Asthma in Children - passmed Flashcards
What is considered a severe asthma attack in children according to the 2016 BTS/SIGN guidelines?
- SpO2 < 92% - PEF 33-50% of best or predicted - Too breathless to talk or feed - Heart rate >125 bpm if older than 5 years, >140 bpm if between 1-5 years - Respiratory rate >30 breaths/min if older than 5 years, >40 breaths/min if between 1-5 years - Use
What are the signs of a life-threatening asthma attack in children?
- SpO2 < 92% - PEF < 33% of best or predicted - Silent chest - Poor respiratory effort - Agitation - Altered consciousness - Cyanosis
For children over 5 years old, what heart rate indicates a severe asthma attack?
Heart rate over 125 beats per minute.
For children aged 1-5 years, what heart rate is considered severe during an asthma attack?
Heart rate over 140 beats per minute.
What does PEF stand for and what are the critical PEF readings for a severe and life-threatening asthma attack in children?
PEF stands for Peak Expiratory Flow. For a severe attack, PEF is between 33-50% of the best or predicted value. For a life-threatening attack, PEF is below 33% of the best or predicted value.
What respiratory rate indicates a severe asthma attack in children older than 5 years?
A respiratory rate over 30 breaths per minute.
What respiratory rate indicates a severe asthma attack in children between 1 to 5 years old?
A respiratory rate over 40 breaths per minute.
General management strategy for children with severe or life-threatening asthma.
Children with severe or life-threatening asthma should be transferred immediately to the hospital.
Criteria for a moderate asthma attack in children aged 2-5 years.
SPO2 > 92% - No clinical features of severe asthma.
Signs of a severe asthma attack in children aged 2-5 years.
SPO2 < 92% - Too breathless to talk or feed - Heart rate > 140/min - Respiratory rate > 40/min - Use of accessory neck muscles.
Indicators of a life-threatening asthma attack in children aged 2-5 years.
SPO2 < 92% - Silent chest - Poor Respiratory effort - Agitation - Altered consciousness - Cyanosis.
Criteria for a moderate asthma attack in children older than 5 years.
- SpO2 > 92% - PEF > 50% of best or predicted - No clinical features of severe asthma.
Signs of a severe asthma attack in children older than 5 years.
- SpO2 < 92% - PEF 33-50% of best or predicted - Can’t complete sentences in one breath or too breathless to talk or feed - Heart rate > 125/min - Respiratory rate > 30/min - Use of accessory neck muscles.
Indicators of a life-threatening asthma attack in children older than 5 years.
- SpO2 < 92% - PEF < 33% of best or predicted - Silent chest - Poor respiratory effort - Altered consciousness - Cyanosis.
Bronchodilator therapy for children with mild to moderate acute asthma.
Give a beta-2 agonist via a spacer; for children < 3 years use a close-fitting mask. Administer 1 puff every 30-60 seconds up to a maximum of 10 puffs. If symptoms are not controlled, repeat beta-2 agonist and refer to hospital.
Steroid therapy recommendation for children with an asthma exacerbation.
Steroids should be given to all children with an asthma exacerbation for 3-5 days.
Usual prednisolone dose for children aged 2-5 years as per BTS and cBNF guidelines.
BTS: 20 mg once daily. cBNF: 1-2 mg/kg once daily (max 40mg).
Usual prednisolone dose for children older than 5 years as per BTS and cBNF guidelines.
BTS: 30-40 mg once daily. cBNF: 1-2 mg/kg once daily (max 40mg).
What major change did the 2017 NICE guidance introduce in the diagnosis of asthma?
The 2017 NICE guidance advocates moving away from subjective or clinical judgments toward more objective tests for diagnosing asthma.
What is the significance of fractional exhaled nitric oxide (FeNO) in diagnosing asthma?
FeNO testing is emphasized for its ability to measure levels of nitric oxide, which correlate with inflammation levels, especially from eosinophils, thus helping to diagnose asthma.
What objective tests are recommended for all patients aged 5 years and older?
Patients aged 5 years and older should undergo spirometry with a bronchodilator reversibility (BDR) test and a FeNO test.
How is asthma diagnosed in patients younger than 5 years?
In patients younger than 5 years, asthma diagnosis should be made based on clinical judgment.
What should be considered for patients 17 years and older regarding work-related asthma symptoms?
Patients 17 years and older should be asked if their symptoms improve during days away from work or holidays; if so, they should be referred to a specialist for possible occupational asthma.
What is the positive threshold for FeNO levels in adults and children?
A FeNO level of >= 40 ppb is considered positive in adults, and >= 35 ppb is considered positive in children.
What criteria define obstructive lung disease in spirometry?
An FEV1/FVC ratio less than 70% or below the lower limit of normal (if available) is considered indicative of obstructive lung disease.
What constitutes a positive bronchodilator reversibility (BDR) test in adults and children?
In adults, a positive BDR test is an improvement in FEV1 of 12% or more and an increase in volume of 200 ml or more. In children, a positive test is an improvement in FEV1 of 12% or more.
Initial management step for newly diagnosed asthma in children aged 5-16.
Step 1: Use a short-acting beta agonist (SABA).
Next step if asthma is not controlled with SABA alone or if symptoms occur >= 3 times per week or include night-time waking for children aged 5-16.
Step 2: Add paediatric low-dose inhaled corticosteroid (ICS) to SABA.
Management step after Step 2 for children aged 5-16 with asthma.
Step 3: Continue SABA and low-dose ICS, and add a leukotriene receptor antagonist (LTRA).
What is added to the asthma management regimen at Step 4 for children aged 5-16?
Step 4: Add a long-acting beta agonist (LABA) to the regimen of SABA and low-dose ICS, and consider stopping LTRA if it hasn’t helped.
What changes in the asthma management regimen at Step 5 for children aged 5-16?
Step 5: Switch to a maintenance and reliever therapy (MART) that includes a paediatric low-dose ICS.
Management step for more severe asthma in children aged 5-16 that isn’t controlled by previous steps.
Step 6: Use SABA with paediatric moderate-dose ICS MART or consider a fixed-dose regimen of moderate-dose ICS and a separate LABA.
What is considered at Step 7 for the management of asthma in children aged 5-16?
Step 7: Options include increasing ICS to paediatric high-dose, either as part of a fixed-dose regimen or as a MART, trying an additional drug like theophylline, or seeking advice from a specialist.
How is asthma managed in children under 5 according to NICE guidelines?
Start with SABA, and if symptoms are not controlled or occur >= 3 times per week or include night-time waking, initiate an 8-week trial of paediatric moderate-dose ICS.
What to do after the 8-week trial of ICS in children under 5 years if symptoms did not resolve?
Consider an alternative diagnosis if symptoms did not resolve during the trial period.
What to do if symptoms in children under 5 years resolved then reoccurred within 4 weeks after stopping ICS treatment?
Restart ICS at a paediatric low dose as first-line maintenance therapy.
What to do if symptoms in children under 5 years resolved but reoccurred beyond 4 weeks after stopping ICS treatment?
Repeat the 8-week trial of a paediatric moderate dose of ICS.
What is MART in the context of asthma management?
Maintenance and reliever therapy (MART) is a form of combined ICS and LABA treatment using a single inhaler for both daily maintenance and symptom relief, where the LABA has a fast-acting component (e.g., formoterol).
What is the general recommendation from the BTS guidelines regarding the frequency of considering stepping down asthma treatment?
The BTS guidelines recommend considering stepping down treatment approximately every 3 months.
What factors should be considered when stepping down asthma treatment according to the BTS guidelines?
Factors to consider include the duration of treatment, side-effects, and patient preference.
How does the BTS recommend reducing the dose of inhaled steroids when stepping down treatment?
The BTS advises reducing the dose of inhaled steroids by 25-50% at a time when stepping down treatment.
How often are patients with stable asthma likely to have a formal review according to the BTS guidelines?
Patients with stable asthma are likely to have a formal review on an annual basis.
What is the likely review frequency for a patient who has recently had an escalation in asthma treatment?
A patient who has recently had an escalation in asthma treatment is likely to be reviewed on a more frequent basis than annually.
A 6-year-old boy is taken to the emergency department by his mother with several days of wheezing. He also describes some chest tightness and is coughing up clear phlegm. He has a past medical history of asthma and uses a salbutamol inhaler when needed. Over the past few days, he has been using the inhaler several times daily.
On examination, a widespread wheeze is noted on auscultation of the chest. Observations are within normal limits for his age. His peak expiratory flow rate (PEFR) is calculated as 70% of his historic best value. He can speak in full sentences.
What is the most appropriate next step?
Intravenous co-amoxiclav
Intravenous hydrocortisone
Oral amoxicillin
Oral prednisolone
Reassure and monitor
Steroid therapy should be given to all children who have an asthma attack
Oral prednisolone is the most appropriate answer. This child is experiencing an acute exacerbation of asthma. This attack can be described as moderate - his PEFR is between 50% and 75% of his best, his observations are fine and he has no clinical features of severe or life-threatening asthma. Regardless of severity, BTS guidelines state that all children experiencing an asthma attack should be given steroid therapy. For a child of this age, 30-40mg once daily for 3 days is typically used.
Intravenous co-amoxiclav is incorrect. There are no features of infection in this scenario - as such, antibiotics are not warranted.
Intravenous hydrocortisone is incorrect. If the patient were more unwell, or unable to swallow, the parenteral route would be indicated. However, this child seems reasonably well and can talk in full sentences; the oral route will be adequate.
Oral amoxicillin is incorrect. There are no features in this scenario to suggest infection, so antibiotics are not warranted.
Reassurance and monitoring are insufficient alone. Guidance states that all children experiencing an asthma exacerbation, regardless of severity, should be given steroid therapy.
A 7-year-old boy is brought to the emergency department by his mother after he became acutely breathless and wheezy an hour ago and his salbutamol inhaler did not relieve the symptoms.
On examination, a wheeze is heard bilaterally with a respiratory rate of 40/min, heart rate of 110/min and oxygen saturation of 93%. The patient cannot speak in full sentences and peak expiratory flow (PEF) is 36% of predicted.
An arterial blood gas is taken with the following results:
pH 7.45 7.35-7.45
pO2 8.0 kPa 10.6-13.4 kPa
pCO2 5.0 kPa 4.0-6.0 kPa
HCO3 23 mmol/L 22-26 mmol/L
What is the severity of this asthma exacerbation?
Fatal
Life-threatening
Mild
Moderate
Severe
A normal pCO2 in an acute asthma attack indicates it is life-threatening
Life-threatening asthma exacerbation is correct, as the CO2 is normal. When the patient has a high respiratory rate, one would expect a low CO2. Therefore, a high CO2 indicates exhaustion as they can no longer blow it off effectively.
Fatal asthma exacerbation is incorrect, as this is not part of the asthma severity stratification.
Mild is incorrect, as the normal CO2 indicates that this is a life-threatening asthma exacerbation. Additionally, the exacerbation has many features of severe asthma such as the oxygen saturation of 93%, peak expiratory flow of 36% of predicted and respiratory rate of 40/min.
Moderate is incorrect, as the normal CO2 indicates that this is a life-threatening asthma exacerbation. Additionally, the exacerbation has many features of severe asthma such as the oxygen saturation of 93%, peak expiratory flow of 36% of predicted and respiratory rate of 40/min.
Severe is incorrect because the normal CO2 indicates that this is a life-threatening asthma exacerbation. However, as stated above, this scenario has many features of a severe asthma exacerbation.
A 15-year-old girl presents to her GP as she has been suffering with wheeze and shortness of breath on exertion. She has also had a night-time cough for the past year. There is a family history of eczema and she suffers from a peanut allergy.
She undergoes spirometry testing, the results of which are normal with no bronchodilator reversibility.
What is the next best step for this patient?
Consider an alternative diagnosis
Fraction of exhaled nitrous oxide (FeNO) testing
Peak flow variability monitoring
Serum IgE testing
Start a salbutamol inhaler
A negative result on spirometry does not exclude asthma as a diagnosis, and should be further investigated
FeNO testing is correct. This is the next investigation in children aged 5-16 who have a normal spirometry result but a high clinical suspicion of asthma. A positive test is a result of ≥ 35ppm.
Consider an alternative diagnosis is incorrect. A negative spirometry result does not exclude asthma as a diagnosis, especially in this patient who has a very typical history of asthma, so clinical suspicion would remain high.
Peak flow variability monitoring is incorrect. Peak flow can be measured over 2-4 weeks in children being investigated for asthma, however, according to NICE guidance, FeNO testing should be performed first and this test is reserved for those with normal FeNO levels.
Serum IgE testing is incorrect. Although it may be used in the investigation of asthma, FeNO testing is usually performed first due to its higher specificity. Furthermore, this patient has a peanut allergy and therefore may already have high serum IgE.
Starting a salbutamol inhaler is incorrect. It would be the first-line management if this patient were to be diagnosed with asthma, however, it is important to confirm the diagnosis first with FeNO testing.
A 9-year-old girl is brought to the emergency department by her father after becoming acutely breathless half an hour ago. She is a known asthmatic and her salbutamol inhaler has not relieved the symptoms.
On examination, she has a heart rate of 110/min, a respiratory rate of 40/min and an oxygen saturation of 93%. Her chest is silent on examination with a peak expiratory flow (PEF) of 35% predicted.
An arterial blood gas is taken with the following results:
pH 7.49 7.35-7.45
PaO2 8.0 kPa 10.6-13.4 kPa
PaCO2 2.0 kPa 4.0-6.0 kPa
HCO3 23 mmol/L 22-26 mmol/L
What severity is this asthma exacerbation?
Fatal
Life-threatening
Mild
Moderate
Severe
A silent chest is a life-threatening feature of an asthma attack
Important for meLess important
Life-threatening as the chest is silent. It indicates that there is no air entry due to bronchoconstriction and airway inflammation resulting in no audible breath sounds. A silent chest should indicate that the patient is at risk of death and ICU should be called for management of the condition.
Fatal asthma exacerbation is incorrect, as this is not part of the asthma severity stratification.
Mild is incorrect, as the silent chest indicates that this is a life-threatening asthma exacerbation. In a mild exacerbation wheeze may be heard throughout the chest.
Moderate is incorrect, as the silent chest indicates that this is a life-threatening asthma exacerbation. In a moderate exacerbation wheeze may be heard throughout the chest.
Severe is incorrect because the silent chest indicates that this is a life-threatening asthma exacerbation. However, there are many features of a severe exacerbation such as the oxygen saturation of 93%, peak expiratory flow of 35% of predicted, respiratory acidosis and respiratory rate of 40/min.
A nine-year-old boy presents to the urgent GP clinic with a cough. He has a history of asthma and eczema. He walks into the room and looks well. He is speaking in full sentences. His oxygen saturations are 97% in air, peak expiratory flow is 60% of expected, heart rate is 115/min and respiratory rate is 28/min. Chest examination showed widespread wheeze.
What is the management for this patient?
High flow oxygen and salbutamol nebuliser
Oral prednisolone and salbutamol as required
Oral prednisolone and salbutamol via a spacer: one puff every 30-60 seconds to a maximum of 10 puffs
Oral prednisolone, salbutamol and arrange for hospital admission
Salbutamol via a spacer: one puff every 30-60 seconds to a maximum of 10 puffs
Steroid therapy should be given to all children who have an asthma attack
Important for meLess important
This boy is having a moderate acute asthma attack. His oxygen saturations are >92%, he is talking in full sentences, his peak expiratory flow rate is 50%-75% of expected, his respiratory rate is <30/min and his heart rate is <125bpm.
Oral prednisolone and salbutamol via a spacer: one puff every 30-60 seconds to a maximum of 10 puffs is correct. Steroid therapy should be given to all children who have an asthma attack and this is the correct administration of salbutamol for a child of this age.
High flow oxygen and salbutamol nebuliser is incorrect. His SP02 is 97% so oxygen therapy is not required, and he can be given salbutamol via a spacer. A nebuliser is not required.
Oral prednisolone and salbutamol as required is incorrect. One puff of salbutamol should be given every 30-60 seconds to a maximum of 10 puffs with this presentation rather than using it as required. After the management of the acute presentation, it would be appropriate to have a medication review which would include discussing salbutamol use as required.
Oral prednisolone, salbutamol and arrange for hospital admission is incorrect. If this child’s symptoms settle with the appropriate treatment, he could be managed in the community and a hospital admission avoided.
Salbutamol via a spacer: one puff every 30-60 seconds to a maximum of 10 puffs should be given, but steroids are also required for all children who have an asthma attack.
A 7-year-old boy with a history of brittle asthma is brought to the emergency department with worsening dyspnoea and wheezing, unable to talk in full sentences and visible indrawing of intercostal muscles. His mother reports that it started while playing football 1 hour ago. His heart rate is 130/min, respiratory rate 25/min, temperature 37.4ºC, oxygen saturation 91% on room air, and blood pressure is normal.
Capillary blood gas is performed:
pH 7.39 (7.35 - 7.45)
PaCO2 4.8 kPa (4.5 - 6.0)
PaO2 11 kPa (10 - 14)
Na+ 140 mmol/L (135 - 145)
K+ 3.6 mmol/L (3.5 - 5.0)
HCO3- 28 mmol/L (22 - 29)
What feature of this presentation indicates it is life-threatening?
He cannot complete sentences
His heart rate
His respiratory rate
The pCO2 value
Use of accessory muscles
A normal pCO2 in an acute asthma attack indicates it is life-threatening
The correct answer is the pCO2 value. This child is seriously unwell with an asthma attack, and most of the features in his presentation are consistent with a British Thoracic Society definition of acute severe asthma. However, the normal pCO2 value on his arterial blood gas is consistent with a life-threatening attack because it suggests exhaustion and declining respiratory effort. We would expect to find a low pCO2 value and respiratory alkalosis as the child hyperventilates, but as they start to tire, carbon dioxide is retained and the value normalises on blood gas. This is not a reassuring finding!
He cannot complete sentences is incorrect, as this falls under the category of acute severe asthma according to the British Thoracic Society guidelines. Note also that a peak expiratory flow rate (PEFR) was not performed; a PEFR of <33% best or predicted would be consistent with a life-threatening asthma attack, while 33-50% would be consistent with an acute severe asthma attack.
His heart rate is incorrect, as this falls under the category of acute severe asthma according to the British Thoracic Society guidelines.
His respiratory rate is incorrect, as a respiratory rate of 25/min falls under the category of moderate acute asthma according to the British Thoracic Society guidelines. A respiratory rate of greater than 30/min would classify as acute severe asthma.
Use of accessory muscles is incorrect, as this falls under the category of acute severe asthma according to the British Thoracic Society guidelines.
A 12-year-old boy presents to the emergency department with increased work of breathing and a cough for the last 4 hours. His mum gave him 8 puffs of his blue inhaler but this has not improved his symptoms.
On examination, he is struggling to finish his sentences. His oxygen saturations are 90%, his respiratory rate is 30 breaths/min and his heart rate is 125bpm.
The boy is started on 15L oxygen via a non-rebreathe mask and simultaneous nebulised salbutamol. His oxygen saturations increase to 95% and his oxygen requirements are titrated down.
What additional step is required in the management of this patient?
IV aminophylline
IV magnesium sulphate
Inhaled ipratropium bromide
No further additional management currently required
Oral prednisolone 40 mg for 5 days
Steroid therapy should be given to all children who have an asthma attack
Oral prednisolone 40mg for 5 days is the correct answer. This boy has had an acute exacerbation of asthma, demonstrated by the short history of dyspnoea and cough, inability to complete sentences, hypoxaemia, tachypnoea and tachycardia. The initiation of oxygen and nebulised salbutamol improved the boy’s oxygen saturations suggesting that further intensive treatment, such as magnesium sulphate, ipratropium bromide or aminophylline, is not currently indicated. Instead, a corticosteroid (prednisolone) should be prescribed for all patients presenting with an asthma attack and this should continue for 5 days, or until they recover from their attack.
IV aminophylline is the incorrect answer. This should only be prescribed under consultation with senior medical staff and is reserved for life-threatening asthma attacks that have not resolved with other treatments. This boy began to recover after oxygen and nebulised salbutamol therapy suggesting further intensive treatment is not currently indicated. Additionally, other treatments would be trialled before commencing aminophylline, such as ipratropium bromide and magnesium sulphate.
IV magnesium sulphate is the incorrect answer. Whilst this treatment may be used during acute exacerbations of asthma, this boy has begun to recover with oxygen and nebulised salbutamol suggesting further therapies are not currently required. This treatment is usually reserved for life-threatening asthma.
Inhaled ipratropium bromide is the incorrect answer. This is a short-acting muscarinic antagonist that may be used if the child has not responded to beta2-agonist treatment. In this scenario, the boy’s oxygen saturations improved with oxygen and nebulised salbutamol alone, suggesting further therapies are not currently required to control his symptoms.
No further additional management currently required is the incorrect answer. This child has presented with a severe, acute asthma attack. Whilst additional acute therapies are not indicated, such as magnesium sulphate, a corticosteroid is required over the next 5 days to reduce inflammation and the risk of recurrence.
A 7-year-old boy with a history of asthma presents to the emergency department with a two-hour history of increasing shortness of breath and wheezing that has not resolved with his salbutamol inhaler.
On examination, he is too breathless to talk and has a widespread wheeze on auscultation.
His oxygen saturations are 92% so he is started on oxygen-driven nebulised salbutamol.
An arterial blood gas is taken as part of the initial workup:
pH 7.37 (7.35-7.45)
pO2 8.5 kPa (>9kPa)
pCO2 5.0 kPa (4.7-6.0kPa)
Base excess 1.3 (-2 to 2)
Lactate 1.9 mmol/L (<2 mmol/L)
What is the most appropriate classification for this asthma attack?
Life-threatening
Mild
Moderate
Near-fatal
Severe
A normal pCO2 in an acute asthma attack indicates it is life-threatening
Important for meLess important
This boy fulfils the criteria for a life-threatening asthma attack. A normal pCO2 suggests that there is reduced respiratory effort as the chest is tiring and no longer able to efficiently compensate by hyperventilating in response to hypoxia, a normal compensatory process in asthma attacks which ‘blows off’ pCO2, leading to a decreased pCO2. Classification is based on the most dangerous sign present, so whilst some of the other signs fall into the severe category, the normal pCO2 makes this asthma attack life-threatening.
In the 2016 BTS/SIGN guidelines for classifying the severity of asthma attacks in children, there is no mild category, but the term is sometimes used for asthma episodes that don’t meet the criteria for a moderate attack. An asthma attack with a normal pCO2 would never fall under this category as it is a life-threatening feature.
In a moderate asthma attack the pCO2 will be low. This results from hyperventilation, a normal compensatory mechanism of the body to try and maintain oxygen supply. As this boy has a normal PCO2, this is incorrect.
The same can be said for a severe asthma attack, where the pCO2 will also be low due to the ‘blowing off’ of CO2. As this boy has a normal PCO2, this is incorrect.
In a near-fatal asthma attack, the pCO2 would be raised as the body is too tired to even maintain normal breathing (in contrast to moderate or severe asthma attacks where the patient hyperventilates to compensate, and in life-threatening asthma attacks where the patient can no longer efficiently compensate but can maintain ‘normal breathing’). As a result, the CO2 level builds up in the blood. As this boy has no features of a near-fatal asthma attack, this is incorrect.
A 7-year-old girl with a history of asthma is brought to her GP by her mother. Her mother reports that her daughter tends to wake up at least once per week with a cough and wheeze. She adds that her child’s school has informed her that her daughter has to use her salbutamol inhaler in almost all of her physical education lessons. The GP decides that further pharmacological therapy is indicated in the management of the child’s asthma.
What is the most appropriate drug to add to this child’s regular prescription?
Budesonide
Ipratropium bromide
MART regime with beclometasone and formoterol
Montelukast
Salmeterol
Child aged 5-16 years with asthma not controlled by a SABA asthma management in children 5-16 - add a paediatric low-dose ICS
Important for meLess important
Budesonide is correct. NICE have established a pharmacological treatment pathway to manage asthma in 5-to-17-year-olds (NG80). Short-acting beta-2 agonist (SABA) reliever therapy alone is usually given first-line, but NICE recommend adding maintenance therapy if:
a) Symptoms are not controlled with SABA therapy alone; and/or
b) The child is experiencing three or more exacerbations per week; and/or
c) Exacerbations are causing nocturnal waking.
This child’s symptoms are causing her to wake up at night, and she is likely to be having several exacerbations per week (for example, during physical education lessons at school). Provided that the child’s inhaler technique is good - likely administered by her parents or school staff with the aid of a spacer device - further pharmacological therapy is indicated. NICE advise that a low-dose inhaled corticosteroid (ICS) such as beclometasone or budesonide should be used as first-line maintenance therapy, so budesonide is correct.
Ipratropium bromide is incorrect. This may be used during acute asthma exacerbations requiring secondary care input, but does not typically form a part of maintenance therapy for asthma.
MART regime with beclometasone and formoterol is incorrect. ‘MART’ stands for ‘Maintenance and Reliever Therapy’; patients on MART regimes will use the same combination inhaler on a daily basis to prevent symptoms, and also as reliever therapy during acute asthma exacerbations. However, these are usually only instigated as a later treatment option, when other regimes such as ICS therapy, leukotriene receptor antagonists (LRTAs) and long-acting beta-2 agonists (LABAs) have already been tried.
Montelukast is incorrect. This is an LRTA which may be added to a child’s maintenance therapy alongside an ICS when paediatric low-dose ICS therapy alone has not provided an adequate treatment response. ICS therapy should be trialled first, so it would be inappropriate to add montelukast at this time.
Salmeterol is incorrect. This is a LABA which may be added to a child’s maintenance regime when ICS and LRTA combined maintenance therapy has been proven ineffective. Similarly to montelukast, NICE do not recommend trialling this medication without attempting ICS maintenance therapy first.
It is worth noting that a child may be referred to an asthma specialist in secondary care if LABA maintenance therapy has failed (either as a MART or fixed-dose regimen). In this setting, higher ICS doses or other drugs such as theophylline may be trialled.
A 7-year-old boy is brought to his GP by his mother. He has been struggling with a persistent cough and wheezing that is worse at night and after PE lessons in school. He has a history of eczema but is otherwise well in himself.
On examination, there are no signs of infection and there is an obstructive picture on spirometry.
What diagnostic investigation would be used and what result fits this boy’s most likely diagnosis?
Bronchodilator reversibility testing, improvement of 14%
Bronchodilator reversibility testing, improvement of 8%
Fractional exhaled nitric oxide (FeNO) test, 27 parts per billion
Fractional exhaled nitric oxide (FeNO) test, 42 parts per billion
Spirometry is adequate for diagnosis, FEV1/FVC ratio 62%
An increase in the FEV1 of 12% or more after inhalation of a short-acting bronchodilator is indicative of asthma
This case fits with a diagnosis of asthma. He has a cough and wheezing symptoms that show diurnal variation and are worse with exercise. He also has eczema, therefore has a history of atopy. Together with obstructive spirometry, these all point towards asthma.
NICE suggests that in children aged 5-16, bronchodilator reversibility (BDR) testing should be offered to those with obstructive spirometry. An improvement of 12% or more is considered positive. Unlike in adults, FeNO testing is only offered to children if there is uncertainty over their assessment e.g. normal spirometry or obstructive spirometry but negative bronchodilator reversibility testing. With adults, NICE guidelines suggest offering both BDR and FeNO testing.
Bronchodilator reversibility testing measures the FEV1 before and after the administration of a bronchodilator (usually salbutamol). Improvement demonstrates that there is reversible airway obstruction, which is a hallmark of asthma. In FeNO (fraction of exhaled nitrous oxide) testing, the equipment measures the amount of nitrous oxide in exhaled breath. Nitrous oxide is a marker of airway inflammation and therefore is raised in individuals with asthma.
Bronchodilator reversibility testing, improvement of 14% is correct as
BDR test is the diagnostic test of choice and a result >12% fits with a diagnosis of asthma.
Bronchodilator reversibility testing, improvement of 8% is incorrect as a BDR improvement of <12% doesn’t fit with a diagnosis of asthma.
Fractional exhaled nitric oxide (FeNO) test, 27 parts per billion is incorrect, as FeNO is only used in children when there is diagnostic uncertainty and <35 parts per billion would be considered negative in children.
Fractional exhaled nitric oxide (FeNO) test, 42 parts per billion is incorrect as although >/=35 parts per billion would be expected in asthma, the FeNO test is not the main diagnostic test in children.
Spirometry is adequate for diagnosis, FEV1/FVC ratio 62% is incorrect, as although an FEV1/FVC ratio of <70% is consistent with asthma, this picture on spirometry would warrant further investigation and is not diagnostic.
A 10-year-old girl with asthma is brought by ambulance into the emergency department after becoming breathless whilst playing, which did not resolve after using her salbutamol inhaler.
She is too breathless to give a history. On exam, her respiratory rate is 33/min, and no wheezing or coughing is heard on auscultation.
Investigations show the following:
PEF 40% (>75%)
pH 7.37 (7.35-7.45)
pO2 9.2 kPa (>9kPa)
pCO2 4.3 kPa (4.7-6.0kPa)
What feature makes this a life-threatening asthma attack?
Chest auscultation
Level of breathlessness
PCO2 level
Peak expiratory flow (PEF)
Respiratory rate
A silent chest is a life-threatening feature of an asthma attack
Important for meLess important
Chest auscultation revealed a silent chest (absence of wheezing) which in an acute asthma attack indicates it is life-threatening. A silent chest happens due to fatigue and demonstrates the inability to move any air through severely constricted bronchioles. Although all the other features of this patient’s asthma attack fall into the ‘severe’ category, the attack is classified according to the most extreme feature, in this case, the silent chest.
The level of breathlessness was such that the patient was unable to talk, a feature of a severe asthma attack. This feature would not independently make this attack fall under the category of life-threatening.
The pCO2 level of 4.5, which is low, is typically observed in moderate or severe asthma attacks. This results from hyperventilation, a normal compensatory mechanism of the body to try and maintain oxygen supply. A normal pCO2, as opposed to a low pCO2, is a feature of a life-threatening asthma attack as it means the body is too tired to hyperventilate.
Peak expiratory flow (PEF) of 40% is incorrect as a PEF of 33-50% is a feature of a severe asthma attack, not a life-threatening attack. The criteria for a life-threatening attack is a PEF <33%. The PEF correlates with how open the lung’s airways are, so as asthma worsens and the airways obstruct more, the PEF decreases.
The respiratory rate of 33/min is also a feature of a severe asthma attack. This feature would not independently make this attack fall under the category of life-threatening. There is no specific respiratory rate which is a feature of a life-threatening attack according to the 2016 BTS/SIGN guidelines for classifying the severity of asthma attacks in children.
An 11-year-old girl presents with a 6-month history of shortness of breath on exertion and at night. In the last six months, she has had 12 episodes of tightness in her chest during football matches and struggles to breathe. These episodes only last a few minutes and are relieved by rest.
She has a past medical history of eczema and hay fever.
On examination, her chest sounds normal and you arrange spirometry testing.
The patient’s spirometry result is normal.
What is the most appropriate next step?
Diagnose asthma based on history
Monitor peak flow variability for 2 to 4 weeks
Organise exercise stress test
Organise fractional exhaled nitric oxide (FeNO) testing
Reassure the patient that this will likely get better with time
A negative result on spirometry does not exclude asthma as a diagnosis, and should be further investigated
Based on the age of the patient the history of chest tightness, diurnal variation, and her risk factors of hay fever and eczema the most likely diagnosis is asthma. A normal spirometry result does not exclude asthma and NICE recommends further testing at this instant.
Organise fractional exhaled nitric oxide testing is the correct answer. FeNO is the next step to diagnose asthma. It can be used to detect small amounts of NO released during inflammatory processes in the lungs and is highly sensitive and specific for asthmatic patients who have negative spirometry results.
Diagnose asthma based on history is incorrect. The patient does have a high pretest probability of having asthma. However, history alone, in this case, is not enough to diagnose asthma. The next step is FeNO then if that is negative monitor peak flow variability for 2 to 4 weeks in children and only then could a diagnosis based on history be considered.
Reassure the patient that this will likely get better with time is incorrect. The patient has multiple risk factors for asthma and even if it is not asthma you have no reason to think the child will get better over time.
Monitor peak flow variability for 2 to 4 weeks is incorrect. Nice recommends monitoring the peak flow of patients who are suspected of having asthma but only after the FeNO test is negative.
Organise exercise stress test is incorrect. Nice explicitly states that you should not perform exercise stress testing on patients you suspect of having asthma.
A 6-year-old boy is brought to the GP by his mother. Over the last 6 months, he has experienced shortness of breath and wheezing that are both worse on exertion and relieved with rest. During this time, he has also had a dry cough that is worse at night.
On examination, his chest is clear with normal air entry on both sides. There are no additional chest sounds. He has a past medical history of eczema and allergic conjunctivitis. His father was diagnosed with COPD at 35 years of age and there is no family history on his mother’s side.
Given the likely diagnosis, what is the next best step in his management?
Fractional exhaled nitrous oxide
No investigations needed - clinical diagnosis
Spirometry and bronchodilator reversibility
Spirometry and fractional exhaled nitrous oxide
Trial treatment and assess response
Children aged 5-16 years should have both spirometry and a bronchodilator reversibility (BDR) test to diagnosis asthma
Spirometry and bronchodilator reversibility is correct. This patient has signs and symptoms consistent with asthma, characterised by their shortness of breath and dry cough that is worse at night (diurnal variation is present) on a background of eczema and allergic conjunctivitis (both of which are risk factors for asthma). The NICE guidelines focus on using objective tests to diagnose asthma rather than clinical judgement. All children aged 5-16 years of age should have both spirometry and bronchodilator reversibility testing to diagnose asthma. If these are normal, then a fractional exhaled nitrous oxide test should be requested.
Fractional exhaled nitrous oxide is incorrect. This is not the first-line investigation for the diagnosis of asthma in children. All children aged 5-16 years of age should have both spirometry and bronchodilator reversibility testing to diagnose asthma. If these are normal, then a fractional exhaled nitrous oxide test should be requested.
No investigations needed - clinical diagnosis is incorrect. While this method of diagnosing asthma may have been performed in the past, NICE has moved to use objective tests rather than clinical judgement. As such, all children aged 5-16 years of age should have both spirometry and bronchodilator reversibility testing to diagnose asthma.
Spirometry and fractional exhaled nitrous oxide is incorrect. In adults, spirometry with bronchodilator testing and a fractional exhaled nitrous oxide test should all be performed, however, all children aged 5-16 years of age should have both spirometry and bronchodilator reversibility testing to diagnose asthma.
Trial treatment and assess response is incorrect. While this method of diagnosing asthma may have been performed in the past, NICE has moved to use objective tests before starting treatment.
