Asthma Management Handbook

Managing acute wheezing episodes in children 0–5 years

Recommendations

Manage acute wheezing with an inhaled short-acting beta2 agonist bronchodilator (reliever) as indicated, according to age and clinical significance. Educate parents how and when to give reliever.

  • Do not prescribe oral salbutamol. Inhalation is the recommended route for delivering relievers for all children and adults.

Table. Non-emergency use of bronchodilators (relievers) in children aged 0–5 years

Age Notes Salbutamol dose and delivery

0–6 months

Consider discussing with a paediatric respiratory physician or paediatrician before prescribing an inhaled short-acting beta2 agonist (salbutamol).

2–4 puffs (100 mcg per puff) as needed via pressurised metered-dose inhaler, spacer and face mask

6–12 months

Consider managing wheezing episodes with an inhaled short-acting beta2 agonist bronchodilator (salbutamol) only if wheezing is associated with increased work of breathing (i.e. intercostal retraction)

Use inhaled salbutamol with caution and discontinue if wheezing does not resolve promptly after use. 

2–4 puffs (100 mcg per puff) as needed via pressurised metered-dose inhaler, spacer and face mask

1–5 years

Manage wheezing episodes with inhaled short-acting beta2 agonist (salbutamol) as needed if associated with increased work of breathing (i.e. intercostal retraction).

Usual dose: 2–4 puffs (100 mcg per puff) as needed via pressurised metered-dose inhaler, spacer and face mask (infants) or spacer (if old enough to cooperate)

Note: This table lists usual salbutamol doses to be administered by carers in the community to manage symptoms as needed. Doses are higher during acute episodes, including emergencies.

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How this recommendation was developed

Consensus

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

Consider a course of oral corticosteroids for children with acute asthma/wheezing that is associated with increased work of breathing and is severe enough to require hospital admission. (Do not prescribe oral corticosteroids for children younger than 6 years unless acute wheezing is severe enough to require hospitalisation).

How this recommendation was developed

Adapted from existing guidance

Based on reliable clinical practice guideline(s) or position statement(s):

  • van Asperen et al. 2010 1

Do not instruct parents to start a course of oral corticosteroids at their own discretion for wheezing children aged 0–5 years (e.g. as part of the child’s written asthma action plan). Instruct parents to seek medical advice each time.

How this recommendation was developed

Adapted from existing guidance

Based on reliable clinical practice guideline(s) or position statement(s):

  • van Asperen et al. 2010 1
  • Brand et al. 2008 2

If frequent (four or more per year) courses of oral corticosteroids are needed to manage severe acute flare-ups, reassess regular medicine regimen and consider specialist referral.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available), with particular reference to the following source(s):

  • van Asperen et al. 2010 1

Do not prescribe long-term oral corticosteroids without specialist assessment by a paediatric respiratory physician.

How this recommendation was developed

Adapted from existing guidance

Based on reliable clinical practice guideline(s) or position statement(s):

  • van Asperen et al. 2010 1

Advise parents that children taking a regular preventer medicine should keep taking it during wheezing episodes.

How this recommendation was developed

Consensus

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

Do not prescribe high-dose inhaled corticosteroids to manage symptoms, and do not recommend that parents give children high doses of inhaled corticosteroid treatment during wheezing episodes.

Table. Definitions of ICS dose levels in children

Inhaled corticosteroid

Daily dose (mcg)

Low

High

Beclometasone dipropionate

100–200

>200 (up to 400)

Budesonide

200–400

>400 (up to 800)

Ciclesonide

80–160

>160 (up to 320)

Fluticasone propionate

100–200

>200 (up to 500)

† Dose equivalents for Qvar (TGA-registered CFC-free formulation of beclometasone dipropionate)

‡ Ciclesonide is registered by the TGA for use in children aged 6 and over

Source

van Asperen PP, Mellis CM, Sly PD, Robertson C. The role of corticosteroids in the management of childhood asthma. The Thoracic Society of Australia and New Zealand, 2010. Available from: 
http://www.thoracic.org.au/clinical-documents/area?command=record&id=14

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How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available), with particular reference to the following source(s):

  • Brand et al. 20082

More information

Short-acting beta-2 agonist relievers for children: 0–5 years

Inhaled short-acting beta2 agonists are effective bronchodilators in children aged 0–5 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

Paradoxical responses to inhaled short-acting beta2 agonists have been reported in infants.2 Bronchodilators are generally not recommended in children under 6 months old, consistent with current guidelines for the management of acute bronchiolitis.4

Inhaled short-acting beta2 agonists are generally well tolerated in children aged 0–5 years.2 Adverse effects (e.g. muscle tremor, headache, palpitations, agitation or hypokalaemia) have been reported at high doses.2

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

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Oral corticosteroids for children: 0–5 years

Few clinical trials have assessed the effectiveness of oral corticosteroids for managing flare-ups of wheezing in preschool children,2 and there is very little evidence about their effects in children who are not being treated in hospitals or emergency departments.

Short courses of oral corticosteroids initiated by parents in response to the onset of wheezing symptoms do not appear to reduce the need for hospitalisation or treatment in the emergency department for preschool children.2 For children age 1–5 years with wheezing due to a respiratory tract virus such as the common cold, a short course of oral prednisolone does not reduce the severity of symptoms.56

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Parent-initiated oral corticosteroid treatment in children

There is limited and inconclusive evidence from clinical trials evaluating the effectiveness of courses of oral corticosteroids initiated by parents in response to children’s wheezing.7

In children aged 6–14 years, a course of oral prednisolone initiated by parents in response to an asthma flare-up may reduce asthma symptoms and the number of missed school days.8

In children aged 1–5 years with episodic wheezing, oral corticosteroids are not effective in managing the symptoms of acute lower respiratory tract illnesses.9

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Oral corticosteroids for children: adverse effects

A short course of oral corticosteroid therapy (less than 2 weeks) is associated with little risk of long-term suppression of the hypothalamus–pituitary–adrenal axis.1 However, risk can accumulate if frequent courses (four or more per year) are given.1

Recurrent courses of oral corticosteroids may also affect bone mineral density, especially in boys.1

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Administration of inhaled medicines in children: 0–5 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. 

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.10

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

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 firing the device.2 Note that breath-actuated pressurised metered-dose inhalers cannot be used with a spacer.

Even when using pressurised metered dose inhalers and spacers, drug delivery is very variable in young children.11 The inhaler design may improve spacer technique,11 but will not necessarily improve clinical outcomes. The amount of medicine delivered by inhaler devices to the lower airways varies from day to day 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.

When administering salbutamol to relieve asthma symptoms in a preschool child, the standard recommendation is to shake the inhaler, fire one puff at a time into the spacer and have the child take 4–6 breaths in and out of the spacer (tidal breathing).12 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.13

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.10 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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Correct use of inhaler devices

The majority of patients do not use inhaler devices correctly. Australian research studies have reported that only approximately 10% of patients use correct technique.1415

High rates of incorrect inhaler use among children with asthma and adults with asthma or COPD have been reported,16, 17, 18, 19, 20 even among regular users.21 Regardless of the type of inhaler device prescribed, patients are unlikely to use inhalers correctly unless they receive clear instruction, including a physical demonstration, and have their inhaler technique checked regularly.22

Poor inhaler technique has been associated with worse outcomes in asthma and COPD. It can lead to poor asthma symptom control and overuse of relievers and preventers.16, 23, 21, 24, 25 In patients with asthma or COPD, incorrect technique is associated with a 50% increased risk of hospitalisation, increased emergency department visits and increased use of oral corticosteroids due to flare-ups.21

Correcting patients' inhaler technique has been shown to improve asthma control, asthma-related quality of life and lung function.26, 27

Common errors and problems with inhaler technique

Common errors with manually actuated pressurised metered dose inhalers include:22

  • failing to shake the inhaler before actuating
  • holding the inhaler in wrong position
  • failing to exhale fully before actuating the inhaler
  • actuating the inhaler too early or during exhalation (the medicine may be seen escaping from the top of the inhaler)
  • actuating the inhaler too late while inhaling
  • actuating more than once while inhaling
  • inhaling too rapidly (this can be especially difficult for chilren to overcome)
  • multiple actuations without shaking between doses.

Common errors for dry powder inhalers include:22

  • not keeping the device in the correct position while loading the dose (horizontal for Accuhaler and vertical for Turbuhaler)
  • failing to exhale fully before inhaling
  • failing to inhale completely
  • inhaling too slowly and weakly
  • exhaling into the device mouthpiece before or after inhaling
  • failing to close the inhaler after use
  • using past the expiry date or when empty.

Other common problems include:

  • difficulty manipulating device due to problems with dexterity (e.g. osteoarthritis, stroke, muscle weakness)
  • inability to seal the lips firmly around the mouthpiece of an inhaler or spacer
  • inability to generate adequate inspiratory flow for the inhaler type
  • failure to use a spacer when appropriate
  • use of incorrect size mask
  • inappropriate use of a mask with a spacer in older children.

How to improve patients’ inhaler technique

Patients’ inhaler technique can be improved by brief education, including a physical demonstration, from a health professional or other person trained in correct technique.22 The best way to train patients to use their inhalers correctly is one-to-one training by a healthcare professional (e.g. nurse, pharmacist, GP, specialist), that involves both verbal instruction and physical demonstration.28, 16, 29, 30 Patients do not learn to use their inhalers properly just by reading the manufacturer's leaflet.29 An effective method is to assess the individual's technique by comparing with a checklist specific to the type of inhaler, and then, after training in correct technique, to provide written instructions about errors (e.g. a sticker attached to the device).14, 27

The National Asthma Council information paper on inhaler technique includes checklists for correct technique with all common inhaler types used in asthma or COPD.

Inhaler technique must be rechecked and training must be repeated regularly to help children and adults maintain correct technique.26, 16, 17 

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References

  1. van Asperen PP, Mellis CM, Sly PD, Robertson C. The role of corticosteroids in the management of childhood asthma. The Thoracic Society of Australia and New Zealand, 2010. Available from: http://www.thoracic.org.au/clinical-documents/area?command=record&id=14
  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. Ministry of Health, NSW. Infants and children: acute management of bronchiolitis.. Version 2. Ministry of Health, NSW, Sydney, 2012. Available from: http://www0.health.nsw.gov.au/policies/pd/2012/PD2012_004.html
  5. Oommen A, Lambert PC, Grigg J. Efficacy of a short course of parent-initiated oral prednisolone for viral wheeze in children aged 1-5 years: randomised controlled trial. Lancet. 2003; 362: 1433-1438. Available from: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(03)14685-5/fulltext
  6. Panickar J, Lakhanpaul M, Lambert PC, et al. Oral prednisolone for preschool children with acute virus-induced wheezing. N Engl J Med. 2009; 360: 329-328. Available from: http://www.nejm.org/doi/full/10.1056/NEJMoa0804897#t=article
  7. Vuillermin P, South M, Robertson C. Parent-initiated oral corticosteroid therapy for intermittent wheezing illnesses in children. Cochrane Database Syst Rev. 2006; Issue 3: CD005311. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD005311.pub2/full
  8. Vuillermin P, Robertson CF, Carlin JB, et al. Parent initiated prednisolone for acute asthma in children of school age: randomised controlled crossover trial. BMJ. 2010; 340: c843. Available from: http://www.bmj.com/content/340/bmj.c843.long
  9. Beigelman A, King TS, Mauger D, et al. Do oral corticosteroids reduce the severity of acute lower respiratory tract illnesses in preschool children with recurrent wheezing?. J Allergy Clin Immunol. 2013; 131: 1518-1525. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23498594
  10. 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
  11. Schultz A, Sly PD, Zhang G, et al. Incentive device improves spacer technique but not clinical outcome in preschool children with asthma. J Paediatr Child Health. 2012; 48: 52-6. Available from: http://onlinelibrary.wiley.com/doi/10.1111/j.1440-1754.2011.02190.x/full
  12. National Asthma Council Australia. Kids' First Aid for Asthma. National Asthma Council Australia, Melbourne, 2011. Available from: http://www.nationalasthma.org.au/first-aid
  13. 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
  14. Basheti IA, Armour CL, Bosnic-Anticevich SZ, Reddel HK. Evaluation of a novel educational strategy, including inhaler-based reminder labels, to improve asthma inhaler technique. Patient Educ Couns. 2008; 72: 26-33. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18314294
  15. Bosnic-Anticevich, S. Z., Sinha, H., So, S., Reddel, H. K.. Metered-dose inhaler technique: the effect of two educational interventions delivered in community pharmacy over time. The Journal of asthma : official journal of the Association for the Care of Asthma. 2010; 47: 251-6. Available from: https://www.ncbi.nlm.nih.gov/pubmed/20394511
  16. Price, D., Bosnic-Anticevich, S., Briggs, A., et al. Inhaler competence in asthma: common errors, barriers to use and recommended solutions. Respiratory medicine. 2013; 107: 37-46. Available from: https://www.ncbi.nlm.nih.gov/pubmed/23098685
  17. Capanoglu, M., Dibek Misirlioglu, E., Toyran, M., et al. Evaluation of inhaler technique, adherence to therapy and their effect on disease control among children with asthma using metered dose or dry powder inhalers. The Journal of asthma : official journal of the Association for the Care of Asthma. 2015; 52: 838-45. Available from: https://www.ncbi.nlm.nih.gov/pubmed/20394511
  18. Lavorini, F., Magnan, A., Dubus, J. C., et al. Effect of incorrect use of dry powder inhalers on management of patients with asthma and COPD. Respiratory medicine. 2008; 102: 593-604. Available from: https://www.ncbi.nlm.nih.gov/pubmed/18083019
  19. Federman, A. D., Wolf, M. S., Sofianou, A., et al. Self-management behaviors in older adults with asthma: associations with health literacy. Journal of the American Geriatrics Society. 2014; 62: 872-9. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24779482
  20. Crane, M. A., Jenkins, C. R., Goeman, D. P., Douglass, J. A.. Inhaler device technique can be improved in older adults through tailored education: findings from a randomised controlled trial. NPJ primary care respiratory medicine. 2014; 24: 14034. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25188403
  21. Melani AS, Bonavia M, Cilenti V, et al. Inhaler mishandling remains common in real life and is associated with reduced disease control. Respir Med. 2011; 105: 930-8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21367593
  22. National Asthma Council Australia. Inhaler technique for people with asthma or COPD. National Asthma Council Australia, Melbourne, 2016. Available from: https://www.nationalasthma.org.au/living-with-asthma/resources/health-professionals/information-paper/hp-inhaler-technique-for-people-with-asthma-or-copd
  23. Bjermer, L.. The importance of continuity in inhaler device choice for asthma and chronic obstructive pulmonary disease. Respiration; international review of thoracic diseases. 2014; 88: 346-52. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25195762
  24. Haughney, J., Price, D., Barnes, N. C., et al. Choosing inhaler devices for people with asthma: current knowledge and outstanding research needs. Respiratory medicine. 2010; 104: 1237-45. Available from: https://www.ncbi.nlm.nih.gov/pubmed/20472415
  25. Giraud, V., Roche, N.. Misuse of corticosteroid metered-dose inhaler is associated with decreased asthma stability. The European respiratory journal. 2002; 19: 246-51. Available from: https://www.ncbi.nlm.nih.gov/pubmed/11866004
  26. Basheti IA, Reddel HK, Armour CL, Bosnic-Anticevich SZ. Improved asthma outcomes with a simple inhaler technique intervention by community pharmacists. J Allergy Clin Immunol. 2007; 119: 1537-8. Available from: http://www.jacionline.org/article/S0091-6749(07)00439-3/fulltext
  27. Giraud, V., Allaert, F. A., Roche, N.. Inhaler technique and asthma: feasability and acceptability of training by pharmacists. Respiratory medicine. 2011; 105: 1815-22. Available from: https://www.ncbi.nlm.nih.gov/pubmed/21802271
  28. Basheti, I. A., Reddel, H. K., Armour, C. L., Bosnic-Anticevich, S. Z.. Counseling about turbuhaler technique: needs assessment and effective strategies for community pharmacists. Respiratory care. 2005; 50: 617-23. Available from: https://www.ncbi.nlm.nih.gov/pubmed/15871755
  29. Lavorini, F.. Inhaled drug delivery in the hands of the patient. Journal of aerosol medicine and pulmonary drug delivery. 2014; 27: 414-8. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25238005
  30. Newman, S.. Improving inhaler technique, adherence to therapy and the precision of dosing: major challenges for pulmonary drug delivery. Expert opinion on drug delivery. 2014; 11: 365-78. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24386924