Paediatrics: Asthma: clinic management (2)

Asthma: clinic management (2)

0–2yrs

In this age group, a spacer device with an appropriate face mask is used, e.g. a small volume Aerochamber^® or Ablespacer^® which can take any inhaler; or a large volume Volumatic^® or Nebuhaler^®, which only fit cer-tain inhalers. Prophylactic therapy with inhaled steroids is more effective than cromoglicate.

Acute treatment

·  Salbutamol via Volumatic^®: <2400micrograms/day (in 6 doses).

·  Terbutaline via Nebuhaler^®: <6000micrograms/day (in 6 doses).

·  Ipratropium via Volumatic^®: <480micrograms/day (in 4 doses).

Prophylactic treatment

·  Budesonide via Nebuhaler^®: 100–400micrograms/day.

·  Beclometasone via Volumatic^®: 100–400micrograms/day.

3–5yrs

Acute treatment

·  Salbutamol via Volumatic^®: <3600micrograms/day (in 6 doses).

·  Terbutaline via Nebuhaler^®: <6000micrograms/day (in 6 doses).

Prophylactic treatment

·  Budesonide via Nebuhaler^®: 100–800micrograms/day.

·  Beclomethasone via Volumatic^®: 100–800micrograms/day.

·  Fluticasone via Volumatic^®: (>4yrs) 100–200micrograms/day..

·  Salmeterol via Volumatic^®: (>4yrs) 50micrograms/day. Must never be given alone and only when the child is also taking an inhaled steroid.

·  Combination inhaler: Seretide^® (contains fixed doses of fluticasone and salmeterol).

5–12yrs

Acute treatment

·  Salbutamol Accuhaler^®: <7200micrograms/day (in 6 doses).

·  Salbutamol inhaler: (>12 years) <7200micrograms/day (in 6 doses).

·  Terbutaline inhaler: (>12 years) <7200micrograms/day (in 6 doses).

Prophylactic treatment

·  Budesonide Turbohaler^®: 100–800micrograms/day.

·  Beclometasone via Accuhaler^®: 100–800micrograms/day.

·  Fluticasone via Volumatic^®: 100–400micrograms/day.

·  Combination inhaler – Seretide^® (contains fixed doses of fluticasone and salmeterol); or Symbicort turbohaler^® (fixed doses of budesonide and formoterol).

Useful clinic guides

Steroids

·Fluticasone and budesonide are preferable since they have fewer side-effects than beclometasone

·Patients on doses of steroids greater than fluticasone 500micrograms/day, budesonide 800micrograms/day, beclometasone 800micrograms/day should be under the supervision of a specialist clinic

Long-acting β₂-agonists

·Salmeterol may be of value for night-time symptoms or daytime activity

·Should be used as a prophylactic agent

·Consider in patients on inhaled beclometasone or budesonide 400micrograms/day, or fluticasone 200micrograms/day

Allergen avoidance

·Removal of feather or woollen bedding

·Wrapping of mattress in plastic

·Cleaning of carpets and furniture

·No pets in the house if the child is allergic to them

Passive smoking

·No smoking in the house or car.

·Parents/carers must be strongly encouraged to stop smoking completely.

Education

Older patients will need to learn more about their condition and how it is best treated. For example:

·Which medication to use and when

·Best inhaler technique

·What to do if asthma is getting worse

·Not to smoke

·Gargle after steroid inhaler use so as to avoid oral thrush