Volume 8, Issue 7, July 2023 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165
Drug Selection Patterns in Asthma and
Hyperre Active Airway Disease in Children
MOHAMMAD SONY, KEERTHANA KOTA, GUDURU VIJAY KUMAR,Dr. TEJASWI CHILLARA.
DEPARTMENT OF PHARMACY PRACTICE, VAAGDEVI PHARMACY COLLEGE,
BOLLIKUNTA, WARANGAL, TELENGANA.
Abstract:- A prospective observational study was
conducted at Mahatma Gandhi Memorial (MGM)
hospital, Warangal over a period of 6 months. This
study is conducted to evaluate clinical presentation of
various respiratory conditions and to optimize oxygen,
inhalational therapy and antibiotic treatment for
optimal outcome. We conclude that many children were
under 5 commonest age group, suffering from wheeze,
respiratory distress and asthma. Nebulization of
salbutamol was useful in HRAD and asthma rather than
bronchiolitis and LRTI. IV hydrocortisone was
beneficial in HRAD and less beneficial in bronchiolitis.
Supplemental oxygen was most effective treatment in
bronchiolitis condition. None of the children were
receiving holding chambers or spacers. At least some
percentage of the children in the present study may
require spacers in long term use to decrease morbidity.
Keywords:- ASTHMA, HRAD, LRTI, SABA, LABA, PRAM.
I. INTRODUCTION
A. ASTHMA:
Asthma is a severe inflammatory disease, which is
identified by audible wheezing in children, chest tightness,
coughing (most seen at night time), shortness of breath,
fever, cold and several airways obstruction. Asthma
diagnosis is done based on patient history, physical
examination and pulmonary function tests.
 Risk factors: Allergies related to food, Inhalation of dust
particles and adulterants, Parental exposure to allergies,
Rhinitis, Inhalation of secondary smoke, Eczema and
dermatitis, Cool wind. Under diagnosis and under
treatment is due to comorbid conditions such as upper
respiratory tract infection (URTI) and weak condition of
the body, different phenotypes, intermittent occurrences
of coughing and wheezing, non-medication adherence,
poor economic status and disease understanding of the
patient, improper usage of inhaler and continuous
exposure to allergic annoyances. (1)
 TREATMENT:
 SUPPORTIVE THERAPY:
Oxygen therapy- It is the most suitable and beneficial
therapy for mild intermittent, persistent and severe asthma.
Both warm and cold humidifiers are used for various
improvement reasons from life-threatening conditions.
There is no evidence from research side of using oxygen
therapy in acute conditions.
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 Asthma in pre-school-
It is difficult to diagnose asthma in pre-school children
as they experience symptoms which are, most of the time
related to viruses and lead to coryza. Advanced utilization
appertaining to corticosteroids for patients progressed from
1 year to 12 years resulted in no fast breathing for over 7
days.
 LABA-
These are not commonly used because of the adverse
effects. Salmeterol used only in repeated interventions of
exacerbations and for exercise-related asthma. And it should
be discontinued immediately after the child feels less
discomfort. It is used together with ICS, alone can increase
the chances of future asthma-attacks and increase mortality
rate.
 Monoclonal antibodies-
Omalizumab is used with inhaled corticosteroids for its
synergistic effect. However, it is not commonly prescribed
as it may provide lesser obstruction of the airways.
 SABA and bronchodilators-
These are the drugs mainly used to reduce
bronchospasm or shortness of breath associated with nightly
awakenings. Based on a comparative study, it concludes the
use of an inhaled form of salbutamol- 2 puffs has greater
chances and quick response of immediate relaxation of
airways were found compared with oral format of same
drug. It will provide its action with accompanying relaxation
effect on airways.
 Corticosteroids-
Prednisone is converted to prednisolone, an active
metabolite in which its oral dose should be less than 20mg
in children. Increasing the dose of the drug may lead to
serious adverse events. It is metabolized by the liver. It
lowers the inflammation of the airways of bronchioles. After
achieving improvement with combination of LABA/ICS,
discontinuation of LABA should be implicated and use of
ICS should be continued.
 Magnesium sulphate (mgso4)-
It was originally used in the year 1906 by horn in
seizure condition during gestation, then is used in asthma for
relaxation of airways or hyperinflation. Its primary mode of
action is blocking of calcium affluence which is used for
muscle contraction and also cessation of histamine
production such as bradykinins and cytokinin release from
mastocyte.
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 Hyperreactive airway disease:
Hyperreactive airway disease is notably a common
condition in children which will furtherly lead to multi-
trigger wheezer, viral wheezer and recurrent episodes of
wheeze leads to mild, intermittent and mild persistent
asthma (3)
International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165
 Pram scores will be conducted and evaluated in children
of age group 2 – 17 and also who exist with
exacerbations. Pram score is used to measure
seriousness of the asthma patients (6)
II. MATERIALS AND METHODS:

 Aetiology: It is a prospective observational study done to assess

Previously caused infections like RSV is mostly seen in
infants and children. Second hand smoke, tobacco smoke
and maternal smoke, pets, pollen, dust mite allergens,
weather changes, drugs, stress and mediastinal mass
(external compression of airway).
the treatment patterns and clinical presentations of children.
Study was conducted at Emergency service room and
department of pediatrics, Kakatiya medical college,
mahatma Gandhi memorial hospital, Warangal. Data was
collected from 120 subjects for a period of 6 months.

 Diagnosis: Infants to 13 years age group population with a

There are some basic standard rules for diagnosing
asthma;
 Children should consist of 5 years or greater.
 Reoccurrence of symptoms recurrently like episodic
wheezer and airway inflammation and
hyperresponsiveness.
 Keeping a track of forced expiratory volume (FEV1) at
one second and reversible airways blockage following
usage of a SAB2A.
 Treatment:
 Main treatment goals are-
 Providing o2 care while in travel and nebulization
associated with severe respiratory distress.
 Emergency service rooms exist with - mild to moderate
exacerbations (o2 >92%)
 Albuterol (SABA’s are the most used to bring out best
outcomes for management) should be given as primary
treatment either by MDI or by o2 by mask.
 First line management - oral dexamethasone-
0.6mg/kg/dose
 Second line management - oral prednisolone-
2mg/kg/dose
 Nebulization with ipratropium bromide and SABA for
20min
 Severe exacerbations < 92% on RA should be given
with high o2 flow (by mask, inhalational or HFNC,
CPAP, whatever is being indulged). (7)
 2.3 Pram Score {pediatric respiratory assessment
measure}: This score consists of 5 types to assess the
symptoms and signs Likewise they include suprasternal
retractions, scalene muscle contractions, air entry,
wheezing and oxygen saturation.
different diagnosis of acute severe asthma, hyperreactive
airway disease, LRTI with wheeze, episodic viral wheeze,
multi trigger viral wheeze and all children who received
nebulization at admission are included in the study. Known
cases of bronchial asthma children are also included in the
study. Neonates, children with other comorbidities and
diseases which are mimicking bronchitis, bronchiectasis are
excluded based on exclusion criteria.
Data was collected from case reports which include
patient details, past medical and family history, history of
nebulization use, presenting clinical features, diagnosis,
treatment given to the patient, and vitals of the patient and
patient or care taker interview regarding medication
adherence, physical activity, diet and socioeconomic status.
Details of child weight, height, gender and treatment
patterns. Informed Consent form from Parents was taken.
All the above data was collected and included in the data
collection forms.
Data is interpreted using Microsoft excel. Statistical
analysis was performed using ANOVA (analysis of
variance), mean, S.D, p-value was obtained.

III. RESULTS

TABLE 1: STATISTICAL ANALYSIS OF AGE:

Parameters Number Mean SD F-value P-value
Age
ASTHMA 15 95.14 28.03
HRAD 13 51 39.596
EPISODIC VIRAL WHEEZER 26 37.13 33.458 28.76 <0.001
LRTI AND BRONCHIOLITIS 68 15.84 27.788
Total 122 32.87 39.477

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TABLE 2: STATISTICAL ANALYSIS OF WEIGHT:
Parameters Number Mean SD F-value P-value
Weight
ASTHMA 15 19.9486 8.63671
HRAD 13 12.6333 7.16359
EPISODIC VIRAL WHEEZER 26 10.4875 6.45313 17.05 <0.001
LRTI AND BRONCHIOLITIS 68 7.5586 5.0991
Total 122 10.0973 7.20451

TABLE 3: STATISTICAL ANALYSIS OF HEIGHT:

Parameters Number Mean SD F-value P-value
Height
ASTHMA 15 114.29 18.841
HRAD 13 88.25 32.238
EPISODIC VIRAL WHEEZER 26 76.46 24.374 24.809 <0.001
LRTI AND BRONCHIOLITIS 68 59.71 21.346
Total 122 72.28 29.044

TABLE 4: AVERAGE DURATION OF HOSPITAL STAY

Diagnosis Average duration of hospital Stay
severe bronchiolitis 4 to 9 days
HRAD 4 to 7 days
Acute exacerbation of asthma 5 to 13 days
Episodic viral wheezer 5 to 8 days
LRTI 5 to 10 days

TABLE 5: RESPIRATORY RATE OF CHILDREN

Parameters Number Mean SD F-value P-value
Respiratory Rate
ASTHMA 15 42.29 19.66
HRAD 13 44.73 18.391
EPISODIC VIRAL WHEEZER 26 51.79 12.087 2.19 0.092
LRTI AND BRONCHIOLITIS 68 51.34 12.939
Total 122 49.76 14.454

TABLE 6: SPO2 AT ADMISSION

Parameters Number Mean SD F-value P-value
SPO2 at admission
ASTHMA 15 97.14 1.875
HRAD 13 97.58 0.9
EPISODIC VIRAL WHEEZER 26 96.13 2.724 1.188 0.318
LRTI AND BRONCHIOLITIS 68 96.83 2.485
Total 122 96.8 2.375

TABLE 7: SPO2 AFTER THERAPY

Parameters Number Mean SD F-value P-value
SPO2 after therapy
ASTHMA 15 98.43 1.284
HRAD 13 98.58 0.793
EPISODIC VIRAL WHEEZER 26 97.67 1.551 1.878 0.137
LRTI AND BRONCHIOLITIS 68 98 1.228
Total 122 98.04 1.286

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TABLE 8: BIRTH WEIGHT
Parameters Number Mean SD F-value P-value
Birth Weight
ASTHMA 15 2.8214 0.31666
HRAD 13 2.8167 0.73588
EPISODIC VIRAL
0.239 0.869
WHEEZER 26 2.8125 0.62836
LRTI AND BRONCHIOLITIS 68 2.735 0.46199
Total 122 2.7688 0.51253

TABLE 9: PRAM SCORE

Parameters Number Mean SD F-value P-value
PRAM SCORE
ASTHMA 15 1.64 2.405
HRAD 13 2.08 3.088
EPISODIC VIRAL WHEEZER 26 1.54 2.413 4.819 0.003
LRTI AND BRONCHIOLITIS 68 0.4 1.209
Total 122 0.94 1.98

Table 10: Treatment details

Treatment Frequency Percentage
O2 THERAPY 84 68.6
NEB ASTHALIN 60 49.1
IV HYDROCORTISONE 32 26.2
ORAL PREDNISOLONE 5 4.0
ORAL BRONCHODILATOR 95 77.8
MGSO4 11 9.1
SYP CPM 25 20.4
SYP KUFRIL 29 23.7
SYP PCM 82 67.2
INJ AMPICILLIN 72 59
INJ AMIKACIN 31 21.4
IV FLUIDS 62 50.8
NEBULIZATION (BUDECORT,
DUOLIN, ADRENALINE AND 3%NS) 45 36.6

AGE WISE DISTRIBUTION

90 85
80
70
60
50
40
30 24
20 11
10 2
0
1

AGE 1M- 3y AGE 4y-7y AGE 8y-11y AGE 12y-13y

Fig. 1: Age wise distribution of affected children

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GENDER DISTRIBUTION
SEX MALE SEX FEMALE

90

81
80
70
60
50

41
40
30
20
10
0
1

Fig. 2: Gender wise distribution

HOSPITAL STAY
FINAL DIAGNOSIS HOSPITAL STAY

5 - 13DAYS

5- 10DAYS
4- 7DAYS

4- 9DAYS

4-8 DAYS
BRONCIOLITIS
ASTHMA

HRAD

LRTI

SEVERE BRONCHIOLITIS

0 0.2 0.4 0.6 0.8 1 1.2

Fig. 3: Hospital stay of different diagnosis of patients

ECONOMIC STATUS
140
120
100 41
80
60
40 81
20
0
1

ECONOMIC STATUS LOW ECONOMIC STATUS MEDIUM

Fig. 4: Economic status

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FAMILY HISTORY

23

7
2

90

ASTHMA ALLERGY CONSANGUINOUS MARRIAGE NS

Fig. 5: Family history

CHILDREN EFFECTED BY FEVER

140

120
44
100

80

60
78
40

20

0
FEVER YES FEVER NO
1 2
Fig. 6: Children affected by fever

COUGH PERCENTAGE IN
CHILDREN
00

36

86

COUGH YES COUGH NO

Fig. 7: Cough percentage in children

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percentage of COLd in each

INDIVIDUAL
COLD NO COLD YES

21
1
103

0 20 40 60 80 100 120
Fig. 8: percentage of cold in each individual

SHORTNESS OF BREATH IN
PERCENTAGE
1%
23%

76%

SOB YES SOB NO SOB GRADE 1

Fig. 9: Shortness of breath in children

CLINICAL FEATURES
140
119
120
103
100 93
78
80

60

40

20

0
1 2 3

FEVER COUGH COLD SOB

Fig. 10: Clinical features

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chest retractions
140
121 121
120
100
80 71
60 51
40
20
1 1
0
YES NO YES NO YES NO
CHEST RETRACTIONS STRIDOR GRUNTING
Fig. 11: Chest retractions in patients

HEART RATE
90
78
80
70
60
50
40 33
30
20
10 5 4 2
0
1

HR { BPM } 60 - 90 HR { BPM } 91 - 120 HR { BPM } 121 - 150

HR { BPM } 151 - 180 HR { BPM } >180

Fig. 12: Heart rate in children

Respiratory rate
70
58
60

50

40 34
30
18
20
10
10
2
0
>60 51-60 41-50 30-40 <20
RR
Fig. 13: Respiratory rate

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WHEEZE AND CREPTS

NO 81
CREPTS

YES 41

NO 58
WHEEZE

YES 64

0 10 20 30 40 50 60 70 80 90
Fig. 14: Respiratory findings

Both wheeze and crept sound

120
114
100

80

60

40

20
8
0
1 2

BOTH WHEEZE AND CREPTS YES BOTH WHEEZE AND CREPTS NO

Fig. 15: Both wheeze and crept sounds in children

SPO2 AT ADMISSION

>=95% 105
SPO2 1

92 - 94% 10

<92% 7

0 20 40 60 80 100 120
Fig. 16: Severity at admission

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AFTER THERAPY

>=95% 118
SPO2 2

92 - 94% 4

<92%

0 20 40 60 80 100 120 140

Fig. 17: Spo2 after treatment

BIRTH WEIGHT

100

80

60

40

20

0
1

BIRTH WEIGHT { KGS } <1 BIRTH WEIGHT { KGS } 1 to 2

BIRTH WEIGHT { KGS } 2 to 3 BIRTH WEIGHT { KGS } 3 to 3.75

Fig. 18: Birth weight of patients

PRAM SCORE
0

17

12 PRAM SCORE 0

PRAM SCORE 2
MILD

93

Fig. 19: PRAM score

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BAE +
90 82
80
70
60
50
40
28
30
20 12
10
0
DECREASED AIR ENTRY BAE + BAE + ,CS +
BAE +
Fig. 20: BAE+ in children

CHEST X - RAY

7%

CHEST X - RAY NORMAL

CHEST X - RAY
93% ABNORMAL

Fig. 21: Chest x-ray

COMPLETE BLOOD PICTURE

116 110 113

120
100 81
80
60 29
40 8 4 5 5 7 4 5
20 1
0 Series1
NORMAL

NORMAL

HIGH
HIGH
6 to 8

10 to 12

<LOW COUNT
>12

ABNORMAL

LOW

LOW
8 to 10

NORMAL

HB GM% WBC CELLS NEUTROPHILLS LYMPHOCYTES

CBP

Fig. 22: Complete blood picture

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other symptoms

94
100

80

60
28
40

20

0
1

OTHER SYNPTOMS YES OTHER SYNPTOMS NO

Fig. 23: Some other symptoms affected in children

OXYGEN THERAPY
70
60
60
50
38
40
30
20 14
9
10
1
0
1 2

O2 THERAPY O2 BY MASK O2 THERAPY O2 BY INHALATION

O2 THERAPY HFNC O2 THERAPY CPAP
O2 THERAPY NO

Fig. 24: Oxygen supplementation

NEBULISATION
140 118 118
120 105 108
99
100
80 60 62
60
40 17 23
14
20 4 4
0
YES NO YES NO YES NO YES NO YES NO YES NO
ASTHALINSALBUTAMOLBUDECORT DUOLIN 3%NS ADRENALINE
NEB
Fig. 25: Nebulization therapy

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IV AND ORAL STERIODS

140
117
120
100 90
80
60
40 32

20 5
0
1 2

IV HYDROCORTISONE YES IV HYDROCORTISONE NO

ORAL PREDNISOLONE YES ORAL PREDNISOLONE NO

Fig. 26: Steroids

ORAL SALBUTAMOL

95
100
80
60
27
40
20
0
YES NO
ORAL SALBUTOMOL

Fig. 27: SABA

IV MGSO4

11

111

IV MGSO4 YES IV MGSO4 NO

Fig. 28: IV Mgso4

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LIQUID DOSAGE FORMS

97 93
82

40
25 29

YES NO YES NO YES NO

0RAL CPM ORAL KUFRILL ORAL PCM
Fig. 29: DIFFERENT LIQUID DOSAGE FORMS

ANTIBIOTICS

91

72

50

31

YES NO YES NO
AMPICILLIN AMIKACIN
ANTIBIOTICS
Fig. 30: Antibiotics

INTRAVENOUS FLUIDS

62 60

IVF NS+5%D YES IVF NS+5%D NO

Fig. 31: Intravenous fluids

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OTHER DRUGS
121
MONTELUKAST 1
119
ORAL CEFTRIAXONE 3
119
IV DEXAMETHASONE 3
119
IV ADRENALINE 3
117
ORAL CLAVUM 5
117
ORAL AMOXYCLAV 5
0 20 40 60 80 100 120 140

Fig. 32: Other drugs

FINAL DIAGNOSIS
FINAL DIANOSIS ACUTE EXACERABATION OF ASTHAMA
FINAL DIANOSIS SEVERE BRONCHOLITIS
FINAL DIANOSIS BRONCHIOLITIS
FINAL DIANOSIS EPISODIC VIRAL WHEEZER
FINAL DIANOSIS HRAD
FINAL DIANOSIS LRTI
50 45

40

30 26
20
20 15
13
10
3
0
1

Fig. 33: Final diagnosis

IV. DISCUSSION
According to our study, out of 122 cases 85(69.7%)
children are from 1m to 3 years of age, 24(19.7%) children 4
to 7 years of age, 11(9%) are from 8 to 11 years of age,
2(1,6%) children are from 12 to 13years of age group.
Gender wise distribution include 81(66.3%) are male and
41(44.6%) are female, where males are mostly affected in
our study. Among the subjects 15(12.2%) children were
diagnosed with acute exacerbation of asthma, 13(0.6%)
children with HRAD, 68(55.7%) with bronchiolitis and
LRTI, 26(0.6%) with multi trigger wheezer. Based on the
age factor, children who are less than 5 years of age who
suffer with the wheeze and snore are expected with high
chances of getting asthma and HRAD, not all who wheeze
will have asthma some may have bronchiolitis, multi trigger
wheezer and LRTI. The reoccurrence of this episodes may
lead to asthma and HRAD.
Among 120 cases majority of children are from low
economic status with percentage of 65.5% and medium
economic status were found to be 44.5%. Based on their
family history, 90(73%) children have no history of asthma,
23(19,6%) children have history of asthma in father, mother
and paternal uncles. 7(5.7%) children gave history of sin and
food allergy, 2(1.6%) children were from 3 rd
consanguineous marriage.
Out of the 120 samples 78(84.4%) children are
suffering from fever, 86(70%) with cough, 103(84.4%) are
affected with cold, 93(76.2%) with SOB and the rest of the
children are not suffered from these symptoms. Out of 120
samples children with wheeze 64(52.4%) children are
affected, 41(33.6%) children are experiencing with crept
sounds. Children facing both wheeze and crept sounds are
114(93.5%).

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Among 120 cases spo2 at admission 7(5.7%) having <
92% suggests severe LRTI or pneumonia, 10(8.1%) children
are having 92-94%, 105(86.2%) children are with
tachypnoea. spo2 after supplemental o2 therapy 118(96%)
children were improved after therapy, 4(4%) children were
not improved and were upgraded to HFNC and CPAP.
Out of 120 children, birth weight was found to be
1(0.8%) child is <1kg, 7(5.7%) children are between 1-2kg,
22(18%) children are between 3-4kgs.
PRAM score in 93(76.2%) children are having 0 score,
12(9.8%) children are having mild score, 17(13%) children
are having moderate score. The p value was found to be
0.003 and f value was found to be 4.819 which is
statistically significant.
Chest x-rays was normal in 93% of children and
abnormal in 7% children are having opacities, peri bronchial
thickening and pleural cavity effusion. 12(9.8%) children
are with decreased air entry, 82(67.2%) children are with
clear BAE and 28(23%) children are having normal air with
but present with conductivity sounds.
Supplemental oxygen in 84(68.6%), salbutamol
nebulization in 60(49.1%). In addition to SABA
nebulization budecort, ipratropium bromide, adrenaline and
3% NS were nebulized in another 45(36.6%) children.
IV hydrocortisone is given in 32(26.2%), oral
prednisolone in 5(4%), oral bronchodilator in 95(77.8%),
mgso4 in 11(9.1), CPM in 25(20.4%), kufril in 29(23.7%),
PCM in 82(67.2%), antibiotic ampicillin is given in
72(59%), amikacin in 31(21.4%) and IV fluids in 62(50.8%)
children.
Children who are affected with rhinoviruses,
respiratory syncytial virus are having more prone to
bronchiolitis and LRTI infections. Supplemental o2 and
SABA and adding bronchodilators with nebulization will
improve the patient condition. In my present study, more
than 10% children received rescue steroids to prevent the
acute asthma.
V. CONCLUSION
Many children were under 5 commonest age group,
suffering from wheeze, respiratory distress and asthma. To
many children, viral infection was one of the causes for
wheeze, LRTI and other respiratory symptoms. Nebulization
of salbutamol was useful in HRAD and asthma than
bronchiolitis and LRTI. IV hydrocortisone was beneficial in
HRAD and less beneficial in bronchiolitis. Supplemental
oxygen was most effective treatment in bronchiolitis
condition. Average hospital stay of asthma children is 7 to
12 days compared with HRAD was 6 to 7 days and with
wheeze children for 5 to 8 days. Low socioeconomic status
children are having more percentage in this study. Using
PRAM score in our study, we concluded that less children
are facing severity of exacerbations and some children are
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International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165
experiencing moderate types of severity. None of the
children were receiving spacers or holding chambers. At
least some percentage of the children in the present study
may require spacers in long term use to decrease morbidity.
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