Asthma Flashcards
What is the mechanism behind astham?
Chronic inflammatory AW disease - hypersensitive smooth muscle repsonds to stimuli, constricts and causes AW obstruction (bronchoconstriction)
What conditions are likely to occur ith asmtha
Eczema, hayfever/allergies
What presentations suggest astham?
Episodic, intermittent exacerbations
Diurnal variability
Triggers
Dry cough + wheeze + SOB
Atoyp/FH of
What type of wheeze is heard in asthma?
Bilateral widespread polyphonic wheeze
What helps confirm asthma diagnosis?
Symptoms improve with bronchodilators
What sort of physical presentation with astham>
Dry cough
Wheeze
SOB
on trigger exposure
Asthma vs viral induced wheeze
When wheeze only related to coughs and colds
What coughs are probably not asthma?
Isolated or productive
What would a unilateral wheee suggest
Not ashtma - focal lesion, inhaled foreign body or infection
Typical asthma triggers
Dust - house dust mites
Animals
Cold air
Exercise
Smoke
Food allergens - peanuts, shellfish or eggs
Investigations when intermediate probability of asthma or diagnostic doubt for children
Spirometry with reversibility testing
Direct bronchial challenge with histamine or metacholine
Fractional exhaled nitric oxide
Peak flow variability
What age children can spirometry with reversibility testing be used in?
Over 5
Typical triggers
- Dust (house dust mites)
- Animals
- Cold air
- Exercise
- Smoke
- Food allergens (e.g. peanuts, shellfish or eggs)
What to specifically check for in an asthma hisotru>
wheeze, cough or breathlessness, and any daily or seasonal variation in these symptoms
any triggers that make symptoms worse
a personal or family history of atopic disorders
What is considered diagnostic for asthma in a spirometry?
FEV1/FVC <70%
When consider a BDR test in chilfren
<70%
What is a positive peak flow variability for 2-4 weeks?
20% variability
When monitor peak flow variability for 2-4 weeks in children?
When diagnositc uncertainty after initial assessment and a FeNO test and either normal spirometry or obstructive spirometry, irreversiblle AW obstruction (negative BDR) and FeNO over 35ppb
What are the two positive test criteria for children suspected to have asthma that confirm it?
FeNO level > 35ppb AND peak flow variability
OR
obstructive spirometry + positive bronchodulator reversibility
When review diagnosis of asthma
6 weeks by repeating
Whats the difference between FeNO diagnositc level adults vs children?
adults > 40 ppb
children >35ppb
Bronchodilator reversibility test in children and young people?
Improvement in FEV1 >12 %
What should consider in asthma before starting or adjusting asthma medications?
Lack adherence
Suboptimal inhaler technique
Smoking
Occupational exposure
Psychosocial factors
Seasonal or environemtnal factors
When to review response to medications in asthma?
4-8 weeks
When take ICS inhaled theraoy for asthma
Regular daily dose, not intermittent or when required
First line reliever therapy for 5-16 year olds with asthma?
SABA
When can you treat asthma with a SABA reliever alone in 5-16 year olds?
-Infrequent short lived wheeze
-Normal lung function
What is the first line maintenance therapy for asthma in children?
Low dose of ICS
When do you offer a maintenance low dose ICS to children?
Symptoms that clearly indicate need for maintenance therapy eg 3 x a week +
Waking uo at night
OR
Uncontrolled with SABA alone
What is the next step after SABA and low dose ICS for asthma management in children?
LTRA maintenance therapy
What to do if LTRA ineffective in asthma in children?
Swap it for a LABA
What regimen do you start if a ICS + LABA mainteance therapy is still not controlling asthma?
MART regimen with paeds low maintenance ICS dose
What to do if MART regimen not controlling asthma?
Increase paediatric ICS dose for low to moderate
What give to under 5s with suspected asthma initially?
SABA as reliever therapy
When do you consider an 8 week trual of paeds moderate dose ICS in child under 5?
Symptoms clearly indicate (3x a week +, waking from nigth)
OR
suspected asthma uncontrolled with SABA alone
What to review when monitoring asthma control?
Confirm persons adherence to prescribed treatment
Review persons inhaler technique
Review treatments needs to be changed
Occupational asthma
What is a paediatric low dose of ICS?
< or = 200 micrograms budenoside or equivalent
Paediatric moderate dose of ICS?
200 micrograms to 400 micrograms budesonide
Paediatric dose?
400 micrograms
Whaat is MART?
Inhaler containing both ICS nad fast acting LABA
What is uncontrolled asthma?
Coughing, wheezing, SOB, chest tightness impact on persons lifestyle or retricts normal activities
How is uncontrolled asthma defined?
3 or more days a week with symptoms
OR
3 or more days a week with required use of SABA for symptomatic relief
OR
1 or more nights a week with awakening due to asthma
Example of a LABA
Salmeterol
LTRA example
Montelukast
LAMA example
Tiotropium
Why is it important to have a good inhaler technique?
More medication reaches lungs
Otherwise medication in mouth or back of throat
Metered dosed inhaler technique without a spacer
- Remove the cap
- Shake the inhaler (depending on the type)
- Sit or stand up straight
- Lift the chin slightly
- Fully exhale
- Make a tight seal around the inhaler between the lips
- Take a steady breath in whilst pressing the canister
- Continue breathing for 3 – 4 seconds after pressing the canister
- Hold the breath for 10 seconds or as long as comfortably possible
- Wait 30 seconds before giving a further dose
- Rinse the mouth after using a steroid inhaler
Metered dosed inhaler technique without a spacer
- Remove the cap
- Shake the inhaler (depending on the type)
- Sit or stand up straight
- Lift the chin slightly
- Fully exhale
- Make a tight seal around the inhaler between the lips
- Take a steady breath in whilst pressing the canister
- Continue breathing for 3 – 4 seconds after pressing the canister
- Hold the breath for 10 seconds or as long as comfortably possible
- Wait 30 seconds before giving a further dose
- Rinse the mouth after using a steroid inhaler
Complication from poor inhaler technique with ICS
Steroids
MDI technique with a spacer
- Assemble the spacer
- Shake the inhaler (depending on the type)
- Attach the inhaler to the correct end
- Sit or stand up straight
- Lift the chin slightly
- Make a seal around the spacer mouthpiece or place the mask over the face
- Spray the dose into the spacer
- Take steady breaths in and out 5 times until the mist is fully inhaled
Alternatively exhale fully before putting making a seal with the spacer, spray the dose and take one deep breath in to inhale the mist in one breath before holding for 10 seconds.
How to look after spacers
Spacers should be cleaned once a month. Avoid scrubbing the inside and allow them to air dry to avoid creating static. Static can interact with the mist and prevent the medication being inhaled.
Presentation of acute ashtma
- Progressively worsening shortness of breath
- Signs of respiratory distress
- Fast life threatening rate (tachypnoea)
- Expiratory wheeze on auscultation heard throughout the chest
- The chest can sound “tight” on auscultation, with reduced air entry
What is a red flag in an acute asthma attakc?
Silent chest
Peak flow of moderate asthma attack
Peak flow >50%
Normal speech
Severe asthma attack peak flow and saturations
Peak flow < 50%
Saturations <92%
Resp rate in 1-5 year olds severe
> 40
Respiratory rate in >5 years severe asthma attack
> 30
HR in 1-5 years severe asthma attack
> 140
HR in > 5 years severe asthma attack
> 125
Signs of severe asthma attack
Unable to complete sentenves in one breath
Signs of respiratory distress
Life threatening peak flow and saturations attack
Peak flow <33%
Satuations <92%
Signs of life threatening asthma attack
Exhaustion and poor resp effort
Hypotension
Silent chest
Cyanosis Altered consciousness/confusion
Management of viral induced wheeze
- Supplementary oxygen if required (i.e. oxygen saturations less than 94% or working hard)
- Bronchodilators (e.g. salbutamol, ipratropium and magnesium sulphate)
- Steroids to reduce airway inflammation: prednisone (orally) or hydrocortisone (intravenous)
- Antibiotics only if a bacterial cause is suspected (e.g. amoxicillin or erythromycin)
Bronchodilators to treat acute asthma attack
- Inhaled or nebulised salbutamol (a beta-2 agonist)
- Inhaled or nebulised ipratropium bromide (an anti-muscarinic)
- IV magnesium sulphate
- IV aminophylline
Stepqise approach to mod to severe cases
- Salbutamol inhalers via a spacer device: starting with 10 puffs every 2 hours
- Nebulisers with salbutamol / ipratropium bromide
- Oral prednisone (e.g. 1mg per kg of body weight once a day for 3 days)
- IV hydrocortisone
- IV magnesium sulphate
- IV salbutamol
- IV aminophylline
What to do if can’t manage acute asthma attack?
Call anaesthetics
ICU
Intubation and ventialtion
What to assess for after control established in actue asthma attack
cyanosis (central or peripheral), tracheal tug, subcostal recessions, hypoxia, tachypnoea or wheeze on auscultation.
What to assess for after control established in actue asthma attack
cyanosis (central or peripheral), tracheal tug, subcostal recessions, hypoxia, tachypnoea or wheeze on auscultation.
What to assess once control is established in an acute asthma attack?
Review prior to next dose of bronchodilator
Look for evidence of cyanosis, tracheal tug, subcostal recessions, hypoxia, tachypnaea or wheeze
If look well consider stepping down number and frequency of intervention
Step down regime
What is a typical step down regime after acute asthma attack?
10 puffs 2 hourly
10 puffs 4 hourly
6 puffs 4 hour;y
4 puffs 6 hourly
What should monitor for when high doses of salbutamol used?
Potassium levels as draws potassium from blood into cells
Also causes tachycardia and tremor
What drug can cause hypokalemia in asthma treatment?
Salbutamol
When can discharge be considered after acute asthma attack in terms of salbutamol use?
6 puffs 4 hourly for 48 hours
then
4 puffs 6 hourly for 48 hours
then
2-4 puffs as required
Steps to consider after acute asthma attack
Finish the course of steroids if these were started - typically 3 days
Provide safety-net information about when to return to hospital or seek help
Provide an individualised written asthma action plan
How long use facemask on spacer
Until child can follow instructions by themselves
Why hold spaceer at 45 degrees
Vlave is already open 0 babies tidal volume cant open it
How long hold mask over baby with inhaler
10 seconds
How many puffs can take form inhaler
10 breaths
Wait 30s between each breath
What have to do with new volumatic
Prime with a couple of puffs bbefore use
What breaths do you take with inhaler
Tidal volume breaths
What do before use inhaler
BREATHE all way out
Sit uo straight
Reasons for starting ICS
Asthma attack in last 2 years requiring oral corticosteroids
Beta agonsit eg slabuatmol 3 times a week
Symptomatic 3 time a wekmore
Nocturnal symtooms waking one night a week
Under 5 pathogens LRTI
Virsus
Penumococci
Influenza
Bordetella pertussis
Chlamydia
Over 5
Mycopplasma - symptoms worse than signs
Strep pneumoniae
Chlamydia
Myocbacterium TB
Sev penumonia in children features
<92%
RR>70 (>50 in oder children)
Significant tachy
CRT >2s
Difficulty breething
Apnoea, grunting
Not feeding
Chronic conditions
What investgiations do for resp viruses, Mycoplasma and chlamydia
nasopharyngeal secretions or nasal swab for PCR and/or immunofluroesence
What investgiations do for resp viruses, Mycoplasma and chlamydia
nasopharyngeal secretions or nasal swab for PCR and/or immunofluroesence
Antibiotic for pneumonia children
Amoxicillin
Signs of resp distress in a 3 month old
Head bob
Tracheal tug
Nasal flaring
Costal recession
Sternal recession
Increased resp rate and effort
Use of accessory muscels
Bronchiolitis presentation
Prodrome of 1-3 day coryzal symptoms
Cough
Increased work of breathing : increased respiratory rate and chest recession
Apnoea
Wheeze/crackles on auscultation
Reduced feeding
Criteria for admission bronchiolitis
Apnoea
Resp distress
<92% sats
DIFFICULTY FEEDING - 50-75% USUAL
What is pavilizumab
RSV monoclonal antibody
Indications for pavilizumab
<2 with haemodynamically significant CHD
SCID
Long term ventilation
Preterm infants on supplementary oxygen
Treatment for croup
Oral dexamethasone
Nebulised budesonide
Adrenaline nebuliser if severe
IV ceftriazone and fluclozacillin
DONT EXAM AW
Signs epiglottitis
Thumb sign lateral neck x ray
Cherry red epiglottis
Retropharyngeal abscess
Prodrome of 1-3 day coryzal symptoms
Cough
Increased work of breathing : increased respiratory rate and chest recession
Apnoea
Wheeze/crackles on auscultation
Reduced feeding
Children at risk of AKI
Children with underlying nephron-urological, kidney or liver disease
· Children with malignancy or a Bone Marrow Transplant
· Children who depend on others for access to fluid
· Children exposed to nephrotoxins –(eg ACEis, ARBs, NSAIDs, diuretics, aminoglycosides, calcineurin inhibitors)
Known kidney disease e.g. chronic kidney disease or
a kidney transplant
* Heart disease
* Liver disease
* Cancer undergoing treatment
* Bone marrow transplant
* Any condition which makes them dependent on others
for access to fluids
* Treatment with some antibiotics e.g. gentamicin,
tobramycin
* Treatment with other medications e.g. tacrolimus
or ciclospori
Conditions putting child at risk of AKI
Sepsis
· Dehydration
· History of reduced urine output
· Hypoperfusion
· Exposure to nephrotoxin
· Intrinsic renal disease
· Obstruction
· Major surgery
What is creatinine level determined by
Height
When can an AKI be diagnosed in Cchildren
<0.5ml/kg/hour for >8 hour
Bloods in status epilepticus child
Full blood count
Urea & Electrolytes
CRP
Glucose
Magnesium
Calcium
Cultures
