It is a chronic reversible obstructive inflammatory airways disease in which many cells and cellular element play a role by constriction of bronchial smooth muscle causing bronchospasm, oedema of bronchial mucous membrane and blockage of the smaller bronchi with plug of mucous.
Clinical presentation
- wheeze
- shortness of breath
- chest tightness
- cough - presentation particularly at night or in the early morning
- Tachypnea
- Tachycardia
- Diffuse musical wheezes
- Prolonged phase of exhalation
- Chest hyperinflation
- Use of accessory muscle
Investigations
- FBP (Look for eosinophilia)
- Serum IgEa
- ESR
- ABG
- CXR if highly suspicion of pneumonia
- Sputum for cytologya (look for eosinophilia) (a very important test to establish diagnosis of asthma)
- Lung function Test (e.g.: spirometry with reversibility test, PEFR measurement with a peak flow meter), Exhaled NO should be done to asses evidence of variable expiratory airflow limitation
Non-pharmacological Treatment
- Avoid polluted environment (both indoors and outdoors)
- Avoid non-selective β-blockers, which can trigger asthmatic attack
- Avoid heavy exercise
- Stop smoking
- Avoid both overweight and underweight
Note:
- The management of asthma in children is like that in adult. Infants under 18 months, may not respond well in bronchodilator
- Uncertain in diagnosis should prompt early referral, because asthma-COPD overlap has worse outcome.
- Patient intolerant of NSAIDs or who exhibit any of the high-risk clinical features for intolerance to these drugs (severe asthma, nasal polyps or chronic rhino sinusitis) should use NSAIDs only under close medical supervision.
Table 9.5: Assessment and Treatment of Asthma attack in Children ≥2years & Adults
|
Attack |
Clinical Presentation |
Treatment (Children & Adults) |
|
MILD- MODERATE ATTACK |
Able to talk in sentences or phrases Not agitated Pulse rate 100- 120bpm Sat 02(on air)-90- 95% PEF>50% predicted |
I. Salbutamol inhalation (can be given by pMDI or spacer or Nebulization)2 Give: 4-10 puffs by pMDI/ spacer/ every 20minutes for 1sthour A: salbutamol(nebulization) Adult: Salbutamol respules 5mg 6hrly (2-3cycles and reassess); Pediatric: 2.5mg 6hrly (2-3cycles and reassess). If symptoms completely subside observe for 1–4hours, give Salbutamol for 24–48hours (2-4 puffs every 4–6hours) for 3 days. If attack is only partially resolved give 2–4 puffs of Salbutamol every 3–4 hours if attack is mild; 6 puffs every 1–2 hours if the attack is moderate, until symptoms subside. When attack completely resolved proceed as above. II. Prednisolone A: prednisolone (PO): Adult 40mg am 7/7; Pediatrics 1-2mg/kg max 40mg Do tapering if exceed seven days. III: Controlled oxygen (if available): target saturation 93-95% (children: 94-98%) Note: If symptoms worsen or do not improve, treat as SEVERE ATTACK |
|
SEVERE ATTACK |
Talks in words i.e. cannot complete a sentence in 1 breath or too breathless to talk/ feed Sits hunched forward Agitated Respiratory rate >30/min. Accessory muscles being used Pulse rate > 120 bpm O2 saturation (on >air): < 90% PEF ≤ 50% predicted or best |
I. Admit the patient, place in semi-sitting position II. Oxygen continuously 5L/min (maintain O2 saturation for adult 93-95% III. Inhalation A: salbutamol (nebulization) 4-10puffs every 20-30min in children Add S: ipratropium bromide (inhalation)0.25-0.5mg 6-8hourly AND A: hydrocortisone (IV) 5mg/kg in children, 100mg in adults 6hourly then switch to oral A: prednisolone (PO)1-2mg/kg 24hourly to complete 7days of treatment If attack is completely resolved continue with salbutamol inhalation 2–4puffs every 4hours for 24-48hours and oral prednisolone 1-2mg/kg 24hourly to complete 3–5days of treatment. If not improving or condition worsens, treat as LIFE-THREATENING ATTACK |
|
LIFE THREATENING ATTACK |
Altered level of consciousness (drowsiness, confusion, coma) Exhaustion; Silent chest Paradoxical thoracoabdominal movement Cyanosis Collapse Bradycardia in children or arrhythmia/ hypotension in adults O2 saturation<92% |
I. Admit the patient, place in semi-sitting position II. Oxygen continuously 5L/min (maintain O2 saturation between 94-98%) III. A: salbutamol (nebulization) 2.5mg for children <5years and in children >5years & adults 2.5-5mg every 20–30min then switches to salbutamol aerosol when clinical improvement is achieved. Add: S: ipratropium bromide (inhalation) 0.25-0.5mg 6-8hourly. AND A: hydrocortisone (IV) 5mg/kg in children, 100mg (IV) in adults every 6hours then switch to A: prednisolone (PO) 1-2mg/kg 24hourly to complete 7days of treatment In adult administer a single dose of: A: magnesium sulphate (Infusion of 1-2g in 0.9% Sodium Chloride over 20 minutes) In children use continuous nebulization rather than intermittent nebulisation. Patient with life threatening asthma should be managed in HDU/ICU. |
Use a spacer to increase effectiveness. If conventional spacer not available, take a 500ml plastic bottle, insert the mouthpiece 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.Note: Patients who get night attacks should be advised to take their medication on going to bed