Asthma

Question 1

Management of mild asthma attack

Answer 1

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.

Question 2

Management of moderate asthma attack

Answer 2

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.

Question 3

Management of severe asthma attack

Answer 3

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.

Question 4

Management of critical asthma attack

Answer 4

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.

Question 5

Signs of salbutamol toxicity

Answer 5

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.

Question 6

Salbutamol dose for kids

Answer 6

6 puffs if < 6 years old 12 puffs if >6 years old

Question 7

Ipratropium dose for kids

Answer 7

4 puffs if < 6 years old 8 puffs if >6 years old

Question 8

How do you assess for good asthma control?

Answer 8

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.

Question 9

Name some inhaled corticosteroids

Answer 9

beclometasone budesonide ciclesonide fluticasone propionate (FP) fluticasone furoate

Question 10

Name some LABAs

Answer 10

**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)

Question 11

Name some SABAs

Answer 11

Salbutamol Terbutaline

Question 12

What is atrovent?

Answer 12

Ipratropium = anticholinergic (short acting)

Question 13

What is flixotide?

Answer 13

fluticasone propionate = corticosteroid

Question 14

What is Pulmicort Turbuhale?

Answer 14

budesonide = ICS

Question 15

What is Qvar Autohaler?

Answer 15

beclometasone = ICS

Question 16

What is Serevent Accuhaler?

Answer 16

salmeterol = LABA

Question 17

What is Spiriva?

Answer 17

tiotropium = long acting anticholinergic

Question 18

What is ventolin?

Answer 18

salbutamol = SABA

Question 19

What is Seretide Accuhaler?

Answer 19

fluticasone propionate (ICS) + salmeterol (LABA)

Question 20

What is Symbicort?

Answer 20

budesonide (ICS) + formoterol (LABA)

Question 21

Main counselling points for ICS?

Answer 21

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

Question 22

Outline the longterm management in a child with asthma.

Answer 22

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

Question 23

When should you consider adding a low dose ICS in an asthmatic on reliever therapy?

Answer 23

• symptoms >twice a month or
• waking due to asthma in previous month or
• exacerbation requiring systemic corticosteroids in the previous year

Question 24

What are signs of a mild asthma attack?

Answer 24

Normal mental state Subtle or no increased work of breathing accessory muscle use/recession. Able to talk normally

Question 25

What are signs of a moderate asthma attack?

Answer 25

Normal mental state Some increased work of breathing accessory muscle use/recession Tachycardia Some limitation of ability to talk

Question 26

What are signs of a severe asthma attack?

Answer 26

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.

Question 27

What are signs of a critical asthma attack?

Answer 27

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.

Question 28

How to use a spacer?

Answer 28

• 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

Question 29

How to clean a spacer?

Answer 29

• 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

Question 30

When to use a small volume or large volume spacer?

Answer 30

small volume = >4yrs large volume = >8yrs

Question 31

Main triggers to ask about in an asthma history?

Answer 31

Dustmites Exercise Pollen Pets Smoking Viral infections Weather changes DEPPS VW

Question 32

When to bring your child into hospital?

Answer 32

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

Question 33

Asthma hx questions

Answer 33

• 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

Question 34

When is CXR indicated in asthma?

Answer 34

• evidence of acute complication
• difficult to control asthma
• persistent asthma
• symptoms and signs not wholly explained by asthma

Question 35

What is burst therapy?

Answer 35

• one dose of ventolin
  
  • <6 yo 6 puffs
  • >6 yo 12 puffs
• repeat 20 mins later
• repeat again 20 mins later

Question 36

Why do we not use combined therapy in children? (LABA/ICS)

Answer 36

• more flare ups
• increased risk of severe asthma