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Clinical Practice Guideline Code
issued
02/04/2015
For Management of Acute Date
Date Reviewed 02/04/2015
Attack of Bronchial
Next revision 08/04/2016
Pages
i of ii
Asthma in Children
Development
And Consultation
Dissemination
Target Audience
Implementation
Training
Audit
Review
Compliance with
National Guidance and
Accreditation Standards
MH-G24V01.00
Clinical Practice Guideline Code
issued
02/04/2015
For Management of Acute Date
Date Reviewed 02/04/2015
Attack of Bronchial
Next revision 08/04/2016
Pages
ii of ii
Asthma in Children
Table of Contents
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Introduction .........................................................................................................................1
Purpose/Objective of the Guideline ....................................................................................1
Definitions/Abbreviation ......................................................................................................2
Clinical Specialty .................................................................................................................2
Intended Users ...................................................................................................................2
Target Populations ..............................................................................................................2
Guideline.............................................................................................................................2
Indications for Referral to emergency department ..............................................................5
Recommendations ..............................................................................................................5
Appendices .........................................................................................................................5
References .........................................................................................................................5
Associated Documentation .................................................................................................6
MH-G24V01.00
Clinical Practice Guideline Code
issued
02/04/2015
For Management of Acute Date
Date Reviewed 02/04/2015
Attack of Bronchial
Next revision 08/04/2016
Pages
1 of 6
Asthma in Children
Version
0.1
Paragraph
No
All
1.0
1.1
All
All
1.2
All
1.3
All
1.4
All
1.5
All
1.
Description of Change
Date
Approved
Introduction
Asthma is one of the most common chronic disease of childhood and the leading cause of
childhood morbidity measured by school absences, emergency department visits and
hospitalizations. Asthma often begins in early childhood; in up to half of people with asthma,
symptoms commence during childhood.
Risk factors for acute attack:
Prior history of near- fatal asthma ( history of admission to intensive care unit )
Exposures! tobacco smoke, indoor or outdoor air pollution in door allergens( e.g. house
dust mite, cockroach, pets, mold )
2.
2.1.
This guideline is developed to guide clinicians manage acute attacks of bronchial asthma in
children.
2.2.
The guideline aims to standardize evidence based clinical practice in managing acute
attacks of bronchial asthma in children.
MH-G24V01.00
Clinical Practice Guideline Code
issued
02/04/2015
For Management of Acute Date
Date Reviewed 02/04/2015
Attack of Bronchial
Next revision 08/04/2016
Pages
2 of 6
Asthma in Children
3.
Definitions/Abbreviation
Acute exacerbation of asthma (flare- ups or attacks): Is defined as acute or sub-acute
deterioration in asthma symptoms control that is sufficient to cause distress or risk health
and necessitates a visit to GP or requires treatment with corticosteroids. It may occur even
in children taking asthma treatment. Exacerbations usually occur in response to exposure
to an external agent and /or poor compliance with asthma control treatment.
4.
Clinical Specialty
All clinics in PHCC health centers
5.
Intended Users
All Health Care Professionals in primary care clinics within PHCC.
6.
Target Populations
All patients (less than or equal to 18 years of age) attending PHCC health centers clinics
who meet the criteria of the definition.
7.
Guideline
7.1.
Initial assessment:
7.1.1. Follow ABCDEs - refer to ABCDE Procedure.
7.1.2. Refer to patients previous records (if readily available) and carry out a brief focused
history and examination to include:
Current medication
7.1.3. Undertake a focused examination (in addition to ABCDE for initial assessment) to
identify any severe signs and symptoms:
MH-G24V01.00
Clinical Practice Guideline Code
issued
02/04/2015
For Management of Acute Date
Date Reviewed 02/04/2015
Attack of Bronchial
Next revision 08/04/2016
Pages
3 of 6
Asthma in Children
Bradycardia (http://www.webmd.com/asthma/guide/status-asthmaticus)
7.1.4. Acute Asthma Severity Tool: The pulmonary index score (PIS) is an asthma score
based on five clinical variables:
Respiratory rate
Degree of wheezing
Oxygen saturation
score 2 if RR 35 to 50,
Score
RR
Wheezing
None
End expiration
Inspiratory/
expiratory ratio
2: 1
1:1
Accessory
muscle use
None
+
Oxygen
saturation
99 to 100
96 to 98
0
1
30
31 to 45
46 to 60
Entire expiration
1 :2
++
93 to 95
>60
Inspiration
expiration
+++
< 93
and 1 : 3
MH-G24V01.00
Clinical Practice Guideline Code
issued
02/04/2015
For Management of Acute Date
Date Reviewed 02/04/2015
Attack of Bronchial
Next revision 08/04/2016
Pages
4 of 6
Asthma in Children
7.2.
Management:
The initial severity of the exacerbation and level of treatment needed (i.e. Mild, Moderate, or
severe) can be determined by using an asthma exacerbation severity score such as the
pulmonary index score (PIS):
7.2.1. Severe/Acute Life Threatening Attack: PIS 12:
Call 999, inform needs, urgent transfer to Pediatric Emergency Centre (PEC)
Salbutamol at a dose of 0.1 to 0.3mg/Kg, (maximum 2.5mg for less than 5 years
old and 5mg for more than 5 years old), plus Ipratropium at 250mcg should be
nebulized on back-to-back basis every 20 minutes until ambulance arrives. The
patient should get proper clinical evaluation after each dose with proper
documentation. If the patient improves, space out the Salbutamol nebulization
and continue Ipratropium nebulization.
Inhaled Salbutamol at 0.1 to 0.3 mg/kg by nebulizer once, (maximum 2.5mg for
less than 5 years old and 5 mg for more than 5 years old). The other option is 2 6 puffs of inhaled Salbutamol by spacer every 20 minutes for the first hour and
assess severity; if symptoms persist refer the patient to the Pediatric Emergency
Center (PEC).
If the patient has not improved transfer them to the Pediatric Emergency Center
(PEC).
7.2.4. Antibiotics:
Prescribing antibiotics routinely for acute exacerbation of asthma is not
recommended unless there is an evidence of pneumonia or proven or suspected
bacterial infection
MH-G24V01.00
Clinical Practice Guideline Code
issued
02/04/2015
For Management of Acute Date
Date Reviewed 02/04/2015
Attack of Bronchial
Next revision 08/04/2016
Pages
5 of 6
Asthma in Children
8.
9.
10.
Recent treatment with systemic glucocorticoids (includes current treatment with oral
glucocorticoids at the time of presentation) or beta agonist overuse.
Recommendations
Immediate transfer should be arranged to the Pediatric Emergency Center if there are
any signs of severe exacerbation.
Arrange early follow-up after any exacerbation regardless of where it was managed and
within 1week.
Children with poor inspiratory flow or children who cannot cooperate with nebulized
therapy can be treated with Epinephrine administered intramuscularly or subcutaneously
for bronchodilation is 0.01mg/kg ( 0.01ml/kg of 1:1000 solution 1mg/ml)
Appendices
Appendix 1 - Algorithm for the management of asthma exacerbations in primary care
11.
References
11.1. Global Strategy for Asthma Management and Prevention, Revised 2014, Global Initiative
for Asthma (GINA)
11.2. Up to date mar 28. 2014, Acute asthma exacerbations in children, Authors: Gregory
sawicki, MD, MPH. Kenanhaver, MD
11.3. National asthma education and prevention program expert panel report III 2007
11.4. Management of Acute Attack of Bronchial Asthma Clinical Protocol, Hamad Medical
Corporation, CPRO 10520, April 2008 Revised February 2011
11.5. Ortiz-Alvarez, A Mikrogianakis; Canadian Pediatric Society, Acute Care Committee
,Pediatric Child Health 2012;17(5):251-5
MH-G24V01.00
Clinical Practice Guideline Code
issued
02/04/2015
For Management of Acute Date
Date Reviewed 02/04/2015
Attack of Bronchial
Next revision 08/04/2016
Pages
6 of 6
Asthma in Children
11.6. National guideline clearinghouse evidence- based care guideline for management of acute
exacerbation of asthma in children
12.
Associated Documentation
MH-G24V01.00
i of i