6.

11 TREATMENT OF ACUTE ASTHMA IN CHILDREN AGED

LESS THAN 2 YEARS
6.11.1 β2 AGONIST BRONCHODILATORS
A trial of bronchodilator therapy should be considered when
symptoms are of concern. If inhalers have been successfully
administered but there is no response, review the diagnosis
and consider the use of other treatment options.
6.11.2 STEROID THERAPY
Steroid tablets in conjunction with β2 agonists have been
shown to reduce hospital admission rates when used in the
emergency department.
Steroid tablets have also been shown to reduce the length of
hospital stay.
What Can I Expect the Day of Steroid Treatment?
Plan to be at the medical center for about one hour on
the day(s) of your IV steroid treatment.
You may receive blood tests before the treatment to
monitor your complete blood count, sodium,
andpotassium levels.
The nurse will also check your blood
pressure and pulse before and after the treatment. The
medication is given by intravenous drip for 30 to 45
minutes or injected directly into a vein.
After the treatment, you can return to your normal daily
activities, including driving.
Patients generally receive a one- to five-day course of
intravenous treatment with steroids.
 Following the treatments, you may be asked to take an
oral form of a steroid called prednisone. Your nurse
will give you a written schedule of when and how often
to take the drug.
You may also be given a prescription for a medication to
reduce stomach irritation.
Prednisone belongs to a class of drugs known as
corticosteroids. It decreases your immune system's
response to various diseases to reduce symptoms such
as swelling and allergic-type reactions.
Are There Side Effects of IV Steroids?
Not everyone experiences side effects from IV steroid
treatment, but the most common are:
 Stomach irritation, such as indigestion and heartburn
 Rapid heartbeat
 Flushing of the face, neck, or chest
 Feeling warm or cool
 Mood changes (euphoria, irritability, nervousness,
restlessness) or mood swings
 Nausea

Long-term side effects of steroids may include:

 Bone-thinning osteoporosis
 Stomach ulcers
 Weight gain
 Diabetes
http://www.emedicinehealth.com/understanding_asthma_m
edications/page5_em.htm
Steroid Therapy - Current Indications in
Practice
Some of the current indications are:
1.Perioperative replacement therapy.
2.Anti-inflammatory uses and hyper-reactive
airway
3.Post operative nausea and vomiting (PONV)
4.Analgesia adjunct
5.Day care surgery
6.Anaphylaxis
7.Septic shock
8.Other indications like - cerebral oedema,
spinal cord injury, various surgical causes.

Equivalent doses apply only to oral or

intravenous preparations- Short (8-12 Hrs),
L- Long (36-72 Hrs), I- Intermediate (12-36
Hrs)
http://www.ijaweb.org/article.asp?issn=0019-
5049;year=2007;volume=51;issue=5;spage=389;epage=389;a
ulast=Grover
http://patient.info/doctor/corticosteroids-and-
corticosteroid-replacement-therapy
For children, if corticosteroids cannot be given orally,
give intravenously.
Give either of the following:
 hydrocortisone IV initial dose 8–10 mg/kg (maximum
300 mg), and then 4–5 mg/kg (maximum 300 mg)
every 6 hours on day 1, every 12 hours on day 2,
once daily on day 3 and, if needed, once daily on
days 4–5
 methylprednisolone IV initial dose 2 mg/kg
(maximum 60 mg), and then 1 mg/kg (maximum
60 mg) every 6 hours on day 1, every 12 hours on day
2, once daily on day 3 and, if needed, once daily on
days 4–5.

http://www.asthmahandbook.org.au/acute-
asthma/clinical/corticosteroids
Aminophylline
Uses

This medication is used to treat and

prevent wheezing and trouble breathing caused by
ongoing lungdisease (e.g., asthma, emphysema, chronic
bronchitis). Aminophylline belongs to a class of drugs
known as xanthines. It works in the airways by relaxing
muscles, opening air passages to improve breathing,
and decreasing the lungs' response to irritants.
Controlling symptoms of breathing problems can
decrease time lost from work or school.
Side Effects

Stomach pain/cramping, nausea, vomiting, diarrhea,

loss of appetite, headache,trouble sleeping, irritability,
restlessness, nervousness, shaking (tremors), flushing,
and increased urination may occur. If any of these
effects persist or worsen, tell your doctor or pharmacist
promptly.
A very serious allergic reaction to this drug is rare.
However, seek immediate medical attention if you notice
any symptoms of a serious allergic reaction,
including: rash, red/scaly skin, itching/swelling
(especially of the face/tongue/throat), severe dizziness,
trouble breathing.

aminophylline oral : Uses, Side Effects, Interactions,

Pict
http://www.webmd.com/drugs/2/drug-6675/aminophylline-
oral/details#side-effects
Cochrane summaries of asthma management
IV Aminophylline added to Salbutamol and steroids:
In children with a severe asthma exacerbation, the addition
of intravenous aminophylline to ß2-agonists and
glucocorticoids (with or without anticholinergics) improves
lung function within 6 hours of treatment. However there is
no apparent reduction in symptoms, number of nebulised
treatment and length of hospital stay. There is insufficient
evidence to assess the impact on oxygenation, PICU
admission and mechanical ventilation. Aminophylline is
associated with a significant increased risk of vomiting.

http://www.ecinsw.com.au/asthma_controversies
http://www.drugs.com/asthma.html
Drugs and Supplements

Aminophylline (Intravenous Route)

Side Effects
Incidence not known
 Chest pain or discomfort
 dizziness
 fainting
 fast, slow, or irregular heartbeat
 increase in urine volume
 lightheadedness
 persistent vomiting
 pounding or rapid pulse
 seizures
 shakiness
Do NOT use aminophylline if:
 you are allergic to any ingredient in aminophylline

(including ethylenediamine), similar medicines (eg,

theophylline), or xanthines (eg, caffeine, chocolate)
 you are using large amounts of other products that
contain xanthine (such as chocolate or caffeinated
drinks)
 you are taking dipyridamole intravenously (IV) or

halothane
Contact your doctor or health care provider right away if
any of these apply to you.
4. Clinical particulars
4.1 Therapeutic indications
Disease of the cardiovascular system (e.g. an adjunct in
the treatment of pulmonary oedema or paroxysmal
nocturnal dyspnoea caused by left ventricular heart
failure), reversible airways obstruction including status
asthmaticus and acute bronchospasm.

4.2 Posology and method of administration

Aminophylline Injection BP may be given by slow
intravenous injection or intravenous infusion in glucose
injection or sodium chloride injection.

Aminophylline has a narrow therapeutic index,

therefore cautious dosage determination is essential.
Therapeutic serum concentrations of theophylline are
considered to range from 10 to 20 mcg/ml and levels
greater than 20 mcg/ml are often associated with toxic
effects. A range of 5 to 15 mcg/ml may be effective, and
associated with fewer adverse effects.

The dosage should be titrated for each individual and

adjusted with caution. Serum theophylline levels
should be monitored to ensure that they remain within
the therapeutic range. During therapy, patients should
be monitored carefully for signs of toxicity.
Elimination of theophylline in children younger than 6
months of age, especially in neonates, appears to be
reduced. Because of this variation in metabolism the use
of Aminophylline injection in children under 6
months of age is not recommended.

To minimise adverse effects, IV Aminophylline should

be administered slowly, at a rate not exceeding 25mg
Aminophylline per minute, up to a dose of 250-500mg
(5mg/kg). If patients experience acute adverse effects
while loading doses are being infused, the infusion
may be stopped for 5-10 minutes or administered at a
slower rate.
https://www.medicines.org.uk/emc/medicine/20953

Indications for considering referral, where available

 Difficulty confirming the diagnosis of asthma
 Symptoms suggesting chronic infection,
cardiac disease etc
 Diagnosis unclear even after a trial of treatment
 Features of both asthma and COPD, if in doubt
about treatment
 Suspected occupational asthma
 Refer for confirmatory testing, identification of
sensitizing agent, advice about eliminating
exposure, pharmacological treatment
 Persistent uncontrolled asthma or frequent
exacerbations
  Uncontrolled symptoms or ongoing
exacerbations or low FEV1 despite correct
inhaler technique and good adherence with
Step 4
 Frequent asthma-related health care visits
 Risk factors for asthma-related death
 Near-fatal exacerbation in past
 Anaphylaxis or confirmed food allergy with
asthma
 Significant side-effects (or risk of side-effects)
 Significant systemic side-effects
 Need for oral corticosteroids long-term or as
frequent courses
 Symptoms suggesting complications or sub-types of
asthma
 Nasal polyposis and reactions to NSAIDS (may
be aspirin exacerbated respiratory disease)
 Chronic sputum production, fleeting shadows
on CXR (may be allergic bronchopulmonary
aspergillosis)
 Additional reasons for referral in children 6-11 years
 Doubts about diagnosis, e.g. symptoms since
birth
 Symptoms or exacerbations remain
uncontrolled
 Suspected side-effects of treatment, e.g.
growth delay
 Asthma with confirmed food allergy