Childhood asthma

Presented by -
Dr Susheel kumar saini
(MD Paediatrics)

Case scenario
A 3 year old boy Rohit brought by his mother for
recurrent cough for last 1 year. His cough gets worse
at night which is usually associated with musical
respiratory sounds and he coughs a lot after running
or laughing.
She also reported that he frequently had colds for
which he has been nebulized on several occasions in
emergency dept.

Is it Asthma?
 Presence of more than one of the following symptoms :
wheeze, shortness of breathe, cough, chest tightness.
 Symptoms often worse in night or in early morning.
 Symptoms very over time and in intensity.
 Symptoms triggered by viral infections (colds), exercise,
allergen exposure, change in weather, laughter or
irritants.

Definition of Asthma
A heterogeneous chronic inflammatory disease of the
airways with the following clinical features:
 Episodic and/or chronic symptoms of airway obstruction
such as cough, wheeze, chest tightness, breathlessness.
 Bronchial hyper responsiveness to triggers.
 Evidence of at least partial reversibility of the airway
obstruction.
 Alternative diagnoses are excluded.

Wheezing—Asthma?
Wheezing with upper respiratory infections is very
common in small children, but:
 Many of these children will not develop asthma.
 Asthma medications may benefit patients who wheeze
whether or not they have asthma.
All that wheezes is not asthma.

Cough—Asthma?
Consider asthma in children with:
Recurrent episodes of cough with or without
wheezing.
Nocturnal awakening because of cough.
Cough that is associated with exercise/play.
Cough without wheeze is often not asthma.
Cough may be the only symptom
present in patients with asthma.

Asthma Facts
 Asthma is one of the most common chronic diseases
worldwide with an estimated ̴300 million affected
individuals.
 A major cause of school/work absence.
 80% report disease onset prior to 6 years of age.
 Overall prevalence in India- 3% (30 million)
3000/1lakh population.

When does Asthma begin?
• By 1 year – 26%
• 1-5 years – 51.4%
• > 5 years – 22.3%
77% Of Asthma Begins In Children Less
Than 5 Years.

EARLY CHILDHOOD RISK FACTORS FOR ASTHMA
1. Parental asthma (single-20%, both-60%)
2. Allergy
Atopic dermatitis (eczema)
Allergic rhinitis
Food allergy
Inhalant allergen sensitization
3. Severe lower respiratory tract infections requiring hospitalization
Pneumonia
Bronchiolitis
4. Wheezing apart from colds
5. Male gender
6. Low birth weight
7. Environmental tobacco smoke exposure
8. Possible use of acetaminophen (paracetamol)
9. Reduced lung function at birth
10. Eosinophilia (>4%)

ETIOLOGY
• A combination of -
 Host factors
 Environmental factors

Host factors
• Genetic
1. Genes predisposing to atopy
2. Genes predisposing to airway hyper responsiveness
•Obesity
•Sex

Environmental factors
• Allergens –
1. Indoor – Domestic mites, furred animals (dogs, cats, mice),
cockroach allergens, fungi, molds, yeasts.
2. Outdoor – Pollens, fungi, molds, yeasts.
• Infections (predominantly viral)
• Occupational sensitizers
• Tobacco smoke – Passive / Active
• Indoor/Outdoor air pollution
• Diet

Clinical features
• Between attacks, the child may be asymptomatic
• Symptoms of an acute attack:
expiratory wheeze
Shortness of breath
sometimes cough may be the only symptom
symptoms worse at night
most patients may feel chest tightness in the morning
young children may vomit or have reduced appetite

Clinical features
• Signs of an acute attack:
– Child unable speak or to walk due to breathlessness
– Intercostal recession and use of accessory muscles
– Exhausted
– Wheeze with tachypnoea and tachycardia
– Silent chest (severe presentation)
• Chronic asthmatic may have a Harrison's sulcus.

Asthma Diagnosis
• Good History Taking (ASK)
• Careful Physical Examination (LOOK)
• Investigations (PERFORM) – above 5 years only

History taking (Ask)
 Has the child had an attack or recurrent episode of wheezing (high-
pitched whistling sounds when breathing out)?
 Does the child have a troublesome cough which is particularly worse
at night or on waking?
 Is the child awakened by coughing or difficult breathing?
 Does the child cough or wheeze after physical activity (like games
and exercise) or excessive laughing/crying?
 Does the child experience breathing problems during a particular
season?

Physical Examination (Look)
Signs in acute exacerbation
•Respiratory Distress :
–Tachypnea, Working Alae nasai
–Retractions
–Grunting
–Cyanosis, Drowziness, Coma.
•Ausculation :
–Decreased air entry
–Prolonged expiration
–Wheeze, rhonchi
Signs of chronic illness
•Hyperinflated chest
(Barrel-shaped chest)
•Harrison’s sulci

Asthma Diagnosis (investigation)
Spirometry-
 Use spirometry to establish airflow
obstruction:
– FEV1/FVC < 80% predicted
indicate significant airflow
obstruction
– FEV1 60%-80% moderate airflow
obstruction
– FEV1< 60% severe airflow
obstruction
 Use spirometry to establish
reversibility:
 FEV1 increases >12% and at least
200 mL after using a short-acting
inhaled beta2-agonist
 Exercise challenge/challenge to
methacholine -Worsening in FEV1
>12% and ≥ 20% respectively.

The Peak Flow Meter
(like a thermometer for asthma)
• Simple & inexpensive tool to measure airflow.
• Used for diagnosis & monitoring of asthma.
• PEFR monitoring should be started by measuring morning
& evening PEFRs (best of 3 attempts) for several weeks for
patients to practice the technique and to determine a
“personal best” and to correlate PEF values with symptoms.
• PEFR variation >13% is consistent with asthma.
• Girls: 3.43 x ht – 180 lit/min
• Boys: 2.98 x ht – 110 lit/min

Chest radiograph
May be normal in up to 75% of patients.
Reported features with asthma include:
•pulmonary hyperinflation
•bronchial wall thickening: peribronchial cuffing (non specific
finding but may be present in ̴48% of cases with asthma)
•pulmonary oedema (rare): pulmonary oedema due to
asthma (usually occurs with acute asthma)

How to confirm
• No gold standard test to diagnose
• Diagnosis is essentially clinical
• Lung function tests are occasional helpful
• Other causes of recurrent cough should be
ruled out

Asthma Predictive Index
 Identify high risk children :
• ≥4 wheezing episodes in the past year
(at least one must be MD diagnosed)
PLUS
OR One major criterion
• Parent with asthma
• Atopic dermatitis
• Aero-allergen
sensitivity
 Two minor criteria
• Food sensitivity
• Peripheral
eosinophilia (≥4%)
• Wheezing not
related to infection
HIGH SPECIFICITY (97%) & POSITIVE PREDICTIVE VALUE
(77%) FOR PERSISTANT ASTHMA IN TO LATER CHILDHOOD.

© Global Initiative for Asthma
Patient with
respiratory symptoms
Are the symptoms typical of asthma?
Detailed history/examination
for asthma
History/examination supports
asthma diagnosis?
Perform spirometry/PEF
with reversibility test
Results support asthma diagnosis?
Empiric treatment with
ICS and prn SABA
Review response
Diagnostic testing
within 1-3 months
Repeat on another
occasion or arrange
other tests
Confirms asthma diagnosis?
Consider trial of treatment for
most likely diagnosis, or refer
for further investigations
Further history and tests for
alternative diagnoses
Alternative diagnosis confirmed?
Treat for alternative diagnosisTreat for ASTHMA
Clinical urgency, and
other diagnoses unlikely
YES
YES
YES NO
NO
NO
NO
YES
YES
NO

Diagnosis of asthma in children already taking controller treatment
1. Variable respiratory symptoms and variable airflow limitation – Diagnosis of
asthma is confirmed.
2. Variable respiratory symptoms but no variable airflow limitation – Repeat
bronchodilator reversibility test after withholding bronchodilator or during
symptoms. If normal consider alternate diagnosis.
(a) If FEV1 is >70% predicted : consider a bronchial provocation test. If
negative, consider stepping down controller treatment and reassess in 2-4 wks.
(b) If FEV1 is <70% predicted : consider stepping up controller treatment for 3
months, then reassess symptoms and lung functions . If no response resume
previous treatment and refer for diagnosis and investigation.

3. Few respiratory symptoms, normal lung function and no variable airflow limitation
– Repeat bronchodilator reversibility test after withholding bronchodilator or
during symptoms. If normal consider alternate diagnosis.
Consider stepping down controller treatment –
(a) If symptoms emerge and lung function falls – Asthma is confirmed.
(b) If no change in symptoms or lung function at lowest controller step – consider
stopping controller and monitor patient closely for at least 12 months.
4. Persistent shortness of breath and fixed airflow limitation – Consider stepping up
controller treatment for 3 months, then reassess symptoms and lung function. If
no response, resume previous treatment and refer patient for diagnosis and
investigation. Consider asthma – COPD overlap syndrome.

Asthma management & prevention
Updated 2015
Five components -
1. Develop Patient-Doctor Partnership
2. Identify and Reduce Exposure to Risk Factors
3. Assess, Treat and Monitor Asthma
4. Manage Asthma Exacerbations
5. Special Considerations

Asthma Management and Prevention Program
Goals of Long-term Management
 Achieve and maintain control of symptoms
 Maintain normal activity levels, including exercise
 Maintain pulmonary function as close to normal
levels as possible
 Prevent asthma exacerbations
 Avoid adverse effects from asthma medications
 Prevent asthma mortality

Component 1
Develop Patient-Doctor Partnership
• Patients can learn to –
 Avoid risk factors
 Take medications correctly
 Understand the difference between controller and reliever
medications
 Monitor their status using symptoms and, if relevant, PEF
 Recognize signs that asthma is worsening and take action
 Seek medical help as appropriate

Key factors to facilitate communication:
 Friendly environment
 Interactive dialogue
 Encouragement and praise
 Provide appropriate information
 Feedback and review

Factors Involved in Non-Adherence
Medication Usage
• Difficulties associated
with inhalers
• Complicated regimens
• Fears about/actual
side effects
• Cost
• Distance to pharmacies
Non-Medication Factors
• Misunderstanding/lack of
information
• Fears about side-effects
• Inappropriate expectations
• Underestimation of severity
• Attitudes toward ill health
• Cultural factors
• Poor communication

Component 2
Identify and Reduce Exposure to Risk Factor
Avoidance measures that improve control of asthma
and reduce medication needs are:
• Reduce exposure to indoor allergens
• Avoid tobacco smoke
• Avoid vehicle emission
• Identify & avoid irritants in the workplace
• Explore role of infections on asthma development,
especially in children and young infants

Component 3
Assess, Treat and Monitor Asthma
• The goal of asthma treatment is to achieve and to
maintain clinical control
• The focus of asthma control is on :
 Attainment a better quality of life
 Reduction in health care use
 Determine the initial level of control to implement
treatment
 Maintain control once treatment has been implemented

Levels of Asthma Control
(Assess patient impairment)
Characteristic
Controlled
(All of the following)
Partially controlled
(Any present in any week)
Uncontrolled
Daytime symptoms
Twice or less
per week
More than
twice per week
3 or more
features of
partly
controlled
asthma
present in
any week
Limitations of
activities
None Any
Nocturnal symptoms
/ awakening
None Any
Need for rescue /
“reliever” treatment
Twice or less
per week
More than
twice per week
Lung function
(PEF or FEV1)
Normal
< 80% predicted or
personal best (if
known) on any day
Assessment of Future Risk (risk of exacerbations, instability, rapid decline in lung
function, side effects)

Assess Patient Risk
Features that are associated with increased risk of adverse
events in the future include:
 Poor clinical control
 Frequent exacerbations in past year
 Ever admission to critical care for asthma
 Low FEV1,exposure to cigarette smoke, high dose medications

•Depending on level of asthma control, the patient is assigned
to one of the treatment steps
•Treatment is adjusted in a continuous cycle driven by changes
in asthma control status. The cycle involves:
- Assessing Asthma Control
- Treating to Achieve Control
- Monitoring to Maintain Control
•A stepwise approach to pharmacological therapy is
recommended
•The aim is to accomplish the goals of therapy with the least
possible medication

Pharmacotherapy of asthma
Relievers
 For treatment of
bronchospasm and to
relieve acute attack
Preventers/controller
 For long term control of
inflammation and to
prevent further attack

Reliever Medications
Rapid-acting inhaled β2-agonists
Systemic glucocorticosteroids
Anticholinergics
Theophylline
Short-acting oral β2-agonists

Preventers/controller medication
 Inhaled
Corticosteroids (ICS)
Long acting B2 agonist
Cromolyn sodium
 Oral
Leucotriene antagonist
Theophylline – SR
Oral prednisolone
Anti Ig E

Short acting beta-2 agonists
 Selective : Salbutmol, levosalbutamol, terbutaline.
Non selective : Adrenaline
•Available in inhaled, pill, liquid, and injectable forms.
• Act as bronchodilators. They relax the muscles lining the airways that carry
air to the lungs (bronchial tubes) within 5 minutes, increasing airflow and
making it easier to breathe. They relieve asthma symptoms for 3 to 6 hours.
•Prevent asthma symptoms before exercise.
• Do not control the inflammation.

Long acting Beta-2 agonist
•Drugs : Salmeterol : 12 µg/puff, 12µg/cap
1 to 2 puff/rota cap/day od/bd
Formoterol : 25 µg/puff, 50 µg/cap
1 to 2 puff/rota cap/day od/bd
•Not used as relievers
•Used with ICS for synergistic effects/steroid sparing effects
•Used in children >4years
•Duration of action 12 to 24 hours
•Prevent asthma symptoms before exercise
•Useful in nocturnal/Exercise induced symptoms

ICS
Most effective long term therapy available
Anti inflammatory effect evident in 2-3 weeks
Local side effects can be minimized by spacer/gargling
Systemic side effects negligible
Most children are controlled with medium doses
In prolonged high doses-monitor growth and eyes

oral steroids
Use limited to severe asthma
Should be used in minimal possible doses
Alternate morning doses preferred
Preferred drug : Prednisolone
Side effects :Excessive weight gain, hypertension, osteoporosis,
decreased linear growth, metabolic derangement and cataract

Drugs : Montelukast 4mg/day (2-5yr), 5mg/day (5-12yr),
10mg/day (>12yr)
Zafirlukast
May be considered as mono therapy in mild asthma where child’s
parents refused for inhalation therapy
Add on in moderate to severe asthma
Weak anti inflammatory effect (inferior to ICS)
Prevent exacerbation in exercise induced asthma
Leukotrine antagonists

Theophylline
Inhibitor of phosphodiesterase
Act as smooth muscle relaxant, bronchodilator, respiratory stimulant,
diaphragmatic muscle contractility improver
Anti inflammatory + immunomodulator effect
Adjunct therapy for mod/severe asthma
Disadvantage : Low therapeutic index
Dose : 10 to 16 mg/kg/day in 2 divided doses

Management
of Asthma in children
6 -11 years and adolescents

Initial treatment for adolescents and
children 6–11 years
•Start reliever medication
•Start controller treatment early (For best results)
•Indications for regular low-dose ICS - any of:
Asthma symptoms more than twice a month
Waking due to asthma more than once a month
Any asthma symptoms + any risk factors for exacerbations
•Consider starting at a higher step if:
Troublesome asthma symptoms on most days
Waking from asthma once or more a week

Initial treatment for adolescents and
children 6–11 years
•If initial asthma presentation is with an exacerbation:
Give a short course of oral steroids and start regular controller
treatment (e.g. high dose ICS or medium dose ICS/LABA, then step down)
•After starting initial controller treatment
Review response after 2-3 months, or according to clinical urgency
Adjust treatment (including non-pharmacological treatments)
Consider stepping down when asthma has been well-controlled for 3
months

Stepwise management -pharmacotherapy
*For children 6-11 years,
theophylline is not
recommended, and preferred
Step 3 is medium dose ICS
**For patients prescribed
BDP/formoterol or BUD/
formoterol maintenance and
reliever therapy
# Tiotropium by soft-mist
inhaler is indicated as add-on
treatment for adults
(≥18 yrs) with a history of
exacerbations
GINA 2015, Box 3-5 (2/8) (upper part)
Diagnosis
Symptom control & risk factors
(including lung function)
Inhaler technique & adherence
Patient preference
Asthma medications
Non-pharmacological strategies
Treat modifiable risk factors
Symptoms
Exacerbations
Side-effects
Patient satisfaction
Lung function
Other
controller
options
RELIEVER
STEP 1 STEP 2
STEP 3
STEP 4
STEP 5
Low dose ICS
Considerlow
dose ICS
Leukotriene receptor antagonists (LTRA)
Low dose theophylline*
Med/high dose ICS
Low dose ICS+LTRA
(or + theoph*)
As-needed short-acting beta2-agonist (SABA) As-needed SABA or
low dose ICS/formoterol**
Low dose
ICS/LABA*
Med/high
ICS/LABA
Refer for
add-on
treatment
e.g.
anti-IgE
PREFERRED
CONTROLLER
CHOICE
Add tiotropium#
High dose ICS
+ LTRA
(or + theoph*)
Add
tiotropium#
Add low
dose OCS

Step 1 – as-needed inhaled short-acting
beta2-agonist (SABA)
PREFERRED
CONTROLLER
CHOICE
Other
controller
options
RELIEVER
STEP 1 STEP 2
STEP 3
STEP 4
STEP 5
Low dose ICS
Consider low
dose ICS
Med/high dose ICS
Low dose ICS+LTRA
(or + theoph*)
Low dose
ICS/LABA*
Med/high
ICS/LABA
Refer for
add-on
treatment
e.g.
anti-IgE
Add tiotropium#
High dose ICS
+ LTRA
(or + theoph*)
Add
tiotropium#
Add low
dose OCS

Step 1 – as-needed reliever inhaler
Preferred option: as-needed inhaled short-acting beta2-agonist (SABA)
Reserved for patients with infrequent symptoms (less
than twice a month) of short duration, and with no risk
factors for exacerbations
Other options : Add regular low dose inhaled corticosteroid (ICS) for
patients at risk of exacerbations

Step 2 – low-dose controller + as-needed
inhaled SABA
PREFERRED
CONTROLLER
CHOICE
Other
controller
options
RELIEVER
STEP 1 STEP 2
STEP 3
STEP 4
STEP 5
Low dose ICS
Consider low
dose ICS
Med/high dose ICS
Low dose ICS+LTRA
(or + theoph*)
Low dose
ICS/LABA*
Med/high
ICS/LABA
Refer for
add-on
treatment
e.g.
anti-IgE
Add tiotropium#
High dose ICS
+ LTRA
(or + theoph*)
Add
tiotropium#
Add low
dose OCS

Step 2 – Low dose controller + as-needed SABA
• Preferred option: regular low dose ICS with as-needed inhaled SABA
• Other options:
– Leukotriene receptor antagonists (LTRA) with as-needed SABA
• Less effective than low dose ICS
– Combination low dose ICS/long-acting beta2-agonist (LABA)
with as-needed SABA
• Reduces symptoms and increases lung function compared with ICS
• More expensive, and does not further reduce exacerbations
– Intermittent ICS with as-needed SABA for purely seasonal allergic
asthma with no interval symptoms
• Start ICS immediately symptoms commence, and continue for
4 weeks after pollen season ends

Step 3 – one or two controllers + as-
needed inhaled reliever
Other
controller
options
RELIEVER
STEP 1 STEP 2
STEP 3
STEP 4
STEP 5
Low dose ICS
Consider low
dose ICS
Med/high dose ICS
Low dose ICS+LTRA
(or + theoph*)
Low dose
ICS/LABA*
Med/high
ICS/LABA
Refer for
add-on
treatment
e.g.
anti-IgE
PREFERRED
CONTROLLER
CHOICE
Add tiotropium#
High dose ICS
+ LTRA
(or + theoph*)
Add
tiotropium#
Add low
dose OCS

Step 3 – one or two controllers + as-needed inhaled reliever
• Before step-up - Check inhaler technique and adherence, confirm diagnosis
• Preferred options:
 Adolescent - Combination of low dose ICS/LABA maintenance with
as-needed SABA
 Children 6-11 years: preferred option is medium dose ICS with as-needed SABA
• Other options
– Adolescents: Increase ICS dose or add LTRA or theophylline (less effective than
ICS/LABA)
– Children 6-11 years – add LABA (similar effect as increasing ICS)

Step 4 – two or more controllers + as-
needed inhaled reliever
Other
controller
options
RELIEVER
STEP 1 STEP 2
STEP 3
STEP 4
STEP 5
Low dose ICS
Consider low
dose ICS
Med/high dose ICS
Low dose ICS+LTRA
(or + theoph*)
Low dose
ICS/LABA*
Med/high
ICS/LABA
Refer for
add-on
treatment
e.g.
anti-IgE
PREFERRED
CONTROLLER
CHOICE
Add tiotropium#
High dose ICS
+ LTRA
(or + theoph*)
Add
tiotropium#
Add low
dose OCS

Step 4 – two or more controllers + as-needed inhaled reliever
• Before step-up - Check inhaler technique and adherence
• Preferred option
 Adolescent : 1. Combination of low dose ICS/formoterol as maintenance and
reliever regimen
2. Combination of medium dose ICS/LABA with as-needed SABA
 Children 6–11 years: Refer for expert advice
• Other options (Adolescents)
– Trial of high dose combination ICS/LABA
– Increase dosing frequency (for budesonide-containing inhalers)
– Add-on LTRA or low dose theophylline

Step 5 – higher level care and/or add-on
treatment
GINA 2015, Box 3-5, Step 5 (8/8)
Other
controller
options
RELIEVER
STEP 1 STEP 2
STEP 3
STEP 4
STEP 5
Low dose ICS
Consider low
dose ICS
Med/high dose ICS
Low dose ICS+LTRA
(or + theoph*)
Low dose
ICS/LABA*
Med/high
ICS/LABA
Refer for
add-on
treatment
e.g.
anti-IgE
PREFERRED
CONTROLLER
CHOICE
Add tiotropium#
High dose ICS
+ LTRA
(or + theoph*)
Add
tiotropium#
Add low
dose OCS

Step 5 – higher level care and/or add-on treatment
• Preferred option : Referral for specialist investigation and
consideration of add-on treatment
– Add-on omalizumab (anti-IgE) for patients with moderate
or severe allergic asthma.
• Other add-on treatment options:
– Sputum-guided treatment: this is available in specialized
centers; reduces exacerbations and/or corticosteroid dose
– Add-on low dose oral corticosteroids (≤7.5mg/day
prednisone equivalent)

Inhaled corticosteroid Total daily dose (mcg)
Low Medium High
Beclometasone dipropionate (CFC) 200–500 >500–1000 >1000
Beclometasone dipropionate (HFA) 100–200 >200–400 >400
Budesonide (DPI) 200–400 >400–800 >800
Ciclesonide (HFA) 80–160 >160–320 >320
Fluticasone propionate (DPI or HFA) 100–250 >250–500 >500
Mometasone furoate 110–220 >220–440 >440
Triamcinolone acetonide 400–1000 >1000–2000 >2000
Low, medium and high dose inhaled corticosteroids (≥ 12 yrs)
• This is not a table of equivalence, but of estimated clinical comparability
• Most of the clinical benefit from ICS is seen at low doses

Low, medium and high dose inhaled corticosteroids (Children 6–11 yrs)
Inhaled corticosteroid Total daily dose (mcg)
Low Medium High
Beclometasone dipropionate (CFC) 100–200 >200–400 >400
Beclometasone dipropionate (HFA) 50–100 >100–200 >200
Budesonide (DPI) 100–200 >200–400 >400
Budesonide (nebules) 250–500 >500–1000 >1000
Ciclesonide (HFA) 80 >80–160 >160
Fluticasone propionate (DPI) 100–200 >200–400 >400
Fluticasone propionate (HFA) 100–200 >200–500 >500
Mometasone furoate 110 ≥220–<440 ≥440
Triamcinolone acetonide 400–800 >800–1200 >1200

Reviewing response and adjusting treatment
•Asthma should be reviewed in -
o1-3 months after treatment started, then every 3-12 months
oAfter an exacerbation, within 1 week
•Stepping up asthma treatment
oSustained step-up, for at least 2-3 months if asthma poorly controlled
oShort-term step-up, for 1-2 weeks, e.g. with viral infection or allergen
oDay-to-day adjustment - For patients prescribed low-dose ICS/
formoterol maintenance and reliever regimen

•Consider stepping down -
When symptoms have been well controlled and lung function stable
for ≥3 months
No respiratory infection, patient not travelling.
•Stepping down ICS doses by 25–50% at 3 month intervals is feasible and safe
for most patients
Stepping down controller treatment

Management
of asthma in children
5 years and younger

Stepwise management - pharmacotherapy
GINA 2015, Box 6-5 (3/8)
Infrequent
viral wheezing
and no or
few interval
symptoms
Symptom pattern consistent with asthma
and asthma symptoms not well-controlled, or
≥3 exacerbations per year
Symptom pattern not consistent with asthma but
wheezing episodes occur frequently, e.g. every
6–8 weeks.
Give diagnostic trial for 3 months.
Asthma diagnosis, and
not well-controlled on
low dose ICS
Not well-
controlled
on double
ICS
First check diagnosis, inhaler skills,
adherence, exposures
CONSIDER
THIS STEP FOR
CHILDREN WITH:
RELIEVER
Other
controller
options
PREFERRED
CONTROLLER
CHOICE
As-needed short-acting beta2-agonist (all children)
Leukotriene receptor antagonist (LTRA)
Intermittent ICS
Low dose ICS + LTRA Add LTRA
Inc. ICS
frequency
Add intermitt ICS
Daily low dose ICS
Double
‘low dose’
ICS
Continue
controller
& refer for
specialist
assessment
STEP 1 STEP 2
STEP 3
STEP 4

Step 1 – As-needed inhaled SABA
GINA 2015, Box 6-5 (5/8)
Infrequent
viral wheezing
and no or
few interval
symptoms
6–8 weeks.
low dose ICS
Not well-
controlled
on double
ICS
CONSIDER
THIS STEP FOR
CHILDREN WITH:
RELIEVER
Other
controller
options
PREFERRED
CONTROLLER
CHOICE
Intermittent ICS
Inc. ICS
frequency
Add intermitt ICS
Daily low dose ICS
Double
‘low dose’
ICS
Continue
controller
& refer for
specialist
assessment
STEP 1 STEP 2
STEP 3
STEP 4

• Preferred option:
 As-needed inhaled SABA
 Not effective in all children
• Other options
– Oral bronchodilator therapy is not recommended.
– For children with intermittent viral-induced wheeze and no interval
symptoms, if as-needed SABA is not sufficient, consider intermittent
ICS.
Step 1 – As-needed inhaled SABA

Step 2 – initial controller + as-needed SABA
GINA 2015, Box 6-5 (6/8)
Infrequent
viral wheezing
and no or
few interval
symptoms
6–8 weeks.
low dose ICS
Not well-
controlled
on double
ICS
CONSIDER
THIS STEP FOR
CHILDREN WITH:
RELIEVER
Other
controller
options
PREFERRED
CONTROLLER
CHOICE
Intermittent ICS
Inc. ICS
frequency
Add intermitt ICS
Daily low dose ICS
Double
‘low dose’
ICS
Continue
controller
& refer for
specialist
assessment
STEP 1 STEP 2
STEP 3
STEP 4

Step 2 – initial controller + as-needed SABA
• Indication
– Child whose symptoms not well-controlled, or ≥3 exacerbations/yr
– May also be used as a diagnostic trial for children with frequent
wheezing episodes
• Preferred option: regular daily low dose ICS + as-needed inhaled SABA
• Other options depend on symptom pattern
– (Persistent asthma) – regular leukotriene receptor antagonist (LTRA)
– (Intermittent viral-induced wheeze) – regular LTRA
– (Frequent viral-induced wheeze with interval symptoms) – consider
episodic or as-needed ICS, but give a trial of regular ICS first

Step 3– medium dose ICS+ as-needed
inhaled SABA
Infrequent
viral wheezing
and no or
few interval
symptoms
6–8 weeks.
low dose ICS
Not well-
controlled
on double
ICS
CONSIDER
THIS STEP FOR
CHILDREN WITH:
RELIEVER
Other
controller
options
PREFERRED
CONTROLLER
CHOICE
Intermittent ICS
Inc. ICS
frequency
Add intermitt ICS
Daily low dose ICS
Double
‘low dose’
ICS
Continue
controller
& refer for
specialist
assessment
STEP 1 STEP 2
STEP 3
STEP 4

Step 3 – medium dose ICS+ as-needed inhaled SABA
• Indication
– When symptoms not well-controlled on low dose ICS
– First check symptoms are due to asthma, and check adherence, inhaler
technique and environmental exposures
 Medium dose ICS with as-needed inhaled SABA
• Other options:
 Consider adding LTRA to low dose ICS

Step 4 – Refer for expert assessment
Infrequent
viral wheezing
and no or
few interval
symptoms
6–8 weeks.
low dose ICS
Not well-
controlled
on double
ICS
CONSIDER
THIS STEP FOR
CHILDREN WITH:
RELIEVER
Other
controller
options
PREFERRED
CONTROLLER
CHOICE
Intermittent ICS
Inc. ICS
frequency
Add intermitt ICS
Daily low dose ICS
Double
‘low dose’
ICS
Continue
controller
& refer for
specialist
assessment
STEP 1 STEP 2
STEP 3
STEP 4

Step 4 – Refer for expert assessment
• Indication
– When symptoms not well-controlled on medium dose ICS
 Continue controller treatment and refer for expert assessment
• Other options (preferably with specialist advice)
– Higher dose ICS and/or more frequent dosing (for a few weeks)
– Add LTRA, theophylline or low dose OCS (for a few weeks only)
– ICS + LABA not recommended in this age group

Inhaled corticosteroid Low daily dose (mcg)
Beclometasone dipropionate (HFA) 100
Budesonide (pMDI + spacer) 200
Budesonide (nebulizer) 500
Fluticasone propionate (HFA) 100
Ciclesonide 160
Mometasone furoate Not studied below age 4 years
Triamcinolone acetonide Not studied in this age group
Low dose inhaled corticosteroids (mcg/day) for children ≤5 yrs

A. Symptom control
In the past 4 weeks, has the child had:
Well-
controlled
Partly
controlled
Uncontrolled
• Daytime asthma symptoms for more than
few minutes, more than once/week? Yes No
None of
these
1-2 of
these
3-4 of
these
• Any activity limitation due to asthma?
(runs/plays less than other children,
tires easily during walks/playing) Yes No
• Reliever needed more than once a
week? Yes No
• Any night waking or night coughing
due to asthma? Yes No
B. Risk factors for poor asthma outcomes
ASSESS CHILD’S RISK FOR:
• Exacerbations within the next few months
• Fixed airflow limitation
• Medication side-effects
Assessment of asthma control in
children ≤5 years

Age Preferred device Alternate device
0–3 years Pressurized metered dose
inhaler plus dedicated spacer
with face mask
Nebulizer with face mask
4–5 years Pressurized metered dose
with mouthpiece
Pressurized metered dose
with face mask, or nebulizer
with mouthpiece or face mask
Inhaler device for children ≤5 years

Management of Acute
Exacerbation in children 6 – 11 yr
and adolescents
Component 4

• A flare-up or exacerbation is an acute or sub-acute worsening of symptoms and
lung function compared with the patient’s usual status
• Consider management of worsening asthma as a continuum
Self-management with a written asthma action plan
Management in primary care
Management in the emergency department and hospital
Follow-up after any exacerbation
Management of Acute Exacerbation

Identify patients at risk of asthma-related death
Any history of near-fatal asthma requiring intubation and ventilation
Hospitalization or emergency care for asthma in last 12 months
Not currently using ICS, or poor adherence with ICS
Currently using or recently stopped using OCS
Over-use of SABAs, especially if more than 1 canister/month
Lack of a written asthma action plan
History of psychiatric disease or psychosocial problems
Confirmed food allergy

Written asthma action plans – medication options
•Increase inhaled reliever
Increase frequency as needed
Adding spacer for pMDI may be helpful
•Early and rapid increase in inhaled controller
Up to maximum ICS of 2000mcg BDP/day or equivalent
Options depend on usual controller medication and type of LABA
•Add oral corticosteroids if needed
Children: 1-2mg/kg/day up to 40mg, usually 3-5 days
Morning dosing preferred to reduce side-effects
Tapering not needed if taken for less than 2 weeks

Managing exacerbations in primary care
PRIMARY CARE Patient presents with acute or sub-acute asthma exacerbation
ASSESS the PATIENT
Is it asthma?
Risk factors for asthma-related death?
Severity of exacerbation?
MILD or MODERATE
Talks in phrases, prefers
sitting to lying, not agitated
Respiratory rate increased
Accessory muscles not used
Pulse rate 100–120 bpm
O2 saturation (on air) 90–95%
PEF >50% predicted or best
SEVERE
Talks in words, sits hunched
forwards, agitated
Respiratory rate >30/min
Accessory muscles in use
Pulse rate >120 bpm
O2 saturation (on air) <90%
PEF ≤50% predicted or best
LIFE-THREATENING
Drowsy, confused
or silent chest
START TREATMENT
SABA 4–10 puffs by pMDI + spacer,
repeat every 20 minutes for 1 hour
Prednisolone:children 1–2 mg/kg,
max. 40 mg
Controlled oxygen(if available): target
saturation 93–95% (children: 94-98%)
TRANSFER TO ACUTE
CARE FACILITY
While waiting: give inhaled SABA
and ipratropium bromide, O2,
systemic corticosteroid
URGENT
WORSENING

START TREATMENT
SABA 4–10 puffs by pMDI + spacer,
repeat every 20 minutes for 1 hour
Prednisolone:adults 1 mg/kg, max.
50 mg, children 1–2 mg/kg, max. 40 mg
Controlled oxygen(if available): target
saturation 93–95% (children: 94-98%)
CONTINUE TREATMENTwith SABA as needed
ASSESS RESPONSE AT 1 HOUR (or earlier)
TRANSFER TO ACUTE
CARE FACILITY
While waiting: give inhaled SABA
and ipratropium bromide, O2,
systemic corticosteroid
WORSENING
ARRANGE at DISCHARGE
Reliever:continue as needed
Controller:start, or step up. Check inhaler technique,
adherence
Prednisolone:continue, usually for 5–7 days
(3-5 days for children)
Follow up: within 2–7 days
ASSESS FOR DISCHARGE
Symptoms improved, not needing SABA
PEF improving, and >60-80% of personal
best or predicted
Oxygen saturation >94% room air
Resources at homeadequate
FOLLOW UP
Reliever: reduce to as-needed
Controller:continue higher dose for short term (1–2 weeks) or long term (3 months), depending
on background to exacerbation
Risk factors: check and correct modifiable risk factors that may have contributed to exacerbation,
including inhaler technique and adherence
Action plan:Is it understood? Was it used appropriately? Does it need modification?
IMPROVING
WORSENING

Managing exacerbations in acute care settings
INITIAL ASSESSMENT
A: airway B: breathing C: circulation
Are any of the following present?
Drowsiness, Confusion, Silent chest
Further TRIAGE BY CLINICAL STATUS
according to worst feature
Consult ICU, start SABA and O2,
and prepare patient for intubation
MILD or MODERATE
Talks in phrases
Prefers sitting to lying
Not agitated
SEVERE
Talks in words
Sits hunched forwards
Agitated
Accessory muscles being used
Pulse rate >120 bpm
O2 saturation (on air) < 90%
NO
YES

MILD or MODERATE
Talks in phrases
Prefers sitting to lying
Not agitated
SEVERE
Talks in words
Sits hunched forwards
Agitated
Accessory muscles being used
Pulse rate >120 bpm
O2 saturation (on air) < 90%
Short-acting beta2-agonists
Consider ipratropium bromide
Controlled O2 to maintain
saturation 93–95% (children 94-98%)
Oral corticosteroids
Ipratropium bromide
Oral or IV corticosteroids
Consider IV magnesium
Consider high dose ICS

Consider ipratropium bromide
Oral corticosteroids
Ipratropium bromide
Oral or IV corticosteroids
Consider IV magnesium
Consider high dose ICS
If continuing deterioration, treat as
severe and re-assess for ICU
ASSESS CLINICAL PROGRESS FREQUENTLY
MEASURE LUNG FUNCTION
in all patients one hour after initial treatment
FEV1 or PEF 60-80% of predicted or
personal best and symptoms improved
MODERATE
Consider for discharge planning
FEV1 or PEF <60% of predicted or
personal best,or lack of clinical response
SEVERE
Continue treatment as above
and reassess frequently

Management of Acute
Exacerbation in children ≤ 5 yr

Initial assessment of acute asthma exacerbations
Symptoms Mild Severe
Altered consciousness No Agitated, confused or drowsy
Oximetry on
presentation (SaO2)
>95% <92%
Speech† Sentences Words
Pulse rate <100 beats/min >200 beats/min (0–3 years)
>180 beats/min (4–5 years)
Central cyanosis Absent Likely to be present
Wheeze intensity Variable Chest may be quiet

© Global Initiative for AsthmaGINA 2015, Box 6-8 (2/3)
PRIMARY CARE
Child presents with acute or sub-acute asthma exacerbation
or acute wheezing episode
ASSESS the CHILD
Consider other diagnoses
Risk factors for hospitalization
Severity of exacerbation?
MILD or MODERATE
Breathless, agitated
Pulse rate ≤200 bpm (0-3 yrs) or ≤180 bpm (4-5 yrs)
Oxygen saturation ≥92%
MONITOR CLOSELY for 1-2 hours
Transfer to high level care if any of:
• Lack of response to salbutamol over 1-2 hrs
• Any signs of severe exacerbation
• Increasing respiratory rate
• Decreasing oxygen saturation
START TREATMENT
Salbutamol 100 mcg two puffs by pMDI + spacer
or 2.5mg by nebulizer
Repeat every 20 min for the first hour if needed
Controlled oxygen (if needed and available):
target saturation 94-98% URGENT
Worsening,
or lack of
improvement
SEVERE OR LIFE THREATENING
any of:
Unable to speak or drink
Central cyanosis
Confusion or drowsiness
Marked subcostal and/or sub-glottic
retractions
Oxygen saturation <92%
Silent chest on auscultation
Pulse rate > 200 bpm (0-3 yrs)
or >180 bpm (4-5 yrs)
TRANSFER TO HIGH LEVEL CARE
(e.g. ICU)
While waiting give:
Salbutamol 100 mcg 6 puffs by pMDI+spacer
(or 2.5mg nebulizer). Repeat every 20 min
as needed.
Oxygen (if available) to keep saturation 94-
98%
Prednisolone 2mg/kg (max. 20 mg for <2 yrs;
max. 30 mg for 2–5 yrs) as a starting dose
Consider 160 mcg ipratropium bromide
(or 250 mcg by nebulizer). Repeat every
20 min for 1 hour if needed.
Primary care management of acute asthma or wheezing

Primary care management of acute asthma or wheezing
MONITOR CLOSELY for 1-2 hours
Transfer to high level care if any of:
• Lack of response to salbutamol over 1-2 hrs
• Any signs of severe exacerbation
• Increasing respiratory rate
• Decreasing oxygen saturation
Worsening,
or lack of
improvement
TRANSFER TO HIGH LEVEL CARE
(e.g. ICU)
While waiting give:
Salbutamol 100 mcg 6 puffs by pMDI+spacer
(or 2.5mg nebulizer). Repeat every 20 min
as needed.
Oxygen (if available) to keep saturation 94-
98%
Prednisolone 2mg/kg (max. 20 mg for <2 yrs;
max. 30 mg for 2–5 yrs) as a starting dose
Consider 160 mcg ipratropium bromide
(or 250 mcg by nebulizer). Repeat every
20 min for 1 hour if needed.
Worsening,
or failure to
respond to
10 puffs
salbutamol
over 3-4 hrs
FOLLOW UP VISIT
Reliever: Reduce to as-needed
Controller: Continue or adjust depending on cause of exacerbation, and duration of need for extra salbutamol
Risk factors: Check and correct modifiable risk factors that may have contributed to exacerbation, including
inhaler technique and adherence
Action plan: Is it understood? Was it used appropriately? Does it need modification?
Schedule next follow up visit
DISCHARGE/FOLLOW-UP PLANNING
Ensure that resources at home are adequate.
Reliever: continue as needed
Controller: consider need for, or adjustment of, regular controller
Check inhaler technique and adherence
Follow up:within 1-7 days
Provide and explain action plan
CONTINUE TREATMENT IF NEEDED
Monitor closely as above
If symptoms recur within 3-4 hrs
• Give extra salbutamol 2-3 puffs per hour
• Give prednisolone 2mg/kg (max. 20mg for
<2 yrs; max. 30mg for 2-5 yrs) orally
IMPROVING
IMPROVING

Managing exacerbations in acute care settings if….
Features of severe exacerbation 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
 Persisting tachypnea despite 3 administrations of inhaled SABA

Indication for transfer of child in ICU
• Child presenting with life threatening attack
• Child with severe distress has shown poor response to therapy after observed for
few hours
• Develop sign of impending respiratory failure during therapy like hypoxia (Po2 <60
mm Hg), hpercarbia (Pco2 > 45 mm Hg).

ICU management
 Continue oxygen
 Inhaled short acting Beta agonist every 60 min or continuous + inhaled
Anticholinergics.
 Continue systemic rescue steroids.
 Continue intensified ward plan/ intensify therapy by adding bronchodilator: -
Magnesium sulphate, Aminophylline, Terbutaline infusion.
 Continuous monitoring with pulse oximetry and repeated ABG are mandatory
since most of these patient are not in condition to perform PEFR
 If indicated intubate child and start mechanical ventilation

Failure of maximum pharmacotherapy
Pao2<60 ,Paco2 >45
Minimal chest movements
Minimal air exchange
Severe chest retractions
Deterioration of mental status
Respiratory/ cardiac arrest
Indication of mechanical ventilation

Stepping down acute care
• Follow the principle “last in first out”
Discontinue terbutaline/aminophylline drip in 24 hrs
Discontinue ipratropium neb in 24-48 hrs
Reduce nebulisation with SA β2 agonist to q 2-4 hrly and then q 4-6 hrly
Replace IV rescue steriod  Oral steroid
• Discharge Criteria :
Pulmonary score index < 3
Sleep well at night
Feeding well
Appears comfortable
Receiving less frequent β2 agonist

Seasonal Asthma
• Asthma attack start with onset of particular season and persist during that season
till allergen persist otherwise child is normal remaining part of year.
• Child can be started on controller drugs 2 weeks in advance of start of season.
• Medications are given as per the severity of asthma
• Child should be examined again after discontinuing meds after season is over

Exercise Induced Asthma
• Symptoms and bronchoconstriction typically worsen after cessation of
exercise
• Managed by SABA/LABA/LTRAS
• Short acting B agonists are given just before activity as they have short
duration of action
• Long acting bronchodilators / leukotriene receptor antagonists can be
given in the morning

Primary prevention of asthma
 Avoid exposure to allergen
 Avoid exposure to tobacco smoke in pregnancy and early life
 Encourage vaginal delivery
 Advise breast-feeding for its general health benefits
 Where possible, avoid use of paracetamol (acetaminophen)
and broad-spectrum antibiotics in the first year of life.

Asthma medication
inhalation therapy

Inhalation therapy
• To get the maximum amount of medication into your lungs
with minimum side effects.
• Use a spacer with a puffer to minimize side effects and
deliver more medication to lungs
• Asthma improves more rapidly
• Better control is maintained
• Less medication is needed

Inhaler Device
• MDI with spacer
• Metered dose
inhaler (MDI)
• Dry powder inhaler
• Nebulizer
Delivery
10-15%
5-10%
5-10%
1-5%
Drug delivery by inhalation device

INHALERS
Two types : 1. Aerosol inhaler
2. Dry powder inhaler

Aerosol inhalers
•These inhalers use an aerosol canister to produce a fine mist of medication.
•Two types:
1 Puffers (pMDI)- Press and breathe
2 Autohalers - As you breathe in; your breath will activate the device

Puffer
Using your puffer :
1. Remove the cover from the puffer mouthpiece
2. Hold the puffer upright and shake vigorously
3. Breathe out
4. Tilt the chin up
5. Put the puffer mouthpiece in your mouth and create a seal with your lips
6. Start to breathe in through your mouth, then fire one puff of medication
and continue to breathe in steadily and deeply
7. Remove the puffer from your mouth, close your mouth and hold your
breath for 10 seconds
8. Breathe out through your nose
9. The length of time between inhalation is 15- 20 seconds
10. Replace the cover

 Puffers require good coordination so it is important to press down on
the canister and breathe in at the same time.
Cleaning your puffer
1. Remove metal canister. Do not wash canister
2. Wash the plastic casing only. Rinse the mouthpiece through the top
and bottom under warm running water for at least 30 seconds. Wash
mouthpiece cover
3. Allow to air dry
4. Reassemble
Puffer

Spacer
Using your spacer
1. Assemble the spacer
2. Remove the cap from the puffer and shake
the puffer well
3. Attach the puffer to the end of the spacer
4. Place the mouthpiece of the spacer in your mouth and close your lips
around it. If using a spacer with a facemask, place the facemask over the
mouth and nose to ensure a good seal
5. Press down on the puffer canister once to fire the medication into the
spacer
6. Breathe in and out normally for 4 - 5 breaths
7. To take more medication, shake the puffer and repeat steps

Cleaning your spacer
• About every month the spacer should be washed in clean
soapy warm water.
• Allowed to drip dry.
• Do not rinse or wipe dry.
Role of spacer
• Spacers overcome coordination problem of actuation and
inhalation
• Increase delivery of drug to lung
• Can reduce potential side effects.
Spacer

Dry powder inhalation device(DPIs)
• DPIs disperse medication as dry powder(2-5 µm) without use
of propellant.
• DPIs are breath actuated so no coordination problem
between actuation and inhalation.
• Used above 6 years
Two types
-unit dose DPIs( rotahaler and revoliser)
-multi dose DPIs(multihaler)

Rotahaler (single dose DPI device)
How to use
•Insert a capsule into the rotahaler .
•Twist the rotahaler to break the capsule
•Inhale deeply to get powder into the airway
•Several breath may be required
•Does not require the coordination of the aerosol

Revolizer (single dose DPI device)
How to use
• Simply open the Revolizer,
• Insert the rotacap
• Shut the device and inhales

How to clean DPI
• Rotahaler should be cleaned twice a week.
• Separate two halves of rotahaler.
• keep in running tape water over 1-2 minute.
• Put at clean place to become dry.
• Revolizer should be cleaned once a week.

Multihaler (multi dose DPI device)
How to use
1. To load a dose, hold the DPI with mouthpiece up to ensure proper
loading of the medication.
2. Twist the grip fully in one direction as far as it will go and then fully
back again. You will hear a click. The DPI is now loaded with a dose.
3. Breathe out away from the device
4. Place the device in your mouth and breathe in as forcefully and deeply
as you can.
5. Hold your breath for 10 seconds.
6. Take the DPI away from your mouth and exhale slowly.
7. If more than one dose is prescribed, repeat steps 1 through 5 for each
dose.

Nebulizer
 Nebulizer is device used for converting a liquid drug into a
fine mist which inhaled directly into the lungs via face mask
or mouth piece.
 The device is driven by compressor (electric/battery
operated)or oxygen.
 Gas flow of 6-8 L/min is normally required to drive the
nebulizer.
 Drug inhalation is accomplished by normal tidal breathing
over 5-10 minutes.

Nebulizer
 Two types - 1. Jet nebulizer
2. Ultrasonic nebulizer
Jet nebulizer Ultrasonic nebulizer

Nebulizer
How to use
• Plug the compressor unit into the mains.
• Connect the tubing from the compressor unit to the bottom of the
nebuliser chamber.
• Unscrew the top of the nebuliser chamber.
• Measure out the correct amount of drug solution and pour into the
nebuliser chamber.
• Add normal saline to make total solution 4-5ml which is required in
the nebuliser chamber for it to work properly.
• Screw on the top of the nebuliser chamber and attach the face
mask or mouthpiece to the top of the chamber.

• Place the facemask over patient mouth and nose and place the
strap over your head.
• Sit up, well supported, in a chair or in bed and keep the nebulizer
chamber upright.
• Switch the compressor unit on and breath in and out as normal.
• Nebulisation usually completed in 5-10 minute.
• A small amount of solution may be left in the nebuliser at this
stage.
• Switch off the compressor unit and disconnect the nebuliser
chamber from the tubing.
Nebulizer

 Advantage
• Provide therapy for patients who cannot use other inhalation
modalities (MDI, DPI)
• Allow administration of large doses of medicine
• Patient coordination not required
• Effective with tidal breathing
• Dose modification possible
• Can be used with supplemental oxygen
Nebulizer

Nebulizer
 Disadvantage
• Decreased portability
• Longer set-up and administration time
• Higher cost
• Electrical power source required
• Contamination possible

Allergen specific immunotherapy
• Allergen immunotherapy (also termed desensitization) is a medical
treatment aiming at patients suffering from allergies that are
insufficiently controlled by symptomatic treatments.
• Greatest benefit of specific immunotherapy using allergen extracts has
been obtained in the treatment of allergic rhinitis
• The role of specific immunotherapy in asthma is limited
• Specific immunotherapy should be considered only after strict
environmental avoidance and pharmacologic intervention, including
inhaled glucocorticosteroids, have failed to control asthma
•Perform only by trained physician treatments.

What’s New
1. Dry powder inhalers can be used to deliver SABA in mild or moderate
exacerbations.
2. While arranging transfer to acute care facility, give inhaled ipratropium bromide
as well as SABA, systemic corticosteroids, and oxygen.
3. Pre-school children with acute exacerbations or wheezing episodes –
a. Parent-administered oral steroids or high dose ICS not generally encouraged
b. A new flow-chart for management of acute exacerbations or wheezing
episodes
4. High usage of SABA is a risk factor for exacerbations.

5. Very high usage of SABA (e.g. >200 doses/month) is a risk factor for asthma-
related death
6. Breathing exercises –
a. Evidence level down-graded from A to B following review of quality of
evidence and a new meta-analysis
b. The term ‘breathing exercises’ (not ‘techniques’) is used
7. If cardioselective beta-blockers are indicated for acute coronary events, asthma is
not an absolute contra-indication.
What’s New

Childhood asthma

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