Pediatric asthma Flashcards
How is diagnosis made in children age 1-5?
clinical diagnosis (history and physical)
HISTORY:
-recurrent episodes wheeze, cough, SOB, chest tightness (hyperactivity)
EXAM confirms wheezing that improves with SABA (reversibility)
absence of alternative explanation
Diagnosis with spirometry in children 6 and older:
what is spirometry finding that is diagnostic of asthma?
reduced FEV1/FVC of <80%
improvement of 12% in FEV1 after SABA/ICS
*normal spirometry does not exclude asthma
What do you do if normal spirometry and suggestive symptoms of asthma?
methacholine challenge
will show drop of >20% in FEV1 in response to methacholine
What are clinical features that increase probability of asthma in children?
- recurrent or severe episodes of wheeze (needing ER visit or steroids)
- worse at night
- with or without viral illness
- expiratory wheeze
- personal/family hx of asthma or atopy
- atopy on exam (swollen nasal turbinates, eczema, dark circles under eyes, linear nasal crease)
How often should asthma control and risk for exacerbation be assessed?
EVERY VISIT
How to assess asthma control?
mnemonic DARN
daytime asthma symptoms (>2/week)
any night time symptoms
reliever needed (>2/week)
activity limitations
DARN
(daytime, activity, reliever, night time)
Yes to 1-2 Q = partly controlled
Yes to 3+ = uncontrolled
What is the objective marker of airway obstruction?
How often should spirometry be done?
FEV1
(<60% = increased risk of exacerbation)
Q3-6 months
Controller medication for children 6 and under
-name generic and brand name
Fluticasone propionate aka FLOVENT
*approved for age 1 and older
step 2: 50 mcg BID
step 3: 100-125 mcg BID
Montelukast aka SINGULAIR
*approved for age 2 and older
4 mg daily
Controller medication for children 6 to 18
-name generic and brand name
-ciclesonide aka ALVESCO
step 2: 100 mcg daily
step 3: 200-400 mcg daily
-fluticasone propionate aka FLOVENT
step 2: 50-100 mcg BID
step 3: 125 mcg BID
-budesonide aka PULMICORT
step 2: 100-200 mcg BID
step 3: 200-400 mcg BID or 400 mcg OD
-montelukast aka SINGULAIR
5 mg if 6-14
10 mg if 15+
Controller ICS-LABA for 6-18
budesonide/formeterol aka SYMBICORT
- 100-200 mcg BID or 200-400 daily
- *only approved for 12 and older
fluticasone/salmeterol aka ADVAIR
100-125 mcg BID
**diskus approved for 4 and older
how are moderate to severe asthma exacerbations defined?
- need po steroids
- ER visit/hospitalization
- PRAM 7-12
choice of inhaler device:
- kids 2-4 years old
- kids 4-6 years old
- kids 6 and older
2-4 y.o: spacer and facemask
4-6 y.o.: spacer and mouthpiece
6 and older: spacer and mouthpiece OR dry powder inhaler
in yellow zone: what do you write for controller:
-maintain same dose of ICS as green zone
Children under age 4 should use _____ with MDI
patient teaching
mask + spacer
- shake puffer x 15 sec
- cover nose and mouth with mask
- press puffer, take 6-10 slow deep breaths
- repeat in 30 seconds if second dose needed
- rinse mouth
Children age 4-6 should use ____ with MDI
patient teaching
mouthpiece + spacer
-when able to seal around mouthpiece and breathe through mouth
- shake x 15 sec
- seal lips around mouthpiece
- child needs to breathe through mouth, not nose
- breathe out fully
- press puffer, take 6-10 slow deep breaths OR hold breath for 6-10 sec
- if whistling: breathing too quickly
- repeat in 30 seconds if second dose needed
- rinse mouth
Turbuhaler patient teaching
- never shake
- hold upright
- turn base in one direction, then back until you hear click
- mouthpiece between teeth, close lips
- tilt chin up
- breathe in quickly and deeply through mouth, REMOVE turbuhaler, breathe out
- repeat in 30 sec if repeated dose needed
- rinse mouth
Diskus patient teaching
- open cover until click
- slide lever until click
- breathe out
- close lips around mouthpiece
- breathe in quickly and deeply through mouth
- hold breath for 10 seconds
- remove diskus, breathe out
- rinse mouth
SABA dose counting
- need to manually track
- SABA MDIs have 200 doses
- no accurate way to know when inhaler is empty (inhalers will continue to dispense propellant and make a sound)
how often should asthma action plans be reviewed?
- twice a year
- within 3 months of medication change
- within 2 weeks of ER/hospital visit
Common asthma triggers
what should you counsel re: exercise specifically?
• Viral illness (most common) ○ Get flu vaccine! • Smoke • Cold air • Dust mites (pillow covers) • Animals (keep out of bedroom if not able to remove from home) • Pollens
Exercise: do not need to limit but should warm up)
What are the 5 components of PRAM
- suprasternal retractions
- scalene muscle contractions (palpable, not visible)
- air entry (absent = max 3 points)
- wheezing (audible without stethoscope or silent chest = max 3 points)
- O2 sat (<92% = max 2 points)
PRAM clinical score:
mild:
moderate:
severe:
impending resp failure :(
mild: 0-3
moderate: 4-7
severe: 8-12
Impending resp failure: regardless of score BUT presence of lethargy, cyanosis, decreasing resp effort, rising CO2
Asthma action plans
Green zone
- indications
- teaching
GREEN = well controlled
- No cough/wheeze
- Not missing school
- Parents not needing to miss work
- Using <2 doses of SABA/week
Take controller EVERY DAY
Asthma action plans
Yellow zone
- indications
- teaching
- Getting a cold
- Cough/wheeze/SOB esp at night or with playing/activity
TEACHING
○ Keep taking controller (dose does not increase)
○ Use reliever PRN q4h
SEEK CARE If SABA needed q4h OR not improving after 1 day
Asthma action plan
Red zone
- indication
- teaching
EMERGENCY
- Resp distress
- Reliever not lasting 4 hours
TEACHING
○ 911 or go to ER
Take 5 puffs of reliever q20 min on way to hospital
up to ____ % of kids will outgrow symptoms by age 6
50%
Risk factors associated with severe exacerbations (CTS guidelines)
mnemonic PPSS
- PREVIOUS severe asthma exacerbation
- POORLY controlled asthma
- overuse of SABA
- current SMOKING
Re-assessment of asthma control should be considered with following use of reliever:
> 2 doses/week
>2 canisters/year
Daily ICS
-will start to see improvement within ______ weeks
within 1-2 weeks of starting daily ICS
Before escalating treatment of poorly or partially controlled asthma, need to assess:
ATE-C
- adherence
- technique
- environment (triggers and occupation)
- comorbidities (eg GERD, sinusitis, anxiety)
How would you manage a child under 6 who is not controlled on medium dose ICS?
refer to asthma clinic
review adherence, technique, environment, comorbidities
How would you manage a child age 6-11 who is not controlled on medium dose ICS?
review adherence, technique, environment, comorbidities
start second controller
eg ICS-LABA (limited formulations aside from Advair diskus so really would refer to asthma clinic) or LTRA
How would you manage patients 12 and older who are not controlled despite adherence to low dose ICS?
review adherence, technique, environment, comorbidities
start daily ICS-LABA
Alternative: add LTRA or increase to medium ICS
How would you manage patients 12 and older on ICS-LABA with poor control or prone to exacerbation?
switch to budesonide/formeterol maintenance AND reliever (keep same dose of budesonide)
review adherence, technique, environment, comorbidities
What is the max daily dose of fluticasone propionate for:
kids age 1-4?
kids age 4-16?
1-4: 200 mcg/day
4-16: 400 mcg/day
PO steroids
when would they be included in written asthma action plan?
-not recommended for routine asthma action plan
UNLESS
recent severe exacerbation that did not respond to inhaled SABA
Asthma severity (CTS guidelines)
define
- very mild asthma
- mild asthma
- moderate asthma
- severe asthma
very mild: well controlled on PRN SABA
mild: well controlled on low dose ICS (or LTRA) and PRN SABA
or PRN bud/form
moderate: well controlled on low dose ICS + second controller AND PRN SABA
or
moderate dose ICS +/- second controller and PRN SABA
or
low-moderate dose bud/form and PRN bud/form
severe: high dose ICS and second controller OR systemic steroids for 50% of previous year to prevent it from being uncontrolled
Indications for referral to asthma specialist
- Uncertain diagnosis
- Kids not controlled on medium dose ICS with correct technique and adherence
- Suspected severe asthma
- Admission to ICU
- Need for allergy testing if suggestive clinical history
- Suspected work-related asthma
- ANY asthma hospitalization (all ages)
- 2 or more ED visits (all ages)
- 2 or more courses systemic steroids (kids)
Follow up
How would you manage if asthma is well controlled for 3-6 months with no severe exacerbations?
reduce med to minimum necessary dose to maintain asthma control
