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MH-G24V01.

00
Clinical Practice Guideline Code
issued
02/04/2015
For Management of Acute Date
Date Reviewed 02/04/2015
Attack of Bronchial
Next revision 08/04/2016
Pages
i of ii
Asthma in Children

DOCUMENT CONTROL SHEET

Development
And Consultation

Dissemination

Target Audience

Implementation

Training
Audit

Review

Compliance with
National Guidance and
Accreditation Standards

This Guideline is adapted and developed from HMCs guideline on


management of asthma. Modified and drafted by Dr Muna Al
Saadi member walk in services working group at PHCC. The
guideline is review and ratified by PHCC Guideline Review
Committee (PGRC), which is then approved by the Executive
Director of Clinical Affairs
This Guideline will be disseminated to all PHCC Directorates and
Health Centre Managers and clinicians through announcements,
memos and training. It will also be available to view and download
from PHCC intranet web site.
All Health Care professionals in PHCC (with main focus on those
who are involved in triage).
The Head of Section for Primary Care walk in services is
responsible for ensuring the promotion of the Guideline throughout
the organization. The Regional Directors (Operations) are
responsible for ensuring that the Guideline is adhered to in all the
services they are responsible for that are delivering triage. The
Health Centre Managers (Operations) are responsible for
implementing triage within their health centres.
The PHCC Management will ensure that staff receives appropriate
training and support in implementing this Guideline.
The Accreditation Management Team and issuing Directorate are
responsible for auditing this Guideline and verifying that it is
produced to a high standard.
The issuing Directorate in consultation with necessary group(s)
will review this Guideline after 1 year for the first revision cycle and
then every 3 years.
This Guideline complies with National Health Strategy 2011-2016
Goal 2.1.2 and other accreditation bodies such as Accreditation
Canada International (ACI) and national standards where
applicable.

MH-G24V01.00
Clinical Practice Guideline Code
issued
02/04/2015
For Management of Acute Date
Date Reviewed 02/04/2015
Attack of Bronchial
Next revision 08/04/2016
Pages
ii of ii
Asthma in Children

Table of Contents
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.

Introduction .........................................................................................................................1
Purpose/Objective of the Guideline ....................................................................................1
Definitions/Abbreviation ......................................................................................................2
Clinical Specialty .................................................................................................................2
Intended Users ...................................................................................................................2
Target Populations ..............................................................................................................2
Guideline.............................................................................................................................2
Indications for Referral to emergency department ..............................................................5
Recommendations ..............................................................................................................5
Appendices .........................................................................................................................5
References .........................................................................................................................5
Associated Documentation .................................................................................................6

MH-G24V01.00
Clinical Practice Guideline Code
issued
02/04/2015
For Management of Acute Date
Date Reviewed 02/04/2015
Attack of Bronchial
Next revision 08/04/2016
Pages
1 of 6
Asthma in Children

REVISION CONTROL SUMMARY


Edited By

Version

Dr Muna Al Saadi/ PUC


Working Group (WG)
Ronnie Viner
Dr Muna Al Saadi

0.1

Paragraph
No
All

1.0
1.1

All
All

PUC Working Group


(WG)
Naseer Ahmed Iqbal

1.2

All

1.3

All

Naseer Ahmed Iqbal

1.4

All

Naseer Ahmed Iqbal

1.5

All

1.

Description of Change

Date
Approved

Incorporate comments from WG


Incorporate into template
Make further amendments on
subsequent review
Incorporate comments from WG
Definition of mild asthma and list
of life threatening signs and
symptoms
Update paragraph 2,4,5 for
consistency
Update following review at CG
Committee on 05.03.15

Introduction
Asthma is one of the most common chronic disease of childhood and the leading cause of
childhood morbidity measured by school absences, emergency department visits and
hospitalizations. Asthma often begins in early childhood; in up to half of people with asthma,
symptoms commence during childhood.
Risk factors for acute attack:

Uncontrolled asthma symptoms

One or more severe exacerbation in the previous year.

Prior history of near- fatal asthma ( history of admission to intensive care unit )

The start of the childs usual( flare up ) season ( especially if autumn/fall)

Exposures! tobacco smoke, indoor or outdoor air pollution in door allergens( e.g. house
dust mite, cockroach, pets, mold )

Major psychological or socio-economic problems for child or family

Poor adherence with controller medication, or incorrect inhaler technique

2.

Purpose/Objective of the Guideline

2.1.

This guideline is developed to guide clinicians manage acute attacks of bronchial asthma in
children.

2.2.

The guideline aims to standardize evidence based clinical practice in managing acute
attacks of bronchial asthma in children.

MH-G24V01.00
Clinical Practice Guideline Code
issued
02/04/2015
For Management of Acute Date
Date Reviewed 02/04/2015
Attack of Bronchial
Next revision 08/04/2016
Pages
2 of 6
Asthma in Children
3.

Definitions/Abbreviation
Acute exacerbation of asthma (flare- ups or attacks): Is defined as acute or sub-acute
deterioration in asthma symptoms control that is sufficient to cause distress or risk health
and necessitates a visit to GP or requires treatment with corticosteroids. It may occur even
in children taking asthma treatment. Exacerbations usually occur in response to exposure
to an external agent and /or poor compliance with asthma control treatment.

4.

Clinical Specialty
All clinics in PHCC health centers

5.

Intended Users
All Health Care Professionals in primary care clinics within PHCC.

6.

Target Populations
All patients (less than or equal to 18 years of age) attending PHCC health centers clinics
who meet the criteria of the definition.

7.

Guideline

7.1.

Initial assessment:
7.1.1. Follow ABCDEs - refer to ABCDE Procedure.
7.1.2. Refer to patients previous records (if readily available) and carry out a brief focused
history and examination to include:

Suspected cause of exacerbation

The time of onset of exacerbation

Current medication

Recent use of beta agonists (dose and frequency) and / or systemic


glucocorticoids

Risk factors for severe, uncontrolled disease such as emergency department


visits, hospital and intensive care unit admissions.

7.1.3. Undertake a focused examination (in addition to ABCDE for initial assessment) to
identify any severe signs and symptoms:

Pulse oximetry on presentation (SaO2) < 92% in children 5 years or less

Pulse oximetry < 90 % in 6 years or more.

Assessment of ( and any changes in ) the state of consciousness

Fatigue, perspiration, anxiety and agitation

Persistent shortness of breath

Use of accessory muscles of breathing

The inability to speak in full sentences

MH-G24V01.00
Clinical Practice Guideline Code
issued
02/04/2015
For Management of Acute Date
Date Reviewed 02/04/2015
Attack of Bronchial
Next revision 08/04/2016
Pages
3 of 6
Asthma in Children

Breathlessness even while lying down

Bluish tint on lips

No response to inhaled bronchodilators

Absence of wheeze ( Silent chest)

Bradycardia (http://www.webmd.com/asthma/guide/status-asthmaticus)

7.1.4. Acute Asthma Severity Tool: The pulmonary index score (PIS) is an asthma score
based on five clinical variables:

Respiratory rate

Degree of wheezing

Inspiratory to expiratory ratio

Accessory muscle use

Oxygen saturation

7.1.5. Respiratory Rate (RR) for age 6 years:

score zero if RR < 20 min

Score one if RR 21to 35 min,

score 2 if RR 35 to 50,

Score 3 if RR > 50 min.

Pulmonary index score (PIS)

Score

RR

Wheezing
None
End expiration

Inspiratory/
expiratory ratio
2: 1
1:1

Accessory
muscle use
None
+

Oxygen
saturation
99 to 100
96 to 98

0
1

30
31 to 45

46 to 60

Entire expiration

1 :2

++

93 to 95

>60

Inspiration
expiration

+++

< 93

and 1 : 3

o The total score ranges from 0 to 15


o A score of less than 7 indicates a mild attack
o A score of 7 to 11 indicates moderately severe attack
o A score of 12 or greater indicates a severe attack.

MH-G24V01.00
Clinical Practice Guideline Code
issued
02/04/2015
For Management of Acute Date
Date Reviewed 02/04/2015
Attack of Bronchial
Next revision 08/04/2016
Pages
4 of 6
Asthma in Children
7.2.

Management:
The initial severity of the exacerbation and level of treatment needed (i.e. Mild, Moderate, or
severe) can be determined by using an asthma exacerbation severity score such as the
pulmonary index score (PIS):
7.2.1. Severe/Acute Life Threatening Attack: PIS 12:

Call 999, inform needs, urgent transfer to Pediatric Emergency Centre (PEC)

High flow oxygen

Salbutamol at a dose of 0.1 to 0.3mg/Kg,(maximum 2.5mg for less than 5 years


old and 5mg for more than 5 years old), plus Ipratropium at 250mcg If < 20 kg ,
500 mcg dose if > 20 kg should be nebulized on back-to-back basis until
ambulance arrives

Oral Prednisolone at 1-2 mg/kg stat or Hydrocortisone 50-100mg IM.

7.2.2. Moderate Acute Attack: PIS 7 to 11:

Call for Urgent Ambulance

High flow oxygen

Salbutamol at a dose of 0.1 to 0.3mg/Kg, (maximum 2.5mg for less than 5 years
old and 5mg for more than 5 years old), plus Ipratropium at 250mcg should be
nebulized on back-to-back basis every 20 minutes until ambulance arrives. The
patient should get proper clinical evaluation after each dose with proper
documentation. If the patient improves, space out the Salbutamol nebulization
and continue Ipratropium nebulization.

Oral Prednisolone at 1-2 mg/kg stat or Hydrocortisone 50-100mg IM

7.2.3. Mild Acute Asthma: PIS <7:

Inhaled Salbutamol at 0.1 to 0.3 mg/kg by nebulizer once, (maximum 2.5mg for
less than 5 years old and 5 mg for more than 5 years old). The other option is 2 6 puffs of inhaled Salbutamol by spacer every 20 minutes for the first hour and
assess severity; if symptoms persist refer the patient to the Pediatric Emergency
Center (PEC).

Oral Prednisolone at 1-2mg/kg once a day for 3 days.

If good response sustained at least 1 hour, discharge home on Salbutamol


inhaler via spacer / nebulizer 2-4 hourly as needed

If the patient has not improved transfer them to the Pediatric Emergency Center
(PEC).

7.2.4. Antibiotics:
Prescribing antibiotics routinely for acute exacerbation of asthma is not
recommended unless there is an evidence of pneumonia or proven or suspected
bacterial infection

MH-G24V01.00
Clinical Practice Guideline Code
issued
02/04/2015
For Management of Acute Date
Date Reviewed 02/04/2015
Attack of Bronchial
Next revision 08/04/2016
Pages
5 of 6
Asthma in Children
8.

9.

10.

Indications for Referral to emergency department

Severe asthma exacerbations

Underlying lung disease

A history of rapid progression of severity in past exacerbations

Lack of response to initial bronchodilator treatment

Recent treatment with systemic glucocorticoids (includes current treatment with oral
glucocorticoids at the time of presentation) or beta agonist overuse.

Poor social support system at home.

Recommendations

Effective management of exacerbations incorporates the same four components of


asthma management used in managing asthma long term: assessment and monitoring,
patient education, environmental control, and medications.

Immediate transfer should be arranged to the Pediatric Emergency Center if there are
any signs of severe exacerbation.

Chest x ray is not routinely recommended.

Antibiotics should not be routinely prescribed for asthma exacerbations.

Arrange early follow-up after any exacerbation regardless of where it was managed and
within 1week.

A written asthma action plan

Children with poor inspiratory flow or children who cannot cooperate with nebulized
therapy can be treated with Epinephrine administered intramuscularly or subcutaneously
for bronchodilation is 0.01mg/kg ( 0.01ml/kg of 1:1000 solution 1mg/ml)

Appendices
Appendix 1 - Algorithm for the management of asthma exacerbations in primary care

11.

References

11.1. Global Strategy for Asthma Management and Prevention, Revised 2014, Global Initiative
for Asthma (GINA)
11.2. Up to date mar 28. 2014, Acute asthma exacerbations in children, Authors: Gregory
sawicki, MD, MPH. Kenanhaver, MD
11.3. National asthma education and prevention program expert panel report III 2007
11.4. Management of Acute Attack of Bronchial Asthma Clinical Protocol, Hamad Medical
Corporation, CPRO 10520, April 2008 Revised February 2011
11.5. Ortiz-Alvarez, A Mikrogianakis; Canadian Pediatric Society, Acute Care Committee
,Pediatric Child Health 2012;17(5):251-5

MH-G24V01.00
Clinical Practice Guideline Code
issued
02/04/2015
For Management of Acute Date
Date Reviewed 02/04/2015
Attack of Bronchial
Next revision 08/04/2016
Pages
6 of 6
Asthma in Children
11.6. National guideline clearinghouse evidence- based care guideline for management of acute
exacerbation of asthma in children
12.

Associated Documentation

12.1. Triage Procedure - SDHP-P1V01.00


12.2. ABCDE Procedure - PUC-P1V01.00
12.3. Asthma Clinical Guideline - MH-G14V01.00

Appendix 1 - Algorithm for Code


the management of
asthma exacerbations in Pages
primary care

MH-G24V01.00
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Appendix 1 - Algorithm for the management of asthma exacerbations in primary care