What are the guidelines for managing asthma in children in Queensland?

Queensland Guidelines for Asthma Management in Children

The Queensland guidelines for managing asthma in children recommend a stepwise approach to treatment with inhaled corticosteroids (ICS) as the cornerstone of therapy for persistent asthma, alongside appropriate inhaler technique education and written asthma action plans. 1

Diagnosis and Assessment

• Diagnosis relies on identifying key symptoms:

  • Wheezing
  • Coughing (particularly at night/early morning)
  • Chest tightness
  • Shortness of breath
  • Sleep disturbance due to symptoms 1

• Assessment should focus on:

  • Impairment (frequency/intensity of symptoms, functional limitations)
  • Risk (likelihood of exacerbations, decline in lung function) 1
  • For young children (0-2 years), diagnosis is more challenging as symptoms may be variable and associated with viral infections 2

• Severity indicators requiring urgent attention:

  • Inability to speak in sentences
  • Respiratory rate >25/min
  • Heart rate >110/min
  • Oxygen saturation below normal
  • Peak expiratory flow <50% predicted 1

Stepwise Management Approach

1. Initial Assessment and Inhaler Technique

   • Ensure appropriate inhaler device for child's age
   • Verify correct inhaler technique
   • Educate parents on management principles 2

2. Treatment Based on Severity

   • Mild Asthma: Low-dose ICS-formoterol as needed or daily low-dose ICS plus as-needed SABA
   • Moderate Asthma: Low-dose ICS-formoterol as maintenance and reliever or medium-dose ICS plus as-needed SABA
   • Severe Asthma: High-dose ICS plus LABA 1

3. Special Considerations for Young Children (0-2 years)

   • Consider that wheeze/cough may be associated with viral infections without family history of asthma
   • Recognize that bronchodilator response is variable in the first year of life
   • Rule out mimics: gastro-oesophageal reflux, cystic fibrosis, chronic lung disease of prematurity 2

Medication Administration Guidelines

• Inhaler Devices:

  • Most children cannot use unmodified metered dose inhalers (MDIs) correctly
  • Use large volume spacers with MDIs, especially for inhaled steroids 2
  • For spacer use: actuate MDI, breathe in one puff, repeat actuation, then breathe in second puff 2

• Inhaled Corticosteroids:

  • Mainstay of preventive treatment
  • Use lowest effective dose for symptom control
  • Monitor growth - short-term reductions in growth rate may occur with doses >400 μg/day 2
  • Every child using inhaled steroids from an MDI should use a large volume spacer 2

• Relief Medications:

  • Can be repeated 2-4 hourly for acute symptoms
  • Failure to respond requires immediate medical assessment 2
  • For severe exacerbations: oxygen (40-60%), nebulized salbutamol 5-10 mg, systemic corticosteroids, and consider adding ipratropium bromide 0.5 mg 1

Self-Management Education

• Provide a written asthma action plan that includes:

  • Daily management instructions
  • How to recognize worsening symptoms
  • How to respond to worsening symptoms
  • When to seek emergency care 1

• Educate patients/parents on:

  • Proper inhaler technique
  • Difference between relievers and preventers
  • Recognition of worsening asthma, especially nocturnal symptoms 2

• Empower patients/parents to manage treatment rather than requiring doctor consultation before making changes 2

Monitoring and Follow-up

• Assess treatment outcomes using:

  • Days off school due to asthma
  • Daytime and nighttime cough frequency
  • Frequency of relief medication use
  • Activity limitations and wheeze
  • Appropriateness of inhaler for age and dosages 2
  • Consider peak flow monitoring in children 5 years and older 1

• Monitor height and weight velocities, particularly in children on inhaled steroids 2

Common Pitfalls to Avoid

• Underuse of inhaled corticosteroids in persistent asthma 1
• Overuse of nebulizers (expensive, time-consuming, inefficient) when large volume spacers may be more appropriate 2
• Failure to address comorbidities that can worsen asthma control 1
• Inadequate attention to inhaler technique and adherence before escalating therapy 2
• Not providing written asthma action plans 1

By following these guidelines, healthcare providers in Queensland can effectively manage childhood asthma, minimize symptoms, prevent exacerbations, and improve quality of life for affected children.