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Asthma > Pediatric asthma > Flashcards

Pediatric asthma Flashcards

1
Q

How is diagnosis made in children age 1-5?

A

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

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2
Q

Diagnosis with spirometry in children 6 and older:

what is spirometry finding that is diagnostic of asthma?

A

reduced FEV1/FVC of <80%
improvement of 12% in FEV1 after SABA/ICS

*normal spirometry does not exclude asthma

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3
Q

What do you do if normal spirometry and suggestive symptoms of asthma?

A

methacholine challenge

will show drop of >20% in FEV1 in response to methacholine

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4
Q

What are clinical features that increase probability of asthma in children?

A
  • 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)
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5
Q

How often should asthma control and risk for exacerbation be assessed?

A

EVERY VISIT

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6
Q

How to assess asthma control?

mnemonic DARN

A

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

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7
Q

What is the objective marker of airway obstruction?

How often should spirometry be done?

A

FEV1
(<60% = increased risk of exacerbation)

Q3-6 months

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8
Q

Controller medication for children 6 and under

-name generic and brand name

A

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

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9
Q

Controller medication for children 6 to 18

-name generic and brand name

A

-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+

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10
Q

Controller ICS-LABA for 6-18

A

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

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11
Q

how are moderate to severe asthma exacerbations defined?

A
  • need po steroids
  • ER visit/hospitalization
  • PRAM 7-12
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12
Q

choice of inhaler device:

  • kids 2-4 years old
  • kids 4-6 years old
  • kids 6 and older
A

2-4 y.o: spacer and facemask
4-6 y.o.: spacer and mouthpiece
6 and older: spacer and mouthpiece OR dry powder inhaler

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13
Q

in yellow zone: what do you write for controller:

A

-maintain same dose of ICS as green zone

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14
Q

Children under age 4 should use _____ with MDI

patient teaching

A

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
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15
Q

Children age 4-6 should use ____ with MDI

patient teaching

A

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
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16
Q

Turbuhaler patient teaching

A
  • 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
17
Q

Diskus patient teaching

A
  • 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
18
Q

SABA dose counting

A
  • 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)
19
Q

how often should asthma action plans be reviewed?

A
  • twice a year
  • within 3 months of medication change
  • within 2 weeks of ER/hospital visit
20
Q

Common asthma triggers

what should you counsel re: exercise specifically?

A 
• 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)

21
Q

What are the 5 components of PRAM

A
  • 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)
22
Q

PRAM clinical score:
mild:
moderate:
severe:

impending resp failure :(

A

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

23
Q

Asthma action plans

Green zone

  • indications
  • teaching
A

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

24
Q

Asthma action plans

Yellow zone

  • indications
  • teaching
A
  • 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

25
Q

Asthma action plan

Red zone

  • indication
  • teaching
A

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

26
Q

up to ____ % of kids will outgrow symptoms by age 6

A

50%

27
Q

Risk factors associated with severe exacerbations (CTS guidelines)

mnemonic PPSS

A
  • PREVIOUS severe asthma exacerbation
  • POORLY controlled asthma
  • overuse of SABA
  • current SMOKING
28
Q

Re-assessment of asthma control should be considered with following use of reliever:

A

> 2 doses/week

>2 canisters/year

29
Q

Daily ICS

-will start to see improvement within ______ weeks

A

within 1-2 weeks of starting daily ICS

30
Q

Before escalating treatment of poorly or partially controlled asthma, need to assess:

ATE-C

A
  • adherence
  • technique
  • environment (triggers and occupation)
  • comorbidities (eg GERD, sinusitis, anxiety)
31
Q

How would you manage a child under 6 who is not controlled on medium dose ICS?

A

refer to asthma clinic

review adherence, technique, environment, comorbidities

32
Q

How would you manage a child age 6-11 who is not controlled on medium dose ICS?

A

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

33
Q

How would you manage patients 12 and older who are not controlled despite adherence to low dose ICS?

A

review adherence, technique, environment, comorbidities
start daily ICS-LABA

Alternative: add LTRA or increase to medium ICS

34
Q

How would you manage patients 12 and older on ICS-LABA with poor control or prone to exacerbation?

A

switch to budesonide/formeterol maintenance AND reliever (keep same dose of budesonide)

review adherence, technique, environment, comorbidities

35
Q

What is the max daily dose of fluticasone propionate for:
kids age 1-4?
kids age 4-16?

A

1-4: 200 mcg/day

4-16: 400 mcg/day

36
Q

PO steroids

when would they be included in written asthma action plan?

A

-not recommended for routine asthma action plan
UNLESS
recent severe exacerbation that did not respond to inhaled SABA

37
Q

Asthma severity (CTS guidelines)

define

  • very mild asthma
  • mild asthma
  • moderate asthma
  • severe asthma
A

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

38
Q

Indications for referral to asthma specialist

A
  • 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)
39
Q

Follow up

How would you manage if asthma is well controlled for 3-6 months with no severe exacerbations?

A

reduce med to minimum necessary dose to maintain asthma control

Asthma (2 decks)

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