Bronchial Asthma and

Acute Exacerbation of Asthma

by : Sireranjani and Izyan
 Definition
• Chronic airway inflammation leading to increase airway
responsiveness that leads to recurrent episodes of
wheezing, breathlessness, chest tightness and
coughing particularly at night or early morning.
• Often associated with widespread but variable airflow
obstruction that is often reversible either
spontaneously or with treatment.
• Reversible and variable airflow limitation as evidenced
by :
⮚ > 20% improvement in PEFR
(Peak Expiratory Flow Rate), or
⮚ a > 12% improvement in FEV1
(Forced expiratory volume in 1 second)
in response to administration of a bronchodilator.
Diagnosis
Ddx
 Wheezing in child < 5 years old
Acute Bronchiolitis Viral induced wheeze Multi trigger wheeze

● < 2 years old ● Wheezing during discrete ● Wheeze during discrete

● Associated with wheezing , episodes episodes
respiratory distress ● Associated with viral trigger ● Symptoms in between episodes
● No symptoms in between ● URTI usually the trigger
○ May decline at the age of ● Wheeze also in responds to
6 other trigger
○ Continues in childhoes ● Possible evolution to asthma
○ Becomes MTW ● Strong history of asthma

Tx: Tx: Tx :
Symptomatic treatment 1st episode : Oral Montelukast 4mg Oral prednisolone 1mg/kg
- Supply oxygen OD for 2/52 MDI Budesonide low dose
2nd episode: Oral Montelukast 4mg
OD for 2/52
3rd episode : Oral MOntelukast 4mg
OD for 3/12
LONG TERM GOALS OF ASTHMA CONTROL

• To achieve good control of symptoms and maintain

normal activity level
• To minimize the risk of asthma-related death,
exacerbations, persistent airflow limitation and side
effects

( GINA 2019)
• Explain to parents and patient about asthma and all
therapy.
• Ensure compliance, optimal inhaler technique before
progression to next step.
• Step-up; assess patient after 1 month of initiation of
treatment and if control is not adequate, consider step-
up after looking into factors as above.
• Step-down; review treatment every 3 months and if
control sustained for at least 4-6 months, consider
gradual treatment reduction.
INHALER
SIDE EFFECTS OF MEDICATIONS
SIDE EFFECTS

SALBUTAMOL 1. Slight tremor (particularly in the hands)

2. Headache
3. Peripheral dilatation
4. Palpitations
5. Tachycardia
6. Arrhythmias
7. Disturbances of sleep and behavior in children
8. Muscle cramps
9. Hypersensitivity reactions including paradoxical bronchospasm, urticaria, angioedema, hypotension, pulmonary
oedema, erythema multiforme

IPRATROPIUM BROMIDE 1. Gastrointestinal motility disorders (e.g. constipation, diarrhea, vomiting)

2. Dryness of the mouth
3. Increased heart rate, palpitations, supraventricular tachycardia, atrial fibrillation
4. Urinary retention
5. Cough
6. Local irritation
7. Mydriasis
8. Increased intraocular pressure, narrow-angle glaucoma, eye-pain
9. Skin rashes or urticarial
10. Pruritus
11. Angio-edema of the tongue, lips and face
12. Laryngospasm
INHALER SIDE EFFECTS

BUDESONIDE 1. Mild irritation of the throat and thirst

2. Candidiasis of the mouth and throat
3. Cough
4. Generally reversible hoarseness of the voice
5. Bad taste and dryness of the throat
6. Paradoxical bronchoconstriction
7. Headache
8. Nausea
9. Tiredness
10. Diarrhea
11. Skin reaction
12. Osteoporosis

BECLOMETHASONE 1.Secondary hypocortisolism

2. Cataract
3. Glaucoma
Drug Therapy and Delivery Devices
 Prevention
Identifying and avoiding the following common triggers:
• Environmental allergens
⮚ House dust mites, animal dander, insects like cockroach, mould and pollen.
Useful measures: damp dusting, frequent laundering of bedding
with hot water, encase pillow/mattresses with plastic/vinyl covers,
remove carpets from bedrooms, frequent vacuuming, remove pets
from the household.

• Cigarette smoke

• Respiratory tract infections - commonest trigger in children.

• Food allergy - uncommon trigger, occurring in 1-2% of children

• Exercise - Although a recognised trigger, activity should not be limited. Taking a β₂-agonist prior to strenuous
exercise, and
optimizing treatment, are usually helpful.

*Advise patients with moderate to severe asthma to receive an influenza vaccination yearly, there is insufficient
evidence to recommend routine pneumococcal vaccination in people with asthma
Acute exacerbation of bronchial asthma
Definition – exacerbations of asthma are episodes characterised by a
progressive increase in symptoms of SOB, cough, wheezing or chest
tightness and progressive decrease in lung function, may occur in patients
with a pre-existing diagnosis of asthma or occationally as the first
presentation of asthma

GINA MAIN REPORT 2019

Paediatric Asthma Score

Mild : <6
Moderate : 7-10
Severe : >11
INITIAL (ACUTE ASSESSMENT)-ASSESSING THE
SEVERITY
• DIAGNOSIS: symptoms eg. cough, wheezing,
breathlessness, pneumonia
• TRIGGERS: food, weather, exercise, infection, emotion,
drugs, aeroallergens
• SEVERITY: RR, colour, breathing effort, conscious level
SELF MANAGEMENT OF EXACERBATIONS
WITH A WRITTEN ASTHMA ACTION
PLAN
MDI Budesonide 1 puff OD
MDI Salbutamol 2 puffs PRN

MDI Salbutamol 2 puffs 15- 30 mins prior

MDI Salbutamol 4 puffs 6 hourly

MDI Budesonide 1 puff OD

MDI Salbutamol 6 puffs every 15 min

 CRITERIA FOR ADMISSION
• Failure to respond to standard home treatment
• Failure of those with mild or moderate acute asthma to
respond to neb B₂-agonists
• Relapse within 4 hours of neb B₂-agonists
• Severe acute asthma
B₂-agonists
Salbutamol Nebulisation 0.15mg/kg/dose (ma x 5mg)
5mg/ml or 2.5mg/ml <2 y/o :2.5 mg/dose
nebule >2y/o: 5.0mg/dose
Continuos : 500 mcg/kg/hr
Bolus:
15mcg/kg over 10min (max 250mcg)
Infusion:
start 0.5-1.0mcg/kg/min, adjusted
according to response and heart
rate up to max 5 mcg/kg/min

Terbutaline Nebulisation 10mg/ml, 0.2-0.3 mg/kg/dose or

2.5mg/ml or 5mg/ml <20kg:2.5 mg/dose
respule >20kg:5.0 mg/dose

Parenteral 5-10mcg/kg/dose

Corticosteroid
Prednisolone Oral 1-2 mg/kg/day (for 3-7 days)
Hydrocortisone IV 4-5mg/kg/dose 6 hourly (max 100mg)
Methylprednisolone IV 1mg/kg 6 hourly DAY 1, then 12hourly DAY 2, then 24
hourly
Other agents

Ipratropium bromide Nebuliser solution (250mcg/ml) <5y/o :250mcg 4-6 hourly

>5 y/o: 500mcg 4-6 hourly

Aminophylline IV 6mg/kg slow bolus (if not previously on

theophylline) followed by infusion 0.5-1.0
mg/kg/hr (adjusted according to TDM)
 CASE
Muhammad Rayyan Amsyar bin Ahmad Saifulnizal
8 year 5 months old
born via SVD
NKMI/ NKDFA
CW: 18.4kg
Height: 119.4cm
Currently 3rd hospitalisation

1st hospitalisation- admitted to C3 when he was 5 years old for upper respiratory tract
infection, admitted for 4 days highest on face mask 5L/min
Started on antibiotics then discharged well

2nd hospitalisation- admitted to KPJ in August 2022 for upper respiratory tract infection was
admitted for 4-5 days highest on face mask
Started on antibiotics
Patient presented with
+ rapid breathing
+ productive cough for 2 day associated with yellowish sputum
-no post tussive vomiting
+ runny nose for 2 days
+ reduce oral intake

otherwise
- active as usual
- no fever
- no vomiting
- no loose stool
- no history of sick contact
 Cough profile
● Daytime sx: every once/ twice per week
● Nighttime Sx :Nil
● Exercise induced Sx : Once / Twice in a month
● Family H/O : elder brother has bronchial asthma , father has bronchial asthma, mother has
allergic rhinitis
● Has h/o neb x3 this year, last taken in August 2023
● Father is non smoker
● Patient does not allergic rhinitis / eczema
● Trigger :cold weather, cold drinks
● Has carpets and cats at home

Dietary history
● Consumes normal adult diet
● Usually consume rice and chicken

Developmental History
● Patient is Standard 2 student at Sk Batu Kurau , able to follow teaching lessons well .
● Has friends at home , play sport with friends and able to social well with others
Family history

38 y/o 40 y/o
U/L BA U/L allergic rhinitis
works at factory housewife

15 y/o 10y/o
U/L BA NKMI
Patient went to KK , Upon arrival to KK , noted patient tachypneic with RR 52 breaths / mins,speak in
partial sentence , Sp02: 97% under RA , noted subcostal recession

on auscultation , generalised rhonchi heard

What is PAS score for this child ?

Pas score : 10 - moderate asthma - given Neb VN x2 back to back

In ward ,
General examination : active , good pulse volume , warm peripheries , CRT < 2s , mildly tachypneic , RR:
27 + mild subcostal recession

Lungs : prolonged expiratory phase and occasional rhonchi

CVS : DRNM
PA : Soft

CXR :Hyperinflated lungs

Pas score : 7
Blood Investigations
FBC 12/12/23
Hb: 14.9
WBC;14.9
PLT 358

Diagnosis : Moderate AEBA secondary to URTI with underlying of newly diagnosed mild
persistent bronchial asthma

Treatment :
1. Keep SpO2> 95%
2. Neb VN 4 hourly
3. Oral Prednisolone 20 mg OD x 5/7
4. MDI Budesonide 200 mcg OD

Discharged with MDI salbutamol 200mcg PRN

MDI Budesonide 200mcg OD
T. Loratadine 5mg OD
ORal Prednisolone 20mg OD for 3 days
Upon Discharge , patient not tachypneic , RR 24 , no recession , able to speak full
sentence

Lungs : equal air entry , prolonged expiratory phase

Pas Score : 5

Discharged with MDI salbutamol 200mcg PRN

MDI Budesonide 200mcg OD
T. Loratadine 5mg OD
ORal Prednisolone 20mg OD for 3 days
 REFERENCES
• Paediatric protocols 4th ed
• GINA main report 2023
• Handling of inhaler devices: a practical guide for
pharmacists