management of non-acute asthma in children

Question 1

is there a cure for asthma

Answer 1

no

only palliation

sometimes spontaneous resolution

Question 2

what is treatment of asthma based on

Answer 2

patient’s experience
- how is it affecting QOL (sleep, exercise, education etc)

take into account severity but focus is on patient

Question 3

what are the goals of asthma treatment

Answer 3

minimal symptoms during day and night
minimal need for reliever medication (<2 days/wk)
no attacks/exacerbations
no limitation of physical activity

normal lung function - FEV1 and/or PEF >80% predicted or better

Question 4

how to measure control of asthma - SANE

Answer 4

Short acting beta agonist use/wk (>2 days/wk?)

Absence from school/nursery

Nocturnal symptoms/wk (waking >1 night/wk?)

Exertional symptoms/wk

Question 5

decisions to make when managing asthma

Answer 5

are symptoms controlled

is treatment being taken

will this treatment change help

if well controlled: reduce treatment/no change?

• consider stepping down if completely symptom free for 3mths

Question 6

what to think about if asthma isn’t well controlled

Answer 6

not taking treatment

not taking treatment correctly

not asthma - stop asthma treatment

none of the above - increase treatment

Question 7

step up step down approach to ICS

Answer 7

start on low dose ICS - severe asthma may respond to minimal treatment

review after 2mths

• no change is easier than step down
• consider inhaler holiday to see if symptoms return (do it over easter as coughs and colds are less common so exacerbation is less likely)

Question 8

classes of medication for asthma

Answer 8

SABA - short acting beta agonists

ICS - inhaled corticosteroids

LABA - long acting beta agonists (add on)

LTRA - leukotriene receptor antagonists (add on)

theophyllines (add on)

oral steroids - not commonly used in paeds

Question 9

BTS/SIGN guideline for asthma management

Answer 9

step up step down approach

• treatment trial to confirm diagnosis
  
  • ICS doses overlap with adults

Question 10

differences between management of asthma in children and adults

Answer 10

max dose ICS 800mcg (<12y/o)

no oral B2 tablet

LTRA 1st line preventer in <5y/o

no LAMA

only 2 biologics

Question 11

when to use a regular preventer (step 2)

what do we use

Answer 11

• as part of a diagnostic test
• if using B2 agonist >2x/wk
• symptomatic ≥3x/wk or waking 1night/wk

start w/ very low dose ICS (or LRTA in <5s)

Question 12

what to remember about using LABA as an add on preventer

Answer 12

do not use w/o ICS

use as fixed dose inhaler

Question 13

initial add on preventers (step 3)

Answer 13

add on LABA or LTRA (BTS/SIGN)

add on LTRA (NICE)

increase ICS dose (GINA)

• ADD ON LABA BUT KEEP OPEN MIND (additional add-on therapies - increase ICS, LTRA)

Question 14

when to refer to a specialist

Answer 14

uncontrolled asthma requiring high dose therapy and continuous oral steroids

Question 15

severe asthma

Answer 15

50% psychological issues, >50% compliance issues

very small amount of people w/ genuine severe disease

remainder have troublesome asthma - behaviour around their condition is abnormal and might reflect on: attention seeking behaviour, underlying individual/familial psychological issue

Question 16

how to approach asthma management

Answer 16

1. what does the individual want to do (lifestyle factors and behaviours)
2. recognise individuality
3. objective PFT
4. adherence to treatment measured
5. link treatment to 3 and 4

Question 17

what are the 2 types of delivery systems for asthma medications

Answer 17

MDI/spacer

dry powder device

Question 18

use of spacers

Answer 18

<5% lung deposition w/o spacer

≤20% lung deposition w/ spacer

MDI + spacer = 4x MDI

Question 19

how to improve the efficacy of a spacer

Answer 19

shake inhaler between puffs - shake = 2x no shake

wash spacer monthly to reduce static - wash = 2x no wash

Question 20

deposition of inhaled drugs in infants

Answer 20

not tightly fitting face mask 0.1%

crying during inhalation 1%

quietly inhaling 8%

Question 21

what are these

when can they be used

lung deposition

Answer 21

dry powder devices

licensed in >5, <8 cannot use them

20% lung deposition

Question 22

nebulisers and why are they not commonly used

Answer 22

not indicated for day to day use

MDI spacer vs nebuliser:

• quieter, quicker
• valve mechanism
• don’t break down
• portable and cheaper

Question 23

other management of asthma - lifestyle and environment

Answer 23

• stop tobacco smoke exposure
• remove environmental triggers - pets, house dust mite
• diet - evidence is negative
• no evidence for altered humidity
• no evidence for weight reduction in improving asthma symptoms