Asthma Flashcards
Management of mild asthma attack
Salbutamol by MDI/spacer (dose below table) - give once and review after 20 mins. Ensure device / technique appropriate. Good response - discharge on B2-agonist as needed. Poor response - treat as moderate. 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. Provide written advice on what to do if symptoms worsen. Consider overall control and family’s knowledge. Arrange follow-up as appropriate.
Management of moderate asthma attack
Oxygen if O2 saturation is < 92%. Need for Oxygen should be reassessed. Salbutamol by MDI/spacer - 1 dose ( dose below ) every 20 minutes for 1 hour ; review 10-20 min after 3rd dose to decide on timing of next dose. Oral prednisolone - 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.
Management of severe asthma attack
Oxygen if O2 saturation is < 92%. Need for Oxygen should be reassessed. 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) very 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.
Management of critical asthma attack
Involve senior staff. Oxygen Continuous nebulised salbutamol (use 2 x 5mg/2.5mL 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. Aminophylline, magnesium and salbutamol must be given via separate IV lines. Intensive care admission for respiratory support (facemask CPAP, BiPAP, or intubation/IPPV) may be needed.
Signs of salbutamol toxicity
tachycardia, tachypnoea, metabolic acidosis. 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.
Salbutamol dose for kids
6 puffs if < 6 years old 12 puffs if >6 years old
Ipratropium dose for kids
4 puffs if < 6 years old 8 puffs if >6 years old
How do you assess for good asthma control?
Good asthma control is having, in the previous 4 weeks: - daytime symptoms <2 days a week - need for reliever <2 days a week (not including doses for preventing exercise-induced bronchoconstriction) - no limitation of activity and - no symptoms during the night or on waking. Additionally, consider risk factors for exacerbations, eg smoking, accelerated lung function decline, history of exacerbations in the preceding 12 months, or any intubation/intensive care admission for asthma. Review such patients frequently and reduce treatment cautiously, even if asthma control is good.
Name some inhaled corticosteroids
beclometasone budesonide ciclesonide fluticasone propionate (FP) fluticasone furoate
Name some LABAs
**If using a LABA for asthma, always use with an ICS. Formoterol (eformoterol) Indacaterol Olodaterol (only available with tiotropium) Salmeterol Vilanterol (only available with fluticasone or umeclidinium)
Name some SABAs
Salbutamol Terbutaline
What is atrovent?
Ipratropium = anticholinergic (short acting)
What is flixotide?
fluticasone propionate = corticosteroid
What is Pulmicort Turbuhale?
budesonide = ICS
What is Qvar Autohaler?
beclometasone = ICS
What is Serevent Accuhaler?
salmeterol = LABA
What is Spiriva?
tiotropium = long acting anticholinergic
What is ventolin?
salbutamol = SABA
What is Seretide Accuhaler?
fluticasone propionate (ICS) + salmeterol (LABA)
What is Symbicort?
budesonide (ICS) + formoterol (LABA)
Main counselling points for ICS?
After using this medicine rinse your mouth with water, gargle and spit out. Do not use this medicine for immediate relief of symptoms; follow your asthma action plan. Use this medicine every day even if you are feeling better; do not reduce dosage or stop this medicine unless your doctor tells you to. *** A preventer needs to be taken EVERY DAY - keep it in a glass with your toothbrush to remind you
Outline the longterm management in a child with asthma.
STEP 1 - as needed reliever (SABA) STEP 2 - as needed reliever (SABA) PLUS motelukast/ICS (low dose)/cromone STEP 3 - as needed reliever (SABA) PLUS ICS (high dose) or ICS (low dose) + montelukast or ICS + LABA
When should you consider adding a low dose ICS in an asthmatic on reliever therapy?
- symptoms >twice a month or
- waking due to asthma in previous month or
- exacerbation requiring systemic corticosteroids in the previous year
What are signs of a mild asthma attack?
Normal mental state Subtle or no increased work of breathing accessory muscle use/recession. Able to talk normally
What are signs of a moderate asthma attack?
Normal mental state Some increased work of breathing accessory muscle use/recession Tachycardia Some limitation of ability to talk
What are signs of a severe asthma attack?
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.
What are signs of a critical asthma attack?
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.
How to use a spacer?
- shake the medicine, take the lid off - ensure good lip seal around mouth piece - 1 puff at a time, followed by 4 breaths in and out - repeat x 4, wait 4 minutes - if no improvement, try again - can have up to 6 puffs if <6yrs, 12 puffs if >6yrs - if no response, increased WOB, SOB, lethargy, increasing concern etc, call an ambulance
How to clean a spacer?
- wash once a month in warm soapy water - do not rinse, leave bubbles on spacer - place on drying rack - do not towel dry; this can create static which results to medicine sticking to the walls of the spacer - if spacer is >1yr old, or cracked/broken, needs to be replaced
When to use a small volume or large volume spacer?
small volume = >4yrs large volume = >8yrs
Main triggers to ask about in an asthma history?
Dustmites Exercise Pollen Pets Smoking Viral infections Weather changes DEPPS VW
When to bring your child into hospital?
If they need more than 3hrly ventolin if they are finding it difficult to breathe if they are unable to talk - get them to read a book or count to 20 really fast signs of WOB - nasal flaring, cyanosis, intercostal/subcostal recession
Asthma hx questions
- duration and nature of symptoms
- family history of atopy
- dose of medication given at home + how often
- how was it given? (puffer or spacer)
- what was the response?
- what do they think was the trigger?
- dust, exercise, pollen, pets, viral illness, weather
- have they been taking preventive treatment regularly?
- preivous admissions
- when, how long for, what treatment
- any PICU admissions
- how many courses of steroids have they had?
- triggers for previous episodes
- interval symptoms
- daytime symptoms, after exercise, waking from sleep
- cough, SOB, wheeze
- frequency of the symptoms
- how often do they use ventolin when they are well?
- preventitive treatment
- ICS, montelukast
When is CXR indicated in asthma?
- evidence of acute complication
- difficult to control asthma
- persistent asthma
- symptoms and signs not wholly explained by asthma
What is burst therapy?
- one dose of ventolin
- <6 yo 6 puffs
- >6 yo 12 puffs
- repeat 20 mins later
- repeat again 20 mins later
Why do we not use combined therapy in children? (LABA/ICS)
- more flare ups
- increased risk of severe asthma
