The diagnosis and management of asthma in young children can be challenging since there are many different types of wheezing associated with numerous underlying disorders. In order to assist clinicians, the Vietnamese clinical practice guideline for asthma was revised in 2018 by the members of Vietnam Respiratory Society and Medical Services Administration, under the Ministry of Health.
Trang 1VIETNAM NATIONAL GUIDELINE FOR THE DIAGNOSIS AND TREATMENT OF ASTHMA IN CHILDREN UNDER 5 YEARS:
A SUMMARY
1 Medical Sevices Administration, Ministry of Health, Vietnam
2 Department of Internal Medicine, Hanoi Medical University, Hanoi, Vietnam
3 Respiratory Center, Bach Mai Hospital, Hanoi, Vietnam
4 Respiratory Department, National Pediatric Hospital, Hanoi, Vietnam
5 Department of Pediatrics, Hue University of Medicine and Pharmacy, Hue, Vietnam
6 Vietnam Respiratory Society, Vietnam
7 Respiratory Department, Children’s Hospital number 1, HCM City, Vietnam
8 Department of Pediatrics, Ho Chi Minh City Medicine And Pharmacy University, HCM City, Vietnam
9 Department of Pediatrics, Bach Mai Hospital, Hanoi, Vietnam The diagnosis and management of asthma in young children can be challenging since there are many different types of wheezing associated with numerous underlying disorders In order to assist clinicians, the Vietnamese clinical practice guideline for asthma was revised in 2018 by the members of Vietnam Respiratory Society and Medical Services Administration, under the Ministry of Health This guideline focused on diagnosis and management of asthma in children under 5 years old, with subjects including the definition, diagnosis, assessment and treatment of asthma We expect this guideline will be a useful tool for physicians as well as other health care professionals in clinical practice to diagnose and manage the asthma patients in children under 5 years old.
I INTRODUCTION
Keywords: Asthma, children, guideline, GINA, Global initiative for asthma
Asthma is a common respiratory disease in
children, and the rate of asthma in children is
rising rapidly in both developed and developing
countries Statistics from the World Health
Organization showed that the prevalence of
childhood asthma was about 7-10% [1; 2] In
Vietnam, there are no systematic, national statistics on the incidence and deaths resulting from childhood asthma Some regional studies have shown that the prevalence of childhood asthma is about 4 - 8% [15]
The diagnosis of asthma in children under
5 years is often difficult, especially in children under 2 years old because it is easily confused with bronchiolitis Diagnosing asthma clinically
in young patients is standard as it is laborious
to do spirometry for children and immunological allergy tests are also non-specific for asthma
Hospital, Hanoi, Vietnam
Email: ngoquychaubmh@gmail.com
Received: 27/11/2018
Chau Quy Ngo 2,3,6 , Khue Ngoc Luong 1 , Quy Tran 9 , Dung Tien Nguyen 9 , Diem Huu Nguyet Phan 7 , Hong Thi Minh Pham 8 , Huong Thi Minh Le 4 , Son Binh Bao Bui 5 ,
Thuy Thi Dieu Nguyen 4 , Tuan Minh Dao 4 , Tuan Anh Tran 7 , Ngoc Van Le Truong 1 , Tru Van Nguyen 1 , Nguyen Thuy Nguyen 1 , Doi Quang Nguyen 6 , Giap Van Vu 2,3,6
Trang 2since they can yield a positive result in many
other diseases, such as allergic rhinitis,
eczema, etc Early diagnosis and treatment will
improve the outcome of the disease
In 2009, the Vietnamese Ministry of Health
published a guideline for diagnosis and
management of asthma in children but it has
not been updated until now [16] Therefore, in
2018, experts of Vietnam Respiratory society
worked together to revise this guideline based
on new evidence from the latest studies around
the world This revision has been approved by
Vietnam Ministry of Health to apply throughout
the country
2 Definition
Asthma is pathologically characterized
by chronic airway inflammation, airway hyperresponsiveness (bronchospasm, edema, congestion, mucus hypersecretion), and airway obstruction Expiratory airflow limitation leads to signs such as wheeze, shortness of breath, chest tightness, and recurrent coughing fits Symptoms often occur at night and early morning that may resolve spontaneously or due to medication [2]
3 Diagnosis
A diagnosis of asthma in children under 5 years old should be based on clinical history and clinical symptoms associated with subclinical features while also considering other differential diagnoses [1], [2]
3.1 Clinical
Table 1 Clinical Features that Increase the Probability of Asthma
Factors that increase the probability of asthma Factors that lower the probability
of asthma
Wheezing with one of the symptoms:
Cough
Dyspnea Any signs of the following:
Symptoms happen only in cold air
Isolated cough in absence of wheeze
or difficulty breathing Normal lung auscultation despite symp-toms
Signs / symptoms suggestive of other diagnoses
No response to a trial of asthma
thera-py (bronchodilators and asthma preven-tive medications)
AND Any signs of the following:
Symptoms recurring frequently
Symptoms are worse at night or in the early morning
Occurs on exertion, laughing, crying, or exposure to
tobacco smoke, cold air, pets
Occurs when no evidence of respiratory infections
A history of allergy (allergic rhinitis, eczema)
A family history of atopy and allergic diseases
(par-ents, siblings)
Has widespread wheezing/ rhonchi heard on
auscul-tation
Response to adequate asthma treatment
Note: Wheezing must be correctly confirmed by doctor, because parents may mistake wheezing with other abnormal sounds
Trang 33.2 Subclinical
No any laboratory test to make correctly diagnosis asthma in children under 5 years old
Table 2 Subclinical tests
Chest X ray
Chest x ray is not recommended for routine assess-ment
Indicated in cases of severe asthma or clinical signs that suggest another diagnosis
The tests can be performed if available
Prick tests or Specific IgE testing
The test is used to evaluate susceptibility status to allergens Positive allergy tests to help to increase the probability of asthma diagnosis However, a negative test does not exclude asthma diagnosis
Spirometry or peak flow meter
(if the child is capable of cooperating)
The airway obstructive syndrome that responds to pos-itive bronchodilator test (Increase in at least 12% and
200 mL in FEV1, PEF after bronchodilator test) (chil-dren under 5 years are often not possible)
Impulse Oscillometry (IOS) Measurements of specific airway resistance, which
contributes to the assessment of airflow limitation FeNO measurement Assessing airways inflammation, is not recommended
routinely
Note: Normal spirometry results do not necessarily exclude a diagnosis of asthma, particularly in the case of intermittent or mild asthma Bronchodilator test is negative neither do exclude asthma
3.3 Diagnostic criteria
Satisfying the following criteria: (see Table 1 Factors that suggests the possibility of asthma): (1) Wheezing ± persistent recurrent cough
(2) Airway obstruction syndrome: widespread wheeze/rhonchus heard on auscultation (± Impulse Oscillometry)
(3) Response to bronchodilator drugs or response to a trial of asthma therapy (4-8 weeks) and clinical status is worse when the drug is discontinued
(4) Past or family history of allergic diseases or has trigger factors
(5) The other wheezing etiologies were excluded
Trang 4Table 3 Asthma Predictive Index
Parents of children with asthma
Eczema (to be diagnosed by doctor)
Allergic reaction to inhaled allergens (determined by
medical history or allergic tests)
Wheezing not related to a cold Peripheral blood Eosinophils ≥ 4%
Food allergy
3.4 Differential Diagnosis
Not all that wheezes are asthma The bronchodilator test should be performed in children with wheezing (inhaled salbutamol spray 2.5mg/time, continuously 2-3 times in 20 minutes) If the child does not respond or responds poorly after 1 hour, should consider the differential diagnosis of the following:
Table 4 Differential diagnosis
Bronchiolitis
Children under 24 months, wheezing occurs for the first time, with symptoms of upper respiratory viral infections, poor response to bronchodilators [2], [6]
Rhinosinusitis
Abnormal breathing sounds coming from the nose and throat, nose and throat examination find antrocho-anal polyp accompanied by odor, lung examination is completely normal [9], [7]
Foreign body aspiration
Occurs suddenly, the child coughs, wheezing, difficulty breathing, has a history of infiltration syndrome, localized air trapping on chest x-ray, bronchoscopy removal of foreign bodies [2]
Anatomical malformations (vascular
ring, congenital tracheal stenosis ),
Abnormal function
(dyskinesia tracheobronchial,
dysfunction of vocal cords, vascular
rings or laryngeal webs, vocal cord
dysfunction)
Wheezing occurs early before 6 months of age, should be combine clinical and subclinical features, bronchoscopy, CT scan [11], [12]
Bronchial compression by:
medias-tinal tumors, enlarged lymph nodes,
bronchial cysts
Coughing, wheezing, persistent shortness of breath, no response to bronchodilator drugs Diagnosis based on posterior-anterior and lateral chest X-ray film, chest CT scan found the airway is compressed by tumor [1]
Trang 5Diseases Manifestations
Pulmonary infiltrates with increased
eosinophils
Clinical symptoms like asthma, caused by parasites, roundworms or other causes such as drugs or other allergens, progressing well and can heal itself [2]
Gastroesophageal reflux
drome or recurrent aspiration
syn-drome, bronchoesophageal fissure
With a history of vomiting or recurrent respiratory in-fections, esophageal pH test, bronchoscopy, contrast enhanced esophagography to confirm the diagnosis [7]
Congenital immunodeficiency
Recurrent respiratory infection, do not respond to con-ventional antibiotic therapy, IgG levels less than 2 SDs below the mean for age, Family history of sibling have congenital immunodeficiency [5]
3.5 Assessment of the level of severe asthma
Table 5 Assessment the Intensity of asthma exacerbation
- Alert
- Shortness of breath
on exertion, can be
lying-flat positioning
- Talks in whole
sen-tences
- Tachypnea, no
dyspnea
- SpO2 ≥ 95%
- Alert
- Shortness of breath, prefer to sit more than supine position
- Talks in short phrases
- Tachypnea, chest wall indrawing
- SpO2: 92 - 95%
- Agitated
- Continuously short-ness of breath, must
in head elevation position
- Talks in single/few words,
- Tachypnea, chest wall indrawing clearly
- SpO2 < 92%
- Drowsy, confused, coma
- Slow breathing, apnea episodes
- Unable to talk
- Reduced vesicular breathing sounds or silent chest
- Cyanosis, SpO2
< 92%
Table 6 Classifying asthma severity
Components of
Persistent
Daytime Symptoms ≤ 2 times/
week
≤ 2 times/week but
Throughout the day
Nighttime awakenings 0 1 to 2 times/month 3 to 4 times/month > 1 time/week Short-acting beta2
agonist use for
symptom control
≤ 2 times/
week
> 2 times/week but
Several times per day
Interference with
nor-mal activity None Minor limitation Some limitation
Extremely limited
Trang 6Table 7 Assessment of Asthma Control Clinical symptoms
In the past 4 weeks, has the child had: Well controlled
Partially controlled Uncontrolled
Daytime asthma symptoms for more than a
few minutes, more than once a week?
□ Yes □ No
None of these 1 – 2 of these 3 – 4 of these
Activity limitation due to asthma
□ Yes □ No
Reliever medication needed more than once
a week
□ Yes □ No
Night waking or night coughing due to
asth-ma
□ Yes □ No
4 Treatment
4.1 Treatment of acute attack
4.1.1 Management of asthma at home
Initial treatment at home
- Two puffs Salbutamol 200 mcg inhalation spray by pMDI + spacer, may be repeated every
20 minutes, if needed
- Then take the child to the medical facility as soon as possible
Need to take the child to the health facility immediately if your child has any of the following signs:
- Children too breathless
- Symptoms of children dose not reduce immediately after 6 puffs bronchodilator inhalation spray for 2 hours
- The parents and care-givers cannot treat asthma attack at home
4.1.2 Management of asthma attack in the hospital
Trang 7Figure 1 Approach for managing mild and moderate asthma
Moderate Asthma
OUTPATIENT TREATMENT
- Nebulized salbutamol 2,5 mg/time
- Salbutamol inhalation spray with MDI plus
Spacer (2 - 4 puffs/times every 20 minutes x 3
times if needed (re-assess after every
inhalation spray) [10]
No response
- Still have w heeze,
dyspnea, chest wall indrawing
- SaO 2 < 92 %
Partial response
- Stlill have w heeze
- Still have dyspnea
- SaO 2 92 - 95%
Good response
- Not wheezing
- Not dyspnea
- SaO2 ≥ 95%
Consider for admission
Nebulized Salbutamol + Ipratropium 250 mcg/times)
- Soon oral prednisone (when does not respond to 1 st times of nebulization)
Outpatient treatment
- Continue to
Salbutamol inhalation
spray by MDI every 3 -
4 hours for 24 - 48
hours
- Re-examination
appointment
Hospitalized
-Nebulized salbutamol + Ipratropium x 3 times if needed
- Oral prednisolone (if after 3 times of nebulization, management as severe asthma attacks
Assess after one hour
Mild Asthma
OUTPATIENT TREATMENT
- Nebulized salbutamol 2,5 mg/time -Salbutamol inhalation spray with MDI plus Spacer (2 - 4 puffs/times every 20 minutes x 3 times if needed (re-assess after every inhalation spray) [10]
Trang 8Figure 2 Approach severe and life threatening asthma Dosing:
- Intravenous Hydrocortisone 5 mg/kg or methylprednisolone 1mg/kg every 6 hours [10]
- Magnesium sulfate (>1 year), average dose of 50mg/kg intravenous infusion for 20 minutes [10]
- Theophylline (≤ 1 year)
- Intravenous infusion Aminophylline: attack dose of 5mg/kg for in 20 minutes, maintenance dose: 1 mg/kg/hour If feasible, should monitor the blood theophylline levels in the 12th hour and then every 12 - 24 hours (keep 60 - 110mmol/l is equivalent to 10 - 15mg/ml) [10]
- Subcutaneous Adrenalin (Adrenalin 1 ‰ 0.01 ml / kg, maximum 0.3 ml/time every 20 minutes, maximum 3 times [2]
- Salbutamol: attack dose of 15 mg/kg by intravenous infusion for 20 minutes, then maintain 1 mg/kg/minute Need to check blood gases and potassium every 6 hours [10]
Assess the risk factors for severe events
Life threatening asthma
Admit to ICU
-Oxygen via face mask
-Subcutaneous adrenalin every 20 minutes x 3 times
-Nebulized salbutamol combination with ipratropium
bromide every 20 minutes x 3 times (re-assess after
each nebulisation)
-Intravenous Hydrocortisone or Methyl -prednisolon
Incomplete response
- Transfer to ICU
- Nebulized salbutamol every hour
- Nebulized ipratropium every 2 - 4 hours
- Can use high dose ICS
- Intravenous hydrocortison or Methyl-prednisolon
- Infusion Magnesium sulfat (> 1 year)
- Infusion Aminophylin
- Infusion salbutamol, intubation and mechanical ventilation
Good response
Continue
- Nebulized salbutamol ± Ipratropium every 4 – 6h for 24h
- Intravenous Hydrocortison or Methyl-prednisolon
Severe Asthma
Admit to ICU
- Oxygen via face mask
- Nebulized salbutamol combination with
ipratropium bromide every 20 minutes x 3 times
(re-assessment after each nebulization)
- Intravenous hydrocortisone or methyl
prednisone
Re-assess after 1 hour
Good response
- Not dyspnea
- SaO2 ≥ 95%
OUTPATIENT TREATMENT
- Salbutamol inhalation spray by MDI every 3 - 4 hours for 24 - 48 hours
- Oral Prednisolone for 3 days
- Re-examination appointment
Trang 9- History of severe and life threatening asthma attack.
- Emergency hospitalization or endotracheal intubation for acute asthma in the past year
- Currently using or recently discontinued oral corticosteroids
- Too dependent on short acting bronchodilator drugs (β2 agonist)
- A history of psychiatric disorders or excessive panic
- Not cooperate or uncontrol asthma
Medications and interventions that should not be used in acute asthma
- Antibiotics: use only when there is evidence of infection
- Infusion: use only when there are signs of dehydration (be careful to avoid fluid overload)
- Sedatives, expectorant drugs (group of acetylcysteine causes bronchospasm), group of antihistamine causes decreased secretion, cough syrup medications containing dextromethorphan, respiratory physiotherapy
4.2 Maintenance treatment
4.2.1 Objectives
The goals of asthma management in young children are to:
- Achieve good control of symptoms and maintain normal activity levels
- Minimize future risk – that is, reduce the risk of flare - ups, maintain lung function and lung development as close to normal as possible and minimize side effects from medications
4.2.2 Indication
- The child’s symptom pattern suggests a diagnosis of asthma and respiratory symptoms are uncontrolled and/or wheezing episodes are frequent (e.g three or more episodes in a season)
- Children have severe wheezing episodes which triggered by virus although less frequently (1 - 2 episodes in a season)
- The child has been having asthma symptoms and needs to use regular inhaled SABA ( > 1 - 2 times/week)
- The children have been to hospitalized with severe and life threatening asthma attack
4.2.3 Drug selection
When drug selection should note two phenotypes
- Intermittent wheezing is onset due to virus: Montelukast (LTRA)
- Wheezing is onset due to many factors: inhaled corticosteroid (ICS)
4.2.4 Treatment of asthma severity
Choose the initial treatment method according to the severity at the first time of assessment
Table 8 Choose the initial treatment method according to the severity
Components of severity Preferred option Other option
Intermittent As needed inhaled SABA, LTRA
Moderate Persistent Moderate dose ICS Low dose ICS + LTRA
Severe Persistent High dose ICS Moderate dose ICS + LTRA
Trang 10SABA: short - acting beta2 agonists ; ICS: inhaled corticosteroid; LTRA: leukotriene receptor antagonist
For intermittent asthma use LTRA during first episode when symptoms of upper respiratory viral infection and maintain 7 - 21 days
4.2.5 Treatment base on the level of symptom control
After the initial assessment, the therapy is chosen depending on the level of asthma control Access to treatment maintenance under “step up” or “step down” to control symptoms and minimize the risk of acute attacks as well as side effects of the drug in the future Steps to maintain a specific treatment are presented in Table 9 [2]
Table 9 Stepwise approach to asthma treatment base on the level of symptom control
Step 4 Step 3
Asthma not well - con-trolled on moderate dose ICS
Step 2
Asthma di-agnosis, and but not well
- controlled
on low - dose ICS
Step 1 Symptom pattern
con-sistent with asthma and asthma symptoms not well - controlled, or ≥ 3 exacerbations per year;
Symptom pattern not consistent with asthma but wheezing episodes occur frequently (e.g
every 6 - 8 weeks) Give diagnosis trial for three months
Consider this step
for children with
Intermittent wheezing onset
by virus and no
or few interval symptoms
Preferred
con-troller choice LTRA(2 - 4 week) Daily low - dose ICS Moderate dose ICS
Continue moderate dose ICS + refer for expert assessment
Other controller
- Addition of LTRA
- Increasing the dose of ICS
Caution for all children
Assess symptom control, future risk, comorbidities
Self - management: education, inhaler skills, written asthma action plan, adherence
Regular review: assess response, adverse events, establish minimal effective treatment
(Where relevant): environmental control for smoke, allergens, indoor/outdoor air pollution
For children 0 - 2 years old: maintenance treatment decision according to Table 10