Addressing Current Management of

Children with Acute Asthma Exacerbation

NASTITI KASWANDANI

Dept of Child Health

University of Indonesia
Cipto Mangunkusumo Hospital Jakarta

 Pediatric asthma burden

• Asthma prevalence increased in
children & adolescents,
particularly in Low-Middle
Income Countries (LMICs).
• Factors: host (genetics, atopy)
and environments (microbial
exposure, exposure to passive
smoking & air pollution)
• Asthma is one of the main
causes of hospitalization which
are particularly common in
children aged < 5 years with a
prevalence that has been
increased lately.
Ferrante G, La Grutta S (2018). The Burden of Pediatric Asthma.
Front. Pediatr. 6:186. doi: 10.3389/fped.2018.00186

 Challenging issues of pandemic-related

asthma in children
• Is it asthma or Covid ?
• similar respiratory symptoms
• viral-induced wheezing
• Establishing diagnosis of asthma
• Spirometry: aerosol generating procedure
• Impact of asthma in Covid morbidity & mortality
• Management of acute asthma exacerbation
• Maintaining control of asthma -> 2nd topic

•
Definition of Asthma Exacerbation (GINA 2021)
Global Initiative for Asthma

• Exacerbations represent an acute or sub-acute

worsening in symptoms and lung function from the
patient’s usual status, or in some cases, a patient
may present for the first time during an
exacerbation.
• The terms ‘episodes’, ‘attacks’ and ‘acute severe
asthma’ are also often used, but they have variable
meanings. The term ‘flare-up’ is preferable for use
in discussions with most patients.

PATHOPHYSIOLOGY
AIRWAY
HYPERRESPONS
AIRWAY IVENESS
HYPERSECRETION
EDEMA OF MUCOUS

AIRWAY
BRONCHO
CONSTRICTION AIRWAY REMODELLING

NARROWING
RISK FACTORS TRIGGER FACTORS

www.ginaasthma.org

EXACERBATION

What’s new ?
 Asthma attack severity assessment

Mild-to-moderate Severe Asthma attack with risk

asthma attack asthma attack of respiratory arrest
• Speak in sentences • Speak in words Criteria for severe asthma
• Prefer sit than lie down • Sit with leaning on arms attack fulfilled, with
• Unrestlessness • Anxious addition:
• Increased breathing • Increased breathing • Drowsiness
frequency frequency • Lethargic
• Increased palpitation • Increased palpitation • Absent of breathing
• Minimum retraction • Obvious retraction sound
• SpO2 (room air): 90 – • SpO2 (room air) < 90%
95% • PEF < 50% predicted or
• PEF > 50% predicted or best
best

 High-risk patients
Patients with history:

• Life-threatening asthma attack • Emergency visit or hospital visit

due to asthma in the last one year
• Intubation caused by asthma
attack • Lack of adherence to treatment
plan
• Pneumothorax and/or
pneumomediastinum • Lack of perception about shortness
of breath
• Asthma attack lasted for long
time • Psychiatric disease or psychosocial
problems
• Systemic steroid use (currently or
just stopped) • Food allergy with severe
symptomps

Systemic steroid (oral or parenteral) needs to be administered

in initial management despite it is mild-to-moderate attack in
initial assessment

Asthma attack management steps

in primary healthcare facility (1)



Asthma attack management step in hospital/ER
 Additional information for asthma attack management
steps in healthcare facility

**Steroid options for asthma attack

Generic name
Metilprednisolone
Metilprednisolone succinate injection
Prednisone
Hidrocortisone succinate injection
Deksametasone injection
Betametasone injection
Dosage Form Dose
tablet 4 mg, tablet 8 mg 1-2mg/kgBW/day, every 6 hour
1-2 mg/kgBW, every 12 hour
vial 125 mg, vial 500 mg
not exceed 60 mg/day
tablet 5 mg 1-2 mg/kgBW/day, every 12 hour
vial 100 mg 2-4 mg/kgBW/dose , every 6 hour
Ampoule 4 mg/ml, 0,5-1 mg/kgBW – bolus, continue with
Ampoule 10 mg/ml 1 mg/kgBW/day, given every 6-8 hour
Ampoule 6 mg/ml 0,05-0,1 mg/kgBW - every 6 hour

*** When pulse oximetry is not available, continue to give oxygen supplementation with
monitoring sign and symptoms of respiraoty distress, including levels of consciousness



 Management at ward (1)

• Oxygen administration is continued

• Correct dehydration and acidosis, if it exist
• Intravenous steroid is given as bolus, every 6-8 hour, with
dose 0,5-1 mg/kgBW/day
• β2-agonist + ipratropium bromide nebulization is
continued every 1−2 hour ! If after 4-6 times
administration there is clinical improvement, administration
time can be broaded into every 4-6 hour.
 Management at ward (2)

Aminophylline rate should be measured

Initial dose Maintenance anddose
Never had maintained at 10-20
6-8 mg/kgBW, dissolved in mcg/ml
if, response is not
amynophylline before dextrose fluid or physiologic salt optimal followed by
as much as 20 ml, and given for 0,5-1 mg/kgBW/hour
30 minutes, using infusion
pump or microburet

Have had 3-4 mg/kgBW, dissolved in 0,25-0,5 mg/kg/hour

amynophylline dextrose fluid or physiologic salt
(< 8 hours) as much as 20 ml, and given for
30 minutes, using infusion
pump or microburet

 Management at ward (3)

• If clinical condition improves, continue nebulization

every 6 hour until reach 24 hour, replace steroid and
aminophyllin with oral preparations.
• If after 24 hours patient still stable, patient can be
discharged with take home medicines:
– β2-agonist (inhalation or oral) every 4-6 hour for 24-48 hour
– Continue oral steroid until 3-5 days, then visit to outpatient
clinic for reevaluation

Asma serangan ringan-sedang

Rekomendasi 1
• Pasien yang mengalami serangan asma ringan-sedang diberikan inhalasi
β2 agonist kerja pendek (short-acting β2 agonist/ SABA).
• Untuk anak di atas 5 tahun, selain β2 agonist juga diberikan
kortikosteroid sistemik atau kortikosteroid inhalasi dosis tinggi
sebagai pereda.
• Untuk anak balita, jika menunjukkan perbaikan klinis setelah terapi
dengan inhalasi SABA, kortikosteroid tidak perlu diberikan.
Rekomendasi 2
• Pemberian obat pereda inhalasi menggunakan pMDI+spacer sama
efektifnya dengan pemberian melalui nebuliser.
• Kortikosteroid ampul harus diberikan dengan nebuliser jet, tidak boleh
dengan nebuliser ultrasonik.
• Cara inhalasi dengan DPI tidak sebaik nebuliser / pMDI+spacer.
 

Asma serangan berat

Rekomendasi 3
• Pasien anak asma yang mengalami serangan asma berat, diberi
inhalasi kombinasi SABA dan antikolinergik ditambah dengan
kortikosteroid sistemik intravena sebagai pereda.
• Jika setelah terapi tidak ada perbaikan, maka selanjutnya
ditambah dengan kortikosteroid inhalasi dosis tinggi.

Asma dengan ancaman henti napas

Rekomendasi 4
• Pasien anak asma yang mengalami serangan asma berat dengan
ancaman henti napas, lakukan inhalasi kombinasi SABA dan
antikolinergik ditambah dengan kortikosteroid sistemik
intravena dan kortikosteroid inhalasi dosis tinggi yang
keduanya diberikan sebagai obat pereda.
Rekomendasi 5
• Terapi inhalasi pada asma serangan berat dan ancaman henti
napas diberikan dengan menggunakan nebuliser.

Asthma and Covid-19

 COVID-19 and asthma - medications

n Advise patients to continue taking their prescribed asthma medications, particularly inhaled
corticosteroids
§ For patients with severe asthma, continue biologic therapy or oral corticosteroids if prescribed
n Are inhaled corticosteroids (ICS) protective in COVID-19?
§ In one study of hospitalized patients aged ≥50 years with COVID-19, ICS use in those with asthma was
associated with lower mortality than in patients without an underlying respiratory condition (Bloom, Lancet RM 2021)
n Make sure that all patients have a written asthma action plan, advising them to:
§ Increase controller and reliever medication when asthma worsens (see GINA report Box 4-2)
§ Take a short course of OCS when appropriate for severe asthma exacerbations
n Avoid nebulizers where possible, to reduce the risk of spreading virus
§ Pressurized metered dose inhaler via a spacer is preferred except for life-threatening exacerbations
§ Add a mouthpiece or mask to the spacer if required

3
Updated 26 April 2021 © Global Initiative for Asthma, www.ginasthma.org
 context of the COVID-19 pandemic. matics with very little paediatric guid-
ance. For example, the advice regarding
NEBULISED BRONCHODILATOR continued use of home nebulisers should SALBUTAMOL+
THERAPY be interpreted with caution. Adults with MDI
The COVID-19 pandemic has resulted asthma may have nebulisers prescribed for Twenty-one good
in stringent infection control measures, airway clearance and at times for admin- that nebulised
including use of full PPE while admin- istration of asthma therapies. The use of with IB significa
istering nebulised bronchodilators. nebulisers for bronchodilator therapies at tion. However,
Evidence of risk of infection spread by home in asthmatic children is not recom- istered by MDI
viral aerosolisation through a nebuliser mended.6 The rapid review guidance reduce hospital
itself is unclear.3 The advice from Public published by the RCPCH concludes that these studies wer
Health England (PHE) is that nebulisation there is no evidence for or against cate- an hour. An Aus
is not a viral droplet-generating proce- gorising nebuliser therapy as an aerosol- dren with a med
dure: the droplets are from the machine generating procedure. no reduction
The ongoing debate as to whether increased side e
1
Respiratory Medicine, Birmingham Women’s and nebulisers generate aerosol or droplets is were noted in
Children’s Hospital NHS Foundation Trust, Birmingham, COMMENTARY
unlikely to yield a definite answer during 84–168 mcg thr
UK the current pandemic, and there is a need four times the us
2
Birmingham Acute Care Research, University of for a pragmatic approach. Any child from Japan also
Birmingham, Birmingham, UK
Managing
3
RespiratoryAsthma during
Pediatrics, King’s CollegeCoronavirus
Hospital, London, Disease-2019: An Example for
presenting with an asthma attack with summary, there
UK Other Chronic Conditions in Children saturations of <92% in room air should
and Adolescents the use of inhale
be administered nebulised bronchodila- istered as MDI in
Correspondence to Dr Atul Gupta, Respiratory1,2
ElissaHospital,
Pediatrics, King’s College M. Abrams, MD,SE5
London MPH9RS,, and torsJ. as
UK; Stanley perMD
Szefler, the
3,4
British Thoracic Society children with m
atul.gupta@kcl.ac.uk (BTS) guidelines. Moreover, in children The administrat

T
he novel coronavirus disease-2019 (COVID-19), Fever, a common presenting symptom of COVID-19, may
Viewpoint
caused by the pathogen severe acute respiratory syn- help to Nagakumar
differentiate P, et al.
COVID-19Arch Dis Child
from anMonth
asthma2020 Vol 0 No 0
exacerba-
drome corona virus (SARS-CoV-2), has now spread tion,with
although fever(ie,can besaturations
present in other virus-triggered

Arch Dis Child: first published as 10.113

Acute asthma management
around the globe with more than 1.8 million individuals asthma
severe wheeze
of <92%
oxygen
and severe respiratory
exacerbations 3,10-12
distress),
as well. Other less common
considerations
and more than in 110children and
1-4 the efficacy of nebulised salbutamol alone
affected 000 deaths internationally. symptoms of COVID-19, better described in the adult popu-
is inferior to nebulised salbutamol with
As of April 12, 2020, there are 530 830 cases in the US with lation, may help
ipratropium to differentiate
bromide COVID-19 from asthma and
(IB),7 and therefore,
adolescents
more during
than 20 000 deaths. 2,3
The the COVID-19
Institute for Health Metrics a combination
include myalgia, of salbutamol
confusion andheadache,
ipratro- pharyngitis, rhinor-
pium should be administered. Although
pandemic
and Evaluation has predicted that this pandemic could
exceed current healthcare capacity in the US with a total of
rhea,theloss
vomiting.
of sense of smell and taste, diarrhea, nausea, and
risks of infection spread from a child
12
undergoingAnebuliser
travel history,
therapy toclose
health-contact with someone in-
81 114Nagakumar
deaths (95% ,CI, 1,2 38 242-162 106) through1 August3 carewith
fected workers is not quantifiable,
COVID-19, and absence the of a prior atopic history
Prasad Benjamin Davies , Atul Gupta current available evidence supports that
2020.5 in a the
child
risksalso helplowtoasdifferentiate
are very the droplets arethe two.
Asthma is one of the most common chronic diseases of
The perceived risk of nosocomial trans- (liquid bronchodilator drug particles), not
Because
presumedthere is substantial
to originate overlap between the clinical
from the nebuliser
8
device and not from the patient. The
Fig. 1 Mild-moderate asthma algorithm
 Pro-Cons To Avoid Nebulization as
Aerosol Generating Procedures
PRO Nebs Contra Nebs
• NICE • WHO
• PHE
• WAO
• HPS
• RCH/Australia
“because aerosols comes • Canadian
from the fluid in neb • GINA
chamber and not carry
virus particle from • etc…
patients”

Nebulizer versus MDI with

Spacer
 Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.: CD005536. DOI: 10.1002/14651858.CD005536.pub2.

Conclusion: there was no statistically signi cant difference

between these two methods for delivering bronchodilator therapy to
children with acute asthma or lower airways obstruction attacks.
fi
Study
homemade VHC, made of a paper coffee
cup, and a drinking water bottle vs  a
standard commercial VH

Conclusion:
Homemade VHC is effective for an MDI
bronchodilator delivery.

Since it is very cheap and easy to make, it

may be used as a disposable device to
minimize airborne transmission especially
when commercial VHC is not available.
:

 SUMMARY
• Asthma still become one of most important chronic disease in
children with increased prevalence in LMICs
• Treatment of acute exacerbation asthma in children is based on
severity, and inhalation therapy of short beta-2 agonist is still the
first choice
• MDI + spacer/VHC is the recommended route of inhalation for
mild-moderate acute exacerbation
• For certain children and severe asthma, nebulization should be
perfomed with precautions of infection control (PPE, neg-press,
distance..)
• Study found that home-made spacer / valve-holding chamber was
effective esp if commercial/standar VHC is not available