Asthma Flashcards
Most common chronic disease of childhood
Asthma 15%
Suggestive of asthma in children
- Recurrent wheeze/cough that responds to bronchodilator therapy
Confirmation of diagnosis
Good response to bronchodilators, either in symptom control or PEFR
CXR findings
- Hyperinflation due to air trapping
- Collapse due to mucus plugging
Goal of good asthma management
- Reduction in symptoms
- Normal activity
- School attendance
- Growth
When should a MDI with spacer + face mask definitely be used
Younger than 5 years
At what oxygen saturation should children be admitted to hospital
AT LESS THAN 92%
Describe cough in asthma
- Recurrent
- Dry
- Worse at night
- Worse with exercise
Describe wheeze in asthma
- Expiratory
- Triggered by viral
- Responds to bronchodilators
Triggers for shortness of breath
- Exercise
- Cold
- Allergens
- Smoke!!!
Brief pathology overview
Environmental triggers cause broncho-constriction, mucosal oedema, excess mucus in genetically predisposed child Airway narrowing causes wheeze and SOB
Assessing severity
- Mild/Moderate
Walk, speak whole sentences in one breath
>94% oxygen saturation
- Severe
Use of accessory muscles, intercostals, tracheal tug
Unable to complete sentences
Obvious respiratory distress
90-94% saturation
- Life threatening
Reduced consciousness/collapse
Exhaustion
Cyanosis
<90% O2 sats
Poor respiratory effort
Soft/absent breath souds
Suggestive of asthma in children
- Recurrent wheeze/cough that responds to bronchodilator therapy, difficulty breathing, tightness, cough
- Recur
- Worse at night/mornign
- Triggers->exercise, cold, pets
- History of allergies, family history of allergies
- Widespread wheeze on auscultation
- Lung function + with bronchodilator
Confirmation of diagnosis
- Good response to bronchodilators, either in symptom control or PEFR
- FEV1 before and 10-15 after bronchodilator, reversible +>12% for FEV1
Investigations and significance
- PEFR->record in PEF diary to monitor change, beta-2 agonist bronchodilator response, defined as a 12% or greater improvement in either FEV1 or FVC 10 to 15 minutes after inhalation of beta-2 agonist
- CXR->Exclude pneumothorax in severe.
- Avoid ++radiographs
- Allergy test->skin prick most useful. Specific IgE to common inhaled allergens may identify allergens to avoid
Goal of good asthma management
- Reduction in symptoms Normal activity School attendance Growth
Describe cough in asthma
Recurrent Dry Worse at night Worse with exercise
Describe wheeze in asthma
Expiratory Triggered by viral Responds to bronchodilators
Triggers for shortness of breath
Exercise Cold Allergens Smoke
Evidence of poor asthma control (4)
- Poor growth
- Chronic chest deformity
- Miss school
- Frequent exacerbations
Brief pathology overview
Environmental triggers cause broncho-constriction, mucosal oedema, excess mucus in genetically predisposed child Airway narrowing causes wheeze and SOB
Assessing severity
- Mild: -breathless, not distressed -PEFR reduced, still >50% 2. Severe: -too breathless to talk or feed -RR >50 bpm, >130 tachyC -PEFR
History
- Cough and wheeze?
- Worse at night, dry cough
- Triggers- exercise, viral, temperature
- Acute exacerbations, severity, management
- Affect on life, school, activity
- Revleiver use?
- Effectiveness?
- Other atopic symptoms
- Parental smoking
Examination
- In well controlled, may not have signs between exacerbations
- Respiratory distress
- Chest wall deformity->barrel chest, Harrison’s sulcus
- Listen for wheeze
- Features of atopy
- Measure PEFR with hand held meter
- Check height and weight->poorly controlled asthma shunts growth, as will overuse corticosteroids
- Check inhaler technique
Investigations and significance
PEFR->record in PED diary to monitor change. beta-2 agonist bronchodilator response, defined as a 12% or greater improvement in either FEV1 or FVC 10 to 15 minutes after inhalation of beta-2 agonist CXR->Exclude pneumothorax in severe. Avoid ++radiographs Allergy test->skin prick most useful. Specific IgE to common inhaled allergens may identify allergens to avoid
Management overview categories (4)
- Medications
- Environmental control->avoid passive smoke, dust mites
- Self monitoring of disease progress->PEFR, symptom diary, management plan
- Education->all involved, inhaler technique, emergency management, asthma action plan
Most important parameters in assessment of severity
- General appearance/mental state
- Work of breathing
SpO2 considerations- to give or not
- Oxygen may be required for low saturations, DO NOT give for wheeze or increased work of breathing. arterial oxygen saturation (SaO2) may be reduced in the absence of significant airway obstruction due to factors such as atelectasis and mucous plugging of airways.
- SaO2 is purely a measure of oxygenation, which may be preserved in the presence of deteriorating ventilation (with CO2 retention).
Mild severity and management
- Mild
Normal MS Subtle +WOB
Talking in full sentences
Salbutamol by MDI/spacer (dose below table) - give once (<6, 6 puffs, >6 12 puffs, and review after 20 mins. If non acute care->arrange transfer
- Ensure device / technique appropriate.
- Good response - discharge on B2-agonist as needed.
- Poor response - treat as moderate-add ipratropium bromide (8 puffs >6, 4 puffs <6 every 20 minutes via mDI)
- Oral prednisolone for acute episodes which do not respond to bronchodilator alone - 2 mg/kg (max 60 mg) initially, only continuing with 1 mg/kg daily for further 1-2 days if there is ongoing need for regular salbutamol.
- Observe for 1 hour after breathing difficulty resolves
- Post acute care
Provide written advice on what to do if symptoms worsen.
Consider overall control and family’s knowledge.
Ensure regular inhaled preventor if indicated
Inhaler technique
Spacer
Interim asthma action plan
- Arrange follow-up as appropriate.
- Discharge pack
What is in discharge pack
- Review need for preventative treatment
- Check inhaler technique
- Family education
- Prescription
- Follow up-> GP and pediatrician (4-6 weeks)
- Written action plan
- Communication with GP
Review need for preventative
- Intermittent asthma->regular preventor not recommended
- Frequent intermittent, viral induced with frequent symptoms
Monteleukast 5mg once daily, reasses response in 2-4 weeks
<2 years->sodium cromoglycate
- Moderate to severe
Regular low dose inhaled corticosteroid
Couselling on use of puffer: reason, how it is given, benefits, how to use and care for
- Your child has come to hospital for treatment of asthma.
- If your child has had asthma before, he/she may have been given medicine through a nebuliser or “pump”.
- We now know that asthma medication given through a puffer and spacer relieves asthma symptoms just as well as a nebuliser.
- Most children who come to hospital will now have their asthma medicine through an puffer and spacer.
- The benefits of using an puffer and spacer are that it is:
a) effective in relieving asthma symptoms, easy to use, portable, inexpensive, easy to care for - It is important to remember the following when using a puffer and spacer:
puffer and spacer is better than using a puffer alone as more medication gets to the lungs where it is needed
the number of puffs given in hospital is more than is usually given at home as the asthma is usually worse (in hospital your child will have 6 or 12 puffs of ‘ventolin’ at a time depending on his/her age)
you and your child (if he/she is old enough) need to know how to use the puffer and spacer properly for the medication to work as well as it can (see over)
you and your child (if he/she is old enough) need to know to care for the spacer
Initial explanation of inhaler
- Type of inhaler, purpose and when to use Inhaler contains set dose of medication
- Aim is to get into the lungs
- Drug is released by pressing the cannister/twisting as shown
Steps for using the inhaler
- Check expiration
- SHake
- Remove cap, see if clean
- Sit/stand up straight
- Hold inhaler upright with index and thumb
- Breathe out completely
- Seal mouth around
- Simultaneously press down and breathe in slowly and deeply- aim for back of throat not tongue
- Hold breath for 10 seconds 10.
- Breath out slowly
- Replace cap
- Repeat after one minute if required
Other advice when talking about inhaler
- Seek help if symptoms not relieved
- See GP if having side effects
- Ask if any questions or concerns.
Breathing with a spacer
How to use your Large Volume Spacer
- Put together the spacer following the instructions that came with it.
- Remove the protective cap from the puffer.
- Shake the puffer well and insert (place) it firmly into the end of the spacer.
- Place the mouth piece of the spacer in your mouth and put it between your teeth. Now, close your lips around the spacer mouth piece. Make sure your lips cover the entire mouth piece so there are no gaps. Hold the spacer level so that it does not tilt up or hang down.
- Breathe out gently.
- Press the puffer ONCE to release a dose of the medicine into the spacer. Do not remove the puffer.
- Breathe in very slowly until you have taken a deep breath. You will hear a whistle sound if you are breathing in too fast. Hold your breath for a few seconds, then breathe out slowly and deeply through your mouth.
- Breathe in and out 4 or 5 times (do not remove your mouth from the mouthpiece in between each breath - there is a 2 way valve system which will prevent any of the medication from escaping from the chamber).
Care of the spacer
- Clean once a week , or however often you feel it is dirty based on how often you use it
- Wash with warm soap and water
- Always leave to drip dry
- Replace every 6-12 months
Use of turbuhaler
- To load the medication, you need to turn the base of the Turbuhaler all the way in one direction and then all the way back in the other direction.
- If your child needs more than dose of medicine, twist the base again - first one way, then the other to load the next dose.
- If your child is taking a preventer medicine, it is best if they clean their teeth or have a drink after using the medicine so that none stays in their mouth.
- Talk to your doctor, pharmacist or nurse if you have any questions about these instructions.
- If your child has to have regular medication every day ( such as a preventer) - it can be helpful to keep it with their tootbrush.
Moderate severity and management
- Salbutamol
- Reassess
- Ipratropium bromide
- Consider add on therapy
- Systemic corticosteroid 2mg/kg day 1, 1mg/kg day 2 and 3
- Reassess after 1 hour
- Nil issue->observe 1 hour, post-acute care: enducation, managing at home, oral prednisilone 3-5 days, preventer at home, inhaler technique, spacer, asthma action plan, F/U, GP
- If ongoing breathing difficulty
Admit
Continue bronchoD + add on therapy-> IV magnesium sulphate, I salbutamol, NIPPV
Severe severity and management
- Agitated/distressed
Moderate-marked increased work of breathing accessory muscle use/recession.
Tachycardia
Marked limitation of ability to talk
Note: wheeze is a poor predictor of severity.
- Oxygen as above
- Salbutamol by MDI/spacer - 1 dose (dose below) every 20 minutes for 1 hour; review ongoing requirements 10-20 min after 3rd dose.
- If improving, reduce frequency. If no change, continue 20 minutely.
- If deteriorating at any stage, treat as critical. Ipratropium by MDI/spacer - 1 dose (dose below) every 20 minutes for 1 hour only.
- Aminophylline If deteriorating or child is very sick. Loading dose: 10 mg/kg i.v. (maximum dose 500 mg) over 60 min.
- Unless markedly improved following loading dose, give continuous infusion (usually in ICU), or 6 hourly dosing (usually in ward). Drug doses
- Magnesium sulphate 50% (500 mg/mL) Dilute to 200 mg/mL (by adding 1.5mls of sodium chloride 0.9% to each 1ml of Mg Sulphate) for intravenous administration 50 mg/kg over 20 mins
- If going to ICU, this may be continued with 30 mg/kg/hour by infusion
- Oral prednisolone (2 mg/kg); if vomiting give i.v. methylprednisolone (1 mg/kg)
- Involve senior staff.
- Arrange admission after initial assessment.
Critical severity and management
- Confused/drowsy, Maximal work of breathing accessory muscle use/recession, Exhaustion, Marked tachycardia, Unable to talk
SILENT CHEST, wheeze may be absent if there is poor air entry. Involve senior staff.
Be sure to arrange transfer if beyond management in that hospital
- Oxygen
- Continuous nebulised salbutamol (use 2 x 5mg/2.5L nebules undiluted) - see below re toxicity.
- Nebulised ipratropium 250 mcg 3 times in 1st hr only, (20 minutely, added to salbutamol).
- Methylprednisolone 1 mg/kg i.v. 6-hourly.
- Aminophylline as above
- Magnesium sulphate as above.
- In ICU patients on Mg infusion, aim to keep serum Mg between 1.5 and 2.5mmol/L.
- May also consider i.v. salbutamol. Limited evidence for benefit. 5 mcg/kg/min for one hour as a load, followed by 1-2 mcg/kg/min.
- Intensive care admission for respiratory support (facemask CPAP, BiPAP, or intubation/IPPV) may be needed.
Salbutamol toxicity
- Beware salbutamol toxicity: tachycardia, tachypnoea, metabolic acidosis, hypokalemia
- Can occur with both IV and inhaled therapy.
- Lactate commonly high.
- Consider stopping/reducing salbutamol as a trial if you think this may be the problem.
Can aminophylline, salbutamol and magnesium be give by same IV line
No, need seperate
Salbutamol dose
6 puffs if <6 years old
12 puffs if >6 years old
Ipratropium dose
4 puffs if <6 years
8 puffs if >6 years
Investigations
- CXR not usually required
- ABG and spirometry not required in immediate assessment
When to consider discharge
Consider discharge when:
- Assess patient for clinical improvement 1 hour following initial therapy and discharge if clinically well. If necessary, reassess again after 30 minutes
- Adequate oxygenation - Oxygen saturation of less than 92 percent should not preclude discharge if patient is clinically well and has responded well to treatment
- Adequate oral intake
- Adequate parental education and ability to administer salbutamol via spacer
Defining good asthma control
- No limit on activity
- No nocturnal symptoms
- Good exercise tolerance
- Minimal b2 agonist use
- No severe attacks
- No medication side effects
- Near/normal lung function >80%
6 Step long term management
- Assess severity
- Achieve best lung function
- Avoid triggers
- Maintain best lung function
- Individualised written asthma plan
Reasons for suboptimal asthma management
- Poor adherence
- Inefficient use of inhaler
- Procrastination introducing therapy
- Patient fears
- Doctor reluctance
Long term management of intermittent and definition
Xweekly- >6 weeks apart PEFR > 80
SABA PRN
Long term management of mild, and definition
- weekly, Xevery day , >2 monthly nocturnal , Regular imapact activity >80% PEFR
Regular inhaled CS or monteleukast (>5) or sodium cromoglycate <5 + SABA –>2 SAβA 2–3 times daily
Long term management of moderate
- daily, weekly nocturnal, Other triggers, 60-80%
SABA prn, LABA + Regular inhaled CS +dose or ICS + monteleukast
Long term management of severe
- Symptoms every day, Wakes frequently with cough/ wheeze, Chest tightness on waking, Limitation of physical activity
- ICS high dose or ICS low + monteleukast or ICS low + LABA
SABA PRN
- Referral to specialist
Options for LABA
1 eformoterol 12 micrograms by inhalation, twice daily OR
1 salmeterol 50 micrograms by inhalation, twice daily.
Combination medication
- fluticasone + salmeterol (Seretide) MDI: 50/25; 125/25; 250/25 mcg dose: adults, 2 inhalations bd; children 4–12, 2 inhalations bd 50/25 Accuhaler: 100/50; 250/50; 500/50 dose: adults, 1 inhalation bd; children 4–12, 1 inhalation bd 100/50
- budesonide + eformoterol (Symbicort) Turbuhaler 100/6; 200/6; 400/12; 1–2 inhalations bd
Exercise induced treatment
salbutamol 100 to 400 micrograms by inhalation, 5 minutes before exercise
If frequent->monteleukast
Common side effects of iCS
- Oral candidiasis
- Hoarse voice
- Bronchial irritation/cough
- Adrenal suppresion >2000mcg
What is contained in an asthma action plan
- Medication taken every day
- How to tell if asthma is getting worse
- What to do when symptoms getting worse
- What to do if having an asthma attack
When my asthma is well controlled
- No regular wheeze, or cough or chest tightness at night time, on waking or during the day
- Able to take part in normal physical activity without wheeze, cough or chest tightness
- Need reliever medication less than three times a week (except if it is used before exercise
Take preventer, reliever and combination medication as usual
When my asthma is getting worse
- At the first sign of worsening asthma symptoms associated with a cold
- Waking from sleep due to coughing, wheezing or chest tightness
- Using reliever puffer more than 3 times a week (not including before exercise)
Peak Flow* between 60-80
Increase medication and see doctor about getting worse
When my asthma is severe
- Need reliever puffer every 3 hours or more often
- Increasing wheezing, coughing, chest tightness
- Difficulty with normal activity
- Waking each night and most mornings with wheezing, coughing or chest tightness
- Feel that asthma is out of control
Peak Flow* between < 60
See doctor for advice
How to recognise life threatening and manage
- Dial 000 for an ambulance and/or 112 from a mobile phone if you have any of the following danger signs:
• extreme difficulty breathing • little or no improvement from reliever puffer • lips turn blue and follow the Asthma First Aid Plan below while waiting for ambulance to arrive.
- A serious asthma attack is also indicated by: • symptoms getting worse quickly • severe shortness of breath or difficulty in speaking • you are feeling frightened or panicked • Peak Flow* below 60
Asthma First Aid Plan
1 Sit upright and stay calm.
2 Take 4 separate puffs of a reliever puffer (one puff at a time) via a spacer device.
Just use the puffer on its own if you don’t have a spacer.
Take 4 breaths from the spacer after each puff.
3 Wait 4 minutes. If there is no improvement, take another 4 puffs.
- If little or no improvement CALL AN AMBULANCE IMMEDIATELY (DIAL 000 and/or 112 from mobile phone) and state that you are having an asthma attack.
- Keep taking 4 puffs every 4 minutes until the ambulance arrives.
- See your doctor immediately after a serious asthma attack.
Option for exercise induced asthma, multiple allergen triggers
- Sodium cromoglycate
- Monleukast
Also for children with nasal polyps, aspirin hypersensitivity, allergic asthma
