Paediatrics: Respiratory, Allergy Flashcards
What are urticaria/hives?
Raised, itchy red rashes
What causes urticaria?
Allergies or idiopathic
How do you manage urticaria?
1) Antihistamines ± steroids
2) But rash often self-limiting within hours
When can urticaria be an emergency?
When it presents as part of anaphylaxis - where there is acute, multi-systems compromise as a result of exposure to an allergen
How does asthma present in children?
1) Cough
2) Breathlessness
3) Wheeze
4) Chest tightness
- History of recurrent episodes of symptoms and symptom variability which may be triggered by dust, smoke, exercise or animal hair
What are example triggers of asthma?
Dust, smoke, exercise or animal hair
What are other differential diagnoses in asthma?
1) Respiratory tract infections
2) Viral wheeze
3) Foreign body inhalation
4) Bronchiolitis
5) Allergic reactions
6) Anaphylaxis
What do you note on examination in an acute asthma exacerbation?
Widespread wheeze on auscultation of the chest
What % of children in the UK have asthma?
Almost 10%
What are risk factors for asthma?
1) FH of asthma
2) History of atopy (allergy/eczema)
How do you diagnose asthma?
1) Detailed history - to establish episodic nature of wheeze, breathlessness, cough and chest tightness
2) Serial expiratory peak flow readings - when symptomatic and asymptomatic as the airflow obstruction is reversible
3) If suspected high probability of asthma can start on a trial of SABA inhaler
4) Spirometry
5) Where cases are unclear - FeNO testing
What are the non-medication parts of chronic asthma management in children?
1) Personalised written asthma plan - regularly checked and updated
2) Use of a spacer is the preferred method of delivery for inhaled treatments > inhaler
What is the stepwise management of chronic asthma in children?
1) Inhaled SABA PRN ± monitored initiation of very low to low dose ICS
2) Add very low dose ICS OR LTRA if < 5 years
3) Add very low dose ICS AND LTRA if < 5 years OR LTRA/LABA if > 5 years
4) If no response to LABA - consider stopping LABA and increase ICS to low dose
5) If some benefit from LABA but inadequate - increase ICS to low dose
6) If benefit from LABA + low dose ICS but inadequate - consider trial of LTRA
7) Consider increase ICS to medium dose ICS
8) Addition of fourth drug e.g. theophylline
9) Refer patient for specialist care
10) Daily steroid tablet + maintain medium- dose ICS (consider other Tx to minimise use of steroid tablets)
Is a rescue pack including abx and oral steroids indicated in astham?
No - COPD
Which vaccine is recommended to all patients with asthma who are taken regular corticosteroid therapy incl. inhaled?
Influenza vaccine - IM/nasal spray (nasal spray CI in children with severe asthma who are taking regular steroids as it is a live attenuated vaccine)
Which vaccine is recommended to all patients with asthma who are taken regular corticosteroid therapy incl. inhaled?
Influenza vaccine - IM/nasal spray (nasal spray CI in children with severe asthma who are taking regular steroids as it is a live attenuated vaccine)
What type of hypersensitivity reaction causes anaphylaxis?
Type 1 - acute allergic reaction resulting in multi-systems compromise
What are causes of anaphylaxis?
1) Animals - insect stings, animal dander
2) Food - nut, peanuts, shellfish, fish, eggs, milk
3) Medication - abx, IV contrast, NSAIDs
What are the clinical features of anaphylaxis?
1) Airway - swollen lips/tongue, sneezing
2) Breathing - wheezing, SOB (low sats, high RR), stridor, sudden onset resp distress
3) Circulatory - tachycardia, hypotension/shock, angioedema (pale and clammy)
4) GI - abdo pain, D&V
5) Skin - urticaria, pruritis, flushed skin
What investigation can be done to confirm a diagnosis of anaphylaxis?
Serum levels of mast cell tryptase
What is the critical treatment of anaphylaxis?
IM adrenaline 1:1000
What is the general management of anaphylaxis?
1) Remove trigger if possible
2) Call for help early
3) Lie patient flat and raise legs
4) Administer adrenaline
When skills + equipment is available:
5) Manage airway and administer high flow oxygen
6) IV fluids if shocked
7) Administer 100mg slow IV hydrocortisone (not urgent)
8) Attach pt to monitoring
How long should patients with anaphylaxis be monitored for after initial presentation in case of a rebound episode?
6-12 hours
What should be given to newly diagnosed patients with anaphylaxis and their carers before being discharged?
1) Counselling on how to use adrenaline auto-injectors
2) Supply of 2 auto-injectors
3) Written advice
4) A referral to the local allergy service for follow-up
What is the treatment of anaphylaxis in children > 12 years and adults?
500 micrograms IM adrenaline (1:1000) - 0.5ml
What is an additional drug you would give in anaphylaxis?
5mg slow IV chlorphenamine (anti-histamine - Piriton)
What is the treatment of anaphylaxis in children aged 6-12 years?
300 micrograms IM adrenaline (1:1000) - 0.3ml
What is the treatment of anaphylaxis in children < 6 years?
150 micrograms IM adrenaline (1:1000) - 0.15ml
What is the treatment of anaphylaxis in children < 6 months?
100-150 micrograms IM adrenaline (1:1000) - 0.1-0.15ml
What action should be taken if an asthma patient is well maintained on an ICS + LABA?
Reduce the dose of ICS but maintain LABA at current doses
How much should changes in doses be limited to when changing asthma medication?
25-50% reduction at a time
What is an example of an ICS?
Budesonide, beclometasone
What is an example of a LABA?
Formoterol/Salmeterol
What type of hypersensitivity reaction is acute asthma?
Type 1 - like anaphylaxis and allergy - leads to bronchoconstriction (smooth muscle contraction), mucus plugging and bronchial oedema, IgE mediated
What are signs of acute severe asthma?
1) Respiratory distress (use of accessory muscles of respiration, breathlessness resulting in inability to complete sentences, tachypnoea with a RR ≥ 25 or > 30 in child over 5 years)
2) HR ≥ 110 (or > 125 in child over 5 years)
3) Peak expiratory flow rate 33-50% of predicted
What are life-threatening features of acute asthma in a child?
1) Peak exploratory flow rate is <33% predicted
2) Oxygen saturations <92%
3) Silent chest on auscultation
4) Weak or no respiratory effort
5) Hypotension
6) Exhaustion
7) Confusion/altered conscious level
What are important differentials in acute severe asthma?
1) Pneumothorax
2) Anaphylaxis
3) Inhalation of a foreign body
4) Cardiac arrhythmia
What is the stepwise approach for treating acute asthma in a child?
1) Maintain O2 sats between 94-98% with high flow O2 if necessary
2) Inhaled salbutamol
3) Nebulised salbutamol
4) Add nebulised ipratropium bromide
5) If O2 sats < 92% add magnesium sulphate
6) Add IV salbutamol if no response to inhaled therapy
7) If severe or life-threatening asthma not responsive to inhaled therapy add aminophylline
8) Contact senior if pt not responding to salbutamol or ipratropium
What should all patients with acute asthma receive?
Steroids - give IV if the patient is unable to take the dose orally
What is an example of a LTRA (leukotriene receptor antagonist)
Montelukast
When would you refer to resp paediatrician in asthma?
Children < 2 years or if there is persistent poor control with montelukast
