for up to 3 days Continue prednisolone for up to 3 days Arrange follow-up clinic visit Arrange follow-up clinic visit POOR RESPONSE Stay with patient until ambulance arrives Stay with patient until ambulance arrives Send written assessment and referrral details Send written assessment and referrral details Repeat ß 2 agonist via oxygen-driven nebuliser in ambulance Repeat ß 2 agonist via oxygen-driven nebuliser in ambulance LOWER THRESHOLD FOR ADMISSION IF: Attack in late afternoon or at night Attack in late afternoon or at night Recent hospital admission or previous severe attack Recent hospital admission or previous severe attack Concern over social circumstances or ability to cope at home Concern over social circumstances or ability to cope at home NB: If a patient has signs and symptoms across categories, always treat according to their most severe features

24. 24 Treatment of acute asthma in children aged >2 years Thorax 2003; 58 (Suppl I): i1-i92D Use structured care protocols detailing bronchodilator usage, clinical assessment, and specific criteria for safe discharge  Children with life threatening asthma or SpO 2 <92% should receive high flow oxygen via a tight fitting face mask or nasal cannula at sufficient flow rates to achieve normal saturations A Inhaled ß 2 agonists are first line treatment for acute asthma * A pMDI and spacer are preferred delivery system in mild to moderate asthma B Individualise drug dosing according to severity and adjust according to response B IV salbutamol (15mg/kg) is effective adjunct in severe cases * Dose can be repeated every 20-30 minutes

25. 25 Steroid therapy for acute asthma in children aged >2 years Thorax 2003; 58 (Suppl I): i1-i92A Give prednisolone early in the treatment of acute asthma attacks  Use prednisolone 20mg (2-5 years), 30-40mg (>5 years) Use prednisolone 20mg (2-5 years), 30-40mg (>5 years) Those already receiving maintenance steroid tablets should receive 2 mg/kg oral prednisolone up to a maximum dose of 60 mg Those already receiving maintenance steroid tablets should receive 2 mg/kg oral prednisolone up to a maximum dose of 60 mg Repeat the dose of prednisolone in children who vomit and consider IV steroids Repeat the dose of prednisolone in children who vomit and consider IV steroids Treatment up to 3 days is usually sufficient, but tailor to the number of days for recovery Treatment up to 3 days is usually sufficient, but tailor to the number of days for recovery  Do not initiate inhaled steroids in preference to steroid tablets to treat acute childhood asthma

26. 26 Hospital admission for acute asthma in children aged >2 years Thorax 2003; 58 (Suppl I): i1-i92 Children with acute asthma failing to improve after 10 puffs of  2 agonist should be referred to hospital. Further doses of bronchodilator should be given as necessary whilst awaiting transfer  Treat with oxygen and nebulised  2 agonists during the journey to hospital  Transfer children with severe or life threatening asthma urgently to hospital to receive frequent doses of nebulised  2 agonists (2.5-5mg salbutamol or 5-10 mg terbutaline)  Decisions about admission should be made by trained physicians after repeated assessment of the response to further bronchodilator treatment B Consider intensive inpatient treatment for children with SpO 2 <92% on air after initial bronchodilator treatment

27. 27 Treatment of acute asthma in children aged <2 years Thorax 2003; 58 (Suppl I): i1-i92B Oral  2 agonists are not recommended for acute asthma in infants A For mild to moderate acute asthma, a pMDI with spacer is the optimal drug delivery device C 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 3 days) is the preferred steroid preparation B Consider inhaled ipratropium bromide in combination with an inhaled  2 agonist for more severe symptoms

28. 28 Thorax 2003; 58 (Suppl I): i1-i92 Try to confirm diagnosis with objective tests before long-term therapy is started Inhaled steroids are the recommended preventer drug In children >5 years, add inhaled ß 2 agonists rather than increasing the dose of inhaled steroids above 400mcg/day pMDI + spacer is preferred delivery method in children aged 0-5 years, and as effective as other delivery methods for other age groups Assess and act promptly in acute asthma – admit patients with any feature of a life threatening or near fatal attack, or severe attack persisting after initial treatment Overview: Paediatric asthma