Are We Adequately Managing Children with Wheeze Using the Standard Case Management Guidelines?
Sorasak Lochindarat MD*, Shamim A Qazi MD**, Thanyanat Bunnag MD*, Yasir Bin Nisar MD***, Pravit Jatanachai MD*
Affiliation : * Queen Sirikit National Institute of Child Health, Department of Medical Services, College of Medicine, Rangsit University, Bangkok, Thailand ** World Health Organization, Geneva, Switzerland *** Children Hospital, Pakistan Institute of Medical Sciences, Islamabad, Pakistan
Introduction: Prevalence of wheezing is increasing, bronchodilators are sub-optimally utilized and antibiotics
are over-prescribed. In Thailand, current case management guidelines based on WHO guidelines, recommend
two doses of rapid-acting bronchodilator for children with audible wheeze and fast breathing (FB) and/or
lower chest indrawing (LCI).
Objective : To document the response of children with wheeze with FB and/or LCI to up to three doses of
bronchodilator therapy and followed children whose FB and LCI disappeared for 7 days.
Material and Method: We documented response to up to three dose of inhaled salbutamol in consecutively
assessed eligible children 1-59 months of age presenting with auscultatory/audible wheeze and FB [WHO
defined non-severe pneumonia (NSP)] and/or LCI [WHO defined severe pneumonia (SP)] at the outpatient
department of a referral hospital. Data were collected for up to 7 days in responders to bronchodilator therapy.
Results : Of 534 children were screened from November 2001 to February 2003, 263(49.3%) had wheeze and
NSP and 271(50.7%) had wheeze and SP. Forty-eight children (9%) had audible wheeze. At screening, 224/
263 (85.2%) children in the NSP group and 195/271 (72.0%) in the SP group responded to inhaled salbutamol.
86/419 (20.5%) responded to the third dose of bronchodilator. Four hundred and nineteen responders were
enrolled and followed up. On follow-up, 14/217 (6.5 %) responders among the NSP group and 24/190
(12.6%) among the SP group showed deterioration. Age 1-11 months at screening was identified as an
independent predictor of subsequent deterioration. Two seasonal peaks from December to March and from
August to October were documented.
Conclusion : A third dose of bronchodilator therapy at screening will improve the specificity of case manage-
ment guidelines and reduce antibiotic use. Physicians should use auscultation for management of wheeze.
Keywords : Child, Wheeze, Bronchodilator, Pneumonia, Antibiotics
