The South African Childhood Asthma Working Group (SACAWG), being a subcommittee of the Allergy Society of South Africa (ALLSA), published its first guideline for the management of chronic asthma in children and adolescents in 1992, its second edition in 1994, the third in 2000 and the most recent in 2009. Meanwhile, there have been significant changes regarding diagnostic criteria, especially in young children, in assessing asthma control, management principles, new drugs and new drug-delivery devices. No doubt, pharmacotherapy has been the core of asthma management. The choice of drugs and delivery devices should be selected based on the needs and characteristics of the patients. Periodic assessment of asthma control and review of management is one of the key methodologies for better control of the disease and restriction of side effects from medication.
Methods
SACAWG reconvened in January 2017 with 6 working groups; Each of these was led by a leader forming the editorial committee on asthma epidemiology, assessment, diagnosis, control, treatment, novel treatments and self-management plans. Each of the asthma medications had working groups led by leaders: They used evidence levels when making recommendations under critical scientific literature review as well as adapted methodology in existing guidelines. PubMed and Google Scholar were consulted to find the current level of evidence since the last published guideline. The level of evidence and key recommendations were graded on the GRADE system (Appendix B). After completing each sub-section, it was circulated among the working group for discussion, comment and revision. Any disagreements or inconsistencies were set aside by round robin, whereby, with disagreements, it would depend on the majority recommendation based on the evidence.Severity assessment for starting therapy
The process of assessment is in line with the standards of international assessment. The process of severity assessment is done while placing a child in a certain group that is to be started in the treatment process. This assessment will include a child's signs and lung volumes such as peak expiratory flow (PEF) or forced expiratory flow in 1 second (FEV1) if the child is not treated in the long term. Severity can also be assessed once asthma control is achieved through the stepping up of medications used to maintain control. The most severe grade should have one or more features, with grading of severity being assigned based on which features occur.Medication Principles
When medication is being prescribed to an asthmatic patient, the following are the principles that apply: Routine anti-inflammatory medication is indicated for persistent asthma, but inhaled therapy is preferred, particularly inhaled bronchodilators and inhaled steroids.Drugs are classified into:
• Relievers (bronchodilators) for quick relief of symptoms, including short-acting beta2-agonists (SABAs) (evidence level I) and anticholinergics. Short-acting xanthines are not used in the maintenance treatment of asthma. Anticholinergics are less potent, have a slower onset of action (30 - 60 minutes) and can be used during exacerbations.
• Controllers (anti-inflammatory drugs) for long-term control may alter the airway inflammation that is typical of asthma. The most effective controller therapy for asthma is the use of inhaled corticosteroids (ICS). Anti-inflammatory agents leukotriene receptor antagonists (LTRAs) act by a different mechanism than ICs. Much weaker anti-inflammatory action is possessed by long-acting beta2 agonists. Slow-release theophyllines have much weaker anti-inflammatory actions at lower doses than those needed for bronchodilation.
There are several forms of ICS preparations in SA. ICSs are recommended at standard twice-daily doses. The only two approved once-daily ICSs are Budesonide and Ciclesonide, which are recommended for children over 12 years of age for the treatment of asthma. Furthermore, the majority of patients aged >5 years show a good control when treated with ICS preparations with once-daily or every-other-day doses: 100–200 µg Budesonide and 100 µg Fluticasone as well as their Beclometasone counterparts. Wheezing from viral infections is very common in <2 years and resolves spontaneously and remits after age.</mark> Their use should be strictly restricted to very troublesome symptomatology. Furthermore, ICS would only be acceptable for use with a clear response in treatment if it requires adjunct therapy with oxygen therapy. Above all, the initiation of ICS should be prevented with a lack of remission or a poor response to treatment.
LABAs should be administered adjunctly in combination with ICS. LABAs are mainly added as add-on therapy in children over 5 years of age whose asthma does not respond satisfactorily to a moderate dose of ICS (II evidence level).
LTRAs are short acting (1-3 hours of action and once a day administration. These drugs are administered in 5mg tablet, 4mg chewable tablet formulations and in 4mg oral granules formulations. Device and once-daily administration, the use of LTRA alone is sufficient. Children, ICS are better regarding improvement in symptoms and reduction in exacerbation frequency and hospitalization therapy. It can also be used as first-line alternative therapy for ICSS for children ˂5 years old in the management of episodic or mild persistent asthma (level II). For ages >12 years and for adults; its use is contraindicated as a result of the safety risks involved. Corticosteroids should only be employed orally in a setting of asthmatic emergencies for patients, but were taken for limited courses up to 3 d, as prednisone at a dose of 0.5 - 1 mg/kg/dose once/day. This applies only to children under 5 years of age who are being hospitalized due to an exacerbation.
Administration routes
INHALED MEDICATIONS
Inhaled Treatmentent: should be the mainstay of asthma treatment in all children. All children can potentially be instructed on the proper use of inhaled treatments. Inhaled devices are various for different age groups, and may need to include a pressurized metered-dose inhaler with or without a holding chamber (spinner). Alternatively a dry powder metered-dose inhaler is available. This includes the ability of the administered drug to have effective delivery within the body after inhalation, as well as, cost, ease of use, convenience, as well as potency in a population age group, 5 pMDI with holding chamber (spacer). Preferred over nebulized therapy and is convenient in that it has better side effects in lung deposition and less expense.
Valuable holding chamber: The valuable holding chamber also known as the "spacer": allows breathing at the usuclear rate and ventilation by actually matching actuation with inspiration. Holding chambers therefore improve the ease of inhalation. It holds many of the larger sized particles that would otherwise rise to the oropharynx. This eliminates all possibility of side effects resulting from oropharyngeal deposition. They reduce systemic absorption, and therefore also reduce bioavailability. This is more practical with ICSs such as Beclomethasone and Budesonide which suffer from the problem of first-pass metabolism.
Nebulisers: An MDI with a spacer is equivalent to and probably superior to nebulised treatment for an acute, severe asthma exacerbation. Nebulisers use imprecise dosing and are expensive and waste a large amount of the drug into the ambient air. Nebulisers should be used very rarely in the home and only in situations in which oxygen therapy is required and practical (Evidence Level I).
Dry powder inhaler: A DPI is a breath-activated device that contains micronized drug particles with a mass average aerodynamic diameter of ˂5 μm. Between inhalation and device activation. The disadvantage of DPI is the high inspiratory flow rate (30 - 120 L/min) required to aerosolize the drug. In one study, the age at which most children who had never used a DPI could achieve a peak inspiratory flow rate of ≥30 L/min was 4 years, and the age at which most children could achieve a peak inspiratory flow rate of ≥60 L/min was 9 years. In addition, panting for the best and adequate deposition to the lungs would be very exhausting for pediatric patients, so it should be supplemented by both MDI and DPI. In addition, the uniform dosage for the above devices also varies.
Available therapies
Treat only after assessing symptom control, steroid side effects and other comorbid conditions, eg, allergic rhinitis. Educate the patient well on his or her treatment, eg, inhaler skills, adherence and written asthma action plan. Assess environmental exposure to allergens and irritants, particularly tobacco smoke. Poor adherence or incorrect technique with the inhaler should be diagnosed as an alternative diagnosis. Treating without addressing these problems is contraindicated.Step 1: As-needed use of a short-acting beta2-agonist: If mild symptoms; not severe enough to require oral steroids or hospitalization with supplemental oxygen, dedicated spacer device, facemask and appropriate technique combined with a SABA will be prescribed. Reserved for episodic symptoms and will not prevent future exacerbations. ICS should be considered for patients with any of the following asthma-related features: • An asthma attack in the past 2 years, requiring the use of bronchodilators and systemic steroids ≥3 times a week • Nocturnal awakening ≥1 time a week.
Step 2: Controller treatment with as-needed reliever treatment : All children should be given regular low-dose ICS as first-line controller treatment, which are the most potent preventive drugs for adolescents and older children, to realize overall treatment objectives. Recommended: i). Low-dose ICS improve symptoms of asthma, lung function and quality of life, reduce the risk of exacerbations and hospitalizations for asthma, as well as the risk of asthma-related mortality (grade of recommendation: i). As an alternative, regular LTRAs in young children with recurrent virally induced wheezing improved some asthma outcomes compared with placebo, but did not reduce the frequency of hospitalizations, courses of prednisone, or the number of symptom-free days.
On the other hand, some positive clinical effects of LTRAs have been demonstrated; thus, they can be used as a first controller therapy in children unwilling or unable to use ICS for those patients who will eventually develop side effects of intolerance from ICS or from those with concomitant allergic rhinitis, level II evidence.
Intermittent corticosteroids
These should only be considered in strictly seasonal allergic asthma and only if there is no associated intractable asthma, with initiation at the onset of symptoms to continue for 4 weeks from the end of the relevant pollen season (quality evidence level IV). In all practical markers of lung function and indices of inflammation, as well as control/reliever use, daily is superior to intermittent use. In itself, the strength of the evidence for this duration of treatment demands not to assume equity between these options and therefore advocates for using daily ICS at level I.
Step 3. ICS treatment should be managed with an advance to a moderate dose of ICS, with SABA as needed as an alternative course of management.
In children 6 years of age and older, an alternative treatment is the addition of moderate dose ICSs or LTRA. For children >6 years of age, as an alternative option, an as-needed SABA can be used in combination with a low-dose ICS/LABA combination. Thus, evidence suggests that these two treatments have equivalent outcomes. However, meta-analyses pointed to a trend for an increased risk of exacerbations requiring rescue therapy and hospitalization with ics/LABA treatment in children compared with medium-dose ICS (evidence level I). This information forms the basis for current recommendations to escalate therapy to medium-dose ICS as the preferred option in this age group. The first choice is the addition of a LABA to ICS if a child is greater than or equal to 12 years of age. There are two possible approaches to this.
There exists evidence for combining as-needed SABA reliever therapy with ICS/LABA therapy to enhance asthma control, along with evidence of its superiority over ICS-alone treatment in real-life settings. However, ICS/formoterol may be more convenient for maintenance and reliever therapy or in a single-inhaler therapy approach, as opposed to the classic fixed-dose ICS/LABA therapy approach. Comparative studies between the two have revealed lower daily doses of ICS, in addition to a lower need for oral steroids or hospitalization in the latter group (Evidence Level I). Most important is that no matter the age, LABAs should never be used without ICS; instead they are used when ICS therapy is used alongside it. Adding slow-release theophylline to a low-dose ICS increases it to the level of medium/high-dose ICS. Level II evidence.
Step 4: Two or more controllers and a reliever drug needed as a second controller on top of a high-dose ICS is the option in this category. Moreover, adding a third controller to a failed medium-dose ICS/LABA regime can also be applied. Tiotropium, via mist inhaler, is also known to be potent in controlling asthma in patients who are continuing on moderate dose ICS/LABA therapy. It was no less effective in add-on therapy with satrol than moderate/high steroid monotherapy alone in severe asthma (Evidence Level I). Slow release theophylline 70
Addon of an LTRA is also effective in a severe asthmatic (Evidence level II) or along with slow release theophylline. On a related topic, ICSs have a fairly flat dose response curve. The most benefit appears to be achieved by low to medium-dose steroids. Escalation to high-dose steroids has little benefit at the cost of more side-effects (Evidence level I). It is better to add a second or another controller to a failed regimen rather than increase the steroid burden.
Step 5: View all
Children with severe asthma should be referred to a pediatrician or pediatric pulmonologist for further management and to confirm whether the condition was indeed diagnosed properly and if there were aggressive comorbid diseases ruled out.
Step-down treatment
Patients who achieved excellent asthma control at 3 months and stabilization of lung function should be considered for step-down therapy (level of evidence: IV). All step-down treatments will be based on the characteristics of the patients as there are very few studies on step-down done in children. Treat each step as a therapeutic trial. Give appropriate instructions and asthma action plan. Follow up on symptoms or PEF. Most patients can reduce their ICS dose by 25 - 50% at 3 monthly follow-up without significant compromise in control of asthma (evidence level I). This should ideally be a morning dose when stepping down to once daily.
