paediatric viral wheeze and asthma Flashcards
comparing moderate, severe and life-threatening asthma attacks in children:
how is the SpO2 affected
moderate >92%
severe- <92%
life-threatening- <92%
comparing moderate, severe and life-threatening asthma attacks in children:
how is the PEF affected
moderate >50% best or predicted
severe- 33-50% best or predicted
life threatening- <33% best or predicted
point about presenation of moderate asthma attacks
no features of severe attacks
in severe asthma attacks in children:
how is the presentation 2
severe- too breathless to talk or feed
use of accessory neck muscles
in life-threatening asthma attacks in children:
how is the presenation 5
silent chest
poor repsiratory effort
agitation
altered consciousness
cyanosis
in severe asthma attacks in children:
heart rate in 1-5 yo and >5 yo
1-5 yo - >140
5>yo - >125
in severe asthma attacks in children:
respiratory rate in 1-5yo and >5 yo
1-5yo >40
> 5yo >30
mild to moderate asthma attack management 2
beta-2 agnoist via spacer
-if <3 yo use close fitting mask
1 puff every 30-60 secs up to max 10 puffs
symptoms not controlled-> repeat beta2-agnoist and refer to hospital
stroids
-oral pred 3-5days
2-5yo 20mg OD
>5 yo 30-40mg OD
managment of severe /life threatening asthma attack
use mild/moderate managemnt
+
ipratropium bromide
+
nebulised magneiusm sulphate- specialist
+
Iv hydrocort
+
IV salbutamol
+
IV aminophyliine
presenation of a child suggesting asthma diagnosis 8
episodic symptoms w intermittent exacerabtions
diurinal variability
-worse at night and early morning
dry cough w wheeze and SOB
typical triggers
atopic FHx
atopic personal Hx
bilateral wheeze on asculatation
symptoms imporve w bronchodilator
presenation indicating a diagnoisis OTHER than asthma 5
wheeze only related to coughs and colds (MORE SUGGESTIVE OF VIRAL INDUCED WHEEZE)
isolated or productive cough
normal investiagtions
no response to treatment
unilateral wheeze-> focal lesion,inhaled foregin body or infection
typical asthma triggers 5
dust
animals
cold air
exercise
smoke
food alergens (peanuts, shellfish or eggs)
age of diagnoiss of asthma in children
not until they are at least 2 to 3 years old
investiagtions for asthma diangosis 4
spirometry with reveristybility testing
-only in children >5yo
direct bronchial challenge test w histamine or methacholine
fractional exhaled nitric oxide (FeNO)
peak flow variability
-diary of peak flow measurements severeal times a day for 2-4 weeks
prinicples of asthma managemnt in children 5
start at most apporpriate step for severeity of syx
review at regular intervals
step up and down ladder based on syx
aim to achieeve no syx or exacerabitons on lwoest dose and no of treatments
always check inhaler technqiue and adherence at each review
medical therapy for asthma in under 5 yo
1st line 1
SABA
medical therapy for asthma in under 5 yo
2nd line 2
SABA
+
low dose corticosteroid inhaler or leukotriene atnagonist (ie oral montelukast)
medical therapy for asthma in under 5 yo
3rd line
SABA
+
low dose corticosteroid inhaler
+
leukotriene atnagonist (ie oral montelukast)
medical therapy for asthma under 5yo
fourth line 1
rrefer to specalist
medical therapy for asthma aged 5-12 yo
1st line
SABA
medical therapy for asthma aged 5-12 yo
second line 2
SABA
low dose coritosteroid inhaler
medical therapy for asthma aged 5-12 yo
third line 3
saba
low dose cortico inhaler
LABA(salmeterol)
-only continue if patient has good response
medical therapy for asthma aged 5-12 yo
fourth line 4
saba
MEDIUM dose cortico inhaler
LABA(salmeterol)
-only continue if patient has good response
consider adding:
-oral leukotriene receptor antagonist (montelukast)
-oral theophylline
medical therapy for asthma aged 5-12 yo
fifth line 4
saba
HIGH dose cortico inhaler
LABA(salmeterol)
-only continue if patient has good response
consider adding:
-oral leukotriene receptor antagonist (montelukast)
-oral theophylline
medical therapy for asthma aged 5-12 yo
sixth line 4
refer specalist
medical therapy for asthma aged >12 yo
first line
SABA
medical therapy for asthma aged 5-12 yo
seocnd line 2
SABA
low dose corticosteriod inhaler
medical therapy for asthma aged >12 yo
third line
saba
low dose cortico inhaler
LABA(salmeterol)
-only continue if patient has good response
medical therapy for asthma aged >12 yo
fourth line 4
saba
MEDIUM dose cortico inhaler
LABA(salmeterol)
-only continue if patient has good response
consider adding:
-oral leukotriene receptor antagonist (montelukast)
-oral theophylline
-inhlaed LAMA (tiotropium)
medical therapy for asthma aged >12 yo
fourth line 4
saba
HIGH dose cortico inhaler
LABA(salmeterol)
-only continue if patient has good response
consider adding:
-oral leukotriene receptor antagonist (montelukast)
-oral theophylline
-inhlaed LAMA (tiotropium)
-ORAL BETA AGONIST
-REFER TO SPECALIST
important point regarding use of inhalred corticosteroids in children
parents can be worried that regular steroids can slow growth
growth in children and inhaled corticosetoid use
there is evidence that it slightly reduced growth
-reduction is up to 1cm when used long term (for more than 12 months)
-effects are dose-dependent
-less of a problem with smaller doses
It is worth putting this in context for the parent by explaining that these are effective medications that work to prevent poorly controlled asthma and asthma attacks that could lead to higher doses of oral steroids being given. Poorly controlled asthma can lead to a more significant impact on growth and development. The child will also have regular asthma reviews to ensure they are growing well and on the minimal dose required to effectively control symptoms.
inhaler technique without a spacer
Remove the cap
Shake the inhaler (depending on the type)
Sit or stand up straight
Lift the chin slightly
Fully exhale
Make a tight seal around the inhaler between the lips
Take a steady breath in whilst pressing the canister
Continue breathing for 3 – 4 seconds after pressing the canister
Hold the breath for 10 seconds or as long as comfortably possible
Wait 30 seconds before giving a further dose
Rinse the mouth after using a steroid inhaler
inhaler technique with a spacer
Assemble the spacer
Shake the inhaler (depending on the type)
Attach the inhaler to the correct end
Sit or stand up straight
Lift the chin slightly
Make a seal around the spacer mouthpiece or place the mask over the face
Spray the dose into the spacer
Take steady breaths in and out 5 times until the mist is fully inhaled
define a viral induced wheeze
acute wheezy illness cuased by a viral infection
basic pathophys of viral induced wheeze
small children (under 3 yo) have small airways-> can encouter a virus (usually RSV or rhinovirus)-> develop small amount of inflammatino and oedema
air flowing through narrow airways causes the wheeze and the restricted ventialation leads to respiratory distress
types of viruses causing viral induced wheeze-MOST COMMON (2)
RSV
RHinovirus
association to viral induced wheeze (1)
family hisotry
-alwasy enquire
factors of a viral induced wheeze that differentiate it from asthma 3
before 3yo
no atopic history
only occurs during viral infections
triggers of asthma compared to viral induced wheeze 5
whilst asthma can be triggered by viral or baterial infections
-there are other triggers:
-exercise
-cold weather
-dust
-strong emotions
presenation of viral induced wheeze
symptoms- 1
signs -2
SOB
signs of respiratory distress
expiratory wheeze throughout chest
focal wheeze in viral induced wheeze or asthma?
NO
-these do not cause a focal wheeze so be wary anf investigate further for foreign body or tumour
management of viral induced wheeze?
same as acute asthma
moderate:
Nebulised beta-2 agonists (i.e. salbutamol 5mg repeated as often as required)
Nebulised ipratropium bromide
Steroids. Oral prednisolone or IV hydrocortisone. These are continued for 5 days
Antibiotics if there is convincing evidence of bacterial infection
Severe:
Oxygen if required to maintain sats 94-98%
Aminophylline infusion
Consider IV salbutamol
Life threatening:
IV magnesium sulphate infusion
Admission to HDU / ICU
Intubation in worst cases – however this decision should be made early because it is very difficult to intubate with severe bronchoconstriction
ABGs in asthma and viral induced wheeze
respiratory alkalosis
-as tachypnoea -> drop in CO2
noraml pCO2 or hypoxia in acute viral induced wheeze or asthma?
CONCERNING
-indicates they are tiring and is a feature of life threatening asthma
respiratory acidosis in asthma or viral induced wheeze?
VERY BAD SIGN
-due to high CO2
how to monitor response to treatment in acute asthma or viral induced wheeze 5
resp rate
resp effort
peak flow
O2 sats
chest auscultation
during an acute asthma attack or viral induced wheeze, when the patient is given salbutamol what needs to be monitored (2) and why
potatisum - can be lowered
heart rate- can cause tachy
follow up after asthma attack 2
give them ‘asthma action plan’
-provdes clear plan for everything nthey need to know about their ashtma in one place
-consider prescribing rescue pack (steroids) if they have another exacerabtion
when should patients be referred to respiratroy specialist after asthma attacks
after 2 attacks in 12 months
