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9.2 Obstructive Lung Diseases

Table of Contents

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
≤40/min

Child >5 yrs
≤30/min

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
>140/min

Child >5yrs
>125/min

Adult ≥110/min

Osaturation ≥92%

Admit the patient, place in semi-sitting position Oxygen continuously 5L/min (maintain Osaturation 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

Osaturation<92%

Admit the patient, place in semi-sitting position Oxygen continuously 5L/min (maintain Osaturation 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

 

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