J. Paediatr. Child Health (1990) 26, 72-74
Childhood asthma: Application of the international view of management in Australia and New Zealand* R . HENRY, L. LANDAU, C. MELLIS, P. VAN ASPEREN, J. MORTON, P. COOPER, D. COOPER, A. KEMP, C. ROBERTSON, P. PHELAN, P. SLY, R. STAUGAS, J. MARTIN, A. ISLES, B. MASTERS, P. LeSOUEF, J. HOBDAY, E. MITCHELL, I. ASHER and K. DAWSON
Recently a consensus statement has been made about international guidelines for the management of childhood asthma.' In June 1989 a meeting of Australian and New Zealand respiratory paediatricians discussed these guidelines. In particular, the application of these international views to Australia and New Zealand was discussed. There was broad agreement with the international view for the proposed management of asthma. In particular, children and their parents should be reassured that if asthma is properly controlled, each child should be able to lead a normal, physically active life. However a number of changes to the guidelines were suggested and are summarized in this document. This paper should therefore be read in conjunction with the international consensus statement.' The diagnosis of asthma in children who are too young to perform lung function tests should be based on a combination of history, physical examination and, where appropriate, a trial of anti-asthma therapy. If the diagnosis is in doubt, or if there is failure of drug therapy, the general practitioner should consider a chest X-ray as well as the referral of the child for specialist opinion. In children who are able to perform lung function tests, additional help in diagnosing asthma may be gained by employing simple lung function tests such as peak expiratory flow (PEF) and forced expiratory volume in one second (FEV1) in addition to a clinical history, physical examination and response to drug therapy. A peak flow meter can be used to assess baseline lung function and bronchial responsiveness to bronchodilator at each visit. Alternatively, a peak flow meter at home for twice daily measurements before and after bronchodilator provides an opportunity to document variability over 24 h. A level of 10-20% variation between maximum and minimum PEF in 24 h correlates with mild symptoms of asthma, 20-30V0 with moderate symptoms and greater than 30% severe symptoms. Treatment should aim to reduce variability to less than 10%. Peak flow readings can also be used to educate patients, especially those who have problems assessing severity and those on high-dose inhaled or oral corticosteroids,to identify times when steroid treatment should be intensified. Once again, if the diagnosis is in doubt, or there is a poor response to a therapeutic trial, a chest X-ray should be obtained and the child referred for further evaluation (which will almost always include a more detailed assessment of lung function).
Correspondence: Dr R. L. Henry, Department of Paediatrics. University of Newcastle. Mater Misericordiae Hospital, Waratah, NSW 2298, Australia. 'A statement prepared by Australian and New Zealand paediatric respimtory physicians following a workshop in the Hunter Valley, New South Wales, Australia in June 1989. Accepted for publication 15 January 1990.
In most cases the role of allergen skin tests (or immunoglobulin E [lgE RAST] tests) is in classifying patients as atopic, rather than to identify specific causative triggers. Routine allergy tests are not necessary for all asthmatic patients. At all levels of medical supervision, high priority should be placed on education of parents and children about asthma. This education often includes advice about environmental manipulation. However studies of allergen control measures have provided conflicting results. There are few well-designed, controlled trials examining the role of house dust avoidance, and reduction in symptoms has been reported only with extreme intervention. The clinical benefit of measures against the housedust mite, such as the use of plastic mattress covers and pillow cases, the removal of bedroom carpet and soft toys from the bed, spraying, and regular vacuum cleaning, have not been MILD
(Not constitutionallydisturbed)
L
11
Fig. 1 Outpatient management of asthma in children aged less than 1 year. Areas requiring specialist care are highlighted.
Childhood asthma
73
Inhaled or oral intermittent p2 -stimulants
MODERATE INTERMITENT
I
Replace oral with inhaled intermittent p2-stimulants (spacer/nebulizer)
I
I Consider inhaled sodium cromoglycate with spacer or nebulizer. andor oral theophylline (taking care with dose, due to nsk of side-alfects) CONSIDER SPECIALIST CARE
I
I
I
MODERATE CONTINUOUS OR FREQUENT SEVERE
Replace with inhaled steroids and regular inhaled p2 -stimulants
Consider ipratropium bromide
+ oral steroids (low dose, alternate day)
need for children to avoid both active and passive cigarette smoking is reinforced. However the usual mechanism by which cigarette smoke is considered to be harmful is by an irritant effect and not an allergic effect. Elimination of specific foods from the diet is not commonly helpful. Other non-allergic triggers such as food additives (sodium metabisulphite and monosodium glutamate), aspirin and non-steroidal anti-inflammatory agents may be important in some children. lmmunotherapy has no role in the treatment of childhood asthma. The potential dangers of immunotherapy must be recognized and fatal reactions may occur. In general, inhaled drugs should be used whenever possible in preference to oral medication. Beta-2-agonists, sodium cromoglycate and steroids are the main medications used in the treatment of out-patients. lpratropium bromide is a safe and moderately effective bronchodilator. There is considerable controversy regarding the evidence for increased benefit of ipratropium bromide compared with that of pragonists. Some would use it as second line treatment, while others would not use it at all. Xanthines have a limited role in the management of most children. They have a narrow therapeutic toxic ratio, and even in the therapeutic range, side effects are common. These include gastrointestinal symptoms, headaches and learning difficulties. Double blind trials have shown that ketotifen is of little benefit in asthma, and it is not recommendedfor this condition. Ketotifen is not readily available in Australia.
Fig. 2 Outpatient management of asthma in children aged 1-3 years. Areas requiring specialist care are highlighted.
MILO
MILD Inhaled intermittent pr-stimulants (dry powder/MDI with spacer)
I
MODERATE I ~~
+ sodium cromoglycate (nebulized or dry powder, or MOI with spacer) CONSIDER SPECIALIST CARE
I
SEVERE
I
Symptoms persist Replace sodium cromoglycate with inhaled steriods + regular inhaled p~-stimulants,2-3 months to evaluate control
Consider high dose inhaled steroids I
Consider slow release theophylline
Consider ipratropium bromide
Consider addition of slow release theophylline
Consider addition of
1
I t
I
oral steroids (alternate day dosing. preferably) I
Fig. 4 Outpatient management of asthma in children and adolescents (aged 5-18 years). Areas requiring specialist care are highlighted.
Fig. 3 Outpatient management of asthma in children aged 3-5 years. Areas requiring specialist care are highlighted.
established, although some of these measures may reduce the amount of allergen in the environment. Similarly, the efficacy of air conditioners, negative-ion generators and air filters in reducing exposure to seasonal pollens remains unproven. The
Figure 1 shows the algorithm for the management of asthma in the first year of life. Currently there is no evidence of objective benefit of any drug, although some claim an effect from ipratropium bromide. In many cases wheezing in the absence of physical distress does not require medication. If the disease in children of this age is severe enough to warrant therapy, referral to a paediatrician is recommended. Trials of the various options may be considered. Figure 2 stresses the trend away from oral towards inhaled medications, even in children of 1-3 years of age. Apart from
74
ACUTE SEVERE
Antippaled
Unexped
r"l Oral steroids
Rater to hospital
IN HOSPITAL
@ Oxygen
R. Henryetal.
a nebulizer, some of the spacer devices appear encouraging in terms of adequate drug delivery to the airways of these children. Figure 3 has a similar algorithm, except that dry powder inhalation devices and metered dose inhalers (MDI) with spacers are both feasible for this age group. Figure 4 stresses the need for preventive therapy in moderate and severe asthma. When slow-release p2-stimulants become available throughout Australia and New Zealand they may replace slow-release theophyllines. Figure 5 summarizes the management of acute, severe asthma. The three principal drugs used are &agonists, oxygen and corticosteroids. lpratropium bromide may be added as a second bronchodilator. Intravenous aminophylline is not often necessary. An acute attack of asthma represents a failure of medical management and demands a reappraisal of baseline therapy. Children with mild asthma can be managed with B-agonists alone; sodium cromoglycate is used in mild to moderate asthma; and inhaled steroids are used for moderate to severe asthma.
REFERENCE Admit to intensive care unit +/- salbvtamol I v , mechanical venttlation
Fig. 5
Management ot acute severe asthma.
1
Warner J.O., Gotz M.. Landau L. I., Levison H.,Milner A. D.. Pedersen S.. Silverman M. Management of asthma: a consensus statement. Arch. Dis. Child. 1989: 64: 1065-79.
Childhood asthma: Application of the international view of management in Australia and New Zealand* R . HENRY, L. LANDAU, C. MELLIS, P. VAN ASPEREN, J. MORTON, P. COOPER, D. COOPER, A. KEMP, C. ROBERTSON, P. PHELAN, P. SLY, R. STAUGAS, J. MARTIN, A. ISLES, B. MASTERS, P. LeSOUEF, J. HOBDAY, E. MITCHELL, I. ASHER and K. DAWSON
Recently a consensus statement has been made about international guidelines for the management of childhood asthma.' In June 1989 a meeting of Australian and New Zealand respiratory paediatricians discussed these guidelines. In particular, the application of these international views to Australia and New Zealand was discussed. There was broad agreement with the international view for the proposed management of asthma. In particular, children and their parents should be reassured that if asthma is properly controlled, each child should be able to lead a normal, physically active life. However a number of changes to the guidelines were suggested and are summarized in this document. This paper should therefore be read in conjunction with the international consensus statement.' The diagnosis of asthma in children who are too young to perform lung function tests should be based on a combination of history, physical examination and, where appropriate, a trial of anti-asthma therapy. If the diagnosis is in doubt, or if there is failure of drug therapy, the general practitioner should consider a chest X-ray as well as the referral of the child for specialist opinion. In children who are able to perform lung function tests, additional help in diagnosing asthma may be gained by employing simple lung function tests such as peak expiratory flow (PEF) and forced expiratory volume in one second (FEV1) in addition to a clinical history, physical examination and response to drug therapy. A peak flow meter can be used to assess baseline lung function and bronchial responsiveness to bronchodilator at each visit. Alternatively, a peak flow meter at home for twice daily measurements before and after bronchodilator provides an opportunity to document variability over 24 h. A level of 10-20% variation between maximum and minimum PEF in 24 h correlates with mild symptoms of asthma, 20-30V0 with moderate symptoms and greater than 30% severe symptoms. Treatment should aim to reduce variability to less than 10%. Peak flow readings can also be used to educate patients, especially those who have problems assessing severity and those on high-dose inhaled or oral corticosteroids,to identify times when steroid treatment should be intensified. Once again, if the diagnosis is in doubt, or there is a poor response to a therapeutic trial, a chest X-ray should be obtained and the child referred for further evaluation (which will almost always include a more detailed assessment of lung function).
Correspondence: Dr R. L. Henry, Department of Paediatrics. University of Newcastle. Mater Misericordiae Hospital, Waratah, NSW 2298, Australia. 'A statement prepared by Australian and New Zealand paediatric respimtory physicians following a workshop in the Hunter Valley, New South Wales, Australia in June 1989. Accepted for publication 15 January 1990.
In most cases the role of allergen skin tests (or immunoglobulin E [lgE RAST] tests) is in classifying patients as atopic, rather than to identify specific causative triggers. Routine allergy tests are not necessary for all asthmatic patients. At all levels of medical supervision, high priority should be placed on education of parents and children about asthma. This education often includes advice about environmental manipulation. However studies of allergen control measures have provided conflicting results. There are few well-designed, controlled trials examining the role of house dust avoidance, and reduction in symptoms has been reported only with extreme intervention. The clinical benefit of measures against the housedust mite, such as the use of plastic mattress covers and pillow cases, the removal of bedroom carpet and soft toys from the bed, spraying, and regular vacuum cleaning, have not been MILD
(Not constitutionallydisturbed)
L
11
Fig. 1 Outpatient management of asthma in children aged less than 1 year. Areas requiring specialist care are highlighted.
Childhood asthma
73
Inhaled or oral intermittent p2 -stimulants
MODERATE INTERMITENT
I
Replace oral with inhaled intermittent p2-stimulants (spacer/nebulizer)
I
I Consider inhaled sodium cromoglycate with spacer or nebulizer. andor oral theophylline (taking care with dose, due to nsk of side-alfects) CONSIDER SPECIALIST CARE
I
I
I
MODERATE CONTINUOUS OR FREQUENT SEVERE
Replace with inhaled steroids and regular inhaled p2 -stimulants
Consider ipratropium bromide
+ oral steroids (low dose, alternate day)
need for children to avoid both active and passive cigarette smoking is reinforced. However the usual mechanism by which cigarette smoke is considered to be harmful is by an irritant effect and not an allergic effect. Elimination of specific foods from the diet is not commonly helpful. Other non-allergic triggers such as food additives (sodium metabisulphite and monosodium glutamate), aspirin and non-steroidal anti-inflammatory agents may be important in some children. lmmunotherapy has no role in the treatment of childhood asthma. The potential dangers of immunotherapy must be recognized and fatal reactions may occur. In general, inhaled drugs should be used whenever possible in preference to oral medication. Beta-2-agonists, sodium cromoglycate and steroids are the main medications used in the treatment of out-patients. lpratropium bromide is a safe and moderately effective bronchodilator. There is considerable controversy regarding the evidence for increased benefit of ipratropium bromide compared with that of pragonists. Some would use it as second line treatment, while others would not use it at all. Xanthines have a limited role in the management of most children. They have a narrow therapeutic toxic ratio, and even in the therapeutic range, side effects are common. These include gastrointestinal symptoms, headaches and learning difficulties. Double blind trials have shown that ketotifen is of little benefit in asthma, and it is not recommendedfor this condition. Ketotifen is not readily available in Australia.
Fig. 2 Outpatient management of asthma in children aged 1-3 years. Areas requiring specialist care are highlighted.
MILO
MILD Inhaled intermittent pr-stimulants (dry powder/MDI with spacer)
I
MODERATE I ~~
+ sodium cromoglycate (nebulized or dry powder, or MOI with spacer) CONSIDER SPECIALIST CARE
I
SEVERE
I
Symptoms persist Replace sodium cromoglycate with inhaled steriods + regular inhaled p~-stimulants,2-3 months to evaluate control
Consider high dose inhaled steroids I
Consider slow release theophylline
Consider ipratropium bromide
Consider addition of slow release theophylline
Consider addition of
1
I t
I
oral steroids (alternate day dosing. preferably) I
Fig. 4 Outpatient management of asthma in children and adolescents (aged 5-18 years). Areas requiring specialist care are highlighted.
Fig. 3 Outpatient management of asthma in children aged 3-5 years. Areas requiring specialist care are highlighted.
established, although some of these measures may reduce the amount of allergen in the environment. Similarly, the efficacy of air conditioners, negative-ion generators and air filters in reducing exposure to seasonal pollens remains unproven. The
Figure 1 shows the algorithm for the management of asthma in the first year of life. Currently there is no evidence of objective benefit of any drug, although some claim an effect from ipratropium bromide. In many cases wheezing in the absence of physical distress does not require medication. If the disease in children of this age is severe enough to warrant therapy, referral to a paediatrician is recommended. Trials of the various options may be considered. Figure 2 stresses the trend away from oral towards inhaled medications, even in children of 1-3 years of age. Apart from
74
ACUTE SEVERE
Antippaled
Unexped
r"l Oral steroids
Rater to hospital
IN HOSPITAL
@ Oxygen
R. Henryetal.
a nebulizer, some of the spacer devices appear encouraging in terms of adequate drug delivery to the airways of these children. Figure 3 has a similar algorithm, except that dry powder inhalation devices and metered dose inhalers (MDI) with spacers are both feasible for this age group. Figure 4 stresses the need for preventive therapy in moderate and severe asthma. When slow-release p2-stimulants become available throughout Australia and New Zealand they may replace slow-release theophyllines. Figure 5 summarizes the management of acute, severe asthma. The three principal drugs used are &agonists, oxygen and corticosteroids. lpratropium bromide may be added as a second bronchodilator. Intravenous aminophylline is not often necessary. An acute attack of asthma represents a failure of medical management and demands a reappraisal of baseline therapy. Children with mild asthma can be managed with B-agonists alone; sodium cromoglycate is used in mild to moderate asthma; and inhaled steroids are used for moderate to severe asthma.
REFERENCE Admit to intensive care unit +/- salbvtamol I v , mechanical venttlation
Fig. 5
Management ot acute severe asthma.
1
Warner J.O., Gotz M.. Landau L. I., Levison H.,Milner A. D.. Pedersen S.. Silverman M. Management of asthma: a consensus statement. Arch. Dis. Child. 1989: 64: 1065-79.
