Nursing Children with Asthma

Asthma is a chronic disease that may not only be life-limiting, but possibly life-threatening. The World Health Organisation defines asthma as 'A disease characterised by recurrent attacks of breathlessness and wheezing, which can vary in severity and frequency from person to person' (WHO 2020).

In Australia, asthma affects about 10% of people aged 0-14, making it the most common chronic illness experienced by children (AIHW 2020).

Signs and Symptoms of Asthma in Children

When identifying asthma in children you might notice signs of respiratory distress. The child may have a costal/intercostal recession or tracheal tug. Nasal flaring or head bobbing in younger children may also be apparent (PCH 2018).

Upon auscultation of the chest, reduced air entry and/or wheezing may be heard. A child may be unable to speak in sentences or even may be short of breath after walking a short distance (SA DoH 2020).

Beware of a silent chest. If there is no audible wheeze and no obvious breath sounds, this could mean the child is having a severe asthma attack. This is a life-threatening situation (SA DoH 2020).

The patient’s history is important when assessing asthma. Is there any family history of atopy? Does the child usually need an inhaler and if so, when did they last need it? Any previous ICU admissions? Any viral prodrome? (SA DoH 2020)

On presentation to the emergency department, many children may already have seen a GP or commenced treatment at home. Assessing the child in regards to previous recent treatment is also useful to assess treatment efficacy. A child who has had back-to-back Salbutamol at the GP’s surgery may need more than just six puffs of his inhaler.

Although the diagnosis of asthma in younger children is sometimes difficult, the National Asthma Council has developed the below table to aid clinicians in decision-making. The RCH Melbourne’s Asthma Guidelines also advise to consider bronchiolitis as an alternative in children under 12 months – in these children, Salbutamol will provide little therapeutic relief.

Asthma more likely	Asthma less likely
More than one of: wheeze difficulty breathing feeling of tightness in the chest cough	Any of: symptoms only occur when child has a cold, but not between colds isolated cough in the absence of wheeze or difficulty breathing history of moist cough dizziness, light-headedness or peripheral tingling repeatedly normal physical examination of chest when symptomatic normal spirometry when symptomatic (children old enough to perform spirometry) no response to a trial of asthma treatment clinical features that suggest an alternative diagnosis
AND
Any of: symptoms recur frequently symptoms worse at night and in the early morning symptoms triggered by exercise, exposure to pets, cold air, damp air, emotions, laughing symptoms occur when child doesn’t have a cold history of allergies (e.g. allergic rhinitis, atopic dermatitis) family history of allergies family history of asthma widespread wheeze heard on auscultation symptoms respond to treatment trial of reliever, with or without a preventer lung function measured by spirometry increases in response to rapid-acting bronchodilator lung function measured by spirometry increases in response to a treatment trial with inhaled corticosteroid (where indicated

(Adapted from National Asthma Council 2019)

Treatment of Children with Asthma

Once asthma has been diagnosed, the initial treatment is usually an inhaled bronchodilator (beta-agonist). Salbutamol is most commonly used. Oxygen should only be used for hypoxia (saturations of less than 90%), not for work of breathing or wheeze (RCHM 2018).

With this in mind, a Cochrane review concluded that spacers were no less effective than nebulisers in delivering beta-agonist relievers to children. Use a spacer for all children; smaller ones are easier to use, store and hold. Large volume spacers should only be used with older children. Practically, a smaller spacer can be used for all ages and with good effect (Cates, Welsh & Rowe 2014).

Salbutamol is either age or weight dependent. As a general rule, children younger than six (or less than 20 kgs) should receive six puffs of Salbutamol via an MDI or 2.5 mg via a nebuliser. Children over six require 12 puffs or 5 mg. Initially, in an acute presentation, Salbutamol is given as a ‘burst’ - that is, every 20 minutes for three doses, then reviewed and given as needed (SA DoH 2020; RCHM 2018).

Some clinicians also choose to give inhaled ipratropium bromide (atrovent) as an initial treatment (SA DoH 2020).

Prednisolone is also given orally in acute asthma exacerbations. The current RCH guidelines advise 2 mg per kg as an initial dose and then 1 mg per kg per dose per day for two more days (RCHM 2018).

Caution is advised when considering giving steroids to pre-schoolers. The new advice is to give only if the child will be admitted to a children’s ward or ICU with a wheeze that responds to bronchodilators in this age range (RCHM 2018).

For children who are sicker and are slower to respond to inhaled therapy, IV medications should be considered.

IV magnesium sulphate is considered a good option for the management of acutely unwell children. It is a smooth muscle relaxant, although its exact mechanism is unclear. Hospital policies vary but if more than two doses of magnesium are given this is often an indication that admission to a hospital with HDU or ICU facilities is required. The child will at the very least need to be admitted under the care of a paediatrician. IV Salbutamol is also an option and once again is likely to lead to admission (RCHM 2018).

Long-Term Treatment of Children with Asthma

Preventative options for children with frequent episodic asthma should be considered. Montelukast (singlair) or a low dose inhaled corticosteroid such as flixitide can be used as first line preventers. Children requiring a preventer should be taken to a GP regularly to help manage their asthma and monitor symptoms and exacerbations (RCHM 2018).

All patients with asthma, whether visiting a GP’s surgery or an emergency department, should receive a written asthma management plan. There is good evidence that written plans aid education and improve compliance (RCHM 2018).

A safety net for both families and clinicians is good discharge advice, especially advice about when to return to hospital or seek a GP review. If a child needs Salbutamol more frequently than every three hours, a review should be sought (SA DoH 2020).

Notes

This advice is general in nature and local hospital clinical guidelines should be followed. A good resource for those seeking further information is The Royal Children’s Hospital Melbourne Clinical Practice Guidelines. This site also provides excellent parental handouts.

This article is the second in a series of articles about paediatric respiratory conditions and, ideally, should be read in conjunction with Paediatric Respiratory Assessment.

Note: This article is intended as a refresher and should not replace best-practice care. Always refer to your facility's policy on treating paediatric asthma.

Additional Resources

• Australian Asthma Handbook
• Royal Children’s Hospital Melbourne, Clinical Practice Guidelines: Asthma Acute
• South Australia Department of Health, South Australian Paediatric Clinical Practice Guidelines: Acute Asthma in Children
• Asthma: How Does it Affect the Body?
• Chest Auscultation
• Important Lung Sounds Made Easy: A Practical Guide (With Full Audio)
• Paediatric Respiratory Assessment

References

• Australian Institute of Health and Welfare 2020, Australia's Children, Australian Institute of Health and Welfare, viewed 5 June 2020, https://www.aihw.gov.au/reports/children-youth/australias-children/contents/health/chronic-conditions-and-burden-of-disease
• Cates, CJ, Welsh, EJ & Rowe, BH 2014, ‘Holding Chambers (Spacers) Versus Nebulisers for Beta-agonist Treatment of Acute Asthma (Review)’, Cochrane Database of Systematic Reviews, viewed 5 June 2020, https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD000052.pub3/pdf/CDSR/CD000052/CD000052_abstract.pdf
• Perth Children’s Hospital 2018, Serious Illness Assessment, Perth Children’s Hospital, viewed 5 June 2020, https://pch.health.wa.gov.au/For-health-professionals/Emergency-Department-Guidelines/Serious-illness
• Royal Children’s Hospital Melbourne 2018, Asthma Acute, Royal Children’s Hospital Melbourne, viewed 5 June 2020, https://www.rch.org.au/clinicalguide/guideline_index/Asthma_acute/
• South Australia Department of Health 2020, South Australian Paediatric Clinical Practice Guidelines: Acute Asthma in Children, South Australia Department of Health, viewed 5 June 2020, https://www.sahealth.sa.gov.au/wps/wcm/connect/8169868040d035a79695be40b897efc8/Acute+Asthma+in+Children_Paed_v3_1.pdf
• World Health Organisation 2020, Asthma, World Health Organisation, viewed 5 June 2020, https://www.who.int/news-room/fact-sheets/detail/asthma