Paediatric Respiratory Flashcards by Ailsa Morris

What is the prevalence of asthma in the paediatric population?

Around 10%

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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

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What positive findings may examination show in a child with asthma?

Barrell-shaped chest
Hyperinflation -> hyperresonance
Wheeze and prolonged expiratory phase of respiration

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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)

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PEFR can be useful in assessing for asthma, at what level below normal would it be considered a positive finding?

> 20%

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FEV1/FVC is a positive findings in asthma at what level below normal?

<70% of lower limit for age and height

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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

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What levels dictate a positive response to bronchodilators in spirometry

> 12% increase in FEV1 or PEFR

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FeNO is +ve in ages 4-16 at what level?

> 35ppb

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Other than spirometry and CXR what other tests may prove useful in a diagnosis of asthma?

Allergen testing (serum or skin)
Blood eosinophil count

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What percentage of variability of PEFR over 30 days is indicative of asthma?

> 20%

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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

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What is the 2nd step treatment in asthma?

Low dose inhaled corticosteroid

+ SABA

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What alternatives to corticosteroid can be given at stage 2 in the asthma treatment plan for 0-4 year olds?

Montelukast (0-4)

+ SABA

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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

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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

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What is stage 3 treatment in asthma?

Medium-dose inhaled corticosteroid

+ SABA

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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

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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