Asthma

Question 1

Natural history of asthma in child

Answer 1

Transient early wheezing:

• more common males
• usually resolves 5 y o (increase in airway)
• small airway narrowing/ obstruction due to inflammation and abberant inflammation to viral infection
• episodic nature- triggered by viruses causing cold
• decreased lung function and small airway diameter from birth
• Risk factors:
  
  • ​maternal smoking during pregnancy/ postpartum
  • preterm birth

Persistent and recurrent wheezing

• evidence of allergy to 1+ inhaled allergens (skin-prick or IgE test) termed atopic asthma
• persistent symptoms
• decreased lung function
• +eczema, rhinoconjuntivitis and food allergy
• family history

Question 2

Presentation of asthma

Answer 2

• wheezing on 1+ occassion
• expiratory/ high-pitched
• upper respiratory noises
• worse at night/ early morning
• triggers- exercise, pets, dust, cold air, emotions
• interval symptoms
• personal or family history of atopic disease
• positive response to asthma therapy

Question 3

Presentation of chronic asthma

Answer 3

Question 4

Examination of child with asthma

Answer 4

• Normal in between attacks
• Long-standing- hyperinflation of the chest
• Generalised polyphonic expiratory wheeze and prolonged expiratory phase
• Harrison sulci- depression base of thorax with associated muscular insertion of diaphragm
• Eczema, rhinitis
• Growth plots- normal unless severe

Question 5

Investigations of child with asthma

Answer 5

• Hx and examination
• Skin-prick
• CXR
• PEFR before and after bronchodilator (increase of 10-15%)

Question 6

Differential diagnoses

Answer 6

• GORD
• CF
• Bronchiectiasis
• Viral induced wheezing
• Bronchiolitis
• Croup

Question 7

Assessment of child with acute asthma

Answer 7

• wheeze and tachypnoea
• increasing tachycardia
• accessory muscle
• chest recession
• pulsus paradoxus (difference between systolic BP on inspiration and expiration)
• ability to talk
• CYANOSIS, FATUGUE & DROWSINESS + silent chest= LIFE-THREATENING ASTHMA, CHILD CLOSE TO ARREST

Question 8

Management of acute exacerbation of asthma

Answer 8

Question 9

5 steps of SIGN/ NTS management of asthma (5-12 years)

Answer 9

Question 10

5 steps of SIGN/ NTS management of asthma (less than 5 years)

Answer 10

Question 11

Assessment asthma control

Answer 11

• Control symptoms (suffering from? frequency?triggers?)
• Are symptoms affecting:
  
  • school
  • sleep
  • general activites
• Step down treatment over few months
• Prevent exacerbations (how many?)
• Minimise treatment and side effects
• Inhaler technique
• Spacer
  
  • ​0-2 yrs spacer and face mask
  • 2 yrs + spacer alone
  • NB contraversial in acute asthma
• Breath-actuated metered dose
  
  • ​6+ yrs
  • Out and about with older children
• Dry powder​
  
  • 4+ yrs
  • Needs good inspiratory flow- not good in severe or acute asthma
  • Easy to use when out and about
• Nebuliser​
  
  • acute asthma
  • +O2
  • brittle asthma- home use

Question 12

Parent advice for child with asthma

Answer 12

• Medication types
  
  • Relievers (B2 agonists)
    
    • ​SA (2-4h effectiveness, few side effects)
    • LA (12h effectiveness, useful in exercise induced)
    • Ipratropium bromide (young infants, other bronchodilators are innefective or severe asthma)
  • Preventers
    
    • Inhaled corticosteroids (+LABA, systemic side effcts in high doses- impaired growth, adrenal suppression and altered bone metabolism)
  • Add-ons
    
    • LABA (5-12 yrs)
    • Leukotiene receptor antagonist (montelukast) (< 5yrs)
    • Slow release oral theophylline- side feccts: vomiting, insomnia, headaches, porr concentration)
  • Other
    
    • Oral steroids- prednisolone (severe Tx failed asthma)
    • Anti IgE- omalizumab (severe atopic asthma)
• Side effects
• Inhaller technique and types
  
  • Spacer
    
    • ​0-2 yrs spacer and face mask
    • 2 yrs + spacer alone
    • NB contraversial in acute asthma
  • Breath-actuated metered dose
    
    • ​6+ yrs
    • Out and about with older children
  • Dry powder
    
    • ​4+ yrs
    • Needs good inspiratory flow- not good in severe or acute asthma
    • Easy to use when out and about
  • Nebuliser
    
    • ​acute asthma
    • +O2
    • brittle asthma- home use
• Avoidance of allergens/ triggers
  
  • history or allergy testing
  • asthma should not limit exercise with appropriate treatment
    
    • SABA just before exercise
    • LABA + inhaled steroid gives greater protection
• Smoking
• Symptoms of acute attack- what to do
• Psychological input in chronic asthma children