Summary Charts For Diagnosis And Management Of Asthma In Children And Adolescents In Family Practice

Transcription

1 Summary Charts For Diagnosis And Management Of Asthma In Children And Adolescents In Family Practice Lee Bee Wah, Daniel YT Goh The following tables and flow charts have been developed and adapted from the most recent asthma consensus guideline updates: 997 National Heart Lung, and Blood Institute Guidelines for the Diagnosis and Management of Asthma ( and The 995 British Guidelines on Asthma Management (Thorax 997; (Suppl ); S-2.). Included are the Peak Expiratory Flow and FEV nomograms for our local children. The %predicted value = patient s reading 5 reading for patient s Ht (see charts) x Contents Diagnosis Grading of severity/chronicity Long term treatment according to severity grading Other aspects on long term management Acute asthma management Guide on when to refer to Paediatric Asthma Specialist Peak Expiratory Flow and FEV Nomograms for Singapore children Sample Peak Flow DiaryManagement

2 Diagnostic Approach Episodic wheeze and cough Nocturnal symptoms <5 years old Positive Trigger factors Supportive Evidence Upper respiratory tract infections atopic features Exercise family history asthma Allergen exposure Strong emotional expression(laugh/cry) >5 years old *Home PEF *Reversible airway *Bronchial Variability obstruction provocation (PEF diary) Bronchodilator response: Exercise 2% diurnal 5% PEF Methacholine variation 2% FEV Histamine Exclude alternative diagnosis eg pulmonary tuberculosis suppurative lung disease aspiration syndromes including foreign body, dysfunctional swallowing congenital abnormalities chronic lung disease of prematurity congenital malformationsof lung congenital heart disease Do CXR if other diagnosis suspected/consider other diagnostic tests eg neonatal/early onset failure to thrive frequent vomiting/choking focal lung signs vocal cord dysfunction Commence on trial of asthma therapy Review diagnosis if response is poor * Home PEF is most practical at primary health care level, but is the least reliable, because PEF is highly effort dependent. Other modes of presentation:. Cough variant asthma without wheezing. May be the group over diagnosed as asthma. Rule out rhinitis and sinusitis. 2. Hypersecretory asthma cough and excessive secretions, usually young patients, more crepitations than wheezing.. First acute wheeze exclude infection and foreign body aspiration. Recurrent viral wheezing in -2 year age group without atopy may not respond to asthma treatment.

3 Assessment of Asthma Severity Features before anti-inflammatory therapy* Symptoms* STEP 5 Persistent Severe STEP Persistent Moderate STEP Persistent Mild STEP 2 Intermittent Frequent exacerbations STEP Intermittent Infrequent exacerbations Continual symptoms Limited physical activity Frequent exacerbations Daily symptoms Daily use of inhaled short-acting beta agonist Exacerbations affect activity Exacerbations 2 times a week, may last several days Symptoms 2 times per week but < time per day Exacerbations may affect activity Symptoms <2 times per week Asymptomatic and normal PEF between exacerbations Exacerbations brief (few hours to few days, more than once a month Symptoms <2 times per week Asymptomatic and normal PEF between exacerbations Exacerbations brief (few hours to few days, less than once a month Nighttime Lung Function between symptoms exacerbations Frequent FEV or PEF 6% predicted PEFvariability >% > time a week FEV or PEF>6%-<8% predicted PEF variability >% >2 times a month FEV or PEF 8% predicted PEF variability 2-% 2 times a month FEV or PEF 8% predicted PEF variability <2% 2 times a month FEV or PEF 8% predicted PEF variability <2% * The presence of one of the features of severity is sufficient to place a patient in that category. An individual should be assigned to the most severe grade in which any feature occurs. An individual s classification may change over time. ** Patients at any level of severity can have mild, moderate or severe exacerbations. Some patients with intermittent asthma experience severe and life-threatening exacerbations separated by long periods of normal lung function and no symptoms. Those with life-threatening symptoms should be treated as a separate category.

4 Pharmacotherapy This stepwise approach is a general guideline. Asthma is highly variable; clinicians should tailor specific medication plans to the needs and circumstances of individual patients. Ιnhaled β 2 - agonists* Regular inhaled antiinflammatory medications* Others Step down therapy STEP 5 Persistent Severe STEP Persistent Moderate STEP Persistent Mild STEP 2 Intermittent Frequent exacerbations STEP Intermittent Infrequent exacerbations As required Moderate to high dose inhaled steroids Consider regular slow release theophylline or inhaled long acting β 2 agonist (>yrs) before stepping up inhaled steroids if still symptomatic. #Consider regular oral steroids (>5yrs) in a single daily dose in addition to other therapy As required Low to moderate dose inhaled Consider regular slow release theophylline or inhaled steroids long acting β 2 agonist (>yrs) before stepping up inhaled steroids if still symptomatic As required Low dose inhaled steroids Nil As required As required Or oral Consider Cromoglycate (especially <5 yrs), Nedocromil sodium (>6yr), or low dose inhaled steroids Nil Trial of ketotifen may be considered in young children (-2 yr), especially in those with associated troublesome rhinitis. Nil If control is achieved a stepwise reduction in treatment may be possible in three to six months. Regularly review the need to decrease inhaled steroids. There is currently no marker that can be used to predict relapse after cessation of therapy. In young children(-2yr) with non-atopic recurrent viral wheeze who do not respond to regular therapy, consider reevaluation of diagnosis and alternative therapy. *Inhaled medications: most children require a spacer device for pmdi. Small volume (<6ml) spacers with face mask for - years and large volume (>6ml) spacers for > years. As a guide, dry powder inhalers can be used efficiently in those above 6 years. Different inhaler devices may result differences in drug delivery to lungs. Nebulisers may be considered for infants who are unable to use other inhaler devices. Dosage for inhaled steroids: Low dose: -ug beclomethasone/budesonide; half the dose for fluticasone propionate (>yrs) Moderate dose: -8ug beclomethasone/budesonide; half the dose for fluticasone propionate (>yrs) High dose: 8-ug beclomethasone/budesonide; half the dose for fluticasone propionate (>yrs) # Before starting regular oral steroids, review diagnosis and consider factors contributing to asthma severity eg. chronic sinusitis, mucus plugging and collapsed segment/lobe of lung, and environmental factors eg. increased exposure to allergens.

5 General guidelines on referral to Paediatric Asthma Specialist. Moderate and severe persistent asthma. Regular monitoring of lung function for those >5 years is recommended. 2. Persistent asthma in those < years of age.. Have had a life threatening asthma exacerbation.. atypical signs and symptoms requiring further diagnostic evaluation. 5. Not responding well to therapy. 6. Requiring additional education and guidance on complications of therapy or, problems with compliance. Other Aspects of Management. Exposure to allergens and irritants (eg passive smoke) 2. Patient education on disease and management, monitoring asthma control, proper use of inhaler devices, and written asthma action plan. 5

6 Management of Children with Acute Asthma Exacerbation in General Practice Step : Evaluation of Severity MILD MODERATE SEVERE LIFE-THREATENING coughing, too breathless to talk cyanosis wheezing too breathless to feed silent chest ± shortness of breath use of accessory muscles poor respiratory effort chest tightness suprasternal retractions fatigue or exhaustion agitation or level of consciousness PEFR>8% 5-8% -5% <% predicted or personal best Step 2: Treatment *Nebulised β 2 agonist or β 2 agonist pmdi puffs via spacer at 2 min intervals X and observe for up to -H BETTER NOT BETTER High flow O 2 (if available) consider sending or relapse O 2 driven nebulised *β 2 agonist ± home with*β 2 agonist within - hrs *Ipratropium bromide at 2 min nebulised or pmdi -H intervals x as needed (or s/c adrenaline.mg/kg max. mg) Consider doubling dose Oral Prednisolone -2 mg/kg/d x -5D of inhaled steroids days (max -6mg/day) or i/v/im Hydrocortisone 5mg/kg if unable to retain Consider review next day or advise parents: If still requires β 2 agonist -H for more than 2Hs, start short course oral Prednisolone To Hospital Do not delay transfer if life threatening attack Review in next few days Nebulised β 2 agonist salbutamol 2.5-5mg/dose, terbutaline 5-mg/dose (infants < year use half the dose). Ipatropium bromide.25mg per dose (infants.mg, >5years.5mg) 6

7 NB:. Children with severe attacks may not appear distressed. Assessment in very young children may be difficult. 2. Other causes of breathlessness and wheezing must be borne in mind especially foreign body aspiration.. Children with previous life-threatening asthma seriously consider hospitalisation. Children who have already used frequent doses of inhaled β 2 agonist before consultation should advance one step further in the algorithm. FEV for Height in Singapore CHINESE BOYS.5 Litres 5th Connett et al., 99 (Thorax) 7

8 6 Litres/minute Nomogram of PEFR for Height in Singapore GIRLS th Dept Paeds, NUS, 986 survey 8

9 .5 Litres FEV for Height in Singapore CHINESE GIRLS.5 5th Connett et al., 99 (Thorax) 9

10 .5 Litres FEV for Height in Singapore INDIAN GIRLS th Connett et al., 99 (Thorax)

11 .5 Litres FEV for Height in Singapore MALAY GIRLS.5 5th Connett et al., 99 (Thorax)

12 .5 Litres FEV for Height in Singapore MALAY BOYS 5th Connett et al., 99 (Thorax) 2

13 Litres/minute Nomogram of PEFR for Height in Singapore BOYS 5th Dept Paeds, NUS, 986 survey

14 .5 Litres FEV for Height in Singapore INDIAN BOYS 5th Connett et al., 99 (Thorax)

15 .5 Litres FEV for Height in Singapore CHINESE GIRLS.5 5th Connett et al., 99 (Thorax) 5