Asthma in children

Question 1

Asthma in children Ix

Answer 1

Resp exam
basic obs
PEFR

Question 2

Medical Mx of Asthma in children <5y

Answer 2

1. SABA reliever
2. consider 8 wk trial of mod dose ICS (if asthma Sx >3/wk)
3. After 8wks stop ICS and monitor
   - not resolved: consider alt. Dx
   - Sx resolved but recurred within 4wks restart ICS at low dose
   -Sx resolved but recurred after 4wks repeat moderate dose ICS trial
4. If asthma is uncontrolled on paediatric low dose ICS consider adding LRTA (montelukast)
   5 If still uncontrolled stop LRTA and refer to asthma expert

Question 3

Medical Mx of Asthma in children (5-16)

Answer 3

1. SABA reliever
2. paediatric low dose ICS (offer first line to children w/Sx >3/wk at presentation or uncontrolled by SABA alone >3uses/wk, woken >1/wk with Sx)
3. LTRA in addition and r/v 4-8wk
4. stop LTRA, start LABA
5. Change ICS+LABA to MART regimen w/low dose ICS
6. moderate maintenance dose ICS
7. Specialist care (paediactric high dose ICS, or additional drug e.g theophylline)

Question 4

Non-pharm aspects of asthma Mx in children

Answer 4

Assess baseline status (asthma control questionnaire, spirometry)
Personalised asthma action plan (asthma UK)
Immunisations
signpost asthma UK
trigger avoidance (allergens, smoke, beta-blockers NSAIDS)
Anxiety and depression
Ensure pt has their own PFM
Inhaler technique

Question 5

Other therapies in Asthma in children

Answer 5

Severe persistent unresponsive: PO pred
Omalizumab (anti-IgE)
Antihistamines and nasal steroids in allergic rhinitis

Question 6

Complete control of Asthma in children

Answer 6

Absence of day or nighttime Sx, no limit on activities, no need for reliever use, normal lung functions and no exacerbation (need for hospital or oral steroids for 6mo)

Question 7

Asthma in children R/V

Answer 7

Adherence
inhaler technique
r/v effectiveness of Mx
occupational asthma and triggers

Question 8

Paediatric doses of budesonide

Answer 8

Low <200ug
mod 200-400 ug
high >400ug

Question 9

PACES counselling of Asthma in children

Answer 9

Dx: airways sensitive and tighten suddenly making it difficult to breathe
Mx: discuss where you are on the ladder and if you need r/v
Action plan: carry blue inhaler 10 puffs every 30-60s when breathless, call 999 if no response
explain PFM
identify trigger
Asthma UK, itchywheezysneezy.co.uk

Question 10

Acute asthma attack Ix

Answer 10

Resp exam
basic obs
PEFR

Question 11

Moderate acute asthma attack

Answer 11

PEFR 50-75%

normal speech

Question 12

Severe acute asthma attack

Answer 12

PEFR: 33-50%
RR: >40 (2-5), >30(5-12), >25(>12)
HR: >140 (2-5), >125 (5-12), >110 (>12)
Unable to complete sentences in one breath
Accessory muscle use
Inability to feed
SpO2 >92

Question 13

Life threatening acute asthma attack

Answer 13

PEFR <33%
SpO2 <92%
Altered LOC
Exhaustion
Arrhythmia
Hypotn
cyanosis
poor resp effort
silent chest

Question 14

admit to hospital acute asthma attack

Answer 14

anyone w/severe or LT

esp. if persists after bronchodilators

Question 15

Mx while awaiting admission

Answer 15

1.Supplemental O2 to hypoxic pts (venturi/nc) aim for 94-94%
2. SABA:
- LT asthma: neb. ideally oxygen driven, 2.5mg if 2-5 5mg if >5 (if no nebs use MDI w/large volume spacer)
3. If SABA ineffective neb. tiotropium bromide 10mg if <2 20mg if 2-5, 30-40mg if >5
consider:
- MgSO4
- aminophylline
- IV salbutamol

Question 16

Aminophylline consideration

Answer 16

needs to be infused slowly (or seizure, vomiting, arrhythmia)
ECG, electrolytes measured when using aminophylline and IV salbutamol

Question 17

Mx of acute asthma attack not requiring admission

Answer 17

SABA w/large vol spacer
- 1 puff every 30-60s up to 10
- 5 tidal breaths with each puff
Oral pred 3-7d
?Abx
Once Sx subsided return to SABA prn up to 4/day (not exceeding 4hlry)
do NOT alter ICS
Monitor PEFR at home
consider starting montelukast if >2yrs

Question 18

FU of acute asthma attack

Answer 18

NOT admitted: FU within 48hrs of presentaion

Admitted: FU within 2 working days

Question 19

Patient education of acute asthma attack

Answer 19

Before d/c r/v:
1. When drugs should be used (regular/PRN)
2. inhaler technique
3. What does each drug do?
4. How much of each to use
5. What to do if things get worse
Inform parents of signs of poorly controlled asthma (cough, wheeze, dib, difficulty walking/talking, decreasing relief from bronchodilators)
Measurement of PF at home allows recognition of deteriorating asthma

Question 20

Summary of acute asthma attack

Answer 20

Bronchodilator therapy:
beta-2 agonist via a spacer
1 puff every 30-60s up to 10
if Sx not controlled repeat beta-2 agonist and refer to hospital
Steroids:
given to all exacerbations
PO pred 3-5d:
2-5y 20mg OD
>5 30-40mg OD

Question 21

Steps in acute asthma attack Mx

Answer 21

Burst:
Salbutamol x3
ipratropium x2
PO pred x1

IV Bolus:
MgSO4
salbutamol
aminophylline

IV Infusion
aminophylline
salbutamol

panic:
intubate and ventilate