Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Paediatric asthma Thorax 2003; 58 (Suppl I): i1-i92 Diagnosis of asthma in children Presenting features • wheeze • dry cough • • breathlessness noisy breathing Detailed history and physical examination • pattern of illness • differential clues • severity/control Is it asthma? Thorax 2003; 58 (Suppl I): i1-i92 Clues to alternative diagnoses in wheezy children Clinical clue Possible diagnosis Perinatal and family history • symptoms present from birth or perinatal • cystic fibrosis; chronic lung disease; ciliary dyskinesia; lung problem • family history of unusual chest disease • severe upper respiratory tract disease 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 • cystic fibrosis; recurrent aspiration; host defence disorder • reflux (aspiration) • swallowing problems (aspiration) • laryngeal problem • developmental disease; postviral syndrome; bronchiectasis; • inspiratory stridor as well as wheeze • failure to thrive tuberculosis • central airway or laryngeal disorder • cystic fibrosis; host defence defect; gastro-oesophageal reflux Investigations • focal or persistent radiological changes • developmental disorder; postinfective disorder; recurrent aspiration; inhaled foreign body; bronchiectasis; tuberculosis Thorax 2003; 58 (Suppl I): i1-i92 Delivery of ß2 agonists Adults A Children Children 5-12 <5 years years A Use pMDI and large volume spacer for adults and children aged 2-12 years with mild and moderate exacerbations of asthma pMDI + spacer preferred delivery method for children aged 0-5 years In children aged 5-12 years with chronic asthma, pMDI + spacer is as effective as any other hand held inhaler In adults, pMDI ± spacer is as effective as any other hand held inhaler, but patients may prefer dry powder inhalers A A Base choice of reliever inhaler for stable asthma on patient preference/ability to use, as many patients will not carry a spacer A Salbutamol non-CFC pMDI can be substituted for CFC pMDI at 1:1 dosing Thorax 2003; 58 (Suppl I): i1-i92 Delivery of inhaled steroids Adults Children Children 5-12 <5 years years A A A pMDI + spacer preferred delivery method for children aged 0-5 years For children aged 5-12 years, pMDI + spacer is as effective as any dry powder inhaler In adults, a pMDI ± spacer is as effective as any dry powder inhaler HFA-BDP pMDI can be substituted for CFC-BDP pMDI at 1:2 dosing, but should incorporate period of close monitoring Fluticasone non-CFC pMDI can be substituted for CFC pMDI at 1:1 dosing Thorax 2003; 58 (Suppl I): i1-i92 Initial assessment of acute asthma in children aged >2 years in A&E Moderate exacerbation Severe exacerbation Life threatening asthma • SpO2 92% • PEF 50% best/ • SpO2 <92% • PEF <50% best/ • SpO2 <92% • PEF <33% best/ predicted (>5 years) • No clinical features of severe asthma • Heart rate: - 130/min (2-5 years) - 120/min (>5 years) • Respiratory rate: - 50/min (2-5 years) - 30/min (>5 years) predicted (>5 years) • Too breathless to talk or eat • Heart rate: - >130/min (2-5 years) - >120/min (>5 years) • Respiratory rate: - >50/min (2-5 years) - >30/min (>5 years) • Use of accessory neck muscles predicted (>5 years) • Silent chest • Poor respiratory effort • Agitation • Altered consciousness • Cyanosis Thorax 2003; 58 (Suppl I): i1-i92 Management of acute asthma in children aged >2 years in A&E Moderate exacerbation • ß2 agonist 2-10 puffs via • spacer ± facemask Reassess after 15 minutes RESPONDING • Continue inhaled ß2 agonists 1-4 hourly • Add soluble oral prednisolone - 20mg (2-5 years) - 30-40mg (>5 years) Severe exacerbation Life threatening exacerbation • Give nebulised ß2 agonist: • • salbutamol (2-5 years: 2.5mg; >5 years: 5mg) or terbutaline (2-5 years: 5mg; >5 years: 10mg) with oxygen as driving gas Continue oxygen via facemask/nasal prongs Give prednisolone (2-5 years: 20mg; >5 years 30-40mg) or IV hydrocortisone (2-5 years: 50mg; >5 years: 100mg) NOT RESPONDING • Repeat inhaled ß2 agonist every 20-30 minutes • Add soluble oral prednisolone - 20mg (2-5 years) - 30-40mg (>5 years) IF LIFE THREATENING FEATURES PRESENT Discuss with senior clinician, PICU team or paediatrician. Consider: • Chest x-ray and blood gases • Repeat nebulised ß2 agonists plus ipratropium bromide 0.25mg nebulised every 20-30 minutes • Bolus IV salbutamol 15g/kg of 200g/ml solution over 10 minutes • IV aminophylline Thorax 2003; 58 (Suppl I): i1-i92 Response to treatment of acute asthma in children aged >2 years in A&E Moderate exacerbation Severe exacerbation Life threatening exacerbation RESPONDING TO TREATMENT NOT RESPONDING TO TREATMENT IF POOR RESPONSE TO TREATMENT ARRANGE ADMISSION (lower threshold if concern over social circumstances) ARRANGE IMMEDIATE TRANSFER TO PICU/HDU DISCHARGE PLAN • Continue ß2 agonists 1-4 hourly prn • Consider prednisolone 20mg (2-5 years) 30-40mg (>5 years) daily for up to 3 days • Advise to contact GP if not controlled on above treatment • Provide a written asthma action plan • Review regular treatment • Check inhaler technique • Arrange GP follow up Thorax 2003; 58 (Suppl I): i1-i92 Treatment of acute asthma in children aged >2 years D A A B B Use structured care protocols detailing bronchodilator usage, clinical assessment, and specific criteria for safe discharge Children with life threatening asthma or SpO2 <92% should receive high flow oxygen via a tight fitting face mask or nasal cannula at sufficient flow rates to achieve normal saturations Inhaled ß2 agonists are first line treatment for acute asthma * pMDI and spacer are preferred delivery system in mild to moderate asthma Individualise drug dosing according to severity and adjust according to response IV salbutamol (15mg/kg) is effective adjunct in severe cases * Dose can be repeated every 20-30 minutes Thorax 2003; 58 (Suppl I): i1-i92 Steroid therapy for acute asthma in children aged >2 years A Give prednisolone early in the treatment of acute asthma attacks • 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 • 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 Do not initiate inhaled steroids in preference to steroid tablets to treat acute childhood asthma Thorax 2003; 58 (Suppl I): i1-i92 Other therapies for acute asthma in children aged >2 years A A C If poor response to 2 agonist treatment, add nebulised ipratropium bromide (250mcg/dose mixed with 2 agonist) * Aminophylline is not recommended in children with mild to moderate acute asthma Consider aminophylline for children in high dependency/intensive care with severe or life threatening bronchospasm unresponsive to maximal doses of bronchodilators and steroid tablets Do not give antibiotics routinely in the management of acute childhood asthma ECG monitoring is mandatory for all intravenous treatments * Dose can be repeated every 20-30 minutes Thorax 2003; 58 (Suppl I): i1-i92 Hospital admission for acute asthma in children aged >2 years 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 SpO2 <92% on air after initial bronchodilator treatment Thorax 2003; 58 (Suppl I): i1-i92 Treatment of acute asthma in children aged <2 years B A C B Oral 2 agonists are not recommended for acute asthma in infants For mild to moderate acute asthma, a pMDI with spacer is the optimal drug delivery device 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 Consider inhaled ipratropium bromide in combination with an inhaled 2 agonist for more severe symptoms Thorax 2003; 58 (Suppl I): i1-i92