Management of Asthma in Children Non-Acute Flashcards
Medical treatment of asthma - is there a cure?
- There is no cure for asthma, only palliation or spontaneous resolution
- BTS/SIGN (UK) and GINA and NICE (UK)
what are the goals of treatment?
- “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)
How do you to measure control?
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
Complex treatment decisions in asthma
what quesitons should you ask yourself?
- Are symptoms controlled? (Are they really??)
- Is treatment being taken? (Is it really??)
- Will this treatment change help? (Will it really??)
Complex treatment decisions:
if well controlled, what should you do?
- No change?
- Reduce?
If symptoms free for 3 months then consider step down
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?
Step up step down approach - what do you start on adn when do you review?
- 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)
what are the classes of medication?
- 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”
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?
This is what is looks like now
Step up or down depending on symptoms
2016 BTS/SIGN guideline - what approach is used for children?
- One figure for all children
- ICS doses overlap with adults - Very low, Low, Medium, High
- Acknowledges areas of uncertainty when ICS are not sufficient
Contrast with adults - what is different in children?
- Max dose ICS 800 microg (<12 yo)
- No oral B2 tablet
- LTRA first line preventer in <5s
- No LAMAs
- Only two biologicals
Regular preventer (“Step 2*”) - when would oyu use it and what with?
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)
Inhaled corticosteroids - are they useful?
- These are fab!
- Very useful for diagnosis
- Very effective (when taken)
- Very safe (when prescribed correctly)
we tend to use low and middles does of ICS, why?
If go from low to middle dose you get a big increase in effect and small increase in side effects
whata re the Adverse effects - ICS?
Purple and orange are more potent
Oral steroids can cause hypertension and cataracts
Add on preventer – Long acting beta agonist
Only 2 things to remember! - what are they?
- 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
Add on preventer – Leukotriene receptor antagonist
is it efefctive?
- 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
Initial add on preventer (“Step 3*”) - what do you add?
- Add on LABA or LTRA (BTS/SIGN)
- Add on LABA but keep an open mind!
- Additional add-on therapies
- Increase ICS
- LTRA
how do you manage the last 2 steps?
Refer!
Specialist care at this stage
Severe asthma - what is the cause and how should it be managed?
- Experimental medicine
- 50% psychological issues
- >50% compliance issues
- Question the diagnosis
•Minority with genuine severe disease
•Role of biologics unproven
Asthma management - How should it be done?
- “With” and not “to”
- Recognise individuality
- Objective PFT
- Adherence measured
- Link Rx to 3 and 4
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
Delivery systems:
what are the two types?
- MDI/spacer
- Dry powder device
(Meter dose inhaler - doesn’t work on its own that much, adults may get some use)
are spacers effective?
<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
how should a spacer be used to be more effective?
- 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
Deposition with infants
Lung deposition in a 3 year old child inhaling:
- With a not tightly fitting face mask (0.1%)
- Crying during inhalation (1%) (a lot of it has been swallowed and not a lot has went into the lungs)
- Quietly inhaling (8%)
Dry powder devices - who can use them? and how should they be used?
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
Nebulisers:
•Not indicated for day-to-day use
MDI spacer vs nebuliser?
- Quieter
- Quicker
- Valve mechanism
- Don’t break down
- Portable
- Cheaper
Other management:
what is the non-medicinal management of asthma?
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
