CPS Statements Post-Exam

Question 1

True or false: wheezing in early life has been associated with reduced lung function at 6 years of age that generally persists until adulthood.

Answer 1

True! The magnitude of the reduction is a 10% lower FEV1 compared with healthy peers
-this might be due to airway remodelling and irreversible damage to the airways in untreated toddlers

Question 2

Why is early diagnosis of asthma in preschool years important?

Answer 2

1. Avoid treatment delay
   - there is evidence that recurrent preschool wheezing responds to inhaled corticosteroid therapy similar to older children and adults
2. Reduce morbidity
3. Maximize lung growth and function since lungs continue to grow until 8 yo

Question 3

What is the diagnostic criteria for asthma in children 1-5 yo?

Answer 3

• **Overall: need documentation of air flow obstruction and documentation of reversability of airflow obstruction
  1. Frequent asthma-like symptoms (8 or more days/month) OR recurrent exacerbations (2 or more episodes with asthma like signs)
  2. Documentation of airflow obstruction = need to see wheeze/cough/difficulty breathing
  3. Documentation of reversability of airflow obstructions: symptoms improve with SABA OR parental report of symptomatic response to a 3 month therapeutic trial of medium dose inhaled corticosteroids with prn SABA OR SABA prn alone.
  3. Absence of clinical factors suggestive of alternative diagnosis
• ***Personal or family history of atopy is NOT necessary for diagnosis!
• ***This also applies to children with recurrent (2 or more) asthma like symptoms or exacerbations even when only triggered by viral respiratory infections

Question 4

What is the most specific sign of airflow obstruction?

Answer 4

Wheezing

Question 5

What is the most common cause of recurrent cough?

Answer 5

Recurrent URTIs with postnasal drip = NOT associated with wheeze or difficulty breathing

Question 6

In children > 1 yo, what is the best way to distinguish between bronchiolitis and asthma?

Answer 6

Response to asthma medications!

Question 7

How old does a child have to be to be diagnosed with asthma?

Answer 7

1 years old! Below this age is more likely to be bronchiolitis UNLESS there’s 2 or more wheezing episodes before 1 year of age, then you should be suspicious of asthma and refer to a specialist!

Question 8

In a child presenting with current airflow obstruction and is receiving asthma medications, what change in PRAM score is considered to be clinically important enough to be called “evidence of airflow obstruction reversability”?

Answer 8

Change of 3 or more points in PRAM score

Question 9

If you are prescribing dexamethasone for asthma exacerbation, what are the dosing options?

Answer 9

Dex 0.6 mg/kg OD x 2 days

Question 10

What is the management of a child with frequent symptoms (2 or more days/week OR 8 or more days/month) or 1 or more moderate or severe asthma like exacerbation (treated with oral corticosteroids or hospital admission)?

Answer 10

Therapeutic trial with a medium daily dose of ICS (200-250 mcg total) and SABA prn

• need to do this EVERY DAY for 3 months straight before you can assess for improvement!
• need to see them in follow up in 6 weeks (ie half way through the 3 month mark) to see how compliance is going

Question 11

What is deemed a “satisfactory clinical response” to a 3 month therapeutic trial of medium dose inhaled corticosteroid in a query asthma patient?

Answer 11

1. ~50% reduction in number of exacerbations requiring PO steroids
2. Shorter duration of exacerbations
3. Decreased severity of exacerbations
4. Fewer symptoms in between exacerbations

Question 12

What are the indications for referral to asthma specialist in a 1-5 yo patient you’ve diagnosed with asthma?

Answer 12

1. Suspicion of comorbidity
2. Poor symptom and exacerbation control despite ICS at 200-250 mcg daily doses
3. Life-threatening event (PICU admission or intubation)

Question 13

When do you use the spacer with a facemask? What about spacer with the mouthpiece?

Answer 13

• Spacer with facemask: for children 1-3 yo

- Spacer with mouthpiece: children 4 yo and older if able to form a good seal around the mouthpiece

Question 14

When would you consider stepping down asthma medication to lowest effective dose?

Answer 14

ONLY when adequate control has been sustained over 3 months despite exopsure to child’s typical unavoidable asthma triggers (ie. URTI, cold air, etc.)
-can trial off medication when symptoms are minimal on a low dose of ICS during the season when the child is usually most symptomatic

Question 15

What is the preferred 1st line management for asthma in preschool age?

Answer 15

Daily ICS at lowest effective dose!