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Year 3 - Paediatrics > Clinical Features of Asthma in Children > Flashcards

Clinical Features of Asthma in Children Flashcards

1
Q

what are the challenges of dealing with asthma?

A
  • No definition
  • No tests
  • Two national guidelines
  • Symptom based
  • Identical to LRTI symptoms (cough, SOB, noisy breathing)
  • Relapse and remission
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2
Q

Tips to dealing with asthma:

  1. No _________, no asthma
  2. Tests ___ help decision
  3. If…..

QoL affected, confirm the diagnosis with trial of ___ (to confirm diagnosis)

QoL not affected (by symptoms), _____ ___ ___

A

wheeze

may

ICS

watch and see

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3
Q

If child doesn’t wheeze then they don’t have ______

A

asthma

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4
Q

What is asthma?

A
  • Literally “panting”
  • Chronic
  • Wheeze, cough and SOB
  • Multiple triggers
  • Variable/reversible
  • Responds to asthma Rx
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5
Q

what 3 things msut you have to have asthma?

A

•Wheeze, cough and SOB

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6
Q

for asthma you have to have a ________, it has to _______ to treatment and it has to be _______

A

wheeze

respond

variable

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7
Q

No longer a diagnosis of _________

A

exclusion

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8
Q

what are the 3 Key words in relation to asthma?

A
  1. Wheeze
  2. Variability
  3. Respond to treatment
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9
Q

What causes asthma?

A

No one really knows what causes it

What we know:

  1. Host response to environment
  2. Infection important
  3. Physiology abnormal before symptoms
  4. It is a syndrome
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10
Q

Many inconsistencies in asthma such as what?

A
  • “Transient” vs persistent (symptoms)
  • VIW versus asthma/MTW (multi trigger wheeze)
  • Different severities
  • Different age at onset
  • Heterogeneity in response
  • Different triggers
  • How can a single condition do this???
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11
Q

Asthma syndromes - can occur in many setting

example picture shown

A
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12
Q

What causes asthma? - how are genes involved?

A
  • Genes - 30-80% of causation
  • ~10 variants making modest contribution
  • ADAM33, ORMDL3 (People with these genes don’t all have asthma)
  • Interact with environment (If predisposed to asthma, its only when you encounter environment when you get asthma symptoms)
  • Epigenetics (the study of changes in organisms caused by modification of gene expression rather than alteration of the genetic code itself)
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13
Q

does allergy cause asthma? - probably not

so what expalines the link between allergy and asthma?

A

•Primary epithelial abnormality (skin/airway/gut) results in:

  1. Eczema/asthma/etc
  2. Allergy

•Allergy then fuels eczema/asthma/etc

Allergic sensitisation fuels the symptoms in the affected organ (skin, lung, gut)

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14
Q

what is the epidemiology of asthma?

A

a very British problem - Burden of asthma in UK is highest in world (prob same now a days)

  • 1.1 million UK children
  • 110, 000 in Scotland
  • 5% of UK children on inhaled steroids!
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15
Q

Asthma “epidemic” probably over

So why the rise and fall?

A
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16
Q

Westernisation! - what is it to do with asthma?

A

Burden of asthma/eczema/hay fever is higher on the western side of these geographically very closely placed areas, these areas where genetic diversity is very limited/very similar so only reason to explain these 2 is lifestyle and/or diagnostic threshold

Western lifestyle is associated with an increased risk of asthma and probably in the first 3 years this is having an influence

  • Retained if move >3 yo
  • Acquire “Western” risk if born there
17
Q

what is Proof of causation?

A

Two RCTs proven causation

Offspring at risk for asthma

Complex

  • Feeding - Breast, Late weaning
  • Allergen (reduced exposure) - Ante- and post-natal
  • Smoking (parents stop)
18
Q

What happens in _____ life, often before we are born, is a really important ___________ of our later respiratory life course

A

early

determinant

19
Q

if they do have asthma like symptoms affecting their QoL then what do you do?

A

give them a trial of inhaled steroids as a diagnostic test

20
Q

So when is it asthma? - how do you make the diagnosis?

A
  • All in the history!
  • Examination unhelpful - Unlikely to be wheezing, Stethoscope never important (often unhelpful)
  • No diagnostic asthma test in children:
  • Peak flow random number generator
  • Allergy tests irrelevant (Majority of people with allergy don’t have asthma and 25% of people with asthma don’t have allergy)
  • Spirometry lacks specificity
  • Exhaled nitric oxide unproven

•Tests can be useful (excluding > diagnosing)

21
Q

how may spirometry be done to be useful?

A

do it

then make them take a BDR (bronchodilator response)

then repeat and see if it has changed

22
Q

Asthma diagnosis - NICE

  1. Spirometry
  2. BDR
  3. FeNO
  4. Peak flow
A

Asthma diagnosis – BTS/SIGN

  1. Spirometry
  2. BDR
  3. FeNO
  4. Peak flow
23
Q

what is the problem with asthma in paediatrics?

A
  • Uncertainty greatest in <5s
  • Tests not reliable in <5s
  • Tests not great anyway
24
Q

how is a wheeze present in asthma?

A
  • A “must have”
  • But not in isolation
  • Cough variant asthma does not exist (in children)
  • Cough predominant asthma not uncommon
25
Q

Is it really wheeze?

A
  • Aberdeen 75% wheeze in two year olds not genuine
  • Rattle versus whistle is a good dichotomy

Rattle = bronchitis

Whistle = asthma

Majority will be one of these 2 but mainly rattles

26
Q

SOB at reast is a importnat feature of asthma - what is it?

A
  • Significant resp difficulty - <30% lung function
  • Airway obstruction
  • “Sooking” in of ribs with wheeze
27
Q

cough is a feature of asthma but the problem is:

  • Everyone coughs!
  • Only 10% have asthma

what isa cough like in asthma?

A
  • Dry
  • Nocturnal (just after falling asleep)
  • Exertional
28
Q

what other histories may be helpful?

A
  • Parental Hx asthma (is one parent currently on asthma treatment)
  • Personal history
  • Eczema
  • Hayfever
  • Food allergies

a personal history of allergy is circumstantially helpful but the majority of children with eczema, hay fever and food allergies don’t have asthma

29
Q

What has asthma symptoms and responds to asthma treatment?

A
  • Asthma treatment = ICS for 2 months
  • Remember “false positive responses” – holiday (stop inhaler and see if symptoms come back and if they don’t then you have false positive response)
30
Q

Asthma is a hindsight diagnosis

ideally to make the diagnosis what should be present?

A

Wheeze (with and without URTI)

SOB@rest

Parental asthma

Responds to treatment

31
Q

A word about trial of treatment - what is the harm and benefits?

A

Benefits greatly outweigh harm

32
Q

My approach to wheeze

A
33
Q

So when is it not asthma?

A

All that is chronic and paediatric and respiratory is not asthma

Simplistically:

  • Under 18 months, most likely infection
  • Over 5 years, most likely asthma

•BUT if it sounds like asthma and responds to asthma it is asthma regardless of age!

34
Q

what are Differential diagnosis for “asthma”?

A

Important to know age of onset when working out differentials

Habitual – no wheeze

Pertussis – LRTI, cough but no wheeze

35
Q

Asthma vs VIW

A
36
Q

My approach to the preschool cough

A
37
Q

no wheeze = ???

A

no asthma

38
Q
  1. No _______, no asthma
  2. Tests ___ help decision
  3. If…..

I. QoL affected, confirm the diagnosis with trial of ___

II. QoL ___ _______, watch and see

A

wheeze

may

ICS

not affected

Year 3 - Paediatrics (40 decks)

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