Are we adequately managing children with wheeze using the standard case management guidelines?

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).

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.

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.

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.

A third dose of bronchodilator therapy at screening will improve the specificity of case management guidelines and reduce antibiotic use. Physicians should use auscultation for management of wheeze.