Asthma in Children

Question 1

Presentation

Answer 1

Cough
Breathlessness
Wheeze
Chest tightness

There will be a history of recurrent episodes of symptoms and symptom variability, which may be triggered by dust, smoke, exercise or animal hair.

On examination, widespread wheeze will be heard on auscultation of the chest during an acute episode.

Question 2

Risk Factors

Answer 2

Family history of asthma

History of atopy (allergy/eczema)

Question 3

Diagnosis and investigations

Answer 3

A detailed history is required to establish the episodic nature of wheeze, breathlessness, cough and chest tightness

Investigations should include:

Serial peak flow readings, both when symptomatic and asymptomatic, as the airflow obstruction is reversible

Those suspected of having a high probability of asthma can be started on a trial of a short acting beta agonist (SABA) inhaler

Where possible, spirometry should be performed in children

Where cases are unclear, FeNO testing may be helpful

Question 4

Notes on management

Answer 4

All patients should receive a personalised written asthma plan. This should be regularly checked and updated

Use of a spacer is the preferred method method of delivery for inhaled treatments from a metred dose inhaler

Question 5

Step One Management of Chronic Asthma in Children

Answer 5

Inhaled SABA PRN and consider monitored initiation of very low to low dose inhaled corticosteroid (ICS)

Question 6

Step Two Management of Chronic Asthma in Children

Answer 6

Add very low dose ICS (or leukotriene receptor antagonist (LTRA) if <5 years)

Question 7

Step Three Management of Chronic Asthma in Children

Answer 7

Very low dose ICS and:
Age < 5 years old: add LTRA
Age > 5 years old: add LTRA or LABA

Question 8

What are two examples LTRA?

Answer 8

Montelukast and zafirlukast are two of the most commonly prescribed LTRA available worldwide.

Question 9

Additional Add-On Therapy

Answer 9

No response to LABA: Consider stopping LABA and increase ICS to low-dose
If some benefit from LABA but still inadequate: increase ICS to low-dose
If benefit from LABA and low-dose ICS but still inadequate: Consider trial of LTRA

Question 10

High dose therapies

Answer 10

Consider increasing ICS to medium dose ICS
Addition of fourth drug e.g. theophylline
Refer to patient for specialist care

If the above is inadequate, use daily steroid tablet and maintain medium-dose ICS. Consider other treatments to minimise use of steroid tablets.