Vietnam national guideline for the diagnosis and treatment of asthma in children under 5 years: A summary

JOURNAL OF MEDICAL RESEARCH

VIETNAM NATIONAL GUIDELINE FOR THE DIAGNOSIS AND
TREATMENT OF ASTHMA IN CHILDREN UNDER 5 YEARS:
A SUMMARY
Chau Quy Ngo2,3,6, Khue Ngoc Luong1, Quy Tran9, Dung Tien Nguyen9,
Diem Huu Nguyet Phan7, Hong Thi Minh Pham8, Huong Thi Minh Le4, Son Binh Bao Bui5,
Thuy Thi Dieu Nguyen4, Tuan Minh Dao4, Tuan Anh Tran7, Ngoc Van Le Truong1,
Tru Van Nguyen1, Nguyen Thuy Nguyen1, Doi Quang Nguyen6, Giap Van Vu2,3,6
1
2

Medical Sevices Administration, Ministry of Health, Vietnam

Department of Internal Medicine, Hanoi Medical University, Hanoi, Vietnam
3
4

5

Respiratory Center, Bach Mai Hospital, Hanoi, Vietnam

Respiratory Department, National Pediatric Hospital, Hanoi, Vietnam

Department of Pediatrics, Hue University of Medicine and Pharmacy, Hue, Vietnam
6
7

8

Vietnam Respiratory Society, Vietnam

Respiratory Department, Children’s Hospital number 1, HCM City, Vietnam

Department of Pediatrics, Ho Chi Minh City Medicine And Pharmacy University, HCM City, Vietnam
9

Department of Pediatrics, Bach Mai Hospital, Hanoi, Vietnam

The diagnosis and management of asthma in young children can be challenging since there are many different
types of wheezing associated with numerous underlying disorders. In order to assist clinicians, the Vietnamese
clinical practice guideline for asthma was revised in 2018 by the members of Vietnam Respiratory Society
and Medical Services Administration, under the Ministry of Health. This guideline focused on diagnosis and
management of asthma in children under 5 years old, with subjects including the definition, diagnosis, assessment
and treatment of asthma. We expect this guideline will be a useful tool for physicians as well as other health care
professionals in clinical practice to diagnose and manage the asthma patients in children under 5 years old.
Keywords: Asthma, children, guideline, GINA, Global initiative for asthma

I. INTRODUCTION
Asthma is a common respiratory disease in
children, and the rate of asthma in children is
rising rapidly in both developed and developing
countries. Statistics from the World Health
Organization showed that the prevalence of
childhood asthma was about 7-10% [1; 2]. In
Corresponding author: Ngo Quy Chau, Bach Mai

Hospital, Hanoi, Vietnam
Email:
Received: 27/11/2018
Accepted: 12/3/2019

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Vietnam, there are no systematic, national
statistics on the incidence and deaths resulting
from childhood asthma. Some regional studies
have shown that the prevalence of childhood
asthma is about 4 - 8% [15].
The diagnosis of asthma in children under
5 years is often difficult, especially in children
under 2 years old because it is easily confused
with bronchiolitis. Diagnosing asthma clinically
in young patients is standard as it is laborious
to do spirometry for children and immunological
allergy tests are also non-specific for asthma
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since they can yield a positive result in many
other diseases, such as allergic rhinitis,
eczema, etc. Early diagnosis and treatment will
improve the outcome of the disease.
In 2009, the Vietnamese Ministry of Health
published a guideline for diagnosis and
management of asthma in children but it has
not been updated until now [16]. Therefore, in
2018, experts of Vietnam Respiratory society
worked together to revise this guideline based
on new evidence from the latest studies around

the world. This revision has been approved by
Vietnam Ministry of Health to apply throughout

the country.
2. Definition
Asthma is pathologically characterized
by chronic airway inflammation, airway
hyperresponsiveness (bronchospasm, edema,
congestion, mucus hypersecretion), and
airway obstruction. Expiratory airflow limitation
leads to signs such as wheeze, shortness of
breath, chest tightness, and recurrent coughing
fits. Symptoms often occur at night and early
morning that may resolve spontaneously or
due to medication [2].

3. Diagnosis
A diagnosis of asthma in children under 5 years old should be based on clinical history and
clinical symptoms associated with subclinical features while also considering other differential
diagnoses [1], [2].
3.1. Clinical
Table 1. Clinical Features that Increase the Probability of Asthma
Factors that increase the probability of asthma

Factors that lower the probability
of asthma

Wheezing with one of the symptoms:
Cough 
Dyspnea

AND
Any signs of the following:
Symptoms recurring frequently 
Symptoms are worse at night or in the early morning
Occurs on exertion, laughing, crying, or exposure to
tobacco smoke, cold air, pets
Occurs when no evidence of respiratory infections. 
A history of allergy (allergic rhinitis, eczema)
A family history of atopy and allergic diseases (parents, siblings)
Has widespread wheezing/ rhonchi heard on auscultation

Any signs of the following:
Symptoms happen only in cold air.
Isolated cough in absence of wheeze
or difficulty breathing
Normal lung auscultation despite symptoms.
Signs / symptoms suggestive of other
diagnoses
No response to a trial of asthma therapy (bronchodilators and asthma preventive medications).

Response to adequate asthma treatment.
Note: Wheezing must be correctly confirmed by doctor, because parents may mistake wheezing
with other abnormal sounds.
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3.2. Subclinical

No any laboratory test to make correctly diagnosis asthma in children under 5 years old.
Table 2. Subclinical tests
Test

Value
Chest x ray is not recommended for routine assess-

Chest X ray

ment.
Indicated in cases of severe asthma or clinical signs
that suggest another diagnosis 

The tests can be performed if available
The test is used to evaluate susceptibility status to
Prick tests or Specific IgE testing

allergens. Positive allergy tests to help to increase the
probability of asthma diagnosis. However, a negative
test does not exclude asthma diagnosis.
The airway obstructive syndrome that responds to pos-

Spirometry or peak flow meter 

itive bronchodilator test (Increase in at least 12% and

(if the child is capable of cooperating)

200 mL in FEV1, PEF after bronchodilator test) (children under 5 years are often not possible).

Impulse Oscillometry (IOS)
FeNO measurement

Measurements of specific airway resistance, which
contributes to the assessment of airflow limitation
Assessing airways inflammation, is not recommended
routinely

Note: Normal spirometry results do not necessarily exclude a diagnosis of asthma, particularly in
the case of intermittent or mild asthma. Bronchodilator test is negative neither do exclude asthma.
3.3.

Diagnostic criteria

Satisfying the following criteria: (see Table 1. Factors that suggests the possibility of asthma):
(1) Wheezing ± persistent recurrent cough.
(2) Airway obstruction syndrome: widespread wheeze/rhonchus heard on auscultation (±
Impulse Oscillometry).
(3) Response to bronchodilator drugs or response to a trial of asthma therapy (4-8 weeks) and
clinical status is worse when the drug is discontinued.
(4) Past or family history of allergic diseases or has trigger factors
(5) The other wheezing etiologies were excluded.

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Table 3. Asthma Predictive Index

Major criteria

Minor criteria

Parents of children with asthma

Wheezing not related to a cold

Eczema (to be diagnosed by doctor)

Peripheral blood Eosinophils ≥ 4%

Allergic reaction to inhaled allergens (determined by
medical history or allergic tests)

Food allergy

3.4. Differential Diagnosis
Not all that wheezes are asthma. The bronchodilator test should be performed in children with
wheezing (inhaled salbutamol spray 2.5mg/time, continuously 2-3 times in 20 minutes). If the child
does not respond or responds poorly after 1 hour, should consider the differential diagnosis of the
following:
Table 4. Differential diagnosis
Diseases

Manifestations

Bronchiolitis

Children under 24 months, wheezing occurs for the first

time, with symptoms of upper respiratory viral infections,
poor response to bronchodilators [2], [6]

 Rhinosinusitis

Abnormal breathing sounds coming from the nose and
throat, nose and throat examination find antrochoanal polyp accompanied by odor, lung examination is
completely normal [9], [7]

Foreign body aspiration

Occurs suddenly, the child coughs, wheezing, difficulty
breathing, has a history of infiltration syndrome, localized
air trapping on chest x-ray, bronchoscopy removal of 
foreign bodies [2]

Anatomical malformations (vascular Wheezing occurs early before 6 months of age,
ring, congenital tracheal stenosis ...), should be combine clinical and subclinical features,
Abnormal function
bronchoscopy, CT scan [11], [12]
(dyskinesia tracheobronchial,
dysfunction of vocal cords, vascular
rings or laryngeal webs, vocal cord
dysfunction)
Bronchial compression by: mediastinal tumors, enlarged lymph nodes,
bronchial cysts

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Coughing, wheezing, persistent shortness of breath, no

response to bronchodilator drugs. Diagnosis based on
posterior-anterior and lateral chest X-ray film, chest CT
scan found the airway is compressed by tumor [1]

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Diseases

Manifestations

Pulmonary infiltrates with increased
eosinophils

Clinical symptoms like asthma, caused by parasites,
roundworms or other causes such as drugs or other
allergens, progressing well and can heal itself [2]

Gastroesophageal reflux syndrome or recurrent aspiration syndrome, bronchoesophageal fissure

With a history of vomiting or recurrent respiratory infections, esophageal pH test, bronchoscopy, contrast
enhanced esophagography to confirm the diagnosis [7]

Congenital immunodeficiency

Recurrent respiratory infection, do not respond to conventional antibiotic therapy, IgG levels less than 2 SDs
below the mean for age, Family history of sibling have
congenital immunodeficiency [5]

3.5. Assessment of the level of severe asthma
Table 5. Assessment the Intensity of asthma exacerbation
Mild
- Alert
- Shortness of breath
on exertion, can be
lying-flat positioning
- Talks in whole sentences 
- Tachypnea, no
dyspnea
- SpO2 ≥ 95%

Moderate

Severe

- Alert
- Shortness of breath,
prefer to sit more than
supine position 
- Talks in short phrases
- Tachypnea, chest
wall indrawing
 - SpO2: 92 - 95%

Life threatening

- Agitated
- Continuously shortness of breath, must
in head elevation

position  
- Talks in single/few
words, 
- Tachypnea, chest
wall indrawing clearly
- SpO2 < 92%

- Drowsy, confused,
coma
- Slow breathing,
apnea episodes.
- Unable to talk 
- Reduced vesicular
breathing sounds or
silent chest
 - Cyanosis, SpO2 
< 92%

Table 6. Classifying asthma severity
Components of
severity

Intermittent

Daytime Symptoms

Persistent
Mild

Moderate

Severe

≤ 2 times/
week

≤ 2 times/week but
not daily

Daily

Throughout
the day

Nighttime awakenings

0

1 to 2 times/month

3 to 4 times/month

> 1 time/week

Short-acting beta2 
agonist use for
symptom control

≤ 2 times/
week

> 2 times/week but
not daily

Daily

Several times
per day

Interference with normal activity

None

Minor limitation

Some limitation

Extremely
limited

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Table 7. Assessment of Asthma Control
Clinical symptoms
In the past 4 weeks, has the child had:

Well controlled

Partially
controlled

Uncontrolled

Daytime asthma symptoms for more than a
few minutes, more than once a week?
□ Yes
□ No
Activity limitation due to asthma
□ Yes
□ No
Reliever medication needed more than once None of these
a week
□ Yes
□ No

1 – 2 of these 3 – 4 of these

Night waking or night coughing due to asthma
□ Yes
□ No
4. Treatment
4.1. Treatment of acute attack
4.1.1. Management of asthma at home
Initial treatment at home
- Two puffs Salbutamol 200 mcg inhalation spray by pMDI + spacer, may be repeated every
20 minutes, if needed.

- Then take the child to the medical facility as soon as possible
Need to take the child to the health facility immediately if your child has any of the following
signs:
- Children too breathless.
- Symptoms of children dose not reduce immediately after 6 puffs bronchodilator inhalation
spray for 2 hours.
- The parents and care-givers cannot treat asthma attack at home.
4.1.2. Management of asthma attack in the hospital

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Moderate Asthma

Mild Asthma

OUTPATIENT TREATMENT

OUTPATIENT TREATMENT
- Nebulized salbutamol 2,5 mg/time
- Salbutamol inhalation spray with MDI plus
Spacer (2 - 4 puffs/times every 20 minutes x 3
times if needed (re-assess after every
inhalation spray) [10]

- Nebulized salbutamol 2,5 mg/time

-Salbutamol inhalation spray with MDI plus
Spacer (2 - 4 puffs/times every 20 minutes x 3
times if needed (re-assess after every
inhalation spray) [10]

Assess after one hour

Good response
- Not wheezing
- Not dyspnea
- SaO2 ≥ 95%

Outpatient treatment
- Continue to
Salbutamol inhalation
spray by MDI every 3 4 hours for 24 - 48
hours
- Re-examination
appointment

Partial response
- Stlill have wheeze
- Still have dyspnea
- SaO2 92 - 95%

Consider for admission
Nebulized Salbutamol +
Ipratropium 250 mcg/times)
- Soon oral prednisone (when
does not respond to 1st times of

nebulization)

No response
- Still have wheeze,
dyspnea, chest wall
indrawing
- SaO2 < 92 %

Hospitalized
-Nebulized salbutamol +
Ipratropium x 3 times if needed
- Oral prednisolone (if after 3
times of nebulization,
management as severe asthma
attacks

Figure 1. Approach for managing mild and moderate asthma

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Incomplete response
- Transfer to ICU
- Nebulized salbutamol every hour
- Nebulized ipratropium every 2 - 4 hours
- Can use high dose ICS
- Intravenous hydrocortison or Methylprednisolon

- Infusion Magnesium sulfat (> 1 year)
- Infusion Aminophylin
- Infusion salbutamol, intubation and
mechanical ventilation

Severe Asthma
Admit to ICU
- Oxygen via face mask
- Nebulized salbutamol combination with
ipratropium bromide every 20 minutes x 3 times
(re-assessment after each nebulization)
- Intravenous hydrocortisone or methyl
prednisone

Re-assess after 1 hour

Life threatening asthma
Admit to ICU
-Oxygen via face mask
-Subcutaneous adrenalin every 20 minutes x 3 times
-Nebulized salbutamol combination with ipratropium
bromide every 20 minutes x 3 times (re-assess after
each nebulisation)
-Intravenous Hydrocortisone or Methyl -prednisolon

Good response
Continue
- Nebulized salbutamol ± Ipratropium every 4 –
6h for 24h
- Intravenous Hydrocortison or Methylprednisolon

Good response
- Not dyspnea
- SaO2 ≥ 95%

OUTPATIENT TREATMENT
- Salbutamol inhalation spray by MDI
every 3 - 4 hours for 24 - 48 hours
- Oral Prednisolone for 3 days
- Re-examination appointment

Figure 2. Approach severe and life threatening asthma
Dosing:
- Intravenous Hydrocortisone 5 mg/kg or methylprednisolone 1mg/kg every 6 hours [10].
- Magnesium sulfate (>1 year), average dose of 50mg/kg intravenous infusion for 20 minutes
[10].
- Theophylline (≤ 1 year).
- Intravenous infusion Aminophylline: attack dose of 5mg/kg for in 20 minutes, maintenance
dose: 1 mg/kg/hour. If feasible, should monitor the blood theophylline levels in the 12th hour and
then every 12 - 24 hours (keep 60 - 110mmol/l is equivalent to 10 - 15mg/ml) [10].
- Subcutaneous Adrenalin (Adrenalin 1 ‰ 0.01 ml / kg, maximum 0.3 ml/time every 20 minutes,
maximum 3 times [2].
- Salbutamol: attack dose of 15 mg/kg by intravenous infusion for 20 minutes, then maintain 1
mg/kg/minute. Need to check blood gases and potassium every 6 hours [10].
Assess the risk factors for severe events
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- History of severe and life threatening asthma attack.
- Emergency hospitalization or endotracheal intubation for acute asthma in the past year.
- Currently using or recently discontinued oral corticosteroids.
- Too dependent on short acting bronchodilator drugs (β2 agonist).
- A history of psychiatric disorders or excessive panic.
- Not cooperate or uncontrol asthma.
Medications and interventions that should not be used in acute asthma
- Antibiotics: use only when there is evidence of infection.
- Infusion: use only when there are signs of dehydration (be careful to avoid fluid overload).
- Sedatives, expectorant drugs (group of acetylcysteine causes bronchospasm), group of
antihistamine causes decreased secretion, cough syrup medications containing dextromethorphan,
respiratory physiotherapy.
4.2. Maintenance treatment
4.2.1. Objectives
The goals of asthma management in young children are to:
- Achieve good control of symptoms and maintain normal activity levels
- Minimize future risk – that is, reduce the risk of flare - ups, maintain lung function and lung
development as close to normal as possible and minimize side effects from medications
4.2.2. Indication
- The child’s symptom pattern suggests a diagnosis of asthma and respiratory symptoms are
uncontrolled and/or wheezing episodes are frequent (e.g. three or more episodes in a season).
- Children have severe wheezing episodes which triggered by virus although less frequently
(1 - 2 episodes in a season).
- The child has been having asthma symptoms and needs to use regular inhaled SABA ( > 1 - 2
times/week).
- The children have been to hospitalized with severe and life threatening asthma attack.
4.2.3. Drug selection

When drug selection should note two phenotypes
- Intermittent wheezing is onset due to virus: Montelukast (LTRA)
- Wheezing is onset due to many factors: inhaled corticosteroid (ICS)

4.2.4. Treatment of asthma severity
Choose the initial treatment method according to the severity at the first time of assessment.
Table 8. Choose the initial treatment method according to the severity
Components of severity

Preferred option

Other option

Intermittent

As needed inhaled SABA, LTRA

Mild Persistent

Low dose ICS

LTRA

Moderate Persistent

Moderate dose ICS

Low dose ICS + LTRA

Severe Persistent

High dose ICS

Moderate dose ICS + LTRA

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SABA: short - acting beta2 agonists ; ICS: inhaled corticosteroid; LTRA: leukotriene receptor
antagonist
For intermittent asthma use LTRA during first episode when symptoms of upper respiratory viral
infection and maintain 7 - 21 days.
4.2.5. Treatment base on the level of symptom control
After the initial assessment, the therapy is chosen depending on the level of asthma control.
Access to treatment maintenance under “step up” or “step down” to control symptoms and minimize
the risk of acute attacks as well as side effects of the drug in the future. Steps to maintain a specific
treatment are presented in Table 9 [2].
Table 9. Stepwise approach to asthma treatment base on the level of symptom control
Step 4
Step 3
Step 2
Step 1

Consider this step
for children with

Preferred controller choice

Symptom pattern consistent with asthma and
asthma symptoms not
well - controlled, or ≥ 3
exacerbations per year; 
Intermittent
wheezing onset Symptom pattern not
by virus and no consistent with asthma
but wheezing episodes
or few interval
occur frequently (e.g.
symptoms
every 6 - 8 weeks). Give
diagnosis trial for three
months.

LTRA
(2 - 4 week)

Daily low - dose ICS

Asthma diagnosis, and
but not well
- controlled
on low - dose
ICS

Moderate
dose ICS

Continue
moderate
dose ICS
+ refer
for expert
assessment

low - dose
ICS + LTRA

- Addition of
LTRA
- Increasing
the dose of
ICS

Other controller
choice

No

Reliever

As needed short - acting beta2 agonists  (all children)

LTRA

Asthma not
well - controlled on
moderate

dose ICS

Caution for all children
Assess symptom control, future risk, comorbidities
Self - management: education, inhaler skills, written asthma action plan, adherence
Regular review: assess response, adverse events, establish minimal effective treatment
(Where relevant): environmental control for smoke, allergens, indoor/outdoor air pollution
For children 0 - 2 years old: maintenance treatment decision according to Table 10
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Table 10. Decide on asthma treatment in children from 0 to 2 years
Preferred controller
choice
Viruses induced trigger
asthma
Many factors induced
Asthma symptom onset
or there is evidence of
allergy
Persistent asthma

LTRA

Low dose ICS

Assess after 4 weeks

Good response:
Discontinuing drug
treatment
and follow up

Not response:
- Switch to ICS,
- Refer for expert
assessmen

Good response:
Continue for 3
months, then
Discontinuing drug
treatment

Not response:
- Refer for expert
assessment
- Moderate dose ICS
- OR combination with
LTRA

4.2.6. Assess response and treatment adjusting
Table 11. Assess response and treatment adjusting
Level of asthma symptom
control

Management

Well controlled

Consider stepping down when asthma symptoms are well controlled for 3 months or more. Choose an appropriate time when
stepping down (not during respiratory infections, not traveling,
not during weather changes). For children treated with ICS,
reduce the maintenance dose ICS 25 - 50% every 3 months.

Partly controlled

Before stepping up treatment, check the following: technical
adjustment, ensure compliance with the prescribed dose, look
for risk factors i.e. exposure to allergens, cigarette smoke ...

Uncontrolled

Need to step up treatment after checking the above issues.

4.2.7. Re - examination
- After each acute asthma exacerbation, the child should be re - examined within 1 week.
Frequency of re - examination depends on levels of initial asthma control, response to treatment
and self - management capabilities of the child's parents. Ideally, the child should be re - examined
within 1 - 3 months of starting treatment, then every 3 - 6 months/time.
- Assess asthma control level, risk factors, side effects of medication, adherence, and ask
parents not to worry child at each visit. Follow up child's height at least 1 time/year.
- If the child can use spirometry or Impulse Oscillometry (IOS), they should be measured every
3 months to help decide whether or not to step up or step down treatment.
4.2.8. Discontinuation of treatment
- Consider discontinuing maintenance therapy if the patient sustained resolution of symptoms

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within 6 - 12 months, is at the lowest step of treatment and has no exposure to risk factors. However,
the physician should not stop treatment during seasons when respiratory infections and airborne
pollen are common and while children are traveling.
- Once maintenance therapy has been discontinued, re - examination should be considered
after 3 - 6 weeks to check for symptom recurrence.
4.2.9. Maintenance therapy medication dosages
Table 12. Maintenance therapy medication dosages for children under 5 years
Dose (mcg/day)

Medications

Low

Moderate

High

Fluticasone propionate MDI (HFA) + spacer

100

200

400

Beclomethasone dipropionate MDI (HFA) + spacer

100

200

400

Budesonide MDI + spacer

200

400

800

Child from 6 months to 5 years: oral 4 mg/
day at night

Montelukast
HFA: hydrofluoroalkane; MDI: metered dose inhaler
Conflicts of Interest

No potential conflict of interest relevant to this article was reported.

Acknowledgments
The authors would like to express the
great appreciation to Dr Ai Lan Kobayashi
(Omaha- USA), Dr Josh Solomon (ColoradoUSA), Dr Laurie Manka (National Jewish
Health, Colorado - USA), Dr Vu Thi Thu Trang

(Respiratory Center- Bach Mai Hospital), Dr
Dao Ngoc Phu (Respiratory Center- Bach
Mai Hospital) for their valuable work during
the translation this guideline into English
version. Their willingness to give their time so
generously has been very much appreciated.

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