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OR Reproduce: Pocket Guide For Asthma Management and Prevention in Children 5 Years and Younger
OR Reproduce: Pocket Guide For Asthma Management and Prevention in Children 5 Years and Younger
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Pocket Guide for
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Asthma Management and
Prevention in Children
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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
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GLOBAL INITIATIVE
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FOR ASTHMA
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PREFACE .......................................................................................2
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WHAT IS KNOWN ABOUT ASTHMA?...........................................3
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DIAGNOSING ASTHMA ..............................................................4
Table 1. Is it Asthma? ..........................................................4
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CLASSIFICATION OF ASTHMA BY LEVEL OF CONTROL ...............5
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Table 2. Levels of Asthma Control in Children
5 Years and Younger ...............................................5
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MANAGEMENT AND PHARMACOLOGIC TREATMENT .................6
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Develop a Partnership Family/Caregivers and Health Care
Providers Identify and Reduce Exposure to Risk Factors ................6
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Table 5.
Low Daily Doses of Inhaled Glucocorticosteroids for
Children 5 Years and Younger ..............................10
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PREFACE
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Asthma is a major cause of chronic morbidity and mortality throughout the
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over the past 20 years, especially in children. The Global Initiative for
world and there is evidence that its prevalence has increased considerably
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Asthma was created to increase awareness of asthma among health pro-
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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-
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able scientific evidence, encourages dissemination and implementation of
the recommendations, and promotes international collaboration on asthma
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research.
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Recommendations in this Pocket Guide present special challenges that must
be taken into account to manage asthma in children during the first 5
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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,
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maintain asthma control for most patients that can be adapted to local
health care systems and resources. Program publications include:
professionals.
Pocket Guide for Asthma Management and Prevention in Children
5 Years and Younger (2009). Summary of patient care information
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This Pocket Guide has been developed from the Global Strategy for
Asthma Management and Prevention in Children 5 Years and Younger
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tions from the scientific literature are included in the source document.
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WHAT IS KNOWN
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ABOUT ASTHMA?
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Unfortunately asthma is the most common chronic disease of child-
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hood and the leading cause of childhood morbidity from chronic disease
as measured by absence from day care, emergency department visits, and
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hospitalizations. There are special challenges that must be taken into
account in managing asthma in children during the first 5 years of life.
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Fortunately asthma in this young age group can be effectively treated
and control can be achieved in most patients.
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When asthma is under control children can:
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Avoid troublesome symptoms night and day
Use little or no reliever medication
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Have productive, physically active lives
Avoid serious attacks
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
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is chronically present.
For many patients, controller medication must be taken daily to prevent
symptoms, improve lung function, and prevent attacks. Reliever medica-
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DIAGNOSING ASTHMA
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Making a definite diagnosis of asthma in children 5 years and younger is
challenging because episodic respiratory symptoms such as wheezing and
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cough are also common in children who do not have asthma, particularly in
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ma, and the younger the child, the greater the likelihood that an alterna-
those younger than 3 years. Not all young children who wheeze have asth-
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considered and excluded before an asthma diagnosis is made.
Alternative causes of recurrent wheezing, particularly in early infancy,
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include infections (recurrent viral lower respiratory tract infections, chronic
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rhino-sinusitis, tuberculosis); congenital problems (cystic fibrosis, bronchopul-
monary dysplasia, congenital malformation causing narrowing of the
intrathoracic airways, primary ciliary dyskinesia syndrome, immune deficien-
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cy, and congenital heart disease) and mechanical problems (foreign body
aspiration).
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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
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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.
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careful clinical assessment of family history and physical findings (Table 1).
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Table 1. Is It Asthma?
Consider asthma if any of the following signs or symptoms are present:
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Pollen
Respiratory (viral) infections
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CLASSIFICATION OF ASTHMA
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BY LEVEL OF CONTROL
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For all patients with a confirmed diagnosis of asthma, the goal of treatment
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is to achieve and maintain control of the disease. However, assessing
asthma control in children 5 years and younger is difficult, because health
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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
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asthma. Additional information about asthma control may be gleaned from
the childs need for reliever/rescue treatment (with increased use indicating
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worsening control).
in any week)
difficult breathing typically for short periods periods on the order or hours or recur, but
of on the order of of minutes and rapidly partially or fully relieved
minutes and rapidly relieved by use of with rapid-acting
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reliever/rescue
treatment
* Any exacerbation should prompt review of maintenance treatment to ensure that it is adequete. Although patients
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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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MANAGEMENT AND
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PHARMACOLOGIC TREATMENT
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Control of asthma can be achieved in a majority of children 5 years and
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younger with an intervention strategy that includes:
A partnership between the childs family/caregivers and the health care team
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Avoidance of risk factors
A plan to assess, treat with appropriate pharmacologic therapy, and
monitor asthma control
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recognize an asthma attack and initiate treatment, recognize a severe
An action plan to enable the childs family members and caregivers to
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episode, and identify when urgent treatment at a hospital (health care
facility) is required.
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Develop a Partnership
Family/Caregivers and Health Care Providers
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With the help of everyone on the health care team, families/caregivers can
be actively involved in managing asthma to prevent problems and enable
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children to live productive, physically active lives. They can learn to:
Help the child avoid risk factors
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caused by asthma, a written asthma action plan based on the levels of res-
For wheezy children 5 years and younger, when wheeze is suspected to be
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Identify and Reduce Exposure to Risk Factors
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To improve control of asthma and reduce medication needs, patients
toms (Table 3). However, many asthma patients react to multiple factors
should take steps to avoid the risk factors that cause their asthma symp-
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that are ubiquitous in the environment, and avoiding some of these factors
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completely is nearly impossible. Thus, medications to maintain asthma
control have an important role because patients are often less sensitive to
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these risk factors when their asthma is under control.
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Table 3. Strategies for Avoiding Common Allergens and Pollutants
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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
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should not smoke.
Drugs, foods, and additives: Avoid if they are known to cause symptoms.
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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
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kill mitesbut make sure the patient is not at home when the treatment
occurs.)
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Animals with fur: Use air filters. (Remove animals from the home, or at least
from the sleeping area. Wash the pet.)
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Cockroaches: Clean the home thoroughly and often. Use pesticide spray
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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.
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Indoor mold: Reduce dampness in the home; clean any damp areas fre-
quently.
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ASSESS, TREAT, AND MONITOR ASTHMA
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The goal of asthma treatmentto achieve and maintain clinical control
can be reached in most patients through a continuous cycle that involves
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Assessing Asthma Control
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Treating to Achieve Control
Monitoring to Maintain Control
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Assessing Asthma Control
Each patient should be assessed to establish his or her current treatment regi-
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men, adherence to the current regimen, and level of asthma control. Current
impairment (day and night symptoms, activity level impairment, need for res-
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cue medications) and future risk (likelihood of acute exacerbation in the
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Treating to Achieve Control
For the treatment of asthma inhaled medications are preferred because
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they deliver drugs directly to the airways where they are needed, resulting
in potent therapeutic effects with fewer systemic side effects.
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prescribed for their child, as different devices need different inhalation techniques.
Give demonstrations and illustrated instructions.
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Information about use of various inhaler devices is found on the GINA
Website (www.ginasthma.org).
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A variety of controller and reliever medications for asthma are available.
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The recommended treatments discussed below are guidelines only. Local
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resources and individual patient circumstances should determine the spe-
cific therapy prescribed for each patient.
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tion to use as needed for quick relief of symptoms. (Parents and care-
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givers should be aware of how much reliever medication the child is
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reliever medication for most patients in this age group.
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If the childs asthma is not controlled with as-needed use of reliever med-
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controller treatment (Table 4).
ication, a low-dose inhaled glucocorticosteroid is the recommended initial
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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
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Table 4. Asthma Management Approach Based on
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Control for Children 5 Years and Younger
Asthma education, Environmental control, and As needed rapid-acting 2-agonists
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on as needed on as needed partly controlled on
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rapid-acting 2-agonists rapid- acting 2-agonists low-dose inhaled
glucocorticosteroid*
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Controller options
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rapid-acting 2-agonists
Continue as needed Low-dose inhaled Double low-dose inhaled
glucocorticosteroid glucocorticosteroid
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Leukotriene modifier Low-dose inhaled
glucocorticosteroid plus
Leukotriene modifier
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*Oral glucocorticosteroids should be used only for treatment of acute severe exacerbations of asthma.
Shaded boxes represent preferred treatment options.
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Drug g)
Low Daily Dose (
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Ciclesonide NS
Mometasone furoate NS
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Triamcinolone acetonide NS
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* 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.
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Monitoring to Maintain Control
Ongoing monitoring is essential to maintain control and establish the low-
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est step and dose of treatment to minimize cost and maximize safety.
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Typically, patients should be seen one to three months after the initial visit,
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and every three months thereafter. After an exacerbation, follow-up should
be offered within two weeks to one month.
Adjusting medication:
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If asthma is not controlled within one to three months by doubling the ini-
tial dose of inhaled glucocorticosteroids, assess and monitor the childs
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inhalation technique, compliance with medication regimen, and avoid-
ance of risk factors.
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If control is maintained for at least 3 months, decrease treatment to the
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least medication necessary to maintain control. Monitoring is still neces-
sary even after control is achieved, as asthma is a variable disease;
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treatment has to be adjusted periodically in response to loss of control as
indicated by worsening symptoms or the development of an exacerbation.
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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-
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Manage Acute Exacerbations
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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-
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temic glucocorticosteroids.
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Do not underestimate the severity of an attack (Table 6); severe asthma
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attacks may be life threatening. Early symptoms may include any of the
following:
An increase in wheeze and shortness of breath
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An increase in coughing, especially nocturnal cough
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Lethargy or reduced exercise tolerance
Impairment of daily activities, including feeding
A poor response to reliever medication
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Upper respiratory symptoms frequently precede the onset of an asthma
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exacerbation.
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Home Management
A health care provider may recommend steps for the family/caregiver to
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more
Seek medical attention the same day if inhaled bronchodilator is
required for symptom relief more than every 3 hours or for more than
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24 hours.
ately.
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Table 6. Initial Assessment of Acute Asthma in Children
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Five Years and Younger
Symptoms Mild Severea
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Altered consciousness No Agitated, confused or
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drowsy
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< 90%
(SaO2)
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Pulse rate < 100 bpmd > 200 bpm (0-3 years)
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> 180 bpm (4-5 years)
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Central cyanosis Absent Likely to be present
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Wheeze intensity Variable May be quiet
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Table 7. Indications for Immediate Referral to Hospital
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short-acting 2-agonist within 1-2 hours
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No response to three (3) administrations of an inhaled
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Tachypnea despite 3 administrations of an inhaled short-acting 2-agonist
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(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
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Cyanosis
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Subcostal retractions
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Oxygen saturation when breathing room air < 92%
Social environment that impairs delivery of acute treatment;
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caregivers unable to manage acute asthma at home
Sedatives.
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Mucolytic drugs.
Chest physical therapy/physiotherapy.
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Table 8: Initial Management of Acute
Severe Asthma in Children 5 Years and Younger*
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Therapy Dose and Administration
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Supplemental Deliver by 24% face mask (flow set to manufacturers
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oxygen instructions, usually 4L/minute)
Maintain oxygen saturation above 94%
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2-agonist
Short-acting 2 puffs salbutamol by spacer,
or
2.5 mg salbutamol by nebulizer
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Every 20 minutes for first hoursa
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Ipratropium 2 puffs every 20 minutes for first hour only
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Oral prednisolone
(1-2 mg/kg daily for up to 5 days)
Systemic
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glucocorticosteroids or
Intravenous methylprednisolone
1 mg/kg every 6 hours on day 1;
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Oral 2-agonists
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No
Long-acting 2-agonist No
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a If inhalation is not possible an intravenous bolus of 5 g/kg given over 5 minutes, followed by
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Follow up:
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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:
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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
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A written individualized action plan including details of accessible
emergency services
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A supply of bronchodilator and, where applicable, the remainder of
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the course of oral or inhaled glucocorticosteroids or leukotriene modifier
bation
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NOTES
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The Global Initiative for Asthma is supported by educational grants from:
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www.ginasthma.org
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