Management of Asthma in Children

Question 1

What are the main goals of asthma treatment?

Answer 1

Minimal symptoms during the day and night

Minimal need for reliever medication

No attacks (exacerbations)

No limitation of physical activity

(normal lung function, FEV1 & PEFR > 80% predicted / best)

Question 2

What questions should be asked to decipher how well controlled a patients asthma is?

Answer 2

Mnemonic - SANE:

• Short acting beta agonist use per week?
• Absences at school due to condition
• Nocturnal symptoms experienced per week?
• Excertional symptoms per week?

Question 3

How many times is the upper limit for an asthma patient using their SABA per week?

Answer 3

2 times

If they are using their blue inhaler more than 2 times per week they are poorly controlled

Question 4

How often should a well controlled asthma patient be experiencing nocturnal and excertional symptoms per week?

Answer 4

They shouldn’t

Experiencing these symptoms indicated poor control

Question 5

If an asthma patient has been well controlled for more than 3 months, what should be considered?

Answer 5

Stepping down their treatment

Might not be needing treatment to the extent they’re recieving it

Question 6

What is the first step in asthma management?

Answer 6

2 months of low dose inhaled ICS. Always first step bc part of the diagnostic process

Review effect after 2 months

(Need to take a break from the inhaler to make sure it’s actually asthma, usually done around easter bc low chance of infection & exacerbation)

Question 7

What classes of medications are available for the treatment of paediatric asthma?

Answer 7

Short acting beta agonists (SABA)
Inhaled corticosteroids 
Long acting beta agonists (LABA)
Leukotriene receptor antagonists 
Theophyllines 
Oral steroids

Question 8

What is the first line treatment for paediatric asthma in the stepwise progression?

Answer 8

Inhaled corticosteroids for children > 5yrs

Leukotriene receptor agonists for children under 5 years of age

Question 9

What is the maximum dose of ICS in children?

Answer 9

800 microg

Question 10

What symptoms would indicate a trial of ICS should be started? (or LRTA’s in under 5s)

Answer 10

• Symptomatic 3 or more times per week (need blue inhaler)

- waking 1 or more nights per week

Question 11

What is one possible side effect of using too high a dosage of ICS?

Answer 11

Adrenocortical suppression

Question 12

What are 2 things to remember when it comes to using long acting beta agonists?

Answer 12

Don’t use without ICS

Give them in a fixed dose inhaler

Question 13

How do kids tend to respond to treatment with LRTA’s? What is one advantage of them?

Answer 13

Rule of thirds (1/3 good response, 1/3 some response, 1/3 no response)

Better adherence due to tablet / granule form

Question 14

What is the second step in asthma treatment? (already on ICS)

Answer 14

Add on a LABA

This doesn’t work best for everyone though and response in some individuals is better with:

• LTRA added on
• Increased ICS dose

Question 15

What are the two types of severe asthma?

Answer 15

1. Treatment resistant asthma (very rare in paeds)
2. Troublesome asthma (the patient says they’re taking the treatment, but they aren’t taking the treatment - may have psychological / domestic issues)

Question 16

If a patient has severe treatment resistant asthma what class of drugs is available?

Answer 16

Biologics

omalizumab / Mepolizumab

Question 17

What is one group of asthma treatment medications that is not available for chilfdren?

Answer 17

LAMA’s

Question 18

What are the two types of delivery systems for asthma medications?

Answer 18

Meter dosed inhaler +spacer (can use without spacer but you get less than 5% of the medication in your lungs compared to 20% with spacer)

Dry powder device

Question 19

What are two important things to remember when using inhalers with spacers?

Answer 19

Shake the inhaler before using

Wash the spacer monthly with detergent

Question 20

Which medication delivery devices are used by children of different ages?

Answer 20

under 8s - MDI + spacer

Boys 8-11 - MDI + spacer

Girls 8-11 - dry powder device

12+ - MDI

Question 21

When are nebulisers used? What is a nebuliser?

Answer 21

Not usually

Maybe if the person is unconscious, but they have low drug deposition and intrinsic mechanics break down more often so not much upside

Basically an oxygen mask but spits out meds instead

Question 22

What are some non-pharmacological methods of improving childs asthma?

Answer 22

Stop smoking (usually directed at parents)

Removing environmental triggers (such as cats if they trigger the child - if they don’t trigger them then they’re chill)

Question 23

What medication would be given to a child that is suffering a mild asthma attack?

Answer 23

SABA via a spacer

Or if more severe:
SABA via a spacer + prednisolone

Question 24

What medication would be given to a child that is suffering a moderate asthma attack?

Answer 24

SABA via a spacer + prednisolone

Or if more severe:
SABA via spacer + ipratropium bromide via nebuliser + prednisolone

Question 25

What does ipratropium bromide do?

Answer 25

Bronchodilator

Question 26

For children experiencing severe asthma attacks, what treatment options are available?

Answer 26

• IV salbutamol
• IV aminophylline
• IV magnesium
• IV hydrocortisone
• Intubation and ventilation

Question 27

If a patient presents to the hospital having an asthma attack and seems very agitated or otherwise strange, what may they be suffering from?

Answer 27

Hypoxia causing confusion

Question 28

What are some of the factors that you need to pay close attention to when first examining the patient presenting with an acute asthma attack?

Answer 28

Resp and heart rate
Work of breathing 
Oxygen saturation
Ability to speak (complete sentences without breathing?)
Confusion
Air entry 

Presence of symptoms indicates severity and therefore treatment

Question 29

What signs are seen when a child is having a respiratory attack?

Answer 29

Stomach bulging in and out (due to force of diaphragmatic contractions)

Contraction of the intercostal muscles

Tracheal tug

Question 30

What is the difference between the steroids given for chronic asthma management and acute?

Answer 30

Chronic - inhaled roids

Acute - oral roids