Asthma Flashcards
1
Q
What proportion of children in the UK are affected by asthma?
A
at least 1 in 11
2
Q
What is the trend of incidence of asthma?
A
significant increase worldwide in past 40 years but has now plateaued in many hig-income countries
3
Q
How many deaths from asthma in children each year in the UK are there?
A
20
4
Q
Why is it difficult to diagnose asthma in preschool children?
A
approximately half of all children wheeze at some time during first 3 years of life; this follows three different patterns
5
Q
What are the 3 patterns of wheezing in preschool children?
A
- Viral episodic wheezing - only in response to viral infections
- Multiple trigger wheeze - multiple triggers, more likely to develop into asthma over time
- Asthma
6
Q
What is the most common pattern of wheeze in preschool children?
A
viral episodic wheeze
7
Q
At what age does viral episodic wheeze occur?
A
up to 5 years of age
8
Q
What is multiple trigger wheeze?
A
preschool and school-aged children can have frequent wheeze triggered by many stimuli, not just viruses but also cold air, dust, animal dander and exercise
9
Q
What are 5 examples of triggers for multiple trigger wheeze?
A
- Viruses
- Cold air
- Dust
- Animal dander
- Exercise
10
Q
Why is it useful to distinguish between multiple-trigger wheeze and asthma in the preschool age group?
A
A formal diagnosis of asthma may be unjustified in this group but they may still benefit from asthma preventer therapy
11
Q
What is often the outcome following diagnosis of multiple trigger wheeze for preschool children?
A
a significant proportion go on to have asthma
12
Q
When is a diagnosis of atopic asthma made?
A
when recurrent wheezing is associated with symptoms between viral infections (interval symptoms) and evidence of allergy to one or more inhaled allergens such as: house dust mite, pollens or pets
13
Q
How can evidence of allergy in suspected atopic asthma be confirmed? 2 ways
A
- positive skin-prick testing
- presence of IgE on blood testing
14
Q
What are the 3 key diseases that atopic asthma is strongly associated with?
A
- Eczema
- Rhinoconjunctivitis
- Food allergy
15
Q
What is a key part of the history likely to be positive in atopic asthma?
A
Family history
16
Q
Is all asthma atopic?
A
no
17
Q
What are 7 examples of asthma triggers in the environment?
A
- Upper respiratory tract infections
- Allergens (e.g. house dust mite, grass pollens, pets)
- Smoking (active or passive)
- Cold air
- Exercise
- Emotional upset or anxiety
- Chemical irritants e.g. paint, aerosols
18
Q
What are the 4 stages of the pathophysiology of asthma that lead to its symptoms?
A
- Genetic predisposition, atopy, environmental triggers
- Bronchial inflammation
- Bronchial hyperresponsiveness
- Airway narrowing
⇒symptoms
19
Q
What are 3 features of bronchial inflammation that contributes to the symptoms of asthma?
A
- Oedema
- Excessive mucus production
- Infiltration with cells (eosinophils, mast cells, neutrophils, lymphocytes)
20
Q
What is meant by bronchial hyperresponsiveness in asthma?
A
exaggerated ‘twitchiness’ to inhaled stimuli
21
Q
How does airway narrowing manifest in the clinical features of asthma?
A
Reversible airflow obstruction e.g. peak flow variability
22
Q
How can you clarify that parents/ patients are describing true wheeze?
A
wheeze is a ‘whistling in chest when child breathes out’ - does that fit your child’s symptoms?
ideally, confirm by auscultation
23
Q
What does asthmatic wheeze sound like?
A
polyphonic (multiple pitch) noise coming from airways - believed to represent many airways of different sizes vibrating from abnormal narrowing
24
Q
When should asthma be suspected in a child based on wheezing?
A
any child wheezing on more than one occasion, particularly if there are interval symptoms
more common if personal or family history of atopy
25
What are 5 features associated with a high probability of a child having asthma?
1. symptoms worse at **night** and in **early morning**
2. symptoms have **nonviral** triggers
3. **interval** symptoms i.e. between acute exacerbations
4. personal or family history of an **atopic disease**
5. **positive** **response** to asthma therapy
26
What are 5 symptoms to ask once asthma is suspected regarding the specific phenotype in the patient?
1. How frequent are symptoms?
2. What triggers the symptoms? Are sport and general activities affected by the asthma?
3. How often is sleep disturbed by asthma?
4. How severe are the interval symptoms between exacerbations?
5. How much school has been missed due to asthma?
27
What is examination of the chest normally like between attacks of asthma? 4 key features
* usually normal
* if long-standing, may be
* hyper-inflation of chest
* generalised polyphonic expiratory wheeze
* prolonged expiratory phase
* Harrison's sulci (if onset in early childhood)
28
In addition to the chest examination in asthma, what are 3 further elements of the examination to perform?
1. Look for evidence of **eczema**
2. Examine **nasal** **mucosa** for allergic rhinitis
3. Plot **growth** - usually normal unless extremely severe asthma
29
What are 4 things on examination that would make you suspect a diagnosis other than asthma, and what are 2 conditions this could be?
1. Wet cough
2. Sputum production
3. Finger clubbing
4. Poor growth
Cystic fibrosis, bronchiectasis
30
What are Harrison's sulci?
depression at the base of the thorax associated with muscular insertion of the diaphragm - caused by chronic obstruction airways disease during childhood from chronic inreased work of breathing
31
What is the approach to making a diagnosis of asthma in children compared with adults?
Adults - more based on objective tests, more clinical in children, based on history and exam
More than one of wheeze, cough, chest tightness, shortness of breath
32
What are 5 tests which can be performed to support or aid a diagnosis of asthma?
1. Skin prick testing for common allergens
2. Peak expiratory flow rate (PEFR)
* monitoring, good for serial measurements
3. Spirometry
* offered to all symptomatic patients over 5 years
4. Bronchodilator reversibility
* consider if 5-16y and obstructive spirometry
5. Fractional exhaled nitric oxide (FeNO) testing
* if diagnostic uncertainty and other tests inconclusive
* positive if \>35ppb
33
What age of children are generally able to perform peak flow measurements and spirometry?
most children over 5 years
34
What will peak flow show in poorly controlled asthma?
Increased variability, both diurnal variability (morning lower than evening) and day-to-day variability
35
What result of PEFR supports a diagnosis of asthma?
\>20% variability using at least 4 PEF readings per day, during active asthma
36
How can spirometry be used to diagnose asthma?
involves measurement of forced expiratory volume in 1 second blowing out as hard and as fast as possible (FEV1)
This provides non-invasive measure of flow through larger airways (to the bronchioles)
FEV1/FVC ratio normally greater than 70%; \<70 suggests airflow limitation (obstructive), and lower limit of normal can also be used to diagnose
37
How can bronchodilator reversibility (BDR) be used with spirometry in children to help make a diagnosis of asthma?
Can be used if obstructive spirometry (FEV1/FEVC \<70%) Positive if improvement of **FEV1 of 12% or more** with beta-2 agonists or corticosteroids
38
What is likely to happen to bronchodilator reversibility in spirometry of FEV1 following treatment for asthma?
often reduces or disappears completely
39
What is the algorithm for asthma management in children **5-17 years** based on NICE guidance? 7 steps
1. SABA - all symptomatic patients
2. Low dose Inhaled corticosteroid (ICS) preventer (200μg)- if use SABA ≥3x a week/ woken at night one or more a week
3. Consider offering leukotriene receptor antagonist (LTRA) in addition to lower dose ICS, review response 4-8 weeks
4. If still uncontrolled, stop LTRA and offer LABA with ICS
5. If still not controlled, change ICS and LABA to maintenance and reliever therapy (MART) with low dose ICS
6. If still uncontrolled, increase ICS to moderate dose (400μg)
7. If uncontrolled, moderate ICS+LABA either as MART or fixed dose regimen, expert advice
40
What is an example of a leukotriene receptor antagonist (LTRA)?
Montelukast, Zafirlukast
41
What is meant by MART therapy?
Maintenance and reliever therapy: just one inhaler containing combation of ICS and LABA, used both for maintenance with regular dose but also as required
42
What are 2 examples of MART inhalers?
1. Fostair: beclometasone/formoterol
2. Symbicort: budesonide/formoterol
43
What is the stepped asthma management for chilren aged 0-5 years? 5 steps
1. SABA
2. _8 week trial_ of **moderate** dose ICS if symptoms indicate need for maintenance therapy (occur 3 or more times a week, waking at night, uncontrolled with SABA only)
3. After 8 weeks, **stop** and continue to monitor symptoms
* if didn't resolve, consider alternative diagnosis
* if resolved then reoccurred within 4 weeks of stopping, restart ICS as low dose
* if resolved but recurred beond 4 weeks, repeat 8 week trial of moderate dose of ICS
4. if uncontrolled on low dose ICS as **maintenance**, consider **LTRA** in addition to ICS
5. if still uncontrolled, stop LTRA and refer to specialist
44
What does the trial of inhaled corticosteroid involve in children with suspected asthma \<5 years and what are 3 possible outcomes?
8 week trials of moderate (rather than low) paediatric dose of ICS
1. if symptoms resolve - monitor only (continue SABA)
2. if symptoms resolved then reoccurred within 4 weeks of stopping ICS, restart at paediatric low dose
3. if resolved by recurred beyond 4 weeks after stopping, repeat 8 week trial of moderate dose of ICS
45
What is the speed of onset of action of short-acting beta-2 agonists?
10-15 minutes
46
What are 2 examples of SABAs?
1. Salbutamol
2. Terbutaline
47
How long are SABAs effective for?
2-4 hours
48
What are 2 examlpes of LABAs?
1. Formoterol
2. Salmeterol
49
How long are LABAs effective for?
12 hours
50
What medication should LABAs not be used without?
Inhaled corticosteroid
51
Which type of asthma are LABAs particularly useful for?
exercise-induced asthma
52
What drug is sometimes given to **young** **infants** when other bronchodilators (SABAs, LABAs) are found to be ineffective, and are also used to treat severe acut easthma?
Ipratropium bromide: anticholinergic bronchodilator (SAMA)
53
What is the most effective inhaled prophylactic therapy for asthma and how must they be taken?
Inhaled corticosteroids; only effective if taken regularly
54
What is the mechanism of action of inhaled corticosteroids to treat asthma?
they decrease airway inflammation, resulting in decreased symptoms, asthma exacerbations and bronchial hyperactivity
55
What are 3 possible side effects of inhaled corticosteroids in higher doses?
1. Impaired growth
2. Adrenal suppression
3. Altered bone metabolism
56
What is one possible side effect of inhaled corticosteroids at lower doses?
Mildly reduced height velocity, but usually followed by catch-up growth in late childhood
57
What is done to minimise side effects from inhaled corticosteroids?
lowest doses possible are used
58
What should always be monitored in children with asthma and why (in addition to respiratory features)?
growth - risk of reduced growth when taking regular corticosteroids (oral or inhaled)
59
What is an alterntive to LTRA that is occasionally used in children?
slow-release oral theophylline
60
Why is theophylline rarely used for long term asthma treatment in children?
High incidence of side effects: vomiting, insomnia, headaches, poor concentration
61
When is oral prednisolone used long term for asthma?
severe persistent asthma when other treatment has failed
62
How is prednisolone given and why?
alternative days usually to minimise adverse effect on growth
All children on this therapy must be managed by specialist in childhood asthma
63
What is an injectable add-on therapy in asthma and how is it given?
Anti-IgE therapy e.g. omalizumab - injectable monoclonal antibody
Given as subcutaneous injection, only administered by specialist in childhood asthma
64
When might anti-IgE therapy (omalizumab) be prescribed in asthma?
severe atopic asthma
65
How does anti-IgE therapy (omalizumab) work to treat severe atopic asthma?
monoclonal antibody acts against IgE, natural antibody that mediates allergy
66
What are 2 treatment sometimes useful in the treatment of allergic rhinitis, which may coexist with atopic asthma?
1. Antihistamines e.g. loratidine (non-drowsy)
2. Nasal steroids
67
What is the definition of complete control of asthma? 5 elements
1. absence of daytime or night-time symptoms
2. no limit on activities (including exercise)
3. no need for reliever use
4. normal l**ung function**
5. no **exacerbations** (need for hospitalisation or oral steroids) in the previous **6 months**
68
What are 4 types of non-pharmacological measures in the management of asthma?
1. Allergen avoidance e.g. dust mite-impermeable mattress covers
2. Allergen immunotherapy (desensitisaion) if single allergen causing atopic asthma
3. Advise parents of effects of cigarette smoking in house
4. Psychological intervention in chronic severe asthma
69
What limits the use of allergen immunotherapy for atopic asthma caused by a single allergen?
risk of systemic allergic reactions
70
What are the 4 categories of asthma exacerbation?
1. Mild
2. Moderate
3. Severe
4. Life-threatening
71
What are 4 features of a moderate asthma exacerbation?
1. Peak flow \>50% predicted or best or usual measurement
2. Some inercostal recession
3. O2 sats \>92%
4. Able to talk
72
What are 4 features of a severe acute asthma exacerbation?
1. PEFR 33-50% predicted, best or usual
2. Sats \<92%
3. Use of accessory neck muscles
4. Too breathless to talk
73
What are 9 features of a life-threatening acute asthma exacerbation?
1. PEFR \<33% predicted, best or usual
2. Sats \<92%
3. Poor respiratory effort
4. Silent chest
5. Exhaustion
6. Arrhythmia
7. Hypotension
8. Altered consciousness, agitation or confusion
9. Cyanotic tongue
74
What are 9 things to consider in the assessment of an acute asthma exacerbation?
1. Determine severity - mild, moderate, severe, life-threatening
2. Too breathless to talk?
3. Increased work of breathing - tachypnoea, chest recession, wheeze, silent chest
4. Cardiovascular - tachycardia, arrhythmia, hypotension
5. Altered consciousness, agitation or confusion
6. Tongue - cyanotic?
7. Peak flow
8. O2 saturation
9. Trigger for attack
75
What are 9 causes of acute breathlessness in the older child?
1. Asthma
2. Pneumonia or lower respiratory tract infection
3. Foreign body
4. Anaphylaxis
5. Pneumothorax or pleural effusion
6. Metabolic acidosis - diabetic ketoacidosis, inborn error of metabolism, lactic acidosis
7. Severe anaemia
8. Heart failure
9. Panic attacks (hyperventilation)
76
What are 4 criteria indicating hospital admission for asthma exacerbation?
If **after high-dose inhaled bronchodilator therapy** they:
1. Have not responded adequately clinically i.e. persisting breathlessness or tachypnoea
2. Becoming exhausted
3. Still have marked reduction in predicted (or usual best) peak flow rate or FEV1 (\<50%)
4. Have a reduced oxygen saturation (\<92% in air)
77
What are 3 indications for chest x-ray in acute asthma exacerbation?
1. Asymmetry of chest signs suggesting pneumothorax
2. Chest signs suggesting lobar collapse
3. Signs of severe infection
78
When are blood gases indicated in acute asthma exacerbations and why?
only if life-threatening or refractory
often normal until chid is in extremis
79
What are 7 aspects of the management of an acute asthma exacerbation?
1. High flow oxygen if sats \<92
2. Salbutamol inhaler via spacer (neb if severe to life-threatening)
3. 3-7 day course oral prednisolone or IV hydrocortisone
4. Inahled/nebulised ipratropium in severe/life-threatening
consider:
1. IV salbutamol OR
2. IV aminophylline OR
3. IV magnesium
80
How should SABA e.g. salbutamol be delivered in an acute asthma exacerbation?
via spacer, unless evere to life-threatening, then given by nebuliser with high flow oxygen
81
What course of oral prednisolone is given in acute asthma exacerbations?
short course, 3-7 days
82
What respiratory rate would place a child in the 'moderate' acute asthma category for the following ages?
1. 2-5 years
2. 5-12 years
3. 12-18 years
1. ≤40
2. ≤30
3. ≤25
83
What heart rate would place a child into the 'moderate' category of acute asthma exacerbation for the following ages?
1. 2-5 years
2. 5-12 years
3. 12-18 years
1. ≤140 bpm
2. ≤125 bpm
3. ≤110 bpm
84
What respiratory rate would place a child into the 'severe' category of acute asthma exacerbation for the following ages?
1. 2-5 years
2. 5-12 years
3. 12-18 years
1. \>40
2. \>30
3. \>25
85
What are 4 steps of management of moderate asthma exacerbations?
1. Keep calm and reassure child and parents
2. Short-acting β2-agonist via spacer (with face mask for those under 3), 2-4 puffs, increasing by 2 puffs every 2 min to 10 puffs if required
3. Oral prednisolone 1-2mg/kg, maximum 40mg
4. Monitor response for 15-30min
86
How much SABA should be administered in moderate asthma exacerbations?
2-4 puffs, increasing by 2 puffs every 2 min to 10 puffs if required
87
What dose of oral prednisolone should be given in acute asthma exacerbations?
1-2mg/kg, maximum 40mg
88
What are 7 aspects of the management of severe or life-threatening asthma exacerbations?
1. High flow oxygen (if available)
2. SABA, 10 puffs or nebulised (2.5mg salbutamol in \<8 years, 5mg in \>8 years)
* assess response and repeat as required
* assess continuously in life-threatening (back to back)
3. Oral prednisolone or IV hydrocortisone
4. Consider: inhaled ipratropium
5. IV salbutamol or
6. IV aminophylline or
7. IV magnesium
89
What dose of nebulised salbutamol should be given in severe/life threatening asthma?
* 10 puffs or 2.5mg nebulised in \<8 years, 5mg in \>8 years
* severe: assess response and repeat as required
* Back to back in life-threatening, assess response continuously
90
What are 3 things you should do after assessing response to treatment for asthma exacerbation and the child is responding?
1. Continue bronchodilators 1-4h prn
2. Discharge when stable on 4 hour treatment
3. Continue oral prednisolone for 3-7 days
91
What are 3 things to do at disharge following an acute asthma exacerbation?
1. **Review** **medication** and inhaler **technique**
2. Provide personalised asthma action **plan**
3. Arrange appropriate **follow-up**
92
What are 5 things you should do if you have assessed response to treament in an acute asthma exacberation but the patient is not responding?
1. Transfer to **HDU/PICU**
2. Ensure **senior** medical review
3. Consider **IV therapies** not already used (magnesium, aminophylline, salbutamol)
4. Consider **CXR** to check for pneumothorax or infection, and **blood gases**
5. Consider need for **mechanical ventilation**
93
Why might inhaled therapies not always be successful for acute asthma exacerbations?
drugs may be delivered in suboptimal doses to areas of lung that are poorly ventilated
94
What are the 3 types of intravenous therapy which may be needed for severe or life-threatening asthma exacerbations if they do not respond to inhaled therapy?
1. Magnesium
2. aminophylline
3. Salbutamol
95
Of the 3 types of IV therapy that can be given in severe or life-threatening acute asthma, which is the best and why?
Magnesium sulfate: least side effects and most evidence of benefit
- therefore increasingly used as first choice for IV therapy
96
How is IV aminophylline given in an acute or severe asthma exacerbation?
Loading dose given over 20 minutes followed by continuous infusion
However if on oral theophylline, omit loading dose
97
What are 3 possible adverse results of giving a rapid IV infusion of aminophylline?
1. Severe vomiting
2. Seizures
3. Fatal cardiac arrhythmias
98
When should ECG monitoring and blood electrolytes be checked in an acute asthma exacerbation?
when giving IV aminophylline or salbutamol
99
When should antibiotics be given in acute asthma exacerbations?
only if clinical features of bacterial infection
100
What are 5 aspects of patient educationn to deliver prior to discharge after an acute asthma admission?
1. When drugs should be used (regularly or 'as required')
2. How to use drug - inhaler technique
3. What each drug does - relief vs prevention
4. How often and how much can be used (frequency and dosage)
5. What to do if asthma worsens (a written personalised asthma management actoin plan should be compiled)
101
What are 5 things to point out to child and parents that indicate poorly controlled asthma?
1. Cough
2. Wheeze
3. Breathlessness
4. Difficulty in walking, talking or sleeping
5. Decreasing relief from bronchodilators
102
What technique can help allow earlier recognition of gradual deterioration of asthma?
peak flow rate at home
103
What medication can be useful to have as home in particularly troublesome asthma, with details in the action plan on when to start it?
Oral steroids
104
What are 9 clinical features to check in the periodic assessment of the child with asthma?
1. Growth and nutrition
2. Peak flow/spirometry
3. Chest for: hyperinflation, Harrison's sulcus, wheeze
4. Other allergic disorders: rhinitis, eczema, food allergy
5. Atypical features present pointing to another diagnosis (clubbing, sputum, growth failure)
6. Monitoring of clinical features
7. Considering triggers
8. Check if up to date personalised asthma management plan
9. check family have necessary meds/ equipment to manage acute exacerbation
105
What are 8 aspects of the monitoring of disease that should be considered at the periodic assessment of the child with asthma?
1. Peak flow diary
2. Severity and frequency of symptoms
3. Exercise tolerance
4. Intolerance with life, time off school
5. Is sleep disturbed
6. Use of preventer and reliver medication - are they appropriate
7. Inhaler technique
8. Lung function tests
106
What are 4 ways that inhaled drugs can be administered in children?
1. Pressurised metered dose inhaler and spacer
2. Breath-actuated metered dose inhalers e.g. Autohaler, Easi-Breathe
3. Dry powder inhaler
4. Nebuliser
107
Which age group of children can use pressurised metered dose inhalers and spacers?
all age groups;
* 0-2 years: spacer and face mask
* \>3 years: spacer alone
108
Who is recommended to use a spacer for inhaled drugs and why?
all children, as increases drug deposition to the lungs and reduces oropharyngeal deposition, reducing steroid side-effects
109
In what situation can the use of pressurised metered dose inhalers and a spacer be useful?
acute asthma attacks when poor inspiratory effort may impair use of inhalers direct to the mouth
110
Which age group of children can use breath-actuated metered dose inhalers and what are 2 examples?
* 6+ years
* autohaler, easi-breathe
111
What is an advantage of breath-actuated metered dose inhalers over pressurised MDIs without a spacer?
less coordination needed for breath-actuated than pressurised without a spacer
112
What is an example of a scenario that breath-actuated metered dose inhalers are useful for?
out and about use in older children
113
What age group of children can use dry powder inhalers?
4+ years
114
Which situation aren't dry powder inhalers good for and why?
need a good inspiratory flow so less good in severe asthma and during an asthma attack
115
What situation are dry powder inhalers useful for?
out and about in older children
116
What age can nebulisers be used?
any age
117
What are nebulisers used for?
only in acute asthma where oxygen is needed in addition to inhaled drugs
occasionally used at home as part of an acute management plan in those with rapid-onset severe asthma (brittle asthma)
118
Why is it important to show children/ their parents how to use their inhalers and their ability checked?
many children fail to gain benefit of their treatment
