Asthma Flashcards
1
Q
Asthma - overview (3)
A
- Definition = chronic inflammatory disease of airways characterised by reversible airway obstruction and bronchospasm
- Onset of asthma can occur at any age, including within the first few years of life. Can occur
2
Q
Asthma - risk factors for poor outcome (3)
A
- Previous ICU admission
- Poor compliance to asthma therapy
- Poorly controlled/significant interval symptoms
3
Q
Asthma - risk factors
A
- Male
- FHx asthma or atopy
- PHx atopy
- Exposure to second-hand smoke
- Obesity
4
Q
Asthma - symptoms
A
- Wheeze
- Cough
- SOB
- Chest tightness
+ 5. Triggers (4) = viruses, exercise, allergen exposure, cold air
5
Q
Asthma - signs
A
Acute attack
- Wheeze (not a good marker of severity), general appearance/mental state (important)
- Work of breathing (accessory muscle use, recession)
Chronic asthma
- Barrel-shaped chest
- Hyperinflation
- Wheeze and prolonged expiration
6
Q
Asthma - ax of severity for acute attack (4, 3 for each)
A
- Mild
i. Normal mental state
ii. Subtle or no increased WOB
iii. Able to talk normally - Moderate
i. Normal mental state
ii. Some increased WOB, tachycardia
iii. Some limitation of ability to talk - Severe
i. Agitated/distressed
ii. Moderate to markedly increased WOB, tachycardia
iii. Marked limitation of ability to talk
NOTE: wheeze is a poor predictor of severity - Critical
i. Confused, drowsy or exhaused
ii. Maximal WOB, marked tachycardia
iii. Unable to talk, SILENT CHEST (wheeze may be absent if there is poor air entry)
7
Q
Asthma - classification of chronic asthma
A
Intermittent
- No baseline or nocturnal symptoms
- Infrequent
- Exacerbations = brief/mild, occurring less than every 4-6 weeks - Frequent
- Exacerbations = >2/mo (once every two weeks)
____
Persistent
- Baseline or nocturnal symptoms - Mild
- Baseline symptoms >1/wk, but 2/mo
- Exacerbations = may affect activity and sleep - Moderate
- Baseline symptoms = daily
- Nocturnal symptoms = >1/wk
- Exacerbations >/=2/wk, affect activity and sleep - Severe
- Baseline symptoms = continual
- Nocturnal symptoms = frequent
- Exacerbations = frequent, restrict activity
8
Q
Asthma - ix
A
- Spirometry (where possible, >5y) (5)
- FEV1/FVC ratio used to detect airflow obstruction
- FEV1 expressed as percentage to grade severity
- Mild obstruction = FEV1 > 0.8
- Moderate obstruction = FEV1 between 0.6 and 0.8
- Severe obstruction = FEV1
9
Q
Asthma - acute mx (mild)
A
- Salbutamol by MDI + spacer. 6 puffs if 6 years old. Give once and review after 20 mins
- Good response - discharge on beta-2 agonist as needed
- Poor response - tx as moderate
- Oral prednisolone for acute episodes which do not respond to bronchodilator alone - 2mg/kg (max 60mg initially), only continuing with 1mg/kg daily for further 1-2d if there is ongoing need for regular salbutamol
- Provide written advice on what to do if symptoms worsen. Consider overall control and family’s knowledge
10
Q
Asthma - acute mx (moderate - 3)
A
- Oxygen if O2 saturation 6 years old, 1 dose every 20 mins for 1 hour, review 10-20 mins after 3rd dose to decide on timing of next dose
- Oral prednisolone - 2mg/kg (max 60mg) initially, only continuing with 1mg/kg daily for further 1-2d if there is ongoing need for regular salbutamol
11
Q
Asthma - acute mx (severe, 6+2)
A
- Oxgyen if O2 saturation 6 years old, 1 dose every 20 mins for 1hr, review ongoing requirements 10-20 mins
- Salbutamol (…)
- Ipratropium by MDI + spacer - 4 puffs if 6 years old. 1 dose every 20 mins for 1hr only
- Aminophylline if deteriorating or child very sick
- Magnesium sulphate, 50mg/kg IV over 20 mins. If going to ICU, may be continued with 30mg/kg/hr by infusion
- Oral prednisolone (2mg/kg), if vomiting give IV methylprednisolone (1mg/kg)
+ 7. Involve senior staff
8. Arrange admission after initial ax
12
Q
Asthma - acute mx (critical)
A
- Involve senior staff
- Oxygen
- Continuous nebulised salbutamol - 2 x 5mg/2.5L nebules undiluted (beware salbutamol toxicity - tachycardia, tachypnoea, metabolic acidosis)
- Nebulised ipratropium - 250mcg 3 times in 1st hour only
- IV methylprednisolone 1mg/kg, 6-hourly
- Aminophylline if child deteriorating or very sick
- IV magnesium sulphate 50mg/kg over 20 mins. If going to ICU, may be continued with 30mg/kg/hr by infusion
+ 7. May consider IV salbutamol (but limited evidence for benefit)
+ 8. Aminophylline, magnesium and salbutamol must be given via separate IV lines
+ 9. ICU admission for respiratory support (facemask CPAP, BiPAP or intubation) may be needed
13
Q
Asthma - maintenance mx (5+3)
A
Infrequent intermittent asthma
1. SABA on demand, preventer therapy not indicated
Frequent intermittent or persistent asthma
- All children = SABA on demand (salbutamol or terbutaline)
- Some children = SABA + regular preventer (low dose ICS [beclomethasone, budesonide, ciclesonide, fluticasone propionate], or leukotriene receptor antagonist (montelukast), or cromone (cromoglycate, necrodomil - not as effective as ICS)
- Few children = SABA + stepped-up regular preventer (high-dose ICS, or low-dose ICS + montelukast, or low-dose ICS + LABA)
- If still not controlled, refer to specialist
General principles
- Before stepping up, check that sx are due to asthma, inhaler technique is correct and adherence is adequate
- Consider stepping up if good control not achieved
- When asthma is stable and well-controlled for 2-3mo, consider stepping down (reducing dose or stopping ICS)
