Management of Asthma - Children Flashcards
What are the goals of treatment for asthma?
- “minimal” symptoms during day and night
- minimal need for reliever medication
- no exacerbations
- no limitation of physical activity
normal lung function (in practical terms FEV1 and/or PEF >80% predicted or best
How do you measure control of asthma?
SANE
- Short acting beta agonist/week
- Absence school/nursery
- Nocturnal symptoms/week
- Excertional symptoms/week
What are the classes of medications?
- Short acting beta agonists
- Inhaled corticosteroids (ICS)
- Long acting beta agonists*
- Leukotriene receptor antagonists*
- Theophyllines*
- Oral steroids
* “add ons”
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When do you review after just starting a course of low dose ICS?
2 months
Why stepping down hard?
Can’t tell if the aleviation of symptoms is because of treatment or because the patient has spontaneously got better
How does treatment between adults and children contrast?
- Max dose ICS 800 microg
- No oral B2 tablet
- LTRA first line preventer in <5s
What is step 1?
SABA as required
What is step 2?
Regular preventer
When should you prescribe a regular preventer?
When using inhaled B2 agonists three times a week or more
When symptomatic three times a week or more, or waking one night a week
What are the regular preventers that you prescribe?
•Start very low dose inhaled corticosteroids (or LTRA in <5s)
What is step 3?
Add on preventer
What are the three options for adding on preventer?
- Add on LABA
- Add on LTRA
- Increase ICS dose
What should you do in under 5 patients before prescribing high dose therapies?
Refer for confirmation of diagnosis
WHat should you do when prescribing continuous or regular oral steroids?
REFER!
Why are inhaled corticosteroids fab?
- Very useful for diagnosis
- Very effective (when taken)
- Very safe (when prescribed correctly) (Large therapeutic range – unlikely to cause harm)
What is the general trend in dose response for ICS?
Large increase in positive effects for the initial dose of steroids - the rate of increase of positive effects gradually decreases as the dose increases.
How do the adverse effects of ICS compare?
What are the adverse effects of ICS?
Height suppression (1cm)
Oral candidiasis?
Adrenocortical suppression?
What are the two things to remember about a long acting beta agonist?
Do not use without ICS - you can die in you use them on their own
Use as fixed dose inhaler
What are the benefits of having a combination inhaler of LABA and ICS?
Better compliance as well as potential synergy between the two chemicals
What is step 4?
Additional add on therapies
What is step 5?
High dose therapies
What is step 6?
Experimental medicine
What are the possible reasons for the medication not working by stage 6?
Psychological issues
Compliance issues
Wrong diagnosis
What are the best ways to increase the inhaled dose of an inhaler?
For goodness sake shake, wash and use a spacer!
Can under 8’s use dry powder devices?
no
What is important to note about nebulisers?
•Not indicated for day-to-day use
Why is a MDI better than a nebuliser?
Quieter
Quicker
Valve mechanism
Don’t break down
Portable
Cheaper
What are the non-pharmocological methods of management?
Stop tobacco smoke exposure
Remove environmental triggers
What are the treatments for mild acute asthma?
SABA via spacer
SABA via spacer and prednisolone
What is the treatment for patients for moderate acute asthma?
SABA via nebuliser + prednisolone
SABA and ipratropium via nebuliser and prednisolone
What are the treatments for patients with severe acute asthma?
IV salbutamol
IV aminophyline
IV magnesium
IV hydrocortisone
Intubate and Ventilate
How do you make the differential dagnosis between mild, moderate and severe acute asthma treatments?
Look at the following features of the patient:
- Repiratory rate
- Work of breathing
- Heart rate
- Oxygen saturations
- Ability to complete sentences
- Confusion - related to hypoxia
- Air entry
What is a measure of work of breathing between children and adults?
Subcostal recession in children
Adults - use of accessory muscles
What is the overall guide for treatment of acute asthma?
- Start treatment and reassess in 1 hour
- Step up or down as appropriate
When do you use inhaled steroids versus oral?
- Chronic/ maintenance treatment =inhaled steroids
- Acute treatment =oral steroids – for kids with asthma attac
