Asthma guideline for children
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Asthma guideline for children Asthma guideline for children Document Transcript

  • 1 ะเทศไทย (The Thai National Guideline for Diagnosis and Management of Childhood Asthma) 1. บทนำ 2. 3. (Treatment of acute exacerbations) 4. (Chronic therapy for childhood asthma) 5. (Prevention of asthma) ร
  • 2 I บทนำ - )
  • 3 มำตรฐำนจำก NHLBI (GINA)
  • 4
  • 5 (goal of therapy) 1. 2. กำร 3. ) 4. และในโรงพยำบำล 5. 6. 1. (educate patient and establish partnership)
  • 6 2. ของปอด (assessment of asthma severity) 3. ของโรค (avoidance and control of triggers) 4. กษำระยะยำว (establish medication plans for long- term management) 5. กำรวำง (establish plans for managing exacerbations) 6. (provide regular follow-up care)
  • 7 II 1. Airway inflammation 2. Increased airway responsiveness to a variety of stimuli 3. Reversible or partial reversible airway obstruction 1. 2. กษำ (reversible airway obstruction) 3. ด (wheeze) โดย 1.1
  • 8 ยหลอดลม 1.2 ฯลฯ 1.3 ( 2.1 (forced inspiratory/expiratory wheeze) 2.2 (increased A-P diameter) 2.3 atopic dermatitis
  • 9 recurrent wheezing ( 3.1 (chest X- pneumothorax, atelectasis
  • 10 3.2 (pulmonary function test) 1 ของ FEV1 2 Peak flow variability = PEFmax - PEFmin x 100% 1/2 (PEFmax + PEFmin) 3.3 (allergy skin prick test)
  • 11 3.4 (bronchoprovocation test) croup, foreign body, vascular ring ฯลฯ BPD (bronchopulmonary dysplasia) ฯลฯ 3. gastroesophageal reflux (GER), congestive heart failure ฯลฯ (Classification of asthma by severity) NHLBI (National Heart Lung and Blood I (intermitte 1)
  • 12 (Classification of asthma severity) 4 : (Severe persistent) อำกำรหอบตลอดเวลำ (Exacerbation อยมำก PEF FEV1 60% > 30% 3 : (Moderate persistent) อำ (Exacerbation 2- agonist PEF FEV1 >60% - <80% >30% 2 : (mild persistent) (Exacerbation PEF FEV1 80% 20-30% 1: (Intermittent) (Exacerbation exacerbation PEF FEV1 80% <20%
  • 13 I (Treatment of acute asthmatic attacks) 1. 2. FEV1, PEFR 3. as - inhaled 2-agonist - - theophylline, anticholinergic drug ฯลฯ - 4. asthma exacerbations 1. asthma exacerbations
  • 14
  • 15 asthma exacerbations Mild Moderate Severe วะ Respiratory arrest อำกำร (Symptoms ) หำยใจลำบำก อำกำรแสดง (Signs) จ – – – หำยใจ wheeze หำยใจออก wheeze ) < 100 100 – 120 > 120 – – – Pulsus paradoxus (< 10 mm Hg) (10–25 mm Hg) – ศษ (Functional Assessment) PEF % predicted or % personal best > 80% ประมำณ 50– 80% < 50% PaO2 (on air) > 60 mm Hg < 60 mm Hg PaCO2 < 42 mm Hg < 42 mm Hg > 42 mm Hg SaO2% (on > 95% 91 – 95% < 91%
  • 16 air) 2. asthma exacerbations inhaled 2-agonist และประ 1 asthma exacerbations PEF) Inhaled short-acting 2– MDI*
  • 17 - 2-agonists 4 – 6 ชม 24 – 48 ชม. - – - 2- 2 ชม. น - 2- ม กษำ MDI MDI 3.
  • 18
  • 19 asthma exacerbations ในโรงพยำบำล ( ) - - SaO2, PEFR, EFV1 - Inhaled short-acting 2-agonist 3 doses - oxygen SaO2 > 95% - systemic corticosteroid - อำกำร, อำกำรแสดง - SaO2, PEFR, FEV1 - inhaled short-acting 2- agonist - systemic corticosteroid - - - inhaled short-acting 2-agonist continuous nebulization inhaled anticholinergic - oxygen - systemic corticosteroid - distress - SaO2 > 95% - PEF > 70% ง - - SaO2 < 95% - PEF 50% - 70% - - PEF < 30% - PCO2 > 45 mm Hg - SaO2 < 90% - PaO2 < 60 mm Hg Discharge - inhaled 2- agonist systemic corticoste short course - กษำ - ล - inhaled 2-agonist - oxygen - systemic corticosteroid - anticholinergic - theophylline intensive care - inhaled 2-agonist - systemic corticosteroid - oxygen - systemic 2-agonist: SC, IV, IM - continuous 2-agonist IV theophylline - anticholinergic -
  • 20 – Oxygen – Bronchodilators: 2-agonist, anticholinergics, adrenaline – Corticosteroids – Oxygen – FEV1 PEFR SaO2 > 95% – face mask – SaO2
  • 21 – water nebulizer 2 - Agonists – inhaled short-acting 2 - Nebulizers – - PEFR – nebulization oxygen flow 6-8 L/min – Metered-dose inhaler (MDI) with spacer – - bronchodilatation nebulizers Injection
  • 22 – 0.01 mg/kg/dose 0.3 mg
  • 23 3 ขนำดของยำแ 2-agonist ในภำวะ asthma exacerbations ขนำดของยำ Inhaled short – acting 2-gonist. - Salbutamol nebulizer solution - - - continuous nebulization selective 2- 2.5 – 4 6-8 L/min - Salbutamol MDI (100 g/puff) - - Systemic (injected) 2- agonists - Terbutaline - aerosol therapy
  • 24 Epinephrine – angioedema – 2- – epinephrine 0.01 mg/kg 0.01 ml/kg 0.5 mL 3 doses Anticholinergics – inhaled 2- acute exacerbation – inhaled 2- severe airflow obstruction (Ipratropium bromide - Atroven Beta2- salbutamol)
  • 25 Ipratropium bromide 2-agonist ipratropium bromide nebulizer solution (0.25 mg/ml) initial - Combivent unit dose 2.5 cc ½ unit dose/ 10 kgs anticholinergics (hypertrophic subaortic stenosi atropine Corticosteroids acute asthmatic a – inhaled 2-agonists – inhaled 2- 3-4 inhaled 2-
  • 26 – Severe acute episode corticos - 5 asthma exacerbations Steroid Anti- inflammator y Effect Growth Suppre ssion Effect Salt- retaining Effect Plasma Half-life (min) Biologi cal Half-life (hr) Hydrocortison e 1.0 1.0 1.0 80-120 8 Prednisolone 4 7.5 0.8 120-300 16-36 Methylprednis olone 5 7.5 0.5 120-300 16-36 Dexamethaso ne 30 80 0 150-300 36-54
  • 27 5 ขนำดของยำ corticosteroids อยำ ขนำดยำ Methylprednisolon e (IV) loading dose 2 มก./กก. - 6 ชม. Methylprednisolone succinate (Solu-Medrol ) 40 mg/1 ml = 159 บำท 125 mg/ 2 ml = 336 บำท Hydrocortisone (IV) loading dose 5-7 มก./กก. 4-6 ชม. Hydrocortisone succinate (Solu-Cortef ) 100 mg/2 ml = 50 บำท Prednisolone (oral) - - 1 tablet = 5 mg Other treatments – Theophylline first line drug acute asthmatic attack therapeutic index side effect inhaled 2- asthmatic attack
  • 28 initial bolus dose 5 mg/kg infusion 0.5-0.9 mg/kg/hr 10-20 g/dL – Antibiotics sinusitis, otitis media และ pneumonia – I – C – S 4. asthma exacerbations – –
  • 29 – – – signs, symptoms และ functional assessment – – – – pulse oxim –
  • 30 กษำในโรงพยำบำ ล – blood gases โดยเฉพำะ PaCO2 5. 2 impending respiratory failure ค - - -
  • 31 - retraction ของ paradoxical thoracoabdominal movement - ง wheeze เลย (silent chest) - - Pulsus paradoxus 20 mmHg - PEF 50% ของ predicted/personal base value - PaO2 - PaCO2 42 mmHg - SaO2 room air 90% - pneumomediastinum 6. emergency department Criteria - - peak expiratory flow personal base value Medications - -
  • 32 7. - - inhaler และ peak flow meter - - -
  • 33 IV แนวทำงก (Chronic therapy for childhood asthma) 1 ยำขยำยหลอดลม (Bronchodilator) acute asthma 2 (Anti-inflamma (Preventer, Controller) - 6)
  • 34 1 - 2- 2
  • 35 FEV1 ( (variability) ประมำณ 20-30% : inhaled low-dose corticostero leukotriene receptor antagonists - - oral long-acting 2- 3 FEV1 - 30%
  • 36 - - sustained-release theophylline, long-acting inhaled 2- long acting oral 2-agonist leukotriene-receptor antagonist 4 FEV1 ≤ 30 % - - inhaled long-acting 2-agonist, sustained-release theophylline, long-acting oral 2-agonist, leukotriene-receptor antagonist ตลอดเวลำ อ
  • 37 รงของโรค - high-dose inhaled corticosteroid low-dose inhaled steroid peak flow meter peak flow meter
  • 38 (life-threatening asthma) 6 (long-term preventive medications for asthma in children) ำ 1. Inhaled corticoster oid - และคว 2) - - - - ดม - ) 2. Cromolyn sodium - nebulized (20 mg/2ml) - - MDI (1และ 5 mg/puff) - - - - ก - กกำร - รำคำแพง - - 3. Leukotrie ne - - - - รำคำแพง -
  • 39 receptor antagoni st กกำร 4. Ketotifen - (1 mg/5 ml) - (1 mg/tab) ขนำด 0.5 mg bid 1 mg bid - - - - - - 1-3
  • 40 3 องโรค ยะยำว (Long-term Preventive) (Quick-Relief) 4   short acting 2- ลดลง (Step down)  inhaled medium-to- high dose มำก (severe corticosteroid persistent) - long-acting inhaled 2--agonist จำรณำลด - sustained-release theophylline ขนำดและจำนวนยำลง - long-acting oral 2- agonist - leukotriene-receptor antagonist  prednisolone 3  inhaled medium-dose corticosteroid  short acting 2- (Step up) ปำนกลำง  inhaled low-dose corticosteroid - (moderate persistent) - long-acting inhaled 2- agonist
  • 41 - sustained-release theophylline - long-acting oral 2- agonist - leukotriene-receptor antagonist 2  inhaled low dose corticosteroid  short acting 2 (mild  inhaled cromolyn sodium - persistent)  sustained-release theophylline  leukotriene-receptor antagonist  ketotifen 1   short acting 2- - (intermittent inhaled 2- inhaled asthma)
  • 42 7 ขนำดของ corticosteroid Types of corticosteroids Low dose (g) Medium dose (g) High dose (g) Beclomethasone -MDI (50,250 g) -Diskhaler (100,200,400 g) 100-400 400-600 >600 Budesonide -Turbuhaler (100,200 g) -MDI (50, 100,200 g) -Nebulized solution (500,1000 g) 100-200 100-400 - 200-400 400-600 1,000-2000 >400 >600 >2,000 Fluticasone (MDI 25,125,250 g) 50-200 200-300 >300 8 nebulizer MDI with spacer (with mask)
  • 43 - MDI with spacer DPI MDI with or without spacer DPI MDI = metered-dose inhaler DPI = dry powder inhaler IV 1. Primary prevention
  • 44 ก. มำ 25-30 ข. และ 1.2.1. (Indoor environment) 1.2.2. (Outdoor environment) 1.2.3. 1.2.4.
  • 45 1.2.5 1.2.6 1) 2) 1.2.7. อำหำรและโภชนำกำร -
  • 46 indo 2. Secondary prevention 1. 2. 1. 10 2. 3. (identify and avoid triggers) 1. house dust mite)
  • 47 2. สำบ 3. 4. 5. 6. 7. 8. 9.
  • 48 19 550 ทำควำมส ) (exterminator)
  • 49 HEPA (high efficiency particulate air สำมำรถก
  • 50 - long-acting cromolyn - - -
  • 51 I. บทนำ 1. National Heart, Lung and Blood Institute, National Institutes of Health. Global initiative for Asthma. NIH/NHLBI publication no 95-3659. Washington DC:NIH;1995. 2. National Heart, Lung and Blood Institute, National Institutes of Health. Guidelines for the diagnosis and management of asthma. Expert panel report 2. NIH/NHLBI publication no. 97-4051. Washington DC:NIH:1997. 3. Vichyanond P, Jirapongsananuruk O, Visitsuntorn N, Tuchinda M. Prevalence of asthma, rhinitis, and eczema in children from the Bangkok area using the ISAAC (International study for asthma and allergy in children) questionnaires. J Med Assoc Thai 1998;81:175-81. 4. Vichyanond P, et al. Guidelines on the diagnosis and treatment of childhood asthma in Thailand. Thai J Pediatrics 1995;34:3:194-211. 5. Sullivan SD. Cost and cost-effectiveness in asthma. Immunol Allergy Clin N America 1996;16:819-38. II.
  • 52 1. National Heart, Lung and Blood Institute, National Institutes of Health. Global initiative for Asthma. NIH/NHLBI publication No 96-3659. Washington DC:NIH;1998. 2. National Heart, Lung and Blood Institute, National Institutes of Health. Guidelines for the diagnosis and management of asthma. Expert panel report 2. NIH/NHLBI publication No. 97-4051. Washington DC:NIH:1997. III. 1. National Heart, Lung and Blood Institute, National Institutes of Health. Guidelines for the diagnosis and management of asthma. Expert panel report 2. NIH/NHLBI publication No. 97-4051. Washington DC:NIH:1997. 2. Global NHLBI/WHO Workshop Report: Global Strategy for Asthma Management and Prevention. NIH Publication No. 96-3659A. December 1995
  • 53 Anticholinergic Agents in Acute Asthma 1. Brian J L. Treatment of acute asthma. Lancet 1997;350(suppl II):18-23. 2. O'Driscoll RB, Taylor RJ, Horsley MG, Chambers DK, Bernstein A. Nebulised salbutamol with and without ipratropium bromide in acute airflow obstruction. Lancet 1989;i:1418-20. 3. Schuh S, Johnson DW, Callahan S, Cally G, Levison H. Effects of frequent nebulised ipratropium bromide added to frequent high dose albuterol therapy in severe childhood asthma. J Paediatr 1995;126:639-45. 4. Karpel JP, Schacter NE, Fanta C, et al. A comparison of ipratropium and albuterol versus albuterol alone for the treatment of acute asthma. Chest 1996;110:611-16. 5. Fitzgerald MK, Grunfeld A, Parae PD, et al. The clinical efficacy of combination nebulised anticholinergic and adrenergic bronchodilators versus nebulised adrenergic bronchodilator alone in acute asthma. Chest 1997;111:311-15. Intravenous bronchodilator therapy for acute asthmatic attack
  • 54 1. Janson C. Plasma levels and effects of salbutamol after inhaled or iv administration for stable asthma. Eur Respir J 1991;4:544-50. 2. Swedish Society of Chest Medicine. High dose inhaled versus intravenous salbutamol combined with theophylline in severe acute asthma. Eur Respir J 1990;3:163-70. 3. Salmeron S, Brochard L, Mal H, et al. Nebulised versus intravenous albuterol in hypercapnic acute asthma. Am J Respir Crit Care Med 1994;149:1466-70. 4. Cheong B, Reynolds SR, Rajan G, Ward MJ. Intravenous 2-agonist in severe acute asthma. BMJ 1988;297:448- 50. 5. Browne GJ, Penna AS, Phung X, Soo M. Randomised trial of intravenous salbutamol in early management of acute severe asthma in children. Lancet 1997; 349: 301- 05. 6. Murphy DG, McDermott MF, Rydman RJ, Sloan EP, Zalenski RJ. Aminophylline in the treatment of acute asthma when -adrenergics and steroids are provided. Arch Intern Med 1993;153:1784-88. 7. Huang D, O'Brien RG, Harman E, et al. Does aminophylline benefit adults admitted to the hospital in
  • 55 acute exacerbation of asthma. Ann Intern Med 1993; 119: 1155-60. 8. DiGiulio G, Kercsmar C, Krug S, Alpert S, Marx C. Hospital treatment of asthma: lack of benefit from theophylline given in addition to nebulised albuterol and intravenously administered corticosteroid. J Pediatr 1993;122:464-69. 9. Strauss ARE, Wertheim DL, Bonagura VR, Velacer DJ. Aminophylline therapy does not improve outcome and increases adverse effects in children hospitalised with acute asthmatic exacerbations. Paediatrics 1994;93:205- 10. Theophylline 1. Miles Weinberger, Leslie Hendeles. Drug Therapy: Theophylline in Asthma. NEJM 1996;21:334. 2. DeNicola LK, GF Monem, MO Gayle, and N Kissoon. Treatment of Critical Status Asthmaticus in Children. Pediatr Clin N America 1994;41:1293-325. 3. Brian J Lipworth. Treatment of acute asthma. Lancet 1997;350(suppl II):18-23 4. Practice Parameters for the Diagnosis and Treatment of Asthma: Joint Task Force on Practice Parameters; The
  • 56 American Academy of Allergy, Asthma, and Immunology, The American College of Allergy, Asthma, and Immunologyand the Joint Council of Allergy, Asthma, and Immunology Editors: Sheldon L. Spector, MD; Richard A. Nicklas, MD. J Allergy Clin Immunol 1995;96(5):2. IV. (Chronic therapy for childhood asthma) 1. National Heart, Lung and Blood Institutes of Health. Global initiative for asthma. NIH/NHLBI publication no 95- 3659. Washington DC: NIH;1995. 2. National Heart, Lung and Blood Institutes of Health. Guidelines for the diagnosis and management of asthma. Expert panel report 2. NIH/NHLBI publication no. 97-4501. Washington DC: NIH;1997. 3. Warner JO, Naspitz CK, Croup GJA. Third international pediatric consensus statement on the management of children asthma. Pediatr Pulmonol 1998;25:1-17. 4. De Jongste JC. Prophylactic drugs in asthma: their use and abuse. Clinical Pediatr 1995;3:379-98. 5. Price JF. The management of chronic childhood asthma. In: Silverman M, ed. Childhood asthma and other
  • 57 wheezing disorders. London: Chapman & Hill, 1995:357- 74.
  • 58 V. ด 1. National Heart, Lung and Blood Institute, National Institutes of Health. Global initiative for Asthma. NIH/NHLBI publication no 95-3659. Washington DC:NIH;1995. 2. National Heart, Lung and Blood Institute, National Institutes of Health. Guidelines for the diagnosis and management of asthma. Expert panel report 2. NIH/NHLBI publication no. 97-4051. Washington DC:NIH:1997. 3. Warner JO, Naspitz CK, Croup GJA. Third international pediatric consensus statement on the management of childhood asthma. Pediatric Pulmonol 1998;25:1-17. 4. Warner JO, Warner JA. Preventing Asthma. In: Silverman M, ed. Childhood asthma and other wheezing disorders. London: Chapman & Hall; 1995;429-40. 5. Partridge MR. Education of patients, parent, health professionals and other. In: Silverman M, ed. Childhood asthma and other wheezing disorders. London: Chapman & Hall; 1995:465-72.
  • 59 1. 2. 1. 2. 3. 4. 3. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.
  • 60 13. 14. 15.