Asthma in Children Flashcards
Presentation
Episodic symptoms with intermittent exacerbations
Diurnal variability, typically worse at night and early morning
Dry cough with wheeze and shortness of breath
Typical triggers
A history of other atopic conditions such as eczema, hayfever and food allergies
Family history of asthma or atopy
Bilateral widespread “polyphonic” wheeze heard by a healthcare professional
Symptoms improve with bronchodilators
Presentation indicating a diagnosis other than asthma
Wheeze only related to coughs and colds, more suggestive of viral induced wheeze
Isolated or productive cough
Normal investigations
No response to treatment
Unilateral wheeze
suggesting a focal lesion, inhaled foreign body or infection
Typical triggers
Dust (house dust mites)
Animals
Cold air
Exercise
Smoke
Food allergens (e.g. peanuts, shellfish or eggs)
Investigations
Spirometry with reversibility testing (in children aged over 5 years)
Direct bronchial challenge test with histamine or methacholine
Fractional exhaled nitric oxide (FeNO)
Peak flow variability measured by keeping a diary of peak flow measurements several times a day for 2 to 4 weeks
Long term manegment
BTS/SIGN guidelines
Start at the most appropriate step for the severity of the symptoms
Review at regular intervals based on the severity
Step up and down the ladder based on symptoms
Aim to achieve no symptoms or exacerbations on the lowest dose and number of treatments
Always check inhaler technique and adherence at each review
Medical treatment in under 5 years old
Start a short-acting beta-2 agonist inhaler (e.g. salbutamol) as required
Add a low dose corticosteroid inhaler or a leukotriene antagonist (i.e. oral montelukast)
Add the other option from step 2.
Refer to a specialist.
Medical treatment in 5-12 years old
Start a short-acting beta-2 agonist inhaler (e.g. salbutamol) as required
Add a regular low dose corticosteroid inhaler
Add a long-acting beta-2 agonist inhaler (e.g. salmeterol). Continue salmeterol only if the patient has a good response.
Titrate up the corticosteroid inhaler to a medium dose.
Consider adding:
Oral leukotriene receptor antagonist (e.g. montelukast)
Oral theophylline
Increase the dose of the inhaled corticosteroid to a high dose.
Referral to a specialist. They may require daily oral steroids.
Inhaled Corticosteroids in Children
There is evidence that inhaled steroids can reduce growth and can cause a small reduction in final adult height of up to 1cm when used long term (>12 months).
This effect was dose-dependent, meaning it was less of a problem with smaller doses.
Presentation of acute asthma
Progressively worsening shortness of breath
Signs of respiratory distress
Fast respiratory rate (tachypnoea)
Expiratory wheeze on auscultation heard throughout the chest
The chest can sound “tight” on auscultation, with reduced air entry
Silent chest
Moderate acute asthma
Peak flow > 50 % predicted
Normal speech
Severe acute asthma
Peak flow < 50% predicted
Saturations < 92%
Unable to complete sentences in one breath
Signs of respiratory distress
Respiratory rate:
> 40 in 1-5 years
> 30 in > 5 years
Heart rate:
> 140 in 1-5 years
> 125 in > 5 years
Life threatening acute asthma
Peak flow < 33% predicted
Saturations < 92%
Exhaustion and poor respiratory effort
Hypotension
Silent chest
Cyanosis
Altered consciousness / confusion
Management of acute asthma
Supplementary oxygen if required (i.e. oxygen saturations less than 94% or working hard)
Bronchodilators (e.g. salbutamol, ipratropium and magnesium sulphate)
Steroids to reduce airway inflammation: prednisone (orally) or hydrocortisone (intravenous)
Antibiotics only if a bacterial cause is suspected (e.g. amoxicillin or erythromycin)
Bronchodilator step up in acute asthma
Inhaled or nebulised salbutamol (a beta-2 agonist)
Inhaled or nebulised ipratropium bromide (an anti-muscarinic)
IV magnesium sulphate
IV aminophylline
How can mild cases of acute asthma be controlled?
Outpatient with regular salbutamol inhalers via a spacer (e.g. 4-6 puffs every 4 hours).
