Paediatric Respiratory Flashcards
What is the prevalence of asthma in the paediatric population?
Around 10%
What should be asked in the history of a child to try and make a diagnosis of asthma?
Recurrent symptoms: (wheeze, cough, SOB, chest tightness) Triggers: (URTI, allergens, exercise) Cough after exercise or during sleep Daily or seasonal variation History of atopy FHx of atopy
What positive findings may examination show in a child with asthma?
Barrell-shaped chest
Hyperinflation -> hyperresonance
Wheeze and prolonged expiratory phase of respiration
Although CXR is rarely useful in a child with asthma, what might it show?
Hyperinflation (flattened hemidiaphragm and increased anterior rib spacing) Peribronchial cuffing (https://test3.teachingmedicine.com/tutorial/CHF/Peribronchial_cuffing)
PEFR can be useful in assessing for asthma, at what level below normal would it be considered a positive finding?
> 20%
FEV1/FVC is a positive findings in asthma at what level below normal?
<70% of lower limit for age and height
In asthma what shape would the expiratory flow-volume curve be expected to be?
Concave, scooped shape
https://www.researchgate.net/figure/Flow-volume-curve-of-a-child-with-asthma-showing-the-characteristic-concave-expiratory_fig2_9014150
What levels dictate a positive response to bronchodilators in spirometry
> 12% increase in FEV1 or PEFR
FeNO is +ve in ages 4-16 at what level?
> 35ppb
Other than spirometry and CXR what other tests may prove useful in a diagnosis of asthma?
Allergen testing (serum or skin) Blood eosinophil count
What percentage of variability of PEFR over 30 days is indicative of asthma?
> 20%
What is the 1st line treatment for asthma in children?
PRN SABA (salbutamol) Trigger avoidance Patient/carer education Create an asthma action plan Smoking avoidance
What is the 2nd step treatment in asthma?
Low dose inhaled corticosteroid
+ SABA
What alternatives to corticosteroid can be given at stage 2 in the asthma treatment plan for 0-4 year olds?
Montelukast (0-4)
+ SABA
What alternatives to corticosteroid can be given at stage 2 in the asthma treatment plan for 5-11 year olds?
Leukotriene receptor antagonist (LRA) - (Montelukast/zafirlukast) OR Sodium cromoglicate OR Nedocromil OR Theophylline
AND
SABA
What alternatives to corticosteroid can be given at stage 2 in the asthma treatment plan for >=12 year olds?
LRA OR Sodium chromoglicate OR Nedocromil OR Theophylline
AND
SABA
What is stage 3 treatment in asthma?
Medium-dose inhaled corticosteroid
+ SABA
What alternatives to standard plan corticosteroid can be given at stage 3 in the asthma treatment plan for 5-11 year olds?
Low dose inhaled corticosteroid
AND
LABA (salmeterol) OR Theophylline OR LRA
AND
SABA
What alternatives to standard plan corticosteroid can be given at stage 3 in the asthma treatment plan for >=12 year olds?
Low dose corticosteroid
AND
LABA OR LRA OR Theophylline
AND
SABA
What is the stage 4 treatment for asthma for 0-4 year olds?
Medium-dose inhaled corticosteroid AND SABA AND Monteluakst
What is the stage 4 treatment for asthma for >=5 year olds?
Medium dose inhaled corticosteroids
AND
LABA OR LRA OR Theophylline
AND
SABA
What is the stage 5 treatment for asthma for 0-4 year olds?
High dose inhaled corticosteroid AND Montelukast AND SABA
What is the stage 5 treatment for asthma for 5-11 year olds?
High-dose inhaled corticosteroids
AND
LABA OR LRA OR Theophylline
AND
SABA
+/- immunomodulator (omalizumab)
What is the stage 6 treatment for asthma for 0-4 year olds?
High dose inhaled corticosteroid
AND
LABA
OR
Montelukast
AND
Oral corticosteroid
What is the stage 6 treatment for asthma for 5-11 year olds?
High-dose inhaled corticosteroids
AND
LABA OR LRA OR Theophylline
AND
Oral corticosteroid
AND
SABA
+/- immunomodulator (omalizumab)
What is the stage 5 treatment for asthma for >=12 year olds?
High-dose inhaled corticosteroids
AND
LABA OR LRA OR Theophylline
AND
Oral corticosteroid
AND
SABA
+/- tiotropium
+/- immunomodulator (omalizumab)
What is the stage 6 treatment for asthma for >=12year olds?
High-dose inhaled corticosteroids
AND
LABA OR LRA OR Theophylline
AND
SABA
+/- tiotropium
+/- immunomodulator (omalizumab)
What are the 2 types of preschool wheeze?
Episodic viral wheeze (commonest)
Multi-trigger wheeze (resembles asthma)
What are the risk factors for preschool wheeze?
Tobacco smoke exposure
Prematurity
IUGR
Exposure to viruses, bacteria and allergens
What is the treatment plan for preschool wheeze?
Tobacco smoke/allergen avoidance SABA trial PO corticosteroids if hospitalised Trial of inhaled corticosteroids if persistent Trial of leukotriene if persistent still
What are some common comorbidities for adolescent asthma?
Anxiety disorder
Major depression
Panic attacks
What are the side affects of steroid use in asthma?
Mainly with prolonger oral or high-dose steroids: Impaired growth Adrenal suppression Oral candidiasis Altered bone metabolism
What are the side effects of theophylline use in asthma?
Vomiting Sleep disturbance Headaches Poor concentration Arrythmias
What characteristics does status asthmaticus have?
SpO2 <90%
PEFR <33%
Silent chest/poor resp effort
What are end stage signs in status asthmaticus?
Raised PCO2/PaCO2
Hypotension
Exhaustion
What is the treatment for life-threatening status asthmaticus?
IV bronchodilators
Anaesthetist review
How does a severe asthma attack present?
PEFR 33-50%
Speaking in short sentances
What is stage 1 in treatment of severe asthma attack?
Inhaled bronchodilator
10x puffs salbutamol via MDI and spacer
OR
2.5-5mg nebulized
What is stage 2 in treatment of severe asthma attack?
Ipratropium bromide
250mcg nebulised and mixed with salbutamol if no response to stage 1
What is stage 3 in treatment of severe asthma attack?
Magnesium sulphate
250mcg can be added to ipratropium and salbutamol nebs in 1st hour for acute severe onset asthma
What is stage 4 in treatment of severe asthma attack?
Steroids
Give oral steroids early (pred)
If already on maintenance dose give 2mg/kg upto max 60mg
If life-threatening consider IV hydrocortisone
What is stage 5 in treatment of severe asthma attack?
IV magnesium sulphate
40mg/kg for children who respond poorly to initial treatment
What is stage 6 in treatment of severe asthma attack?
IV salbutamol
Consider early bolus in life-threatening cases
(15mcg/kg over 10 mins as bolus, then infusion (1mcg/kg/min (max 20mcg/kg)))
Monitor for toxicity (lactic acidosis, jitteriness, N&V, hypokalaemia)
What is stage 7 in treatment of severe asthma attack?
IV aminophylline
If unresponsive to bronchodilators and steroids
5mg/kg IV loading dose followed by infusion
Monitor for toxicity (headaches, gastric irritation, arrthymias)
Use continuous cardiac monitoring
Sample plasma theophylline levels every 12 hours
When is it safe to discharge a patient who has had an asthma exacerbation?
SpO2 >94% in air
3-4hourly inhaled bronchodilator therapy
Follow-up within 2 days in community
