Asthma management in children

Question 1

What are the goals of treatment for asthma ?

Answer 1

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)

Question 2

How do you measure asthma control ?

Answer 2

SANE

Short acting beta agonist/ week
Absence school/ nursery
Nocturnal symptoms/ week
Exertional symptoms/ week

Question 3

What are the classes of medications ?

Answer 3

Short acting beta agonists 
Inhaled corticosteroids (ICS)
Long acting beta agonists 
Leukotriene receptor antagonists 
Theophylline's
Oral steriods 
'Add ons '

Question 4

What is the step up step down approach ?

Answer 4

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

Question 5

Why stepping down hard ?

Answer 5

Can’t tell if the alleviation of symptoms is because of treatment or because the patient has spontaneously got better

Question 6

How does treatment between adults and children contrast ?

Answer 6

Max dose ICS 800microg (<12y)
No oral B2 tablet
LTRA 1st line preventer <5s
No LAMAs

Question 7

What is step 1 ?

Answer 7

SABA as required

Question 8

What is step 2 ?

Answer 8

Regular preventer

Question 9

When should a regular preventer be prescribed ?

Answer 9

Using B2 agonist >2 times/ week

When symptomatic 3 times a week or more, or 1 waking night

Question 10

What regular preventers are prescribed ?

Answer 10

Start with very low dose ICS (or LTRA in <5s)

Question 11

Why are ICS good ?

Answer 11

Very useful for diagnosis
Very effective when taken
Very safe when prescribed correctly

Question 12

What are the adverse effects of ICS ?

Answer 12

Height suppression (1cm)
Oral candidiasis
Adrenocortical suppression ???
Go brown inhaler

Question 13

What is step 3 ?

Answer 13

Add on preventer

Question 14

What are the 3 options for add on preventers ?

Answer 14

Add on LABA
Add on LTRA
Increase ICS

Question 15

What are the two things to remember about a long acting beta agonist ?

Answer 15

Do not use without ICS - you can die in you use them on their own
Use as fixed dose inhaler

Question 16

What are the benefits of having a combination inhaler of LABA and ICS ?

Answer 16

Better compliance as well as potential synergy between the two chemicals

Question 17

What are things to remember when prescribing LTRA ?

Answer 17

Montelukast only
Rule of 3rds
Better adherence
Granules for reluctant toddlers

Question 18

What is step 4 ?

Answer 18

Additional add on therapies

Question 19

What is step 5 ?

Answer 19

High-dose therapies

Question 20

What should you do in under 5 patients before prescribing high dose therapies ?

Answer 20

Refer for confirmation of diagnosis

Question 21

What is step 6 ?

Answer 21

Continuous or frequent use of oral steroids

Experimental medicine

Question 22

What should you do when prescribing continuous or regular oral steroids ?

Answer 22

Refer !!

Question 23

What are the possible reasons for the medication not working by stage 6 ?

Answer 23

Psychological issues
Compliance issues
Wrong diagnosis

Question 24

What is severe asthma ?

Answer 24

Experimental medicine
50% psychological issues 
>50% compliance issues
Question with diagnosis 
Minority with genuine severe distress
Role of biologics unproven

Question 25

What are the main ways of delivering asthma medication ?

Answer 25

MDI/spacer
Dry power devices
Nebulisers

Question 26

What are the best ways to increase the inhaled dose of an inhaler ?

Answer 26

Shake, wash and use a spacer

Question 27

What are the considerations when using dry powder devices ?

Answer 27

Under 8s cannot use them

Question 28

What % of lung deposition is achieved when using dry powder devices ?

Answer 28

20%

Question 29

What is an important consideration of nebulisers ?

Answer 29

Not indicated for day to day use

Question 30

Why is a MDI better than a nebuliser ?

Answer 30

Quieter
Quicker
Valve mechanism
Don't break down
Portable 
Cheaper

Question 31

What are the non-pharmacological methods of management ?

Answer 31

Stop tobacco smoke exposure

Remove environmental triggers

Question 32

What are the treatments for mild acute asthma ?

Answer 32

SABA via spacer (bronchodilators)

SABA via spacer + prednisolone

Question 33

What are the treatments for moderate acute asthma ?

Answer 33

SABA via nebuliser + prednisolone

SABA + ipratropium via nebuliser + prednisolone

Question 34

What are the treatments for severe acute asthma ?

Answer 34

IV salbutamol
IV aminophylline
IV magnesium
IV hydrocortisone
Intubate and Ventilate

Question 35

How do you make the differential diagnosis between mild, moderate and severe acute asthma treatments ?

Answer 35

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

Question 36

What is a measure of work of breathing between children and adults ?

Answer 36

Children- subcostal recession

Adults - use of accessory muscles

Question 37

When do you use inhaled steroids v oral ?

Answer 37

Chronic/ maintenance treatment =inhaled steroids

Acute treatment =oral steroids – for kids with asthma attack