MANAGEMENT PROTOCOL OF PEDIATRICS

SEVERE ASTHMA PATIENTS IN ASELA

TEACHING AND REFERAL HOSPITAL

BY TESFA G/MESKEL

ASELA
ETHIOPIA
SEPTEMBER 2017
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Contents: Page

1. Introduction……………………………………………………….4

1.1. Definition of Asthma………………………………………………………4

1.2. Early childhood risk factors for persistent asthma…………………..…5
1.3. Hyperactive Airways Disease or Reactive Airways Disease………….6
1.4. Etiology and pathogenesis of asthma……………………………………7
1.5. Types of Childhood Asthma………………………………………………8
1.6. Patterns of respiratory symptoms that are characteristic of asthma….8

2. Asthma exacerbations……………………………………………10
2.1. Monitoring……………………………………………………………………10
2.2. Criteria for admission………………………………………………………. 11
2.3. Pulmonary Index Score……………………………………………………. 11
2.4. Classifying Severity of Asthma Exacerbations…………………………...13
2.5. Management of Asthma Exacerbations…………………………………..15

2.5.1. Management of Mild Asthma Exacerbations………………………15

2.5.2. Management of Moderate Asthma Exacerbations………………..17
2.5.3. Management of Severe Asthma Exacerbations………………….. 18
2.5.4. Management of life threatening asthma…………………………… 21

2.6. Criteria for Discharge………………………………………………………..27

2.7. Management of Infantile severe Asthma…………………………………..28
2.8. Asthma Management during Surgery………………………………………29

3. Treatment of chronic Asthma During follow up………………..30

3.1. Classification of Chronic Asthma Severity and Initiating Treatment………31

3.2. Stepwise Approach for Managing Asthma: Preferred Therapy by Age Group...33
3.3. Assessing Asthma control and adjusting therapy in children……………………34
3.4. Estimated Comparative Daily dosages for Inhaled Steroids…………………….35
3.5. Usual dosage for long term Asthma medications…………………………………36

4. Doses of drugs for asthma exacerbations…………………………….37

5. Summary of management of Asthma Exacerbations……………....38
6. References…………………………………………………………………43
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Abbreviations:
API = Asthma Predictive Index
AHR = Airways Hyper Responsiveness
Bid = Twice a day
BiPAP = Bilevel positive airway pressure
cAMP = cyclic Adenosine MonophosPhate
CPAP = Continuous positive airway pressure
CVS = Cardiovascular System
DPI = Dry powder inhaler
ETS = Environmental Tobacco Smoke.
ETT = Endotrachial Tube
FVC = Forced Vital Capacity
FEV1 = Forced expiratory volume in 1 second
GINA = Global Initiative for Asthma
HFA = Hydrofluoroalkane
ICU = Intensive care unit
I:E = inspiration to expiration ratio
Ig = Immunoglobulin
ICS = Inhaled corticosteroids
IM = Intramascular
IV = Intravenous
LABA = Long Acting β Agonists
Min = minutes
Mo = month
NPPV = Noninvasive positive pressure ventilation
OCS = Oral corticosteroids
PCO2 = partial pressure of carbon dioxide
PO2 = partial pressure of oxygen
PEFR = Peek Expiratory Flow Rate
PFT = Pulmonary function tests
PIS = Pulmonary Index Score
pMD = pressurized metered dose inhaler
PRVC = Pressure regulated volume control
PSV = Pressure for spontaneous ventilation
Qid = 4 times a day;
SABA = Short Acting β Agonist
SaO2 = arterial oxygen saturation
Sc = Subcutaneous
SIMV = Synchronized intermittent mechanical ventilation
SOB = Shortness of Breath
TV = tidal volume
TLC = Lung Capacity
URTI = Upper Respiratory Tract Infection
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VC = volume controlled
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Yr = Year
Introduction
Asthma is defined as a disease of the airways with inflammation, constriction of airway
smooth muscles, mucous production and edema that lead to obstruction and air
trapping. i.e: airway inflammation, bronchial hyperreactivity, and reversibility of
obstruction.

It is characterized by the history of respiratory symptoms such as cough, wheezing,

chest tightness, prolonged exhalation, and/or shortness of breath together with variable
expiratory airflow limitation. Both symptoms and airflow limitation characteristically vary
over time and in intensity. These variations are often triggered by factors such as
exercise, allergen or irritant exposure, change in weather, or viral respiratory infections.

When the airways of patients with asthma are exposed to environmental triggers, they
respond with exaggerated bronchoconstriction, a phenomenon that is commonly
described as airway hyperresponsiveness.

Not all children who wheeze have asthma. There are three identified patterns of infant
wheezing:
 The transient early wheezer wheeze at least once with a lower respiratory
infection before the age of 3 yr , but never wheeze again and is seen in 19.9% of
the general population.
 The persistent wheezer has wheezing episodes before age 3 yr and is still
wheezing at 6 yr of age and is seen in 13.7% of the general population.
 The late-onset wheezer does not wheeze before age 3 yr but is wheezing by 6 yr
and is seen in 15% of the general population.
The remaining 50% of the population never wheezing prior to age 6 yr.
Of all the infants who wheezed before 3 years old, almost 60% stopped wheezing by
age 6 yr.
Multiple studies have tried to predict which early wheezers will go on to have asthma in
later life.

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Early childhood risk factors for persistent asthma:
Parental asthma
Allergy:
• Atopic dermatitis (eczema)
• Allergic rhinitis
• Food allergy
• Inhalant allergen sensitization
• Food allergen sensitization
Severe lower respiratory tract infection:
• Pneumonia
• Bronchiolitis requiring hospitalization
Wheezing apart from colds
Eosinophilia (>4%),
Male gender
Low birthweight
Environmental tobacco smoke exposure
Reduced lung function at birth

Children with a history of four or more wheezing exacerbations (at least one is
diagnosed by physician) and either one major or two minor criteria at 3 years of age will
have 4–10 fold increase in the risk of having asthma during later childhood. On other
side, children with negative modified- API will have 95% chance of outgrowing their
asthma later on life.

Modified Asthma Predictive Index:

History of ≥4 wheezing episodes with at least one physician-diagnosed and either
One (or more) of the major criteria Two (or more) of the minor criteria
Parental history of asthma Eosinophilia (≥4%)
Skin test positive to aero-allergens or Wheezing unrelated to colds
Eczema (physician-diagnosed atopic Allergic sensitization to milk, egg, or
dermatitis) peanuts

For pre–school-age children with frequent wheezing in the past year, one major criterion
or two minor criteria provide a high specificity (97%) and positive predictive value (77%)
for persistent asthma into later childhood.

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“Hyperactive Airways Disease or Reactive Airways Disease”

Perhaps the most common use of the term "reactive airways" is employed in
pediatrics to those children having cough, shortnrss of breath and wheezing in
general before the age of 3 years. Its use is generated by the fact that:
 Wheezing is quite common in infants, and only about a third of those
infants who wheeze ever develops true asthma,
 The history is difficult to obtain,
 Good quality pulmonary function tests cannot be obtained,
 Asthma is a diagnosis that carries a negative connotation for the patients.

Thus, the term ―reactive airways disease‖ may be used as a nonspecific term in
clinical contexts ranging from asthma, to wheezy bronchitis, to viral bronchiolitis, or
even to pneumonia. Because of this, rather than refer to wheezing infants, who
may never really be asthmatics, as having asthma (and thus labeling them with
the disease), many physicians have employed the term "reactive airways" to
refer to this group of children. Asthma can be considered a reactive airways
disease, but the term "reactive airways disease" refers to many other conditions
which have only been loosely defined and it is highly nonspecific.

The problem with the term reactive airways or reactive airways disease is not just that
they represent an annoyance to purists of terminology and to those who want to
maintain diagnostic clarity in practical medical discipline, but the terms may provide
physicians with a false sense of diagnosis security and the term represents a form of
diagnostic laziness and ascribing a label of reactive airways to a patient may be harmful
in this context, because it may prevent work-up of the cause of the symptom complex
that led to the diagnosis of reactive airways disease in the first place.

Some setups have abandoned this terminology from the medical practice. Because this
term alone cannot stand as a clear diagnosis by itself; admitted patients shouldn‘t be
discharged with the diagnosis of Hyperactive airway disease or Reactive airway disease
before the actual Diagnosis is settled.

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Etiology and pathogenesis of asthma: A combination of environmental and genetic
factors in early life shape how the immune system develops and responds to ubiquitous
environmental exposures. Respiratory microbes, inhaled allergens, and toxins that can
injure the lower airways target the disease process to the lungs. Unusual immune and
repair responses to airways injury underlie persistent disease:

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AHR, airways hyperresponsiveness; ETS, environmental tobacco smoke.

Types of Childhood Asthma:

 Based on different natural courses: there are 2 common types of childhood

asthma:
 Recurrent wheezing in early childhood, primarily
triggered by common respiratory viral infections, usually resolves during the
preschool/lower school years
 Chronic asthma associated with allergy that persists into later childhood and
often adulthood

 Based on disease severity, Asthma is also classified as:

 Intermittent
 Persistent [mild, moderate, or severe]

 Based on disease control(especially for asthma management purposes),

Asthma is also classified as:
 Well controlled
 Not well controlled
 Very poorly controlled.

 Based on treatment response and medication requirements children with asthma

can also be characterized as:
 Easy-to-treat: well controlled with low levels of controller therapy
 Difficult-to-treat: well controlled with multiple and/or high levels of controller
therapies
 Exacerbators: despite being well controlled, continue to have severe
exacerbations
 Refractory asthma: continue to have poorly controlled asthma despite multiple
and high levels of controller therapies.

Patterns of respiratory symptoms that are characteristic of asthma

The following features are typical of asthma and, if present, increase the probability that
the patient has asthma:
 More than one symptom (wheeze, shortness of breath, cough, chest tightness)
 Symptoms often worse at night or in the early morning
 Symptoms vary over time and in intensity
 Symptoms are triggered by viral infections (colds), exercise, and allergen
exposure, changes in weather, laughter, or irritants such as car exhaust fumes,
smoke or strong smells.
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 Asthma diagnosis in children
Symptom and sign Remarks
History of multiple flare-ups of caugh, SOB >3 flare-ups/season
and wheezing in a season
Coughing >2 weeks, during sleep, not related to URTI
Wheezing Equal at both sides of the chest, during
expiratory phase, especially on forced
expiration
Atopy Eczema, environmental/food sensitization
Family history Atopy, Asthma
Breath sounds Prolonged expiratory phase
Therapeutic trial Trial of short-acting bronchodilator or
corticosteroid therapy
Spirometry Typically in children >6 years with
bronchodilator response assessment
Chest X-ray May be considered in infants to rule out
congenital causes or complications
Tests for hypersensitivity Both skin testing or/and allergen-specific IgE
blood testing
SOB=Shortness of breath, URTI=Upper respiratory tract infection, IgE=Immunoglobulin E

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Asthma exacerbations:
Exacerbations of asthma are episodes characterized by a progressive increase in
symptoms of shortness of breath, cough, wheezing or chest tightness and progressive
decrease in lung function

Exacerbations may occur in patients with a pre-existing diagnosis of asthma or,

occasionally, as the first presentation of asthma. Exacerbations usually occur in
response to exposure to an external agent (e.g. viral upper respiratory tract infection,
pollen or pollution) and/or poor adherence with controller medication.

Monitoring:

Clinical status and response to therapy must be monitored frequently during treatment
for acute asthma exacerbation. A variety of tools are used for this purpose in children:

Clinical assessment: vital signs, sign symptom for respiratory distress and pulse
oximetry should be assessed immediately upon arrival to the inpatient unit. Patients
typically are assessed every 15 minutes to every four hours, depending upon clinical
status.

Asthma scores: the score is the sum of numeric ratings for five parameters:
respiratory rate, accessory muscle use, air exchange, wheeze, and inspiratory:
expiratory ratio. Bronchodilator is administered for a score of 2 or more.

Pulmonary function:

Pulmonary function tests (PFT) provide objective and reproducible measurements of

airway function and lung volumes. PFTs are used to characterize disease, assess
severity and follow response to therapy.

Peek Expiratory Flow Rate (PEFR): is the maximum flow rate generated during a forced
expiratory maneuver. It is useful in following the course of asthma and response to
therapy. Compare a patient‘s PEFR to the ―previous personal best‖ and the normal
predicted value. Normal predicted values vary across different racial groups. Therefore,
the best indicator of patient condition is comparison to their own personal best.

PEFR may be unobtainable and/or of limited value during an exacerbation.

Diurnal variation in PEF >20% is consistent with asthma

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Spirometry: is the plot of airflow versus time. Measurements are made from a rapid,
forceful and complete expiration from Total Lung Capacity (TLC) to Residual Volume
(RV). Spirometry is usually performed before and after a bronchodilator to assess
response to therapy or after bronchial challenge to assess airway hyperreactivity:

 Forced Vital Capacity (FVC): is the maximum volume of air exhaled from the
lungs after a maximum inspiration. Bedside measurement of vital capacity with a
handled spirometer can be useful in conforming or predicting hypoventilation
associated with muscle weakness. FVC < 15ml/kg may be an indication for
ventilatory support.
 Forced Expiratory Volume in 1 second (FEV 1): volume exhaled during the first
second of FVC maneuver. It is the single best measure of airway function.
 Forced Expiratory Flow (FEF25 – 75%): mean rate of airflow over the middle half of
the FVC between 25% and 75% of FVC. sensitive to medium and small airway
function.

Measuring exhaled nitric oxide (FENO): a marker of airway inflammation

in allergy-associated asthma, may possibly help adjust anti-inflammatory
management and confirm the diagnosis of asthma.

Criteria for admission:

 Children who require beta 2-agonist therapy more often than every 2 to 3 hours,
 Those who require supplemental oxygen
 A history of rapid progression of severity in past exacerbations
 Poor adherence with outpatient medication regimen
 Inadequate access to medical care
 Poor social support system at home

Asthma scores — several scoring systems have been developed to standardize and
facilitate assessment of asthma severity in children. These scores also can be used to
evaluate the response to treatment and guide changes in the frequency of
bronchodilator administration. However, they must be used with caution in preschool-
aged children.

Pulmonary index — 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, and oxygen saturation. Each variable is assigned a score
from 0 to 3. Total scores range from 0 to 15.

The PIS has been validated and used as an outcome measure in several clinical trials.
It can be used to assess initial severity, judge response to treatment, and facilitate
admission and discharge planning.
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NB: Respiratory rate for patients ≥age 6: through 20, score 0; 21-35, score 1; 36-50,
score 2; >50, score 3. The total score ranges from 0 to 15. If no wheezing due to
minimal air entry, score 3. Accessory muscle use: 1 point for suprasternal or intercostal
retractions; 2 points for subcostal retractions, 3 points for neck or abdominal muscle use
with paradoxical movement.

In general, a score of less than 7 indicates a mild attack, a score of 7 to 11 indicates a

moderately severe attack and a score of 12 or greater indicates a severe attack.
However, the Pulmonary Index Score may underestimate the degree of illness in an
older child.

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Classifying Severity of Asthma Exacerbations in the Emergency care setting:
Parameter Mild Moderate Sever Impending
respiratory
failure
Pulmonary Pis < 7 Pis 7 - 11 Pis > 12
index score(Pis)
Symptoms

Breathlessness While walking While at rest While at rest

Can lie down (infant—softer, (infant—
shorter cry, stops feeding)
difficulty Sits upright
feeding)
Prefers sitting
Talks in Sentences Phrases Words Unable to talk

Alertness May be agitated Usually agitated Usually agitated Drowsy or confused

Signs

Respiratory rate Increased Increased Often >30

(Normal values breaths/min
by age):
Age <2 mo, <60
breaths/min
age 2-12 mo,
<50 breaths/min
age 1-5 yr, <40
breaths/min
age 6-8 yr, <30
breaths/min
Use of Usually not Commonly Usually Paradoxical
accessory thoracoabdominal
movement
muscles
(suprasternal
retractions)
Wheeze Moderate; often Loud; throughout Usually loud; Absence of wheeze,
only exhalation throughout silent chest
end-expiratory inhalation and
exhalation
Pulse rate <100 100-120 >120 Bradycardia
(Normal values
by age):
age: 2-12 mo,
<160 beats/min
age; 1-2 yr,
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<120 beats/min
age; 2-8 yr,
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<110 beats/min
Pulsus Absent May be present Often present Bradycardia Absence
paradoxus <10 mm Hg 10-25 mm Hg >25 mm Hg suggests respiratory
(adult) muscle fatigue
20-40 mm Hg
(child)
Functional assessment

Peak expiratory ≥70% Approx. 40-69% <40% <25%§

flow or response
lasts <2 hr
(value predicted
or
personal best)
Pao2 (breathing Normal (test not ≥60 mm Hg (test <60 mm Hg;
air) usually not usually possible
necessary) necessary) cyanosis

PCO2 <42 mm Hg <42 mm Hg ≥42 mm Hg; possible

respiratory failure
SaO2 (breathing >95% 90-95% <90%
air) at sea level
Hypercapnia (hypoventilation) develops more readily in young children than in adults and adolescents

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Management of Asthma Exacerbations:
Patients with lack of response or worsening of these parameters need more frequent
treatments. Patients who are stable but not significantly improved should continue on
the same frequency of treatments. Patients with clear improvement of the above
parameters should have the interval between their treatments increased. In addition to
the regularly scheduled beta 2-agonist treatment, "as needed" treatments should be
available for episodes of acute bronchospasm or worsening respiratory distress.

The primary therapies for the management of an exacerbation to relieve airflow

obstruction and hypoxemia include:
 All patients with exacerbations need repetitive administration of rapid-acting
inhaled β2-agonist bronchodilator;
 Many of them need early introduction of systemic glucocorticosteroids and
oxygen supplementation.

Management of Mild Asthma Exacerbations:

Mild asthma exacerbations are just outside the normal range of variation for an
individual patient and are difficult to distinguish from transient loss of asthma control.

Children with mild asthma exacerbation (PIS <7), can be managed at home or at OPD
level and the following management is suggested:

 Inhaled β2 agonists (Salbutamol) are preferably delivered by pressurized

metered dose inhaler (pMDI) with a spacer 4 puffs to be given every 20 minutes
for the first hour; each puff (100 microgram/puff) is inhaled separately with five
tidal breaths or at 10 - 15 second intervals.
 If there is improvement and the response lasts for 4 to 6 hours the SABA can be
given as 4 puffs every 6 hours for 24 to 48 hours then PRN.
 If there is incomplete improvement, continue the SABA 4 puffs every 1 hourly for
4 – 6 hours, then if there is good response that lasts for 4 to 6 hours give the
SABA every 4 to 6 hourly for 24 – 48 hours then PRN.
 SAΒ-Agonists are: Sympathomimetic agents

 That cause bronchodilatation due to bronchial smooth muscle relaxation

by activating β2-adrenergic receptors, which increase intracellular cyclic
adenosine monophosphate (cAMP) concentrations within smooth
muscles. cAMP inhibits the release of calcium ion from intracellular stores
and reduces the membrane calcium entry and its intracellular
sequestration, leading to airway smooth muscle relaxation.
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  The most reported adverse drug reactions with SAβ-agonists are
 CVS: Tachycardia, diastolic hypotension, arrhythmias, and
prolonged QTc interval.
 Tremors,
 Nausea
 Hypokalemia as a result of intracellular potassium shifting from an
increased number of sodium-potassium pumps.

Age Preferred device Alternative device

<4 years MDI + spacer with face Nebulizer with face mask
mask
4–6 years MDI + spacer with Nebulizer with mouthpiece
mouthpiece
>6 years Dry powder inhaler, breath Nebulizer with mouthpiece
actuated pressurized MDI,
MDI + spacer with
mouthpiece
MDI=Metered dose inhaler, GINA=Global Initiative for Asthma

 Homemade spacers from plastic bottles are as effective as commercial spacers

in the treatment of acute asthma.
 Administration of supplemental oxygen if oxygen saturation is ≤92% in room air,
to maintain oxygen saturation at > 92%.Because frequent SAβ-agonist therapy
can cause ventilation–perfusion mismatch and hypoxemia, Oxygen is important
part of the management in Asthma exacerbations.
 Administration of systemic glucocorticoids to those who fail to improve after one
inhalation therapy, a short course of oral corticosteroid therapy (prednisone 1
mg/kg/day for 3 to 5 days). The effect starts within 1 to 3 hours and peaks at 4 to
8 hours.
 Steroids control airway inflammation( Mucous production is decreased, and
inflammatory cell infiltration and activation are reduced) through a number of
mechanisms, such as:

 Reducing the number and activation of lymphocytes, eosinophils, mast

cells, and macrophages;
 Suppressing the production of cytokines, tumor necrosis factor-α,
granulocyte-macrophage colony-stimulating factor, adhesion molecules,
 Suppressing the production of inducible enzymes: including nitric oxide
synthase and cyclooxygenase-2.
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Management of Moderate Asthma Exacerbations:

Moderate asthma exacerbations (PIS 7 to 11)

 For Moderate acute asthma attacks, Inhaled β2 agonists (Salbutamol) are

preferably delivered by pressurized metered dose inhaler (pMDI) with a spacer
4puffs to be given every 20 minutes for the first hour; each puff (100
microgram/puff) is inhaled separately with five tidal breaths or at 10 - 15 second
intervals.
 If there is good response that lasts for > 3hrs, continue Inhaled SABA every 4
hourly for 24 hours, then every 6 hourly for 24 – 48 hours then PRN.
 If there is incomplete improvement, continue the SABA 4 puffs every 1 hourly for
4 – 6 hours, then if there is good response that lasts for >3hours give the SABA
every 4 hourly for 24 hours then every 6 hourly for 24 – 48 hours then PRN.
 Administration of supplemental oxygen if oxygen saturation ≤92% in room air, to
maintain oxygen saturation at > 92%.
 Administration of systemic glucocorticoids soon after arrival in the emergency
department or after the first inhalation therapy is initiated as oral
prednisolone1mg/kg daily for 3 - 5days.
 If there is incomplete improvement after the first hour Ipratropium bromide can be
added. Ipratropium, in 0.25 to 0.50 mg doses, can be used every 20 minutes for
1 hour, followed by the same dose range every 6 hours. Nebulized ipratropium
bromide is considered as an important adjunct in the treatment of moderate to
severe asthma exacerbation. Ipratropium bromide is usually given with a SAB2-
agonist to augment and sustain bronchodilatation in acute asthmatics.
 Ipratropium bromide nebuluzed mixed with SABA: Ipratropium with
albuterol:Nebulizer solution (0.5 mg ipratropium + 2.5 mg albuterol/3 mL vial) can
be used every 20 minutes for 1 hour, followed by the same dose range every 6
hours for 48 hours.
 Ipratropium bromide can produce bronchodilatation by inhibition of cholinergic-
mediated bronchospasm, occurring without the inhibition of mucociliary
clearance. The parasympatholytic effect is produced by blocking acetylcholine
interaction with the muscarinic receptors on bronchial smooth muscle cells and
reducing intracellular cyclic guanosine monophosphate concentrations that
impair bronchoconstriction.

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Management of Severe Asthma Exacerbations:

Severe asthma exacerbations: formerly known as status asthmaticus, is defined as

severe exacerbation of asthma that does not improve with standard therapy or to
repeated courses of ß2 agonist therapy.

For children with severe asthma exacerbation (PIS ≥12,), the following approach is
suggested:

 Oxygen Administration: It is imperative to give supplemental oxygen to all

hypoxemic patients with acute severe asthma to maintain a SpO2 level of ≥92%.
A lack of pulse oximetry should not prevent the use of oxygen.
 Treatment with β-agonists may aggravate hypoxemia by increasing cardiac
output and eliminating the compensatory hypoxic pulmonary vasoconstriction.
Oxygen should be used as carrier gas for intermittent or continuous nebulization.
 The preffered therapy is with Nebulised albuterol/salbutamol: with a dose of 2.5
mg for children who weigh less than 30 kg and 5 mg for children who weigh more
than 30 kg, may be used diluted with 3 mL saline every 20 minutes for 1 hour.or
Continuous nebulized albuterol is typically given at a dose of 0.5 mg/kg per hour.

 In our setup we can use Inhaled β2 agonists (Salbutamol) delivered by

pressurized metered dose inhaler (pMDI) with a spacer 6 puffs to be given every
20 minutes for the first hour; each puff is inhaled separately with five tidal breaths
or at 10 - 15 second intervals. Continue with 6 puffs as appropriate every one-to-
four hourly.
 Increase SABA dose by 2 puffs every 2 minutes according to response up to 10
puffs.
 Administration of systemic glucocorticoids soon after arrival in the emergency
department or after the first inhalation therapy is initiated as oral prednisolone1
mg/kg daily for 3 - 5days. Or if the patient is unable to take po, IV Hydrocortisone
4mg/kg QID or administration of IV methylprednisolone 1mg/kg, in 2 divided
doses can be given then change to PO prednisolone 1mg/kg/day when patient is
able to tolerate orally to complete for 5 days.
 Nebulised ipratropium in 0.25 to 0.50 mg doses, can be used every 20 minutes
for 1 hour, followed by the same dose range every 6 hours.The preferred method
is to use Ipratropium bromide nebuluzed mixed with SABA: Ipratropium with
albuterol:Nebulizer solution (0.5 mg ipratropium + 2.5 mg albuterol/3 mL vial) can
be used every 20 minutes for 1 hour, followed by the same dose range every 6
hours for 48 hours.
 Subsequent management depends upon response to initial therapy.

 For patients who improve after the initial treatment, the approach is as described
above for moderate exacerbations on improvement: continue the SABA 6 puffs
every 1 hourly for 4 – 6 hours, then if there is good response that lasts for
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>3hours give the SABA every 4 hourly for 24 hours then every 6 hourly for 24 –
Page

48 hours then PRN.

 For patients with a poor response to initial treatment, we recommend several
therapies, including:
 Nebulized racemic epinephrine 0.01ml/kg (maximum 0.5ml) diluted
with 3ml NS every 20 minits for one hour can be used successfully
to treat severe acute asthma following failure of standard first-line
therapies.
 magnesium sulfate: for the treatment of acute asthma exacerbation
refractory to conventional therapies, an initial bolus dose of 50
mg/kg (maximum dose, 2 g) infused for 20 minutes is
recommended, followed by continuous infusion dependent on the
patient‘s weight. Children weighing less than 30 kg may receive an
infusion of 25 mg/kg/h and children weighing more than 30 kg may
receive 20 mg/kg/h, although infusion rates must not exceed 2 g/h
in any patient. Can repeat once or twice after 4-6 hrs.
 Magnesium Sulfate:
 Magnesium is a calcium antagonist that causes smooth
muscle relaxation as a result of the inhibition of calcium
uptake.
 With respect to asthmatic patients, mechanisms such as the
inhibitory action on smooth muscle contraction, histamine
release from mast cells, acetylcholine release from nerve
terminals, and sedative action.
 Adverse drug reactions, such as nausea, flushing,
somnolence, vision changes, muscle weakness, and
hypotension, were reported with magnesium concentrations
above 9 mg/dL.

 For patients who do not respond to these interventions,

 Parenterally administered epinephrine: Adrenaline 0.01 ml/kg of a
1:1000 solution administered SC or IM may be used in patients who
are moribund on presentation to the ED, or where inhaled therapy
is not available.
 Alternatively terbutaline (0.01 mL/kg of a 1 mg/mL solution) with a
maximum dose of 0.4 mg (0.4 mL) may be administered
intramuscularly or subcutaneously for children with poor inspiratory
flow or children who cannot cooperate with nebulized therapy.
 Terbutaline: Intravenous β2-agonist should be considered in
patients who are not improving with continuous albuterol
nebulization, probably owing to decreased respiratory flow and tidal
volume resulting in a reduction of drug delivery to the small
airways.
 Administration of IV terbutaline infusion may be indicated: bolus
with 10 microgram/kg over ten minutes, then 0.3 to 0.5
microgram/kg per minute; infusion may be increased by 0.5
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microgram/kg per minute every 30 minutes to a maximum of 5

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microgram/kg minute.
 Salbutamol IV: Bolus: 5microgram/kg/min for first hour then
consider Infusion: 1-2 microgram/kg/min
 Iv aminophyline:
 Methylxanthines are formed by the methylationof xanthines,
such as theophylline.
 The combination of theophylline and ethylenediaminen
generates a water-soluble salt, aminophylline.Theophylline
dose is 80% of the aminophylline dose. The therapeutic
range for theophylline is narrow, 10 to 20 mcg/mL, and
overlaps with toxicity concentrations, which occurs above 15
mcg/mL. Theophylline should be used for children with
severe acute asthma exacerbation or with impeding
respiratory failure.
 A loading intravenous dose, 5mg/kg of theophylline or 6
mg/kg of aminophylline, given during 20 minutes is needed
to achieve a therapeutic concentration. The drug clearance
is decreased in neonates and infants, and, therefore,
infusion rates are based on patient age. Recommended
doses for infants younger than 6 months are 0.5 mg/kg/h; for
infants 6 months to 1 year, 0.85 to 1 mg/kg/h; for children 1
to 9 years, 1 mg/ kg/h; and for children older than 9 years,
0.75 mg/kg/h.
 The proposed mechanism for bronchodilatation involves:
 The non-selective inhibition of phosphodiesterase
isoenzymes, which reduces the intracellular
degradation of cAMP.
 Other mechanisms include increased respiratory
drive and diaphragmatic contractility, stimulation of
endogenous catecholamine release, prostaglandin
antagonism, and inhibition of afferent neuronal
activity.
 In addition, theophylline is known to have anti-
inflammatory and immunomodulatory effects.
 Inhaled heliox (helium and oxygen mixture) have demonstrated
some benefit as adjunctive therapies in patients with severe status
asthmaticus.
 Helium-Oxygen Mixture (Heliox): Limited evidence exists for the
efficacy of helium-oxygen mixtures (i.e., heliox), typically 70%:30%
or 79%:21%, in children with severe acute asthma
 Helium is a low-density gas that, when used in a mixture
with oxygen, reduces turbulent airflow, enhancing laminar
flow and in consequence reducing airflow resistance.
 Heliox promotes a greater delivery and percentage of
particle retention from nebulized albuterol.
20
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Management of life threatening asthma:

Risk factors for potentially fatal asthma in children; acute severe asthma
associated with a respiratory arrest:

 A history of near-fatal asthma requiring intubation and mechanical ventilation

 Hospitalization or emergency care visit for asthma in the past year
 Currently using or having recently stopped using oral corticosteroids (a marker of
event severity)
 Not currently using inhaled corticosteroids
 Excessive use of or overdependence on ß2 agonists
 Poor adherence with asthma medications and/or poor adherence with (or lack of)
a written asthma action plan
 Food allergy in a patient with asthma
 Repeated attendances at emergency unit for asthma treatment, especially if in
the last year
 ‗Brittle‘ asthma (sudden onset of acute severe asthma attacks)
 Psychosocial and/or family problems

Management:

 Start with A B C of life

 A: make sure the patency of Airways
 B: Children with a severe life threatening acute asthma attack should be given
100% oxygen.
 C: secure IV line with IV 1/3 NS + 2/3 DW as maintenance infusion.

 Start with the management of Severe Asthma exacerbation

 The preffered therapy is with Nebulised albuterol/salbutamol: in the form of

Nebulized albuterol: with a dose of 2.5 mg for children who weigh less than 30
kg and 5 mg for children who weigh more than 30 kg, may be used diluted with 3
mL saline every 20 minutes for 1 hour.or Continuous nebulized albuterol is
typically given at a dose of 0.5 mg/kg per hour.

 In our setup we can use Inhaled β2 agonists delivered by pressurized metered

dose inhaler (pMDI) with a spacer 6 puffs to be given every 20 minutes for the
first hour; each puff is inhaled separately with five tidal breaths or at 10 - 15
second intervals. Continue with 6 puffs as appropriate every one-to- four hourly.
 Increase SABA dose by 2 puffs every 2 minutes according to response up to 10
21

puffs.
Page
 Ipratropium bromide nebuluzed mixed with SABA: Ipratropium with
albuterol:Nebulizer solution (0.5 mg ipratropium + 2.5 mg albuterol/3 mL vial) can
be used every 20 minutes for 1 hour, followed by the same dose range every 6
hours for 48 hours.
 Hydrocortisone 4 mg/kg IV QID.
 Give bolus magnesium sulphate IV 50 mg/kg (Magnesium sulphate 50%
solution 0.1 mL/kg, diluted 1 in 5 with 5% Dextrose or 0.9% Sodium Chloride and
administered over 20 min).
 Nebulized racemic epinephrine can be tried
 Alternatively,Parenteral (subcutaneous or intramuscular) epinephrine or
terbutaline may be effective in patients with life-threatening obstruction that is not
responding to high doses of inhaled β-agonists, because in such patients,
inhaled medication may not reach the lower airway: Epinephrine or terbutaline
(0.01 mL/kg of a 1 mg/mL solution) with a maximum dose of 0.4 mg (0.4 mL)
may be administered intramuscularly or subcutaneously for children with poor
inspiratory flow or children who cannot cooperate with nebulized therapy.
 Also consider aminophylline 6 mg/kg IV over 20 min. Following loading dose
consider giving continuous infusion.
 If poor response to IV aminophylline, or child is very sick, also give IV
salbutamol 5 microgram/kg/min for one hour as a load, followed by 1-2
microgram/kg/min (Aminophylline and salbutamol must be given via
separate IV lines).
 Inhaled Heliox is Helium and oxygen blended gas that reduces turbulent flow of
oxygen to lower airway and reduces work of breathing.

 Then if no response: Mechanical ventilation

 Although respiratory failure is infrequent in asthma, children experiencing severe

asthma exacerbations occasionally deteriorate, and respiratory support may be
required.

 Noninvasive positive pressure ventilation (NPPV) involves the delivery of positive

airway pressure, either as continuous pressure (continuous positive airway
pressure, CPAP) or as mechanically assisted breaths (bilevel positive airway
pressure, BiPAP), without placement of an artificial airway.

 Bilevel positive airway pressure (BPAP) ventilation can offer significant

respiratory support to selected children with life threatnening asthma and may
allow these children to avoid intubation.
 Typically recommended settings with BPAP include an inspiratory positive airway
pressure of 10 cm H2O, an expiratory positive airway pressure of 5 cm H2O, with
or without a low back-up ventilation rate.
22
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 Bilevel Positive Airway Pressure is a noninvasive ventilation that:
 Increases oxygenation
 Increases delivery of inhaled beta agonists
 Reduces work of breathing

 Those judged to require mechanical ventilation should initially be placed

 on a fraction of inspired oxygen (FIO2) of 1,
 with low tidal volumes of between of 5-7 ml/Kg,
 a low positive end expiratory pressure (PEEP) of below 5 cm H20,
 a long expiratory time with a Inspiratory to Expiratory Ratio (I: E
ratio) of more than 1:2
 a low breathing frequency of 8- 10 per minute.
 The peak inspiratory pressure should be limited to below 40
cmH2O.
 Signs of deterioration and impending respiratory failure include:
 Poor air movement
 Worsening hypoxemia or increasing dyspnoea
 Fatigue
 Change in mental status: confusion,
 a pulsus paradoxus of more than 40 mmHg
 Carbon dioxide retention: a rising PaCO2 of 5-10 mm/ h or PaCO2
>55 mmHg, respiratory acidosis with a pH <7.25.
 Hypotension
 Bradicardia
 For children with refractory symptoms and impending respiratory failure,
intubation may be necessary. All other therapies should be attempted and
maximized prior to intubation.
 Indications for intubation in children with status asthmaticus include:
 Cardiopulmonary arrest,
 Severe hypoxia, or
 Rapid deterioration in mental state
 In a child who responds poorly to initial therapy and shows a rising
PCO2.

 Intubation:
 Patients must be preoxygenated with 100% oxygen, and hypotension should be
anticipated as a result of positive pressure ventilation.
 ETT Size and depth:
 Size of cuffed ETT = age in year/4 + 3.5(preferred)
 Size of uncuffed ETT = age in year/4 + 4
 Depth of ETT = age/2 + 12 or 3 x ETT size

 Rapid sequence intubation should proceed with premedication (if indicated), a

23

sedative or anesthetic, and a rapid-acting paralytic. Pretreatment can be given to

attempt to attenuate the adverse effects of laryngoscopy and intubation:
Page
 In infants and children aged < 8 years, atropine may be given to blunt the
reflexive bradycardia that may result from vagal stimulation during
endotracheal intubation.
 Lidocaine may also be given to patients of all ages to diminish the reflex-
ive bronchospasm that may occur in those with reactive airway disease as
well as to prevent increases in intracranial pressure in patients with
intracranial pathology.
 Ketamine is the preferred induction agent in patients with severe asthma
due to its bronchodilatory action:
 Ketamine, a non-competitive N-methyl-Daspartate receptor
antagonist, is used routinely as an anesthetic, analgesic, sedative
and bronchodilator.
 In critically ill children with asthma, a loading dose of ketamine (2
mg/kg) followed by continuous infusions (20-60 mcg/kg/min)
significantly improved the PaO2/FiO2 ratio in all patients, the
dynamic compliance and PaCO2, and peak inspiratory pressures in
mechanically ventilated patients.
 Ketamine infusions have been used in patients with near-fatal
asthma, in combination with other bronchodilator therapies. Several
small case series of nonintubated children treated with ketamine
suggest that ketamine improves acute asthma

 Succinylcholine and rocuronium are the 2 most commonly preferred

neuromuscular blockade agents for rapid sequence intubation in most
children. Succinylcholine has a high side-effect profile (including malignant
hyperthermia, hyperkalemia, bradycardia, and prolonged blockade) due to
a deficiency or absence of pseudocholinesterase. In contrast, rocuronium
is generally safe and has very few side effects, so it is often the preferred
agent; however, the prolonged duration of action of rocuronium must be
weighed against the risk of side effects associated with succinylcholine.

24
Page
Considerations for Intubation of a Child with Asthma
Indications
Poor response to therapy
Rising CO2 (PCO2 > 50 mm Hg)
Severe hypoxia (PO2 < 60 mm Hg)
Waning mental status or fatigue
Impending respiratory arrest
Cardiopulmonary arrest
Preparation Steps
Preoxygenate
Establish IV access
Consider fluid administration to prevent hypotension
Endotracheal tube
Begin rapid sequence intubation (ketamine, +/- atropine, paralytic)

Goals
SaO2 > 92%
Permissive hypercarbia
pH > 7.2

Settings
Premedication = Atropine, Ketamine, IV fluid
Child, New/ Previous patient, Invasive/ non invasive
Mode = SIMV; (If available, the preferred mode is PRVC or SIMV/VC)
Limit/Control = volume control mode to prevent barotraumas; TV = 5-6 mL/kg
Trigger = flow trigger
Respiratory rate = half normal for age
I:E ratio = 1:3
PEEP = 0 - 3 cm H2O
FiO2 = 100%
PSV = depends on diameter of ETT

Complications
Hypotension, Desaturation, Pneumothorax, Subcutaneous emphysema, Tension
pneumothorax, Cardiac arrest …

Abbreviations: I:E, inspiration to expiration ratio; IV, intravenous; PCO2, partial pressure
of carbon dioxide; PEEP, positive end-expiratory pressure; PO2, partial pressure of
oxygen; SaO2, arterial oxygen saturation; SIMV, synchronized intermittent mechanical
ventilation; TV, tidal volume. PSV=Pressure for spontaneous ventilation. VC= volume
controlled. PRVC= Pressure regulated volume control.
25
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Weaning from Mechanical Ventilation:

One of the goals for mechanical ventilation is to ease the patient's work of breathing and
allow the muscles of respiration to rest. Once initiated, mechanical ventilation should be
continued for at least 24 to 48 hours. Beyond that, the duration of mechanical ventilation
varies from patient to patient. Most patients can be extubated within four to five days.

Positive response to therapy is indicated by:

 Improvement in and normalization of arterial blood gas measurements

 Decreased wheezing in the expiratory phase of respiration
 Decreased need for supplemental oxygen (indicating improvement in ventilation-
perfusion [V/Q] mismatch)
 Decrease in the amount of peak inspiratory pressure necessary to deliver the
desired tidal volume

Weaning from mechanical ventilation should be considered as the patient's hypercarbia

improves (eg, when a normal PaCO2 is maintained despite decreases in the minute
ventilation).

As the clinical status improves, the patient can be permitted to breathe spontaneously.

26
Page
Criteria for Discharge:

Patients may be discharged when:

 They no longer require supplemental oxygen.

 They are receiving a treatment regimen that can be reasonably duplicated at
home (eg, they are tolerating oral medications and the frequency of inhalation
treatments can be managed by the caregiver). If possible, patients should be
observed in the hospital for at least one interval while receiving the treatments
that will be prescribed after discharge. If patients have been receiving nebulized
medications they may be changed to MDI-spacer upon discharge provided they
can demonstrate proper technique.
 If spirometry is readily available and the patient can perform it, FEV1 should be
greater than 70 percent of expected.
 Accesses to medications and appropriate follow-up have to be confirmed.
 Asthma education is complete.

Discharge medications should include a SABA, either via nebulizer or MDI with a
spacer, oral glucocorticoids and there may be a need for daily controller therapy.

Asthma action plan: Patients should be given a written asthma action plan that includes:

 A list of the daily medications and the time(s) of day they are to be taken.
 A list of the rescue medication(s) and a description of the symptoms for which
they should be taken.
 The phone number they should call if they have questions.
 A list of triggers that may exacerbate their asthma.

Follow up: Patients discharged from the hospital should have follow-up visit in 1 to 2
week.

27
Page
Management of Infantile Asthma:
1. The preferred management is SABA in the form of Nebulized SABA (2.5
mg of salbutamol or equivalent diluted in 3 mL of sterile normal saline)
delivered by an oxygen-driven nebulizer.
Otherwise Salbutamol by MDI: 4 puffs every 20 min for 1 hr.Then:
 If good response; SABA 4 puffs every 4 – 6 hrly for 24 – 48 hr then PRN.
 If incomplete response: SABA 4 puffs every 1hourly for 4 – 6 hrs followed
by SABA 4 puffs every 4 – 6 hrly then PRN.
2. Oxygen: to keep saturation > 92% (to maintain oxygen saturation 94 -
98%)
3. Steroid, if patient is able to take po: Prednisolon 1mg/kg/day for 3 – 5
days; If patient is unable to take po: Hydrocortisone 4mg/kg/dose QID; or
intravenous methylprednisolone 1 mg/kg 6-hourly till patient is able to take
PO then complet for 5 days with Prednisolon.
4. If no response with the above treatment: Ipratropium bromide nebuluzed
with SABA. Ipratropium with albuterol:Nebulizer solution (0.25 mg
ipratropium + 2.5 mg albuterol/3 mL vial) can be used every 20 minutes for
1 hour, followed by the same dose range every 6 hours for 48 hours.
5. Nebulized racemic epinephrine: 0.01ml/kg (maximum 0.5ml) diluted with
3ml NS every 20 minits for one hour can be used to treat severe acute
asthma following failure of standard first-line therapies.
6. Magnesium sulphate 50mg/kg as slow infusion over 20 - 60 min iv or by
nebulizer(age > 2yrs)
7. Amynophyline A loading intravenous dose 6 mg/kg given over 20 minutes
followed by infusion with recommended doses for infants younger than 6
months are 0.5 mg/kg/h; for infants 6 months to 1 year, 0.75 mg/kg/h.

28
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Asthma Management during Surgery
Treatment options prior to surgery are based upon the level of the severity of the
disease. Frequently, all that is needed is a short-term ―stepup‖ in the treatment regimen.
 Controlled asthmatics may only need a short-acting β-2 agonist
(Salbutamol 4 puffs over 20 minutes) just prior to surgery.
 Moderately controlled patients should add inhaled corticosteroids to their
β-2 agonists one week prior to surgery.
 Poorly controlled asthmatics may need to add systemic corticosteroids to
their regimen(PO prednisolone 1mg/kg/day if they tolerate, otherwise IV
hydrocortisone 4mg/kg/dose QID started before surgery and continued for
at least 3 days)

It is important that the patient be at a deep level of anesthesia prior to instrumenting the
airway, as tracheal intubation during light levels of anesthesia can precipitate
bronchospasm. . This may be accomplished by increasing the concentration of volatile
anesthetic or by the administration of rapidacting intravenous bronchodilators such a
propofol or ketamine.

 Intravenous lidocaine has been successfully used to decrease airway irritability

and also reduces ↑ ICP with laryngoscope. (Dose: 1 – 2 mg/kg IV bolus, given 2
– 5 minuts before laryngoscope).
 Drugs like atropine (Dose: 0.01 – 0.02 mg/kg IV (minimum 0.1 and maximum
1mg), given 1 – 2 minits before intubation) may decrease secretions prior to
induction.
 Propofol (Dose: 2mg/kg IV) is the induction agent of choice in the
hemodynamically stable patient due to its ability to attenuate the bronchospastic
response to intubation both in asthmatics and non-asthmatics. Care should be
taken in patients with depressed cardiac function, as propofol decreases cardiac
contractility and chronicity.
 Ketamine(1 – 4 mg/kg IV.Onset of action is 1 – 2 min; duration of action is 30 –
60 min) is an ideal induction agent for hemodynamically unstable asthmatics due
to its ability to produce direct smooth muscle relaxation and bronchodilation
without decreasing arterial pressure or systemic vascular resistance. However,
ketamine-induced bronchodilation is not as pronounced as with propofol.
 Vecuronium, rocuronium are safe for use in asthmatics.
 Vecuronium: 0.1 – 0.2 mg/kg IV will produce paralysis for intubation
in 90 – 120 seconds; duration of action is 30 – 90 min.
 Rocuronium; developed from Vecuronium, has fast onset of action;
0.6 – 1.2 mg/kgIV; onset of action is within 60 sec; duration of action
is 30 – 60 min.

Subsequently, SA β-2 agonists by nebulizer, parentrally or by MDI; and other drugs

29

include administering anticholinergics like ipratropium and Intravenous steroids.

Page
Treatments of chronic Asthma During follow up:
The pharmacological options for long-term treatment of asthma fall into the following
three main categories.
• Controller medications: these are used for regular maintenance treatment. They
reduce airway inflammation, control symptoms, and reduce future risks such as
exacerbations and decline in lung function.
• Reliever (rescue) medications: these are provided to all patients for as-needed relief of
breakthrough symptoms, including during worsening asthma or exacerbations. They are
also recommended for short-term prevention of exercise-induced bronchoconstriction.
Reducing and, ideally, eliminating the need for reliever treatment is both an important
goal in asthma management and a measure of the success of asthma treatment.
• Add-on therapies for patients with severe asthma, may be considered when patients
have persistent symptoms and/or exacerbations despite optimized treatment with high
dose controller medications (usually a high dose ICS and a LABA) and treatment of
modifiable risk factors.

Asthma severity is the intrinsic intensity of disease, and assessment is generally most
accurate in patients not receiving controller therapy.
Hence, assessing asthma severity directs the initial level of therapy. The 2 general
categories are intermittent asthma and persistent asthma,
the latter being further subdivided into mild, moderate, and severe.

In contrast, asthma control refers to the degree to which symptoms, ongoing functional
impairments, and risk of adverse events are minimized, and goals of therapy are met. In
children receiving controller therapy, assessment of asthma control is important in
adjusting therapy and is categorized in 3 levels: well-controlled, not well-controlled, and
very poorly controlled. Responsiveness to therapy is the ease or difficulty with which
asthma control is attained by treatment.

30
Page
Classification of Chronic Asthma Severity:

Classifying Severity and Initiating Treatment: Children 0 to 4 Years

Impairment Risk
Days and Nights Interference With Exacerbations
Severity Category With Symptoms Normal Activity Preferred Treatment
Severe Persistent Throughout (days) Extremely limited (see below) Step 3: Medium-dose ICS
>1 night/wk (nights) and consider short-
course OCS
Moderate Daily (days) Some limitation (see below) Step 3: Medium-dose ICS
Persistent 3 to 4 nights/month and consider short course
OCS
Mild Persistent 3 to 6 days/wk Minor limitation 2 or more/6 months Step 2: Low-dose ICS
(days) or
1 to 2 nights/month >4 episodes of
(nights) wheezing/yr with
risk factors for
asthma
Intermittent <2 days/wk (days) None 0 to 1/yr Step 1: SABA PRN
0 nights/month
(nights)
Exacerbation: episode requiring OCS.
Risk factors for asthma: parent history of asthma, patient has eczema, patient sensitized to aeroallergens, or two
of following: patient sensitized to foods, eosinophilia, wheezing apart from colds.
ICS_inhaled corticosteroids, LABA_long-acting beta2 agonist, OCS_oral corticosteroids, SABA short-acting
beta2 agonist

Classifying Severity and Initiating Treatment: Children 5 to 11 Years

Impairment Risk
Days and Nights Interference Pulmonary Exacerbations
Severity With Symptoms With Function Preferred Treatment
Category Normal Activity
Severe Throughout Extremely FEV1: <60% 2 or more/yr Step 4: Medium-dose
Persistent (days) limited FEV1/FVC: ICS + LABA and
Often (nights) <75% consider short-course
OCS
Step 3: Medium-dose
ICS and consider
short-course OCS
Moderate Daily (days) Some limitation FEV1: 60% 2 or more/yr Step 3: Medium-dose
Persistent 1 night/ week to 80% ICS and consider
(nights) FEV1/FVC: short-course OCS
75% to
80%
Mild Persistent 3 to 6 days/wk Minor limitation FEV1: >80% 2 or more/yr Step 2: Low-dose ICS
(days) FEV1/FVC:
3 to 4 >80%
nights/month
(nights)
Intermittent <2 days/wk None FEV1: >80% 0 to 1/yr Step 1: SABA PRN
(days) FEV1/FVC:
<2 nights/month >85%
31

(nights)
FEV1_forced expiratory volume in 1 second, FVC_forced vital capacity, ICS_inhaled corticosteroids,
Page

LABA_long-acting beta2 agonist, OCS_oral corticosteroids, SABA_short-acting beta2 agonist.

Classifying Severity and Initiating Treatment: Youth 12 Years of Age and Older

Impairment Risk
Days and Interference Pulmonary Exacerbations
Severity Nights With Function Preferred
Category With Normal Treatment
Symptoms Activity
Severe Throughout Extremely FEV1: 2 or more/yr Step 5: High-
Persistent (days) limited <60% dose ICS
Often FEV1/FVC: + LABA and
7x/week Reduced consider
(nights) >5% short-course
OCS
Step 4: Medium-
dose
ICS + LABA and
consider short-
course
OCS
Moderate Daily (days) Some FEV1: 60% 2 or more/yr Step 3: Low-dose
Persistent 2 to 6 nights/ limitation to 80% ICS
week FEV1/FVC: + LABA
(nights) Reduced OR
5% Medium-dose
ICS and
consider short-
course
OCS
Mild 3 to 6 Minor FEV1: 2 or more/yr Step 2: Low-dose
Persistent days/wk limitation >80% ICS
(days) FEV1/FVC:
3 to 4 Normal
nights/month
(nights)
Intermittent <2 days/wk None FEV1: 0 to 1/yr Step 1: SABA
(days) >80% PRN
<2 FEV1/FVC:
nights/month Normal
(nights)
FEV1_forced expiratory volume in 1 second, FVC_forced vital capacity; ICS_inhaled corticosteroids,
LABA_long-acting beta2 agonist, OCS_oral corticosteroids, SABA_short-acting beta2 agonist
32 Page
Stepwise Approach for Managing Asthma: Preferred Therapy by Age Group
Age Step 1 Step 2 Step 3 Step 4 Step 5 Step 6
0 to 4 yr SABA PRN Low-dose ICS Medium-dose Medium- High-dose High-dose ICS + OCS
ICS dose ICS ICS + either + either
+either LABA or LABA or montelukast
LABA or montelukast
montelukast
5 to 11 yr SABA PRN Low-dose ICS Low-dose ICS Medium- High-dose High-dose ICS +
+ either dose ICS ICS + LABA LABA + OCS
LABA, LTRA, +LABA
or
theophylline
OR Medium-
dose ICS
12 yr to adult SABA PRN Low-dose ICS Low-dose ICS Medium- High-dose High-dose ICS +
+ LABA OR dose ICS + ICS + LABA + OCS*
Medium-dose LABA LABA*
ICS
ICS_inhaled corticosteroid, LABA_long-acting beta agonist, LTRA_leukotriene receptor antagonist, OCS_oral
corticosteroids, SABA_short-acting beta2 agonist
All patients need quick-relief medication (SABA).
Each Step: Patient education, environmental control, and management of comorbidities.
Steps 2–4 (5 yr to adult): Consider subcutaneous allergen immunotherapy for patients who have persistent,
allergic asthma.
*Steps 5–6 (12 yr to adult): Consider omalizumab for patients who have allergies.

NB:
•Level of severity is determined by both impairment and risk. Assess impairment domain
by patient‘s/caregiver‘s recall of previous 2-4 wk. Symptom assessment for longer
periods should reflect a global assessment, such as inquiring whether a patient‘s
asthma is better or worse since the last visit. Assign severity to the most severe
category in which any feature occurs.
• At present, there are inadequate data to correspond frequencies of exacerbations with
different levels of asthma severity. For treatment purposes, patients who had ≥2
exacerbations requiring oral systemic corticosteroids in the past 6 mo, or ≥4 wheezing
episodes in the past year, and who have risk factors for persistent asthma may be
considered the same as patients who have persistent asthma, even in the absence of
impairment levels consistent with persistent asthma.
•At each step: Patient education, environmental control, and management of
comorbidities is necessary.
•Age ≥5 yr: Steps 2-4: Consider subcutaneous allergen immunotherapy for patients who
have allergic asthma.
•SABA as needed for symptoms. Intensity of treatment depends on severity of
symptoms: up to 3 treatments at 20-min intervals as needed. Short course of oral
systemic corticosteroids may be needed.
•Caution: Use of SABA >2 days/wk for symptom relief (not prevention of exercise-
induced bronchospasm) generally indicates inadequate control and the need to step up
treatment.
33 Page
 Assessing Asthma control and adjusting therapy in children

Well-controlled Not Well- Very Poor Control

controlled
Child 0 to 11 Years
Day symptoms <2 days/wk >2 days/wk Throughout
Night symptoms 0 to 1/month >2/mo >2/wk
FEV1 percent >80% 60% to 80% <60%
predicted
FEV1/FVC ratio >80% 75% to 80% <75%
Exacerbations 0 to 1/yr >2/yr >2/yr (>3/yr for 0 to
4 yr)
Action Maintain; consider Review ICE Review ICE
step down Step up Step up 1 to 2 steps
(if well-controlled for Recheck in 2 to 6 Consider OCS
3 months) weeks Recheck in 2 to 6
Recheck in 1 to 6 weeks
months
12 years to Adult
Day symptoms <2 days/wk >2 days/wk Throughout
Night symptoms 0 to 1/month 1 to 3/wk >4/wk
FEV1 percent >80% 60% to 80% <60%
predicted
Exacerbations 0 to 1/yr >2/yr >2/yr
Action Maintain; consider Review ICE Review ICE
step down Step up 1 step Step up 1 to 2 steps
(if well-controlled for Recheck in 2 to 6 Consider OCS
3 months) weeks Recheck in 2 weeks
Recheck in 1 to 6
months
ICE_inhaler technique, compliance, environmental control and comorbidities, FEV1_forced expiratory
volume in 1 second, FVC_forced vital capacity, OCS_oral corticosteroids

34
Page
 Estimated Comparative Daily dosages for Inhaled Steroids:
Drug LOW DAILY DOSE MEDIUM DAILY DOSE HIGH DAILY DOSE BY
BY AGE BY AGE AGE
0-4 5-11 ≥12 yr 0-4 yr 5-11 yr ≥12 yr 0-4 yr 5-11 ≥12 yr
yr yr yr
Beclomethasone NA 80- 80-240 NA >160- >240- NA >320 >480
40 or 80 μg/puff 160 μg 320 μg 480 μg μg μg
μg
Budesonide 90, NA 180- 180- NA >400- >600- NA >800 >1200
180, or 200 μg/ 400 600 μg 800 μg 1200 μg μg
inhalation μg μg
Budesonide 0.25- 0.5 NA >0.5- 1.0 mg NA >1.0 2.0 mg NA
inhaled 0.5 mg 1.0 mg
suspension for mg mg
nebulization,
0.25,
0.5, and 1.0
mgdose
Flunisolide, NA 500- 500- NA 1000- >1000- NA >1250 >2000
250 μg/puff 750 1000μg 1250μg 2000μg μg μg
μg
Flunisolide HFA, NA 160 320 μg NA 320 μg >320- NA ≥640 >640
80 μg/puff μg 640 μg μg μg
Fluticasone HFA/ 176 88- 88-264 >176- >176- >264- >352 >352 >440
MDI: 44, 110, or μg 176 μg 352 352 μg 440 μg μg μg μg
220 μg/puff μg μg
Fluticasone DPI, NA 100- 100- NA >200- >300- NA >400 >500
50, 200 300 μg 400 μg 500 μg μg μg
100, or 250 μg/ μg
inhalation
Mometasone NA NA 220 μg NA NA 440 μg NA NA >440
DPI, μg
110 μg and
220 μg/inhalation
Triamcinolone NA 300- 300- NA >600- >750- NA >900 >1500
acetonide, 75 600 750 μg 900 μg 1500 μg μg
μg/puff μg μg
DPI, dry powder inhaler; HFA, hydrofluoroalkane; MDI, metered-dose inhaler; NA, not approved and no
data available for this age group.
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Usual dosage for long term Asthma medications
Medication AGE
0-4 yr 5-11 yr ≥12 yr
Inheled corticosteroids Mensioned above
Methylprednisolone: 0.25-2 mg/kg daily 0.25-2 mg/kg daily 7.5-60 mg daily in a single dose
2, 4, 8, 16, 32 mg tablets in single in single in A.M. or qod as needed for
dose in A.M. or dose in A.M. or qod control
qod as as
needed for control needed for control
Prednisolone: Short-course Short-course Short-course ―burst‖ to achieve
5 mg tablets; 5 mg/5 mL, ―burst‖: ―burst‖: 1-2 mg/ control: 40-60 mg/day as single
15 mg/5 mL 1-2 mg/kg/day; kg/day; maximum or 2 divided doses for 3-10
Prednisone: maximum 60 mg/day days
1, 2.5, 5, 10, 20, 50 mg tablets; 5 30 mg/day for 3- for 3-10 days
mg/ 10 days
mL, 5 mg/5 mL
Fluticasone/salmeterol: NA 1 inhalation bid; 1 - 2 inhalation bid; dose
DPI: 100, 250, or 500 mg/50 mg dose depends depends
HFA: 45 μg/21 μg, 115 μg/21 μg, on level of severity on level of severity or control
230 μg/21 μg or control
Budesonide/formoterol: NA 2 inhalations bid; dose depends
HFA: 80 μg/4.5 μg, 160 μg/4.5 μg on level of severity or control
Mometasone/formoterol 2 inhalations bid; dose depends
HFA: 100 μg/5 μg, 200 μg/5 μg on level of severity or control
Cromolyn: 1 ampule qid; NA 1 ampule qid 1 ampule qid
Nebulizer 20 mg/ampule <2 yr of ag
Leukotriene receptor antagonists: 4 mg qhs (1-5 yr 5 mg qhs (6-14 yr) 10 mg qhs
Montelukast: of age)
4 or 5 mg chewable tablet
4 mg granule packets
10 mg tablet
Zafirlukast: NA 10 mg bid (7-11 yr) 40 mg daily (20 mg tablet bid)
10- or 20-mg tablet
5-Lipoxygenase inhibitor: NA NA 1,200 mg twice daily (give 2
Zileuton CR: 600-mg tablet tablets bid)
Theophylline: Starting dose 10 Starting dose 10 Starting dose 10 mg/kg/day up to
Liquids, sustained-release tablets, mg/kg/day; mg/kg/day; 300 mg maximum; usual
and capsules usual max: usual maximum: 16 maximum 800 mg/day
• <1 yr of age: 0.2 mg/kg/day
(age in wk)
+ 5 = mg/kg/day
• >1 yr of age: 16
mg/kg/day
Immunomodulators: NA NA 150-375 mg SC q 2-4 wk,
Omalizumab (anti-IgE): depending on body weight and
Subcutaneous injection, pretreatment serum IgE level
150 mg/1.2 mL after reconstitution
with 1.4 mL sterile water for
injection
bid, Twice a day; DPI, dry powder inhaler; HFA, hydrofluoroalkane Ig, immunoglobulin; MDI, metered-dose inhaler;
q, every; qhs, every night; qid, 4 times a day;
36

qod, every other day; SC, subcutaneous.

Page
 Doses of drugs for asthma exacerbations
Medication Dosages Remarks
Albutero/Salbutamol Nebulized 2.5 0.15 mg/kg (minimum dose 2.5 mg) For optimal delivery, dilute
mg/3 mLl every 20 minutes for 3 doses then 0.15- aerosols to minimum of 3 mL at
0.3 mg/kg up to 10 mg every 1-4 hours gas flow of 6-8 L/min.
5.0 mg/ml as needed, or 0.5 mg/kg/hour by
continuous nebulization.
Albuterol/Salbutamol Metered-dose 4-8 puffs every 20 minutes for 3 doses, Dose is not well-established.
inhaler (MDI) 90 - 100mcg/puff then every 1-4 hours as needed. Reasonable starting points: 1/4
to 1/3 puff/kg, maximum 8 puffs
Salbutamol IV Bolus: 5microgram/kg/min for first hour
then consider infusion.
Infusion: 1-2 microgram/kg/min
Epinephrine (sc/im) 0.01 mg/kg up to 0.3-0.5 mg every 20
minutes for 3 doses (administered
1:1000 (1 mg/mL) subcutaneously or IM). 0.01 mL/kg to a
maximum of 0.5 mL/dose)
Nebulized racemic epinephrine Racemic epinephrine (dose0.01 mL/kg
to a maximum of 0.5 mL in 3 mL of
normal saline)
Terbutaline(sc/im) 0.01 mg/kg every 20 minutes for 3
doses then every 2-6 hours as needed
1 mg/mL (administered subcutaneously).
Terbutaline (IV) 10 microgram/kg IV loading dose
administered over 10 minutes, followed
by an infusion of 0.1 to
10 microgram/kg per minute), and/or
Ipratropium Nebulized 0.5 Nebulizer:
mg/2.5 mL; MDI 18 μg/inhalation) <20 kg: 250 mcg/dose
>20 kg: 500 mcg/dose
QID as needed
MDI: 2 puffs qid
Ipratropium with albuterol: 1 vial by nebulizer qid Acts synergistically with
Nebulizer solution (0.5 mg albuterol, not as a single agent
ipratropium + 2.5 mg albuterol/3 mL
vial)
Prednisolone 5 mg tablets 1 - 2 mg/kg/day; Max dose: 60 mg/day 2 mg/kg (maximum 60 mg) by
for 3 - 5 days mouth for the first dose, and
then 1 mg/kg bid for subsequent
doses starting the following day;
a three to ten day course is
generally given
Methylprednisolone 1 - 2 mg/kg divided q12h Max 60mg; for
3 - 5 days
Dexametasone 0.6 mg/kg PO, IM, IV Max May be equally efficacious at
dose: 16 mg 0.15 mg/kg dose
Magnesium sulfate 25-75 mg/kg IV over 20 min 50mg/kg iv/io in 100 NS slowly
Max dose: 2 g over 20 min, may decrease
hypotension.
Aminophylline 6 mg/kg IV loading dose , followed by
37

infusion of 0.6 to 1 mg/kg per hour

Ketamine 1mg/kg/hr IV Induction dose Continuous IV infusion:
Page

Sedation: 5-20 mcg/kg/minute

Summary of management of Asthma Exacerbations:

I. First assess Severity and classify.

II. Management for Mild Asthma Exacerbations:

1. SABA: 4 puffs every 20 min for 1 hr.
 If good response; SABA 4 puffs every 4 – 6 hrly for 24 – 48 hr then PRN.
 If incomplete response: SABA 4 puffs every 1hourly for 4 – 6 hrs followed
by SABA 4 puffs every 4 – 6 hrly then PRN.
2. Oxygen: to keep saturation > 92%
3. if no response after the first inhalation therapy: Steroid po Prednisolon
1mg/kg/day for 3 – 5 days
4. If there is improvement discharge and appoint to come after 7 days.

III. Management for Moderate Asthma Exacerbations:

1. SABA: 4 puffs every 20 min for 1 hr.
 If there is good response that lasts for > 3hrs, continue Inhaled
SABA every 4 hourly for 24 hours, then every 6 hourly for 24 – 48
hours then PRN.
 If there is incomplete improvement, continue the SABA 4 puffs
every 1 hourly for 4 – 6 hours, then if there is good response that
lasts for >3hours give the SABA every 4 hourly for 24 hours then
every 6 hourly for 24 – 48 hours then PRN.
2. Oxygen: to keep saturation > 92%
3. Steroid, If patient is able to take po: Prednisolon 1mg/kg/day for 3 – 5
days; If patient is unable to take po: Hydrocortisone 4mg/kg/dose QID till
patient is able to take PO then complet for 5 days with Prednisolon.
4. Ipratropium bromide nebuluzed mixed with SABA: Ipratropium with
albuterol:Nebulizer solution (0.5 mg ipratropium + 2.5 mg albuterol/3 mL
vial) can be used every 20 minutes for 1 hour, followed by the same dose
range every 6 hours for 48 hours.
5. If there is improvement discharge and appoint to come after 7 days.

38
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IV. Management for Severe Asthma Exacerbations:

1. The preffered therapy is with Nebulised albuterol/salbutamol: in the

form of Nebulized albuterol: with a dose of 2.5 mg for children who weigh
less than 30 kg and 5 mg for children who weigh more than 30 kg, may be
used diluted with 3 mL saline every 20 minutes for 1 hour.or Continuous
nebulized albuterol is typically given at a dose of 0.5 mg/kg per hour.
2. In our setup we can use Inhaled β2 agonists in the form of Salbutamol
delivered by pressurized metered dose inhaler (pMDI) with a spacer 6
puffs to be given every 20 minutes for the first hour; each puff is inhaled
separately with five tidal breaths or at 10 - 15 second intervals. Continue
with 6 puffs as appropriate every one-to- four hourly.
3. Oxygen: to keep saturation > 92%
4. Steroid, If patient is able to take po: Prednisolon 1mg/kg/day for 3 – 5
days; If patient is unable to take po: Hydrocortisone 4mg/kg/dose QID till
patient is able to take PO then complet for 5 days with Prednisolon.
5. Ipratropium bromide nebuluzed mixed with SABA: Ipratropium with
albuterol:Nebulizer solution (0.5 mg ipratropium + 2.5 mg albuterol/3 mL
vial) can be used every 20 minutes for 1 hour, followed by the same dose
range every 6 hours for 48 hours.
6. For patients who improve after the initial treatment, the approach is as
described above for moderate exacerbations on improvement: continue
the SABA 6 puffs every 1 hourly for 4 – 6 hours, then if there is good
response that lasts for >3hours give the SABA every 4 hourly for 24 hours
then every 6 hourly for 24 – 48 hours then PRN.
7. If no response several treatment options can be considered in the
following sequence:

 Nebulized racemic epinephrine 0.01ml/kg (maximum 0.5ml)

diluted with 3ml NS every 20 minits for one hour can be used
successfully to treat severe acute asthma following failure of
standard first-line therapies.
 Magnesium sulphate: an initial bolus dose of 50 mg/kg (maximum
dose, 2 g) infused for 20 minutes is recommended, followed by
continuous infusion dependent on the patient‘s weight. Children
weighing less than 30 kg may receive an infusion of 25 mg/kg/h
and children weighing more than 30 kg may receive 20 mg/kg/h,
although infusion rates must not exceed 2 g/h in any patient. Can
repeat once or twice after 4-6 hrs.
 Parenterally administered epinephrine: Adrenaline 0.01 ml/kg of a
1:1000 solution administered SC or IM may be used in patients who
are moribund on presentation to the ED, or where inhaled therapy
is not available.
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Page
  Alternatively terbutaline (0.01 mL/kg of a 1 mg/mL solution) with a
maximum dose of 0.4 mg (0.4 mL) may be administered
intramuscularly or subcutaneously for children with poor inspiratory
flow or children who cannot cooperate with nebulized therapy.
 Administration of IV terbutaline infusion may be indicated: bolus
with 10 microgram/kg over ten minutes, then 0.3 to 0.5
microgram/kg per minute; infusion may be increased by 0.5
microgram/kg per minute every 30 minutes to a maximum of 5
microgram/kg minute.
 Salbutamol IV: Bolus: 5microgram/kg/min for first hour then
consider Infusion: 1-2 microgram/kg/min
 Amynophyline: a loading intravenous dose 6 mg/kg of
aminophylline, given during 20 minutes is needed to achieve a
therapeutic concentration. Then recommended doses as infusion
for infants younger than 6 months are 0.5 mg/kg/h; for infants 6
months to 1 year, 0.85 to 1 mg/kg/h; for children 1 to 9 years, 1 mg/
kg/h; and for children older than 9 years, 0.75 mg/kg/h.

8. Heliox: Helium mixed with Oxygen mixture with proportion of 70%:30% or

79%:21%, have demonstrated some benefit as adjunctive therapies in
patients with severe status asthmaticus.

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V. Management for Life threatening Asthma Exacerbations:

1. Start with A B C of life

 A: make sure the patency of Airways
 B: Children with a severe life threatening acute asthma attack should
be given 100% oxygen.
 C: secure IV line with 1/3 NS + 2/3 DW for maintenance.

2. Start with the management of Severe Asthma exacerbation

 SABA: The preferred approach is Continuous nebulized salbutamol

otherwise SABA in the form of Salbutamol by MDI
 Oxygen: to keep saturation > 92%
 Steroid: Hydrocortisone 4mg/kg/dose QID till patient is able to take
PO then complet for 5 days with Prednisolon.
 Ipratropium bromide nebuluzed mixed with SABA
 Magnesium sulphate 50mg/kg over 20 min then Infusion

 Nebulized racemic epinephrine was used successfully to treat

severe acute asthma following failure of standard first-line therapies.
 Turbutaline/Epinephrine Sc or IM
 Salbutamol/Turbutaline IV
 Amynophyline: a loading intravenous dose 6 mg/kg of
aminophylline, given during 20 minutes then Infusion
 Heliox: Helium mixed with Oxygen
3. If no Improvement with Signs of deterioration and impending respiratory
failure admit to the ICU for Ventilation; preferably BPAP;typically
recommended settings with BPAP include an inspiratory positive airway
pressure of 10 cm H2O, an expiratory positive airway pressure of 5 cm H2O,
with or without a low back-up ventilation rate.
4. As a last resort, after using any available alternatives, if no response:
Intubation and Mechanical ventilation.

 Indications for Intubation:

 Poor response to therapy
 Rising CO2 (PCO2 > 50 mm Hg)
 Severe hypoxia (PO2 < 60 mm Hg)
 Waning mental status or fatigue
 Impending respiratory arrest
 Cardiopulmonary arrest
41
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 Settings
 Premedication = Atropine, Ketamine
 Child, New/ Previous patient, Invasive/ non invasive
 Mode = SIMV;
 Limit/Control = volume control mode to prevent barotraumas;
 TV = 5-6 mL/kg
 Trigger = flow trigger
 Respiratory rate = half normal for age
 I:E ratio = 1:3
 PEEP = 0-3 cm H2O
 FiO2 = 100%
 PSV = depends on diameter of ETT

5. Weaning from Mechanical Ventilation:

 Mechanical ventilation should be continued for at least 24 to 48 hours.

Beyond that, the duration of mechanical ventilation varies from patient to
patient. Most patients can be extubated within four to five days.
 Positive response to therapy is indicated by:

 Improvement in and normalization of arterial blood gas

measurements
 Decreased wheezing in the expiratory phase of respiration
 Decreased need for supplemental Oxygen
 Decrease in the amount of peak inspiratory pressure necessary
to deliver the desired tidal volume
 As the patient's hypercarbia improves (eg, when a normal
PaCO2 is maintained despite decreases in the minute
ventilation).

 As the clinical status improves, the patient can be permitted to breathe

spontaneously.

42
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