1

(The Thai National Guideline for Diagnosis and

Management of Childhood Asthma)
1.
2.

3. (Treatment of acute
exacerbations)
.

4. (Chronic therapy for

childhood asthma)
.

5.

(Prevention of asthma)

. .2539-40 4.5 ..
2530 13 ( 3 )
(,, , )

1.8

NHLBI

(GINA)

..
2538

. .2541

400

()
4
..

..
4

(goal of therapy)

1.
2.
3. (
)
4.

5.

6.

1.
/ (educate patient and
establish partnership)
2.

(assessment of asthma severity)

3.
(avoidance and control of triggers)
4.
(establish medication plans for long-term
management)
5. (establish plans for
managing exacerbations)
6. (provide regular
follow-up care)

II

1. Airway inflammation
2. Increased airway responsiveness to a variety
of stimuli
3. Reversible or partial reversible airway
obstruction

1.
2.

3.

(reversible airway obstruction)

1.

1.1

(wheeze)

1.2

(allergen)

1.3
(atopic dermatitis) (allergic
rhinitis) (food allergy)

2.

2.1

(wheeze)

(forced

inspiratory/expiratory wheeze)
2.2 (increased A-P diameter)
2.3 allergic rhinitis,
allergic conjunctivitis atopic dermatitis

recurrent wheezing ( 3 )
asthma
atopic background

wheeze

atopic
background wheeze bronchiolitis
wheeze
3.
3.1 (chest X-ray)

1
2
3
4

pneumothorax,
atelectasis
3.2 (pulmonary function
test)
1
(reversible airway obstruction)
FEV1 (forced expiratory volume at 1 second)
spirometer PEF (peak expiratory flow)
15
2 peak flow variability ()
peak flow meter 20

Peak flow variability =

PEF max - PEFmin
x 100%
1/2 (PEFmax + PEFmin)
3.3 (allergy
skin prick test) ( 70)

6
(atopic status)
(
)

3.4

methacholine

histamine

(bronchoprovocation test)

1.
2. croup, foreign body,
vascular ring
3. BPD (bronchopulmonary
dysplasia)
3. gastroesophageal reflux (GER),
congestive heart failure

severity)

(Classification of asthma by

NHLBI

(National

Heart Lung and Blood Institute)

4

(intermittent), (mild persistent),
(moderate persistent) (severe persistent)

guideline
( 1)

1 (Classification of
asthma severity)

4 : (Severe
persistent)

(Exacerbation)

PEF FEV1
60%
> 30%

3 : (Moderate

7
persistent)

(Exacerbation)

2- agonist
PEF FEV1
>60% - <80%
>30%

2 : (mild
persistent)

(Exacerbation)

2
PEF FEV1
80%
20-30%

1:
(Intermittent)

(Exacerbation)

2

exacerbation

PEF FEV1

III

(Treatment of acute
asthmatic attacks)

1.

asthma

exacerbations
2. asthma exacerbations
,
FEV1,
PEFR
3. asthma exacerbations
- inhaled 2-agonist

systemic
corticosteroids

exacerbations
- theophylline, anticholinergic drug

8
4.

oxygen

exacerbations

asthma exacerbations

1. asthma exacerbations

exacerbations

asthma exacerbations

Mild

Moderate

Severe

(Sympto
ms)

(Signs)

wheeze

(/)

Pulsus
paradoxus

< 2
< 60 /
2 12
< 50 /
1 5
< 40 /
6 8
< 30 /

< 100

100 120

2 12
< 160 /
1 2
< 120 /
2 8
< 110 /

(< 10 mm
Hg)

(1025 mm
Hg)

> 120

Respirato
ry arrest

wheeze

> 25 mm
Hg

2040 mm Hg

(Functional Assessment)
PEF
%
predicted
or
% personal
best
PaO2 (on
air)
PaCO2

> 80%

> 60 mm Hg

< 60 mm Hg

< 42 mm Hg

< 42 mm Hg

> 42 mm Hg

80%

50

< 50%

10
SaO2% (on
air)

> 95%

91 95%

< 91%

2. asthma exacerbations

inhaled

2-agonist

asthma exacerbations

,
( peak flow meter PEF)

Inhaled short-acting 2agonists MDI*

2 puffs 3 20

2-agonists
4 6 .

24 48 .
- inhaled
steroids dose

2 7 10

3
- 2-agonists
2 .

2-agonists

* MDI MDI
1

11
3. asthma exacerbations

exacerbations

()

asthma exacerbations

12

, , ,
,
SaO , PEFR, EFV
2

Inhaled short-acting 2-agonist 20

3 doses
oxygen SaO > 95%
2
systemic corticosteroid

SaO2, PEFR,
FEV1

inhaled short-acting

inhaled short-acting 2-agonist 1

continuous nebulization
inhaled anticholinergic
oxygen
systemic corticosteroid

2-agonist

systemic corticosteroid
1-3

distress
SaO2 > 95%
PEF > 70%

Discharge

inhaled 2-agonist
systemic
corticosteroid
short course

Oxygen

SaO2 < 95%

PEF 50% - 70%

inhaled -agonist
2

oxygen
systemic corticosteroid
anticholinergic

theophylline

PEF < 30%

PCO2 > 45 mm
Hg
SaO2 < 90%
PaO2 < 60 mm
Hg

care

intensive

inhaled 2-agonist
systemic corticosteroid
oxygen
systemic 2
agonist: SC, IV, IM
continuous 2
agonist / IV
theophylline
anticholinergic

13
Bronchodilators:

2-agonist,

anticholinergics,

adrenaline
Corticosteroids
Other treatments: theophylline
Oxygen
oxygen hypoxemia FEV1
PEFR < 50% predicted value, SaO2
> 95%
oxygen nasal cannula face mask
SaO2 oxygen
(humidification) water
nebulizer
2 - Agonists
inhaled short-acting 2 - agonists
3

Nebulizers
20 - 30
,
airflow obstruction wheezing /
PEFR
nebulization flow oxygen flow
6-8 L/min

continuous
nebulization
Metered-dose inhaler (MDI) with spacer
MDI with spacer (6-12 puffs)
bronchodilatation nebulizers
Injection
severe bronchospasm
terbutaline salbutamol

(subcutaneous) 0.01
mg/kg/dose 0.3 mg

3 doses

14

15
3

exacerbations

Inhaled short
acting 2-gonist.
- Salbutamol
nebulizer solution

- Salbutamol MDI
(100 g/puff)
Systemic (injected)
2-agonists
- Terbutaline

-agonist

asthma

0.05-0.15 mg/kg/dose selective

(maximum dose 2.5
2-agonist
mg) 20 3
normal saline
doses 0.15 2.5 4 mL
0.3 mg/kg 1-4

gas flow 6-8
0.5 mg/kg/hour
L/min
continuous
nebulization
4-8 puffs 20 nebulizer

3 doses, 1-4

spacer
0.01 mg/kg
aerosol
subcutaneous (
therapy
dose 0.3 mg)
20 3 doses
2-6

Epinephrine

anaphylaxis

angioedema
asthma 2-agonist
epinephrine 0.01 mg/kg 0.01
ml/kg 1:1,000 (1 mg/ml) 0.5 mL
subcutaneous 20 3 doses
Anticholinergics
inhaled 2-agonists
first line drug acute exacerbation

16
ipratropium bromide inhaled 2agonists bronchodilator effect

severe airflow obstruction

(Ipratropium
bromide
-Atrovent) Beta2-agonist Berodual (
fenoterol) Combivent ( salbutamol)

17
Ipratropium bromide

2-agonist

ipratropium bromide nebulizer solution (0.25 mg/ml)

initial 0.25 mg 20 3 doses, 2-4
Combivent unit dose 2.5 cc salbutamol
2.5 mg ipratroium bromide 0.5 mg
salbutamol unit dose/ 10 kgs
anticholinergics

(hypertrophic
subaortic
stenosis),
,

fenoterol
hydrobromide, salbutamol atropine
Corticosteroids

corticosteroid acute
asthmatic attack
moderate acute episode
inhaled -agonists
inhaled 2-agonists attack
3-4
inhaled 2-agonists
Severe acute episode
corticosteroid

asthma

wheezing-associated
respiratory illness (WARI) wheezing
corticosteroid
4 5
2

potency side effects

systemic corticosteroids asthma
exacerbations

Steroid

AntiGrowt
inflamma
h
tory
Suppr

Saltretaini
ng

Plasm
a
Half-

Biolo
gical
Half-

18
Effect
Hydrocortiso
ne
Prednisolone
Methylpred
nisolone
Dexametha
sone

ession
Effect

Effect

1.0

1.0

7.5

0.8

7.5

0.5

30

80

1.0

life
(min)
80120
120300
120300
150300

life
(hr)
8

16-36
16-36
36-54

19

corticosteroids

Methylprednisolo loading dose 2 ./.

ne (IV)
1-2 ././
6 .

Hydrocortisone
(IV)

loading dose 5-7

./.
5 ./. 4-6

Prednisolone
(oral)

1-2

././

60 ./
2-3

Methylprednisolone
succinate

(Solu-Medrol )
40 mg/1 ml = 159
125 mg/ 2 ml = 336

Hydrocortisone succinate

(Solu-Cortef )
. 100 mg/2 ml = 50
1 tablet = 5 mg
50

Other treatments

Theophylline first line drug

acute asthmatic attack therapeutic index
side effect inhaled 2agonist
asthmatic attack
initial bolus dose 5 mg/kg infusion
0.5-0.9 mg/kg/hr 10-20 g/dL
, ,

Antibiotics
sinusitis, otitis media pneumonia

Inhaled mucolytic drugs

Chest physical therapy

20

Sedation

exacerbations

4. asthma exacerbations

anatomy

physiology

hypoxemia

ventilation/perfusion

acute wheezing illness

RSV

subjective objective parameters

signs, symptoms functional
assessment

oral corticosteriod
rehydration dehydration

acute wheezing

antibiotic
pulse oximetry arterial blood gas

90%

oxygen saturation > 95%

severe airway obstruction

PaCO2 ventilation
5.

department

blood gases

emergency

intensive care 2
intensive care unit

21
severe asthmatic attack impending
respiratory failure ICU
-
-
-
- accessory muscles retraction

suprasternal
notch

paradoxical
thoracoabdominal movement
- wheeze
wheeze (silent chest)
-
- Pulsus paradoxus > 20 mmHg
- PEF < 50% predicted/personal base value
- PaO2 < 60 mmHg room air

- PaCO2 42 mmHg
- SaO2 room air < 90%
- pneumothorax pneumomediastinum
6. Discharge emergency department
Criteria
- stable 1
nebulized bronchodilator
- peak expiratory flow 70%
predicted personal base value
Medications
- 3-5
7.
-
- inhaler peak flow meter
- exacerbation

22
-

23

IV

(Chronic therapy for

childhood asthma)
2
(Bronchodilator)

(quick relief medication)

acute

asthma
2 (Anti-inflammatory agent)
(Preventer, Controller)

longterm
preventive
therapy

inhaled
corticosteroid,
cromolyn
sodium,
leukotriene
receptor antagonist, ketotifen ( 6)
( 3)
4
1 (intermittent asthma)
1 2-3

-agonist

2 (mild persistent)

PEF FEV1 (80%

(variability) 20-30%

: inhaled low-dose corticosteroid

24
: inhaled cromolyn
receptor antagonists

sodium

leukotriene

ketotifen

8-12

sustained-release
theophylline inhaled
drug
(nocturnal asthma)
oral long-acting 2-agonist
inhaled form

3 (moderate persistent)
1 /
PEF FEV1
60-80% 30%
inhaled corticosteroid
medium-dose inhaled steroid lowdose inhaled corticosteroid
sustained-release theophylline, long-acting inhaled
2-agonist long acting oral 2-agonist
leukotriene-receptor antagonist
4 (severe persistent)

PEF

FEV1

60%

30 %
medium-to-

inhaled
high dose corticosteroid 1
inhaled long-acting 2-agonist, sustained-release
theophylline, long-acting oral 2-agonist, leukotrienereceptor antagonist
corticosteroid

25

3-

dose inhaled corticosteroid

5
1.

high-

2. mild persistent
2 cromolyn sodium ketotifen
low-dose inhaled steroid
3. moderate severe persistent refer
specialist
persistent
wheezing
peak flow meter

peak flow meter 5

3 4 ( )
(life-threatening asthma)

6
(long-term
preventive
medications for asthma in children)

1. Inhaled corticoste
roid

( 2)
spacer

2.
- nebulized (20
Cromolyn
mg/2ml)
sodium
2 ml x 3-4
/
- MDI (1 5

2-4

- systemic side
effect
(>800
g/)
-

3-4

26

3.

mg/puff)
1-2 puff x 3-4
/
6-8

Leukotri
ene
recepto
r
antagon
ist

4.
Ketotifen

- (1 mg/5
ml)
- (1
mg/tab)

< 3 0.5 mg
bid
> 3 1 mg
bid
8

1-3

27

(Long-term Preventive)

(Quick-Relief)

short acting 2- agonist

inhaled medium-to-high dose

(severe

corticosteroid

persistent)

- long-acting inhaled 2--agonist

- sustained-release theophylline

(Step down)

- long-acting oral 2- agonist

- leukotriene-receptor antagonist

prednisolone

inhaled medium-dose corticosteroid

(Step up)

(moderate

persistent)

inhaled low-dose corticosteroid

- long-acting inhaled 2- agonist

- sustained-release theophylline

- long-acting oral 2- agonist

- leukotriene-receptor antagonist

short acting 2- agonist

3-4 /

28

inhaled low dose corticosteroid

(mild

persistent)

short acting 2 agonist

inhaled cromolyn sodium

3-4 /

sustained-release theophylline

leukotriene-receptor antagonist

ketotifen

(intermittent
asthma)

short acting 2- agonist

1-3

inhaled 2- agonist inhaled

cromolyn sodium

29

corticosteroid

Types of
corticosteroids
Beclomethasone

-MDI (50,250 g)
-Diskhaler
(100,200,400 g)
Budesonide
-Turbuhaler (100,200
g)
-MDI (50, 100,200 g)
-Nebulized solution
(500,1000 g)
Fluticasone
(MDI
25,125,250 g)

Low
dose
(g)

Mediu
m dose
(g)

High
dose
(g)

100-400

400-600

>600

100-200
100-400
-

200-400
400-600
1,0002000

>400
>600
>2,000

50-200

200-300

>300

<4

4-7

>7

inhaled drugs

nebulizer
MDI with spacer (with

mask)

MDI with spacer

DPI
MDI

with
spacer
DPI

MDI = metered-dose inhaler

or

without

30
DPI = dry powder inhaler

IV

2
1. Primary prevention

1.1
.
25-30
.

50

1.2

1.2.1.

1.2.2.

(Indoor environment)

(Outdoor environment)

1.2.3.

1.2.4.

1.2.5

2,500

31
1.2.6

1)
2)

1.2.7.

4-6

Primary prevention

indoor allergens

2. Secondary prevention

1.
2.

1.

2.

( identify and avoid triggers)

10

3.

(identify and avoid triggers)

1.

2.

(Domestic

house dust mite)

3.

4.

5.

6.

32
7.

8.

9.

33

19

()

(
)

30

( pesticides)

(exterminator)

550

HEPA (high efficiency particulate

airfilter)

34

shortacting long-acting 2 agonist

cromolyn sodium 15-30

(warm-

up)

6-10

35

I.

1. National Heart, Lung and Blood Institute, National

Institutes of Health. Global initiative for Asthma.
NIH/NHLBI publication no 95-3659. Washington
DC:NIH;1995.
2. National Heart, Lung and Blood Institute, National
Institutes of Health. Guidelines for the diagnosis
and management of asthma. Expert panel report
2.
NIH/NHLBI
publication
no.
97-4051.
Washington DC:NIH:1997.
3. Vichyanond P, Jirapongsananuruk O, Visitsuntorn N,
Tuchinda M. Prevalence of asthma, rhinitis, and
eczema in children from the Bangkok area using the
ISAAC (International study for asthma and allergy in
children) questionnaires.
J Med Assoc Thai
1998;81:175-81.
4. Vichyanond P, et al. Guidelines on the diagnosis
and treatment of childhood asthma in Thailand.
Thai J Pediatrics 1995;34:3:194-211.
5. Sullivan SD.
Cost and cost-effectiveness in
asthma.
Immunol Allergy Clin N America
1996;16:819-38.

II.

1. National Heart, Lung and Blood Institute, National

Institutes of Health. Global initiative for Asthma.
NIH/NHLBI publication No 96-3659. Washington
DC:NIH;1998.
2. National Heart, Lung and Blood Institute, National
Institutes of Health. Guidelines for the diagnosis
and management of asthma. Expert panel report
2.
NIH/NHLBI
publication
No.
97-4051.
Washington DC:NIH:1997.

36

III.

1. National Heart, Lung and Blood Institute, National

Institutes of Health. Guidelines for the diagnosis
and management of asthma. Expert panel report
2.
NIH/NHLBI
publication
No.
97-4051.
Washington DC:NIH:1997.
2. Global NHLBI/WHO Workshop Report: Global
Strategy for Asthma Management and Prevention.
NIH Publication No. 96-3659A. December 1995

37
Anticholinergic Agents in Acute Asthma
1. Brian J L. Treatment of acute asthma. Lancet
1997;350(suppl II):18-23.
2. O'Driscoll RB, Taylor RJ, Horsley MG, Chambers DK,
Bernstein A. Nebulised salbutamol with and without
ipratropium bromide in acute airflow obstruction.
Lancet 1989;i:1418-20.
3. Schuh S, Johnson DW, Callahan S, Cally G, Levison
H.
Effects of frequent nebulised ipratropium
bromide added to frequent high dose albuterol
therapy in severe childhood asthma. J Paediatr
1995;126:639-45.
4. Karpel JP, Schacter NE, Fanta C, et al.
A
comparison of ipratropium and albuterol versus
albuterol alone for the treatment of acute asthma.
Chest 1996;110:611-16.
5. Fitzgerald MK, Grunfeld A, Parae PD, et al. The
clinical
efficacy
of
combination
nebulised
anticholinergic and adrenergic bronchodilators
versus nebulised adrenergic bronchodilator alone
in acute asthma. Chest 1997;111:311-15.
Intravenous bronchodilator therapy for
acute asthmatic attack
1. Janson C. Plasma levels and effects of salbutamol
after inhaled or iv administration for stable
asthma. Eur Respir J 1991;4:544-50.
2. Swedish Society of Chest Medicine. High dose
inhaled versus intravenous salbutamol combined
with theophylline in severe acute asthma. Eur
Respir J 1990;3:163-70.
3. Salmeron S, Brochard L, Mal H, et al. Nebulised
versus intravenous albuterol in hypercapnic acute

38
asthma.
Am J Respir
Crit Care Med
1994;149:1466-70.
4. Cheong
B, Reynolds SR, Rajan G, Ward MJ.
Intravenous 2-agonist in severe acute asthma.
BMJ 1988;297:448-50.
5. Browne GJ, Penna AS, Phung X, Soo M.
Randomised trial of intravenous salbutamol in
early management of acute severe asthma in
children. Lancet 1997; 349: 301-05.
6. Murphy DG, McDermott MF, Rydman RJ, Sloan EP,
Zalenski RJ. Aminophylline in the treatment of
acute asthma when -adrenergics and steroids are
provided. Arch Intern Med 1993;153:1784-88.
7. Huang D, O'Brien RG, Harman E, et al. Does
aminophylline benefit adults admitted to the
hospital in acute exacerbation of asthma. Ann
Intern Med 1993; 119: 1155-60.
8. DiGiulio G, Kercsmar C, Krug S, Alpert S, Marx C.
Hospital treatment of asthma: lack of benefit from
theophylline given in addition to nebulised
albuterol
and
intravenously
administered
corticosteroid. J Pediatr 1993;122:464-69.
9. Strauss ARE, Wertheim DL, Bonagura VR, Velacer
DJ.
Aminophylline therapy does not improve
outcome and increases adverse effects in children
hospitalised with acute asthmatic exacerbations.
Paediatrics 1994;93:205-10.
Theophylline
1. Miles Weinberger, Leslie Hendeles. Drug Therapy:
Theophylline in Asthma. NEJM 1996;21:334.
2. DeNicola LK, GF Monem, MO Gayle, and N Kissoon.
Treatment of Critical Status Asthmaticus in

39
Children. Pediatr Clin N America 1994;41:1293325.
3. Brian J Lipworth.
Treatment of acute asthma.
Lancet 1997;350(suppl II):18-23
4. Practice Parameters for the Diagnosis and
Treatment of Asthma: Joint Task Force on Practice
Parameters; The American Academy of Allergy,
Asthma, and Immunology, The American College
of Allergy, Asthma, and Immunologyand the Joint
Council of Allergy, Asthma, and Immunology
Editors:
Sheldon L. Spector, MD; Richard A.
Nicklas, MD. J Allergy Clin Immunol 1995;96(5):2.

IV.
childhood asthma)

(Chronic

therapy

1. National Heart, Lung and Blood Institutes of

Health. Global initiative for asthma. NIH/NHLBI
publication no 95-3659.
Washington DC:
NIH;1995.
2. National Heart, Lung and Blood Institutes of
Health. Guidelines for the diagnosis and
management of asthma. Expert panel report 2.
NIH/NHLBI publication no. 97-4501. Washington
DC: NIH;1997.
3. Warner JO, Naspitz CK, Croup GJA.
Third
international pediatric consensus statement on the
management of children asthma.
Pediatr
Pulmonol 1998;25:1-17.
4. De Jongste JC. Prophylactic drugs in asthma: their
use and abuse. Clinical Pediatr 1995;3:379-98.
5. Price JF. The management of chronic childhood
asthma. In: Silverman M, ed. Childhood asthma
and other wheezing disorders. London: Chapman
& Hill, 1995:357-74.

for

40

V.
1. National Heart, Lung and Blood Institute, National
Institutes of Health. Global initiative for Asthma.
NIH/NHLBI publication no 95-3659. Washington
DC:NIH;1995.
2. National Heart, Lung and Blood Institute, National
Institutes of Health. Guidelines for the diagnosis
and management of asthma. Expert panel report
2.
NIH/NHLBI
publication
no.
97-4051.
Washington DC:NIH:1997.
3. Warner JO, Naspitz CK, Croup GJA.
Third
international pediatric consensus statement on the
management of childhood asthma.
Pediatric
Pulmonol 1998;25:1-17.
4. Warner JO, Warner JA. Preventing Asthma. In:
Silverman M, ed. Childhood asthma and other
wheezing disorders. London: Chapman & Hall;
1995;429-40.
5. Partridge MR.
Education of patients, parent,
health professionals and other. In: Silverman M,
ed.
Childhood asthma and other wheezing
disorders. London: Chapman & Hall; 1995:465-72.

41

1.

15

2541

400

2. 4
1. .
2. .
3. .
4. .
3.

1. .
2. .
3. .
4. .
5. .
6. .
7. .
8. .
9. .
10. .
11. .
12. .
13. .
14. .
15. .