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Iap respiratory chapter.doc

lAP Respiratory Chapter
Step 1 - Qualifying some terms
Recurrent: The adjective 'recurrent' is essential to the clinical definition of
asthma. More than three episodes of airflow obstruction are considered significant by several widely followed guidelines. Cough variant asthma: Recurrent isolated cough of unclear etiology may be a
sole and distressing manifestation of asthma. Nocturnal cough: Owing to circadian rhythms bronchial caliber in all humans is
narrow at in the early hours of the morning (4 a.m.). Nocturnal cough may, thus, be the sole manifestation of asthma. In children under treatment, the persistence of nocturnal symptoms suggests the need for better control. Recurrent pneumonic infiltrates: This is defined as more than two episodes in
a year of more than three episodes over any period of time. Consider asthma in the differential diagnosis if the infiltrates recur in different lobes. Step 2 - Pitfalls in auscultation
Localized wheeze: It is important to differentiate this from generalized wheeze,
sin suggests a local obstruction e.g. foreign body. Stridor: Care should be taken to differentiate stridor from wheeze in very small
Conducted sounds: Noisy breathing may occur due to upper airway obstruction
by enlarge tonsils/adenoids/allergic sinusitis/rhinitis. Snoring, mouth breathing, saliva staining the pillow, restless sleep, long unequal breathing pauses with sudden wakening are the features that suggest upper airway obstruction. Diagnosis and assessment of severity
of asthma
Four easy steps
All asthmatic children
Step-1 : Suspect asthma in all children whose
do not wheeze
presenting symptoms may suggest recurrent airflow Symptoms suggestive of recurrent airflow
Beware of pitfalls in
Also consider asthma in the following clinical situations Recurrent pneumonic infiltrates in different lobes Recurrent 'lower respiratory infections'. Asthma being
Step – 2 : Identify signs that suggest generalized
episodic, there may be
no signs at the time of
Signs suggestive of generalized airflow obstruction evaluation
Typical features
Afebrile episodes: This feature may help to differentiate asthma from infectious causes of wheezing in early childhood {page 3). Prolonged cough and / or wheeze after viral respiratory infections may suggest asthma. Personal atopy: If a child has other manifestations of atopic disease, the risk of
asthma increases. Look for flexural dermatitis, eczema and allergic rhinoconjunctivitis which are other atopic manifestations. Pre-existing eczema is probably most important - mainly because eczema is common in the first year of life and thus, predates the development of asthma in most individuals. Atopy / Asthma in a parent or sibling: This doubles the risk of asthma in the
child. 1) both parents have asthma the risk is more than three times as compared Exercise / Activity: In a smaller child, laughing or crying may provoke
Triggers: These are usually inhaled irritants or aeroallergens (page 10).
Seasonality: Sudden temperature changes, flowering season and harvesting
time are risk situations. This feature can be judged only after observation over a Relief with bronchodilator ± short-course oral steroid: A past history of
usage of such drugs with relief or a therapeutic trial with these drugs in a case presenting for the first time are of great importance. This is a clinical indicator of reversible airflow obstruction The regime is discussed under management of an ALTENRATIVE DIAGNOSES
Onset below 6 months of age
Persistent respiratory symptoms
symptoms, fever Persistent cough, constitutional Unusual symptoms
Recurrent multifocal bacterial infections malabsorption, failure to thrive
First life-threatening episode
localized wheeze, unequal air entry
History suggestive of diet allergy (see
Assess clinically to qualify the above symptoms
Clinical features
That merit follow up
In children, asthma is a
clinical diagnosis, made by
evaluation over time either
retrospectively or
Investigations help in
confirming or ruling out
alternative diagnoses,
rather than in diagnosing
Situation 1
In children with a strong family/personal history of atopy, asthma may be suspected even after the first afebrile wheezy illness. Early recognition of asthma in this situation promotes an early and active approach in terms of advice to parents, trigger avoidance and pharmacotherapy. Situation 2
As mentioned earlier, asthma is the commonest cause o( recurrent airflow obstruction in the older child. Early onset asthma i.e. onset in infancy / toddlerhood is, however, well recognized. There exists a group o( infants who are born with anatomically small airways. This predisposes them to wheeze with viral infections (wheeze associated with lower respiratory infections). Each viral infection results in an inflamed hyperreactive airway and further narrowing of airway caliber. As these infants grow older, the airways grow in size and the symptoms progressively abate. Thus, not ail wheeze and cough are caused by asthma and caution is needed to avoid giving infants and young children inappropriately prolonged On the other hand, asthma in early childhood is frequently underdiagnosed (receiving labels such as recurrent bronchitis, asthmatic bronchitis, wheezy bronchitis and recurrent upper respiratory tract infections) and thus, many infants and young children are deprived of the benefits of preventer therapy. Therapeutic strategies for wheezy infants must address the possibility that for those who will go on to develop asthma, a prolonged delay in anti- inflammatory treatment leads to poor growth, school absenteeism, a poor quality of life and: possibly to a permanent loss in pulmonary function. In deciding when to initiate daily long-term control therapy, the clinician must, therefore, weigh the long -term effects of inadequately controlled asthma versus the possible adverse effects of medicarions given over prolonged periods, initiation of the lo ng term control therapy should be considered strongly for infants and young children who in the past year have had more than three episodes of wheezing that lasted more than 1 day and affected sleep, ANE) who in addition have identifiable risk factors for development of persistent asthma as indicated by either a) physician diagnosis of atopic dermatitis or a parental history of asthma OR b) two of the following conditions : physician diagnosed allergic rhinitis, greater than 4 percent peripheral blood eoxinophilia*, or wheezing apart from colds. It should also be considered if they consistently require symptomatic treatment more than two times per week or have severe exacerbations (requiring inhaled beta 2 agonist more frequently than every 4 hours over 24 hours) that occur less than 6 weeks apart. If clear benefit is not observed within 4-6 weeks, alternative diagnoses or therapy must be considered. * In our setting, parasitic infections arc a common cause of peripheral blood Step 3 : continued Clinical features that merit follow up
Situation 1: < 3 episodes of symptoms of airflow
Early recognition of
obstruction in a child with a family history of asthma / asthma leads to
atopy or personal history of atopy
early intervention
• Follow up this child irrespective of age of onset. • Caution parents about future recurrences and advise • Identify trigger factors that may be operative in the child's environment and advise avoidance / special
Continue to look for other qualifying features on follow • Assess the severity over time prospectively as on Distinct pathogenic

Situation 2: Frequent symptoms of airflow obstruction in contribute to
a child between 6 months - 3 years of age bronchoconstriction
but the differing

Wheeze associated lower respiratory infection (WALRl) wheezing
phenotypes may be
and early onset asthma are the common causes of difficult to set apart
wheezing in this age group. While children with asthma in the clinical
do benefit from a preventer drug regime, preventer therapy in WALRl continues to be subject of debate. Early onset asthma
The toddler who
wheezes frequently

is often a
dilemma. “To treat
or not to treat is
the question”
Grading of asthma
In the event of overlapping criteria, it is appropriate to label the patient as In each grade the patient may have a mild, moderate or severe exacerbation. Grading the severity of acute episodes is described on page 17. Note that while grading, the patient may be on treatment with preventer Since asthma is a dynamic condition, the grade of severity may change Peak expiratory flow (PEF) in diagnosis (page 5) Step 4 : Having diagnosed asthma, quantify the symptoms
over a period of time to assess severity Grades of severity of
Symptoms of
Night time
airflow obstruction
expiratory flow

≤ 60% of

> once a day
> one a
>60% -
severity helps
<80% of
to decide the
best or


regime for
> once a week
> twice a
but < once a

<once a week
< twice a
and normal

** A diurnal variation of <10 % in PEF values is normal. Lowest PEF levels are seen on waking and highest levels Children with intermittent asthma but severe exacerbations should be treated as having moderate persistent asthma. Investigations in diagnosis
Hemogram: In asthma, as in other atopic states, mild eosinophilia is common.
Dieth carbamazine is often irrationally prescribed in the setting of wheezy illness with m: eosinophilia. Its use should be reserved for tropical eosinophilia, which should considered when the absolute eosinophil count exceeds 3000 / X-Ray chest: A baseline chest X-Ray is advisable in every case to exclude other
diagnose possibilities mimicking asthma e.g. congenital anomalies, foreign body. Repeat radiograp at frequent intervals or with every exacerbation are not required. In most cases, the chi X-Ray is normal between episodes. Evidence of generalized hyperinflation may be prese in those with severe symptoms or in Spirometry: While spirometry offers objective and sensitive criteria, by no
means are that specific to a diagnosis of asthma. Spirometric findings are thus, to be interpreted in conc with the clinical setting. In children below 7-8 years, spirometry is difficult to perform, is technician dependent and reproducibility of test results is poor. Spirometric results 01 reflect the lung function on the day of testing and may thus be normal since asthma is dynamic condition. The procedure is expensive and the equipment is not widely available For all these reasons, the consensus group feels that spirometry has a very restricted r< in the diagnosis of asthma in the Indian setting. PEF: Standard values for various populations have not been defined. Thus, the
curren accepted norm is to utilize 'personal best' values as a benchmark. In order to obtain persoi best values, monitoring of PEF should be performed over one to two weeks {8.00 a.m. a 8.00 p.m. daily) during asymptomatic periods. This limits the role of PEF in initial diagnc and assessment of severity but makes it better suited to monitor therapy and in follow for reassessment of the grade of severity. Technique, compliance and reproducibility are a difficulties that may be encountered. Children can be trained to use the peak flow me after approximately 5 years of age. Asthma, being a dynamic condition as mentioned early the only merit of PEF monitoring over spirometry is that it can be performed over a o to two week period at home thereby giving a temporal profile. Serum IgE, RAST, Skin allergy testing: These tests may help to confirm atopy,
but t asthma. The various allergens have not been well standardized and skin allergy testing cumbersome, expensive and not widely available. Results of these tests seldom contribute additionally to pharmacotherapy in managing most asthmatics. Hence, these tests are r recommended routinely by the consensus The place of investigations in diagnosis
Which test?
What information?
As a baseline
May reveal mild
eosinophilia in
X-ray chest
situations where diagnosis if: clinical diagnosis of • FEV, and Investigations
are not a
prerequisite to
treatment. In
cases, when
spirometry is
not feasible, a
therapeutic trial
with appropriate

Peak expiratory flow A poor tool for
regime is
of >10 % in PEF when not on bronchodilator therapy or diurnal variation of >20 % in PEF when on bronchodilator therapy Serum IgE levels,
RAST, skin allergy
required prior to immunotherapy to identify incriminating allergens. Goals of long term asthma care
Acute attacks and emergency doctor / hospital visits Daily activities and sports participation Towards reaching the goals.
Keep the child
subjectively and

• Dealing with triggers / precipitants • Dealing with poor asthma control
• Other treatment modalities
Patient education: partnering a long
term strategy with the parents
Patient education is the most important facet of management of childhood asthma. Besides patents, involve the child (if possible) and other caregivers in the discussion. The ten commandments (Checklist of inputs to parents
during the first consultation)
Consider calling
• Discuss that asthma is a chronic condition with episodic these children
at protected
symptoms and explain the need for continuous preventer times; start or
end your day
with a session

• Emphasize that the drugs used 'control' but do not 'cure' asthma. Reassure parents that a majority of children Clear myths and misconceptions regarding inhaled therapy and emphasize merits of the inhaled route. • Discuss the selected regime and address concerns • Discuss the usage and maintenance of the inhaler device • Advise the parent to carry the inhaler device at each • Counsel regarding approximate time taken to note improvement and emphasize the need for compliance with the prescribed preventer drugs. Advise regarding dealing with triggers / precipitants. Emphasize that diet has a small role in causation of symptoms. Advise the parent to maintain a diary of events and carry it at each follow up visit. They may record days that there Group
are events such as daytime cough, nocturnal cough, education
wheeze, reliever medication use, doctor /hospital visits. reassures
parents that
(The prototype asthma diaries described in literature are they are not
detailed and need to be logged in daily and may be used alone and helps
them interact.
in those with persistent symptoms or poor control. Besides, it
Maintaining a daily diary even on 'well days' is less likely saves time
• Educate regarding management of acute exacerbations at • Schedule the first follow up visit 2-4 weeks alter institution of preventer regime. Subsequent visits may he planned 2- 8 weekly according to the severity or earlier in case of The eleventh commandment (During follow up)
Identify any lacunae in understanding and reinforce the More about devices
MDI: Difficulty with coordination of actuation and inhalation precludes the usage
of this device without a spacer in most individuals. Direct usage also causes deposition of more than 80 percent of actuated dose in the orophyarynx. Usage with a spacer is always strongly recommended. Chlorofluorocarbons are known to damage the ozone laye r and are now being replaced by hydrofluoroalkanes. Inhalers which use propellants other than chlorofluorocarbons have been recently introduced in India. They do not offer any additional patient benefit but are environment-friendly. MDI with Spacer*: The age at which one may expect the cooperation and
understanding of a child to move from an 'active' device i.e. MDI with spacer with mask to a 'passive' device i.e. MDI with spacer is approximately 3 years, as tidal breathing is adequate to ensure delivery of drug to the lower airways. An older child may be taught to breathe in and pause after inspiration to a count of'5'. After each actuation of the MDI, the child should be made to inhale a few times rather than breathing once after multiple actuations. *Spacers: Spacers or volume holding chambers eliminate the need for
coordinating inhalation and actuation while using an MDI. For a child on a regime containing medium or high dose inhaled steroid, use of a spacer with the MDI minimizes oral steroid deposition and consequently, the local effects of inhaled steroid therapy viz. thrush and dysphonia. Mouth washing and gargling are further effective in reducing the quantity of swallowed drug. Small and large volume spacers are equally efficacious in drug delivery to lungs. However, small volume spacers may not entirely overcome the problem of coordination of actuation and inhalation. Some children cannot generate the inspiratory flows required to move the valve of the valved spacers. In such children a valved spacer may be used with the child lying down and the spacer vertical so that the valve lies in the open position or alternatively a non-valved spacer may be used. Polyamide spacers are stated to have lesser electrostatic charge lining the inside of the chamber thus making more aerosol available for Spacers should be cleaned monthly rather than weekly as per manufacturers recommendations or performance is adversely affected. They should be washed in soap water solution and allowed to dry in air. The mouthpiece should be wiped clean of detergent before use. Spacers should be replaced yearly for optimum Commercially designed spacers give assured drug delivery, though preliminary data on home made spacers (mineral water bottles) is encouraging. Such home made devices may be considered if cost is a barrier to initiating inhaled therapy. DPI: By the age of 7-8 years, the child can usually be trained to generate
appropriate inspiratory flow (30 - 60 L/min) which is required for optimal drug delivery using a DPI. Lower or higher rates leac to either oral or pharyngeal deposition. During acute exacerbations, the patient may not be able tc generate flows within the specified range. Thus, in this setting the use of DPIs may lead t( Nebulizer: The purchase of a nebulizer for home use is not routinely
recommended. MDI and DP ensure adequate drug delivery and are significantly cheaper and more convenient for daily prevente therapy. MDIs control the size of droplets of aerosol better than nebulizers and rapidly deliver a measure amount of medication. Even in management of acute episodes at home, the use of MDI with spact and mask has been found to give results comparable to a nebulizer. Nebulizers, however, do find plac for management of acute episodes in emergency room / inpatient settings, since, • In acute severe episodes inability to generate optimal inspiratory flows and reduced tidal volumes may result in unreliable delivery. The nebulizer delivers the drug over a longer perk and overcomes the problems of reduced delivery per breath. • Mixing of drugs e.g. short acting beta2 agonist (SA β2 agonist) with anticholinergic nebulize solutions is possible. Initiating inhaled therapy
Select the appropriate device
For preventer
For acute episodes
The advent of
inhaled therapy
9daily use)
will be known as
the most
milestone in the
history of asthma
When it comes to
inhaled therapy
in asthma,
children are not
orphans. New
drugs and novel
devices help
children reap rich

*Spacer devices are inhaler aids used as accessories to benefits
MDIs. In smaller children who are unable to understand or
co-operative, a facemask can be attached to the
mouthpiece of the spacer. Commercially available spacers
differ in size 9small volume large volume), design
(valved/non-valved) and the material used (polyamide /
polycarbonate). For practical purposes drug delivery
through any of these is comparable. Home made spacer may provide an option. Highlight advantages of the inhaled route to the
'Smaller dose': Contrast the milligram (mg) concentration
of syrups and tablets with the microgram (nicy)
concentration of the same drug in the inhaled form.
'Target delivery' - 'Quicker action': Drug is delivered
directly to the site of action. Reliever drugs, therefore, act The metered
dose inhaler with
a spacer is the
'Safer': Smaller dose and thus, much better safety profile most versatile
device. It can be
than with oral therapy. :This is particularly relevant for used through all
ages, for all the

Clear misconceptions that parents may harbour
regimes arid for
Is inhaled therapy addictive.' Emphasize that addiction managemaU of
liability is a property of the drug rather than device / route. acute episodes
Illustrate with an example that alcohol, though oral, is still addictive. Reiterate that none of the asthma medications Is inhaled therapy strong.' Discuss advantages of inhaled treatment as above. Emphasize the microgram Is inhaled therapy expensive.' The inhaler device is a one- time purchase. Only drugs need to be purchased subsequently. A few inhaled drugs may be slightly more expensive than oral drugs on a per "dose basis hut, discuss these in the context of the child's well being, safety and Are inhalers easy enough for children to use? Discuss device selected and the ease |of training required for Instruct parents parents and the child (if possible) regarding usage of the device (see appendix). Alternative regimes
Alternative regimes such as cromones, leukotriene receptor antagonists, and SR theophylline are lest effective than inhaled corticosteroids in mild persistent asthma. Furthermore, alternative add-of therapies to inhaled corticosteroids in moderate persistent asthma, which include leukotriene receptor antagonists and SR theophylline, are less effective than inhaled LARA. Oral regimes are not necessarily a cheaper option; the cost per day of oral therapy being similar to regimes consisting of inhaled steroid alone. If initial expense is a constraint, home made spacers ma be considered. The' drugs in the various regimes
Inhaled corticosteroids (steroids): Inhaled steroids are the most effective
preventer drugs and are hence the 'gold standard'. Beclomethasone dipropionate(BDP), Budesonide(BUD), and Fluticasone propionate(FP) show benefit within 2 to 3 weeks of starting therapy. Low dose refers to usage of inhaled BDP or BUD at < 400 meg/day, medium dose at 400-800 meg day and high dose > 800 meg/day. The corresponding dose of FP is half of these. All comparison use CFC propelled BDP as a reference. When used in equivalent doses the efficacy and advers effect profile are practically similar. Though twice daily administration of ICS is recommended having achieved control, one can administer them once daily. Local adverse affects such as thrush and dysphonia (because of laryngeal myopathy) are occasiona The smallest dose of ICS compatible with maintaining disease control should be used. At highe doses, add on agents, for example LABA, should be actively considered. Administration of IG at or above 400 meg per day of BDP or equivalent should be followed up for systemic side effect such as short-term growth suppression and adrenai suppression. Patients on high dose therapy nee° monitoring of growth and periodic ophthalmic assessment. In practice most patients require low to medium dose of ICS which are safe and devoid of any adverse effects. All the three compound are also available as nasal spray for managing allergic rhinitis. Inhaled long acting β2 agonists (LAB As): Inhaled LABAs are the preferred add- on drugs to ICS for treatment of moderate persistent asthma in children above 5 years of age. Salmeterol / formoterc act synergistically when combined with inhaled steroids and have a steroid sparing role. They are not recommended for use alone in preventer therapy. This class of drugs is particularly effective it children with frequent nocturnal or exercise induced symptoms. For want of children, package inserts advise their use beyond 4 years (salmeterol) or 5 years (formoterol) Potential for developing tolerance Sodium Cromoglycate: Cromoglycate has limited effectiveness but a strong
safety profile it persistent asthma. It could be considered in treatment of mild corticosteroids. The benefits of cromoglycate are usually evident about 3-4 weeks after starting the drug. Ideally, it should he used in 4 daily doses, but in school goiii] children this is often not practical and 3 daily doses may be Leukotriene receptor antagonists (LTRAs): Zafirlu least (for children = years)
and Montelukas (for children = 1 years), are alternative options, hut not preferred therapy for treatment of milt persistent asthma. They also may be used with ICS as add-on therapy in the treatment of moderan persistent asthma (preferred in children < 5 years) and as an alternative to inhaled LABAs in childret >5 years. Theophylline: This drug is no longer recognized as a reliever. Ir possesses anti-
inflammatory am immunomodulator properties and is recommended as an adjunct to inhaled steroids. These effect are seen at serum levels of 5-15 mcg/ml. Syrup formulations have a short duration of action am are, therefore, not suited for preventer therapy. Sustained release formulations are available, but thei dosage forms may be suited only for older children. Oral corticosteroids: If needed, prednisolone may be administered as a single
morning dose ir order to prevent compromise of the hypothalamic-pituitary axis. The morning dose is convemen for school going children and working parents. Selecting the optimal preventer regime
Starting therapy:
Assess grade of severity of asthma. Start the regime appropriate to the grade assessed and titrate upwards if First choice
Other options
Medium to high dose
inhaled steroid + LABA
If needed
Add oral steroid

Low dose inhaled
Low / medium dose
plans must
steroid + LABA* or
steroid + Leukotriene
Medium dose inhaled
receptor antagonist/SR
the fact that
If recurring severe
asthma is both
Medium dose inhaled

a chronic and
steroid + LABA*
a dynamic
Low dose inhaled
Cromolyn, LTRA, SR
(Listed alphabetically)
No daily medication
*** Evidence to date does not support using a third long-term control medication added to inhaled corticosteroids and long-acting inhaled β2 - agonists in order to avoid using systemic corticosteroid therapy. Note: - At every grade of severity, acute episodes should be managed with reliever drugs as discussed on page 18. - If a trial of an add-on treatment is ineffective, stop the drug (or in case of increased inhaled steroid, reduce to the original Onwards:
If goals of treatment achieved i.e. good control - step down If goals of treatment not achieved i.e. poor control - step up treatment if required, as discussed on page l5. Animal dander may persist for a few months after the pet is given away. Therefore improvement in asthma may not be immediately evident. Weather and temperature changes
In general, most acute episodes of asthma are reported in the winter and the Aspirin sensitivity
Aspirin and NSAIDs are not contraindicated in all children with asthma. The triac syndrome is very rare below 8 years of age and may pose an occasional problem in the adolescent. Onset of symptoms ranges from 30 minutes to 2 ho\irs after drug ingestion am is not IgE mediated. There may be accompanying nasal, ocular, dermal or gastrointestina manifestations. The role of diet in the precipitation of asthma symptoms is over-emphasized in our setting While nuts, eggs, chocolates, sea food and certain preservatives are the commoner foot; allergens, providing a general avoid list of food items to all Suspect food allergy only if :
• Symptoms are recurrent, invariable and occuring rapidly after ingestion of • Ingestion often leads to perioral rash and/or gastrointestinal symptoms in • Sudden severe life threatening episodes occur without prior warning. • A child has severe / poorly controlled asthma where other trigger factors have Confirm by avoidance and challenge, if necessary and feasible, with full Dealing with triggers / precipitants
Inhaled allergens/
Advise avoidance and / or special actions
irritants and viral
infections are the

most important
Concurrent medical conditions
Allergic rhinitis: This is suspected in a child with afebrile episodes of
rhinorrhoea, sneezing, stuffiness of nose, features of upper airway obstruction and nocturnal cough (postnasal drip). Examination reveals nasal mucosal edema, hyperemia, clear nasal discharge, post-nasal drip, 'cobblestone' pharyngeal wall, horizontal creases under the eyes(Dennie Morgan lines), bluish/dark discoloration under the eyes(allergic shiners) and a transverse crease The dosage of nasal steroid spray should be added to that of inhaled steroid in order to compute the total dose of steroid therapy. Newer antihistaminics lack anticholinergic and sedative properties and are safe and less troublesome to use in children with allergic rhinitis or eczema accompanying asthma. There is no role for continuing them as therapy in asthma Seasonal asthma
A few children experience asthma symptoms only in relation to certain pollens, spores or molds. The time of the year (harvesting or flowering season) Children with asthma are at risk for complications during and after surgery. Acute bronchoconstriction may be triggered by intubation, impaired cough reflex, atelectasis or respiratory infections. The likelihood of these complications depends upon the severity of the bronchial hyperresponsiveness, mucous Addressing special situations
Concurrent medical conditions
• Allergic rhinitis / • Intranasal steroid sprays: Asthma and
allergic rhinitis
frequently co-
exist-the concept
of one airway,
one disease
• Avoid oral bronchodilators / Perioperative
• For those who have received steroids may be
needed in this
risk situation
months, intravenous hydrocortisone must be given 8 hourly on the day of surgery reducing the dose within 24 hours Exercise induced asthma (E1A)
In some children, EIA may be the only manifestation of asthma, while in most patients it is an expression of poorly controlled asthma and in them, preventer Non-pharmacological advice: Teaching the child the correct breathing technique and avoiding exercise on cold mornings, ensure that warm air reaches the lungs. Each individual has a threshold of activity above which EIA may occur. Initial exercise below that threshold (warming up) induces a latent period of about 1 hour during which span heavier exercise does not provoke symptoms. Pharmacological advice: Optimal anti-inflammatory preventer medications will
reduce airway responsiveness and consequently the occurence of EIA. SA β 2 agonist: They are good for those who exercise infrequently or when the
exercise is planned. Tachyphylaxis is observed and therefore, these agents are not .advisable if exercise is repeated throughout the day or over many days. Inhaled LA β 2 agonist: They may be added in a child on a preventer regime of
inhaled steroid whose exercise induced symptoms are persistent. Administration, of short acting inhaled agents before exercise at school is not always practical in our setting and use of LA P2 agonist with preventer regime is preferred. They may also be used in exercise induced asthma, especially if the time of exercise is not predictable or in children who take part in frequent sporting activities. Formoterol may be considered if exercise is expected early in the day owing to its rapid onset of action. With sustained usage of salmeterol (> 1 month duration), the protective effect of each dose may reduce to 6-9 hours after administration. LTRAs: They are useful whenever the exercise is too frequent or unpredictable
or when exercise induced asthma exists in an otherwise well controlled child with mild asthma. Montelukast, in particular, is a long acting once daily drug and covers for the whole day. It can be used above the age of 1 year making it a preferred option in children below 5 years. Unlike with LA p2 agonist, patients do not exhibit tolerance to the protective effect of LTRA. Addressing special situations
Exercise induced Non-pharmacological advice: • For those not initiated to a particular game, Exercise is the
Avoidance of outdoor exercise on winter mornings only trigger the
child must be
trained to conquer
and not avoid
• Advise a short period of warming up within • Notify teacher / coach about child's condition and advise the need for inhaled medication prior to activity Pharmacological advice :
For prevention
• Grade severity of asthma and institute If EIA persists, select additional options from below: Exercise induced
asthma should not
limit either
participation or
success in sport
effect observed 2-3 hours after salmeterol and within 1 hour after formoterol dose, lasting for 10-12 hours. Leukotriene receptor antagonists (LTRAs) (children 1-4 years), 5mg OD (children 5-12 years) or 10 mg OD (children > 12 years) For treatment
If exercise induces symptoms, treat with inhaled SA J32 agonists Monitoring weight and height
Untreated / Poorly controlled asthma is an important cause of failure to thrive. Once appropriate treatment is instituted, increase in growth velocity is noted. Growth velocity monitoring is also very important in children on high dose inhaled steroid / continuous oral steroid regimes. Such children also need periodic ophthalmic assessment for development of posterior subcapsular Adverse effects of theophylline
Serum theophylline levels need to be monitored in case of symptoms and • Concomitant administration of macrolides, fluoroquinolones, anticonvulsant or Stepping down therapy
Reduction in therapy should be gradual because asthma can deteriorate at a highly variable rate and intensity. Brittle asthma
Brittle asthma is characterized by sudden and unpredictable fall in lung function, often with no evident triggers. The suddenness of the attacks suggests a neurogenic origin. Since some children are poor perceivers of initial bronchospasm and since the condition is labile, continuous long term peak expiratory flow monitoring is recommended. Inhaled bronchodilators, rather than rescue steroids, form the mainstay of therapy. Mechanical ventilation may be Asthma in remission
A child with a past history consistent with persistent asthma who has neither had symptoms of airflow obstruction nor taken therapy for the past 12 Follow up
• Call for first follow up at 1-2 weeks after initiating therapy and subsequent follow up 2-8 weekly-Review regime prescribed and diary of events since the past visit. Enquire specifically regarding bronchodilator usage, school absenteeism, limitation of activity and sleep disturbance. • Assess if symptoms and signs of asthma are present at the time of visit and monitor weight and height. • Check for adverse effects (relevant especially, if on oral drugs Re-emphasize the need for continued compliance and clarify any doubts regarding asthma and its management {page 7). In most cases,
Assess whether goals of treatment (page 6) have been follow up is

Goals of treatment
• At 3-6 months, good control continues principle "Last in - First out" In the • Step down to the regime suitable for a Risk factors for
persisting into
inhaled steroid (grade 2 regime) for 3-6 adulthood
2 out of 3
children with
asthma outgrow
• Onset after the symptoms
• Follow up 3-6 monthly for a period of 1- resumption of preventer regime if recurrences Clinic situations:
Recurrence of symptoms and signs of airflow obstruction during follow-up – Assess as mentioned under poor control. Beware the brittle asthmatic. Irregular follow up - Assess grade of severity on presentation, prescribe appropriate preventer regime and reiterate need for compliance and follow up. Peak expiratory flow (PEF)
In well-controlled children with mild-moderate asthma, routine PEF monitoring is not necessary. Introduction of the concept not only adds to the number of inputs that the parents have to imbibe initially and but also increases the initial cost. The best time to introduce the concept of PEF monitoring is after an acute episode in response to the question, "How do I know an attack is coming ?" or "How do I judge the severity of an attack at home ?". All currently available peak flow meters are comparable. Low reading peak flow meters (those calibrated for a lower range of peak flow) are suited for pediatric The norms for different child populations have not been standardized. It is inappropriate to use 'normals' in the charts supplied with the-devices, since they Ascertain what the normal value for the child is by observin; the child's 'personal best'. This may be done by asking the parents / child to record 8 a.m. and 8 p.m. readings over 7-14 days when the child is asymptomatic. Recheck instrument efficacy and personal best periodically. Readjust personal best values upwards on a yearly basis to account for growth. Parental supervision of recordings is highly desirable because the measurement of PEF is dependent on effort and technique. Patients need instructions, demonstrations and frequent reviews of technique. The procedure is effort dependent - beware a malingering adolescent and ignore a reading when the child has coughed into the device. Caution:
• PEF monitoring during acute episodes may worsen the symptoms by leading to collapse of peripheral airways during forced expiration. • In long term daily monitoring, compliance may be an issue to deal with. Usage of the device is described in the appendix. Spirometry
Spirometry is most helpful to ensure that an apparently well-controlled child has normal lung function. A persistent bronchodilator response in an asymptomatic child is an indicator that preventer therapy should not be reduced. Place of investigations in follow up
PEF and
spirometry may
help to follow
up older
children in
assessment of severity for patients with poor perception of airflow obstruction e.g. britde asthmatics Correctable issues :
Reasons for non-adherence :
Medication – related factors
Patient – related factors
• Misunderstanding the need for • Denial for diagnosis • Difficulties in delivering inhaled • Cultural issues (traditions/ beliefs) Reasons for poor drug delivery – the 3 D’s :
• Incorrect dosing e.g. • Inappropriate device • MDI used directly with • Spacer prescribed, • Mask not apposed to • MDI attached directly • Inability to distract because of humidity • Inability to generate Short course steroid
A temporary increase in anti-inflammatory therapy using oral steroids may be indicated to re-establish control. However, one should resist overuse of oral steroid as an alternative to daily inhaled preventers. Stepping up closes / grades
While stepping up, first step up in the same grade towards the higher range of doses and after this has been achieved, consider stepping up to a higher grade of preventer regime. At each step, give sufficient time for action of Dealing with poor asthma control
A deterioration of asthma may be characterized by reduction in PEF, by failure of inhaled bronchodilators to produce a sustained response, by a reduced tolerance to
exercise or activity or by the development of increasing
nocturnal symptoms. In case of poor response to preventer treatment, the following steps are needed. Rule out alternative diagnosis
Review the history, clinical features and investigations as Usually, 'difficult'
asthma has easy
Identify correctable issues
Adherence: Ascertain adherence with prescribed preventer regime. This may be done by questioning the parents or by comparing the prescribed dose count over a period of time with the number of canisters of inhalers used. Drug delivery: Ask the parent / patient to demonstrate the technique of usage of the inhaler device Trigger elimination: Review the list of triggers. A detailed description of the child's environment may uncover a less Concurrent medical conditions
Reassess the child for concurrent medical conditions viz. allergic rhinitis or gastroesophageal reflux that may be Consider short course steroid
To regain control, a short course of oral prednisolone (1-2 mg / kg / day, maximum 60 mg / day, for 3-10 days) is often effective. \{ asthma symptoms do not recur and PEF remains normal, no additional therapy is necessary. However, if the prednisolone burst does not control symptoms, is effective only for a short period of time (less than 1-2 weeks) or needs to be repeated frequently, Step up preventer dose regime after objective
In children with poor control, an objective assessment of daily trends in peak flow is desirable. Besides comparing with personal best values> diurnal variations need to be studied (page 4). Suitable changes in preventer regime Specialist referral
If poor control still persists, repeat steps described above and consider specialist referral and infrequently needed treatment options e.g. methotrexate, immunotherapy (page 16). Consider complications of asthma such as allergic bronchopulmonary aspergillosis or bronchiectasis. Immunotherapy
The course of allergen immunotherapy is typically of 3-5 years duration. Reactions to immunotherapy, especially bronchoconstriction are more frequent among patients with poorly controlled asthma compared to those with other atopic conditions such as allergic rhinitis. It is, therefore, important to have the asthma relatively stable when starting immunotherapy. Immunomodulators
Immunomoduiator drugs that reduce oral systemic steroid dependence should be used only in selected patients who. are under the supervision of an asthma specialist. Although, some of the compounds have steroid sparing effects, their use in asthma remains complicated because of highly variable effects, potential toxicity and limited clinical experience. The drugs tried include troleandomycin, cyclosporine, methotrexate, gold, intravenous immunoglobulin, dapsone and Complementary medicine
A review of multiple trials on the use of acupuncture in asthma concluded that they lacked quality and that the effectiveness of acupuncture in treating asthma has not been established. One trial, however, demonstrated benefit in EIA. Homeopathy, based on the "law of similars" and the use of infinitesimatly small doses is as yet unproven for asthma. No controlled clinical trials have been reported on herbal medicines and the claims of effectiveness of western plant derivatives for asthma remain unsubstantiated. Efficacy of 'Asmaron', an ayurvedic drug developed by CSIR is yet to be substantiated by scientific trials in children. Other treatment modalities
and immuno-

Usage: As an adjunct to preventer therapy.
drugs have

evidence of

• Poorly controlled asthmatics on maximal benefit but find
use in a very
preventer therapy in whom allergy testing small select
shows sensitivity to one or at the most two group
unavoidable indoor allergens e.g. dust mite. Prerequisites:
• Only in a hospital setting with full resuscitative • Asthma is relatively stable at the time of • Relatively early in the natural history of the disease before irreversible changes have
Immunosuppresive drugs
Methotrexate and gold salts have the best evidence for There is some
positive effects.
evidence of the

Usage: • As an adjunct to preventer therapy.
adjunctive role
of yoga and

• Poorly controlled asthmatics on optimal preventer therapy with good compliance and elimination of triggers or in whom side effects of Prerequisites:
Other modalities
Ketotifen: This oral mast-cell stabilizer has been used as a
preventer drug. Its role in asthma is not well defined. Yoga: Some qualitative research performed without including
control grouops has shown beneficial effect. It may be used
as a supplement to pharmacotherapy.
Acupuncture: Results of published trials examining long-
term benefit are conflicting. Acupuncture has been demonstrated to have a mild bonchodilator effect superior to No data exists
to support other
'placebo' and 'no treatment' when measuring its effect on forms of
methacholine induced bronchoconstriction. Lack of scientific complementary
evidence and experience prevents mention or discussion of other modalities such as homeopathy, ayurveda, fish therapy, Assessment of severity of an acute episode
Assess for presence of 'Red flag' signs which suggest threat • Altered sensoriurn (drowsy or very agitated) Assessment is
clinical and has
Excessive use of accessory muscles or state of exhaustion (vocalization limited to 1-2 words) to be quick
ABG: rate of rise of pC02>5mm Hg/hr, pCO2>40 mm Hg, pO2<60 mm Hg, metabolic acidosis (- If Red flag signs are absent, grade seventy of
exacerbation as below :
Respiratory rate
Wheezing present*
muscle usage
<6 yrs > 6 yrs
< 30 < 20
No apparent
31-45 21-35
Terminal expiration with Questionable
46-60 36-50
Entire expiration with Increase
> 60 >50
During inspiration and Maximum
expiration without activity

* If wheezing absent (due to
minimal air flow), score > 3
4-6 Moderate
> 6 severe
Ascertain the following information:
• Medications the child is already using as The decision
involves two
parts; how to
Reliever medications taken before reporting to treat and where
to treat
Identify risk factors for acute severe asthma:
• Prior intensive care admission / mechanical • Poor compliance with preventer therapy • Rapid onset and progress-of symptoms • Frequent visits to doctor in preceding few days • Visit to emergency room in past 48 hours • Economic and logistic constraints to healthcare Hypoxia is due to ventilation-perfusion mismatch. SA P; agonists may increase the mismatch by attenuating the hypoxic pulmonary vasoconstriction. Hence, oxygen must always be administered along with nebuteed SA P: agonists. Oxygen saturation must be maintained > 91%. Hydration
The child may need more than maintenance fluids initially due to increased insensible Josses. Fluids are also required to make secretions less viscous. The amount required reduces when the patient is ventilated. SIADH must be anticipated, especially if the patient is on positive pressure ventilation. Drugs used in management
Short-acting β2 agonists (SA β2, agonists): SaJbutamoi and terbutaline are similar in their efficacy, actions, kinetics and adverse effects. An isomer of salbutamol (Laevalbuterol), which is now available in the Indian market, is equipotent to salbutamol at half the dose but there is no added advantage as far as side effects or efficacy are concerned. While inhalation is the method of choice, oral alternatives may be justified in children whose symptoms are mild and infrequent. High dose /frequent nebulization with β2 agonists may result in hypokalemia. This has been postulated as a cause of the occurrence of arrhythmia and sudden death. Long-acting β2 agonists have no role in the management of acute episodes. If a child is on a preventer containing this class of drugs, there is an additional need for SA β2 agonists for relief from acute Rescue steroid: Advent of this regime of steroid usage has drastically reduced
morbidity and hospitalization in children with acute exacerbations. Steroid therapy directly reduces inflammation and also induces expression of β2 agonist receptors. Rescue steroids take about 6-8 hours to document an effect, irrespective of route of administration and in situations assessed to be moderate to severe, it is justified to initiate usage early. Underuse of steroids has been incriminated in fatal cases. Oral prednisolone is the best option. Rescue therapy used for 3-7 days has no contraindications and adverse effects with such usage are insignificant. No tapering of dose is necessary. Parenteral steroids do not confer any advantage in an outpatient setting but may be used in hospitalized children who are severely distressed, drowsy or unable to retain oral medication. High dose inhaled steroids are under trial for their role as rescue agents and some studies have reported encouraging results. Ipratropium bromide: Inhaled ipratropium may add to the bronchodilator
benefits seen with inhaled p, agonists but is less effective when used alone. Usage may be limited to 24-48 hours to minimize incidence of atropine-like side- Aminophylline: Aminophylline still finds place in the management of acute
severe episodes in a ward / JCU setting. Improved diaphragm contractility and mucociliary clearance may be beneficial effects. The risk for adverse effects is high, especially in those who are on long acting theophylline as a preventer drug and a loading dose must be avoided in such patients. A calculated intravenous drip rather than a bolus dose is a safer option. Practices not routinely followed
Antibiotics: Antibiotics are not routinely required since bacterial infections
seldom trigger asthma . Consider antibiotics only in those who do not improve in response to bronchodilators, have purulent secretions or have radiological Mucolytics: These may dislodge thick secretions and increase airflow-
Sedatives: This group of drugs may depress the respiratory drive, suppress the
cough reflex and mask the vita! sign of deterioration of sensorium. Chest physiotherapy: This is not routinely indicated. It may actually add to the
child's discomfort. If there is evidence of collapse (invariably due to a mucous plug), gentle cupping and vibration with the palm of the hand is helpful. Formulations available
Short acting β2 agonists
2-4 puffs as needed. May be repeated thrice at 20 min interval and then 1-4 hourly as needed DPI Rotcap 200 1-2 Rotacapas as needed. May be repeated thrice mcg/dose at 20 min intervals and then 1-4 hourly if needed. Neb respirator 0.15 mg/kg, minimum 0.25ml < 6 months age, 0.5 solution 5 mg/ml ml > 6 months age, 0.5-1 ml older children. For continuous nebulization 10mg/10 ml saline via jet nebulizer Use equivalent doses as respirator solution Laevalbuterol
Neb respirator 2-5 mg diluted and nebulized solution 10mg/ml 0.075 mg/kg/dose may be repeated thrice at 20min intervals. Bolus 5-10 mcg/kg over 10 minutes followed by 2-10 mcg/kg/hour iv (1ml terbutaline + 50ml 5% dextrose, thus, 1 ml = 10 mcg terbutaline) Non-selective β2 agonists
Possible adverse
• Nebulizer solution of salbutamol is compatible with nebulizer solution of sodium cromoglycate • Subcutaneous terbutaline is not recommended • IV terbutaline drip necessitates continuous heart rte and ECG monitoring. If heart rate >180/min or if ECG changes develop, havle the drip rate. • Discontinue nebulized β2 agonist if using high • Dose of iv terbutaline is to be halved if concurrently used with theophylline drip. • Since dry powder devices require an optimal inspiratory flow rate they may not be suited to manage acute episodes. May be used for mild • Non selective β2 agents such as isoproterenol and adrenaline are used infrequently because of • May be used when inhaled therapy is not feasible or as an adjunct to inhaled therapy in very severe Formulations
available in India
thrice at 20 mins interval and then 6-8 hourly as needed. 0.5 ml < 1 year, 1 ml > 1 year every 20 Neb respule 0.5mg/2ml Use equivalent doses as respirator Corticosteorids
0.5-1 mg/kg/hr continuous infusion in 5% dextrose. Other drugs
25-50 mg/kg in normal saline infused over sulphate
Possible adverse effects
Dryness of mouth, increased • Slower onset of than β2 agonists but may wheezing in some, blurred • Alternative in children in bronchospasm due Seldom any with short term Rescue therapy or burst therapy : use. • Short-term therapy should continue till glucose metabolism, fluid • Tapering is not necessary. retention, mood alteration may be observed. • Inhaled steroids are not yet proven effective Consideration should be given to co-existing conditions such • Injectable steroids do not confer quicker episodes or when the child is likely to vomit • Aminophylline is superfluous for routine treatment of acute exacerbations in patients receiving optimal j32 agonists and steroids. Use justified only in children with respiratory failure since studies for efficacy have excluded such patients for ethical reasons. Improvement of mucociliary clearance and diaphragm contractility may be important mechanisms in this setting. • Theophylline mg/kg = aminophylline mg/kg x Tachycardia, hypotension, • Calcium channel modulation by this drug muscle weakness results in decreased histamine and acetyl-choline release. Formulations available in
Mast cell
Beclomethasone MDI 50,100,200, 250 mcg/dose 50-400 mcg twice a day
Maintenance dose : 0.25 – 0.5 mg twice a day Fluticasone

Possible adverse effects
Hardly any. Medicinal taste and • 4 times daily regime is difficult to implement. For reflex coughing are minimized by practical purposes three times daily regime may • A dose half hour prior to exercise provides protection from EIA for about 4-6 hours. Cough, dysphonia (laryngeal • Systemic effects of inhaled steroids may occur myopathy), oral thrush. due to pulmonary absorption and intestinal absorption of orally deposited drug. The newer steroids-budesonide and fluticasone propionate are almost completely inactivated by the liver during first-pass metabolism and thus have negligible systemic effects. Fluticasone is not and budesonide have negligible • When using inhaled fluticasone propionate, the beclomethasone dipropionate or budesonide by may occur though studies are not conclusive. These effects include adrenal suppression, growth • Growth monitoring is important if high doses are • Injectable dexamethasone is not recommended for inhalation since systemic absorption is considerable. Comparable to placebo. • Bioavailability not affected by food intake. Uncommonly, may cause • Effect starts soon after initiation of therapy (1st syn¬drome (eosinophilic vasculitis) has been documented on tapering oral steroids Formulations available in India
Long-acting β2
Fluticasone (FP)
Almeterol (Sml)

Formoterol (Form)

Sustained-release anhydrous Getting started theophylline tab/cap 100 mg, 200 mg, > 1 year: (rule of 3's) 300 mg, 450 mg Increments 3 mg/ kg Space the increments 3 days apart Monitor levels 3 days after any increment and then only periodically if poor control/ suspicion of adverse effects <1 year: 0.2 x age in weeks + 5 (gives the dose in mg/kg) Obese: Use average weight for height corticosteroids

Possible adverse effects
Inhaled corticosteroids See • Combination of inhaled steroid with long acting previous page (3, agonists has been shown to have a synergistic effect. • Not to be used for treatment of acute symptoms. • Potential for developing tolerance exists but • significance is probably not relevant. • To be used with inhaled steroid therapy and not • Literature recommends usage only .for children Potential for serious toxicity at • Doses less than 12 mg/kg being used - serum level > 20 mcg/ml- Early caffeine-like adverse effects are • Doses more than 28 mg/kg being used - • Several drugs and clinical situations alter theophylline kinetics (particular care to be taken with macrolides, fluoroquinolones, antitubercular and anticonvulsant therapy). • Introducing the drug gradually reduces incidence Increased appetite, abnormalities • Significant side effects may occur with in glucose metabolism, fluid retention, mood alteration, growth • Low doses for prolonged duration may occasionally be required in severe steroid co-existing conditions such as herpes, varicella or tuberculosis • Use minimum possible dose to control symptoms. Single morning dose is convenient. expensive and do not confer additional benefit. Spacer / Volume holding chamber
Ask the child / parent to:
Assemble the spacer, lining up the notch of one half with the slot of the other half. Then, push the two parts firmly together. Remove tbiL cap of the inhaler, shake the inhaler and insert it into one end Place the mouthpiece of the spacer in the child's mouth. Seal the child's lips around the mouthpiece by gently placing the finger of one hand Encourage the child to breathe in and out slowly and gently. This will make a 'clicking' sound as the valve opens and closes. Once the breathing pattern is well established, depress the canister with the free hand and leave the device in the same position as the child continues to breathe (tidal breathing) 4 to 5 times. An older child may be taught to breathe in deeply and pause after inspiration to a count of '5'. Remove the device from the child's mouth. If a second puff is required, wait for about one minute before repeating For children below about three years, a face mask should be attached to theYnouthpiece of the spacer and apposed closely to the face before Cleaning the spacer:
Wash with a mild soap / detergent solution every month. Allow to drip dry. Do not rinse or use a cloth to dry. This minimizes the static charge and thus, reduces drug deposition on the spacer wall. Metered Dose Inhaler
Ask the child / parent to:
Remove the mouthpiece cover and shake the inhaler. Place the mouthpiece of the inhaler in the mouth between the teeth and seal lips around it taking care not to bite. Start breathing in, slow and deep. Press the canister and continue to Remove the inhaler from the mouth and hold the breath for about 10 Wait for at least one minute before taking another inhalation. Parents must assist and supervise those children who need help in using their MDl correctly. The MDl may be used without spacer only in older children. Accuhaier
Ask the child / parent to:
Slide the purple dust cover to open the device. Hold the Accuhaier with the dose counter facing upward and the Use the thumb to push the lever back till you hear a click. Purse the lips around the mouthpiece and breathe in normally. Close the device by sliding back the cover. Parents must assist and supervise those children who need help in using Rotahaler
Ask the child / parent to:
Hold the Rotahaler vertically and insert a Rotacap, transparent end first, into the small raised square hole of the Rotahaler. Make sure that the top of the Rotacap is level with the top of the hole. (If the shell from previous use is still lodged in the square hole, it will be pushed out when the fresh Hold the mouthpiece and rotate the base. The fin separates the two Instruct the child to breathe out gently. Let the child grip the mouthpiece between the teeth (without biting) and seal his/her lips around it. Then, let the child breathe in the powder slowly and deeply. (If the child is doing this correctly, the Rotacap shell will make a low rattling sound inside the Remove the Rotahaler from the child's mouth and ask him/her to hold the breath for about 10 seconds. Parents must assist and supervise those children who need help in using their Rotahaler correctly. Nebulizer
Optimal volume of solution in nebulizer chamber is 2 to 4 ml Practical points on usage:
• Saline should be used as the diluent and not distilled water. This is because hypo-osmolar solutions can lead to reflex bronchospasm. ^ • Delivery may be effected through a mouthpiece or mask, depending upon the • If a mask is used, it should be held as close to the face as is comfortable for the child. Any gap reduces drug delivery significantly. Cleaning the nebulizer:
After each treatment
After each day
0. Disassemble the nebulizer 0. Disassemble the nebulizer 0. Rinse the tubing, medication cup, 0. Submerge the tubing, medication cup and mouthpiece/mask in a mild liquid detergent and warm water for air-dry between a folded paper towel. Avoid drying in dusty or 0. Using a small bristle brush, scrub all smoky areas. parts to remove any sediment that may have accumulated. Note : If the equipment is not likely to be used again for a few days, it should be placed m a plastic bag with a twist tie and stored in a clean area. * Acetic acid solution is made by mixing one pan white vinegar and three pans water and should be freshly prepared every day. Peak flow meter
There are several types o( peak flow meters available in the Indian market. The steps for using a peak flow meter are similar for alt types. Ask the parent to:
Fit the mouthpiece to the peak flow meter. Ensure that the child stands up and holds the peak flow meter horizontally without restricting movement of the pointer. Adjust the Nose clips are unnecessary. Ask the child to breathe in deeply {as far as possible) with the mouth wide open. Place the mouthpiece in the child's mouth and seal his / her lips around it. Ask the child to blow out as hard and fast as possible. The child should be told to blow out vigourously, as if blowing out candles on his birthday cake. In case the child coughs, disregard that reading. Make sure that the child's tongue is not blocking the mouthpiece. Record the result. Make the child repeat steps 2-4" thrice and record the highest of three


Speech by the rt hon lord owen on the occasion of the doubleday/manchester award 2011, wednesday 26 october

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