It’s a chronic airway disease which result in airway flow limitation can be either reversible or irreversible.
Diagnostic Criteria
- Wheezing
- Difficulty in breathing
- Coughing
- Finger clubbing
9.2.1 Asthma
It is a chronic reversible obstructive inflammatory airways disease caused by constriction of bronchial smooth muscle causing bronchospasm, oedema of bronchial mucous membrane and blockage of the smaller bronchi with plug of mucous.
Diagnostic Criteria
- wheeze,
- shortness of breath,
- chest tightness
- cough
Non-pharmacological
- Avoid polluted environment which can trigger asthmatic attack
- Avoid heavy exercise
- Stop smoking
Note: The management of asthma in children is similar to that in adult. Infants under 18 months, may not respond well in bronchodilator
Table 9.4: Assessment and treatment of severity of asthma attack in children ≥2 years & adults
| Clinical
Presentation |
Treatment (Children & Adults) | |
| MILD-
MODERATE ATTACK |
Able to talk in sentences Respiratory rate
Child 2-5 yrs Child >5 yrs And No criteria of severity
|
Salbutamol inhalation3
Give: 2–4 puffs every 20-30 min up to 10 puffs if necessary during 1st hour – If symptoms completely subside observe for 1–4 hrs, give Salbutamol for 24–48 hrs (2-4 puffs every 4–6 hours) for 3 days – If attack is only partially resolved give 2–4 puffs of Salbutamol every 3–4 hrs if attack is mild; 6 puffs every 1–2 hrs if the attack is moderate, until symptoms subside. When attack completely resolved proceed as above – If symptoms worsen or do not improve, treat as SEVERE ATTACK |
| SEVERE ATTACK | Cannot complete sentences in 1
breath Or Too breathless to talk/ feed Respiratory rate Child 2-5 yrs>40/min Child >5 yrs>30/min Adult ≥25/min Pulse Child 2-5 yrs Child >5yrs Adult ≥110/min O2 saturation ≥92% |
Admit the patient, place in semi-sitting position Oxygen continuously 5L/min (maintain O2 saturation between 94-98%)
Salbutamol inhalation4 2–4 puffs every 20-30 min up to 10 puffs if necessary in children <5 yrs, up to 20 puffs in children >5 yrs and adults Hydrocortisone injection (IV) 5mg/kg in children, 100mg in adults every 6 hrs until the patient stabilizes, then switch to oral Prednisolone 1-2mg/kg once daily to complete 3–5 days of treatment If attack is completely resolved continue with Salbutamol inhalation 2–4 puffs every 4 hrs for 24-48 hours and oral Prednisolone 1-2mg once daily to complete 3–5 days of treatment. If not improving or condition worsens, treat as LIFE-THREATENING ATTACK |
| LIFE-
THREATENING ATTACK |
Altered level of consciousness (drowsiness, confusion, coma)
Exhaustion Silent chest Paradoxical thoracoabdominal movement Cyanosis Collapse Bradycardia in children or arrhythmia/ hypotension in adults O2 saturation<92% |
Admit the patient, place in semi-sitting position Oxygen continuously 5L/min (maintain O2 saturation between 94-98%)
Salbutamol nebulizer 2.5 mg for children <5 yrs and in children >5 yrs&adults 2.5-5 mg every 20–30 min then switch to Salbutamol aerosol when clinical improvement is achieved Hydrocortisone injection (IV) 5mg/kg in children, 100mg in adults every 6 hrs In adult administer a single dose of Magnesium Sulphate (Infusion of 1 to 2g in 0.9% Sodium Chloride over 20 minutes) In children use continuous nebulization rather than intermittent nebulisation. |
Use a spacer to increase effectiveness. If conventional spacer not available, take a 500ml plastic bottle, insert the mouth piece of the inhaler into a hole on the bottom of the bottle (the seal should be as tight as possible). The child breathes from the mouth of the bottle in the same way as he would with a spacer
Nocturnal Asthma
Patients who get night attacks should be advised to take their medication on going to bed.
9.2.2 Chronic Asthma in Adults
The assessment of the frequency of daytime and nighttime symptoms and limitation of physical activity determines whether asthma is intermittent or persistent. There are 4 categories (see table).
Therapy is step-wise (Step 1–4) based on the category of asthma and consists of:
- Preventing the inflammation leading to bronchospasm (controllers)
- Relieving bronchospasm (relievers)
Controller medicines in asthma
- Inhaled corticosteroids e.g. Beclomethasone
Reliever medicines in asthma
- β2 agonists e.g. Salbutamol (short-acting)
Table 9.5: Long-term treatment of asthma according to severity
| Categories | Treatment | |
| STEP 1
Intermittent asthma – Intermittent symptoms < once/week – Night time symptoms < twice/ month – Normal physical activity |
No long-term treatment
Inhaled Salbutamol when symptomatic |
|
| STEP 2
Mild persistent asthma – Symptoms > once/ week |
Continuous treatment with inhaled
Beclomethasone in children <5 yrs 50-200 µg twice daily; in children >5 yrs and adults 100- |
|
| but < once/ day
– Night time symptoms > twice/ month – Symptoms may affect activity |
250 µg twice daily
Plus Inhaled Salbutamol when symptomatic |
|
| STEP 3
Moderate persistent asthma – Daily symptoms – Symptoms affect activity – Night time symptoms >once/ week – Daily use of Salbutamol |
Continuous treatment with inhaled
Beclomethasone in children <5 yrs 200–400 µg twice daily; in children >5 yrs and adults 250– 500 µg twice daily Plus Inhaled Salbutamol 1–2 puffs four times/day |
|
| STEP 4
Severe persistent asthma – Daily symptoms – Frequent night time symptoms – Physical activity limited by symptoms |
Continuous treatment with inhaled Beclomethasone in children <5 yrs>400 µg twice daily; in children >5 yrs and adults >500 mcg twice daily
+Inhaled Salbutamol 1-2 puffs four–six times/day |
|
