Asthma management in children Flashcards
What are the goals of treatment for asthma ?
Minimal symptoms during day or night Minimum need for reliver medications No exacerbations No limitations of physical activity Normal lung function (FEV1/ PEFR >80% predicted or best)
How do you measure asthma control ?
SANE
Short acting beta agonist/ week
Absence school/ nursery
Nocturnal symptoms/ week
Exertional symptoms/ week
What are the classes of medications ?
Short acting beta agonists Inhaled corticosteroids (ICS) Long acting beta agonists Leukotriene receptor antagonists Theophylline's Oral steriods 'Add ons '
What is the step up step down approach ?
Started on low dose ICS
- severe may respond to minimal treatment
Review after 2 months
- no routine test to monitor progress
- no change easier than down
- need an inhaler holiday
Why stepping down hard ?
Can’t tell if the alleviation of symptoms is because of treatment or because the patient has spontaneously got better
How does treatment between adults and children contrast ?
Max dose ICS 800microg (<12y)
No oral B2 tablet
LTRA 1st line preventer <5s
No LAMAs
What is step 1 ?
SABA as required
What is step 2 ?
Regular preventer
When should a regular preventer be prescribed ?
Using B2 agonist >2 times/ week
When symptomatic 3 times a week or more, or 1 waking night
What regular preventers are prescribed ?
Start with very low dose ICS (or LTRA in <5s)
Why are ICS good ?
Very useful for diagnosis
Very effective when taken
Very safe when prescribed correctly
What are the adverse effects of ICS ?
Height suppression (1cm)
Oral candidiasis
Adrenocortical suppression ???
Go brown inhaler
What is step 3 ?
Add on preventer
What are the 3 options for add on preventers ?
Add on LABA
Add on LTRA
Increase ICS
What are the two things to remember about a long acting beta agonist ?
Do not use without ICS - you can die in you use them on their own
Use as fixed dose inhaler
What are the benefits of having a combination inhaler of LABA and ICS ?
Better compliance as well as potential synergy between the two chemicals
What are things to remember when prescribing LTRA ?
Montelukast only
Rule of 3rds
Better adherence
Granules for reluctant toddlers
What is step 4 ?
Additional add on therapies
What is step 5 ?
High-dose therapies
What should you do in under 5 patients before prescribing high dose therapies ?
Refer for confirmation of diagnosis
What is step 6 ?
Continuous or frequent use of oral steroids
Experimental medicine
What should you do when prescribing continuous or regular oral steroids ?
Refer !!
What are the possible reasons for the medication not working by stage 6 ?
Psychological issues
Compliance issues
Wrong diagnosis
What is severe asthma ?
Experimental medicine 50% psychological issues >50% compliance issues Question with diagnosis Minority with genuine severe distress Role of biologics unproven
What are the main ways of delivering asthma medication ?
MDI/spacer
Dry power devices
Nebulisers
What are the best ways to increase the inhaled dose of an inhaler ?
Shake, wash and use a spacer
What are the considerations when using dry powder devices ?
Under 8s cannot use them
What % of lung deposition is achieved when using dry powder devices ?
20%
What is an important consideration of nebulisers ?
Not indicated for day to day use
Why is a MDI better than a nebuliser ?
Quieter Quicker Valve mechanism Don't break down Portable Cheaper
What are the non-pharmacological methods of management ?
Stop tobacco smoke exposure
Remove environmental triggers
What are the treatments for mild acute asthma ?
SABA via spacer (bronchodilators)
SABA via spacer + prednisolone
What are the treatments for moderate acute asthma ?
SABA via nebuliser + prednisolone
SABA + ipratropium via nebuliser + prednisolone
What are the treatments for severe acute asthma ?
IV salbutamol IV aminophylline IV magnesium IV hydrocortisone Intubate and Ventilate
How do you make the differential diagnosis between mild, moderate and severe acute asthma treatments ?
Look at the following features of the patient:
Respiratory rate Work of breathing Heart rate Oxygen saturations Ability to complete sentences Confusion - related to hypoxia Air entry
What is a measure of work of breathing between children and adults ?
Children- subcostal recession
Adults - use of accessory muscles
When do you use inhaled steroids v oral ?
Chronic/ maintenance treatment =inhaled steroids
Acute treatment =oral steroids – for kids with asthma attack
