Management of Asthma in Children

Question 1

What are the goals of treatment for asthma?

Answer 1

• “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

Question 2

How do you measure control of asthma?

Answer 2

SANE

• Short acting beta agonist/week
• Absence school/nursery
• Nocturnal symptoms/week
• Excertional symptoms/week

Question 3

What are the classes of medications?

Answer 3

• Short acting beta agonists
• Inhaled corticosteroids (ICS)
• Long acting beta agonists*
• Leukotriene receptor antagonists*
• Theophyllines*
• Oral steroids

* “add ons”

Question 4

What is the blank?

Answer 4

Question 5

What is the blank?

Answer 5

Question 6

What is the blank?

Answer 6

Question 7

What is the blank?

Answer 7

Question 8

What is the blank?

Answer 8

Question 9

When do you review after just starting a course of low dose ICS?

Answer 9

2 months

Question 10

Why stepping down hard?

Answer 10

Can’t tell if the aleviation of symptoms is because of treatment or because the patient has spontaneously got better

Question 11

How does treatment between adults and children contrast?

Answer 11

• Max dose ICS 800 microg
• No oral B2 tablet
• LTRA first line preventer in <5s

Question 12

What is step 1?

Answer 12

SABA as required

Question 13

What is step 2?

Answer 13

Regular preventer

Question 14

When should you prescribe a regular preventer?

Answer 14

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

Question 15

What are the regular preventers that you prescribe?

Answer 15

•Start very low dose inhaled corticosteroids (or LTRA in <5s)

Question 16

What is step 3?

Answer 16

Add on preventer

Question 17

What are the three options for adding on preventer?

Answer 17

• Add on LABA
• Add on LTRA
• Increase ICS dose

Question 18

What should you do in under 5 patients before prescribing high dose therapies?

Answer 18

Refer for confirmation of diagnosis

Question 19

WHat should you do when prescribing continuous or regular oral steroids?

Answer 19

REFER!

Question 20

Why are inhaled corticosteroids fab?

Answer 20

• Very useful for diagnosis
• Very effective (when taken)
• Very safe (when prescribed correctly) (Large therapeutic range – unlikely to cause harm)

Question 21

What is the general trend in dose response for ICS?

Answer 21

Large increase in positive effects for the initial dose of steroids - the rate of increase of positive effects gradually decreases as the dose increases.

Question 22

How do the adverse effects of ICS compare?

Answer 22

Question 23

What are the adverse effects of ICS?

Answer 23

Height suppression (1cm)

Oral candidiasis?

Adrenocortical suppression?

Question 24

What are the two things to remember about a long acting beta agonist?

Answer 24

Do not use without ICS - you can die in you use them on their own

Use as fixed dose inhaler

Question 25

What are the benefits of having a combination inhaler of LABA and ICS?

Answer 25

Better compliance as well as potential synergy between the two chemicals

Question 26

What is step 4?

Answer 26

Additional add on therapies

Question 27

What is step 5?

Answer 27

High dose therapies

Question 28

What is step 6?

Answer 28

Experimental medicine

Question 29

What are the possible reasons for the medication not working by stage 6?

Answer 29

Psychological issues

Compliance issues

Wrong diagnosis

Question 30

What are the best ways to increase the inhaled dose of an inhaler?

Answer 30

For goodness sake shake, wash and use a spacer!

Question 31

Can under 8’s use dry powder devices?

Answer 31

no

Question 32

What is important to note about nebulisers?

Answer 32

•Not indicated for day-to-day use

Question 33

Why is a MDI better than a nebuliser?

Answer 33

Quieter

Quicker

Valve mechanism

Don’t break down

Portable

Cheaper

Question 34

What are the non-pharmocological methods of management?

Answer 34

Stop tobacco smoke exposure

Remove environmental triggers

Question 35

What are the treatments for mild acute asthma?

Answer 35

SABA via spacer

SABA via spacer and prednisolone

Question 36

What is the treatment for patients for moderate acute asthma?

Answer 36

SABA via nebuliser + prednisolone

SABA and ipratropium via nebuliser and prednisolone

Question 37

What are the treatments for patients with severe acute asthma?

Answer 37

IV salbutamol

IV aminophyline

IV magnesium

IV hydrocortisone

Intubate and Ventilate

Question 38

How do you make the differential dagnosis between mild, moderate and severe acute asthma treatments?

Answer 38

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

Question 39

What is a measure of work of breathing between children and adults?

Answer 39

Subcostal recession in children

Adults - use of accessory muscles

Question 40

What is the overall guide for treatment of acute asthma?

Answer 40

• Start treatment and reassess in 1 hour
• Step up or down as appropriate

Question 41

When do you use inhaled steroids versus oral?

Answer 41

• Chronic/ maintenance treatment =inhaled steroids
• Acute treatment =oral steroids – for kids with asthma attac