Management of Asthma in Children Non-Acute Flashcards

1
Q

Medical treatment of asthma - is there a cure?

A
  • There is no cure for asthma, only palliation or spontaneous resolution
  • BTS/SIGN (UK) and GINA and NICE (UK)
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2
Q

what are the goals of treatment?

A
  • “minimal” symptoms during day and night
  • minimal need for reliever medication
  • no attacks (exacerbations)
  • no limitation of physical activity
  • normal lung function (in practical terms FEV1 and/or PEF >80% predicted or best)
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3
Q

How do you to measure control?

A

Closed questions

SANE:

  • Short acting beta agonist/week (are you using your blue inhaler more than 2 times a week and if so you are poorly controlled)
  • Absence school/nursery
  • Nocturnal symptoms/week
  • Excertional symptoms/week
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4
Q

Complex treatment decisions in asthma

what quesitons should you ask yourself?

A
  • Are symptoms controlled? (Are they really??)
  • Is treatment being taken? (Is it really??)
  • Will this treatment change help? (Will it really??)
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5
Q

Complex treatment decisions:

if well controlled, what should you do?

A
  • No change?
  • Reduce?

If symptoms free for 3 months then consider step down

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6
Q

Complex treatment decisions - If not well controlled, this may be due to:

  • Not taking treatment
  • Not taking treatment correctly
  • Not asthma
  • None of the above

how would you manage each of the following above reasons for asthma not being well controlled?

A
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7
Q

Step up step down approach - what do you start on adn when do you review?

A
  • Started on low dose ICS - Severe may respond to minimal treatment
  • Review after 2mo:
  • No routine test to monitor progress (?)
  • No change easier than down
  • Need an inhaler holiday (Easter)
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8
Q

what are the classes of medication?

A
  • Short acting beta agonists (blue relieving medication)
  • Inhaled corticosteroids (ICS) (standard preventor)
  • Long acting beta agonists*
  • Leukotriene receptor antagonists*
  • Theophyllines*
  • Oral steroids (uncommonly given)

* “add ons”

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9
Q

BTS/SIGN guidelines have changed:

This is what is used to look like

  • 5 steps for 5-12 yrs
  • 4 steps for <5s
  • Step 3 was rather confusing

what do they look like now?

A

This is what is looks like now

Step up or down depending on symptoms

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10
Q

2016 BTS/SIGN guideline - what approach is used for children?

A
  • One figure for all children
  • ICS doses overlap with adults - Very low, Low, Medium, High
  • Acknowledges areas of uncertainty when ICS are not sufficient
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11
Q

Contrast with adults - what is different in children?

A
  • Max dose ICS 800 microg (<12 yo)
  • No oral B2 tablet
  • LTRA first line preventer in <5s
  • No LAMAs
  • Only two biologicals
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12
Q

Regular preventer (“Step 2*”) - when would oyu use it and what with?

A

When?

  • Diagnostic test
  • B2 agonists >two days a week (means poorly controlled) (blue inhaler)
  • symptomatic three times a week or more, or waking one night a week
  • exacerbations of asthma in the last two years

What with? - Start very low dose inhaled corticosteroids (or LTRA in <5s)

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13
Q

Inhaled corticosteroids - are they useful?

A
  • These are fab!
  • Very useful for diagnosis
  • Very effective (when taken)
  • Very safe (when prescribed correctly)
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14
Q

we tend to use low and middles does of ICS, why?

A

If go from low to middle dose you get a big increase in effect and small increase in side effects

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15
Q

whata re the Adverse effects - ICS?

A

Purple and orange are more potent

Oral steroids can cause hypertension and cataracts

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16
Q

Add on preventer – Long acting beta agonist

Only 2 things to remember! - what are they?

A
  • Do not use without ICS
  • Use as fixed dose inhaler

Blue in haler is a relief medication, these are long acting relief medications

Easier to take one inhaler with 2 medications in it

17
Q

Add on preventer – Leukotriene receptor antagonist

is it efefctive?

A
  • Montelukast only
  • Rule of thirds (1/3 have a big positive benefit form this medication, 1/3 bit of benefit, 1/3 no benefit)
  • Better adherence
  • Granules for reluctant toddlers
18
Q

Initial add on preventer (“Step 3*”) - what do you add?

A
  • Add on LABA or LTRA (BTS/SIGN)
  • Add on LABA but keep an open mind!
  • Additional add-on therapies
  • Increase ICS
  • LTRA
19
Q

how do you manage the last 2 steps?

A

Refer!

Specialist care at this stage

20
Q

Severe asthma - what is the cause and how should it be managed?

A
  • Experimental medicine
  • 50% psychological issues
  • >50% compliance issues
  • Question the diagnosis

•Minority with genuine severe disease

•Role of biologics unproven

21
Q

Asthma management - How should it be done?

A
  1. “With” and not “to”
  2. Recognise individuality
  3. Objective PFT
  4. Adherence measured
  5. Link Rx to 3 and 4
22
Q

Take home messages:

Got to get the diagnosis right first!

Childhood asthma is very steroid sensitive

Different approach to under/over 5s

MDIs useless without spacer

Stratified medicine is coming

A
23
Q

Delivery systems:

what are the two types?

A
  • MDI/spacer
  • Dry powder device

(Meter dose inhaler - doesn’t work on its own that much, adults may get some use)

24
Q

are spacers effective?

A

<5% lung deposition without spacer

≤20% lung deposition with spacer

The way a spacer works is that it has a valve here that means that the content only leaves the chamber when the patient breathes in

4xs as much drug into system

25
Q

how should a spacer be used to be more effective?

A
  • MDI/spacer = 4x MDI
  • Shake = 2x no shake (Shake inhaler between puffs)
  • Wash = 2 x no wash (Wash spacer monthly reduce static)

All this gives you a huge increase down compared to using a MDI on its own

26
Q

Deposition with infants

A

Lung deposition in a 3 year old child inhaling:

  1. With a not tightly fitting face mask (0.1%)
  2. Crying during inhalation (1%) (a lot of it has been swallowed and not a lot has went into the lungs)
  3. Quietly inhaling (8%)
27
Q

Dry powder devices - who can use them? and how should they be used?

A

Licensed in over 5s, under 8s cannot use them

Achieve 20% lung deposition

These don’t require any intrinsic propellant

they just use the person’s breathing in to get the medicine in

Licence in under 8 but most children under 8 cant use them, particularly if they have a Y chromosome

MDI space in under 8, dry powder device in girls between 8 and 11 and thereafter its MDIs all the way in secondary school

28
Q

Nebulisers:

•Not indicated for day-to-day use

MDI spacer vs nebuliser?

A
  • Quieter
  • Quicker
  • Valve mechanism
  • Don’t break down
  • Portable
  • Cheaper
29
Q

Other management:

what is the non-medicinal management of asthma?

A

Parents often ask doctors what they can do to improve their child’s asthma that doesn’t involve medication

HDM – house dust mite – impossible to reduce levels to levels where they do not trigger symptoms