A Pocket Guide for Physicians and Nurses

2009
BASED ON THE GLOBAL STRATEGY FOR
ASTHMA MANAGEMENT AND PREVENTION IN CHILDREN 5 YEARS AND YOUNGER
Available from www.ginasthma.org

Pocket Guide for

Asthma Management and
Prevention in Children
5 Years and Younger
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Disclaimer: Although the recommendations of this document are based on the best published
evidence, it is the responsibility of practicing physicians to consider the cost and benefit of all
treatments prescribed in young children, with due reference to recommendations and licensed
formulations, dosing, and indications for use in their country.
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GLOBAL INITIATIVE FOR ASTHMA

GLOBAL INITIATIVE
FOR ASTHMA

2009 Global Initiative for Asthma

Executive Committee (2009)
Eric D. Bateman, M.D., South Africa, Chair
Louis-Philippe Boulet, MD, Canada
Alvaro Cruz, MD, Brazil
Mark FitzGerald, M.D., Canada
Tari Haahtela, M.D., Finland
Mark Levy, MD, UK
Paul O'Byrne, M.D., Canada
Ken Ohta, M.D., Japan
Pierluigi Paggario, M.D., Italy
Soren Pedersen, M.D., Denmark
Manuel Soto-Quiroz, M.D., Costa Rica
Gary Wong, M.D., Hong Kong ROC
Pediatric Writing Group
Allan Becker, MD, Canada
Robert F. Lemanske, Jr, MD, USA
Soren Erik Pedersen, MD, Denmark
Peter D. Sly MD, Australia
Manuel Soto-Quiroz, MD, Costa Rica
Gary W. Wong, MD, Hong Kong ROC
Heather J. Zar, MD, South Africa
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TABLE OF CONTENTS
PREFACE .......................................................................................2
WHAT IS KNOWN ABOUT ASTHMA?...........................................3
DIAGNOSING ASTHMA ..............................................................4
Table 1. Is it Asthma? ..........................................................4
CLASSIFICATION OF ASTHMA BY LEVEL OF CONTROL ...............5
Table 2. Levels of Asthma Control in Children
5 Years and Younger ...............................................5
MANAGEMENT AND PHARMACOLOGIC TREATMENT .................6
Develop a Partnership Family/Caregivers and Health Care
Providers Identify and Reduce Exposure to Risk Factors ................6
Table 3. Strategies for Avoiding Common Allergens and
Pollutants................................................................7
Assess, Treat, and Monitor Asthma ...............................................8
Table 4. Asthma Management Approach Based on Control
for Children 5 Years and Younger .............................9
Table 5. Low Daily Doses of Inhaled Glucocorticosteroids for
Children 5 Years and Younger ..............................10
Manage Acute Exacerbations ......................................................12
Table 6. Initial Assessment of Acute Asthma in Children
5 Years and Younger...............................................13
Table 7. Indications for Immediate Referral to Hospital
(Health Center) .......................................................14
Table 8. Initial Management of Acute Asthma in Children
5 Years and Younger...............................................15
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PREFACE
Asthma is a major cause of chronic morbidity and mortality throughout the
world and there is evidence that its prevalence has increased considerably
over the past 20 years, especially in children. The Global Initiative for
Asthma was created to increase awareness of asthma among health pro-
fessionals, public health authorities, and the general public, and to improve
prevention and management through a concerted worldwide effort. The
Initiative prepares reports on asthma management based on the best avail-
able scientific evidence, encourages dissemination and implementation of
the recommendations, and promotes international collaboration on asthma
research.
Recommendations in this Pocket Guide present special challenges that must
be taken into account to manage asthma in children during the first 5
years of life, including difficulties with diagnosis, and efficacy and safety
of drugs and delivery systems. Approaches to these issues will vary
among populations based on socioeconomic conditions, genetic diversity,
cultural beliefs, and differences in health care access and deliver.
The Global Initiative for Asthma offers a framework to achieve and
maintain asthma control for most patients that can be adapted to local
health care systems and resources. Program publications include:
Global Strategy for Asthma Management and Prevention (2008).
Scientific information and recommendations for asthma programs.
Pocket Guide for Asthma Management and Prevention (2008).
Summary of patient care information for primary health care
professionals.
Pocket Guide for Asthma Management and Prevention in Children
5 Years and Younger (2009). Summary of patient care information
for pediatricians and other healthcare professionals
What You and Your Family Can Do About Asthma. An information
booklet for patients and their families.
Publications are available from www.ginasthma.org.
This Pocket Guide has been developed from the Global Strategy for
Asthma Management and Prevention in Children 5 Years and Younger
(2009). Technical discussions of asthma, evidence levels, and specific cita-
tions from the scientific literature are included in the source document.
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WHAT IS KNOWN
ABOUT ASTHMA?
Unfortunately asthma is the most common chronic disease of child-
hood and the leading cause of childhood morbidity from chronic disease
as measured by absence from day care, emergency department visits, and
hospitalizations. There are special challenges that must be taken into
account in managing asthma in children during the first 5 years of life.
Fortunately asthma in this young age group can be effectively treated
and control can be achieved in most patients.
When asthma is under control children can:
Avoid troublesome symptoms night and day
Use little or no reliever medication
Have productive, physically active lives
Avoid serious attacks
Asthma causes recurring episodes of wheezing, breathlessness, chest
tightness, and coughing, particularly at night or in the early morning.
Asthma is a chronic inflammatory disorder of the airways. Chronically
inflamed airways are hyperresponsive; they become obstructed and air-
flow is limited (by bronchoconstriction, mucus plugs, and increased
inflammation) when airways are exposed to various risk factors.
Common risk factors for asthma symptoms in young children include
exposure to allergens (such as those from house dust mites, animals,
cockroaches, fungi), exposure to tobacco smoke and biomass fuels, res-
piratory (viral) infections and emotional stress.
Pharmacologic treatment to achieve and maintain control of asthma
should take into account the safety of treatment, potential for adverse
effects, and the cost of treatment required to achieve control.
Asthma attacks (or exacerbations) are episodic, but airway inflammation
is chronically present.
For many patients, controller medication must be taken daily to prevent
symptoms, improve lung function, and prevent attacks. Reliever medica-
tions may occasionally be required to treat acute symptoms such as
wheezing, chest tightness, and cough.
To reach and maintain asthma control in young children requires the
development of a partnership between the family/care giver and the
health care team.
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DIAGNOSING ASTHMA
Making a definite diagnosis of asthma in children 5 years and younger is
challenging because episodic respiratory symptoms such as wheezing and
cough are also common in children who do not have asthma, particularly in
those younger than 3 years. Not all young children who wheeze have asth-
ma, and the younger the child, the greater the likelihood that an alterna-
tive diagnosis may explain recurrent wheeze. These alternatives must be
considered and excluded before an asthma diagnosis is made.
Alternative causes of recurrent wheezing, particularly in early infancy,
include infections (recurrent viral lower respiratory tract infections, chronic
rhino-sinusitis, tuberculosis); congenital problems (cystic fibrosis, bronchopul-
monary dysplasia, congenital malformation causing narrowing of the
intrathoracic airways, primary ciliary dyskinesia syndrome, immune deficien-
cy, and congenital heart disease) and mechanical problems (foreign body
aspiration).
A difficulty with diagnosing asthma in children 5 years and younger is that
the lung function measurements that are key to diagnosis in older children
and adults are not reliable in this age group.
A trial of treatment with short-acting bronchodilators and inhaled glucocorti-
costeroids can help confirm an asthma diagnosis: look for marked clinical
improvement during the treatment and deterioration when treatment is
stopped. The presence of atopy or allergic sensitization also increases the
likelihood that a wheezing child will have asthma.
Taking all of these factors into account, a diagnosis of asthma in these young
children can often be made based largely on symptom patterns and on a
careful clinical assessment of family history and physical findings (Table 1).
Consider asthma if any of the following signs or symptoms are present:
I Frequent episodes of wheezingmore than once a month.
I Activity-induced cough or wheeze.
I Cough particularly at night during periods without viral infections.
I Absence of seasonal variation in wheeze.
I Symptoms that persist after age 3.
I Symptoms occur or worsen in the presence of:
Aeroallergens (house dust mites, companion animals, cockroach, fungi)
Exercise
Pollen
Respiratory (viral) infections
Strong emotional expression
Tobacco smoke
I The childs colds repeatedly go to the chest or take more than 10 days to clear up.
I Symptoms improve when asthma medication is given.
Table 1. Is It Asthma?
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5
For all patients with a confirmed diagnosis of asthma, the goal of treatment
is to achieve and maintain control of the disease. However, assessing
asthma control in children 5 years and younger is difficult, because health
care providers are almost exclusively dependent on the reports of the
childs family members and caregivers who might be unaware of the pres-
ence of asthma symptoms, or of the fact that they represent uncontrolled
asthma. Additional information about asthma control may be gleaned from
the childs need for reliever/rescue treatment (with increased use indicating
worsening control).
Table 2 presents a working scheme to assess asthma control in children 5
years and younger based on these two sources of information.
CLASSIFICATION OF ASTHMA
BY LEVEL OF CONTROL
Characteristic Controlled
(All of the following)
Partly Controlled
(Any measure
present in any week)
Uncontrolled
(Three or more of
features of partly
controlled asthma
in any week)
Daytime symptoms:
wheezing, cough ,
difficult breathing
None
(less than twice/week,
typically for short periods
of on the order of
minutes and rapidly
relieved by the use of
a rapid-acting
bronchodilator)
More than twice/week
(typically for short
periods on the order
of minutes and rapidly
relieved by use of
a rapid-acting
bronchodilator)
More than twice/week
(typically last minutes
or hours or recur, but
partially or fully relieved
with rapid-acting
bronchodilators)
Limitations
of activities
None
(child is fully active,
plays and runs witout
limitation or symptoms)
Any
(may cough, wheeze,
or have difficulty
breathing during
exercise, vigorous
play, or laughing)
Any
(may cough, wheeze,
or have difficulty
breathing during
exercise, vigorous
play, or laughing)
Nocturnal
symptoms/awakening
None
(including no nocturnal
coughing during sleep)
Any
(typically coughs during
sleep or wakes with
cough, wheezing,
and/or difficult breathing)
Any
(typically coughs during
sleep or wakes with
cough, wheezing,
and/or difficult breathing)
Need for
reliever/rescue
treatment
2 days/week > 2 days/week > 2 days/week
Table 2. Levels of Asthma Control in Children 5 Years and Younger*
* Any exacerbation should prompt review of maintenance treatment to ensure that it is adequete. Although patients
with current clinical control are less likely to experience exacerbations, they are still at risk during viral upper
respiratory tract infections and may still have one or more exacerbations per year.
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Control of asthma can be achieved in a majority of children 5 years and
younger with an intervention strategy that includes:
A partnership between the childs family/caregivers and the health care team
Avoidance of risk factors
A plan to assess, treat with appropriate pharmacologic therapy, and
monitor asthma control
An action plan to enable the childs family members and caregivers to
recognize an asthma attack and initiate treatment, recognize a severe
episode, and identify when urgent treatment at a hospital (health care
facility) is required.
Develop a Partnership
Family/Caregivers and Health Care Providers
With the help of everyone on the health care team, families/caregivers can
be actively involved in managing asthma to prevent problems and enable
children to live productive, physically active lives. They can learn to:
Help the child avoid risk factors
Ensure that the child takes medications correctly
Understand the difference between controller & reliever medications
Monitor asthma control status using symptoms
Recognize signs that asthma is worsening and take action
Seek medical help as appropriate
Education should be an integral part of all interactions between health care
professionals and the family/caregivers of young children with asthma.
Using a variety of methodssuch as discussions (with a physician, nurse,
outreach worker, counselor, or educator), demonstrations, written materials,
group classes, video or audio tapes, dramas, and family support groups
helps reinforce educational messages.
For wheezy children 5 years and younger, when wheeze is suspected to be
caused by asthma, a written asthma action plan based on the levels of res-
piratory symptoms can be an effective tool to help family members/care-
givers improve and maintain control of the childs asthma.
MANAGEMENT AND
PHARMACOLOGIC TREATMENT
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Avoidance measures that improve control of asthma and reduce
medication needs:
Tobacco smoke: Stay away from tobacco smoke. Parents and caregivers
should not smoke.
Drugs, foods, and additives: Avoid if they are known to cause symptoms.
Reasonable avoidance measures that can be recommended but have
not been shown to have clinical benefit:
House dust mites: Wash bed linens and blankets weekly in hot water and
dry in a hot dryer or the sun. Encase pillows and mattresses in air-tight cov-
ers. Replace carpets with hard flooring, especially in sleeping rooms.
(If possible, use vacuum cleaner with filters. Use acaricides or tannic acid to
kill mitesbut make sure the patient is not at home when the treatment
occurs.)
Animals with fur: Use air filters. (Remove animals from the home, or at least
from the sleeping area. Wash the pet.)
Cockroaches: Clean the home thoroughly and often. Use pesticide spray
but make sure the patient is not at home when spraying occurs.
Outdoor pollens and mold: Close windows and doors and remain indoors
when pollen and mold counts are highest.
Indoor mold: Reduce dampness in the home; clean any damp areas fre-
quently.
Table 3. Strategies for Avoiding Common Allergens and Pollutants
Identify and Reduce Exposure to Risk Factors
To improve control of asthma and reduce medication needs, patients
should take steps to avoid the risk factors that cause their asthma symp-
toms (Table 3). However, many asthma patients react to multiple factors
that are ubiquitous in the environment, and avoiding some of these factors
completely is nearly impossible. Thus, medications to maintain asthma
control have an important role because patients are often less sensitive to
these risk factors when their asthma is under control.
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ASSESS, TREAT, AND MONITOR ASTHMA
The goal of asthma treatmentto achieve and maintain clinical control
can be reached in most patients through a continuous cycle that involves
Assessing Asthma Control
Treating to Achieve Control
Monitoring to Maintain Control
Assessing Asthma Control
Each patient should be assessed to establish his or her current treatment regi-
men, adherence to the current regimen, and level of asthma control. Current
impairment (day and night symptoms, activity level impairment, need for res-
cue medications) and future risk (likelihood of acute exacerbation in the
future) should both be addressed. A simplified scheme for recognizing con-
trolled, partly controlled, and uncontrolled asthma is provided in Table 2.
Treating to Achieve Control
For the treatment of asthma inhaled medications are preferred because
they deliver drugs directly to the airways where they are needed, resulting
in potent therapeutic effects with fewer systemic side effects.
Devices recommended to deliver inhaled medication for children 5 years and
younger include pressurized metered-dose inhalers (pMDIs) and nebulizers. Spacer
(or valved holding-chamber) devices make inhalers easier to use and reduce
systemic absorption and side effects of inhaled glucocorticosteroids.
Among children in this young age group, inhaler technique may be poor
and should be monitored closely.
Teach family members/caregivers how to use the specific inhaler device(s)
prescribed for their child, as different devices need different inhalation techniques.
Give demonstrations and illustrated instructions.
Ask family members/caregivers to show how their children use the
inhalers at every visit.
For each child, select the most appropriate device. In general:
Children younger than 4 years of age should use a pMDI plus a
spacer with face mask, or a nebulizer with face mask.
Children aged 4 to 5 years should use a pMDI plus a spacer with
mouthpiece, or a pMDI plus a spacer with a face mask or, if nec-
essary, a nebulizer with face mask.
For children using spacers, the spacer must fit the inhaler.
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Information about use of various inhaler devices is found on the GINA
Website (www.ginasthma.org).
A variety of controller and reliever medications for asthma are available.
The recommended treatments discussed below are guidelines only. Local
resources and individual patient circumstances should determine the spe-
cific therapy prescribed for each patient.
All young children with asthma should be prescribed a reliever medica-
tion to use as needed for quick relief of symptoms. (Parents and care-
givers should be aware of how much reliever medication the child is
usingregular or increased use indicates that asthma is not well con-
trolled.) A rapid-acting inhaled
2
-agonist is the recommended choice of
reliever medication for most patients in this age group.
If the childs asthma is not controlled with as-needed use of reliever med-
ication, a low-dose inhaled glucocorticosteroid is the recommended initial
controller treatment (Table 4).
This initial treatment should be given for at least 3 months to establish its
effectiveness in reaching control. If at the end of this period the low dose
of inhaled glucocorticosteroid does not control symptoms, and the child is
using optimal technique and is adherent to therapy, doubling the initial
dose of glucocorticosteroid given in Table 5 may be the best option.
Addition of a leukotriene modifier to the low-dose inhaled glucocorticos-
teroid may also be considered.
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Controlled
on as needed
rapid-acting 2-agonists
Partly controlled
on as needed
rapid- acting 2-agonists
Uncontrolled or only
partly controlled on
low-dose inhaled
glucocorticosteroid*
Table 4. Asthma Management Approach Based on
Control for Children 5 Years and Younger
Asthma education, Environmental control, and As needed rapid-acting
2
-agonists
Continue as needed
rapid-acting

2
-agonists
Low-dose inhaled
glucocorticosteroid
Double low-dose inhaled
glucocorticosteroid
Leukotriene modifier Low-dose inhaled
glucocorticosteroid plus
Leukotriene modifier
Controller options
*Oral glucocorticosteroids should be used only for treatment of acute severe exacerbations of asthma.
Shaded boxes represent preferred treatment options.
Drug Low Daily Dose (g)
Beclomethasone dipropionate 100
Budesonide MDI+spacer
Budesonide nebulized
200
500

Ciclesonide
NS
Fluticasone propionate 100

Mometasone furoate
NS

Triamcinolone acetonide
NS
* A low daily dose is defined as the dose which has not been associated with clinically adverse
effects in trials including measures of safety. This is not a table of clinical equivalence.

NS = Not studied in this age group.
Table 5. Low Daily Doses* of Inhaled Glucocorticosteriods
for Children 5 Years and Younger
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Monitoring to Maintain Control
Ongoing monitoring is essential to maintain control and establish the low-
est step and dose of treatment to minimize cost and maximize safety.
Typically, patients should be seen one to three months after the initial visit,
and every three months thereafter. After an exacerbation, follow-up should
be offered within two weeks to one month.
Adjusting medication:
If asthma is not controlled within one to three months by doubling the ini-
tial dose of inhaled glucocorticosteroids, assess and monitor the childs
inhalation technique, compliance with medication regimen, and avoid-
ance of risk factors.
If control is maintained for at least 3 months, decrease treatment to the
least medication necessary to maintain control. Monitoring is still neces-
sary even after control is achieved, as asthma is a variable disease;
treatment has to be adjusted periodically in response to loss of control as
indicated by worsening symptoms or the development of an exacerbation.
Asthma symptoms remit in a substantial proportion of children 5 years and
younger, and some children have symptoms only during certain seasons of
the year. It is recommended that the continued need for asthma treatment
in children under age 5 should be regularly assessed (every 3-6 months). If
asthma therapy is discontinued, a follow-up visit should be scheduled 3-6
weeks later to verify that the remission of symptoms persists.
Consult with an asthma specialist when other conditions complicate asthma,
if the child does not respond to therapy, or if asthma remains uncontrolled.
Approach to the Child with Intermittent Wheezing Episodes
Intermittent episodic wheezing of any severity may represent unrecognized
uncontrolled asthma, an isolated viral-induced wheezing episode, or an
episode of seasonal or allergen-induced asthma. The initial treatment rec-
ommended includes a dose of rapid-acting inhaled
2
-agonist every 46
hours as needed for a day or more until symptoms disappear.
If a detailed history suggests the diagnosis of asthma, and wheezing
episodes are frequent (e.g., 3 in a season), regular controller treatment
should be initiated. Regular controller treatment may also be indicated in a
child with less frequent, but more severe, episodes of viral-induced wheeze.
Where the diagnosis is in doubt, and when rapid-acting inhaled
2
-ago-
nist therapy needs to be repeated more frequently than every 6-8 weeks, a
diagnostic trial of regular controller therapy should be considered to con-
firm whether the symptoms are due to asthma.
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Manage Acute Exacerbations
Exacerbations of asthma (asthma attacks) are acute episodes of deteriora-
tion in symptom control that are sufficient to cause distress or risk to health
necessitating a visit to a health care provider or requiring treatment with sys-
temic glucocorticosteroids.
Do not underestimate the severity of an attack (Table 6); severe asthma
attacks may be life threatening. Early symptoms may include any of the
following:
An increase in wheeze and shortness of breath
An increase in coughing, especially nocturnal cough
Lethargy or reduced exercise tolerance
Impairment of daily activities, including feeding
A poor response to reliever medication
Upper respiratory symptoms frequently precede the onset of an asthma
exacerbation.
Home Management
A health care provider may recommend steps for the family/caregiver to
care for an asthma attack at home:
.
Initiate treatment with two puffs of inhaled rapid-acting
2
-agonist, given
one puff at a time via a mask or spacer device.
Observe the child and maintain a restful atmosphere for one hour or
more
Seek medical attention the same day if inhaled bronchodilator is
required for symptom relief more than every 3 hours or for more than
24 hours.
Oral glucocorticosteroid treatment by family/caregivers in the home man-
agement of asthma exacerbations in children should be considered only
where the physician is confident that this medication will be used appropri-
ately.
Immediate medical attention should be sought .
For children younger than 1 year requiring repeated rapid-acting
inhaled
2
-agonists over the course of hours
If the child is acutely distressed
If the symptoms are not relieved promptly by inhaled bronchodilator
If the period of relief after a dose of inhaled
2
-agonist becomes pro-
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Table 6. Initial Assessment of Acute Asthma in Children
Five Years and Younger
Symptoms Mild
Severe
a
Altered consciousness No Agitated, confused or
drowsy
Oximetry on presentation
b
(SaO2)
94% < 90%
Talks in
c
Sentences Words
Pulse rate
< 100 bpm
d
> 200 bpm (0-3 years)
> 180 bpm (4-5 years)
Central cyanosis Absent Likely to be present
Wheeze intensity Variable May be quiet
a
Any of these features indicates a severe asthma exacerbation
b
Oximetry performed before treatment with oxygen or bronchodilator
c
The normal developmental capability of the child must be taken into account.
d
bpm = beats per minute.
If a severe exacerbation fails to resolve in 1 to 2 hours in spite of repeated
dosing with rapid-acting inhaled
2
-agonists, with or without the addition
of oral glucocorticosteroids, refer the child to the hospital (or health center)
for observation and further treatment (Table 7).
Other indications for referral to the hospital/health center include:
respiratory arrest or impending arrest
lack of supervision in the home
recurrence of signs of severity within 48 hours of the initial exacerba-
tion (particularly if treatment with systemic glucocorticosteroids has
been given).
For children younger than 2 years, early medical attention should be
sought as the risk of dehydration and respiratory fatigue is increased.
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Table 7. Indications for Immediate Referral to Hospital
ANY of the following:
No response to three (3) administrations of an inhaled
short-acting
2
-agonist within 1-2 hours
Tachypnea despite 3 administrations of an inhaled short-acting
2
-agonist
(Normal respiratory rate < 60 breaths per minute in children 0 2 months;
< 50 in children 2 12 months; < 40 in children 1 5 years)
Child is unable to speak or drink or is breathless
Cyanosis
Subcostal retractions
Oxygen saturation when breathing room air < 92%
Social environment that impairs delivery of acute treatment;
caregivers unable to manage acute asthma at home
Asthma attacks require prompt treatment (Table 8):
Oxygen delivered by face mask given at hospital (health center) if the
patient is hypoxemic (achieve O
2
saturation above 94%).
Inhaled rapid-acting
2
-agonists in adequate doses are essential (two
puffs at 20-minute intervals for an hour).
Failure to respond to bronchodilator therapy at 1 hour, or earlier if the
child deteriorates, requires urgent admission to hospital and a short
course of oral glucocortiocosteroids.
Children prescribed maintenance therapy with inhaled glucocorticos-
teroids or leukotriene modifier or both should continue to take the pre-
scribed dose during and after an attack.
Therapies not recommended for treating attacks include:
Sedatives.
Mucolytic drugs.
Chest physical therapy/physiotherapy.
Epinephrine (adrenaline) may be indicated for acute treatment of ana-
phylaxis and angioedema but is not indicated during asthma attacks.
Intravenous magnesium sulphate has not been studied in young children.
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Table 8: Initial Management of Acute
Severe Asthma in Children 5 Years and Younger*
Therapy Dose and Administration
Supplemental
oxygen
Deliver by 24% face mask (flow set to manufacturer s
instructions, usually 4L/minute)
Maintain oxygen saturation above 94%
Short-acting

2
-agonist
2 puffs salbutamol by spacer,
or
2.5 mg salbutamol by nebulizer
Every 20 minutes for first hours
a
Ipratropium 2 puffs every 20 minutes for first hour only
Systemic
glucocorticosteroids
Oral prednisolone
(1-2 mg/kg daily for up to 5 days)
or
Intravenous methylprednisolone
1 mg/kg every 6 hours on day 1;
every 12 hours on day 2; then daily
Aminophylline
b
Consider in ICU: loading dose
6-10mg/kg lean body weight
Initial maintenance: 0.9 mg/kg/hour
Adjustment according to plasma theophylline levels
Oral
2
-agonists No
Long-acting
2
-agonist
No
a
If inhalation is not possible an intravenous bolus of 5 g/kg given over 5 minutes, followed by
continuous infusion of 5 g/kg/hour.
The dose should be adjusted according to clinical effect and side effects
84
.
b
Loading dose should not be given to patients already receiving theophylline.
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16
Follow up:
Before discharge from the emergency department or hospital, the condition
of the patient should stable, e.g., out of bed and able to eat and drink
without problem. Family/caregivers should receive:
Instruction on recognition of signs of recurrence and worsening of asth-
ma. The factors that precipitated the exacerbation should be identified
and strategies for future avoidance of these factors implemented
A written individualized action plan including details of accessible
emergency services
A supply of bronchodilator and, where applicable, the remainder of
the course of oral or inhaled glucocorticosteroids or leukotriene modifier
Careful review of inhaler technique
Further treatment advice
A follow-up appointment within 1 week and another within 1-2 months
depending on the clinical, social, and practical context of the exacer-
bation
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NOTES
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The Global Initiative for Asthma is supported by educational grants from:
Copies of this document are available at
www.ginasthma.org
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