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Asthma, management of acute

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Introduction

Most children who present to the Starship with asthma will be managed according to this guideline.

The following children may need to be managed differently and should be discussed with a senior:

  • Children who are admitted to PICU with life-threatening asthma
  • Children who are under the care of the Respiratory Team
  • Children who have other serious disorders that affect the management of asthma (e.g. heart disease, neuromuscular disorders)
  • Infants under 1 year of age.

Diagnosing Asthma

Diagnosis of asthma is likely if the following are present:

  • A history of fluctuating wheeze
    This may fluctuate spontaneously or in response to bronchodilators or steroids.
  • Three or more episodes of wheeze
    It may be hard to tell with the chronically wheezy infant or child. A fixed obstruction must be ruled out if the wheeze is continuous.
    Do not diagnose on the first or second episode.
  • Physical signs of airways obstruction
    These are the signs elicited on the Asthma Severity Score plus over-inflation and prolonged expiration.
  • No alternative diagnosis
    Such as foreign body, cystic fibrosis. If in doubt ask your consultant.
  • Family History
    There is often a family history of atopy.
  • Age
    Asthma is rarely diagnosed in a child who is less than 1 year old (check with your consultant).
    For those 1 to 2 years old, a higher degree of certainty is required than for older children.
    In particular, consider whether the child may have acute bronchiolitis or bronchopneumonia. If in doubt discus with a senior.

Investigations

A chest x-ray is usually not necessary. See 'Chest x-ray in Acute Wheeze' guideline for indications for chest x-ray.

Assessment of Asthma Severity

Signs of Life-threatening Asthma

  • Respiratory - hypoxia/exhaustion
  • Neurological - agitation, confusion, drowsiness
  • Cardiovascular - pulsus paradoxus, worsening tachycardia
  • Consider diagnoses other than asthma, especially in infants with poorly responsive respiratory distress
  • In very severe cases, because of extremely poor air entry, you may not hear wheeze
  • Deterioration despite maximal therapy on severe asthma pathway

Oxygen saturations can remain normal in life-threatening asthma.

All children with life-threatening asthma should be discussed with a senior (consultant or fellow) and be managed according to the Life-Threatening Asthma Guideline.

Severe Asthma

  • Too breathless to talk or feed
  • HR > 120/min (over 5 years) or >130/min (2-5 years old)
  • RR . 30/min (over 5 years) or > 50/min (2-5 years old)
  • Marked accessory muscle use
Asthma Severity Score (ASS)
Add wheeze and muscle subtotals to give score 
   Score
Wheeze (beware of silent chest*)  
None (0)  
Expiratory (by auscultation) (1)  
Expiratory & inspiratory (2)  
Heard without stethoscope (3)   
Sub Total  
Accessory muscle use / indrawing   
None (0)   
Mild (1)   
Moderate (2)   
Severe (3)   
Sub Total   
 TOTAL  
  0 - 2 = Mild
3 - 5 = Moderate
6 = Severe 

Acute Asthma Management Algorithm

Algorithm

Steroids

Prednisolone syrup (Redipred®) is the preferred medication for young children because it is better tolerated and easy to use.

Prednisone tablets can be used for older children who are able to swallow them.

Mild asthma Consider on basis of history 
Moderate or severe asthma   Dosage is 1mg/kg/day once daily (max 40mg) for 3-5 days 
Severe  May require IV hydrocortisone if not tolerating oral medication or if slow to respond 

Admission

Consider admission to the ward for the patients who:

  • Require bronchodilators more often than 3hrly despite early administration of corticosteroids and 4 - 6 hours in CED or short stay unit
  • Have persisting oxygen desaturation < 92%
  • Other factors to consider:
    - History of respiratory arrest or life-threatening asthma
    - Underlying medical condition
    - Severity of illness
    - Social (eg access to car/phone, time of day)
    - Parental ability to cope
    - Repeat presentation with the same illness

Discharge

Discharge Guideline

  • Asthma Severity Score (ASS) of 0 -2
  • Anticipate ongoing spacer use less frequently than 2-4 hourly
  • Spacer Technique has been assessed and is satisfactory
  • Prescription for appropriate home treatment and devices
  • Individualised Action Plan has been completed and discussed with family
  • Asthma Information Handouts have been discussed and issued
  • Parents / caregiver feel confident in being able to manage at home
  • Parents / caregiver know who to contact if they are concerned

The child's GP should receive a Discharge letter and copy of the Asthma Action Plan.

The discharge letter should clearly indicate that the patient needs to be followed up within a specified timeframe.

On discharge, parents should be advised to seek further medical attention (preferably from their GP), should the patient's condition deteriorate or if there is no significant improvement within 48 hours

Referral for Asthma Education &/or Medical Follow-up

The patient's General Practice / primary health care providers are the primary source of education. Areas needing further education should be highlighted in the discharge letter. Education and support from asthma education services in the community should be considered additional to the GP and Practice Nurse.

If there is no General Practitioner identified and further education is required, there are Paediatric Asthma Education Providers for the Auckland region.

Families may not absorb all the information they need in the acute situation.

Referral may be appropriate for those children with:

  • No identified GP
  • Newly diagnosed asthma
  • If medication / treatment has been added or altered
  • 2 or more attendances to Emergency Care in 6 months
  • 2 or more admissions to hospital in 1 year
  • Non compliance with preventer
  • Inappropriate use of reliever or delivery device
  • School issues
  • Smoking cessation (adolescents or parents). Refer to Smokechange program.
  • Fearful or lacking confidence to manage their own/their child's asthma

Referral to Outpatient Clinic

Children and young people with asthma are best managed in General Practice, in a family-centred environment, with long-term follow-up.

Indications for Referral

  • If asthma is not controlled with the use of inhaled corticosteroids in doses > 400mcg beclomethasone/budesonide or > 200mcg fluticasone per day.
  • Patients presenting frequently to the emergency department or requiring ≥ 4 courses of oral steroids per year should be considered for paediatrician referral.

Information to be included in Referral
The minimum information that needs to be included in the referral is:

  • specific reason for referral
  • discharge letter
  • action/management plan
  • education checklist

Management of Recurrent Childhood Asthma

Management

Drug Treatment of Recurrent Childhood Asthma

Asthma drug tx

Information for Families

See Kidshealth Factsheets on Asthma

References

British Guideline on the management of asthma.British Thoracic Society 2008.
http://www.brit-thoracic.org.uk/ClinicalInformation/Asthma/AsthmaGuidelines/tabid/83/Default.aspx 

Paediatric Society of New Zealand. Best Practice Evidence Based Guideline. Management of Asthma in Children aged 1-15 years. 2005 
http://www.paediatrics.org.nz/files/guidelines/Asthmaendorsed.pdf

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Document Control

  • Date last published: 01 March 2009
  • Document type: Clinical Guideline
  • Services responsible: Children’s Emergency Department, General Paediatrics, Paediatric Respiratory
  • Owner: Raewyn Gavin
  • Editor: Greg Williams
  • Review frequency: 2 years

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