Summary of the management of asthma in children (from the British guideline on the management of asthma)

The British Thoracic Society & Scottish Intercollegiate Guidelines Network


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Diagnosis

  • Undertake a structured clinical assessment to assess the initial probability of asthma. This should be based on:
    • a history of recurrent episodes (attacks) of symptoms, ideally corroborated by variable peak flows when symptomatic and asymptomatic
    • symptoms of wheeze, cough, breathlessness and chest tightness that vary over time
    • recorded observation of wheeze heard by a healthcare professional
    • personal/family history of other atopic conditions
      (in particular, atopic eczema/dermatitis,
      allergic rhinitis)
    • no symptoms/signs to suggest alternative diagnoses

Diagnostic algorithm

 algorithm for the diagnosis of asthma in children
  • In patients with a high probability of asthma:
    • record the patient as likely to have asthma and commence a carefully monitored initiation of treatment (typically 6-weeks of inhaled corticosteroids)
    • assess the patient's status with a validated symptom questionnaire, ideally corroborated by lung function tests (forced expiratory volume in the first second [FEV1] at clinic visits or by domiciliary serial peak flows)
    • with a good symptomatic and objective response to treatment, confirm the diagnosis of asthma and record the basis on which the diagnosis was made
    • if the response is poor or equivocal, check inhaler technique and adherence, arrange further tests and consider alternative diagnoses
  • If there is a low probability of asthma and/or an alternative diagnosis is more likely, investigate for the alternative diagnosis and/or undertake or refer for further tests of asthma
  • Spirometry, with bronchodilator reversibility as appropriate, is the preferred initial test for investigating intermediate probability of asthma in children old enough to undertake a reliable test
  • In patients with an intermediate probability of asthma and airways obstruction identified through spirometry, undertake reversibility tests and/or a monitored initiation of treatment assessing the response to treatment by repeating lung function tests and objective measures of asthma control
  • In patients with an intermediate probability of asthma and normal spirometry results, undertake challenge tests and/or FeNO to identify eosinophilic inflammation
  • In children with an intermediate probability of asthma who cannot perform spirometry:
    • consider watchful waiting if the child is asymptomatic
    • offer a carefully monitored initiation of treatment if the child is symptomatic

Monitoring

  • Asthma is best monitored in primary care by routine clinical review on at least an annual basis
  • The factors that should be monitored and recorded include:
    • symptom score, e.g. Children’s Asthma Control Test, Asthma Control Questionnaire
    • asthma attacks, oral corticosteroid use, and time off school/nursery due to asthma since last assessment
    • inhaler technique
    • adherence, which can be assessed by reviewing prescription refill frequency
    • possession of and use of a selfmanagement plan/written personalised asthma action plan
    • exposure to tobacco smoke
    • growth (height and weight centile)

Supported self-management

  • All people with asthma (and/or their parents or carers) should be offered self-management education which should include a written personalised asthma action plan and be supported by regular professional review
  • Written personalised asthma action plans based on symptoms are generally preferable for children
  • Strategies that have been used to support effective self-management include:
    • the use of proactive triggers to ensure routine reviews
    • structured protocols for asthma reviews
    • support of community pharmacists
    • routine mailing of educational resources
    • telephone calls to provide ongoing support and advice
    • IT-based education and monitoring
    • involvement of community workers to support clinical teams in deprived and/or ethnic minority communities

Non-pharmacological management

  • Maternal food allergen avoidance during pregnancy and lactation is not recommended as a strategy for preventing childhood asthma
  • Breastfeeding should be encouraged for its many benefits, including a potential protective effect in relation to early asthma
  • Parents and parents-to-be should be advised of the many adverse effects which smoking has on their children including increased wheezing in infancy and increased risk of persistent asthma
  • Weight-loss interventions (including dietary and exercise-based programmes) can be considered for overweight and obese children with asthma to improve asthma control

Pharmacological management

Summary of management in children

Algorithm for the management of asthma in children
  • The aim of asthma management is control of the disease. Complete control of asthma is defined as:
    • no daytime symptoms
    • no night-time awakening due to asthma
    • no need for rescue medication
    • no asthma attacks
    • no limitations on activity including exercise
    • normal lung function (in practical terms FEV1 and/or peak expiratory flow [PEF]>80% predicted or best)
    • minimal side-effects from medication
  • Lung function measurements cannot be reliably used to guide asthma management in children under 5 years of age

Approach to management

  • Start treatment at the level most appropriate to the initial severity
  • Achieve early control
  • Maintain control by:
    • increasing treatment as necessary
    • decreasing treatment when control is good
  • Before initiating a new drug therapy practitioners should check adherence with existing therapies, check inhaler technique, and eliminate trigger factors
  • Anyone prescribed more than one short-acting bronchodilator inhaler device a month should be identified and have their asthma assessed urgently and measures taken to improve asthma control if this is poor
  • Combination inhalers are recommended to:
    • guarantee that the long-acting β2-agonist is not taken without inhaled corticosteroid
    • improve inhaler adherence
Table 1: Categorisation of inhaled corticosteroids by dose—children*
ICS Dose
Very low dose Low dose Medium dose
PRESSURISED METERED DOSE INHALERS (PMDI) WITH SPACER)
Beclometasone dipropionate
Non-proprietary 50 µg two puffs twice a day 100 µg two puffs twice a day 200 µg two puffs twice a day
Clenil Modulite 50 µg two puffs twice a day 100 µg two puffs twice a day 200 µg two puffs twice a day
Qvar (extrafine)
Qvar Autohaler
Qvar Easi-Breathe
50 µg two puffs twice a day 100 µg two puffs twice a day
Ciclesonide
Alvesco aerosol inhaler 80 µg two puffs once a day 160 µg two puffs once a day
Fluticasone propionate
Flixotide Evohaler 50 µg one puff twice a day 50 µg two puffs twice a day 125 µg two puffs twice a day
DRY POWDER INHALERS (DPI)
Beclometasone
Asmabec 100 µg one puff twice a day 100 µg two puffs twice a day
Budesonide
Non-proprietary Easyhaler 100 µg two puffs twice a day 200 µg two puffs twice a day
Pulmicort Turbohaler 100 µg one puff twice a day 100 µg two puffs twice a day or
200 µg one puff twice a day
200 µg two puffs twice a day or
400 µg one puff twice a day
Fluticasone propionate
Flixotide Accuhaler 50 µg one puff twice a day 100 µg one puff twice a day 250 µg one puff twice a day
Mometasone
Asmanex Twisthaler 200 µg one puff twice a day
COMBINATION INHALERS
Budesonide with formoterol
Symbicort Turbohaler 100 µg/6 µg one puff twice a day 100 µg/6 µg two puffs twice a day
200/6 one puff twice a day
Fluticasone propionate with salmeterol
Seretide Accuhaler 100 µg/50 µg one puff twice a day
Seretide Evohaler 50 µg/25 µg two puffs twice a day
* It is the editorial policy of Guidelines not to use proprietary drug or device names, however, an exception has been made in this case to aid discrimination between different devices containing the same drug and or propellant
Different products and doses are licensed for different age groups and some are not licensed for use in children. Prior to prescribing, the relevant summary of product characteristics (SPC) should be checked (www.medicines.org.uk/emc)
Medium doses should only be used after referral of patient to secondary care.

Decreasing treatment

  • Regular review of patients as treatment is decreased is important. When deciding which drug to decrease first and at what rate, the severity of asthma, the side-effects of the treatment, time on current dose, the beneficial effect achieved, and the patient’s preference should all be taken into account
  • Patients should be maintained at the lowest possible dose of inhaled corticosteroid. Reduction in inhaled corticosteroid dose should be slow as patients deteriorate at different rates. Reductions should be considered every 3 months, decreasing the dose by approximately 25–50% each time

Exercise-induced asthma

  • For most patients, exercise-induced asthma is an expression of poorly controlled asthma and regular treatment, including inhaled corticosteroids, should be reviewed
  • If exercise is a specific problem in patients taking inhaled corticosteroids who are otherwise well controlled, consider the following therapies:
    • leukotriene receptor antagonists
    • long-acting β2-agonists
    • sodium cromoglicate or nedocromil sodium
    • oral β2-agonists
    • theophyllines
  • Immediately prior to exercise, inhaled short-acting β2-agonists are the drug of choice

Inhaler devices

Technique and training

  • Prescribe inhalers only after patients have received training in the use of the device and have demonstrated satisfactory technique

β2-agonist delivery

  • Acute asthma: children with mild and moderate asthma attacks should be treated with a pressurised metered dose inhaler (pMDI) + spacer with doses titrated according to clinical response
  • Stable asthma: in children aged 5–12 years a pMDI + spacer is as effective as any other hand-held inhaler

Inhaled corticosteroids for stable asthma

  • In children aged 5–12 years, a pMDI + spacer is as effective as any DPI

Prescribing devices

  • The choice of device may be determined by the choice of drug
  • If the patient is unable to use a device satisfactorily an alternative should be found
  • The patient should have their ability to use the prescribed inhaler device (particularly for any change in device) assessed by a competent healthcare professional
  • The medication needs to be titrated against clinical response to ensure optimum efficacy
  • Reassess inhaler technique as part of structured clinical review
  • Generic prescribing of inhalers should be avoided as this might lead to people with asthma being given an unfamiliar inhaler device which they are not able to use properly
  • Prescribing mixed inhaler types may cause confusion and lead to increased errors in use. Using the same type of device to deliver preventer and reliever treatments may improve outcomes
  • In children, a pMDI and spacer are the preferred method of delivery of β2-agonists or inhaled corticosteroids. A face mask is required until the child can breathe reproducibly using the spacer mouthpiece. Where this is ineffective a nebuliser may be required

Management of acute asthma in children aged 1 year and over

Assess and record asthma severity

  • Acute severe:
    • SpO2<92%
    • PEF 33–50% best or predicted
    • can't complete sentences in one breath or too breathless to talk or feed
    • pulse >125 bpm in children aged >5 years; >140 bpm in children aged 1–5 years
    • respiration >30 breaths/min in children aged >5 years; >40 breaths/min in children aged 1–5 years
  • Life threatening:
    • SpO2 <92%
    • PEF <33% best or predicted
    • silent chest
    • cyanosis
    • poor respiratory effort
    • hypotension
    • exhaustion
    • confusion

Criteria for admission

  • Increase β2-agonist dose by giving one puff every 30–60 seconds, according to response, up to a maximum of 10 puffs
  • Parents/carers of children who have an acute asthma attack at home and symptoms not controlled by up to 10 puffs of salbutamol via pMDI and spacer, should seek urgent medical attention
  • If symptoms are severe additional doses of bronchodilator should be given as needed whilst awaiting medical attention
  • Paramedics attending to children with an acute asthma attack should administer nebulised salbutamol, using a nebuliser driven by oxygen if symptoms are severe, whilst transferring the child to the emergency department
  • Children with severe or life-threatening asthma should be transferred to hospital urgently
  • Consider intensive inpatient treatment of children with SpO2 <92% in air after initial bronchodilator treatment.
  • The following clinical signs should be recorded:
    • pulse rate—increasing tachycardia generally denotes worsening asthma; a fall in heart rate in life-threatening asthma is a pre-terminal event
    • respiratory rate and degree of breathlessness—i.e. too breathless to complete sentences in one breath or to feed
    • use of accessory muscles of respiration—best noted by palpation of neck muscles
    • amount of wheezing—which might become biphasic or less apparent with increasing airways obstruction
    • degree of agitation and conscious level—always give calm reassurance
  • N.B. Clinical signs correlate poorly with the severity of airways obstruction. Some children with acute asthma do not appear distressed

¶ Management of acute asthma in children aged under 1 year should be under the direction of a respiratory paediatrician

Initial treatment of acute asthma

  • Oxygen:
    • children with life-threatening asthma or SpO2<94% should receive high flow oxygen via a tight fitting face mask or nasal cannula at sufficient flow rates to achieve normal saturations of 94–98%
  • Bronchodilators:
    • inhaled β2-agonists are the first-line treatment for acute asthma
    • a pMDI + spacer is the preferred option in mild to moderate asthma
    • individualise drug dosing according to severity and the patient's response
    • if symptoms are refractory to initial β2-agonist treatment, add ipratropium bromide (250 µg/dose mixed with the nebulised β2-agonist solution)
    • repeated doses of ipratropium bromide should be given early to treat children who are poorly responsive to β2-agonists
    • consider adding 150 mg magnesium sulphate to each nebulised salbutamol and ipratropium in the first hour in children with a short duration of acute severe asthma symptoms presenting with an SpO2<92%
    • discontinue long-acting β2-agonists when short-acting β2-agonists are required more often than 4-hourly
  • Steroid therapy:
    • give oral steroids early in the treatment of acute asthma attacks
    • use a dose of 10 mg prednisolone for children under 2 years of age, 20 mg for children aged 2–5 years, and 30–40 mg for children >5 years. Those already receiving maintenance steroid tablets should receive 2 mg/kg prednisolone up to a maximum dose of 60 mg
    • repeat the dose of prednisolone in children who vomit and consider intravenous steroids in those who are unable to retain orally ingested medication
    • treatment for up to 3 days is usually sufficient, but the length of course should be tailored to the number of days necessary to bring about recovery. Tapering is unnecessary unless the course of steroids exceeds 14 days

Follow-up

  • It is essential that the patient's primary care practice is informed within 24 hours of discharge from the emergency department or hospital following an asthma attack
  • Keep patients who have had a near-fatal asthma attack under specialist supervision indefinitely
  • Hospital asthma clinic should follow up in 4–6 weeks if second or subsequent attack in past 12 months
  • Follow-up after treatment or discharge from hospital:
    • GP review within 2 working days
    • monitor symptoms and PEF
    • check inhaler technique
    • written asthma action plan
    • modify treatment according to guidelines for chronic persistent asthma
    • address potentially preventable contributors to admission

References

full guidelines available from...
www.sign.ac.uk/guidelines/fulltext/153/index.html

British Thoracic Society, Scottish Intercollegiate Guidelines Network. British guideline on the management of asthma. September 2016.
Reproduced with kind permission from SIGN.
Additional content on: asthma in pregnancy, asthma in adolescents, and occupational asthma is available online at Guidelines.co.uk


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