Asthma in Children Flashcards
What percentage of children have asthma?
15-20%
What factors contribute to the development of bronchial inflammation which leads to asthma?
- Genetic predisposition
- Atopy
- Environmental triggers
What environmental triggers can cause asthma attacks?
- URTI
- Allergens - pollen, house dust mite, feathers, fur
- Smoking
- Cold air
- Exercise
- Emotional upset
- Chemical irritant
What is the pathophysiology of asthma?
Bronchial inflammation
- Oedema
- Excessive mucus production
- Infiltration of white cells (mast cells, eosinophils, neutrophils, lymphocytes)
What can asthma be related to?
- Eczema
- Hayfever
- Food allergies
- Exercise
- Smoking
How does asthma present in a child?
- Coughing
-
WHEEZE - recurrent
- Worse at night
- Obvious Triggers - precipitated by viral infections
- Responds to treatment
What questions would you ask to assess the severity of asthma on presentation?
- How frequent
- Triggers
- Sleep disturbance
- Severity of interval symptoms
- How much school have they missed
What are the long term signs of asthma in children?
- Hyperinflation
- Harrisons sulci - due to early onset of the disease
- Generalised polyphonic wheeze
What factors can increase the risk of developing asthma?
- Low brithweight
- Family history
- Bottle fed
- Atopy
- Male
- Pollution
How would you investigate for asthma in a child?
- History and examination - usually enough
- Responds to treatment - 10-15% increase in PEFR
What would be a differential diagnosis for a wheezing child?
- ASTHMA
- Viral induced wheeze
- Foreign body
- Cystic fibrosis
- Immune deficiency
- Ciliary dyskinesia
- Tracheo-bronchomalacia
- Aspiration - GORD
- Anaphylaxis
How would you go about assessing a childs control of their asthma?
- Short acting beta agonists/week
- Absence from school/nursery
- Nocturnal symptoms/week
- Exertional symptoms/week
How would you initiate a child with suspected asthma on treatment?
Monitored initiation of very low dose/low dose of ICS
What drugs would you use as a regular preventer in a child over the age of 5?
Very low dose ICS
What drugs would you use asa regular preventer in children under the age of 5?
LTRAs
If very low dose ICS were not controlling asthma well in a child over 5, what would you do next?
Add on therapy:
- Add an inhaled LABA
If a child under the age of 5 was on LRTAs but their control was poor, what would you do next?
Add very low dose ICS
If there was no response ICS and an additional LABA, what would be your next step?
Remove the LABA and increase ICS dose to low dose
If a child who was on very low dose ICS and LABA showed some benefit, but still poor control, what could you change in their management?
- Continue on LABA, and increase ICS dose
OR
- Consider alternative therapy and maintain current doses - LTRA
What are SABAs?
Short acting beta2-agonists
Have an effect over 2-4 hours
Name some SABA medications
- Salbutamol
- Terbutaline
What are LABAs?
Long acting Beta-agonists
Action last up to 12 hours
What circumstances are SABAs used in?
- Increased symptoms
- Acute asthma attacks
How do beta agonists work?
β2 agonists work by mimicking the effect of norepinephrine on β2 receptors. This produces sympathetic effects on tissues containing β2 receptors.
Name some LABA drugs
- Salmeterol
- Formoterol
When are LABAs indicated?
- Exercise induced asthma
- Chronic asthma management
What should always be considered as a cause of poorly controlled asthma?
Poor inhaler technique
What is ipratropium bromide?
Antimuscarinic bronchodilator
Muscarinic antagoinists competitively inhibit cholinergic receptors on bronchial smooth muscle
Block action of acetylcholine on the nerve endings therefore inhibiting parasympathetic effect -> dilatation of the airways.
How do inhaled corticosteroids work?
Reduce inflammation - often known as preventer
What are the side effects of inhaled corticosteroids?
None at low doses, however at high:
- Impaired growth
- Adrenal suppression
- Altered bone
If a child was suffering from exercise induced asthma, how would you manage this?
SABA, and if that doesn’t work progress to LABA + ICS
What clinical features suggest a child is having an asthma attack?
- Wheeze
- Tachypnoea
- Increasing tachycardia
- Accessory muscle use
- Inability to speak
What would indicate moderate acute asthma?
- O2 saturations >92%
- Peak flow >50% predicted
- No clinical features of severe asthma
What would indicate severe acute asthma?
- Too breathless to talk/feed
- Accessory muscle use
- O2 saturations <92%
- RR - >30/min (over 5), >50/min (2-5)
- Pulse - > 130/min (2-5), >120/min (over 5)
- Peak flow - < 50% (if you can get it)
What clinically would indicate life-threatening asthma attack?
- Slient chest
- Poor respiratory effort
- Altered consciousness
- Cyanosis
- Oxygen saturations <92%
- Peak flow < 30% predicted
How would you assess the severity of an asthma attack in a child?
- Ability to talk
- Breathing - tachypnoea, recession, wheeze, silent chest
- Pulse
- Level of consiousness
- Cyanosis
- PEFR
- O2 saturations
How would you treat someone with an acute asthma attack?
- SABA via large volume spacer - 2-4 puffs, increasing by 2 puffs every 2 minutes to 10 puffs
- Consider Oral prednisolone
How would you manage a child with severe asthma attack?
- High flow oxygen - 100% via nasal prongs/face mask
- SABA - inhaler or nebulised
- Oral prednisolone/IV hydrocortisone
- Nebulised ipratropium bromide
How would you treat a child with life threatening asthma?
Call for HELP!!!! and alert ICU
- High flow oxygen + Neb. SABA + Neb. Ipra. Bromide
- IV hydrocortisone
- IV Amynophilline
- IV Magnesium sulfate
- Intubation and ventilation
What would you do if a child with severe/life-threatening asthma was not responding to treatment?
- Move to HDU/ITU
- Consider CXR + Blood gases
- Intubate and ventilate
What should you consider using if IV amynophilline or salbutamol?
Monitor potassium shifts
- ECG
- U+Es
What is the lung deposition of inhaled drug without a spacer?
= 5%
What percentage of an inhaled drug is deposited in the lung when using in combination with a spacer?
= 20%
What are LTRAs?
Leukotriene Receptor Antagonists
Block the effects of leukotrienes at the LTC4, LTD4 and LTE4 receptors in the airways, decreasing both the early and late responses to inhaled allergens.
What are different modes of delivering inhaled drugs?
- pMDI
- Breat actuated metered dose inhaler
- Dry Powder inhaler
- Nebuliser
What is the recommended age group for pMDIs?
- 0-2 years - spacer + facemask
- >2 years - spacer alone
What age are breath actuated metered dose inhalers recommended for?
6+
What is the name of the main LTRA used in asthma?
Montelukast
What common problems can occur when trying to manage asthma?
- POOR INHALER TECHNIQUE
- Inadequate perception/planning for attacks
- Too much inhaled steroid
- Not recognising nocturnal waking as a sign of dangerous asthma
What lifestyle changes can be made to try to improve asthma symptoms?
- Smoking cessation - self and family
- Removal of environmental triggers
What signs would you see on examination in a child with asthma?
- Reduced breathing but hyperinflated chest
- Use of accessory muscles
- Chest wall retraction on breathing
- Hyper-resonant chest
- Wheeze
