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)
.

.
 2

I
..2539-
40 4.5 .. 2530 13
( 3 ) (,
, , )
1.8



1

NHLBI
(GINA)
.. 2538
..2541

400



( )
4 .. ..

4

 3

(goal of therapy)
1.
2.
3. ()
4.

5.

6.

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)

4

 4

II

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

1.
2.
(reversible airway obstruction)
3.

1. (wheeze)
1.1

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


 5

5 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 = PEFmax - PEFmin x 100%

1/2 (PEFmax + PEFmin)

3.3 (allergy skin prick test)

( 70) (atopic status)
(
)

3.4 methacholine histamine
(bronchoprovocation test)
 6

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

(Classification of asthma by severity)

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 persistent)


(Exacerbation)
1
2- agonist
PEF FEV1
>60% - <80%
>30%
 7
2 : (mild persistent)

1
(Exacerbation)


2
PEF FEV1
80%
20-30%

1: (Intermittent)

1
(Exacerbation)

2
exacerbation
PEF FEV1
80%
<20%

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
- oxygen exacerbations
4.
 8

asthma exacerbations
1. asthma exacerbations
exacerbations

2

2 asthma exacerbations

Mild Moderate Severe Respiratory arrest

(Symptoms)

,

(Signs)



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



wheeze wheeze

(/) < 100 100 120 > 120


2 12 < 160 /
1 2 < 120 /
2 8 < 110 /
Pulsus paradoxus > 25 mm Hg
(< 10 mm Hg) (1025 mm Hg) 2040 mm Hg

(Functional Assessment)
PEF > 80% 5080% < 50%
% predicted or
% personal best
PaO2 (on air) > 60 mm Hg < 60 mm Hg
PaCO2 < 42 mm Hg < 42 mm Hg > 42 mm Hg
SaO2% (on air) > 95% 91 95% < 91%
 9

2. asthma exacerbations


inhaled 2-agonist
1

1 asthma exacerbations

,
( peak flow meter PEF)

Inhaled short-acting 2agonists MDI*

2 puffs 3 20

- 2-agonists - 2-agonists
4 6 . 3
24 48 .
- inhaled steroids - 2-agonists
dose 2 .
2 7 10

* MDI MDI
1
 10

3. asthma exacerbations
exacerbations


2
 11

2 asthma exacerbations ( )

- , , , ,

- Inhaled short-acting 2-agonist 20
3 doses
- oxygen SaO > 95%

- ,

- inhaled short-acting 2-agonist - inhaled short-acting 2-agonist 1
continuous nebulization inhaled
- systemic corticosteroid anticholinergic
- 1-3 - oxygen

- -
- , - SaO2 < 95% - PEF < 30%
distress - PEF 50% - 70% - PCO2 > 45 mm Hg
- SaO2 > 95% - SaO2 < 90%

Discharge intensive
- inhaled 2-agonist - inhaled 2-agonist care
systemic - oxygen - inhaled 2-agonist
corticosteroid - systemic corticosteroid - systemic corticosteroid
short course - anticholinergic - oxygen
- systemic 2-agonist:
- - theophylline SC, IV, IM
- continuous 2-
- agonist / IV
theophylline
Oxygen

 12

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
3 doses 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
 13

3 2-agonist asthma exacerbations

Inhaled short acting 2-gonist.
- Salbutamol nebulizer solution 0.05-0.15 mg/kg/dose (maximum selective 2-
dose 2.5 mg) 20 3 doses agonist normal saline
0.15 - 0.3 mg/kg 2.5 4 mL
1-4 gas
0.5 mg/kg/hour flow 6-8 L/min
continuous nebulization
- Salbutamol MDI 4-8 puffs 20 3 doses,
nebulizer
(100 g/puff) 1-4 spacer

Systemic (injected) 2-agonists 0.01 mg/kg subcutaneous ( aerosol therapy
- Terbutaline 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
ipratropium bromide inhaled 2-agonists
bronchodilator effect severe airflow obstruction
(Ipratropium bromide -Atrovent) Beta2-
agonist Berodual ( fenoterol) Combivent ( salbutamol)
 14

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
2

inhaled 2-agonists attack 3-4

inhaled 2-agonists
Severe acute episode
corticosteroid asthma
wheezing-associated respiratory illness (WARI) wheezing
corticosteroid
4 5

4 potency side effects systemic corticosteroids

asthma exacerbations
Steroid Anti-inflammatory Growth Salt-retaining Plasma Biological
Effect Suppression Effect Half-life Half-life
Effect (min) (hr)
Hydrocortisone 1.0 1.0 1.0 80-120 8
Prednisolone 4 7.5 0.8 120-300 16-36
Methylprednisolone 5 7.5 0.5 120-300 16-36
Dexamethasone 30 80 0 150-300 36-54
 15

5 corticosteroids

Methylprednisolone (IV) loading dose 2 ./.
1-2 ././ Methylprednisolone succinate
6 . (Solu-Medrol)
40 mg/1 ml = 159
125 mg/ 2 ml = 336
Hydrocortisone (IV) loading dose 5-7 ./. Hydrocortisone succinate
5 ./. 4-6 . (Solu-Cortef)
100 mg/2 ml = 50
Prednisolone (oral) 1-2 ././ 1 tablet = 5 mg
60 ./ 50
2-3

Other treatments
Theophylline first line drug acute asthmatic attack
therapeutic index side effect
inhaled 2-agonist
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

Sedation exacerbations
 16

4. asthma exacerbations


anatomy physiology

ventilation/perfusion hypoxemia

RSV acute
wheezing illness

subjective objective parameters
signs, symptoms functional assessment

oral corticosteriod
rehydration dehydration
acute wheezing antibiotic
pulse
oximetry arterial blood gas
oxygen saturation > 95%
severe airway obstruction 90%

blood gases PaCO2

ventilation
5.
emergency department

intensive care 2
intensive care unit
severe asthmatic attack impending respiratory failure ICU

-
-
 17

-
- 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

-

-
 18

IV (Chronic therapy for childhood asthma)

2
1 (Bronchodilator)

(quick relief medication)
acute asthma
2 (Anti-inflammatory agent) (Preventer,
Controller)


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

2-agonist


2 (mild persistent) 1
2

PEF FEV1 (80% )
(variability) 20-30%



: inhaled low-dose corticosteroid
: inhaled cromolyn sodium leukotriene receptor antagonists
 19

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 low-dose 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 %
inhaled medium-to-high dose
corticosteroid 1 inhaled long-acting 2-agonist,
sustained-release theophylline, long-acting oral 2-agonist, leukotriene-receptor antagonist
corticosteroid

3-6

high-dose
inhaled corticosteroid
5
1.

 20

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 - - -
corticosteroid 2-4
( 2) - systemic side effect
- spacer (>800 g/)

2. Cromolyn - nebulized (20 mg/2ml) - -
sodium 2 ml x 3-4 / - - 3-4
- MDI (1 5 mg/puff)
1-2 puff x 3-4 /
6-8
3. Leukotriene - -
receptor - -
antagonist -

4. Ketotifen - (1 mg/5 ml) - -
- (1 mg/tab) - -
- -
< 3 0.5 mg bid 1-3
> 3 1 mg bid
8
 21

(Long-term Preventive) (Quick-Relief)

4 short acting 2- agonist (Step down)

inhaled medium-to-high dose
(severe corticosteroid
persistent) 1
- long-acting inhaled 2--agonist 3
- sustained-release theophylline
- long-acting oral 2- agonist
- leukotriene-receptor antagonist
prednisolone

3 inhaled medium-dose corticosteroid short acting 2- agonist (Step up)

inhaled low-dose corticosteroid 3-4 /
(moderate
persistent) - long-acting inhaled 2- agonist
- sustained-release theophylline
- long-acting oral 2- agonist
- leukotriene-receptor antagonist

2 inhaled low dose corticosteroid short acting 2 agonist

(mild inhaled cromolyn sodium 3-4 /
persistent)
sustained-release theophylline

leukotriene-receptor antagonist

ketotifen

1 short acting 2- agonist

1-3
(intermittent inhaled 2- agonist inhaled
asthma) cromolyn sodium

 22

7 corticosteroid
Types of corticosteroids Low dose Medium dose High dose
(g) (g) (g)
Beclomethasone 100-400 400-600 >600
-MDI (50,250 g)
-Diskhaler (100,200,400 g)
Budesonide
-Turbuhaler (100,200 g) 100-200 200-400 >400
-MDI (50, 100,200 g) 100-400 400-600 >600
-Nebulized solution (500,1000 g)
- 1,000-2000 >2,000
Fluticasone (MDI 25,125,250 g) 50-200 200-300 >300

8 inhaled drugs

< 4 nebulizer
MDI with spacer (with mask)

4-7 MDI with spacer

DPI

> 7 MDI with or without spacer

DPI

MDI = metered-dose inhaler

DPI = dry powder inhaler
 23

IV




2
1. Primary prevention


1.1
.
25-30
.
50


1.2
1.2.1. (Indoor environment)

1.2.2. (Outdoor environment)

1.2.3.


1.2.4.


1.2.5 2,500

 24

1.2.6

1)
2)

1.2.7.


4-6
Primary prevention

indoor allergens

2. Secondary prevention

1.
2.

1. ( identify and avoid triggers) 10
2.
3.
(identify and avoid triggers)

1. (Domestic house dust mite)
2.
3.
4.
5.
6.
7.
8.
9.
 25

19


550
30

()

(
)

( pesticides)
(exterminator)





HEPA (high
efficiency particulate airfilter)




 26

short-acting long-
acting 2 agonist cromolyn sodium
15-30

(warm-up)
6-10
 27

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.

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
 28

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 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.
 29

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 Children. Pediatr Clin N America 1994;41:1293-325.
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. (Chronic therapy for childhood asthma)

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.
 30

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.
 31

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. .