Usually diagnosed from the history and examination and no investigations are needed. History Taking • • • • • • • • • • • • Current symptoms Pattern of symptoms Precipitating factors Present treatment Previous hospital admission Typical exacerbations Home/ school environment Impact on life style History of atopy (allergy) Response to prior treatment Prolonged URTI symptoms Family history

Sometimes, specific investigations are required to confirm the diagnosis, or explore the severity and phenotype in more detail.

• Pulmonary Function Testing: I. Spirometry II. Bronchoprovocation challenges (To see whether your airway is hyper responsive) III. Exercise challenges IV. Peak expiratory flow (PFE). (Most children over 5 years of age can use a peak flow meter)
• Radiology: Chest Radiographs • Allergy testing (Skin-prick testing )


Acute Management


• Asthma attacks require prompt treatment. • A patient who has brittle asthma. • Moderate and severe attacks require clinic or hospital attendance.Managing Acute Exacerbations • Mild attacks can be usually treated at home if the patient is prepared and has a personal asthma action plan. previous ICU admissions for asthma or with parents who are either uncomfortable or judged unable to care for the child with an acute exacerbation should be admitted to hospital. .

agonists. • Relapse within 4 hours of nebulized β₂. . • Severe acute asthma.Criteria for Admission • Failure to respond to standard home treatment. • Failure of those with mild or moderate acute asthma to respond to nebulized β₂-agonists.

PEFR. color. . • Hydration . • Efficacy of prednisolone in the first year of life is poor. • On discharge. • IV Magnesium Sulphate : Consider as an adjunct treatment in severe exacerbations unresponsive to the initial treatment. • Avoid Chest physiotherapy as it may increase patient discomfort. • Role of Aminophylline debated due to its potential toxicity. To be used with caution. • Avoid sedatives and mucolytics. It is safe and beneficial in severe acute asthma. ABG and O2 Saturation.Monitoring Acute Asthma • Monitor pulse.give maintenance fluids. patients must be provided with an Action Plan to assist parents or patients to prevent/terminate asthma attacks. Close monitoring for at least 4 hours. • Antibiotics indicated only if bacterial infection suspected. in a controlled environment like ICU.

occurring in 1-2% of children • Exercise . • Food allergy .commonest trigger in children.uncommon trigger.Preventing Chronic Asthma Identifying and avoiding the following common triggers • Environmental allergens • Cigarette smoke • Respiratory tract infections .

Reemphasize compliance to therapy. Peak Expiratory Flow Rate (PEFR) or FEV1 monitoring. Compliance to asthma therapy: Frequency. Technique. Morbidity secondary to asthma. three issues need to be assessed. Frequency and severity of acute exacerbation. Written asthma action plan.Monitoring Chronic Asthma During each follow up visit. Quality of life. . Asthma education: Understanding asthma in childhood. They are: Assessment of asthma control based on: Interval symptoms.

0%).Epidemiology of Asthma Among Malaysian Children • Primary school children : 13.1% • Prevalence was higher in rural (4.5%) than in Urban areas (4.8% • Children aged 13-14 : 9.shows that prevalence of asthma among urban children was the highest (5.7%).7%) . • Prevalence was also higher in those with lower educational status (5. However. and rural children (4. another study was conducted by Universiti Putra Malaysia in 2010 .2%). followed by industrial area (5.6%)and lower income (4.6% • Adult ( self-reported) in National Health and Morbidity Survey (NHMS) : 4.6%).

conscious level . 2. weather. pneumonia) Triggering factors : food. exercise. cough. Diagnosis : symptoms (eg. infection. 3. breathlessness.Grading of Acute Exacerbation 1. colour. wheezing. emotion. respiratory effort. drugs Severity: respiratory rate.

Rate Accessory Muscle usage/ retractions Wheeze Normal to mildly increased Absent Increased Present.moderate Markedly increased Present.severe Moderate. often only end expiratory >95% <100 >80% Loud Usually loud SpO2 (on air) Pulse/ min PEFR1 92-95% 100-120 60-80% <92% >120 (>5yrs) >160 (infants) <60% Cyanosis. Silent chest Talks in Alertness Sentences Maybe agitated Phrases Usually agitated Resp.Parameter Mild Moderate Severe Life threatening Breathless When walking When talking At rest Infants: stop feeding words Usually agitated Unable to speak Drowsy/ confused/coma Poor resp effort Paradoxical thoracoabdominal mov. <92% Bradycardia Unable to perform .

2.Grading of Chronic Asthma 1. Based on severity Based on levels of control Classification Daytime symptoms Nocturnal symptoms FEV1/ PEFR (%) Intermittent Mild persistent Moderate persistent Severe persistent <1/week >1/week Daily Continual daily <1/month >2/month >1/week Daily >80 >80 >60-80 <60 .

Evaluation of the background of newly diagnosed asthma Category Clinical Parameters Intermittent Daytime symptoms less than once a week Nocturnal symptoms less than once a month No exercise induced symptoms Brief exacerbations not affecting sleep and activity Normal lung function Persistent (Threshold for preventive treatment) Daytime symptoms more than once a week Nocturnal symptoms more than twice a month Exercise induced symptoms Mild Persistent Exacerbations > 1x/month affect sleep/activity PEFR / FEV1 > 80% .

. Moderate Persistent Daytime symptoms daily Nocturnal symptoms more than once a week Exercise induced symptoms Exacerbations >2x/month affect sleep. activity PEFR/ FEV1 60-80% Severe Persistent Daytime symptoms daily Daily nocturnal symptoms Daily exercise induced symptoms Frequent exacerbations >2x/month affect sleep. activity PEFR/ FEV1 < 60% .Continued.

. Uncontrolled *A medical guidelines organization which works with public health officials and health care professionals globally to reduce asthma prevalence. Partly control 3. Based on symptoms and 3 levels of control: 1. Well controlled 2.Asthma Severity based to Control Based Proposed by *The Global Initiatives for Asthma (GINA).

Level of Asthma Control (GINA 2006) Characteristics Controlled All of the following: none None None Partly controlled Any measure present in any week >2/week Any Any >3 features of partly controlled asthma present in any week Uncontrolled Daytime symptoms Limitation of activities Nocturnal symptoms/ awakening Need for reliever Lung function test Exacerbations None None none >2/week <80% predicted >1/ year One in any week .

Asthmatic Predictive Index The possibility of those with negative index not becoming asthmatic by 6 years old was 95% whereas those with a positive index have a 65% chance of becoming asthmatic by 6 years old. A clinical index to define Risk of Asthma in young children with Recurrent Wheeze Positive Index ( >3 wheezing episodes / year during first 3 years Major criteria Plus one Major criteria or two Minor criteria • Eczema • Parental asthma • Positive aeroallergen skin test Minor criteria • Positive skin test • Wheezing without URTI • Eosinophillia (>4%) .

ages Age (years) <5 5-8 >8 Oral + MDI + Spacer + + + MDI + Mask + Spacer + Dry Powder Inhaler + *MDI = metered-dose inhaler .Treatment Drug Therapy Delivery System available & recommendation for diff.

agonists Leukotriene modifier SR Theophylline Oral Glucocorticoids Lowest dose Anti-IgE Med / High dose ICS Low dose ICS + Leukotriene modifier Low dose ICS + SR Theophylline .agonists Increase STEP 4 Severe Persistent STEP 5 Severe Persistent STEP 2 Mild Persistent As needed rapid acting β₂.agonists Med / High dose ICS + long acting β₂.Treatment for Chronic Asthma Management Based Control Reduce STEP 1 Intermittent As needed rapid acting β₂.agonists STEP 3 Moderate Persistent Controller Options Select One Select One Add One / more Add One / both Low dose Inhaled steroids Leukotriene modifier Low dose ICS + long acting β₂.

Drug Treatment .

5 mg/dose >20kg : 5.0 mg/dose 5-10 mcg/kg/dose 0. 2.5 mg/dose Formulation Dosage Intravenous • Terbutaline Nebuliser solution 10mg/ml.3 mg/kg/dose or <20kg : 2.5 mg/ml nebule 0.2-0. increase by 1.0 mg/dose Cont: 500 mcg/kg/hour Bolus: 5-10 mcg/kg over 10min Infusion: 0.Drugs Used in Treatment of Acute Asthma Drug B2-agonists (causes bronchodilation of the small airways) • Salbutamol Nebulizer solution 5mg/ml or 2.15 mg/kg/dose (max 5mg) or < 2 y/o : 2.0 mcg/kg/min every 15min to a max of 20 mcg/kg/min 0.0 mcg/kg/min.5-1.5 mg/dose > 2 y/o : 5.5 mg/ml or 5 mg/ml respule Parenteral • Fenoterol Nebuliser solution .12-1.

0 mg/kg/hr 4mg granules 5mg/ tablet on night chewable 10mg/tablet ON • Montelukast Oral .Drug Corticosteroid • Prednisolone • Hydrocortisone • Methylprednisolone Other agents • Ipratropium bromide • Aminophylline oral Formulation Dosage 1-2 mg/kg/day in divided doses (for 3-7 days) 4-5 mg/kg/dose 6 hourly 1-2 mg/kg/dose 6-12 hourly intravenous intravenous Nebuliser solution (250 mcg/ml) Intravenous <5 y/o : 250 mcg 4-6 hourly >5 y/o : 500 mcg 4-6 hourly 6 mg/kg slow bolus (if not previously on theophylline) followed by infusion 0.5-1.

15mg/kg/dose TDS-QID/PRN 100-200 mcg/dose QID-PRN 100-200 mcg/dose QID-PRN 0.Drugs Used in Treatment of Chronic Asthma Drug Relieving drugs B2-agonists • Salbutamol Oral Metered dose inhaler Dry powder inhaler Oral 0.075 mg/kg/dose TDS-QID/PRN 250-500 mcg/dose QID/PRN 500-1000 mcg/dose QID/PRN (max 4000 mcg/daily) 200 mcg/dose QID/PRN Formulation Dosage • Terbutaline • Fenoterol Metered dose inhaler Ipratropium bromide Metered dose inhaler 40-60mcg /dose TDS/QID/PRN .

Drug Preventive drugs Corticosteroid • • • Prednisolone Beclomethasone Diproprionate Budesonide Oral Formulation Dosage 1-2 mg/kg/day in divided doses <400 mcg/day : low dose 400-800 mcg/day : Moderate 8001200 mcg/day: High Metered dose inhaler Dry powder inhaler • Fluticasone Propionate Metered dose inhaler Dry powder inhaler <200 mcg/day : Low 200-400 mcg/day : Moderate 400-600 mcg/day : High 160 microgram daily 320 microgram daily 20mg QID 1-2mg QID or 5-10mg BID-QID • Ciclesonide Metered dose inhaler Sodium cromoglycate Dry powder inhaler Metered dose inhaler Theophylline Oral syrup Slow release 5 mg/kg/dose TDS/QID 10 mg/kg/dose BD .

5mcg Oral 4mg granules 5mg/tablet on night chewable 10mg/tablet ON .5mcg. 50/500mcg Budesonide / formoterol Antileukotrienes (leukotriene modifier) Montelukast Dry powder inhaler 160/4. 50/250mcg. 25/125mcg. 80/4. 25/250mcg 50/100 mcg.Drug Long acting B2-agonist Salmetrol Combination Salmetrol / fluticasone Formulation Dosage Metered dose inhaler Dry powder inhaler 50-100 mcg/dose BD 50-100 mcg/dose BD Metered dose inhaler Dry powder inhaler 25/50 mcg.

Devices used Pressured Metered Dose Inhaler (PMDI) • Used with spacer • Appropriate for all age groups  0-2 years use spacer and facemask  > 2 years use spacer alone • Spacer is recommended as it increases drug deposition in the lungs • Useful for acute asthma attacks when poor inspiratory effort may impair the use of inhalers direct to the mouth .


Breath-Actuated Metered Dose Inhalers  > 6 years old  Useful for delivering beta-agonists when out and about in older children  Don’t have to press canister to release the drug  Do not require a spacer  Medicine comes out automatically as the individual breathes in .

3. The inhaler will release a puff of medicine. Tilt your chin up slightly and breathe out.Steps for Use 1. 7. 4. Push the test fire slide button on the bottom while holding the inhaler upright. Place your lips around the mouthpiece and begin breathing in slowly. Point the inhaler away from you. Shake gently and remove the cap from the mouthpiece. 5. Breathe in slowly through your mouth for 3 to 5 seconds. 6. If the inhaler is new or has not been used in the last 48 hours it must be primed. . Close the flip lever and replace the cap over the mouthpiece. 2. Hold your breath for 10 seconds and then breathe our slowly. Lower the lever and repeat the steps to release the second prime spray. Lift the lever on top of the canister. Hold the inhaler upright and flip open the lever or take off the cap.

Dry Powder Inhaler       > 4 years old Needs good inspiratory flow Less efficient in severe asthma and an acute attack Also used when children are out and about Rely on the individual’s force of inspiration Medication is commonly held either in a capsule for manual loading or a proprietary form (pellet) from inside the inhaler. the operator puts the mouthpiece of the inhaler into their mouth and takes a deep inhalation. holding their breath for 5-10 seconds .  Once loaded or actuated.

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