3. • Asthma: Is a disease of variable airway
inflammation and airflow obstruction
• Asthma exacerbation (attack): acute or
subacute episode of progressively worsening
shortness of breath, cough, wheeze and chest
tightness (or some combination of these
symptoms)
Definitions
4. • Great advances in understanding and
management of asthma
• Improved use of controller medication (Low in
our set up)
asthma exacerbations remain a burden
• Asthma exacerbations occur despite adherence
to adequate controller therapy (Martinez FD, Paediatrics
2009)
Background
5. EPIDERMIOLOGY
• WHO estimates 235 million people currently
suffering from asthma worldwide. (WHO Asthma, fact
sheet no. 307, May 2011.)
• Asthma prevalence in children
- 14% 4yrs in Ifakara District in Tanzania. (Sunyer, J., et al. 2001)
- In Kampala district was found to be 13.8% in primary school children.
(Bitimwine H, 2011. unpublished)
7. • Characterised by decreases in expiratory
airflow that can be measured and monitored
by lung function testing (FEV1 or PERF)
• Severe exacerbations are potentially life-
threatening; require close
monitoring/supervision
Exacerbations
9. • Essential for institution of appropriate
management
• Signs to assess for:
– Respiratory rate
– Pulse rate
– Blood pressure
– Degree of breathlessness (ability to talk & feed)
Assessment of severity
10. – Use of accessory muscles of respiration
– Extent & loudness of wheeze (1/ severity)
∝
– Air entry
– Mental state – consciousness, agitation due to
hypoxia
– Cyanosis and Oxygen saturations
– Peak expiratory flow rate (PEFR)
Signs …..
11. Life threatening asthma
Clinical signs
• Silent chest
• Cyanosis
• Poor respiratory effort
• Hypotension, bradycardia
• Exhaustion
• Confusion or drowsiness
Measurements
• SpO2 <92%
• PERF <33% of best or
predicted
12. Severe asthma exacerbation
Clinical signs
• Unable to complete sentences
(phrases)
• Agitation
• Use of accessory muscles
• PR:>140/min <5yrs; >125/min
• RR: .40/min < 5yrs; >30/min
>yrs
• Confusion or drowsiness
Measurements
• SpO2 <92%
• PERF <33-50%
13. Moderate Exacerbation
Clinical signs
• Able to talk in sentences
• Pulse rate: ≤ 140/min <5 yrs; ≤
125/min >yrs
• Respiratory: >40/min in children
2-5 years old; >30/min in >5
years old
• Reduced air entry
Measurements
• SpO2 <92%
• PERF ≥50%
14. Mild Exacerbation
Clinical signs
• Able to talk in sentences
• Not agitated
• Pulse rate not increased
• Respiratory rate may be
increased
• Mild wheeze
Measurements
• SpO2 >92%
• PERF ≥70%
15. Initial management
Cornerstones of Treatment:
1. Inhaled short-acting β2-agonists (SABA)
Nebulizer: oxygen or air-driven
Pressurised metered-dose inhaler (pMDI) and
spacer combination
2. Corticosteroids
oral, preferred route
3. Oxygen
17. Severity scale of Asthma
Severity of
Asthma
Frequency of
Daytime
Symptoms
Frequency of
Nighttime
Symptoms
PEF of FEV1/ PEF
Variability
Suggested
Management
(with inhaler as
needed)
Mid intermittent ≤2 days per week ≤2 nights per
month
≥80%/<20% None necessary
Mild persistent >2 times per week
<1 time per day
Attacks affecting
activities
>2 nights per
month
≥80%/20-30% Low-dose
inhaled
corticosteroid
Moderate
persistent
Daily
Attacks affecting
activities
>1 night per
week
60-80%/>30% Low to medium
dose inhaled
corticosteroid
Plus long acting β-
agonist
Severe persistent Continuous
Limited physical
activity
Frequent ≤60%/>30% High dose inhaled
corticosteroid plus long
acting β-agonist, oral
anti-inflammatory if
needed and oral
glucocorticoid as
needed
18. Status asthmaticus
• Status asthmaticus is an acute exacerbation
of asthma that remains unresponsive to initial
treatment with bronchodilators.
• Status asthmaticus
- can vary from a mild form to a severe form with
bronchospasm, airway inflammation, and mucus plugging
that can cause difficulty breathing, carbon dioxide retention,
hypoxemia, and respiratory failure.
19. • First-line of therapy
• Salbutamol
– via nebulizer - given as 3 doses 20 min apart or
– Via MDI and spacer – 2-10 puffs according to
severity; one puff at a time
MDI-spacer combination more efficacious & cost-
effective (Schuh S et al J Pediatr 1999; 135: 22-27)
Alternative Salbutamol
– Fenoterol
– Formoterol – LABA with rapid onset of action
Inhaled β2-agonists
20. • Given early, reduce progression in severity
• Onset of action same for both oral and IV route
(3-4 hrs)
• Oral route preferred (Davies G, et al. Arch Dis Child 2008; 93: 952-
958. The British Guideline on the Management of Asthma. May 2008, revised
June 2009. www.brit-thoracic.org.uk. )
• Duration of therapy should be 3 days only
̴
Steroid therapy
21. • Prednisone or prednisolone, oral
– 1-2mg/kg/day; max 40mg/day for 3-5 days. No
need to taper
• Hydrocortisone, IV
– 5mg/kg 6hrly
• Methylprednisolone, IV
– 1-2mg/kg 6hrly
• Dexamethasone, IV
– 0.15mg/kg 6hrly
Steroids….
22. • O2 may be used as a driver for nebs
• Given via a mask or nasal prongs
• Aim at saturations ≥95%
• Indications:
– All children with life-threatening asthma
– Those with SpO2 <94%
Oxygen therapy
23. • Reassess
Good response
• Not tachypnoeic
• Minimal wheezing
• No retraction
• Able to speak and feed (young child)
• PEFR ≥80% predicted or personal best
After initial therapy
24. Incomplete/poor response
• Tachypnoeic
• Persistent wheezing
• Retraction present
• Impaired speech or feeding
• PEFR ≤79% predicted or personal best
Reassess……
25. • If inadequate response
– Add Ipratropium Bromide (IB);
every 20 min x 1-2 hrs
then 4 – 6 hrly and wean off
What next?
26. • Is an anti-cholinergic: blocks PNS activity
• Synergistic effect with β2-agonists
• Can be mixed with the salbutamol in same
neb
• Available singly as nebuliser solution
(0.25mg/ml) or combined with SABA as nebs
or pMDI
• Dose: <2yrs 0.125mg; >2 yrs 0.25mg per dose
Ipratropium bromide
27. Mainly for ICU setting
• IV Salbutamol – once off;
– 15µg/kg over 10 min
– Infusion – loading dose of 5µg/kg/min over 1 hr
the 1-2 µg/kg/min as infusion
• IV Magnesium sulphate – single dose
adequate; 25-50mg/kg/dose (max 2g)
Other therapies
28. • IV Aminophylline – narrow therapeutic index,
severe side effects. Load with 6mg/kg then
0.5-1mg/kg/hr. Monitor levels
• SC Adrenaline – for moribund patients or
when inhaled therapy not available
– Dose: 0.01ml/kg of 1:1000 solution
Other therapies…
29. • No evidence to support or refute their use in
acute asthma
• Majority of exacerbations are due to viral
infections
Therefore, do not give antibiotics
routinely
Antibiotics
30. • Patients with prolonged exacerbations may
become dehydrated (vomiting, poor intake)
• IV Fluids: should not exceed 50ml/kg/24hrs
Hydration
31. • Definite time of discharge difficult to define
• Discharge on treatment manageable at home
with a written Action Plan for exacerbation
• Asthma education – emphasize treatment &
appropriate inhaler technique
• Plan Follow up soon – within a week
Discharge and Follow up
33. Asthma Exacerbations
• Are common
• Occur despite adherence to adequate
controllers
• Cornerstones for treatment remain inhaled
SABAs, oral corticosteroids & oxygen
• Inhaled Ipratropium bromide should be added
to the SABA in the event of poor response to
initial Rx
SUMMARY
34. • Global intiative for Asthma update.
• Current Allergy and Clinical
Immunology/Allergy Society of South Africa
Journal.
• British Guideline on the Management of
Asthma. A National Clinical Guide.
Information sources
Editor's Notes
#17:Adapted from the National Asthma Education and Prevention Program from the National heart lung and blood institute
Alternative for moderate persistent: medium dose inhaled steroid plus oral anti-inflammatory (leukotriene modifiers like zafirlukast or zileuton or long acting theophylline
