Interactive Workshop intended for general pediatrician and general practitioners to raise awareness about Egyptian Pediatric Asthma Exacerbation Management Guidelines

1. Pediatric Asthma Exacerbation
Workshop
Prof. Ashraf Abdel Baky
Head of Pediatrics Department, AFCM
Prof of Pediatric Allergy & Immunology, Ain
Shams University

2. Test Your Knowledge
1- Acute severe asthma is characterized by
oxygen saturation :
A- Below 95%
B- Below 92%
C- Below 85%
D- Below 80%

3. 2- What is meant by giving controlled O2?
A- Give O2 to keep spo2 between 92-95%
B-Give intranasal O2
C- Give O2 to keep spo2 between 94-98%
D- Give intermittent O2

4. 3- How should beta 2 agonist inhalation therapy
be used in asthma exacerbation?
A- Every 20 minutes for the first hour
B- Every 30 minutes for the first two hours
C- Every 10 minutes for the first hour
D- Every 20 minutes for the first two hours

5. 4- Systemic steroid should be given in:
A- All cases of asthma exacerbation 5 years and
younger
B- All cases of asthma exacerbation older than 5
years including the mildest
C- Only severe asthma exacerbation cases older
than 5 years
D- Only Severe asthma exacerbation in 5 years
and younger age

6. 5- When to use ipratropium bromide in asthma
exacerbations?
A- all cases of exacerbation below 5 years and only
moderate to severe exacerbation after 5 years
B- all cases of exacerbation after 5 years and only
moderate to severe exacerbation below 5 years
C- all cases of exacerbation of all age groups
D- moderate to severe exacerbation in all age
groups

7. 6- When to use nebulized isotonic magnesium
sulphate?
A- all cases of exacerbation above 2 years
B- all cases of exacerbation of all age groups
C- moderate/severe exacerbation above 2 years
D- moderate/severe exacerbation in all ages

8. 7- What is the role of inhaled corticosteroids in
the first hour?
A- reduce the need to use inhaled ipratropium
bromide
B- reduce the need to use beta 2 agonist
C- reduce the need to use nebulized Mg
sulphate
D- reduce the need for hospitalization

9. 8- When do you choose to use intravenous Mg
Sulphate?
A- In all cases of acute asthma exacerbation
B- In cases not responding to SABA
C- In cases above 2 years not responding to
initial management
D- In all cases not responding to all other lines of
treatment

10. 9- When you are going to hospitalize the
patient? (2 choices are correct)
A- If there no response to the first hour
treatment
B- Past history of frequent exacerbation
C- Spo2 < 92%
D- Still wheezing but no distress

11. 10- How frequent you are going to give beta 2
agonist if there is no improvement after the first
hour ? (2 choices are correct)
A- For 6 years or more varies from 4–10 puffs every
3–4 hours up to 6–10 puffs every 1–2 hours
B- Continuous SABA nebulization
C- For 5 years and less 2–3 puffs SABA per hour
D- SABA nebulization every 20 minutes

12. 11- What is your management if the patient failed
to respond to initial bronchodilators after one
hour or in earlier deterioration? (2 CORRECT
CHOICES)
A- IV Mg Sulfate in ER and reassess
B- give systemic corticosteroids in ER and reassess
C- urgent admission to hospital and give systemic
corticosteroids
D- urgent admission to hospital and IV Mg Sulfate

13. 12- When do you consider transferring the
patient to ICU? (2)
A- If no response to bronchodilators after 1 hour
B- If oxygen saturation is below 95% without
nasal O2.
C- Respiratory rate exceeding 40 bpm
D- patients who deteriorate despite intensive
bronchodilator and corticosteroid treatment

14. 13- On discharging patients who are already on
prescribed controller medications , Do you: (2)
A- Prescribe the same previous doses
B- Increase the dose of controller medications for 1
weak
C- Increase the dose of controller medications for 2-
4 weaks
D- Increase the dose of controller medications for 2
months

15. Case 1
• An 8 year old girl, a known asthmatic,
presents to ER. She talks in phrases, prefers
sitting to lying, not agitated, respiratory rate
increased <30 breaths/minute, accessory
muscles not used, pulse rate 100 bpm, O2
saturation (on air) >92%, PEF >70% predicted
• Describe initial treatment
• What will be the management if there is no
response to initial management?

16. Case 2
• A 4 year old girl, a known asthmatic, presents to
ER. She is agitated, talks in words, sits hunched
forward, respiratory rate increased >40
breaths/minute, accessory muscles is in use,
pulse rate >180 bpm, O2 saturation (on air) <92%,
PEF <50% predicted and a silent chest.
• Describe initial treatment
• What will be the management if there is no
response to initial management?

17. Case 3
• A 5 year old boy, a known asthmatic, presents
to ER. He Talks in phrases, prefers sitting to
lying, not agitated, respiratory rate increased
<40 breaths/minute, accessory muscles not in
use, pulse rate <100 bpm, O2 saturation (on
air) <95%, PEF >70% predicted.
• Describe initial treatment
• What will be the management if there is no
response to initial management?

18. Case 4
• An 10 year old boy, a known asthmatic,
presents to ER. He looks confused, unable to
sit straight, respiratory rate increased >30
breaths/minute, accessory muscles are in
used, pulse rate >120 bpm, O2 saturation (on
air) <92%, PEF <50% predicted
• Describe initial treatment
• What will be the management if there is no
response to intial management?

19. Figure (1) Asthma Exacerbation Management in Children Algorithm 1
Severe
 Talks in words, sits hunched
forward, agitated
 Respiratory rate increased
>30 breaths/minute
 Accessory muscles in use
 Pulse rate >120 bpm
 O2 saturation (on air) <92%
 PEF ≤50% predicted or best
5 years and younger
 2-6puffs of salbutamol by spacer, or 2.5 mg
of salbutamol by nebulizer, every 20
minutes for the first hour.
 For severe exacerbations: give oral
prednisolone (1–2 mg/kg up to a maximum
20 mg for children <2 years old; 30 mg for
children 2–5 years)
 OR, intravenous methylprednisolone 1
mg/kg 6-hourly on day one.

6years and older
 For mild to moderate exacerbations,
repeated administration of inhaled SABA
(up to 4–10 puffs every 20 minutes for the
first hour)
 Used in all but the mildest exacerbations
1–2 mg/kg/day oral prednisolone for
children 6–11 years up to a maximum of
40mg/day) or 200 mg hydrocortisone in
divided doses Duration (short course)
If Not Improved or
Symptoms recur
within 4 hours:
See Figure 2
If improved:
Discharge home after
4h with home
management plan
Oxygen by face mask to achieve and
maintain percutaneous oxygen
saturation of 94–98%
First: Assess is it asthma?
Risk Factors for Asthma Related Death?
Severity of the exacerbation?
Mild/Moderate
 Talks in phrases, prefers sitting to
lying, not agitated
 Respiratory rate increased <30
breaths/minute
 Accessory muscles not used
 Pulse rate 100-120 bpm
 O2 saturation (on air) >92%
 PEF >50% predicted or best
In Moderate to Severe Cases
Ipratropium bromide at a dose of 250ug by nebulization can be
mixed with SABA to be repeated every 20 minutes (for 1 hour only).
Nebulized isotonic magnesium sulfate 150 mg can be added in
children ≥2 years old

20. Figure (2) Asthma Exacerbation Management Algorithm 2
Assess the child as regards Symptoms:
If symptoms still persistent or worsening
If symptoms recur within 4 hours after improvement
Admit
5 years and younger
 If symptoms improved at 1st
hour but
recurred, give additional 2–3 puffs SABA per
hour
 Admit to hospital if >10 puffs required in 3–4
hours.
 Failure to respond at 1 hour, or earlier
deterioration, should prompt urgent
admission to hospital and a short-course of
oral prednisolone (1–2 mg/kg up to a
maximum 20 mg for children <2 years old; 30
mg for children 2–5 years)
OR, intravenous methylprednisolone 1 mg/kg
6-hourly on day one
 Continue Oxygen by face mask to achieve
and maintain percutaneous oxygen saturation
of 94–98%
(short course).

6years and older
 The dose of SABA required varies from
4–10 puffs every 3–4 hours up to 6–10
puffs every 1–2 hours, or more often.
 Continue Oxygen by face mask to achieve
and maintain percutaneous oxygen
saturation of 94–98%
 Continue or intiate 1–2 mg/kg/day oral
prednisolone for children 6–11 years up to
a maximum of 40mg/day) or 200 mg
hydrocortisone in divided doses Duration
(short course)

For severe asthma exacerbations in children 2 years and
above who fail to respond to initial treatment:
give slow IV infusion of magnesium sulfate as a single dose
of 50 mg/kg/dose (max. 2gm) over 20-60 minutes in the
following setting: Emergency department in hospitals and
with close monitoring of the vital data.
If Not Improving Or Deteriorating
consider PICU ADMISSION
If improved:
Discharge home with: home
management plan
Follow up plan

21. Mild/Moderate Severe
 Talks in phrases, prefers
sitting to lying, not agitated
 Respiratory rate increased
<30 breaths/minute
 Accessory muscles not used
 Pulse rate 100-120 bpm
 O2 saturation (on air) >92%
 PEF >50% predicted or best
 Talks in words, sits
hunched forward, agitated
 Respiratory rate increased
>30 breaths/minute
 Accessory muscles in use
 Pulse rate >120 bpm
 O2 saturation (on air) <92%
 PEF ≤50% predicted or best
Assessment of Acute Asthma Exacerbation Severity in
children ≥ 6 years
GINA Guidelines 2018

22. 180
150

23. International Validation
• Guidelines International Network
• Source Guidelines
• Group of International Experts

24. Immediate transfer to hospital from a primary health care
unit is indicated if a child ≤ 5 year with asthma has any of the
following:
At initial or subsequent assessment
 Child is unable to speak or drink
 Cyanosis
 Subcostal retraction
 Oxygen saturation <92% when breathing room air
 Silent chest on auscultation
Lack of response to initial bronchodilator treatment
 Lack of response to 6 puffs of inhaled SABA (2 separate
puffs, repeated 3 times) over 1- 2 hours.
 Persistent tachypnea* despite three administration of
inhaled SABA, even if the child shows other clinical signs
of improvement.
Social environment that impairs delivery of acute treatment,
or parent/carer unable to manage acute asthma at home.
Indication for Immediate transfer to the hospital for children 5 years
and below

25. Thank You