Asthma Flashcards
What is the pathophysiology of asthma?
Bronchoconstriction Airway inflammation (due to eosinophil infiltration) Mucous plugging
What is the most common cause of wheeze in children younger than 5?
Viral episodic wheeze
What is atopic asthma?
Recurrent wheezing in between viral infections
Evidence of allergy to one or more inhaled allergens (e.g house dust mite, pollens or pets)
What is bronchomalacia?
Where the bronchus is floppy and cannot stay open during breathing
Weak cartilage in the walls of the bronchial tubes
It usually affects children <6 months
How should a wheeze be described to a parent?
A whistling in the chest when your child breathes out
How can transmitted upper respiratory noises be distinguished from wheeze on examination?
If you hold the stethoscope in front of the child’s mouth what you hear will be transmitted upper respiratory noises
What are key features that are associated with a high probability of a child having asthma?
- Symptoms worse at night and in the early morning
- Symptoms that have nonviral triggers
- Interval symptoms, i.e. symptoms between acute exacerbations
- Personal or family history of an atopic disease
- Positive response to asthma therapy.
What should be looked for on examination of a child with ?asthma
- Evidence of eczema
2. Examination of the nasal mucosa for allergic rhinitis
What tests may be carried out to aid the diagnosis of atopy?
Skin-prick testing for common allergens
What can be used in an uncertain diagnosis of asthma/to assess disease severity?
How can peak flow vary throughout the day in asthmatics?
PEFR (not as good for management, can be useful for serial measurements e.g 2W diary)
Spirometry
In poorly controlled asthma:
Peak flow worse in the morning than in the evening
AND THE
Peak flow varies from day to day
What are the usual findings of FEV1/FVC ratio in asthmatics? What reversibility is seen with salbutamol administration?
FEV1/FVC < 70% (obstructive)
improvement of 12% or more confirms bronchodilator reversibility
What is the first step in management of asthma in children?
Second step?
- SABA
2. SABA + paediatric low dose inhaled corticosteroid
What are some examples of inhaled corticosteroids used in children?
Budesonide
Beclometasone
Fluticasone
Mometasone
What is step 3 in the management of asthma in children?
SABA + paediatric low-dose ICS + leukotriene receptor antagonist - e.g Montelukast
What is step 4 in the management of asthma in children?
Give examples
How does this vary to adults?
SABA + paediatric low-dose ICS + long-acting beta agonist (LABA)
LABA = salmeterol or formeterol
In contrast to the adult guidance, NICE recommend stopping the LTRA at this point if it hasn’t helped
In the treatment of moderate acute asthma how may puffs should be given via a spacer and how regularly?
Beta2 agonist 2-10 puffs via spacer
Give one puff of beta2 agonist every 30-60 seconds up to 10 puffs according to response.
Consider oral prednisolone
What clinical findings are considered to be part of a moderate asthma attack?
Able to talk SpO2 > 92% PEF > 50% best or predicted No clinical features of severe asthma May be (some) intercostal recession
What clinical findings are considered to be part of a severe asthma attack?
SpO2 < 92% PEF 33-50% best or predicted Can't complete sentences in one breath or too breathless to talk or feed Heart rate > 125/min (5-12) Respiratory rate > 30/min Use of accessory NECK muscles
What clinical findings are considered to be part of a life threatening asthma attack?
SpO2 < 92% PEF < 33% best or predicted Silent chest Poor respiratory effort Altered consciousness Cyanosis
When both salbutamol and aminophylline are given what should be monitored?
ECG Blood electrolytes(Aminophylline can cause cardiac arrhythmias, salbutamol can cause hyperkalaemia)
DIFFERENT TYPES OF INHALERS AND INHALER TECHNIQUE
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What are atypical features of asthma which should prompt seeking another diagnosis?
Wet cough/Sputum production
Finger clubbing
Growth failure
What are some complications of montelukast?
Sleep disturbance and nightmares
What are some causes of recurrent or persistent childhood wheeze?
Viral episodic wheeze Asthma Multiple trigger wheeze Cystic fibrosis Bronchiolitis OBLITERANS Chronic aspiration Recurrent anaphylaxis
What is usually required in the diagnosis of asthma?
In younger children asthma is usually diagnosed from history and examination alone
- Parental description of the symptoms and response to treatment is KEY
Improvement of FEV1 of 12% or more confirms bronchodilator reversibility and is characteristic of asthma
What does SABA stand for?
What are some examples?
How quickly do they act/last for?
Short acting beta agonist
Salbutamol and terbutaline
rapid onset of action - maximum effects after 10-15 minutes
Effective for 2-4 hours
What is it important to monitor in children with asthma, especially if they are on inhaled corticosteroids?
Growth
If a child is describe to have complete control of their asthma what do they have/not have?
- Absence of day-time or night-time symptoms
- No limit on activities (including exercise)
- No need for reliever use
- Normal lung function
- No exacerbations (need for hospitalisation or oral steroids)
IN 6 MONTHS
What are some causes of acute breathlessness in the older child?
Asthma
Pneumonia or lower respiratory tract infection
Foreign body
Anaphylaxis
Pneumothorax or pleural effusion
Metabolic acidosis - DKA, lactic acidosis, inborn error of metabolism
What is the management of an acute, severe asthma attack?
- SABA - either via spacer or nebulised
- Oral prednisolone or IV hydrocortisone
(Consider)
- Inhaled ipratropium
- IV B2 agonist (salbutamol) or aminophylline or magnesium
What is the management of an acute, life-threatening asthma attack?
- SABA - nebulised
- Oral prednisolone or IV hydrocortisone
- Nebulised ipratropium
(Consider)
4. IV B2 agonist (salbutamol) or aminophylline or magnesium
When SABA is given nebulised to a child having an acute asthma attack what dose is given?
2.5mg in children <8
5mg in children >8
How do you continue management of a child with an asthma attack when they are responding to the treatment?
Continue bronchodilators 1-4 hr prn
When can you discharge a child who has been in hospital for an acute asthma attack?
What steps are involved in discharge?
Discharge when stable on 4 hourly treatment PEFR >75% Continue oral pred for 3-7 days AT DISCHARGE: Review medication and inhaler technique Provide personalised asthma action plan Arrange appropriate follow up
(For adults so ?if the same for children)
GP follow up within 2 working days
Respiratory clinic follow up within 4 weeks
For severe or worse - consider psychosocial factors
What information can be given to patients with regards to their asthma?
Increasing cough, wheeze, breathlessness and difficulty walking, talking and sleeping, or decreasing relief from bronchodilators all indicate poorly controlled asthma
How should acute severe asthma be managed with an inhaler
Oxygen via face mask; 10 puffs of beta2 agonist or nebulised salbutamol
Oral Pred
Beta2 agonist can be repeated every 15 minutes
