Paediatrics: Respiratory, Allergy

Question 1

What are urticaria/hives?

Answer 1

Raised, itchy red rashes

Question 2

What causes urticaria?

Answer 2

Allergies or idiopathic

Question 3

How do you manage urticaria?

Answer 3

1) Antihistamines ± steroids
2) But rash often self-limiting within hours

Question 4

When can urticaria be an emergency?

Answer 4

When it presents as part of anaphylaxis - where there is acute, multi-systems compromise as a result of exposure to an allergen

Question 5

How does asthma present in children?

Answer 5

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

Question 6

What are example triggers of asthma?

Answer 6

Dust, smoke, exercise or animal hair

Question 7

What are other differential diagnoses in asthma?

Answer 7

1) Respiratory tract infections
2) Viral wheeze
3) Foreign body inhalation
4) Bronchiolitis
5) Allergic reactions
6) Anaphylaxis

Question 8

What do you note on examination in an acute asthma exacerbation?

Answer 8

Widespread wheeze on auscultation of the chest

Question 9

What % of children in the UK have asthma?

Answer 9

Almost 10%

Question 10

What are risk factors for asthma?

Answer 10

1) FH of asthma
2) History of atopy (allergy/eczema)

Question 11

How do you diagnose asthma?

Answer 11

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

Question 12

What are the non-medication parts of chronic asthma management in children?

Answer 12

1) Personalised written asthma plan - regularly checked and updated
2) Use of a spacer is the preferred method of delivery for inhaled treatments > inhaler

Question 13

What is the stepwise management of chronic asthma in children?

Answer 13

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)

Question 14

Is a rescue pack including abx and oral steroids indicated in astham?

Answer 14

No - COPD

Question 15

Which vaccine is recommended to all patients with asthma who are taken regular corticosteroid therapy incl. inhaled?

Answer 15

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)

Question 16

Which vaccine is recommended to all patients with asthma who are taken regular corticosteroid therapy incl. inhaled?

Answer 16

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)

Question 17

What type of hypersensitivity reaction causes anaphylaxis?

Answer 17

Type 1 - acute allergic reaction resulting in multi-systems compromise

Question 18

What are causes of anaphylaxis?

Answer 18

1) Animals - insect stings, animal dander
2) Food - nut, peanuts, shellfish, fish, eggs, milk
3) Medication - abx, IV contrast, NSAIDs

Question 19

What are the clinical features of anaphylaxis?

Answer 19

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

Question 20

What investigation can be done to confirm a diagnosis of anaphylaxis?

Answer 20

Serum levels of mast cell tryptase

Question 21

What is the critical treatment of anaphylaxis?

Answer 21

IM adrenaline 1:1000

Question 22

What is the general management of anaphylaxis?

Answer 22

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

Question 23

How long should patients with anaphylaxis be monitored for after initial presentation in case of a rebound episode?

Answer 23

6-12 hours

Question 24

What should be given to newly diagnosed patients with anaphylaxis and their carers before being discharged?

Answer 24

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

Question 25

What is the treatment of anaphylaxis in children > 12 years and adults?

Answer 25

500 micrograms IM adrenaline (1:1000) - 0.5ml

Question 26

What is an additional drug you would give in anaphylaxis?

Answer 26

5mg slow IV chlorphenamine (anti-histamine - Piriton)

Question 27

What is the treatment of anaphylaxis in children aged 6-12 years?

Answer 27

300 micrograms IM adrenaline (1:1000) - 0.3ml

Question 28

What is the treatment of anaphylaxis in children < 6 years?

Answer 28

150 micrograms IM adrenaline (1:1000) - 0.15ml

Question 29

What is the treatment of anaphylaxis in children < 6 months?

Answer 29

100-150 micrograms IM adrenaline (1:1000) - 0.1-0.15ml

Question 30

What action should be taken if an asthma patient is well maintained on an ICS + LABA?

Answer 30

Reduce the dose of ICS but maintain LABA at current doses

Question 31

How much should changes in doses be limited to when changing asthma medication?

Answer 31

25-50% reduction at a time

Question 32

What is an example of an ICS?

Answer 32

Budesonide, beclometasone

Question 33

What is an example of a LABA?

Answer 33

Formoterol/Salmeterol

Question 34

What type of hypersensitivity reaction is acute asthma?

Answer 34

Type 1 - like anaphylaxis and allergy - leads to bronchoconstriction (smooth muscle contraction), mucus plugging and bronchial oedema, IgE mediated

Question 35

What are signs of acute severe asthma?

Answer 35

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

Question 36

What are life-threatening features of acute asthma in a child?

Answer 36

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

Question 37

What are important differentials in acute severe asthma?

Answer 37

1) Pneumothorax
2) Anaphylaxis
3) Inhalation of a foreign body
4) Cardiac arrhythmia

Question 38

What is the stepwise approach for treating acute asthma in a child?

Answer 38

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

Question 39

What should all patients with acute asthma receive?

Answer 39

Steroids - give IV if the patient is unable to take the dose orally

Question 40

What is an example of a LTRA (leukotriene receptor antagonist)

Answer 40

Montelukast

Question 41

When would you refer to resp paediatrician in asthma?

Answer 41

Children < 2 years or if there is persistent poor control with montelukast