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Child Health > Paediatric Resp Medicine - Asthma > Flashcards

Paediatric Resp Medicine - Asthma Flashcards

1
Q

What is the basic pathophysiology of asthma?

A

Mast cells are activated
Mast cell degranulation
Release of inflammatory mediators, histamine and prostaglandins

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2
Q

What does release of histamine cause in the airways?

A

Smooth muscle contraction
Increased secretions
Increased vascular permeability

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3
Q

What is asthma?

A

A chronic reversible inflammatory disorder of the airways associated with airflow obstruction in response to various stimuli

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4
Q

What risk factors are associated with asthma?

A

Family history or atopy (hay fever, eczema)
Male sex
Parental smoking

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5
Q

What is the late phase reaction with regards to asthma?

A

Occur after initial attack

Eosinophil accumulation cause sustained inflammation

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6
Q

Who does late phase reaction tend to affect more and how is it treated?

A

Poorly controlled asthmatics

Treated with steroids

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7
Q

What environmental factors can precipitate an asthma attack?

A

Cold and exercise

Atmospheric pollution

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8
Q

Why does cold and exercise trigger asthma?

A

Dry out mucosa to make it hyperosmolar which causes mast cells to release cytokines

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9
Q

What can be protective against asthma attacks?

A

Fruit and veg - antioxidants

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10
Q

What symptoms are classical of asthma?

A

Wheeze
Short of Breath
Chronic cough
Nocturnal symptoms

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11
Q

What 3 changes happen in asthma which is referred to as “long term remodelling” of the airways?

A

Bronchial basement membrane thicken

Ciliated columnar epithelium replaced with mucus producing cells

Smooth muscle hypertrophy

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12
Q

What patterns of asthma are seen in children?

A

Infrequent episodic
Frequent episodic
Persistent episodic

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13
Q

How do children with infrequent episodic asthma present?

A

Normal lung function and examination

Attack triggered by viral URTI’s

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14
Q

How are children with infrequent episodic asthma managed? What is the prognosis?

A

Intermittent bronchodilators
Short course of oral steroids for severe exacerbations

40% remain symptomatic in adulthood

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15
Q

How do children with frequent episodic asthma present?

A

Abnormal lung function when symptomatic

Severe exacerbations but mild interval symptoms - esp. if exercise induced

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16
Q

How are children with frequent episodic asthma managed? What is the prognosis?

A

Inhaled steroids +- add on therapy

70% remain symptomatic in adulthood

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17
Q

How do children with persistent episodic asthma present?

A

Daily symptoms and use of bronchodilators

Abnormal lung function

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18
Q

How are children with persistent episodic asthma managed and what is the prognosis?

A

Inhaled steroids + add on therapy

90% remain symptomatic in adulthood

19
Q

When auscultating a child with asthma between attacks, what are you likely to hear?

A

Normal lung function

20
Q

What thoracic deformity is associated with chronic asthma?

A

Hyperexpansion
Pectus carinatum (pigeon chest)
Harrison sulcus

21
Q

What investigations would you do if you suspect asthma? What result would indicate asthma?

A

1 Spirometry - FEV1/FVC <70%
2 Bronchodilator reversibility - FEV1 improve >12%
3 Fractional exhaled - NO >35ppb
4 Peak flow monitoring for 2-4 weeks - >20% variability

Move down if previous investigation uncertain

CXR can be useful

22
Q

What differential diagnoses would you consider for asthma?

A 
CF
GORD
Central airways disease
Laryngeal problems
Inhaled foreign body
Postviral wheeze
23
Q

At what age are investigations carried out?

A

Child >5yo

24
Q

How common is asthma in children?

A

1 in 11 children in the UK

25
Q

What drugs can precipitate an asthma attack?

A

NSAID’s - shunt arachidonic acid pathway towards producing leukotrienes - toxic to epithelium

Beta blockers - prevent bronchodilatory effect of catecholamines on airways

26
Q

What features do you want to ask about in an asthma history?

A 
Age of onset of symptoms
Frequency of symptoms
Severity of symptoms
Previous treatment
Hospital attendance?
Food allergies?
Triggers?
Disease history
Family/PMH - atopy
27
Q

What should you look for on examination of a child with asthma?

A

Clubbing - more suggestive of CF or bronchiectasis
Chest shape + symmetry
Breath sounds
Crepitations
Wheeze
Throat assessment - tonsillar enlargement

28
Q

What is the aim of asthma treatment?

A 
No daytime symptoms or waking at night
No exacerbations
No need for reliever
No limitations on activity
Normal lung function
Minimal side effects
29
Q

What is important when trying to meet the aims of asthma treatment?

A 
Patient education
Establish minimum effective dose
Age appropriate delivery device
Accurate diagnosis and assessment of severity - review
Avoid triggers
30
Q

How is asthma managed in under 5’s?

A
  1. Start a short-acting beta-2 agonist inhaler (e.g. salbutamol) as required
  2. Add a low dose corticosteroid inhaler or a leukotriene antagonist (i.e. oral montelukast)
  3. Add the other option from step 2.
  4. Refer to a specialist.
31
Q

When should maintenance dose be increased?

A

> 3 days a week of symptoms

1 night a week of waking

32
Q

When should maintenance be decreased?

A

3 months controlled

33
Q

How is asthma managed for 5-12 yo?

A 
1. Start a short-acting beta-2 agonist inhaler (e.g. salbutamol) as required
2. Add a regular low dose corticosteroid inhaler
3. Add a long-acting beta-2 agonist inhaler (e.g. salmeterol). Continue salmeterol only if the patient has a good response.
4. Titrate up the corticosteroid inhaler to a medium dose. Consider adding:
Oral leukotriene receptor antagonist (e.g. montelukast)
Oral theophylline
5. Increase the dose of the inhaled corticosteroid to a high dose.
6. Referral to a specialist. They may require daily oral steroids.
34
Q

With what should aerosol inhaler devices be used?

A

With a spacer device

35
Q

What must you do when reviewing a child’s asthma control?

A

Check compliance

Check inhaler technique

36
Q

What is the relative strength of fluticasone compared to beclometasone?

A

Fluticasone is twice as potent

37
Q

How can asthma attacks be categorised?

A

Mild
Moderate
Severe
Life threatening

38
Q

With what obs would a patient having a mild/moderate asthma attack present?

A 
Sats >92%
RR age 2-5: <40
RR age >5: <30
HR age 2-5: <140
HR age >5: <125
Able to complete sentences
Wheeze
PEFR >75% (mild) 50-75% (moderate)
39
Q

How would a child having a severe asthma attack present

A 
Sats <92%
RR age 2-5: >40
RR age >5: >30
HR age 2-5: >140
HR age >5: >125
No sentences
No wheeze
PEFR 35-50%
40
Q

How would a child having a life threatening asthma attack present?

A 
Cyanosed
No respiratory effort
Confused
Hypotensive 
Comatosed
Silent chest
PEFR <35%
41
Q

How are asthma attacks managed immediately?

A

Sats <94% - high flow O2 to keep sats between 94-98%

Nebulised salbutamol back to back with ipratropium bromide nebuliser

Oral prednisolone

ABG, record PEF, check sats, CXR - exclude pneumothorax

42
Q

What is second line management for an asthma attack?

A 
IV Salbutamol (with specialist input)
IV Magnesium sulphate
IV salbutamol
IV aminophyline
43
Q

What is the criteria for safe discharge following an asthma attack?

A 
Bronchodilators 4 hourly
Sats >94% in air
Inhaler technique assessed
Written asthma management plan explained to parents
GP review within 2 days

Child Health (30 decks)

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