BNF for Children 2011-2012

146 3.2 Corticosteroids BNFC 2011–20123 Respiratory systemin the mouthpiece and tubing. The extent to which thenebulised solution is deposited in the airways or alveolidepends on particle size. Particles with a median diameterof 1–5 microns are deposited in the airways andare therefore appropriate for asthma whereas a particlesize of 1–2 microns is needed for alveolar deposition.The type of nebuliser is therefore chosen according tothe deposition required and according to the viscosity ofthe solution (antibacterial solutions usually being moreviscous).Some jet nebulisers are able to increase drug outputduring inspiration and hence increase efficiency.Nebulised bronchodilators are appropriate for childrenwith chronic persistent asthma or those with severeacute asthma. In chronic asthma, nebulised bronchodilatorsshould only be used to relieve persistent dailywheeze, however, with the development of spacers withfacemasks, it is now unusual for a child to require longtermnebulised asthma therapy (see Management ofChronic Asthma table, p. 135). The use of nebulisersin chronic persistent asthma should be considered only:. after a review of the diagnosis and use of currentinhaler devices;. if the airflow obstruction is significantly reversibleby bronchodilators without unacceptable sideeffects;. if the child does not benefit from use of conventionalinhaler device, such as pressurised metereddoseinhaler plus spacer;. if the child is complying with the prescribed doseand frequency of anti-inflammatory treatmentincluding regular use of high-dose inhaled corticosteroid.When a nebuliser is prescribed, the child or child’s carermust:. have clear instructions from doctor, specialist nurseor pharmacist on the use of the nebuliser (and onpeak-flow monitoring—see notes above);. be instructed not to treat acute attacks without alsoseeking medical help;. have regular follow up with doctor or specialistnurse.Jet nebulisers are more widely used than ultrasonicnebulisers. Most jet nebulisers require an optimumflow rate of 6–8 litres/minute and in hospital can bedriven by piped air or oxygen; in acute asthma thenebuliser should always be driven by oxygen. Domiciliaryoxygen cylinders do not provide an adequate flowrate therefore an electrical compressor is required fordomiciliary use.Safe practiceThe Department of Health has reminded users of theneed to use the correct grade of tubing when connectinga nebuliser to a medical gas supply orcompressor.Nebuliser diluentNebulisation may be carried out using an undilutednebuliser solution or it may require dilution beforehand.The usual diluent is sterile sodium chloride 0.9%(physiological saline).Sodium Chloride (Non-proprietary) ANebuliser solution, sodium chloride 0.9%, net price20 2.5 mL = £11.50Brands include Saline Steripoule c , Saline Steri-Neb c3.2 CorticosteroidsCorticosteroids are effective in the management ofasthma; they reduce airway inflammation.An inhaled corticosteroid is used regularly for prophylaxisof asthma when a child requires a beta 2 agonistmore than twice a week, or if symptoms disturb sleepmore than once a week, or if the child has sufferedexacerbations in the last 2 years requiring a systemiccorticosteroid or a nebulised bronchodilator (see Managementof Chronic Asthma table, p. 135).In adults, current or previous smoking reduces theeffectiveness of inhaled corticosteroids and higherdoses may be necessary.Corticosteroid inhalers must be used regularly for maximumbenefit; alleviation of symptoms usually occurs 3to 7 days after initiation but may take longer. Beclometasonedipropionate, budesonide, fluticasonepropionate, and mometasone furoate appear to beequally effective. A spacer device should be used foradministering inhaled corticosteroids in children under15 years (see NICE guidance, section 3.1.5); a spacerdevice is also useful in children over 15 years, particularlyif high doses are required.In children 12–18 years using an inhaled corticosteroidand a long-acting beta 2 agonist for the prophylaxis ofasthma, but who are poorly controlled, (see step 3 of theManagement of Chronic Asthma table, p. 135)Symbicort c (budesonide with formoterol) may beused as a reliever (instead of a short-acting beta 2agonist), in addition to its regular use for the prophylaxisof asthma [unlicensed]. Symbicort c can also be used inthis way in children 12–18 years using an inhaledcorticosteroid with a dose greater than 400 microgramsbeclometasone dipropionate daily 1 , but who are poorlycontrolled [unlicensed] (see step 2 of the Managementof Chronic Asthma table, p. 135). When starting thistreatment, the total regular dose of inhaled corticosteroidshould not be reduced. Children and their carersmust be carefully instructed on the appropriate doseand management of exacerbations before initiating thistreatment, preferably by a respiratory specialist. Childrenusing budesonide with formoterol as a relieveronce a day or more should have their treatmentreviewed regularly; see also Side-effects below. Thismanagement approach has not been investigated withcombination inhalers containing other corticosteroidsand long-acting beta 2 agonists.High doses of inhaled corticosteroids can be prescribedfor children who respond only partially to standarddoses of an inhaled corticosteroid and a long-actingbeta 2 agonist or to other long-acting bronchodilators(see Management of Chronic Asthma table, p. 135).High doses should be continued only if there is clearbenefit over the lower dose. The recommended maximumdose of an inhaled corticosteroid should not1. For standard doses of other inhaled corticosteroids, seeManagement of Chronic Asthma table, p. 135