Clinical features and management of Asthma in Children

Question 1

How is asthma diagnosed?

Answer 1

Wheeze
Variable airway obstruction
SOB at rest
Respond to treatment (Often ICS trial)

Question 2

What are some causes of asthma?

Answer 2

Genes (ADAM33, ORMDL3)
Environment
Epigenetics
Smoking
Late weaning
Allergy

Question 3

What are some common presentations of asthma in children?

Answer 3

Coughs a lot
Recurrent “chest infections”
Always at the doctor for a wheezy cough
Always chesty

Question 4

What do we do if QoL is not affected by symptoms?

Answer 4

Watch and wait

Many grow out of symptoms without need for medication

Question 5

When are tests useful for asthma?

Answer 5

Mostly for excluding other causes

Question 6

What is a drawback of spirometry for asthma?

Answer 6

Lacks specificity

Question 7

What is the NICE recommended testing path for children with high index of suspicion for asthma?

Answer 7

Spirometry
Bronchodilator response (blue inhaler)
Nitric oxide
Peak flow

Question 8

What are some associations with asthma in children?

Answer 8

Parental history
Eczema
Hayfever
Food allergies

Question 9

What are the most likely causes for an asthma-like presentation in differ

Answer 9

Infection

Question 10

What is the differential diagnosis for onset under 5 years?

Answer 10

Congenital
CF
PCD
Bronchitis
Foreign body

Question 11

What is the differential diagnosis for onset over 5 years old?

Answer 11

Dysfunctional breathing
Vocal cord dysfunction
Habitual cough
Pertussis

Question 12

What is a suspicion when there are red flags present?

Answer 12

Bronchiectasis

Question 13

What is step 1 after diagnosis from monitored trial of very low dose ICS?

Answer 13

Low does ICS

LTRA for <5

Question 14

What is step 2 after ICS or LTRA added?

Answer 14

Add inhaled LABA

LTRA for <5

Question 15

What is step 3 for no response to LABA?

Answer 15

If Stop LABA and increase ICS to low dose

Question 16

What is step 3 for limited response to LABA?

Answer 16

Continue LABA and increase ICS to low dose

Consider trial of other therapy like LTRA

Question 17

What is step 4 for high dose therapies?

Answer 17

Consider trial of increasing ICS to medium dose

Addition of 4th drug like SR theophylline

Question 18

Which medication is maintained throughout all steps of asthma treatment?

Answer 18

SABA

E.g. salbutamol

Question 19

When do you need to start going through the steps of preventer meds?

Answer 19

After diagnosis start on SABA

If SABA is used more than twice per week then start on preventer

Question 20

What are some adverse effects of ICS?

Answer 20

Height suppression
Oral candidiasis
Adrenocortical suppression

Question 21

What are 2 things to remember for LABA?

Answer 21

Do not use with ICS

Use as fixed dose inhaler

Question 22

What are benefits of using a spacer?

Answer 22

4x more meds get through

Question 23

Why do you need to shake the inhaler before and between puffs?

Answer 23

2x more meds

Question 24

Why do you need to wash spacers?

Answer 24

2x meds compared to no wash

Question 25

What are some benefits of MDI spacer over nebuliser?

Answer 25

``` Quieter Quicker Valve mechanism Don’t break down Portable Cheaper ```

Question 26

What is the escalation of acute asthma treatment?

Answer 26

SABA via spacer + pred SABA via neb + pred IV salbutamol/ aminophylline/ magnesium/ hydrocortisone Intubate and ventilate Start treatment then reassess after 1 hour

Question 27

How do you assess acute attack severity and hence decide treatment?

Answer 27

``` Respiratory rate Work of breathing Heart rate Oxygen saturations Ability to complete sentences Confusion Air entry ```

Question 28

How does steroid use for acute vs chronic treatment?

Answer 28

Inhaled for chronic | Oral for acute