Fiji-Respiratory-Guidelines.pdf

Fiji Respiratory Guidelines 2nd Edition, 2022 Ministry of Health and Medical Services Government of Fiji Ministry of Health and Medical Services, Government of Fiji These Fiji Respiratory Guidelines have been endorsed by the National Medicines and T...

Fiji Respiratory Guidelines 2nd Edition, 2022 Ministry of Health and Medical Services Government of Fiji Ministry of Health and Medical Services, Government of Fiji These Fiji Respiratory Guidelines have been endorsed by the National Medicines and Therapeutics Committee, Ministry of Health and Medical Services, Government of Fiji. Medicines recommended in these guidelines that are not currently included on the Fiji Essential Medicines List (EML) are denoted by non-EML. The medicines included on the EML may change during the lifetime of these guidelines—refer to the most up-to-date EML for more information. For feedback on these guidelines, please email [email protected]. These guidelines have been adapted from Therapeutic Guidelines: Respiratory with permission. Therapeutic Guidelines is an independent not-for-profit organisation which develops and publishes evidence-based, practical treatment advice to assist practitioners with decision making at the point- of-care. For more information or to discuss permission to adapt Therapeutic Guidelines content, email [email protected].  Contents Contents Foreword xiii Acknowledgements xv Respiratory symptoms occurring in children 1 Wheeze 1 Cough 1 Stridor 2 Respiratory symptoms occurring in adults 3 Wheeze 3 Stridor 3 Cough 3 Shortness of breath 3 Asthma in children (up to 15 years) 5 General information 5 Diagnosis 5 Age 0 to 12 months 6 Age 1 to 5 years 6 Age 6 to 15 years 8 Maintenance management of asthma in children 10 Overview 10 Control-based management 10 Drug treatment 12 Nondrug interventions 18 Education and skills training 18 Management of acute asthma in children 1 to 15 years 20 Overview 20 Anaphylaxis and acute asthma 20 First aid for acute asthma for patients and community members 21 Medical management of acute asthma in children 22 Overview 22 Assessment 22 Treatment of acute asthma in children is based on assessment of severity 24 Management 25 Management of mild to moderate acute asthma in children 25 Management of severe acute asthma in children 26 Management of critical / life-threatening acute asthma in children 27 Discharge and follow-up 31 iii Fiji Respiratory Guidelines 2022 Asthma in adults and adolescents 32 Introduction 32 Diagnosis 32 General information 32 Variable airflow limitation 36 Maintenance management of asthma in adults and adolescents 37 Overview 37 Doctor–patient relationship 38 Control-based management 38 Assessing asthma severity 42 Stepwise approach to maintenance drug treatment 43 Overview 43 Route of administration 43 Initiating treatment 43 Stepwise approach to treatment in adults and adolescents 44 Drug doses and administration 47 Inhaled corticosteroids 47 Non-corticosteroid-based inhalers 48 Combination inhaler therapy 49 Modifiable risk factors 50 Smoking 50 Triggers 50 Lifestyle factors 51 Comorbid conditions 52 Nondrug interventions 53 Breathing exercises 53 Complementary medicine 53 Education and skills training 53 Information 53 Inhaler technique 54 Adherence 54 Guided self-management education 54 Review and referral 57 Regular review 57 Failure to respond to adequate treatment 58 Special categories 59 Exercise-induced bronchoconstriction 59 Asthma and pregnancy 60 Asthma in adolescence 60 Asthma in older people 61 iv  Contents Occupational asthma 61 Allergic bronchopulmonary aspergillosis 61 Aspirin-exacerbated respiratory disease 62 Management of acute asthma in adults and adolescents 62 Suspected anaphylaxis 62 First aid 63 Medical management 63 Treatment of acute asthma in adults and adolescents 69 Overview 69 Inhaled bronchodilators 70 Corticosteroids 71 Management of mild to moderate acute asthma 71 Management of severe acute asthma 71 Management of life-threatening acute asthma 72 Oxygen therapy 73 Bronchodilator therapy 73 Oxygen 74 Intravenous magnesium sulfate 74 Additional treatment for persistent life-threatening acute asthma 74 Ventilatory support 75 Rhinitis and rhinosinusitis 81 Rhinitis 81 Introduction 81 Allergic rhinitis 81 Nonallergic rhinitis 86 Rhinosinusitis 87 Introduction 87 Acute rhinosinusitis 87 Chronic rhinosinusitis 87 Chronic obstructive pulmonary disease 90 Diagnosis and assessment 90 Overview 90 Initial presentation 91 Overlap of asthma and COPD 92 Assessment 93 Maintenance management of chronic obstructive pulmonary disease 93 General principles 93 Smoking cessation 94 Physical activity 94 Pulmonary rehabilitation 94 v Fiji Respiratory Guidelines 2022 Immunisation 95 Nutrition 95 Drug treatment 97 Other management considerations 102 Ongoing monitoring and review 104 Management of acute exacerbations of chronic obstructive pulmonary disease 106 Assessing severity 106 Treatment 108 Cough 111 Introduction 111 General principles 114 Nondrug interventions 114 Environmental factors 114 Vocal hygiene 114 Sputum clearance 115 Drug treatment 115 Caution for children 115 Cough suppressants 115 Cough expectorants 115 Antihistamines 116 Proton pump inhibitors 116 Corticosteroids 116 Complementary medicines 116 Acute bronchiolitis 117 Clinical presentation and severity 117 Risk factors for more serious illness 117 Investigations 119 Management 119 Oxygen therapy 122 Hydration/nutrition 122 Medication 122 Discharge Criteria 123 Croup 124 Introduction 124 Risk factors for severe croup 124 Clinical presentation 124 Investigations 124 Assessment of severity 125 vi  Contents Management 125 Initial treatment 125 Divisional hospital admission 128 Discharge requirement 128 Cystic fibrosis 130 Bronchiectasis 131 Definition 131 Causes 131 Clinical features and diagnosis 132 Management 133 Overview 133 General measures 133 Antibiotic therapy 134 Long-term treatment 134 Management of haemorrhage 134 Bronchiectasis in children 135 Pleural disease 136 Pleuritic pain 136 Pneumothorax 136 Decompensated pneumothorax 138 Management 139 Pneumothorax decompression methods 140 Pleural effusion 142 Introduction 142 Management of parapneumonic effusion and empyema 143 Management of malignant pleural effusions 144 Tuberculous pleural effusion 145 Interstitial lung disease 146 Introduction 146 Presentation 148 Investigations 148 Specific adult interstitial lung diseases 149 Idiopathic pulmonary fibrosis 149 Nonspecific interstitial pneumonia 150 Smoking-related interstitial lung disease 150 Pulmonary sarcoidosis 150 Hypersensitivity pneumonitis 151 Childhood interstitial lung disease 151 vii Fiji Respiratory Guidelines 2022 Sleep-disordered breathing 152 Sleep-disordered breathing in adults 152 Introduction 152 Obstructive sleep apnoea 152 Obstructive sleep apnoea with other coexisting respiratory disorders 156 Central sleep apnoea 156 Obesity hypoventilation syndrome 157 Sleep-disordered breathing in children 158 Overview 158 Diagnosis and clinical assessment 158 Investigation and treatment 160 Oxygen therapy 161 Acute oxygen therapy 161 Principles of oxygen use 161 Potential harms of oxygen use 161 Indications 162 Patient groups at risk of hypercapnia 163 Target oxygen saturation 164 Monitoring 164 Domiciliary oxygen therapy 165 Adverse effects of oxygen delivery 166 Noninvasive ventilation 167 Introduction 167 Indications for acute noninvasive ventilation 167 Acute exacerbations of COPD 167 Acute cardiogenic pulmonary oedema 168 Hypoxaemic respiratory failure 168 Weaning from invasive ventilation 168 Acute asthma 168 Contraindications to noninvasive ventilation 168 Using noninvasive ventilation 169 Before using noninvasive ventilation 169 Equipment settings and monitoring 169 Ventilator adjustment and supplemental oxygen 170 Management of problems 171 Stopping noninvasive ventilation 172 Fitness for surgery 173 Nature of the risks 173 Risk groups 173 viii  Contents Assessment 175 Clinical assessment 175 Respiratory function tests 175 Postoperative management 176 Fitness to fly 178 Introduction 178 Cabin environment 178 Pre-flight assessment 179 Assessing the need for in-flight supplemental oxygen 179 Assessment of other respiratory conditions 180 In-flight oxygen therapy 181 In-flight continuous positive airway pressure 181 Fitness to scuba dive 182 Introduction 182 Respiratory conditions affecting fitness to scuba dive 183 Asthma and other obstructive airway disease 183 Pneumothorax 184 Upper respiratory tract problems 184 Other conditions 184 Assessment 185 Guide to pulmonary function testing and thoracic imaging 186 Pulmonary function tests 186 Introduction 186 Role of pulmonary function testing 186 Spirometry and flow–volume loops 187 Bronchial provocation testing 190 Tests of gas exchange and gas transfer 190 Thoracic imaging 193 Introduction 193 Chest X-ray 193 Computed tomography of the chest 195 Ultrasound of the thorax 196 Inhalational drug delivery devices 197 General principles 197 Introduction 197 Inhaler technique 197 Pressurised metered dose inhalers 197 Spacer devices 198 Nebulisers 199 ix Fiji Respiratory Guidelines 2022 Inhalational drug delivery devices and device-specific considerations 200 Respiratory therapy in pregnancy and breastfeeding 202 Pregnancy and respiratory drugs 202 Breastfeeding and respiratory drugs 202 Appendices 207 Tables Table 1: Clinical features that increase and decrease the probability of children 1 to 5 years with wheeze having asthma in later childhood and adulthood 7 Table 2: Clinical features that increase and decrease the probability of asthma in children 6 years and older 8 Table 3: Alternative diagnoses other than asthma to consider in children according to predominant symptoms 9 Table 4: Levels of recent asthma symptom control in children 11 Table 5: Stepwise treatment of asthma in children 15 years and younger 13 Table 6: Corticosteroid-based-inhalers available in Fiji for asthma in children 16 Table 7: Management of triggers for flare-ups of existing asthma in children 18 Table 8: Initial rapid severity assessment of acute asthma in children 24 Table 9: Diagnosis of asthma in adults and adolescents 33 Table 10: Alternative diagnoses other than asthma to consider in adults and adolescents according to predominant symptoms 35 Table 11: Risk factors for adverse asthma outcomes in adults and adolescents 40 Table 12: Corticosteroid-based-inhalers available in Fiji for asthma in adults and adolescents 47 Table 13: Non-corticosteroid-based inhalers available in Fiji for asthma in adults and adolescents 48 Table 14: Rate of response of different measures of asthma control to inhaled corticosteroid 49 Table 15: Triggers for flare-ups (exacerbations) of existing asthma 51 Table 16: Initial rapid severity assessment of acute asthma in adults and adolescents 65 Table 17: Secondary severity assessment of acute asthma in adults, adolescents and children 6 years or older 66 Table 18: Drug dosages for acute asthma in adults and adolescents 77 Table 19: Classification of allergic rhinitis by symptom duration and severity 82 Table 20: Treatment of allergic rhinitis 83 Table 21: Corticosteroid-based-inhalers available in Fiji for COPD 100 Table 22: Regular review of patients with COPD based on severity 105 x  Contents Table 23: Considerations in assessing severity of a COPD exacerbation 107 Table 24: Summary of common and/or important causes of cough 111 Table 25: Assessment of severity of bronchiolitis 118 Table 26: Initial management of bronchiolitis based on severity of illness 120 Table 27: Respiratory rates in children 123 Table 28: Severity assessment of croup 125 Table 29: Clinical course of some interstitial lung diseases 148 Table 30: Common problems with long-term CPAP 155 Table 31: Causes of obstructive sleep apnoea in children 158 Table 32: Classification of ventilatory defects by spirometry 189 Table 33: Normal values for arterial blood gas analysis 191 Table 34: Guide to interpreting acid–base status from arterial blood gas analysis 191 Table 35: Inhalational drug delivery devices and device-specific considerations 200 Table 36: Respiratory drugs in pregnancy and breastfeeding 203 Boxes Box 1: Minimal handling 23 Box 2: Principles of written asthma action plans 56 Box 3: Risk factors for potentially fatal asthma in adults and adolescents 69 Box 4: Reviews required before discharging an adult or adolescent after an acute asthma flare-up 80 Box 5: Possible indicators for hospital assessment or admission in COPD exacerbations 108 Box 6: Alarm symptoms and findings in adults with cough 113 Box 7: Catheter aspiration of a pneumothorax 141 Box 8: Classification of major interstitial lung diseases 147 Box 9: History-taking in suspected obstructive sleep apnoea 153 Box 10: Clinical features of obstructive sleep apnoea in children 159 Box 11: Equipment settings and monitoring for noninvasive ventilation 170 Figures Figure 1: Stepped approach to adjusting asthma medication in children 15 years and younger. 12 Figure 2: Stepped approach to adjusting asthma medication in adults and adolescents 45 Figure 3: Summary of management of acute asthma in adults and adolescents 76 Figure 4: Stepwise management of stable COPD 96 xi Fiji Respiratory Guidelines 2022 Figure 5: Croup management flowchart 129 Figure 6: Management of spontaneous pneumothorax 138 Figure 7: Flow–volume loops showing normal, obstructive and restrictive patterns188 Figure 8: Spirograms showing normal, obstructive and restrictive patterns 189 Images Image 1: An example of an X-ray image in Asthma 32 Image 2: An example of an X-Ray image in COPD 91 Image 3: Example of an X-ray image in bronchiectasis 131 Image 4: An example of an X-ray in pneumothorax 137 Image 5: An example of an X-ray image in pleural effusion 142 Image 6: An example of an X-ray image in a patient with a sputum positive for Mycobacterium tuberculosis 145 Image 7: an example of an X-ray image in interstitual lung disease 146 Image 8: An example of a nasal cannula 163 Image 9: An example of a reservoir mask 163 Images 10.1, 10.2 and 10.3: Examples of chest X-ray images 194 Images 11.1 and 11.2: Examples of nebuliser masks 199 xii  Foreword Foreword The first edition of the Fiji Respiratory Guidelines was published in 2008 which has been reviewed and revised by the Respiratory Guideline Committee to produce this second edition. The Committee has based this second edition of the Fiji Respiratory Guidelines on the Australian Therapeutic Guidelines: Respiratory, version 5, 2015 and updated with the publication of Therapeutic Guidelines: Respiratory, version 6, 2020. This new edition provides the reader with a holistic approach to the management of respiratory diseases. Not only does the Guideline incorporate pharmacological therapies but also includes non-pharmacological aspects of treatment of respiratory diseases to provide users of this guideline with comprehensive treatment options for their patients. Some of the features of this edition includes: y Broader coverage of respiratory diseases y Chest X-ray images for easy reference and recognition y Advice on when to refer the patient to the next level of health care. y Information on asthma action plans including templates The medicines stated in this Guideline are mostly those that are available on the Fiji Essential Medicines List (EML), however, there are some medications that are not available on the EML and these are clearly stated. Generally, these have been included as they are widely available in the private health sector in Fiji. All recommended therapies are either reference based or universally accepted standards. It is hoped that this Guideline will be a reference for all healthcare workers, both in the public and private sector, to care for patients suffering from respiratory diseases. The Respiratory Guideline Committee welcomes any comments and suggestions, which will help in the improvement of the development of future standard treatment guidelines. Please forward your feedback to. I believe that these guidelines will promote quality care for patients in Fiji and trust that they will be widely used by all prescribers. Dr James Fong Permanent Secretary, Ministry of Health and Medical Services xiii  Acknowledgements Acknowledgements This second edition of the Fiji Respiratory Guideline has been based on the Australian Therapeutic Guidelines: Respiratory, version 5, 2015 and updated with the publication of Therapeutic Guidelines: Respiratory, version 6, 2020. The Fiji Respiratory Guideline Committee gratefully acknowledges the permission to use the Guidelines in 2016 from Sue Phillips, (then) Chief Executive Officer of Therapeutic Guidelines Limited, without levy of any fee, and expresses appreciation to Professor Robert Moulds, Chairman of the Respiratory Expert Group and Medical Advisor for the Therapeutic Guidelines Limited, for the first draft of this edition. The Fiji Respiratory Guideline Committee updated this edition of the Respiratory Guideline and acknowledges contributions and comments from: Fiji Respiratory Guidelines Committee Members: y Dr Shrish Acharya, Consultant Physician, Colonial War Memorial Hospital (CWMH); Head of Department (HOD) Medicine y Dr Gyaneshwar Rao, Consultant Physician, Fiji National University y Dr Vikash Sharma, Consultant Physician, Fiji National University y Dr Mafa Vakamocea, Medical Officer, Accident and Emergency, CWMH y Dr Vivek Lal, (then) Medical Officer, Accident and Emergency, CWMH y Ms Ashodra Gautam, Pharmacist, Fiji Pharmaceutical and Biomedical Services Centre (FPBSC) y Ms Mieke Hutchinson-Kern, (then) Australian Volunteer Pharmacist y Mrs Snehlata Bhartu, (then) Australian Volunteer Pharmacist Paediatric sections y Dr Ilisapeci Vereti, Consultant Paediatrician, CWMH; HOD Paediatrics y Dr Ranu Anjali, Consultant Paediatrician, CWMH y Dr Amelita Mejia, Consultant Paediatrician, CWMH y Dr Laila Sauduadua, Consultant Paediatrician, CWMH Other contributors y Dr Pauliasi Bauleka, Orthopaedic Surgeon, CWMH y Dr Elizabeth Bennet, Consultant ICU Physician, CWMH, Assistant Professor in Anaesthetics, Department of Medical Sciences, Fiji National University y Dr Sam Fullman, Principal Medical Officer, PJ Twomey Hospital y Dr Juancho Gallardo, ENT specialist, (then) CWMH y Ms Rashika Gounder, (then) Pharmacist, FPBSC y Dr Sukafa Matanicake, Consultant Physician, CWMH y Dr Amit Sewak, Medical Officer, Accident and Emergency, CWMH y Dr Osea Volavola, (then) Consultant Physician, CWMH; HOD Emergency y Dr Frank Underwood, Consultant Physician, PJ Twomey Hospital xv  Respiratory symptoms occurring in children Respiratory symptoms occurring in children Extensive information on the assessment of respiratory symptoms in children is contained in the Pocket book of hospital care for children: guidelines for the management of common childhood illnesses (‘WHO Blue Book’). Below are brief summaries of important respiratory symptoms in children. Wheeze Wheeze is produced by turbulent airflow in the lower airways. It is most commonly heard in expiration and can be acute or chronic. Parents should be asked specifically about the presence of a high-pitched whistle on expiration. In the first year of life, wheeze is commonly due to conditions other than asthma; hence, wheezy infants should not automatically be treated for asthma. Asthma and bronchiolitis are the most common causes of acute expiratory wheeze in children. There are several other conditions that can cause chronic wheeze. For example, a thriving infant with expiratory wheeze from the first few weeks of life is likely to be due to mild tracheomalacia. These children are often referred to as ‘fat happy wheezers.’ Alternatively, wheeze that occurs for the first time at 3 to 4 months of age, worsens with time, and is associated with increased work of breathing and choking or gagging on feeds, should trigger referral to a specialist paediatrician at a divisional hospital. Referral is indicated for most infants with chronic persistent wheeze. Cough As in adults, the most common cause of cough in children is acute viral respiratory tract infection. The cough can be wet or dry, and symptoms settle spontaneously in 7 to 10 days. Oral antibiotic treatment is not required. A daily wet cough that persists for longer than 3 weeks is suggestive of ‘persistent bacterial bronchitis’ and referral for assessment is recommended. A chronic wet cough can also be a sign of suppurative lung disease such as bronchiectasis. Cough can occur in children with asthma. However, cough alone is a poor marker of asthma, which should not be diagnosed in the absence of other symptoms of airway obstruction (eg recurrent wheeze, tachypnoea and dyspnoea). See the separate topic “Cough” for further information on cough in children, including alarm symptoms and findings. 1 Fiji Respiratory Guidelines 2022 Stridor Stridor is a respiratory noise produced by turbulent airflow through the upper airways. It is most commonly heard in inspiration and can be acute or chronic. The most common causes of acute stridor in children include viral laryngotracheobronchitis (croup), acute tonsillitis (with or without peritonsillar abscess) and epiglottitis. This is rare as Haemophilus influenzae type B vaccine is given routinely in Fiji. Foreign body inhalation should be suspected in children who present with acute stridor after a choking episode. Some children present with a chronic ‘cog-wheel’ high-pitched inspiratory stridor that has been present from birth or the first few days or weeks of life. The most common cause is laryngomalacia. The stridor resolves spontaneously at 1 to 2 years of age. Alternatively, inspiratory stridor that develops for the first time at 6 to 8 weeks of life, worsens and becomes biphasic (present in both inspiration and expiration) may be due to a subglottic haemangioma. All infants and children with stridor need to be discussed with specialist. 2  Respiratory symptoms occurring in adults Respiratory symptoms occurring in adults Wheeze Wheeze in adults is produced by turbulent airflow in the lower airways, is most commonly heard in expiration, and can be acute or chronic. If intermittent wheeze is suspected, patients should be asked specifically about the presence of a high-pitched whistle on expiration. Although asthma is the most common cause of both acute and chronic expiratory wheeze in adults, other common causes are COPD, acute bronchitis, bronchiecstasis, bronchostenotic lesions, heart failure and hypersensitivity reactions. It should not be assumed that wheeze is necessarily caused by asthma. Stridor Stridor in adults is a harsh respiratory noise produced by turbulent airflow through the upper airways – usually the trachea or main bronchi – and is usually heard in inspiration. It is a serious symptom which is usually caused by a significant lesion causing partial obstruction of the trachea or a major bronchus such as a bronchial carcinoma. All patients with stridor require urgent referral to a divisional hospital for further assessment. Cough The most common cause of cough in an adult is an acute viral respiratory tract infection. The cough can be wet or dry, and symptoms usually settle spontaneously in 7 to 10 days. Persistent cough is difficult to diagnose and treat and requires referral to a divisional hospital. Oral antibiotic treatment is not required. Refer to the separate topic “Cough” (page 111) for a more detailed discussion. Shortness of breath Shortness of breath, also termed dyspnoea, is probably the most common and important respiratory symptom in adults. 3 Fiji Respiratory Guidelines 2022 Depending on the cause, it can be of acute onset, progressive in nature, or episodic. In most individuals, a detailed history and physical examination with appropriate investigations (which include baseline blood tests, a chest X-ray and an ECG) will reveal the underlying cause of dyspnoea. A few patients may require further intensive investigations and they warrant referral to a divisional hospital. There are many causes of shortness of breath in an adult; some are physiological, such as aging and obesity, while others are pathological conditions that fall under the following categories: y respiratory diseases y cardiac diseases y anaemia y thyrotoxicosis y metabolic acidosis y psychogenic – to be considered when organic causes have been ruled out Heart failure and chronic obstructive pulmonary disease (COPD) are common causes of persisting shortness of breath in adults. Multiple causes can co-exist, especially in older adults. Individuals not responding to treatment should be discussed with a specialist and may require referral for further assessment. 4  Asthma in children (up to 15 years) Asthma in children (up to 15 years) General information This topic addresses the management of asthma in children from 1 to 15 years; for adolescents, see ‘Asthma in adults and adolescents,’ page 32. y asthma is a chronic inflammatory disease of the airways characterised by reversible airways obstruction and bronchospasm. y exacerbations in children are often precipitated by viral infection y in children less than 12 months of age presenting with wheeze, consider the diagnosis of bronchiolitis. y early recognition and acute management of severe or life-threatening disease is of vital importance. Most children diagnosed with asthma in Fiji have intermittent symptoms triggered by viral respiratory tract infection. Treatment with inhaled salbutamol on an ‘as required’ basis is usually sufficient to control symptoms, which improve with age. In the minority of children with asthma who require preventive treatment with an inhaled corticosteroid, care should be taken to use the lowest dose that controls asthma symptoms. Children with recurrent cough alone are often misdiagnosed with asthma; see below for further information. Diagnosis There is no single reliable test (‘gold standard’) and there are no standardised diagnostic criteria for asthma. The diagnosis of asthma is based on: y history y physical examination y considering other diagnoses y clinical response to a treatment trial with an inhaled short-acting beta2 agonist reliever or preventer Patient history should include: y current symptoms (wheeze, cough, shortness of breath, chest discomfort or tightness) y pattern of symptoms (frequency, time of day or night) y severity of symptoms (impact on work, school or lifestyle) y allergies (eg atopic dermatitis, allergic rhinitis) 5 Fiji Respiratory Guidelines 2022 y aggravating or precipitating factors (eg exercise, viral infections) y smoking history (including exposure to second-hand smoke in the home) and exposure to biomass smoke (eg indoor fires for heating or cooking) y relieving factors (including medication trials) y presence of sinonasal disease y family history of allergies or asthma. The physical examination should include: y chest auscultation y height and weight y inspection for chest deformity y assessment of respiratory rate and work of breathing. If atopy is suspected, inspect the upper respiratory tract for signs of allergic rhinitis (eg inflammation in the nasal passages) and the skin for signs of atopic dermatitis. A chest X-ray is not necessary for diagnosis of asthma—it can be considered for unusual symptoms, or as required for suspected alternative diagnoses (eg lung cancer, pneumonia). An episode of acute asthma can present as a wheeze precipitated by triggers such as tobacco smoke, pets (eg cats, dogs), dust, and other allergens (see Table 7 for list of possible triggers). This is often associated with atopic diseases including allergic rhinitis or atopic dermatitis in children. Table 1 lists features that increase and decrease the likelihood of asthma. Although the probability of asthma does not necessarily change initial management, it can be a useful part of the discussion with parents and carers. Age 0 to 12 months Urgently refer infants with sudden-onset wheeze if foreign body aspiration or anaphylaxis is suspected. Acute wheeze in an infant younger than 12 months is most commonly a symptom of acute bronchiolitis. Asthma cannot be diagnosed in this age group, and infants should not be treated with asthma medication. Age 1 to 5 years Although many individuals later diagnosed with asthma first show respiratory symptoms by the age of 5 years, it is difficult to make the diagnosis of asthma with a high degree of certainty in children aged 1 to 5 years, because: y episodic respiratory symptoms such as wheezing and cough are very common in children, particularly in children under 3 years 6  Asthma in children (up to 15 years) y objective lung function testing by spirometry is usually not feasible in this age group y a high proportion of children who respond to bronchodilator treatment do not go on to have asthma in later childhood (eg by primary school age). Table 1: Clinical features that increase and decrease the probability of children 1 to 5 years with wheeze having asthma in later childhood and adulthood CLINICAL FEATURES THAT INCREASE THE PROBABILITY OF ASTHMA y more than one of the following symptoms: wheeze, breathlessness, chest tightness or discomfort, cough – particularly if symptoms: − are worse at night − occur in response to active play, laughing, allergen exposure or cold air − are recurrent y wheeze occurring when the child does not have a cold y history of atopic disorder (eg allergic rhinitis, atopic dermatitis) y family history of asthma or atopic disorder y widespread wheeze heard on auscultation of the chest y improvement in symptoms in response to trial of asthma therapy y otherwise unexplained peripheral blood eosinophilia y presence of conditions associated with asthma (eg bronchopulmonary dysplasia, obstructive sleep apnoea, recurrent bronchiolitis) CLINICAL FEATURES THAT LOWER THE PROBABILITY OF ASTHMA y chronic productive cough in the absence of wheeze or breathlessness y repeatedly normal auscultation of chest when symptomatic y voice disturbance or throat tightness y prominent dizziness, light-headedness, peripheral tingling y no response to a trial of asthma therapy y clinical features supporting an alternative diagnosis 7 Fiji Respiratory Guidelines 2022 Age 6 to 15 years The first step in assessing a child older than 6 years, is to take a detailed history and perform a physical examination to identify the pattern of symptoms and exclude other causes. The predictive value of a single sign or symptom is poor, but combinations of signs and symptoms can provide a clearer clinical picture to support a diagnosis of asthma. Table 2: Clinical features that increase and decrease the probability of asthma in children 6 years and older INITIAL CLINICAL ASSESSMENT Focus the initial assessment in children suspected of having asthma on: y presence of key features in history and examination y careful consideration of alternative diagnoses (see table below). CLINICAL FEATURES THAT INCREASE THE PROBABILITY OF ASTHMA y more than one of the following symptoms: wheeze, breathlessness, chest tightness or discomfort, cough— particularly if symptoms: − are worse at night and in the early morning − occur in response to exercise, allergen exposure or cold air − occur after taking aspirin or beta blockers − are recurrent y history of atopic disorder (eg allergic rhinitis, atopic dermatitis) y family history of asthma or atopic disorder y widespread wheeze heard on auscultation of the chest y improvement in symptoms or lung function in response to standard asthma therapy y otherwise unexplained low FEV1 or PEF (historical or serial readings) y otherwise unexplained peripheral blood eosinophilia y in children, presence of conditions associated with asthma (eg bronchopulmonary dysplasia, obstructive sleep apnoea, recurrent bronchiolitis) cont... 8  Asthma in children (up to 15 years) CLINICAL FEATURES THAT LOWER THE PROBABILITY OF ASTHMA y chronic productive cough in the absence of wheeze or breathlessness y normal FEV1 when symptomatic [Note 1] y repeatedly normal auscultation of chest when symptomatic y voice disturbance or throat tightness y symptoms that worsen with talking or laughing y prominent dizziness, light-headedness, peripheral tingling y symptoms that only occur with viral respiratory infections, with few or no symptoms in between y no response to a trial of asthma therapy y clinical features supporting an alternative diagnosis Record the basis on which a diagnosis of asthma is suspected. FEV1 = forced expiratory volume in 1 second; PEF = peak expiratory flow Note 1: Normal spirometry when the patient is not symptomatic does not exclude the diagnosis of asthma; ideally, repeat spirometry when the patient is symptomatic. If spirometry is normal when the patient is symptomatic, consider an alternative diagnosis. Repeated measurements of lung function are often more informative than a single assessment. Table 3: Alternative diagnoses other than asthma to consider in children according to predominant symptoms Symptom Possible alternative diagnosis dry cough postinfective cough (respiratory viruses, Bordetella pertussis or Mycoplasma pneumoniae) habit cough, particularly if it resolves during sleep wheeze virus-associated wheeze in young children: y transient infant wheeze y tracheobronchomalacia y airway lesion y inhaled foreign body (unilateral wheeze) y cardiac left-to-right shunt difficulty chronic lung disease of prematurity (bronchopulmonary breathing dysplasia) cardiac left-to-right shunt upper airway dysfunction (vocal cord dysfunction) cont... 9 Fiji Respiratory Guidelines 2022 chest tightness Anxiety wet cough persistent bacterial bronchitis (with sputum chronic suppurative lung disease (including bronchiectasis) production in cystic fibrosis older children) Maintenance management of asthma in children Overview Most children with asthma will experience improvement in symptoms with age. The aim of management of asthma in children is to maintain a normal quality of life, free of asthma symptoms and without adverse effects of asthma treatment. Maintenance management relies on a continuous cycle of reviewing response and adjusting therapy, aiming to establish the minimum drug regimen that achieves good control. Specific questions should be asked about sleep disturbance (due to asthma), early morning symptoms, exercise induced cough or wheeze, and frequency of bronchodilator use. Spacers y A spacer device should be used for children of all ages whenever they use a metered dose inhaler (puffer). y Small volume spacers should be fitted with a well-sealing face mask for infants who cannot reliably seal their lips around the mouthpiece. y Large volume spacers should not be used for children under 6 years - they can be used above this age but are more cumbersome and less convenient than the smaller ones. Small volume spacers are recommended for children of all ages. Control-based management The aim of asthma management in children is to achieve good symptom control and prevent flare-ups (exacerbations) using the lowest effective preventer dose. Asthma symptom control is assessed according to the frequency of asthma symptoms over the previous 4 weeks. This allows definition of control as good, partial or poor; see table below. 10  Asthma in children (up to 15 years) Table 4: Levels of recent asthma symptom control in children [Note 1] Good control Partial control Poor control All of the following Any of the following Either of the following features: features: features: y daytime symptoms y daytime symptoms y daytime symptoms (eg wheezing or (eg wheezing or (eg wheezing or breathing problems) breathing problems) breathing problems) on 2 or fewer days on more than 2 days on more than 2 days per week, lasting per week, lasting per week, lasting only a few minutes only a few minutes from minutes to and rapidly relieved and rapidly relieved hours or recurring, by short-acting by short-acting and partially or fully bronchodilator bronchodilator relieved by short- y no limitation of y any limitation of acting bronchodilator activities; child is fully activities; wheeze y three or more active, runs and plays or breathlessness features of partial without symptoms during exercise, control within the y no symptoms during vigorous play or same week night or on waking, laughter including no coughing y any symptoms during sleep during night or on y need for reliever on waking (eg waking 2 or fewer days per with symptoms week [Note 2] of wheezing or breathing problems) y need for reliever on more than 2 days per week [Note 2] Note 1: Recent asthma symptom control is based on symptoms over the previous 4 weeks irrespective of the current treatment regimen. Note 2: Not including short-acting beta2 agonist taken prophylactically before exercise; record this separately and take into account when assessing management. Source: National Asthma Council Australia. Australian Asthma Handbook, Version 1.0. Melbourne: National Asthma Council Australia; 2014. [http://www.asthmahandbook.org.au/] 11 Fiji Respiratory Guidelines 2022 Drug treatment Stepwise approach to treatment in children Overview A stepwise approach to treating asthma in children is shown below. It applies to children with intermittent asthma and persistent asthma. Asthma severity is defined by the intensity of treatment required to achieve good asthma symptom control. It is a retrospective label that is applied after a child has been using preventer treatment for at least 3 to 6 months. Children are considered to have mild asthma when good symptom control is achieved using optimised treatment at Step 1 or Step 2 (see Figure 1). Children are considered to have moderate or severe persistent asthma when symptoms do not respond to optimised treatment at Step 3 (see Figure 1); referral to a specialist paediatrician is recommended. For detail of drugs used to treat asthma in children, see the next section: ‘Drug doses and administration in children.’ Figure 1: Stepped approach to adjusting asthma medication in children 15 years and younger.  Refer for specialised treatments [Note 4] STEP 3 (few children) Refer children on Step 3 to a specialist stepped-up regular preventer ICS (high paediatric dose) OR  ICS (low paediatric dose) PLUS montelukast [Note 1] OR ICS+LABA (low paediatric dose) [Note 2] [Note 3] (PLUS as-required reliever: salbutamol)  STEP 2 (some children) regular preventer ICS (low paediatric dose) OR montelukast [Note 1]  (PLUS as-required reliever: salbutamol)  STEP 1 (many children) as-required reliever monotherapy SABA (salbutamol) Before considering stepping up treatment, review adherence and inhaler technique, check equipment (eg inhaler, spacer, mask) for breakage or blockage, assess for an alternative diagnosis or a comorbidity (eg rhinitis), and ensure exposure to triggers is minimised. Consider stepping up if good control is not achieved despite good adherence and correct inhaler  technique; see Assessment of asthma control in children for more information. If asthma has been stable and well controlled for at least 3 months, consider stepping down therapy; see  Stepping down asthma therapy in children for more information. cont... 12  Asthma in children (up to 15 years) ICS = inhaled corticosteroid; LABA = long-acting beta2 agonist; SABA = short-acting beta2 agonist Note 1: Montelukast is less effective than ICS and has been associated with neuropsychiatric adverse effects, including nightmares, sleep disturbance, agitation, depression and, rarely, suicidal thinking and behaviour. Counsel parents and carers about these effects. They usually occur in the first 2 weeks of treatment. Stop treatment if these effects occur—the effects usually subside within a few days of stopping treatment. See the Australian Therapeutic Goods Administration (TGA) website for more information: www. tga.gov.au/alert/montelukast Note 2: Always give ICS+LABA therapy as a fixed-dose combination inhaler to avoid the possibility of patients taking a LABA without an ICS; LABA monotherapy increases the risk of exacerbations and asthma- related death. Note 3: There is no evidence to support the use of LABAs in children younger than 5 years; use in this age group is not recommended. Note 4: Children who remain uncontrolled despite Step 3 therapy (with good adherence and inhaler technique, and no likely alternative diagnoses) are considered to have severe asthma. These children require referral to a specialist (paediatrician) for investigation and management. Additional references: Australian Asthma Handbook © 2020 National Asthma Council Australia. Accessed January 2022. Paul V, Bagga A, editor. GHAI Essential Pediatrics. 8th ed. New Delhi: CBS Publishers and Distributors Pvt Ltd; 2013: 387. Table 5: Stepwise treatment of asthma in children 15 years and younger [Note 1] Step 1 Intermittent salbutamol 100 micrograms per puff (actuation) as required child 1 to 5 years: 2 to 6 inhalations via MDI with spacer (and face mask if required) child 6 to 15 years: 2 to 12 inhalations via MDI with spacer If symptoms remain consistent with partial control, eg daytime symptoms on more than 2 days/week, move to Step 2. cont... 13 Fiji Respiratory Guidelines 2022 Step 2 Mild persistent salbutamol 100 micrograms per puff (actuation) as required child 1 to 5 years: 2 to 6 inhalations via MDI with spacer (and face mask if required) child 6 to 15 years: 2 to 12 inhalations via MDI with spacer PLUS one of the following: inhaled corticosteroid (low dose) eg beclomethasone 100 micrograms by inhalation via MDI with spacer ONCE or TWICE daily OR montelukast Child 1 to < 6 years: 4 mg daily Child 6 to 15 years: 5 mg daily Step 3 Moderate to severe persistent Any child with moderate persistent asthma should be referred to a specialist for management salbutamol 100 micrograms per puff (actuation) as required child 1 to 5 years: 2 to 6 inhalations via MDI with spacer (and face mask if required) child 6 to 15 years: 2 to 12 inhalations via MDI with spacer PLUS one of the following: inhaled corticosteroid (high dose) eg beclomethasone 100 to 200 micrograms (maximum dose 400 micrograms per day in severe cases) by inhalation via MDI with spacer twice daily OR inhaled corticosteroid (low dose) PLUS montelukast (refer to doses above) OR combination low dose inhaled corticosteroid and long-acting beta-2 agonist (ICS-LABA given as a fixed-dose combination) non-EML Note 1: See the next section: ‘Drug doses and administration in children,’ for specific drug and dose recommendations. Children who remain uncontrolled despite Step 3 therapy (with good adherence and inhaler technique, and no likely alternative diagnoses) are considered to have severe 14  Asthma in children (up to 15 years) asthma. These children require referral to a specialist (a paediatrician or paediatric respiratory physician) for investigation and management. Specialist management of asthma may include the addition of theophylline or tiotropium (non-EML) to standard therapy. Theophylline should only be initiated by a specialist and ideally requires therapeutic drug monitoring. Drug doses and administration in children Short-acting beta2 agonists Prescribe as-required reliever therapy for all children with a diagnosis of asthma. Use: child 1 to 5 years: 2 to 6 inhalations via MDI with spacer (and face mask if required) child 6 to 15 years: 2 to 12 inhalations via MDI with spacer. Educate parents and carers about how to use the inhaler, including advice about using a spacer (recommended for all children using a MDI) and a mask (if required for children using a MDI). See page 197 for links to instructional videos and patient handouts for devices. A SABA is referred to as a ‘reliever’; the term ‘rescue medication’ may be used in the literature. Inhaled corticosteroids Inhaled corticosteroids (ICS) (beclomethasone) are the most effective preventive therapy in children with asthma. They are referred to as ‘preventers’ and are first-line maintenance treatment. To minimise the risk of oropharyngeal candidiasis and systemic corticosteroid absorption, children should be advised, or helped, to rinse their mouth with water and spit out straight after using inhaled corticosteroids (ICS). Using a spacer with ICS also reduces oropharyngeal candidiasis and dysphonia. y before considering stepping up, ensure correct diagnosis, control of trigger factors, correct inhaler technique, compliance to treatment plan y consider stepping up if good control is not achieved y when asthma is well controlled and stable for at least 3 months, consider stepping down (reduce dose or stop ICS) y oral corticosteroids should not be prescribed long term for the treatment of asthma – for children with moderate to severe persistent asthma, refer to a specialist for management. For children requiring preventer treatment in addition to as-needed reliever treatment (ie Step 2 in figure above), use: a low-dose ICS by inhalation, see below. 15 Fiji Respiratory Guidelines 2022 Review treatment after 2 to 3 months to determine the level of asthma symptom control. Low and high doses of ICS for children are presented below. Use the minimum effective dose of ICS to reduce the risk of adverse effects. Explain to parents and carers that ICS therapy needs to be used every day to be effective and does not relieve acute symptoms. Educate parents and carers about how to use the inhaler, including advice about using a spacer (recommended for all children using a MDI) and a mask (if required for children using a MDI). See ‘Inhalational drug delivery devices,’ page 197 for information about using masks and spacers. Table 6: Corticosteroid-based-inhalers available in Fiji for asthma in children Drug [Note 1] Dosage Low paediatric dose High paediatric dose (Step 2) (Step 3) [Note 3] beclometasone 100 to 200 micrograms 200 micrograms twice per day given in one or daily two doses [Note 2] budesonide 100 to 200 micrograms 300 to 400 micrograms (including combinations twice daily twice daily with LABA) Non-EML fluticasone propionate 50 to 100 micrograms 125 to 250 micrograms (including combinations twice daily twice daily with LABA) Non-EML LABA = long-acting beta agonist Note 1: For information about delivery devices, including links to videos and patient handouts, see Inhalational drug delivery devices page 197. Note 2: A 50 microgram MDI is currently not available on the Fiji EML; the 100 microgram MDI can be used once daily. Note 3: Doses above the upper limit of the high dose range should not be prescribed without specialist advice. Montelukast Montelukast (a leukotriene receptor antagonist) is a tablet used as an alternative to inhaled corticosteroids (ICS). Montelukast is not on the Fiji EML but is available in the private sector. It may be trialled if: y the child is unable to use inhaled therapy y the child also has significant allergic rhinitis 16  Asthma in children (up to 15 years) y the parents have strong concerns about adverse effects of ICS. montelukast (2 to 5 years) 4 mg orally, at night or montelukast (6 to 14 years) 5 mg orally, at night. Montelukast has been associated with neuropsychiatric adverse effects, including nightmares, sleep disturbance, agitation, depression and, rarely, suicidal thinking and behaviour. Counsel parents and carers about these effects. They usually occur in the first 2 weeks of treatment. Stop treatment if these effects occur—the effects usually subside within a few days of stopping treatment. See the Australian Therapeutic Goods Administration (TGA) website for more information: www.tga.gov.au/alert/ montelukast. Theophylline Theophylline should only be initiated by a specialist and children taking theophylline must reviewed regularly. Theophylline has a narrow therapeutic range, the dose should be adjusted according to clinical response and plasma concentrations (monitoring of theophylline plasma concentration is currently not available in Fiji). Educate patients or carers about common symptoms of toxicity such as nausea, vomiting, diarrhoea, tremor or palpitations, and to seek medical attention if they experience any of these. Ideal body weight should be used for dose calculations in obese patients. Cromones Cromones (cromoglycate, nedocromil) are rarely used alternative preventer therapies. Cromones are not as effective as ICS and require more frequent dosing and meticulous daily care to prevent clogging of the inhaler device. Nedocromil has not been studied in children 1 to 5 years. There are no cromones listed on the Fiji EML at the time of publication. Exercise-induced bronchoconstriction In school-aged children with asthma, exercise is usually one of a number of triggers for bronchoconstriction. Less commonly, it may be the only, or predominant, trigger. The level of physical activity needed to trigger exercise-induced bronchoconstriction depends on the child, and also on ambient environmental factors (symptoms are more likely in cold and dry conditions). For children with persistent asthma, regular preventer therapy is the most important factor in controlling exercise-induced bronchoconstriction. In children in whom exercise is the only trigger for asthma symptoms, pre-exercise bronchodilator therapy is usually effective. Use: salbutamol 100 micrograms per puff (actuation), 1 to 2 puffs by inhalation via MDI with spacer, 15 minutes before exercise. 17 Fiji Respiratory Guidelines 2022 Nondrug interventions Avoiding triggers for children with asthma is important. Exposures that increase risk of children developing asthma are discussed above. Respiratory viral infection is the most common trigger in childhood asthma. Exposure to airborne allergens can also trigger asthma symptoms in sensitised children, see Table 7. There is no good evidence for use of complementary medicines to treat asthma in children. Some complementary medicines (eg royal jelly, echinacea) are known triggers for asthma and anaphylaxis. Table 7: Management of triggers for flare-ups of existing asthma in children [Note 1] Action Trigger Always avoid cigarette smoke Avoid or allergens (eg pollen, dust mite) minimise if airborne or environmental irritants (eg cold or dry air, occupational possible irritants, pollution, smoke) drugs associated with asthma exacerbations (eg NSAIDs for patients with aspirin-exacerbated respiratory disease, beta blockers [Note 2]) dietary triggers (either temperature related [eg cold drinks] or allergy related [for patients with food allergies]) [Note 3] Manage respiratory tract infections comorbidities (eg allergic rhinitis, gastro-oesophageal reflux, nasal polyposis, obesity, inducible laryngeal obstruction) physiological and psychological changes (extreme emotions, hormonal changes, pregnancy, sexual activity) NSAID = nonsteroidal anti-inflammatory drug Note 1: No individual item triggers asthma in all people. Note 2: If a patient with asthma develops an indication for beta-blocker therapy (eg heart failure, myocardial infarction), start beta-blocker therapy at a low dose under supervision. Note 3: Food allergies rarely trigger acute asthma; however, a confirmed food allergy is a risk factor for asthma-related death. Education and skills training It is important to provide the parents or carers of children with asthma with information about the natural history of asthma, the rationale for treatment, and the need for good adherence with preventer medication (when prescribed). 18  Asthma in children (up to 15 years) Clearly explain the difference between preventer and reliever therapy to children and their carers. A spacer device is vital for the delivery of all asthma drugs administered via pressurised metered dose inhaler (MDI) in children. Carefully demonstrate the appropriate spacer technique to parent or carer and the child. A written asthma action plan is another important component of management. If asthma symptom control is poor despite apparently adequate treatment, consider poor inhaler technique and/or poor adherence. Regular review is important to ensure optimal control of symptoms with the lowest effective medication dose. Check adherence and device technique at each visit and perform spirometry if the child is capable. Consider stepping down treatment in children with good symptom control in the previous 3 months. Update the written asthma action plan at least yearly or when maintenance treatment is changed. Provide information on avoiding triggers, where appropriate, and managing comorbid conditions (eg allergic rhinitis). Advise on avoiding environmental tobacco smoke, and encourage physical activity, maintaining a healthy weight and a healthy lifestyle. Failure to respond to adequate treatment Most children with asthma have intermittent symptoms and do not require treatment beyond Step 1 of the stepwise approach, see above. Those who do require preventive treatment usually respond very well to first-line preventer therapy (ie Step 2 in figure above). Failure to respond to optimised first-line preventer treatment (ie correct technique and good adherence) should prompt reassessment of the diagnosis, and exploration of possible complicating factors, such as: y exposure to aeroallergens or environmental and tobacco smoke y psychosocial factors including parent or carer mental health problems, or financial hardship. Referral may be warranted at this point; see below for further information about when specialist paediatric consultation is recommended. Referral Refer children for specialist paediatric consultation when there has been: y a life-threatening asthma flare-up or asthma in conjunction with anaphylaxis y frequent flare-ups requiring oral corticosteroids y doubt about the diagnosis of asthma y failure to respond to therapy, indicated by 19 Fiji Respiratory Guidelines 2022 − persistently impaired lung function (in children old enough to perform spirometry) despite control of symptoms − the need for infants or toddlers to use oral or inhaled corticosteroids (ICS) − the need for older children to use maintenance ICS doses in excess of the upper limit of the high-dose range. Management of acute asthma in children 1 to 15 years Overview Acute asthma (also known as an asthma exacerbation, attack or flare up) is an acute worsening of lung function and asthma symptoms. Typical symptoms include shortness of breath, wheeze, cough and chest tightness. Acute asthma usually occurs in response to a trigger, such as a viral respiratory tract infection or an irritant (eg pollen, pollution, cold air). Lack of adherence with preventer therapy is also a common factor. This topic provides advice for managing acute asthma in children 1 to 15 years. For advice about managing acute asthma in adolescents, see asthma in adults and adolescents. Wheezing infants younger than 12 months old should not be treated for acute asthma. Acute wheezing in this age group is most commonly due to acute viral bronchiolitis. In the event of an acute flare-up (exacerbation) of asthma, early intervention with inhaled bronchodilator therapy is the best strategy to prevent further deterioration. Educate parents, carers and children with asthma to recognise early symptoms of deterioration and to initiate the first steps in treatment (see below). Anaphylaxis and acute asthma Anaphylaxis is an important differential diagnosis for children presenting with acute wheeze. Anaphylaxis is a life-threatening condition; the child can deteriorate exceedingly rapidly (ie within minutes). Sudden-onset shortness of breath and typical skin features (eg any of urticarial rash, erythema, flushing or angioedema) is diagnostic of anaphylaxis. Anaphylaxis should also be considered if a patient presents with sudden-onset shortness of breath and cardiovascular symptoms (eg dizziness, hypotension) or gastrointestinal symptoms (eg diarrhoea, vomiting), even if typical skin features are not present. If unsure if anaphylaxis or asthma, give empirical intramuscular adrenaline. 20  Asthma in children (up to 15 years) If anaphylaxis is suspected or cannot be excluded, give empirical intramuscular adrenaline (epinephrine): adrenaline 10 micrograms/kg or 0.01 mL/kg of 1:1000 (maximum 0.5 mL) by IM injection into lateral thigh. Repeat after 5 minutes if the child is not improving. First aid for acute asthma for patients and community members If symptoms are severe or life-threatening urgently call an ambulance and advise that the child is having a ‘severe asthma attack’ (flare-up) and/or organise transport to hospital. Pending its arrival, administer high doses of inhaled short-acting beta2 agonist (SABA) via pressurised metered dose inhaler (MDI) with spacer (if available) or via nebuliser. In children younger than 6 years, use: salbutamol 100 micrograms per puff (actuation), 6 separate puffs by inhalation via MDI with spacer, repeated every 20 minutes or sooner if required OR salbutamol 2.5 mg by inhalation via nebuliser, repeated every 20 minutes or sooner if required. In children 6 years or older, use: salbutamol 100 micrograms per puff (actuation), 12 separate puffs by inhalation via MDI with spacer, repeated every 20 minutes or sooner if required OR salbutamol 5 mg by inhalation via nebuliser, repeated every 20 minutes or sooner if required. If early signs of asthma deterioration are present, first-line treatment with a bronchodilator should be initiated by the child, parent, or carer. Call an ambulance if the child fails to improve significantly with first-line home treatment, or if there are signs of a severe or life-threatening flare-up. Urgent medical review is also required if the child initially responds but bronchodilator therapy is needed more than 3 to 4-hourly. Transfer patient to a higher level of care immediately if there are signs of a severe or life-threatening flare-up or if the child fails to respond rapidly to first-line treatment. There is a ‘first aid plan’ for acute asthma, used by many community and sports organisations, called ‘4×4×4’, which recommends salbutamol MDI; if available, use: y 4 separate puffs, with spacer if available, one puff at a time y take 4 breaths from the spacer after each puff 21 Fiji Respiratory Guidelines 2022 y wait 4 minutes and then give another 4 separate puffs y if the child still cannot breathe normally, call an ambulance, and continue giving 4 separate puffs every 4 minutes until the ambulance arrives. Medical management of acute asthma in children Overview When the patient arrives at the medical facility, perform a rapid assessment to evaluate the severity of the flare-up, which determines initial management. Most cases of acute asthma in children are mild and can be successfully managed in the primary care setting. Treat these children as for mild–moderate acute asthma as outlined above, with ongoing assessment of severity and response to treatment. If the child’s condition worsens, arrange urgent transfer to a divisional hospital. The aim of therapy is to stabilise the child within the first hour, then attempt to lengthen the interval between salbutamol doses in a stepwise fashion. Assessment History Inquire specifically about the duration and nature of symptoms, treatments used (relievers, preventers), trigger factors (including upper respiratory tract infection, allergy, passive smoking), pattern and course of previous acute episodes (eg. admission or ICU admissions), parental understanding of the treatment of acute episodes, and the presence of interval symptoms (see long term asthma control below). Risk factors for severe disease y previous ICU admission y poor compliance to asthma therapy y poorly controlled - significant interval symptoms y past history of anaphylaxis Examination Wheeze is not a good marker of severity. The most important parameters in the assessment of the severity of acute childhood asthma are general appearance/ mental state and work of breathing (accessory muscle use, recession), as indicated in the table. Initial oxygen saturation (SpO2) on room air, heart rate and ability to talk are 22  Asthma in children (up to 15 years) helpful but less reliable additional features. Wheeze intensity, pulsus paradoxus and peak expiratory flow rate are not reliable. Asymmetry on auscultation is often found due to mucous plugging, but warrants consideration of foreign body. Children with respiratory distress should have minimal handling (see below). Oxygen may be required for low saturations (SpO2 less than 90%), do not give for wheeze or increased work of breathing. The arterial oxygen saturation (SaO2) may be reduced in the absence of significant airway obstruction due to factors such as atelectasis and mucous plugging of airways. SaO2 is purely a measure of oxygenation, which may be preserved in the presence of deteriorating ventilation (with CO2 retention). Tachycardia can be a sign of severity—but is also a side effect of beta agonists such as salbutamol. Wheezing is an unreliable indicator of the severity of an asthma flare-up in children. Wheezing may be absent in a severe flare-up (ie ‘silent chest’). Cyanosis is only visible with marked hypoxaemia; it indicates life-threatening acute asthma, but its absence does not exclude life-threatening acute asthma (see Table 5). Box 1: Minimal handling The sick child deteriorates with handling and distressing procedures. Increased distress in an unwell child can: y increase heart rate, respiratory rate and blood pressure y cause de-oxygenation (especially in neonates) y tip a child’s condition from moderate to severe Principles of minimal handling y keep the child with parent or care giver y keep the environment quiet and moderate lighting where possible y allow the child comfort feeds if safe to do so y minimise interventions, including examination and investigations that are not going to impact acute management y group cares - eg observations and oral medications y use comfort techniques for painful procedures such as intravenous catheters – eg local anaesthetic cream, distraction. y do not forcibly alter a child’s posture - especially in respiratory conditions such as croup. Children will naturally adopt the posture that facilitates the least airway obstruction. Republished, with permission, from resources at The Royal Children’s Hospital, Melbourne, Australia. www. rch.org.au. Accessed March 2020. 23 Fiji Respiratory Guidelines 2022 Investigations Chest X-ray is not generally required (discuss with senior doctor if considering). Arterial blood gas and spirometry are not required in the assessment of acute asthma in children. Blood gases are distressing and can cause a child with respiratory compromise to deteriorate further. They are not usually required; the child’s clinical state is more important in guiding therapy. The most important parameters of severity in acute childhood asthma are the child’s general appearance or mental state, and work of breathing (eg accessory muscles use, chest wall recession). Treatment of acute asthma in children is based on assessment of severity Assess severity of the acute asthma episode (moderate, severe or life-threatening) and administer a bronchodilator immediately: y Make a rapid clinical assessment with the child in a sitting position y Measure pulse oximetry while the person is breathing air (unless life threatening) y Start bronchidilator therapy according to severity and age Table 8: Initial rapid severity assessment of acute asthma in children If features of more than one severity category are present, record the higher (worse) category as the overall severity level. Mild to moderate: Severe: Life-threatening: all of the following any of the following any of the following y can walk and speak y unable to complete y reduced whole sentences sentences in one breath consciousness in one breath (for y increased work of y collapse young children; can breathing with use of y exhaustion move around, speak accessory muscles (eg y cyanosis in phrases) tracheal tug, intercostal y poor respiratory effort y SpO2 more than or subcostal recession, y soft or absent breath 94% marked abdominal sounds breathing, chest wall recession in children) y SpO2 less than 90% y obvious respiratory distress y SpO2 90 to 94% cont... 24  Asthma in children (up to 15 years) Important additional information: y The severity category may change when more information is available or over time; ongoing observation is required. y If oxygen therapy has already been started, it is not essential to stop oxygen to monitor oximetry. y Oxygen saturation levels are a guide only; clinical judgement should be applied. y While clinical features can help identify severity of an acute asthma flare-up, they are not specific (either in isolation or in combination); their absence does not exlude a severe or life-threatening asthma flare-up. Of note: − wheezing may be absent in severe acute asthma (ie ‘silent chest’) − pulsus paraoxus is not a reliable indicator of the severity of acute asthma − life-threatening acute asthma can occur without cyanosis. SpO2 = oxygen saturation measured by pulse oximetry Adapted from the Australian Asthma Handbook © 2020 National Asthma Council Australia. Accessed March 2022. Management Consider consultation with the paediatric team if any of the following: y assessed as moderate or severe asthma y poor response to inhaled salbutamol y oxygen requirement Consider transfer to a divisional hospital if any of the following: y severe or critical asthma requiring intravenous treatment or respiratory support y children with escalating oxygen requirement y children poorly responsive to salbutamol or unable to wean salbutamol y children requiring care above the level of comfort of the local hospital. Management of mild to moderate acute asthma in children can walk and speak whole sentences in one breath SpO2 more than 94% For a patient with moderate acute asthma according to the initial rapid assessment, start treatment with salbutamol. Use: salbutamol 100 micrograms per puff (actuation), 1 puff at a time via MDI with spacer child 1 to 5 years: 6 puffs every 20 minutes for 1 hour (or sooner if needed) 25 Fiji Respiratory Guidelines 2022 child 6 years or older: 12 puffs, every 20 minutes for 1 hour (or sooner if needed) OR salbutamol via intermittent nebulisation child 1 to 5 years:2.5 mg every 20 minutes for the first hour (or sooner if needed) child 6 years or older: 5 mg every 20 minutes for the first hour (or sooner if needed). Review the child 10 to 20 minutes after third dose to decide on timing of next dose. Consider oral prednisolone (see below): prednisolone 2 mg/kg (maximum 60 mg) orally for the initial dose, only continuing with 1 mg/kg orally, once daily for a further 1-2 days if there is ongoing need for regular salbutamol. Management of severe acute asthma in children unable to complete sentences in one breath increased work of breathing with use of accessory muscles (eg tracheal tug, intercostal or subcostal recession, marked abdominal breathing, chest wall recession in children) obvious respiratory distress SpO2 90 to 94% If the patient is being managed in primary care, arrange urgent transfer to a divisional hospital. Admit any child with severe acute asthma to ICU and involve a consultant in their care. If oxygen saturation measured by pulse oximetry (SpO2) is less than 92%, start supplemental oxygen therapy. Titrate oxygen to a target SpO2 of 92 to 96%; need for oxygen should be reassessed regularly. Do not give oxygen for wheeze or increased work of breathing. For more detailed advice on supplemental oxygen administration, see ‘Acute oxygen therapy’ page 161. If a child is deteriorating at any stage, treat as critical asthma. For a child with severe acute asthma according to the initial rapid assessment, start treatment with both salbutamol and ipratropium. salbutamol 100 micrograms per puff (actuation), 1 puff at a time via MDI with spacer child 1 to 5 years: 6 puffs every 20 minutes for 1 hour (or sooner if needed) 26  Asthma in children (up to 15 years) child 6 years or older: 12 puffs, every 20 minutes for 1 hour (or sooner if needed) OR salbutamol via intermittent nebulisation child 1 to 5 years:2.5 mg every 20 minutes for the first hour (or sooner if needed) child 6 years or older: 5 mg every 20 minutes for the first hour (or sooner if needed) Review ongoing requirements for salbutamol 10-20 minutes after the third dose. If clinically improving, reduce frequency. If no change, continue to give every 20 minutes. PLUS ipratropium bromide via intermittent nebulisation every 20 minutes for 1 hour for 3 doses only child 1 to 5 years: 250 micrograms per dose child 6 years or older: 500 micrograms per dose PLUS hydrocortisone 4 mg/kg (up to 100 mg) intravenously, 6-hourly for up to 24 hours; switch to an oral corticosteroid once tolerated. If intravenous therapy is still required after 24 hours, reduce frequency to 12-hourly Consider adrenaline if the child is not improving: adrenaline (epinephrine) 1 mg/mL (1:1000, 0.1%) solution, 0.01 mg/kg up to 0.5 mg (0.5 mL) intramuscularly; repeat after 3 to 5 minutes if required. Arrange admission after initial assessment and management. Management of critical / life-threatening acute asthma in children reduced conciousness collapse soft or absent breath sounds poor respiratory effort exhaustion cyanosis SpOo2 less than 90% 27 Fiji Respiratory Guidelines 2022 Consider anaphylaxis as a differential diagnosis—see ‘Anaphylaxis and acute asthma’ for more information. Call for assistance – request urgent involvement from a consultant or senior PICU registrar. For a patient with life-threatening acute asthma according to the initial rapid assessment, arrange immediate transfer to a critical care or high-dependency facility. Early involvement of senior staff is required. Check doses of intravenous medicines carefully – see below for additional information on dosing and administration Supplemental oxygen is almost always required for patients with life-threatening acute asthma. Use high flow via oxygen mask (15 L/minute) and titrate oxygen to a target SpO2 of 92 to 96%. Start immediate treatment with nebulised bronchodilator therapy (both salbutamol and ipratropium). Use oxygen to drive the nebuliser: salbutamol via continuous nebulisation child 1 to 5 years:2.5 mg at a time, undiluted child 6 years or older: 10 mg at a time, undiluted PLUS ipratropium bromide via nebulisation, added to salbutamol, every 20 minutes for 3 doses then every 4 hours child 1 to 5 years: 250 micrograms per dose child 6 years or older: 500 micrograms per dose Give intravenous corticosteroid therapy as soon as possible (and at least within the first hour): hydrocortisone 4 mg/kg (up to 100 mg) intravenously, 6-hourly for up to 24 hours; switch to an oral corticosteroid once tolerated. If intravenous therapy is still required after 24 hours, reduce frequency to 12-hourly If the patient worsens or does not have a rapid and marked response to bronchodilator and oxygen therapy, add intravenous magnesium sulfate (not suitable for children younger than 2 years). Use: magnesium sulfate 10 mmol (2.5 g/5 mL; 50%) (child 2 years or older: 0.1 mmol/kg up to 8 mmol (equivalent to approximately 25 mg/kg up to 2 g) diluted to 50 mL in normal saline, infused intravenously via syringe pump over 20 minutes 28  Asthma in children (up to 15 years) Higher doses are sometimes used – check with a consultant In an ICU setting, this can be continued: magnesium sulfate 10 mmol (2.5 g/5 mL; 50%) (child 2 years or older: 0.12 mmol/kg/hour infused intravenously via syringe pump. Comprehensive monitoring in a critical care or high-dependency environment is required. Consider intravenous salbutamol: salbutamol 10 micrograms/kg (maximum 500 micrograms) intravenously as a single bolus dose given over at least 2 minutes. Consider repeating dose at 10 minutes if not improving. Comprehensive monitoring (blood electrolytes, heart rate, blood lactate) in a critical care or high-dependency environment is required. Consider intravenous aminophylline: aminophylline loading dose (omit in children being treated with oral theophylline) 10 mg/kg (maximum 500 mg) intravenously over 1 hour. If inadequate response, start a continuous infusion (in PICU setting only): aminophylline intravenous infusion via syringe pump child 1 to 9 years: 1.1 mg/kg/hour child 10 to 15 years: 0.7 mg/kg/hour. Comprehensive monitoring in a critical care environment, including cardiac monitoring, is required. Treatment in children is often complicated by nausea and vomiting. Theophylline plasma concentrations should be monitored to ensure they are within the therapeutic range and the dose adjusted accordingly, however this is currently unavailable in Fiji. Note: aminophylline, magnesium and salbutamol must be given via separate IV lines Additional treatment for persistent life-threatening acute asthma Adrenaline (epinephrine) If the patient is unresponsive, has poor respiratory effort, and cannot inhale bronchodilators, or is considered to be peri-arrest, consider adrenaline (epinephrine). Give: adrenaline (epinephrine) 1 mg/mL (1:1000, 0.1%) solution, 0.01 mg/kg up to 0.5 mg (0.5 mL) intramuscularly; repeat after 3 to 5 minutes if required. 29 Fiji Respiratory Guidelines 2022 Monitoring in severe and critical / life-threatening acute asthma Children with severe or critical / life-threatening asthma should be managed by a consultant in a critical care or high dependency environment. Monitoring required: y continuous cardiac monitoring y non-invasive blood pressure, oxygen saturation and respiratory rate y blood electrolytes, including magnesium and calcium, and blood lactate y capullary blood gas (CBGs) and areterial blood gas (ABGs) at baseline and then at least 6-hourly Salbutamol toxicity: tachycardia, tachypnoea, metabolic acidosis; can occur with both intravenous and inhaled treatment. Lactate levels are commonly high. Hypokalaemia and hypomagnesaemia are expected when repeated or high doses are given and should be managed appropriately. The effects on the cardiovascular system may lead to adverse consequences such as myocardial ischaemia or prolonged QT interval; the latter predisposes to arrhythmias, especially in the context of electrolyte disturbances. High doses of salbutamol may paradoxically worsen the respiratory compromise. This effect is thought to be multifactorial; metabolic acidosis, rise in lactate levels and increased metabolic rate may all contribute. If suspected, the patient should be closely observed and salbutamol treatment should be cautiously back-titrated; specialist input is recommended. The safety of repeated doses of magnesium sulfate has not been assessed. Hypermagnesaemia may cause loss of deep tendon reflexes and muscle weakness, including respiratory muscle weakness. The potential harm versus benefit of intravenous aminophylline is considered unfavourable in the majority of situations. It can cause vomiting, arrhythmias, convulsions and sudden death, and is rarely used. Aminophylline interacts with many medicines, including antibiotics such as erythromycin and ciprofloxacin. Check current medications before starting treatment. See the PICU Clinical Practice Guidelines for further information on management of life-threatening asthma, including ventilatatory support. Corticosteroids in the management of acute asthma in children Corticosteroid therapy hastens symptom resolution and prevents relapse in acute asthma. It is recommended for: y all cases of acute asthma in children 6 years or older, except the mildest of cases (eg mild symptoms that respond quickly and completely to bronchodilator therapy) 30  Asthma in children (up to 15 years) y all cases of severe acute wheezing in children 1 to 5 years; in a