Asthma Flashcards
Definition of asthma
A chronic respiratory condition associated with airway inflammation and hyper-responsiveness. It is a heterogenous condition with varying underlying disease processes, clinical course and response to treatment.
Characteristic symptoms of asthma
Cough, wheeze, chest tightness and SOB. Additionally there will be variable expiratory airflow limitation, which can vary over time and intensity.
What factors can trigger symptoms
Exercise, allergen, and viral exposure
Prevalence and peak age of onset of asthma. gender distribution.
- Affects around 11.6% of children aged 6 to 7 years
- In early childhood, asthma incidence is higher in boys than in girls
- It is the most common chronic childhood respiratory
What complicates diagnosis of asthma in young children
Approximately half of all children wheeze at some time during the first 3 years of life (have small airways so should be careful to diagnose asthma)
What are the THREE patterns of wheezing
- Viral episodic wheeze: wheeze developed in response to viral infections.
- Multiple trigger wheeze: in response to multiple triggers- more likely to develop into asthma over time
- Asthma
Pathophysiology of viral episodic wheeze. What are some risk factors for its development
Most wheezy preschool children have viral episodic wheeze, triggered by viral URTIs, with no interval symptoms between episodes.
Results from an abnormal immune response to viral infection causing inflammation and obstruction of the small airways
RFs: Maternal smoking during and/or after pregnancy, prematurity and being male. FHx of asthma or allergy Is NOT a RF
By what age does viral episodic wheeze generally resolve
5 years
Pathophysiology of multiple trigger wheeze
Used to describe wheezy episodes which are tiggered by many stimuli, including viral infections, cold air, dust, animal dander and exercise. A significant proportion have asthma ad most will benefit from asthma preventer therapy
Pathophysiology of atopic asthma. What conditions are associated with it
- Atopic asthma is strongly associated with eczema, rhino-conjunctivitis and food allergy
- Bronchial inflammation (oedema, excessive mucus production, cellular infiltration) leads to bronchial hyperresponsiveness, reversible airway narrowing (bronchoconstriction, airway inflammation) and symptoms
- When recurrent wheezing is associated with symptoms between viral infections (interval symptoms) and evidence of allergy to one or more inhaled allergens such as house dust mite, pollens or pets, it is called ‘atopic asthma.’
Risk factors for asthma
- Personal or FHx of atopic disease
- Male sex
- Respiratory infections in infancy and exposure to tobacco smoke or inhaled particulates
- Premature birth and associated low birth weight
- Obesity and social deprivation
When should asthma be suspected in a child
How can an asthmatic wheeze be described
Asthma should be suspected in any child with wheezing on more than one occasion, particularly if this persists between viral illnesses (interval symptoms).
Ideally, the presence of wheeze is confirmed on auscultation during an acute episode to distinguish it from transmitted upper respiratory noises, which are often loud and easy to hear in children
Asthmatic wheeze is a polyphonic (multiple pitch) noise as multiple airways of different sizes are affected
Presentation of asthma
- A chronic dry cough is common in children with asthma but is rarely the only symptom.
- Wheeze, cough, chest tightness and breathlessness worse at night and in the early morning
- May also be triggered by emotion and laughter
- Examination of the chest is usually normal between attacks
- Long-standing asthma may cause hyperinflation of the chest and generalised polyphonic expiratory wheeze with a prolonged expiratory phase
- Early onset can result in Harrison’s sulci
- Can also check for evidence of eczema and allergic rhinitis
- Growth should be monitored (can be affected in severe asthma)
- Asthma control test can help determine severity- a positive response to asthma therapy is confirmatory of asthma
What reg flag symptoms might suggest an alternative diagnosis to asthma
Failure to thrive, unexplained clinical findings (abnormal voice or cry, dysphagia, inspiratory stridor), symptoms present from birth, excessive vomiting or posseting, URTI evidence, persistent wet or productive cough, FHx of chest disease, nasal polyps
How should asthma be investigated in children < 5 years old
The diagnosis of asthma is based on history, examination and response to treatment (CXR is not necessary unless differentials need to be excluded.)
May perform a skin prick test to determine specific phenotype (eosinophilia of 4% or more and raised allergen specific IgE corroborates atopic status)
What objective asthma investigations exist (for children older than 5)
Spirometry- should be offered to all symptomatic people> 5 years. FEV1/FVC ratio is normally greater than 70%- any lower value suggests airflow limitation (a normal result when the patient is asymptomaticdoes not rule out underlying disease)
Bronchodilator reversibility testing- Should be considered in children and young people with ‘obstructive spirometry’ (FEV1/FVC < 70%)
* An improvement in FEV1 of 12% or more in response to a beta-2 agonist or corticosteroid is regarded as a positive result
PEFR- provides an estimate of the maximum rate of expiration- asthma leads to an increased variability in peak flow rate, with diurnal and day-to-day variability
* A value of more than 20% variability after monitoring at least twice daily for 2-4 weeks is regarded as a positive result
FeNO (fractional exhaled nitric oxide) testing- useful if there is diagnostic uncertainty and normal spirometry OR obstructive spirometry with negative bronchodilator reversibility test- it is a marker of airway inflammation
* A level >35ppb is considered a positive test
When can asthma be diagnosed
For symptomatic children (5-16 yo) diagnose asthma if there is an FeNO level of 35ppb or higher with positive peak flow variability, OR obstructive spirometry with positive bronchodilator reversibility
When should a diagnosis of asthma be reviewed
Should review the diagnosis after 6 weeks by repeating any abnormal tests and reviewing symptoms
Asthma differentials
Viral episodic wheeze, Multiple trigger wheeze, recurrent anaphylaxis (food allergy), chronic aspiration, CF, bronchiolitis, foreign body aspiration
How can we assess a patient’s baseline asthma status
Using the asthma control questionnaire and asthma control test as well as objective testing
What primary prevention strategies exist for asthma exacerbations
A personalised asthma action plan (PAAP) should be given to parents:
* Information on relevant medications and correct inhaler technique
* What to do if asthma symptoms are getting worse or in the event of an asthma attack
Other primary prevention strategies:
* Ensure child is up to date with immunisations
* Advise to avoid asthma trigger factors- specific allergens, air pollution, smoke
* Encourage breast feeding (potential protective effect)
* Weight loss in obese/overweight children
* Advice on smoking cessation for parents
What are the first line medications used in asthma management. What is the duration of action for these medications
Prescribe an inhaled short-acting beta-2 agonist (SABA) to all people with symptomatic asthma, to be used as reliever therapy as required (salbutamol or terbutaline).
These have a rapid onset of action (10-15 mins) and are effective for 2-4 hours
Use of a SABA > 2x per week should prompt the need to start preventer therapy
When should preventer theray be prescribed, what is used first line
Prescribe a (low dose) inhaled corticosteroid (ICS) (beclomethasone, budesonide) (twice daily initially at the lowest dose required for effective asthma control) as preventer therapy for all people who:
- Use an inhaled SABA three times a week or more, and/or
- Have asthma symptoms three times a week or more, and/or
- Are woken at night by asthma symptoms once weekly or more
How should preventer therapy be trialled in children under 5
Should be given as an 8 week trial.
If symptoms recur within 4 weeks, ICS should be restarted at a low dose.
If reoccur more then 4 weeks after stopping should be restarted at a moderate dose.
Next line thearpy if patient’s asthma is not adequately controlled on low-dose ICS.
When should you consider decreasing maintenance therapy
Consider an add-on therapy (after checking adherence, inhaler technique and elimination of trigger factors)
* For children 5-16 yo: consider offering a leukotriene receptor antagonist (LTRA) (montelukast) to the low dose ICS- should review the response to therapy in 4-8 weeks (LTRA is inhaled and taken only at night)
* If the asthma remains uncontrolled offer a long-acting-beta-2 agonist (LABA) (salmeterol) in combination with the ICS (clinical judgment as to whether to continue with the LTRA)
* If this does not work, offer to change to a MART- maintenance and reliever therapy (combination formeterol plus budenoside or beclomethasone exist)
* Then increase the dose of ICS (should refer to specialist)
* If the child is under five, the diagnosis should be confirmed using objective testing whenever possible
* Consider decreasing maintenance therapy once a person’s asthma has been controlled with their current maintenance therapy for at least 3 months
How is ‘complete control’ defined
- Absence of daytime or night-time symptoms
- No limit on activities (including exercise)
- No need for reliever use, normal lung function
- No exacerbations (need for hospitalisation or oral steroids) in the previous 6 months
What are the delivery systemsavailable for asthma medication
Delivery systems for inhaled asthma medications include **dry-powder inhalers (DPIs) **and pressurized metered-dose inhalers (PMDIs).
* In children aged between 5 and 12 years, a PMDI with a spacer is recommended. A face mask is required until the child can breathe reproducibly using the spacer mouthpiece.
* In children aged between 0 and 5 years, there is little or no evidence available on which to base recommendations, and specialist advice should therefore be sought if there is uncertainty
Paediatric low dose and high dose of budenoside
- Low dose- less than 200ug
- High dose- more than 400ug
What should be checked at asthma review
Occurs at least annually
* Number of asthma attacks, oral corticosteroid use, time off school/nursery/work due to asthma
* Growth and development
* Confirm adherence to medication
* Review inhaler technique
* Review if treatment needs to be changed
* Monitor asthma control at each review in anyone aged 5 years and over using either spirometry or peak flow variability testing
Asthma complications
- Respiratory complications- irreversible airway changes (bronchoconstriction, fibrosis), pneumonia, pulmonary collapse (atelectasis caused by mucus plugging of the airways), respiratory failure, pneumothorax, status asthamticus, death
- Impaired quality of life: poor performance at school, fatigue
Important aspects of an asthma history
When asking about wheeze, describe it as ‘a whistling in the chest when your child breathes out’
Key features associated with high chance of asthma
* Symptoms worse at night and early morning
* Symptoms that have non-viral triggers e.g. cold, exercise, dust, changed house, recent pets
* Interval symptoms (symptoms between acute exacerbations)
* Personal or family history of atopic disease
* Positive response to asthma therapy
Key questions to determine asthma phenotype
* How frequent are the symptoms?
* What triggers the symptoms? Specifically, are sport and general activities affected by the asthma?
* How often is sleep disturbed by asthma?
* How severe are the interval symptoms between exacerbations?
* How much school has been missed due to asthma?
How can we determine the severity of an asthma attack
- Note the degree of agitation and behavioural symptoms
- Look for signs of exhaustion, cyanosis, use of accessory muscles, O2 sats
- Examine the chest, pulse rate etc
Management of a severe/life-threatening asthma attack
Admit to hospital
While awaiting hospital admission give controlled supplementary oxygen to patients with hypoxia using a face mask, venturi mask or nasal cannula. Aim O2 sats 94-98%
Give nebulised salbutamol- 5mg for >5yo, 2.5mg for 2-5yo
* Ideally should be oxygen driven (usually 6 L/min)
* Where a nebuliser is unavailable, can use a pressurized metred-dose inhaler with a large volume spacer
Consider the addition of nebulised ipratropium bromide (250ug for children aged 2-12 years)- can be given every 4-6 hours hours (BTS: every 20-30 minutes for the first 2 hours of treatment)
BTS: oral steroids should be given early in the treatment of acute asthma (do not use ICS):
* 10mg Prednisolone for children less than 2yo
* 20mg for children aged 2-5 years
* 30-40mg for children more than 5yo
* Those already receiving maintenance steroid tablets should receive 2 mg/kg prednisolone up to a maximum dose of 60 mg.
* Repeat the dose in children who vomit
* IV hydrocortisone (4mg/kg/hr) should be reserved for severely effected children with poor oral retention
Consider adding 150 mg magnesium sulphate to each nebulised salbutamol and ipratropium in the first hour in children with a short duration of acute severe asthma symptoms presenting with an SpO2 less than 92%.
If there is poor response after treatment, need urgent referral to a specialist + transferto PICU- may require: IV magnesium sulphate, IV β2 agonist or IV aminophylline. early addition of IV salbutamol is recommended if not responding to treatment
Children can be discharged when stable on 3–4 hourly inhaled bronchodilators that can be continued at home. Peak expiratory flow and/or FEV1 should be >75% of best or predicted and SpO2 >94%.
Management of a moderate asthma exacerbation
Admit to hospital if moderate asthma and worsening symptoms despite initial bronchodilator treatment and/ or who have had a previous near fatal asthma attack
Whilst awaiting hospital admission: Give high-flow oxygen if SpO2 less than 94% via tight-fitting facemask or venturi mask or nasal cannula. Aim O2 sats 94-98%
Give salbutamol via a pressurised metred-dose inhaler with a large volume spacer
* Give a puff every 30-60 seconds, up to 10 puffs
* If response is poor, give further doses and consider switching to a nebuliser
Can consider the addition of ipratropium bromide if the response to initial treatment is poor (dosing as above)
Give oral prednisolone as in severe asthma management.
If the child does not require admission:
* Give oxygen as required
* Use salbutamol via a large-volume spacer to relieve acute symptoms
* A puff every 30-60 seconds, up to 10 puffs
* 5 tidal breaths should be taken per puff
* Repeat every 10-20 minutes according to clinical response
* Consider prescribing a short course of oral prednisolone
* Once symptoms have subsided, advise patient to return to using their SABA as required up to 4 times per day (not exceeding 4-hourly)
SafetyNet
* Follow-up within- 48 hours of presentation if not admitted to hospital or 2 working days of discharge if admitted:
* Review symptoms, PEFR, inhaler technique, compliance, vaccinations, smoking
* Ensure that they are adhering to their PAAP
What about the use of Abx. in acute asthma
Abx are not routinely prescribed unless there is suspicion of a bacterial cause for the asthma exacerbation (normally viral cause)
