GINA Asthma Guidelines

1. Pocket Guide for
Asthma Management and
Prevention in Children
5 Years and Younger
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A Pocket Guide for Physicians and Nurses
2009
BASED ON THE GLOBAL STRATEGY FOR
ASTHMA MANAGEMENT AND PREVENTION IN CHILDREN 5 YEARS AND YOUNGER
Available from www.ginasthma.org
© 2010 Medical Communications Resources, Inc

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Disclaimer: Although the recommendations of this document are based on the best published
evidence, it is the responsibility of practicing physicians to consider the cost and benefit of all
treatments prescribed in young children, with due reference to recommendations and licensed
formulations, dosing, and indications for use in their country.

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GLOBAL INITIATIVE
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FOR ASTHMA
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GLOBAL INITIATIVE FOR ASTHMA
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Executive Committee (2009) Pediatric Writing Group
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Eric D. Bateman, M.D., South Africa, Chair Allan Becker, MD, Canada
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Louis-Philippe Boulet, MD, Canada Robert F. Lemanske, Jr, MD, USA
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Alvaro Cruz, MD, Brazil Soren Erik Pedersen, MD, Denmark
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Mark FitzGerald, M.D., Canada Peter D. Sly MD, Australia
Tari Haahtela, M.D., Finland Manuel Soto-Quiroz, MD, Costa Rica
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Mark Levy, MD, UK Gary W. Wong, MD, Hong Kong ROC
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Paul O'Byrne, M.D., Canada Heather J. Zar, MD, South Africa
Ken Ohta, M.D., Japan
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Pierluigi Paggario, M.D., Italy
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Soren Pedersen, M.D., Denmark
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Manuel Soto-Quiroz, M.D., Costa Rica
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Gary Wong, M.D., Hong Kong ROC
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© 2009 Medical Communications Resources, Inc.

4. TABLE OF CONTENTS
PREFACE .......................................................................................2
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WHAT IS KNOWN ABOUT ASTHMA?...........................................3
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DIAGNOSING ASTHMA ..............................................................4
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Table 1. Is it Asthma? ..........................................................4
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CLASSIFICATION OF ASTHMA BY LEVEL OF CONTROL ...............5
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Table 2. Levels of Asthma Control in Children
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5 Years and Younger ...............................................5
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MANAGEMENT AND PHARMACOLOGIC TREATMENT .................6
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Develop a Partnership – Family/Caregivers and Health Care Providers
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Identify and Reduce Exposure to Risk Factors ......................................6
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Table 3. Strategies for Avoiding Common Allergens and
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Pollutants................................................................7
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Assess, Treat, and Monitor Asthma ....................................................8
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Table 4. Asthma Management Approach Based on Control
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for Children 5 Years and Younger .............................9
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Table 5. Low Daily Doses of Inhaled Glucocorticosteroids for
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Children 5 Years and Younger ..............................10
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Manage Acute Exacerbations ..........................................................12
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Table 6. Initial Assessment of Acute Asthma in Children
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5 Years and Younger...............................................13
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Table 7. Indications for Immediate Referral to Hospital
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(Health Center) .......................................................14
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Table 8. Initial Management of Acute Asthma in Children
5 Years and Younger...............................................15
1

5. PREFACE
Asthma is a major cause of chronic morbidity and mortality throughout the
world and there is evidence that its prevalence has increased considerably
over the past 20 years, especially in children. The Global Initiative for
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Asthma was created to increase awareness of asthma among health pro-
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fessionals, public health authorities, and the general public, and to improve
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prevention and management through a concerted worldwide effort. The
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Initiative prepares reports on asthma management based on the best avail-
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able scientific evidence, encourages dissemination and implementation of
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the recommendations, and promotes international collaboration on asthma
research.
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Recommendations in this Pocket Guide present special challenges that must
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be taken into account to manage asthma in children during the first 5
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years of life, including difficulties with diagnosis, and efficacy and safety
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of drugs and delivery systems. Approaches to these issues will vary
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among populations based on socioeconomic conditions, genetic diversity,
cultural beliefs, and differences in health care access and deliver.
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The Global Initiative for Asthma offers a framework to achieve and
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maintain asthma control for most patients that can be adapted to local
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health care systems and resources. Program publications include:
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• Global Strategy for Asthma Management and Prevention (2008).
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Scientific information and recommendations for asthma programs.
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• Pocket Guide for Asthma Management and Prevention (2008).
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Summary of patient care information for primary health care
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professionals.
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• Pocket Guide for Asthma Management and Prevention in Children
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5 Years and Younger (2009). Summary of patient care information
for pediatricians and other healthcare professionals
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• What You and Your Family Can Do About Asthma. An information
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booklet for patients and their families.
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Publications are available from www.ginasthma.org.
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This Pocket Guide has been developed from the Global Strategy for
Asthma Management and Prevention in Children 5 Years and Younger
(2009). Technical discussions of asthma, evidence levels, and specific cita-
tions from the scientific literature are included in the source document.
2

6. WHAT IS KNOWN
ABOUT ASTHMA?
Unfortunately… asthma is the most common chronic disease of child-
hood and the leading cause of childhood morbidity from chronic disease
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as measured by absence from day care, emergency department visits, and
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hospitalizations. There are special challenges that must be taken into
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account in managing asthma in children during the first 5 years of life.
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Fortunately… asthma in this young age group can be effectively treated
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and control can be achieved in most patients.
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When asthma is under control children can:
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3 Avoid troublesome symptoms night and day
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3 Use little or no reliever medication
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3 Have productive, physically active lives
3 Avoid serious attacks TE
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• Asthma causes recurring episodes of wheezing, breathlessness, chest
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tightness, and coughing, particularly at night or in the early morning.
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• Asthma is a chronic inflammatory disorder of the airways. Chronically
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inflamed airways are hyperresponsive; they become obstructed and air-
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flow is limited (by bronchoconstriction, mucus plugs, and increased
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inflammation) when airways are exposed to various risk factors.
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• Common risk factors for asthma symptoms in young children include
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exposure to allergens (such as those from house dust mites, animals,
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cockroaches, fungi), exposure to tobacco smoke and biomass fuels, res-
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piratory (viral) infections and emotional stress.
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• Pharmacologic treatment to achieve and maintain control of asthma
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should take into account the safety of treatment, potential for adverse
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effects, and the cost of treatment required to achieve control.
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• Asthma attacks (or exacerbations) are episodic, but airway inflammation
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is chronically present.
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• For many patients, controller medication must be taken daily to prevent
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symptoms, improve lung function, and prevent attacks. Reliever medica-
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tions may occasionally be required to treat acute symptoms such as
wheezing, chest tightness, and cough.
• To reach and maintain asthma control in young children requires the
development of a partnership between the family/care giver and the
health care team.
3

7. DIAGNOSING ASTHMA
Making a definite diagnosis of asthma in children 5 years and younger is
challenging because episodic respiratory symptoms such as wheezing and
cough are also common in children who do not have asthma, particularly in
those younger than 3 years. Not all young children who wheeze have asth-
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ma, and the younger the child, the greater the likelihood that an alterna-
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tive diagnosis may explain recurrent wheeze. These alternatives must be
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considered and excluded before an asthma diagnosis is made.
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Alternative causes of recurrent wheezing, particularly in early infancy,
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include infections (recurrent viral lower respiratory tract infections, chronic
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rhino-sinusitis, tuberculosis); congenital problems (cystic fibrosis, bronchopul-
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monary dysplasia, congenital malformation causing narrowing of the
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intrathoracic airways, primary ciliary dyskinesia syndrome, immune deficien-
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cy, and congenital heart disease) and mechanical problems (foreign body
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aspiration).
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A difficulty with diagnosing asthma in children 5 years and younger is that
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the lung function measurements that are key to diagnosis in older children
and adults are not reliable in this age group.
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A trial of treatment with short-acting bronchodilators and inhaled glucocorti-
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costeroids can help confirm an asthma diagnosis: look for marked clinical
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improvement during the treatment and deterioration when treatment is
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stopped. The presence of atopy or allergic sensitization also increases the
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likelihood that a wheezing child will have asthma.
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Taking all of these factors into account, a diagnosis of asthma in these young
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children can often be made based largely on symptom patterns and on a
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careful clinical assessment of family history and physical findings (Table 1).
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Table 1. Is It Asthma?
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Consider asthma if any of the following signs or symptoms are present:
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n Frequent episodes of wheezing—more than once a month.
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n Activity-induced cough or wheeze.
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n Cough particularly at night during periods without viral infections.
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n Absence of seasonal variation in wheeze.
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n Symptoms that persist after age 3.
n Symptoms occur or worsen in the presence of:
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• Aeroallergens (house dust mites, companion animals, cockroach, fungi)
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• Exercise
• Pollen
• Respiratory (viral) infections
• Strong emotional expression
• Tobacco smoke
n The child’s colds repeatedly “go to the chest” or take more than 10 days to clear up.
n Symptoms improve when asthma medication is given.
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8. CLASSIFICATION OF ASTHMA
BY LEVEL OF CONTROL
For all patients with a confirmed diagnosis of asthma, the goal of treatment
is to achieve and maintain control of the disease. However, assessing
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asthma control in children 5 years and younger is difficult, because health
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care providers are almost exclusively dependent on the reports of the
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child’s family members and caregivers who might be unaware of the pres-
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ence of asthma symptoms, or of the fact that they represent uncontrolled
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asthma. Additional information about asthma control may be gleaned from
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the child’s need for reliever/rescue treatment (with increased use indicating
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worsening control).
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Table 2 presents a working scheme to assess asthma control in children 5
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years and younger based on these two sources of information.
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Table 2. Levels of Asthma Control in Children 5 Years and Younger*
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Characteristic Controlled Partly Controlled Uncontrolled
(All of the following) (Any measure (Three or more of
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present in any week) features of partly
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controlled asthma
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in any week)
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Daytime symptoms: None More than twice/week More than twice/week
wheezing, cough , (less than twice/week, (typically for short (typically last minutes
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difficult breathing typically for short periods periods on the order or hours or recur, but
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of on the order of of minutes and rapidly partially or fully relieved
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minutes and rapidly relieved by use of with rapid-acting
relieved by the use of a rapid-acting bronchodilators)
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a rapid-acting bronchodilator)
bronchodilator)
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Limitations None Any Any
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of activities (child is fully active, (may cough, wheeze, (may cough, wheeze,
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plays and runs without or have difficulty or have difficulty
limitation or symptoms) breathing during breathing during
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exercise, vigorous exercise, vigorous
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play, or laughing) play, or laughing)
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Nocturnal None Any Any
symptoms/awakening (including no nocturnal (typically coughs during (typically coughs during
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coughing during sleep) sleep or wakes with sleep or wakes with
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cough, wheezing, cough, wheezing,
and/or difficult breathing) and/or difficult breathing)
Need for ≤ 2 days/week > 2 days/week > 2 days/week
reliever/rescue
treatment
* Any exacerbation should prompt review of maintenance treatment to ensure that it is adequete. Although patients
with current clinical control are less likely to experience exacerbations, they are still at risk during viral upper
respiratory tract infections and may still have one or more exacerbations per year.
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9. MANAGEMENT AND
PHARMACOLOGIC TREATMENT
Control of asthma can be achieved in a majority of children 5 years and
younger with an intervention strategy that includes:
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• A partnership between the child’s family/caregivers and the health care team
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• Avoidance of risk factors
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• A plan to assess, treat with appropriate pharmacologic therapy, and
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monitor asthma control
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• An action plan to enable the child’s family members and caregivers to
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recognize an asthma attack and initiate treatment, recognize a severe
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episode, and identify when urgent treatment at a hospital (health care
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facility) is required.
Develop a Partnership – TE
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Family/Caregivers and Health Care Providers
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With the help of everyone on the health care team, families/caregivers can
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be actively involved in managing asthma to prevent problems and enable
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children to live productive, physically active lives. They can learn to:
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• Help the child avoid risk factors
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• Ensure that the child takes medications correctly
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• Understand the difference between “controller” & “reliever” medications
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• Monitor asthma control status using symptoms
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• Recognize signs that asthma is worsening and take action
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• Seek medical help as appropriate
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Education should be an integral part of all interactions between health care
professionals and the family/caregivers of young children with asthma.
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Using a variety of methods—such as discussions (with a physician, nurse,
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outreach worker, counselor, or educator), demonstrations, written materials,
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group classes, video or audio tapes, dramas, and family support groups—
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helps reinforce educational messages.
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For wheezy children 5 years and younger, when wheeze is suspected to be
caused by asthma, a written asthma action plan based on the levels of res-
piratory symptoms can be an effective tool to help family members/care-
givers improve and maintain control of the child’s asthma.
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10. Identify and Reduce Exposure to Risk Factors
To improve control of asthma and reduce medication needs, patients
should take steps to avoid the risk factors that cause their asthma symp-
toms (Table 3). However, many asthma patients react to multiple factors
that are ubiquitous in the environment, and avoiding some of these factors
completely is nearly impossible. Thus, medications to maintain asthma
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control have an important role because patients are often less sensitive to
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these risk factors when their asthma is under control.
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Table 3. Strategies for Avoiding Common Allergens and Pollutants
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Avoidance measures that improve control of asthma and reduce
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medication needs:
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• Tobacco smoke: Stay away from tobacco smoke. Parents and caregivers
should not smoke.
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• Drugs, foods, and additives: Avoid if they are known to cause symptoms.
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Reasonable avoidance measures that can be recommended but have
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not been shown to have clinical benefit:
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• House dust mites: Wash bed linens and blankets weekly in hot water and
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dry in a hot dryer or the sun. Encase pillows and mattresses in air-tight cov-
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ers. Replace carpets with hard flooring, especially in sleeping rooms.
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(If possible, use vacuum cleaner with filters. Use acaricides or tannic acid to
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kill mites—but make sure the patient is not at home when the treatment
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occurs.)
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• Animals with fur: Use air filters. (Remove animals from the home, or at least
from the sleeping area. Wash the pet.)
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• Cockroaches: Clean the home thoroughly and often. Use pesticide spray—
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but make sure the patient is not at home when spraying occurs.
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• Outdoor pollens and mold: Close windows and doors and remain indoors
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when pollen and mold counts are highest.
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• Indoor mold: Reduce dampness in the home; clean any damp areas fre-
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quently.
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11. ASSESS, TREAT, AND MONITOR ASTHMA
The goal of asthma treatment—to achieve and maintain clinical control—
can be reached in most patients through a continuous cycle that involves
• Assessing Asthma Control
• Treating to Achieve Control
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• Monitoring to Maintain Control
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Assessing Asthma Control
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Each patient should be assessed to establish his or her current treatment regi-
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men, adherence to the current regimen, and level of asthma control. Current
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impairment (day and night symptoms, activity level impairment, need for res-
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cue medications) and future risk (likelihood of acute exacerbation in the
future) should both be addressed. A simplified scheme for recognizing con-
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trolled, partly controlled, and uncontrolled asthma is provided in Table 2.
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Treating to Achieve Control TE
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For the treatment of asthma inhaled medications are preferred because
they deliver drugs directly to the airways where they are needed, resulting
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in potent therapeutic effects with fewer systemic side effects.
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Devices recommended to deliver inhaled medication for children 5 years and
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younger include pressurized metered-dose inhalers (pMDIs) and nebulizers. Spacer
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(or valved holding-chamber) devices make inhalers easier to use and reduce
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systemic absorption and side effects of inhaled glucocorticosteroids.
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Among children in this young age group, inhaler technique may be poor
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and should be monitored closely.
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Teach family members/caregivers how to use the specific inhaler device(s)
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prescribed for their child, as different devices need different inhalation techniques.
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• Give demonstrations and illustrated instructions.
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• Ask family members/caregivers to show how their children use the
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inhalers at every visit.
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For each child, select the most appropriate device. In general:
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• Children younger than 4 years of age should use a pMDI plus a
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spacer with face mask, or a nebulizer with face mask.
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• Children aged 4 to 5 years should use a pMDI plus a spacer with
mouthpiece, or a pMDI plus a spacer with a face mask or, if nec-
essary, a nebulizer with face mask.
• For children using spacers, the spacer must fit the inhaler.
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12. Information about use of various inhaler devices is found on the GINA
Website (www.ginasthma.org).
A variety of controller and reliever medications for asthma are available.
The recommended treatments discussed below are guidelines only. Local
resources and individual patient circumstances should determine the spe-
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cific therapy prescribed for each patient.
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All young children with asthma should be prescribed a reliever medica-
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tion to use as needed for quick relief of symptoms. (Parents and care-
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givers should be aware of how much reliever medication the child is
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using—regular or increased use indicates that asthma is not well con-
trolled.) A rapid-acting inhaled β 2-agonist is the recommended choice of
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reliever medication for most patients in this age group.
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If the child’s asthma is not controlled with as-needed use of reliever med-
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ication, a low-dose inhaled glucocorticosteroid is the recommended initial
controller treatment (Table 4). TE
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This initial treatment should be given for at least 3 months to establish its
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effectiveness in reaching control. If at the end of this period the low dose
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of inhaled glucocorticosteroid does not control symptoms, and the child is
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using optimal technique and is adherent to therapy, doubling the initial
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dose of glucocorticosteroid given in Table 5 may be the best option.
Addition of a leukotriene modifier to the low-dose inhaled glucocorticos-
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teroid may also be considered.
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13. Table 4. Asthma Management Approach Based on
Control for Children 5 Years and Younger
Asthma education, Environmental control, and As needed rapid-acting β 2-agonists
Controlled Partly controlled Uncontrolled or only
on as needed on as needed partly controlled on
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rapid-acting β 2-agonists rapid- acting β 2-agonists low-dose inhaled
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glucocorticosteroid*
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Controller options
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Continue as needed Low-dose inhaled Double low-dose inhaled
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rapid-acting β 2-agonists glucocorticosteroid glucocorticosteroid
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Leukotriene modifier Low-dose inhaled
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Leukotriene modifier
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*Oral glucocorticosteroids should be used only for treatment of acute severe exacerbations of asthma.
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Shaded boxes represent preferred treatment options.
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Table 5. Low Daily Doses* of Inhaled Glucocorticosteriods
for Children 5 Years and Younger
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Drug Low Daily Dose (µg)
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Beclomethasone dipropionate 100
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Budesonide MDI+spacer 200
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Budesonide nebulized 500
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†
NS
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Ciclesonide
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Fluticasone propionate 100
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†
Mometasone furoate NS
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Triamcinolone acetonide NS
* A low daily dose is defined as the dose which has not been associated with clinically adverse
effects in trials including measures of safety. This is not a table of clinical equivalence.
† NS = Not studied in this age group.
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14. Monitoring to Maintain Control
Ongoing monitoring is essential to maintain control and establish the low-
est step and dose of treatment to minimize cost and maximize safety.
Typically, patients should be seen one to three months after the initial visit,
and every three months thereafter. After an exacerbation, follow-up should
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be offered within two weeks to one month.
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Adjusting medication:
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• If asthma is not controlled within one to three months by doubling the ini-
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tial dose of inhaled glucocorticosteroids, assess and monitor the child’s
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inhalation technique, compliance with medication regimen, and avoid-
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ance of risk factors.
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• If control is maintained for at least 3 months, decrease treatment to the
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least medication necessary to maintain control. Monitoring is still neces-
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sary even after control is achieved, as asthma is a variable disease;
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treatment has to be adjusted periodically in response to loss of control as
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indicated by worsening symptoms or the development of an exacerbation.
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Asthma symptoms remit in a substantial proportion of children 5 years and
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younger, and some children have symptoms only during certain seasons of
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the year. It is recommended that the continued need for asthma treatment
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in children under age 5 should be regularly assessed (every 3-6 months). If
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asthma therapy is discontinued, a follow-up visit should be scheduled 3-6
weeks later to verify that the remission of symptoms persists.
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Consult with an asthma specialist when other conditions complicate asthma,
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if the child does not respond to therapy, or if asthma remains uncontrolled.
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Approach to the Child with Intermittent Wheezing Episodes
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Intermittent episodic wheezing of any severity may represent unrecognized
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uncontrolled asthma, an isolated viral-induced wheezing episode, or an
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episode of seasonal or allergen-induced asthma. The initial treatment rec-
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ommended includes a dose of rapid-acting inhaled β 2-agonist every 4–6
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hours as needed for a day or more until symptoms disappear.
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If a detailed history suggests the diagnosis of asthma, and wheezing
episodes are frequent (e.g., 3 in a season), regular controller treatment
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should be initiated. Regular controller treatment may also be indicated in a
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child with less frequent, but more severe, episodes of viral-induced wheeze.
Where the diagnosis is in doubt, and when rapid-acting inhaled β 2-ago-
nist therapy needs to be repeated more frequently than every 6-8 weeks, a
diagnostic trial of regular controller therapy should be considered to con-
firm whether the symptoms are due to asthma.
11

15. Manage Acute Exacerbations
Exacerbations of asthma (asthma attacks) are acute episodes of deteriora-
tion in symptom control that are sufficient to cause distress or risk to health
necessitating a visit to a health care provider or requiring treatment with sys-
temic glucocorticosteroids.
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Do not underestimate the severity of an attack (Table 6); severe asthma
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attacks may be life threatening. Early symptoms may include any of the
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following:
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• An increase in wheeze and shortness of breath
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• An increase in coughing, especially nocturnal cough
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• Lethargy or reduced exercise tolerance
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• Impairment of daily activities, including feeding
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• A poor response to reliever medication
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R
Upper respiratory symptoms frequently precede the onset of an asthma
exacerbation.
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Home Management
T
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A health care provider may recommend steps for the family/caregiver to
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care for an asthma attack at home:
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• Initiate treatment with two puffs of inhaled rapid-acting β 2-agonist,
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given one puff at a time via a mask or spacer device.
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• Observe the child and maintain a restful atmosphere for one hour or
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more
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• Seek medical attention the same day if inhaled bronchodilator is
required for symptom relief more than every 3 hours or for more than
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24 hours.
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Oral glucocorticosteroid treatment by family/caregivers in the home man-
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agement of asthma exacerbations in children should be considered only where
IG
the physician is confident that this medication will be used appropriately.
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Immediate medical attention should be sought ….
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• For children younger than 1 year requiring repeated rapid-acting
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inhaled β 2-agonists over the course of hours
• If the child is acutely distressed
• If the symptoms are not relieved promptly by inhaled bronchodilator
• If the period of relief after a dose of inhaled β 2-agonist becomes pro-
gressively shorter
12

16. Table 6. Initial Assessment of Acute Asthma in Children
Five Years and Younger
Symptoms Mild Severea
Altered consciousness No Agitated, confused or
drowsy
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Oximetry on presentationb 94% < 90%
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(SaO2)
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Talks inc Sentences Words
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Pulse rate < 100 bpmd > 200 bpm (0-3 years)
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> 180 bpm (4-5 years)
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Central cyanosis Absent Likely to be present
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Wheeze intensity Variable May be quiet
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a Any of these features indicates a severe asthma exacerbation
b Oximetry performed before treatment with oxygen or bronchodilator
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c The normal developmental capability of the child must be taken into account.
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d bpm = beats per minute.
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If a severe exacerbation fails to resolve in 1 to 2 hours in spite of repeated
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dosing with rapid-acting inhaled β 2-agonists, with or without the addition
ER
of oral glucocorticosteroids, refer the child to the hospital (or health center)
for observation and further treatment (Table 7).
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Other indications for referral to the hospital/health center include:
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• respiratory arrest or impending arrest
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• lack of supervision in the home
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• recurrence of signs of severity within 48 hours of the initial exacerba-
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tion (particularly if treatment with systemic glucocorticosteroids has
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been given).
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For children younger than 2 years, early medical attention should be
sought as the risk of dehydration and respiratory fatigue is increased.
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17. Table 7. Indications for Immediate Referral to Hospital
ANY of the following:
• No response to three (3) administrations of an inhaled
short-acting β 2-agonist within 1-2 hours
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• Tachypnea despite 3 administrations of an inhaled short-acting β 2-agonist
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(Normal respiratory rate < 60 breaths per minute in children 0 – 2 months;
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< 50 in children 2 –12 months; < 40 in children 1 – 5 years)
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• Child is unable to speak or drink or is breathless
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EP
• Cyanosis
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• Subcostal retractions
R
• Oxygen saturation when breathing room air < 92%
O
R
• Social environment that impairs delivery of acute treatment;
TE
caregivers unable to manage acute asthma at home
AL
T
Asthma attacks require prompt treatment (Table 8):
O
N
• Oxygen delivered by face mask given at hospital (health center) if the
O
patient is hypoxemic (achieve O2 saturation above 94%).
-D
• Inhaled rapid-acting β 2-agonists in adequate doses are essential (two
L
puffs at 20-minute intervals for an hour).
IA
ER
• Failure to respond to bronchodilator therapy at 1 hour, or earlier if the
child deteriorates, requires urgent admission to hospital and a short
AT
course of oral glucocortiocosteroids.
M
• Children prescribed maintenance therapy with inhaled glucocorticos-
D
teroids or leukotriene modifier or both should continue to take the pre-
TE
scribed dose during and after an attack.
H
IG
Therapies not recommended for treating attacks include:
R
PY
• Sedatives.
O
• Mucolytic drugs.
C
• Chest physical therapy/physiotherapy.
• Epinephrine (adrenaline) may be indicated for acute treatment of ana-
phylaxis and angioedema but is not indicated during asthma attacks.
• Intravenous magnesium sulphate has not been studied in young children.
14

18. Table 8: Initial Management of Acute
Severe Asthma in Children 5 Years and Younger*
Therapy Dose and Administration
Supplemental Deliver by 24% face mask (flow set to manufacturer’s
oxygen instructions, usually 4L/minute)
E!
Maintain oxygen saturation above 94%
C
U
Short-acting 2 puffs salbutamol by spacer,
D
β 2-agonist or
O
2.5 mg salbutamol by nebulizer
R
Every 20 minutes for first hoursa
EP
R
Ipratropium 2 puffs every 20 minutes for first hour only
R
O
Oral prednisolone
R
Systemic (1-2 mg/kg daily for up to 5 days)
glucocorticosteroids
TE or
Intravenous methylprednisolone
AL
1 mg/kg every 6 hours on day 1;
every 12 hours on day 2; then daily
T
O
N
Consider in ICU: loading dose
Aminophyllineb 6-10mg/kg lean body weight
O
-D
Initial maintenance: 0.9 mg/kg/hour
Adjustment according to plasma theophylline levels
L
IA
ER
Oral β 2-agonists No
AT
Long-acting β 2-agonist No
M
D
a If inhalation is not possible an intravenous bolus of 5 µg/kg given over 5 minutes, followed by
TE
continuous infusion of 5 µg/kg/hour.
The dose should be adjusted according to clinical effect and side effects84.
H
IG
b Loading dose should not be given to patients already receiving theophylline.
R
PY
O
C
15

19. Follow up:
Before discharge from the emergency department or hospital, the condition
of the patient should be stable, e.g., out of bed and able to eat and drink
without problem. Family/caregivers should receive:
• Instruction on recognition of signs of recurrence and worsening of asth-
E!
ma. The factors that precipitated the exacerbation should be identified
C
and strategies for future avoidance of these factors implemented
U
D
• A written individualized action plan including details of accessible
O
emergency services
R
EP
• A supply of bronchodilator and, where applicable, the remainder of
the course of oral or inhaled glucocorticosteroids or leukotriene modifier
R
R
• Careful review of inhaler technique
O
R
• Further treatment advice
TE
• A follow-up appointment within 1 week and another within 1-2 months
AL
depending on the clinical, social, and practical context of the exacer-
bation
T
O
N
O
-D
L
IA
ER
AT
M
D
TE
H
IG
R
PY
O
C
16

20. E!
The Global Initiative for Asthma is supported by educational grants from:
C
U
D
O
R
EP
R
R
O
R
TE
AL
T
O
N
O
-D
L
IA
ER
AT
M
D
TE
H
IG
R
PY
O
C
Copies of this document are available at
www.ginasthma.org
www.us-health-network.com