Asthma Management Handbook

Treatment trial for preschool wheeze

Recommendations

For children over 12 months old with wheezing episodes that are associated with increased work of breathing (e.g. intercostal retraction), consider a trial of treatment with an inhaled short-acting beta2 agonist given as needed.

If the child is wheezing during the consultation, administer 2–4 puffs (200–400 microg) of salbutamol via spacer and mask. Note any response to treatment (improvement in work of breathing, respiratory rate, breath sounds or wheeze).

If there is a positive response:

  • show parents/carers how to give salbutamol via a pressurised metered-dose inhaler plus spacer (older preschool children) or pressurised metered-dose inhaler plus spacer and mask (infants and children unable to use spacer alone)
  • tell parents/carers to give 2–4 puffs (200–400 microg) when child wheezes, and repeat if wheezing recurs
  • ask parents/carers to watch closely for whether child’s breathing improves (e.g. child stops showing signs of increased work of breathing) and report effects.

If the child is not wheezing during the consultation, show parents/carers how to administer salbutamol, and ask them to trial this treatment over 1–2 days, starting the next time wheezing occurs and to monitor the response.

  • If child needs salbutamol again within 4 hours, or increased work of breathing does not respond to salbutamol, parents/carers should seek urgent medical attention (go to emergency department or call 000).

Notes:
If increased work of breathing resolves in response to inhaled bronchodilator (either during a treatment trial at home or observed in the clinic or hospital), consider whether preventer is indicated.

Table. Classification of preschool wheeze and indications for preventer treatment in children aged 1–5

Severity of flare-ups

Frequency of symptoms

Symptoms every 6 months or less

Symptoms every 3–4 months

Symptoms every 4–6 weeks

Symptoms at least once per week

Mild flare-ups

(managed with salbutamol in community)

Not indicated

Not indicated

Consider

Indicated

Moderate–severe flare-ups

(require ED care/oral corticosteroids)

Indicated

Indicated

Indicated

Indicated

Life-threatening flare-ups

(require hospitalisation or PICU)

Indicated

Indicated

Indicated

Indicated

PICU: paediatric intensive care unit; ED: emergency department

Indicated: Prescribe preventer and monitor as a treatment trial. Discontinue if ineffective.

Not indicated: Preventer is unlikely to be beneficial

Consider prescribing preventer according to overall risk for severe flare-ups

Symptoms: wheeze, cough or breathlessness. May be triggered by viral infection, exercise or inhaled allergens

Flare-up: increase in symptoms from usual day-to-day symptoms (ranging from worsening asthma over a few days to an acute asthma episode)

Preventer options: an inhaled corticosteroid (low dose) or montelukast

[!] Advise parents/carers about potential adverse behavioural and/or neuropsychiatric effects of montelukast

Notes:
Preventer medication is unlikely to be beneficial in a child whose symptoms do not generally respond to salbutamol

In children taking preventer, symptoms should be managed with a short-acting inhaled beta2 agonist reliever (e.g. when child shows difficulty breathing).

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The trial can be repeated if it is inconclusive.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

Last reviewed version 2.0

For children aged 12 months and over with a provisional diagnosis of asthma, consider a trial of preventer treatment, if indicated.

Table. Classification of preschool wheeze and indications for preventer treatment in children aged 1–5

Severity of flare-ups

Frequency of symptoms

Symptoms every 6 months or less

Symptoms every 3–4 months

Symptoms every 4–6 weeks

Symptoms at least once per week

Mild flare-ups

(managed with salbutamol in community)

Not indicated

Not indicated

Consider

Indicated

Moderate–severe flare-ups

(require ED care/oral corticosteroids)

Indicated

Indicated

Indicated

Indicated

Life-threatening flare-ups

(require hospitalisation or PICU)

Indicated

Indicated

Indicated

Indicated

PICU: paediatric intensive care unit; ED: emergency department

Indicated: Prescribe preventer and monitor as a treatment trial. Discontinue if ineffective.

Not indicated: Preventer is unlikely to be beneficial

Consider prescribing preventer according to overall risk for severe flare-ups

Symptoms: wheeze, cough or breathlessness. May be triggered by viral infection, exercise or inhaled allergens

Flare-up: increase in symptoms from usual day-to-day symptoms (ranging from worsening asthma over a few days to an acute asthma episode)

Preventer options: an inhaled corticosteroid (low dose) or montelukast

[!] Advise parents/carers about potential adverse behavioural and/or neuropsychiatric effects of montelukast

Notes:
Preventer medication is unlikely to be beneficial in a child whose symptoms do not generally respond to salbutamol

In children taking preventer, symptoms should be managed with a short-acting inhaled beta2 agonist reliever (e.g. when child shows difficulty breathing).

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How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

Last reviewed version 2.0

If wheezing accompanied by increased work of breathing is markedly reduced during a treatment trial with a preventer, then recurs when treatment is stopped, this supports a provisional diagnosis of asthma in a preschool child.

Note: If the diagnosis is in doubt, performing spirometry later, when the child is able, may be useful to confirm the diagnosis

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

Last reviewed version 2.0

More information

Short-acting beta-2 agonist relievers for children: 1–5 years

Infants under 12 months

In infants under 12 months, bronchiolitis is the most likely cause of acute respiratory distress. Bronchodilators are not recommended in children under 12 months old, consistent with current guidelines for the management of acute bronchiolitis.1

Children aged 1–5 years

Inhaled short-acting beta2 agonists are effective bronchodilators in children aged 1–5 years.2

Short-acting beta2 agonists may be less effective for wheezing in children under 2 years old than in older children.3 However, many clinical trials in infants have included those with bronchiolitis, so there is limited evidence for the effects of short-acting beta2 agonists specifically in asthma.3 Studies conducted in emergency departments have shown that short-acting beta2 agonists are more effective than placebo in controlling acute wheeze in children under 2 years, but may not achieve clinically significant improvements.3

Inhaled short-acting beta2 agonists are generally well tolerated in children aged 1–5 years.2 Adverse effects can include muscle tremor, headache, palpitations and agitation. Muscle tremor and agitation are common with initial use of standard doses, but often settle over time. Serious adverse effects such as hypokalaemia have been reported at very high doses.2

Oral short-acting beta2 agonists are associated with adverse effects2 and should not be used for the treatment of asthma in any age group.

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Administration of inhaled medicines in children: 1-5 years

To use inhaler devices correctly, parents and children need training in inhaler technique and in the care and cleaning of inhalers and spacers.

Children need careful supervision when taking their inhaled medicines (e.g. at preschool), especially when using a reliever for acute asthma symptoms. 

Types of inhalers suitable for preschool children

Preschool children cannot use pressurised metered-dose inhalers properly unless a spacer is attached (with mask when necessary), because it is difficult for them to coordinate inspiratory effort with actuating the device.2 Note that breath-actuated pressurised metered-dose inhalers cannot be used with a spacer.

Dry-powder inhalers are usually ineffective for preschool children because they cannot generate sufficient inspiratory air flow.2

Drug delivery is very variable in young children with any type of inhaler, including pressurised metered dose inhalers and spacers.20 Filter studies have shown high day-to-day variability in delivered doses in preschool children.2 This variation might explain fluctuations in effectiveness, even if the child’s parents have been trained to use the device correctly.

Table. Types of inhaler devices for delivering asthma and COPD medicines Opens in a new window Please view and print this figure separately: http://www.asthmahandbook.org.au/table/show/75

Pressurised metered-dose inhalers plus spacers for relievers

During acute wheezing episodes, delivery of short-acting beta2 agonist to airways is more effective with a pressurised metered-dose inhaler plus spacer than with a nebuliser.2 In older children, salbutamol has also been associated with a greater increase in heart rate when delivered by nebuliser than when delivered by pressurised metered-dose inhaler plus spacer.4

When administering salbutamol to relieve asthma symptoms in a preschool child, the standard recommendation is to shake the inhaler, actuate one puff at a time into the spacer and have the child take 4–6 breaths in and out of the spacer (tidal breathing).5 Fewer breaths may suffice; in children with asthma aged 2–7 years (not tested during an acute asthma episode), the number of tidal breaths needed to inhale salbutamol adequately from a spacer has been estimated at 2 breaths for small-volume spacers, 2 breaths for a spacer made from a 500-mL modified soft drink bottle, and 3 breaths for a large (Volumatic) spacer.6

Face masks for infants

When using a spacer with face mask (e.g. for an infant too young or uncooperative to be able to use a mouthpiece), effective delivery of medicine to the airways depends on a tight seal around the face.

When masks are used for inhaled corticosteroids, there is a risk of exposure to eyes and skin if the seal over the mouth and nose is not adequate. Parents should be advised to wash the child's face after administering inhaled corticosteroids by mask.

Babies are unlikely to inhale enough medicine while crying.4 The use of a spacer and face mask for a crying infant may require patience and skill: the child can be comforted (e.g. held by a parent, in own pram, or sitting on the floor) while the mask is kept on, and the actuation carefully timed just before the next intake of breath. Most infants will tolerate the spacer and mask eventually. The child may be more likely to accept the spacer and mask if allowed to handle them first (and at other times), if the devices are personalised (e.g. with stickers), or if the mask has a scent associated with the mother (e.g. lip gloss). The use of a spacer with a coloured valve allows parents to see the valve move as the child breathes in and out.

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Preparation of new spacers before first use

Spacers are made of plastic, antistatic polymer/polycarbonate polyurethane, or cardboard.

Plastic spacers (e.g. Breath-A-Tech, Volumatic)

Electrostatic surface charge on new spacers made of plastic (e.g. Breath-A-Tech, Volumatic) reduces the proportion of medicine available for delivery to the airway. This charge can be reduced by washing the plastic spacer in dishwashing liquid and allowing it to air dry or drip-dry without rinsing or wiping.2

Alternatively, priming the spacer by actuating the device several times into the spacer also overcomes the charge, but this wastes medicine. The optimal number of actuations for priming is not known and the findings of in vitro studies vary widely. One study (using older, CFC-based formulations of asthma medicines) reported that up to 40 actuations fired into a new plastic spacer overcame the effect of the electrostatic charge.7 Others have concluded that the electrostatic charge on plastic spacers does not reduce in vivo efficacy of bronchodilator therapy in children with asthma.8 The number of actuations necessary may be known when the results of recent studies become available.

When a new plastic spacer must be used immediately (e.g. for a person with asthma symptoms), patients, parents and carers should follow the manufacturer's priming instructions. In hospitals and emergency departments, a new spacer that has not been pre-treated by washing can be primed using multiple (at least 10) puffs of salbutamol. (This is an arbitrary number of actuations in the absence of evidence that would enable a precise guideline.)

Non-plastic spacers

Disposable cardboard spacers (e.g. DispozABLE, LiteAire) and polyurethane/antistatic polymer spacers (e.g. Able A2A, AeroChamber Plus, La Petite E-Chamber, La Grande E-Chamber) do not require preparation before first use.2

Note: The term 'priming' is also used for the preparation process that is necessary for new pressurised metered-dose inhalers that have not been used for more than a week. This involves first actuating the inhaler into the air (away from the patient). Users should follow the manufacturer’s instructions for the particular brand of inhaler, which specify the number of actuations required.

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Wheezing phenotypes in preschool children

Longitudinal population-based cohort studies910 of preschool children with wheezing have identified various long-term patterns (wheezing phenotypes).2

Table. Systems for retrospectively classifying the duration of childhood wheeze

Classification system/source Phenotypes identified Description
Tucson Children’s Respiratory Study † ‡ Transient wheeze

Wheezing commences before the age of 3 years and disappear by age 6 years

Persistent wheeze

Wheezing continues until up to or after age 6 years

Late-onset wheeze

Wheezing starts after age 3 years.

Avon Longitudinal Study of Parents and Children § Transient early wheeze

Wheezing mainly occurs before 18 months, then mainly disappears by age 3.5 years

Not associated with hypersensitivity to airborne allergens

Prolonged early wheeze

Wheezing occurs mainly between age 6 months and 4.5 years, then mainly disappears before child’s 6th birthday

Not associated with hypersensitivity to airborne allergens

Associated with a higher risk of airway hyperresponsiveness and reduced lung function at age 8–9 years, compared with never/infrequent wheeze phenotype

Intermediate-onset wheeze

Wheezing begins sometime after age 18 months and before 3.5 years.

Strongly associated with atopy (especially house mite, cat allergen), higher risk of airway hyperresponsiveness and reduced lung function at age 8–9 years, compared with never/infrequent wheeze phenotype

Late-onset wheeze

Wheezing mainly begins after age 3.5 years

Strongly associated with atopy (especially house mite, cat allergen, grass pollen)

Persistent wheeze

Wheezing mainly begins after 6 months and continues through to primary school

Strongly associated with atopy

Notes

Terms can only be identified after the child has stopped wheezing for several years and cannot be applied to a preschool child.

Transient wheeze, persistent wheeze and late-onset wheeze can be episodic or multiple-trigger wheeze.#

Sources

† Martinez FD, Wright AL, Taussig LM et al. Asthma and wheezing in the first six years of life. The Group Health Medical Associates. N Engl J Med 1995; 332: 133-8. Available from: http://www.nejm.org/doi/full/10.1056/NEJM199501193320301#t=article

‡ Morgan WJ, Stern DA, Sherrill DL et al. Outcome of asthma and wheezing in the first 6 years of life: follow-up through adolescence. Am J Respir Crit Care Med 2005; 172: 1253-8. Available from: http://ajrccm.atsjournals.org/content/172/10/1253.long

§ Henderson J, Granell R, Heron J et al. Associations of wheezing phenotypes in the first 6 years of life with atopy, lung function and airway responsiveness in mid-childhood. Thorax 2008; 63: 974-80. Available from: http://thorax.bmj.com/content/63/11/974.long

# Brand PL, Baraldi E, Bisgaard H et al. Definition, assessment and treatment of wheezing disorders in preschool children: an evidence-based approach [European Respiratory Society Task Force]. Eur Respir J 2008; 32: 1096-110. Available from: http://erj.ersjournals.com/content/32/4/1096.full

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Early childhood wheezing phenotypes cannot be recognised or applied clinically, because they are recognised retrospectively.2 In an individual child with episodic wheeze, it is not possible to accurately predict epidemiological phenotype from clinical phenotype.2

Currently available tools for predicting whether a wheezing preschool child will have asthma at school age (e.g. the Asthma Predictive Index11) have limited clinical value.12

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References

  1. Paediatric Research in Emergency Departments International Collaborative. Australasian bronchiolitis guideline. PREDICT; 2016. Available from: http://www.predict.org.au/publications/2016-pubs/
  2. Brand PL, Baraldi E, Bisgaard H, et al. Definition, assessment and treatment of wheezing disorders in preschool children: an evidence-based approach. Eur Respir J. 2008; 32: 1096-1110. Available from: http://erj.ersjournals.com/content/32/4/1096.full
  3. Chavasse RJ, Bara A, McKean MC. Short acting beta2-agonists for recurrent wheeze in children under two years of age. Cochrane Database Syst Rev. 2002; Issue 2: CD002873. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD002873/full
  4. Schuh, S., Johnson, D. W., Stephens, D., et al. Comparison of albuterol delivered by a metered dose inhaler with spacer versus a nebulizer in children with mild acute asthma. The Journal of pediatrics. 1999; 135: 22-7. Available from: https://www.ncbi.nlm.nih.gov/pubmed/10393599
  5. National Asthma Council Australia. Kids' First Aid for Asthma. National Asthma Council Australia, Melbourne, 2011. Available from: http://www.nationalasthma.org.au/first-aid
  6. Schultz A, Le Souëf TJ, Venter A, et al. Aerosol inhalation from spacers and valved holding chambers requires few tidal breaths for children. Pediatrics. 2010; 126: e1493-8. Available from: http://pediatrics.aappublications.org/content/126/6/e1493.long
  7. Berg E. In vitro properties of pressurized metered dose inhalers with and without spacer devices. J Aerosol Med. 1995; 8 Suppl 3: S3-10; discussion S11. Available from: http://www.ncbi.nlm.nih.gov/pubmed/10157897
  8. Dompeling E, Oudesluys-Murphy AM, Janssens HM, et al. Randomised controlled study of clinical efficacy of spacer therapy in asthma with regard to electrostatic charge. Arch Dis Child. 2001; 84: 178-182. Available from: http://adc.bmj.com/content/84/2/178.full
  9. Martinez FD, Wright AL, Taussig LM, et al. Asthma and wheezing in the first six years of life. N Engl J Med. 1995; 332: 133-138. Available from: http://www.nejm.org/doi/full/10.1056/NEJM199501193320301#t=article
  10. Henderson J, Granell R, Heron J, et al. Associations of wheezing phenotypes in the first 6 years of life with atopy, lung function and airway responsiveness in mid-childhood. Thorax. 2008; 63: 974-980. Available from: http://thorax.bmj.com/content/63/11/974.long
  11. Castro-Rodriguez JA. The Asthma Predictive Index: a very useful tool for predicting asthma in young children. J Allergy Clin Immunol. 2010; 126: 212-216. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20624655
  12. Savenije OE, Kerkhof M, Koppelman GH, Postma DS. Predicting who will have asthma at school age among preschool children. J Allergy Clin Immunol. 2012; 130: 325-331. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22704537