Asthma in Children

Question 1

What is asthma

Answer 1

Chronic inflammatory disorder of the airways resulting in reversible airway obstruction as a result of inflammation, bronchoconstriction and mucus build up.

Question 2

What is a wheeze?

Answer 2

• High-pitched adventitious lung sound.
• Produced by narrowing of lower respiratory airways.
• Usually during expiration (when airways at their narrowest)
• Can be inspiratory, expiratory, or biphasic (depends on severity).
• Typically present in obstructive airway disease.
• Not pathognomonic of any disease.

Question 3

What is a rhonchus?

Answer 3

• A lower-pitched variant of wheeze.
• Probably shares the same mechanism of generation.
• Disappears with cough – suggests secretions play a role.

Question 4

What are the risk factors for asthma?

Answer 4

Low birth weight, family history, bottle fed, atopy, male, pollution, and past lung disease

Question 5

What causes/triggers asthma?

Answer 5

Genetics

Pets, Dust, pollen, mould, cold air, exercise, medication, pollutants, and fungus

Question 6

What are the signs and symptoms of asthma?

Answer 6

Wheeze
Breathlessness (especially in cold air, when exercising or at night)
Tight chest
Cough (dry and irritating) 
Atopy

Question 7

How should asthma be investigated?

Answer 7

Inspection – for eczema
Palpation – lung expansion is the same both side
Percussion – for resonance
Auscultation – listen for crackles etc.

Peak Flow
Test peak flow volume – asthma usually different between morning and afternoon.
Spirometry – measures total output when expiring especially FEV1.
Saturation levels

Question 8

What are the management steps for a child with asthma aged 5-16?

Answer 8

1. SABA – short acting beta agonists – Ventolin. If used more than 3 times a week or if nocturnal symptoms require a step up. Salbutamol and Terbutaline
2. Inhaled corticosteroids – (preventer) low dose. Examples: beclomethasone, fluticasone and budesonide.
3. Oral leukotrienes such as Montelukast (preventer)
4. Stop the LTRA and start LABA – long acting Beta agonist – (preventer) examples: salmeterol, formoterol and stop montelukast
5. Switch ICS and LABA for a combined maintenance and reliever therapy (MART) which contains paediatric low dose ICS
6. Increase dose of MART to include a moderate-dose ICS or change back to a fixed dose of a moderate dose ICS and a separate LABA
7. Methylxanthines such as Theophylline (preventer) or increase ICS to high dose
8. Refer to specialist
9. Add oral prednisolone if they have an exacerbation

Question 9

Give two examples of combination therapies

Answer 9

Seretide = Fluticasone + salmeterol 
Symbicort = Budesonide + formoterol

Question 10

How should a child with asthma <5yrs be managed?

Answer 10

1. SABA – short acting beta agonists – Ventolin. If used more than 3 times a week or if nocturnal symptoms require a step up. Salbutamol and Terbutaline
2. Inhaled corticosteroids – (preventer) moderate dose 8 week trial. After 8 weeks stop the ICS and monitor symptoms. If no improvement during ICS trial then review diagnosis, if symptoms resolved then reoccurred within 4 weeks of stopping then restart the ICS, if symptoms resolved but didn’t reoccur until after 4 week then re-do the trial ICS.
3. Paediatric low dose ICS and Oral leukotrienes such as Montelukast (preventer)
4. Stop the LTRA and refer to paediatric asthma specialist

Question 11

What reasons causes asthma to be poorly controlled and so should be asked about in every review?

Answer 11

Non-adherence 
Poor inhaler technique 
Inadequate maintenance therapy 
Passive smoking, started smoking, damp mouldy house etc. 
Chest infection

Question 12

Describe an acute asthma attack in a child

Answer 12

Acute Attacks

Sats > 92%, RR < 30 (over 5s) or <40 (under 5s), speech normal, minimal wheeze and PEFR > 75% predicted.

Question 13

Describe a moderate asthma attack in a child

Answer 13

Moderate attacks

Sats > 92%, RR < 30 (over 5s) or <40 (under 5s), speech normal, lots of wheeze and PEFR > 50-75% predicted.

Question 14

Describe a severe asthma attack in a child

Answer 14

Severe attacks
Pulse > 110, RR > 30 (over 5s) and > 40 (under 5s), too breathless to feed or talk, audible wheeze, use of accessory muscles and PEFR 33-50% predicted

Question 15

Describe a life threatening attack in a child

Answer 15

Life threatening
Sats < 92% and may be cyanosed, silent chest/poor respiratory effort due to exhaustion, altered consciousness and PEFR <33% predicted.

Question 16

What does having a normal PCO2 in an asthma attack indicate?

Answer 16

Note a normal PCO2 kPa indicates life threatening asthma and respiratory fatigue

Question 17

How should an exacerbation of asthma be managed?

Answer 17

1. (Rescue prednisolone) *
2. Sit up and high flow 100% oxygen
3. Salbutamol and Ipratropium bromide (anticholinergics) nebulised with oxygen
4. Hydrocortisone IV or Prednisolone oral or IM
5. If still no improvement add magnesium sulphate IV
6. Aminophylline IV
7. CPAP in ED or Intubate (insert tube) and ITU admission.

*Only if non acute

Question 18

When can someone who’ve had an asthma attack be discharged?

Answer 18

Do not discharge until peak flow is >75% of predicted, they have good inhaler technique, is stable, taking inhaler and oral steroids, have a written management plan and arrange a follow up in the community with GP in 1 week and in clinic in 4 weeks.