This document provides information on the diagnosis and management of asthma in children. It begins with the pathophysiology of asthma including airway inflammation, variable airflow obstruction, and bronchial hyperresponsiveness. Signs and symptoms of asthma include wheezing, coughing, difficulty breathing and triggers such as exercise or cold air. The document outlines the diagnosis, differential diagnosis, and classifications of asthma severity. Management is discussed for acute exacerbations and long term control, including reliever medications, oral steroids, and patient education. Guidelines from the Royal Hobart Hospital and Royal Children's Hospital are referenced. The document concludes with a case scenario of a 7 year old child presenting with breathing difficulty, where the focus is on diagnosis of asthma and

1. Dr.Gopakumar Hariharan
Senior Registrar
Community Paediatrics
Royal Hobart Hospital

2. Pathophysiology
Making a diagnosis – clinical and investigations
Differential diagnosis
Acute management
Follow up and long term management
Case scenario for summary

3. Airway inflammation,
Variable airflow obstruction, and
Bronchial hyper responsiveness.
Chronic inflammatory disease of the
airways - reversible airways obstruction
and bronchospasm.
Antigen exposure
Recurrent episodes of wheeze,cough,and breathlessness

4.  Wheeze
 Difficulty breathing
 Cough
 Frequent recurrence of symptoms
 More at night and early morning
 Triggers- Exercise, pets, cold air
 History of allergy
 Family history of allergies/ Asthma
 Widespread wheeze on auscultation
 Response to reliever
Less than 12 months- Bronchiolitis
 Previous ICU admission
 Poor compliance to asthma therapy
 Poorly controlled - significant
interval symptoms

5.  Foreign body
 Viral pneumonitis
 Cardiac failure
 Structural abnormalities affecting the airways

6. RCH guidelines

7. Increased work of
breathing
Tachycardia
Normal mental state
Some limitation of ability
to talk
Oxygen if saturation less than 92%
Salbutamol puffs every 20 minutes for one hour and reassess
6 puffs – Less than 6 years
12 puffs- More than 6 years
No need to wean the dose
Oral Prednisolone 2 mg/kg( Max 60 mg).
Continue oral prednisolone at 1 mg/kg if there is ongoing requirement
for regular salbutamol
Advice follow up and education
RCH guidelines
Moderate Asthma
Target oxygen saturation – more than 95%

8. Agitated/ Distressed
Moderate or marked
increased work of
breathing
Tachycardia
Inability to talk
Oxygen is SPO2 less than 92
Salbutamol puff every 20 minutes for 3 doses
and reassess for further doses. If improving
reduce the frequency. If deteriorating- manage
as critical
Ipratropium Bromide puff every 20 minutes
for one hour only (Atrovent 20mcg/puff)
dose: 4 puffs if < 6 years old, 8 puffs if >6 years
old
Magnesium sulphate 50 mg/kg over 20
minutes and consider infusion in ICU
Aminophylline
Oral Prednisolone 2 mg/ kg.
Methylprednisolone 1 mg/kg if vomiting
Involve senior staff
Arrange for admission
Wheeze is a poor predictor of severity
Severe Asthma

9. Signs
Confused/ Drowsy
Unable to talk
Maximal work of breathing
Exhaustion
Marked tachycardia
Silent chest
Involve senior staff
Oxygen
Continuous Nebulization
Nebulized Ipratropium 250 mcg every 20 minutes
for one hour
Methyl Prednisolone 1 mg/kg 6 hourly of
Hydrocortisone 4 mg/kg 6 hourly
Magnesium sulphate( Magnesium level – 1.5 to 2.5
mmol/L
Aminophylline/ Salbutamol infusion
ICU admission- CPAP, BiPAP, Intubation and
ventilation
Critical

10. Four-Step Action Plan
1.Sit your child down and remain calm.
2.Immediately shake a blue reliever puffer and give four separate puffs through a spacer. Give
one puff at a time and ask your child to take four breaths from the spacer after each puff.
3.Wait four minutes. If there is no improvement in your child's asthma repeat step 2.
1.If still no improvement after four minutes, call an ambulance immediately. State that your child is
having an asthma attack. Continuously repeat steps 2 and 3 while waiting for the ambulance.

11.  Tachycardia
 Tachypnea
 Metabolic acidosis ( Blood gas not required though unless intervention)
 High Lactate – consider stopping or reducing dose
 Hypokalemia

12.  Do not exceed 8-10 L/min of oxygen
 Increases risk of aerosol infection
 Could be driven by wall oxygen, oxygen cylinder with
high flow regulator
 Adults and children more than 6 years – 5 mg nebule
 Children 0 – 5 years – 2.5 mg nebule
 Continuous nebulization – add 2 nebules
Australian Asthma Handbook

13.  1 - 2 mg/kg( max 50 mg)
 1 mg/ kg each morning for 2 days( could be extended to 5 days)
 No tapering required for short courses
 Less than 5 years – careful use and restricted to those with severe wheeze

14.  History
 Explore symptoms, associated allergies, family history
 Clinical examination – wheeze, respiratory distress
 Differential diagnosis – FTT, finger clubbing, stridor, snoring, nasal polyps, chest deformity,
unilateral lung signs
Episodic viral wheeze in preschool children- a separate entity

15.  Well one hour post salbutamol
 Asthma action plan(RCH/National Asthma council) for
parents and the school
 Letter to GP and school
 Parent handout- RCH website
 Paediatric outpatient follow up – Rapid review clinic
 Link to Asthma clinic – preventative therapy
 Asthma Education nurse – Nurse consultant
Based on clinical status

16.  SABA reliever as needed in all children aged 6–12 years
 In children 5 years and under, a SABA reliever as needed only if symptoms are
associated with increased work of breathing (i.e. intercostal retraction).

18. Persistent cough + No dyspnea/ wheeze Consider other causes – Cystic fibrosis,
Bronchiectasis Ciliary dyskinesia, Immune
deficiencies, Habit cough
Onset from birth or early in life CLD, Congenital anomalies, CF
Hoarseness Upper airway abnormality
Systemic(fever, FTT) Alternate diagnosis
Finger clubbing Cystic fibrosis, Bronchiectasis
Nasal polyps less than 5 years Cystic fibrosis
Severe chest deformity Consider alternative diagnosis

19. Category Symptom pattern(when not taking
inhalers)
Infrequent intermittent asthma
Symptom free for at least 6 weeks at
a time
Frequent intermittent asthma
Flare ups more than once every 6
weeks, but asymptomatic in
between
Persistent Asthma
Mild At least one of
1) Daytime symptoms more than
once a week but not every day
2) Night time symptoms twice a
month but not every week
Moderate Any of
1) Day time symptoms daily
2) Night time symptoms more than
once a week
3) Restriction of activity or sleep

20. Severe Persistent
Any of
1) Continual day time symptoms
2) Frequent night time symptoms
3) Frequent flare ups
4) Affects and restricts daily activities

21.  First line management- Inhaled corticosteroids alone
 Combination inhaler not the first line
 The therapeutic aim – Minimal effected preventer treatment to achieve and
maintain control of symptoms and minimize risk of poor outcomes
 Treatment started according to age and asthma symptoms
 Fluticasone propionate – 100 to 200 micrograms/ day
 Plateau response beyond Fluticasone beyond 200 mcg; Hence escalating dose
unlikely of benefit
(BestAdd-onTherapy GivingEffectiveResponses(BADGER)study
option- Add on LABA/ Leukotriene receptor antagonist )

22. www.asthmaaustralia.org.au
Demonstration

24. 7 year old child present to ED with breathing difficulty
1) Focused history to diagnose the condition
2) Describe initial management

25.  Respiratory rate – 40/min
 HR – 130 / min
 Chest – bilateral wheeze
 Unable to complete sentences
 Getting drowsy

26. Heart Rate Respiratory Rate
Less than one year 110-160 30-40
1 – 2 years 100-150 25-35
2 – 5 years 95-140 25-30
5 – 12 years 80-120 20-25
12-18 years 60-100 15-20
APLS Australia

27.  Diagnosis of Asthma
 Management of Acute Asthma – Inhaler puffs( Salbutamol, Ipratropium,
Magnesium sulphate, Aminophylline, Steroids, Respiratory supports)
 Discharge from ED
 Follow up- differential diagnosis/ Preventers
 Education
 Guidelines- Royal Hobart Hospital, RCH, National Asthma Council

28. Thank You