Bronchiolitis and Asthma Flashcards
Bronchiolitis definition
- lower respiratory tract infection that affects babies and youhng children
- children usually younger than 2, peak with 3-6 months
- causes inflammation and congestion in the samll airways of lung
- almost always caused by virus
Effects of bronchiolar injury
- increased mucus secretion
- bronchial obstruction and constriction
- alveolar cell death, mucus debris, viral invasion
- air trapping
- atelectasis
- reduced ventilation that leads to ventilation-perfusion mismatch
- labored breathing
Symptoms of brichiolitis
- early: runny nose and cough
- fever
- dry and persistent cough
- difficulty breathing
- rapid or noisy breathing (wheezing)
- apnea
- retractions
- fine rales: diffuse, fine wheezing
- hypoxia
- otitis media
severe cases: respiratory destress with tachypnea, nasal flaring, retractions, irritability, cyanosis
Diagnostic tests in bonchiolitis
- usually not necessary when clinical presentation is obvious
- typically done to exclude other diagnoses
- rapid viral antigen test of nasopharyngeal secretions for RSV
- blood gas analysis
- WBC with differential
- CRP
- Pulse oxymetry
- blood cultures
- Urine analysis, specific gravity and culture
- CSF analysis and culture
- serum chemistries
Supportive care in bronchiolitis
- humidified oxygen
- maintentance of hydration
- mechnical ventilation
- nasal and oral suctioning
- apnea and cardiorespiratory monitoring
- temperature regulation in small infants
Do not use any of the following to treat bronchiolitis
- antibiotics
- hypertonic saline
- adrenaline (nebulized)
- salbutamol
- montelukast
- ipratropium bromide
- systmic or inhaled CCS
When to keep bronchiolitis patients in hospital
- chronic lung disease
- hemodynamically significant congenital heart disease
- age in young infants (under 3 months)
- premature birth, particulary under 32 weeks
- neuromuscular disorders
- immunodeficiency
- apnea
- persistent oxygen saturation of less than 92% when breathing air
- inadequate oral fluid intake
- persisting severe respiratory distress
When to consider a pneumonia
- high fever (over 39°)
- persistently focal crackles
Asthma symtpoms
- wheezing
- shortness of breath
- chest tightness
- cough
- variable expiratory airflow
Three mechanisms in asthma
- bronchocontriction
- increased mucus
- airways wall thickening
Symptoms in asthma can be triggered by:
- viral infection
- allergens
- tobacco smoke
- exercise
- stress
- irritants such as fumes, strong smells
- changes in weather
- laughter
Diagnosis of asthma
- based on history of characteristic symtpom patterns
- evidence of limited airflow, from bronchiodilator reversibility teting or other tests
Increased porbability that symptoms are due to asthma, if:
- more than one type of symptom
- symptoms worse at night or in the early morning
- symptoms vary over time and in intensity
- symptoms are triggered by something
Decreased probability that symptoms are due to asthma, if:
- isolated cough with no other respiratory symptoms
- chronic production of sputum –> think of CF or something else
- shortness of breath associated with dizziness or peripheral tingling
- chest pain
- exercise-induced dyspnea with noisy inspiration
Airflow limitation in asthma
- FEV1/FVC is reduced
- normal: >0.75-0.8 in adults and >0.9 in children
- exessive bronchodilator reversibility (children: increase > 12% predicted)
- significant increased in FEV1 or PEF after 4 weeks of controller treatment
- excessive diurnal variability from 1-2 weeks twice-daily PEF monitoring
Physical examinations in asthma
- often normal
- most frequent finding: wheezing on auscultation, especially on forced expiration
- wheezing may be absent during severe asthma exacerbations (“silent chest”)
Different symtpom patterns in asthma in children under 5 years
PATTERN 1
- symptoms for under 10 days in URTI
- 2-3 episodes per year
- no symptoms between episodes
PATTERN 2
- symptoms for over 10 days during URTI
- over 3 episodes per year, or severe episodes and night worsening
PATTERN 3
- symptoms for over 10 days during URTI
- over 3 episodes per year, or severe episodes and nigth worsening
- between episodes child has cough, wheeze or heavy breathing during play or when laughing
- atopy, or family histpry of asthma
Asthma management is aimes at reducing airways inflammation by:
- minimizing proinflammatory environmental exposures
- using daily controller anti-inflammatory medications
- controlling comorbid conditions that can worsen asthma (like GERD, all. rhinitis)
Treatment of asthma in children between 6-11
RELIEVER: as-needed short-acting ß-agonist (SABA)
steps for controlling
STEP 1
- only reliever
STEP 2
- Daily low dose inhaled corticosteroids (ICS)
STEP 3
- low dose ICS-LABA or medium dose ICS
STEP 4
- Medium dose ICS-LABA
STEP 5
- refer to phenotypic assessment and add-on therpay (like anti-IgE)
Treatment of asthma in children over 12
RELIEVER STEP 1/2: as-needed low dose ICS-formoterol
RELIEVER STEP 3/4/5: as-needed low-dose ICS-formoterol for patients prescribed maintencance and reliever therapy
steps for controlling STEP 1 (symtpoms less than twice a month) - as-needed low dose ICS-formoterol
STEP 2: (symtpoms twice a month or more)
- daily low-dose ICS, or as-needed low dose ICS-formoterol
STEP 3 (symtpoms most days, or waking with asthma once a week or more) - low dose ICS-LABA
STEP 4 (symtpoms most days, or waking with astma once a week or more, and low lung function) - medium dose ICS-LABA
STEP 5
- high dose ICS-LABA
- refer to phenotypic assessment and add-on therapy
Possible ICS
- beclometasone dipropionate
- budesonide
- ciclesonide
- fluticasone
- mometasone
Treatment of asthma in children 5 years or younger
RELIEVER: as -needed short-acting ß-agonist
controller steps
STEP 1 (infrequent viral wheezing and no or few interval symtpoms)
- only reliever
STEP 2 (symtpom pattern not consistent with asthma but wheezing episudes occur frequently, symtpom pattern consistnt with asthma and symtpoms not well-controlled or over 3 exacerbations per year) - daily low-dose ICS
STEP 3 (asthma diagnosis and asthma not well-controlled on low dose ICS) - double low dose ICS
STEP 4 (astma no well-controlled on double ICS) - continue controller and refer for specialist assessment
Mild asthma exacerbation in children under 5
- no altered consciousness
- O2 over 95%
- speech in sentences
- pulse over 100/min
- absent central cyanosis
- variable wheeze intensity
Severe asthma exacerbation in children under 5
- agitated, confused, drowsy
- O2 under 92%
- speech in words
- pulse over 200/min (0-3) or over 180/min (4-5)
- central cyanosis likely
- chest may be quiet
Transfer to hospital in asthma exacerbations in children under 5
- child is unable to speak or drink
- cyanosis
- subcostal retraction
- oxygen saturatin under 92
- silent chest
- lack of response to intial bronchodilator treatment
- persisting tachypnea
Initial management of asthma exacerbations in children under 5
- supplemental oxygen
- inhaled SABA
- Systemic CCS
additional options in the first hour of treatment
- ipratropium bromide
- magnesium sulfate
