Clinical Practice

Guidelines for the

Management of
Childhood Asthma
2014

Prepared by: Marlyna Suhaida Rosly

Pegawai Farmasi U44

Hospital Pakar Sultanah Fatimah

Checked by:

Low Yee Shan

Pegawai Farmasi U44
Hospital Pakar Sultanah Fatimah

List of Contents:
Definition

of asthma

Diagnosis
Severity
Goals

& assessment

of therapy

Management

of asthma
2

Definition of Asthma
A

heterogenous condition characterised by

paroxysmal or persistent symptoms such as
dyspnoea, chest tightness, wheezing &
cough against a background of chronic
persistent inflammation and/or;

structural

changes associated with variable

airflow inflammation & airway hyperresponsiveness1,2
3

Diagnosis
Presentation
Differential

diagnosis

Investigations

Presentation

Recurrent episodes of one or more of the

following symptoms of wheeze, cough, and
shortness of breath and chest tightness
usually precipitated by allergen exposure, viral
infections or exercise

At least 50% of children will have had one

episode of wheezing by the age of six years
but less than half of them have asthma. Thus,
recommended to define pre-school wheezing
into 2 main categories

Presentation (cont.)

Wheezing3

i.

episodic: children who wheeze with viral

infections but are well between episodes

ii.

multiple-trigger: children who have discrete

exacerbations & also symptoms in between
these episodes

Presence of atopy (eczema, allergic rhinitis &

conjunctivitis) in the child or family supports
the diagnosis of asthma4
6

Asthma Predictive
Asthma
predictive index can be helpful in
Index
predicting asthma in young children

A child with negative predictive index will

have a 95% chance of not having asthma by
the age of 6 years

Those with positive predictive index will only

havePositive
a 65%
chance of having asthma
index ( > 3 wheezing/year first
3 years) plus 1 major criteria or 2 minor
criteria
Major : Eczema*
Parental asthma*
Minor : Allergic rhinitis*
Wheezing apart from cold
Eosinophilia ( 4 %)

*Doctor-diagnosed

Differential diagnosis for chronic cough and/or

recurrent wheeze

Chronic cough
and/or wheezing in
young children may
be due to other
condition

Adapted from NIH guidelines 2007: EPR 3 Guidelines for the diagnosis and management of asthma:
http;//www.nhlbi.nhi.gov/guidelines/asthmaasthgdln.htm

Investigations
1.

Diagnosis of asthma is based on a good history &

physical examination

2.

Supportive features in diagnosis of asthma include

response to bronchodilator therapy, that is,
symptomatic improvement in the younger children or
improvement in Peak expiratory flow rate (PEFR)
>20% or Forced expiratory volume in 1 sec (FEV 1)
>12% 5,6

3.

Other supportive features of asthma; raised exhaled

nitric oxide & positive skin prick tests to
aeroallergens7,8,9

Investigations (cont.)
Investigations that may be necessary to exclude
other conditions in atypical cases:
Lung function tests
Chest x-ray
Sinus
High

x-ray

Immune

function test

Echocardiogram

Resolution
Computer Tomography Mantoux test
(HRCT) thorax scan

10

Asthma Severity &

Assessment

Asthma Management Handbook. National Asthma Council Australia and the Asthma
Foundations. Content created (Thursday 16 November 2006). Last updated 31 May 2007

Goals of Therapy
i.

Maintenance of normal activities including the

ability to exercise

ii.

No absence from school

iii.

No visits to the emergency department or any

hospitalisation due to asthma exacerbation

iv.

No mortality

v.

No side effects from medication

Management of
Asthma
Patient

education

Avoidance

of trigger factors

Optimisation of
pharmacotherapy

13

Patient Education
i.

Explain the disease nature & its treatment

ii.

Recognise signs & symptoms of asthma,

avoid trigger factors & understand the causal
disease mechanism

iii.

Information about medications- indications,

dosages, timing & technique of using the
device

iv.

Instructions on self-management, written

asthma plans

v.

Educate on exercise; e.g. swimming & sports

Avoidance of trigger
factors
Smoking

& air pollutants

Environmental allergens
Obesity
Food & medication allergy
Respiratory tract infections
Exercise
15

Prevention
1. Smoking & air pollutants

Environmental tobacco smoke (ETS) risk for

developing asthma symptoms at any age during
childhood10
Infants: frequency of lower respiratory tract
infection
Children: > frequent asthma exacerbations

Smoking during pregnancy results in impaired lung

growth in the developing foetus wheezing in early
life11
Other pollutants: traffic/industry, mosquito coil smoke
16

Prevention (cont.)
2. Environmental allergens

e.g: house dust mite (D. pteronyssinus, D. farinae), cat &

dog dander, cockroach, fungi, pollen

Early sensitisation can risk of persistent asthma &

bronchial hyperresponsiveness with lung function 12

exposure to allergens by environmental intervention can

asthma-associated morbidity in children with atopic
asthma13
3. Obesity

incidence of asthma in obese children14

A strong predictor of the persistence of childhood asthma

into adolescence15

Requires additional studies to clarify relationship between

obesity-asthma for effective intervention
17

Prevention (cont.)
4. Food & medication allergy

e.g: cow's milk, egg, soy & wheat usually

resolved by 5 y/o peanuts, tree nuts, fish & shell
fish usually persists16

Limited data on the effect of food

avoidance/supplementation on asthma
Deprivation of food items is not necessary unless
there is clear & reproducible link between
ingestion of an offending food & allergy
symptoms or asthma exacerbations
Food additives (e.g. MSG, sulphites, dyes) may
induce lower airway symptoms17
18

Prevention (cont.)
5. Respiratory tract infections

commonest triggers of asthma exacerbations:

rhinovirus, respiratory synctial virus, human
metapneumovirus18

6. Exercise

can trigger asthma symptoms but important for

children's growth & development
Exercise intolerance may indicate inadequate
asthma control requires further evaluation &
treatment optimisation
19

Optimisation of drug
therapy
Reliever

therapy

Preventer

therapy

20

Algorithm for the long term

management of asthma

reliev
er

preventer

Reliever therapy

Drug of Choice: short acting 2-agonist (SABA)

Routine oral bronchodilator use is discouraged due

to:

- Narrow therapeutic index

-

05/05/15

Erratic GI absorption that results in variable &

inconsistent efficacy20

Preventer therapy
Parameters that determine the choice of preventer
therapy & duration of treatment21:
i. Age of child
ii.Frequency & severity of symptoms
iii.Asthma wheeze phenotype
Drug of Choice: Inhaled corticosteroids (ICS)22
most appropriate for multi-trigger wheeze & atopic
asthma
ICS reduce asthma symptoms & prevent asthma
associated hospitalisation & asthma related death
Standard ICS dose have not been shown to be
beneficial in episodic viral wheeze23 while
intermittent high dose provides a modest benefit but
with significant adverse effects24
05/05/15

Preventer therapy (cont.)

Leukotriene receptor antagonist (LRA)
used as a long term preventer in mild persistent
asthma
intermittent course may have some clinical benefit in
episodic viral wheeze25
e.g.: Montelukast
Long acting 2-agonist (LABA)
added when asthma symptoms cannot be controlled
with standard doses of ICS26
must be used in combination, NEVER as monotherapy
combination of ICS-LABA is superior than ICS-LRA 27
e.g.: Formoterol, Salmeterol

05/05/15

Evaluation of asthma control

28

Reduction in therapy
When asthma control is achieved for at least three months, a step
down approach must be considered from current treatment level.

Special Categories of
Asthma Intermittent severe asthma
Nocturnal
Exercise

(EIA)

Brittle

asthma

induced asthma

asthma

Difficult

asthma
26

Special Categories of
Asthma
1.

Intermittent severe asthma

severe, life-threatening
first sign of an attack should be treated with
inhaled SABA + oral steroid
risk factors are not clearly identified; may be
associated with atopic disease32

2. Nocturnal asthma
commonest indicator of suboptimal treatment &
instability
controlled by ICS
add LABA to relieve uncontrolled symptoms &
morning dip in lung function29

Special Categories of
Asthma (cont.)
3. Exercise induced asthma (EIA)

Affects 40-90% of children but often

undiagnosed30

A transient in airway resistance d/t

bronchoconstriction that occurs following 6-8
mins of strenuous exercise31

Needs anti-inflammatory therapy optimisation

Control further symptoms by administer SABA

10-20 mins before exercise27

Special Categories of Asthma (cont.)

4. Brittle asthma
unstable asthma which is unpredictable
Rare, occurs in only 0.05% of all asthmatic patients
Type I: persistent & chaotic variability in PEF (usually >40% diurnal
variation in PEF for >50% of time) despite considerable medical
therapy
Type II: sporadic sudden falls in PEF on a background of normal lung
function & well-controlled asthma 32
This group of asthma patients should be referred for specialist care
5. Difficult asthma
Asthma not controlled in spite of ICS doses of 800 mcg/day of
budesonide equivalent33
Must rule out other important contributors; e.g. misdiagnosis, poor
adherence, poor inhalation technique, co-morbidities & persistent
exposure to allergens
This group of asthma patients should be referred for specialist care

Inhaler Devices

Inhalation is the preferred route of administration

Delivery system according to the childs age

Home nebuliser therapy: expensive & less

efficient than spacer devices

Assessment of
severity of acute
asthma exacerbation
for children

32

Adapted from British Guidelines on the Management of Asthma. The British Thoracic Society &
Scottish Intercollegiate Guidelines Network (SIGN) May 2006.

Algorithm for
management of acute
exacerbation of
bronchial asthma in
children

34

1st

line treatment for acute

asthma
Administer rapidly after a
quick history, physical
examination, & vital
examination

To

hasten recovery
should be given early
Parenteral route for children who are
vomiting/unable to tolerate orally/ children
with moderate to severe or life threatening
acute exacerbations
duration: 3-5 days (weaning only if course
of steroids 14 days)
For patients with moderate to
severe acute asthma exacerbation/
those not responding to SABA alone

For children with severe/lifethreatening asthma

unresponsive to maximal
dose of
bronchodilators+steroid
(in a HDU or PICU setting)
Adjunct treatment in
severe/life-threatening
exacerbations unresponsive
to initial standard treatment

Long term Asthma Monitoring &

Follow Up
1. Maintain patient with the lowest dose of maintenance
therapy once asthma control is achieved
2. Issues need to be addressed on each follow up visit:
Degree of asthma control
Compliance to asthma therapy (frequency & technique)
Asthma education
3. Identify and closely monitor patients with high risk of
developing near fatal asthma (NFA) or fatal asthma

Evaluation of asthma
control
19

Asthma Action Plan (AAP)

A written asthma action plan detail for the individual patient

on the daily management (medication & environmental control
strategies) & how to recognise & handle worsening asthma

AAP should include35:

1.Recommended doses & frequencies of daily medications
2.Medicine adjustment instructions at home in response to
particular signs, symptoms, peak flow measurement
3.Emergency contact numbers
4.A list of trigger factors that may cause an asthma attack, thus,
to help inform others & the patient of what triggers to avoid
5.PEF monitoring is recommended for moderate to severe
asthma

References

Reddel HK, Taylor R, Bateman ED, Boulet LP, Homer A, et al. An Official American Thoracic Society/European Respiratory Society
Statement: Asthma Control and Exacerbations. Standardising Endpoints for Clinical Asthma Trials and Clinical Practice on behalf
of the American Thoracic Society/European Respiratory Society Task Force on Asthma Control and Exacerbations. AmJRCCM
2009;180:59-99.
2.
Becker A, Berube D, Chad Z, Dolovich M, Ducharme F et al. Canadian Paediatric Asthma Consensus Guidelines 2003 (updated to
December 2004) CMAJ 2005;173:S12-S14.
3.
Brand PLP, Baraldi E, Bisgaard AL, Boner JA, Castro-Rodriguez et al. ERS TASK FORCE: Definition, assessment and treatment of
wheezing disorders in preschool children: an evidence based approach. Eur Respir J 2008; 32: 1096-1110.
4.
Bosquet J, Kjellman NI. Predictive value of tests in childhood allergy. J Allergy Clin Immunol 1986; 78: 1019-1022.
5.
Mueller GA, Eigen H. Pediatricfunction testing in asthma. Pediatr Clin North Amer 1992; 39: 1243-1258.
6.
Pellegrino R, Viegi G, Brusasco V, Crapo RO, Burgos F et al. Series ATS/ERS Task Force: standardisation of lung function
testing. Interpretative strategies for lung function tests. ERJ 2005; 26: 948-968.
7.
Chan EY, Dundas I, Bridge PD, Healy MJ, McKenzie SA. Skin prick testing as a diagnostic aid for childhood asthma. Pediatr Pulmon
2005; 39: 558-562.
8.
Baraldi E, Dario C, Ongaro R et al. Exhaled nitric oxide concentrations during treatment of wheezing during exacerbations in
infants and young children. Am J Respir Crit Care Med 1999; 159: 1284-1288.
9.
Moeller A, Franklin P, Hall GL. Et al. Inhaled fluticasone dipropionate decreases level of nitric oxide in recurrent wheezy infants.
Pediatric Pulmonol 2004; 38: 250-255.
10.
Martinez FD, Wright AL, Taussig LM, Holberg CJ, Halonen M, Morgan WJ. Asthma and wheezing in the first six years of life. The
group Health Medical Associates. N Engl J Med 1995; 332; 133-138 .
11 . Milner AD, Rao H, Greenough A. The effects of antenatal smoking on lung function and respiratory symptoms in infants and
children. Early human development 2007; 83: 707-711.
12.
Platts-Mills TAE, Rakes GP, Heymann PW. The relevance of allergen exposure to the development of asthma in childhood. J Allergy
Clin Immunol 2000; 105: S503-S508.
13.
Morgan WJ, Crain EF, Gruchalla RS, OConnor GT, Kattan M, Evans R et al. Results of a home-based environmental intervention
among urban children with asthma. N Engl J Med 2004; 351: 1068-1080.
14.
Belamaric PF, Luder E, Kahan M, Mitchell H, Islam S, Lynn H, Crain EF. Do obese inner city children with asthma have more
symptoms than non-obese children with asthma. Pediatrics 2000; 106: 1436-1441.
15.
Shore SA, Fredberg JJ. Obesity, smooth muscle, and airway hyperresponsiveness. J Allergy Clin Immunol 2005; 115: 925-927.
16.
Hourihane JO, Roberts SA, Warner JO. Resolution of peanut allergy: case control study. BMJ 1998; 316: 1271-1275.
17. Bird JA, Burks AW. Food allergy and asthma. Primary Care Respiratory Journal 2009; 18(4): 258-265.
18. Yadav R. Viruses associated with acute exacerbation of bronchial asthma among children in University Malaya Medical Centre.
Malaysian J Paed Child Health 2012; 18(1): online.
1.

References

19. Niggemann B, Wahn U. Three cases of adolescent near-fatal asthma: what do they have in common? J asthma 1992;
29(3): 217-220.
20. Selective beta2 agonist-side effects. British National Formulary (5 th ed.) London. BMJ Publishing Group Ltd and Royal
Pharmaceutical Society Publishing. March 2008.
21.
Bis gaard H, Szefler S. Prevalence of asthma-like symptoms in young children. Pediatr Pulmonol 2007; 42: 723-728.
22.
Castro-Rodriguez JA, Rodrigo GJ. Efficacy of inhaled corticosteroids in infants and pre-schoolers with recurrent wheezing
and asthma. N Eng J Med 2000; 343: 1054-1963.
23.
Wilson N, Sloper K, Silverman M. Effect of continuous treatment topical corticosteroid on episodic viral wheeze in preschool children. Arch Dis Child 1995; 72: 317-320.
24.
McKean M, Ducharme F. Inhaled steroids for episodic viral wheeze of childhood. Cochrane Database Syst Rev 2000; (2):
CD001107. Review.
25.
Bisgaard H, Zielen S, Garcia-Garcia ML et al. Montelukast reduces asthma exacerbations in 2 to 5 year-old children with
intermittent asthma. Am J Respir Crit Care Med 2005; 171: 315-322.
26.
Lemanske RF, Mauger DT, Sorkness CA et al. Step up therapy for children with uncontrolled asthma receiving inhaled
corticosteroids. N Eng J Med 2010; Mar 18; 362(11): 975-985.
27.
Ducharme FM, Lasserson TJ, Cates CJ. Long acting beta2 agonists versus anti-leukotrienes as add-on therapy to inhaled
corticosteroids for chronic asthma. Cochrane Database Syst Rev 2006; CD003137. Review.
28.
Asthma Management Handbook. National Asthma Council Australia and the Asthma Foundations. Content created 16
November 2006. Last updated 31 May 2007.
29.
Bacharier LB, Philips BR, Bloomberg GR et al. Severe intermittent wheezing in preschool children: a distinct phenotype. J
Allergy Clin Immunol 2007; 119: 604-610.
30.
Milgrom H, Taussig LM. Keeping children with exercise induced asthma active. Pediatrics 1999; 104: e38.
31.
Hallstrand TS, Curtis JR, Koepsell TD et al. Effectiveness of screening examinations to detect unrecognised exercise
induced bronchoconstriction. J Paediatr 2002; 141: 343-348.
32.
Khajolia R. Exercise induced asthma: fresh insights and an overview. Malaysian Fam Physician 2008; 3(1): e1985-2274.
33.
Ayres JG, Miles JF, Barnes PJ. Brittle asthma. Thorax 1998; 53: 315-321.
34.
Mitchell I, Tough SC, Semple LK, Green FH, Hessel PA. Near-fatal asthma: study of risk factors: a population-based. Chest
2002; 121: 1407-1413.
35.
Global Initiative for Asthma (GINA) A Pocket Guide for Physicians and Nurses Based on Global Strategy for Asthma
Management & Prevention for Adults & Children Older than 5 Years Old, 2009.

43