Asthma - Children Flashcards
What are the challenges with asthma?
No clear definition
No tests
Two national guidelines
Symptom based
Identical to LRTI symptoms
Relapse and remission
In children, No asthma no..
wheeze
What is asthma?
Chronic
Wheeze, cough and shortness of breath
Multiple triggers
Variable
Reversible
Responds to asthma treatment
What 4 things do we know that about causing asthma?
Host response to environment
Infection is important
Physiology is abnormal before symptoms
Is a syndrome
What are some inconsistencies?
Transient vs persistent syndromes
VIW versus asthma
Different severities, age of onset and triggers
Heterogeneity in response
Describe genes and asthma in children
Genes contribute to 30-80% of causation
10 variants that can make contribution
Genes can include ADAM33 and ORMDL3 but people can have these and not have asthma
These genes interact with the environment
Epigenetics can be the reason for this
Explain allergy and asthma
Allergy probably does not cause asthma but a primary epithelial abnormality in skin/gut/airway can result in -eczema/asthma etc. and allergy.
The allergy then fuels eczema/asthma etc.
Give stats of asthma in children in UK
1.1 million UK children
110,000 in Scotland
5% of children on inhaled steroids
Asthma prevalence is on the decline from 2004
What is likely for the rise and fall of asthma?
Diagnostic enthusiasm
Increasing recognition
True rise
What is the age of lungs having 100% FEV1?
25 years
What diagnostics tests are used in asthma?
No tests in children for asthma - peak flow, allergy tests, spirometry and exhaled nitric oxide
Can help exclude diseases
What is a exhaled nitric oxide test?
Is unproven to diagnose asthma in children
It measures the amount of nitric oxide that is exhaled from a breath. Increased levels of nitric oxide are associated with swelling of lung airways
What 4 tests are used to exclude other diseases to give diagnosis of asthma?
1.spirometry
2. BDR
3.FeNO
4.Peak flow
Does a cough variant asthma exist in children?
No
What type of wheeze is associated with asthma in children
Whistle not a rattle
Explain what shortness of breath at rest is like in asthma?
Significant respiratory difficulty <30% lung function
Airway obstruction
Can be sooking in of the ribs with wheeze - stomach sticks out of ribs
Describe what a cough is like in a child with asthma
Dry
Nocturnal - just after falling asleep
Exertional
What personal history can be circumstantial evidence of asthma?
Eczema, Hay fever, Food allergies
Any allergies are circumstantial evidence
Hereditary
What does treatment for asthma look like in children?
ICS for 2 months
Then false positive responses need to be checked so a holiday in Easter is taken from treatment
Does asthma symptoms respond to treatment?
yes
What would give an ideal diagnosis
Responds to treatment
What are some disadvantages of asthma treatment?
Cost
Hassle
0.5-1cm loss in height
Oral thrush if teeth not brushed after inhaler use
What are some benefits of asthma treatment?
Helps diagnosis
If symptoms are responding
Improves QoL
Reduces risk of attacks
What is the approach to a reported wheeze?
Is it genuine - whistle, sleep disturbance
Can watch and see if continues or trail with treatment
If treatment helps then asthma - remember Easter holiday
What can be a differential diagnosis for asthma in under 5s?
Congenital
Cystic Fibrosis
Primary ciliary dyskinesia
Bronchitis
Foreign body
What can be a differential diagnosis for asthma in over 5s?
Dysfunctional breathing
Vocal cord dysfunction
Habitual cough - chronic cough with no underlying cause or diagnosis
Pertussis - highly infectious airway infection
What is the difference between asthma and VIW?
They are the same condition
99% of VIW is preschool children
These is no intervals of wheezing in VIW
Both treated with bronchodilators
What is the approach to preschool cough?
Is it an associated wheeze - yes then wheeze algorithm
no then is it moist/dry
Dry - watch and see
Moist - if shows red flags then might be bronchiectasis
no then bacterial bronchitis or other related diseases
What is treatment to mild asthma in children?
SABA via spacer
SABA via spacer + prednisone
What is treatment to moderate asthma in children?
SABA via nebulizer + prednisone
SABA + ipratropium via nebulizer + prednisone
What is the treatment to severe asthma in children?
IV salbutamol
IV aminophylline
IV magnesium
IV hydrocortisone
Intubate and ventilate
What do you do in acute asthma?
Start treatment and reassess in 1 hour
Step up or down where appropriate
What type of steroids are used in chronic/maintenance treatment?
Inhaled steroids
What type of steroids are used in acute treatment?
Oral steroids
What are the steps for treating acute asthma in children?
The level of treatment is determined by symptoms and sats
Treat and reassess
Be guided by sats/O2 requirement
What are the goals to treating non acute asthma?
Minimal symptoms during the day and night
Minimal need for reliever medication
No attacks/ exacerbations
No limitation for physical activity
How do we measure control?
Closed questions
Use SANE
Short acting beta agonist/week
Absence from school or nursery
Nocturnal symptoms/week
Exertional symptoms
When would you reduce treatment?
Reduce treatment if symptom free for 3 months and watch to see result
What is the step up step down approach?
Started on low dose ICS - severe may respond to minimal treatment
Review after 2 months - need an inhaler holiday
What are the classes of medication used in non acute asthma?
SABA - blue relieving inhaler
Inhaled corticosteroids (ICS)
Oral steroids
LABA, Leukotriene receptor antagonists and theophylline are add ons
What is the contrast with adults for treatment in non acute asthma?
Max dose ICS 800 micrograms in under 12s
No oral B2 tablet
LTRA first line preventer in under 5s
No LAMAs
Only two biologicals
What treatment would you give to a child taking a B2 agonist more than 2 days a week and being symptomatic for 3 days or waking one night a week?
Start with very low dose of inhaled corticosteroids or LTRA in under 5s
What are benefits of ICS?
Useful for diagnosis
Very effective when taken
Very safe when correctly prescribed
What are the dose response for ICS on a graph?
If increased from 200 to 400 the positive effects increase, but doubling after will not change positive effects
What are the dose response for ICS on a graph?
If increased from 200 to 400 the positive effects increase, but doubling after will not change positive effects
Also there is not much increase in adverse effects if you increase drug
Adverse effects of ICS?
Height suppression
Maybe oral candidiasis
Adrenocortical suppression
No hypertension or cataracts
What are two thing to remember with LABA?
Do not use without ICS
Used as fix dose inhaler
Is an add on preventer
What is leukotriene receptor antagonist?
Montelukast only in children
Rule of thirds - 1/3 benefits, no benefits or no change
Better adherence to oral
Granules for reluctant toddlers
What happens if symptoms continue into step 3 of BTS/SIGN guidlines?
Add on LABA but keep open mind
Additional add on therapies include increasing ICS and LTRA
Describe severe asthma in children?
Experimental medicine
50% psychological issues
Less than 50% compliance issues
Question the diagnosis
Minority with genuine severe disease
Role of biologics unproven
What are the two types of delivery systems for non acute asthma?
MDI (metred dose inhaler) with spacer
Dry powder device
What 3 things make taking an MDI more effective?
Taking MDI with a spacer - 4x more lung deposition
Shake inhaler between puffs
Wash spacer monthly to reduce static
Explain dry powder devices?
Licensed in over 5s, under 8s cannot use them
Achieve 20% lung deposition
What is the advantages of MDIs over nebulisers?
Quieter, quicker, valve mechanism. don’t break down, portable and cheaper
What are some non-medical interventions that can help non acute asthma?
Stop tobacco smoke exposure
Remove environmental triggers - pets, HDM had to eliminate
