Asthma Flashcards
How can you diagnose asthma?
- Wheeze is suggestive but not pathognomonic
- Response to bronchodilator is suggestive
- Chronic cough may be a primary manifestation
- HISTORY
History taking questions?
- Recurrent cough or wheeze?
- Cold that “go to the chest” or take >10 days?
- Cough/wheeze during a particular time of the year
- Cough/wheeze/SOB when exposed to certain things?
- Used any medications to help you breathe better?
- in the past 12 months - have you had cough, wheeze, or shortness of breath - At night?, Upon awakening?, After play?
- in the past 4 weeks
Common asthma triggers?
- Animals
- Cockroaches/rodents
- Molds/dampness
- Spring (pollen)
- Rainy season (molds)
- Tobacco
- Wood-burning or paraffin stove
- Perfumes, cleaning agents, bug spray
- maize harvesting season
Differential diagnosis for acute wheezing?
- Asthma
- Bronchiolitis
- Atypical infection - causing atypical pneumonia (Myecoplasma)
- Bacterial tracheitis
- Foreign body
- Anaphylaxis - associated with hives, swollen face, stridor and previous reaction to allergen
Causes of recurrent persistent childhood wheeze?
- viral episodic wheeze
- multiple trigger wheeze
- asthma
- tracheo-bronchomalacia
- bronchopulmonary dysplasia
- recurrent anaphylaxis
- cystic fibrosis
- chronic aspiration
- bronchiolitis obliterans
Structural ddx chronic wheezing?
- Tracheo-bronchomalacia
- Vascular rings
- Tracheal stenosis
- Cystic masses
- Tumors or lymphadenopathy
- Cardiac failure
Functional ddx chronic wheezing?
- Asthma
- Gastroesophageal reflux (GERD)
- Recurrent aspiration (e.g CP)
- Cystic fibrosis
- Immunodeficiency
- Bronchopulmonary dysplacia (ex-premie)
- Retained foreign body
- Bronchiolitis obliterans
- Pulmonary oedema
- Vocal cord dysfunction
- Interstitial lung disease
What are the stages of asthma?
- intermittent
- mild persistent
- moderate persistent
- severe persistent
What is intermittent asthma?
Daytime symptoms 2 or fewer days/week
Nocturnal symptoms 2 or fewer nights/month
No interference in daily activities or play
1 or fewer exacerbations per year
What is mild persistent asthma?
Daytime symptoms 3-6 days/week
Nocturnal symptoms 3-4 nights/month
Minor interference with daily activities or play
2 or more exacerbations per year
Effectiveness of SABAs - rescue inhalers?
- Maximum effect after 10-15minutes
- Effective for 2 -4 hours
Use of inhaled corticosteroids (ICS) - preventers?
The most effective prophylactic inhaled therapy
Side effects of ICS?
- impaired growth
- adrenal suppression
- altered bone metabolism
What is moderate persistent asthma?
Daily symptoms
Nocturnal symptoms more than once per week
Daily inhaler use
Some activity limitation
What is severe persistent asthma?
Symptoms throughout the day
Nocturnal symptoms most nights
Significant limitation in activity
Intermittent asthma management?
Salbutamol as needed (short acting beta-agonist, SABA)
Mild persistent asthma management?
- SABA as needed
- Daily low-dose inhaled corticosteroid (ICS) = beclomethasone
Moderate persistent asthma treatment?
- SABA as needed
- Daily medium-dose ICS
Severe persistent asthma management?
- SABA as needed
- Daily high-dose ICS or Daily medium-dose +leukotriene receptor antagonist (LTRA)
Symptoms of mild asthma?
- breathlessness while walking
- can speak in full sentences
- can sit in any position
- alert
Signs of mild asthma?
- increased respiraory rate
- no use of accessory muscles
- expiratory wheeze
- pulse rate <100
- no pulsus paradoxus
- SpO2>95%
Symptoms of moderate asthma?
- breathless while at rest - trouble feeding, shorter/softer cry
- can only speak phrases
- prefers sitting
- agitated
Signs of moderate asthma?
- increased respiratory rate
- common use of accessory muscles
- wheeze throughout exhalation
- pulse rate: 100-200
- pulsus paradoxus: 10-25 mmHg
- SpO2: 90-95%
Symptoms of severe asthma?
- breathless while at rest - stops feeding
- speaks only words
- sits upright
- agitated, drowsy or confused
Signs of severe asthma?
- respiratory rate>30/min
- use of accessory muscles
- wheeze on inhalation and exhalation OR silent chest
- pulse rate >120 or bradycardia
- pulsus paradoxus: 20-40 mmHg
- SpO2 < 90%
Respiratory rate in children by age?
2 - 12 months <50bpm
1 - 5 years <40bpm
6 - 8 years <30bpm
Pulse rate by age in children?
2 - 12 months <160bpm
1 - 2 years < 120bpm
2 - 8 years <110bpm
Exacerbation treatment?
Step 1: dexamethasone 0.6 mg/kg (max dose 12-16 mg) or prednisolone (1 -2mg/kg)
Step 2: salbutamol nebulizer over 20 minutes
Severe exacerbation treatment?
- Salbutamol nebulizer (“back to back”)
- Magnesium sulfate OR aminophylline
- Oxygen therapy
Other medications used in severe exacerbations in pediatric intensive care setting?
- Ketamine
- Adrenaline (0.01 mg/kg IM or subQ)
- Terbutaline (0.01 mg/kg IM or subQ)
- Heliox
What is Heliox?
- Heliox is a breathing gas mixture of helium (He) and oxygen (O2)
- It is used as a medical treatment for patients with difficulty breathing
- The mixture generates less resistance than atmospheric air when passing through the airways of the lungs, and thus requires less effort by a patient to breathe in and out of the lungs
Respiratory support in severe exacerbations?
- BiPAP > CPAP
- Avoid intubation if possible
What is BiPAP?
bilevel positive airway pressure (BiPAP) - delivers higher pressure on inspiration and lower pressure on expiration
What is CPAP?
Delivers equal pressures both in inspiration and expiration
When to discharge in asthma?
- Able to go 4 hours in between salbutamol treatments
- No longer requiring oxygen
- Able to eat and drink
Discharge planning in asthma?
- Continue salbutamol for next 48 hours then gradually space out
- 3-5 days of prednisone (2 mg/kg first dose then 1 mg/kg BD)
