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967 Block 3 - Pulmonary > Pediatric Asthma > Flashcards

Pediatric Asthma Flashcards

1
Q

At what age are patients most vulnerable to asthma exacerbations that require hospital care?

A

young children

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2
Q

What is the main underlying complication of asthma?

A

airway inflammation

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3
Q

List the steps of an asthma exacerbation.

A
  1. initial airway bronchoconstriction
  2. airway edema and exaggerated mucus production
  3. airway hyper responsiveness
  4. chronic changes in airway epithelium
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4
Q

Pro-inflammatory cytokines are produced primarily by what?

A

Th 2 lymphocytes

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5
Q

What is believed to trigger the intense inflammation of allergic asthma?

A

pro-inflammatory cytokines

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6
Q

What cells are thought to be out of balance in chronic inflammatory asthma?

A

Th 1 and Th 2

Th 1 being decreased and Th 2 being increased

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7
Q

What is the function of chemokines?

A

These proteins recruit pro-inflammatory cells, including Th2 lymphocytes, mast cells, neutrophils, and eosinophils

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8
Q

Which antibody subtype plays a large role in asthma?

A

IgE

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9
Q

What are the risk factors for developing asthma?

A
  • male
  • parental asthma
  • allergies
  • severe LRI
  • tobacco smoke exposure
  • wheezing apart from colds
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10
Q

What are the 3 distinct wheezing phenotypes?

A
  • transiet
  • non-atopic
  • atopic
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11
Q

All children who wheeze develop asthma. (T/F)

A

False

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12
Q

What is the most common cause of LRI?

A

respiratory syncytial virus (RSV)

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13
Q

What is transit wheezing?

A

Infants whose wheezing is associated with one or more LRIs and who cease to wheeze after 3 years of age

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14
Q

What is non-atopic wheezing?

A
  • Children who have relatively more reactive airways
  • a higher incidence of previous RSV infection
  • persistent wheezing after 3 years of age, which may resolve over time.
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15
Q

What is atopic wheezing?

A
  • have higher IgE concentrations
  • prone to allergen-mediated airway hyperresponsiveness
  • more profound lung function deficits at an early age
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16
Q

What type of wheezer is most likely to develop asthma?

A

atopic

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17
Q

At what age can a child be diagnosed with asthma?

A

5

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18
Q

What is the Asthma Predictive Index?

A

A tool used to “diagnose” children under 5 with asthma. Since this is not a definitive diagnosis, it technically predicts that the child will develop resistant asthma after age 5.

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19
Q

What are the criteria for a < 5 yo to get a positive on the Asthma Predictive Index?

A
  • If < 3 and have ≥ 4 wheezing episodes in past year
  • AND one of the following
    • parental history of asthma
    • diagnosis of atopic dermatitis
    • evidence of sensitization to aeroallergen
  • AND two of the following
    • evidence of sensitization to food
    • ≥ 4% peripheral blood eosinophilia
    • wheezing apart from the common cold
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20
Q

What are symptoms likely due to asthma?

A
  • wheezing
  • cough, particularly at night
  • difficulty breathing
  • tachypnea
  • episodic cough, SOA, chest tightness
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21
Q

What is wheezing?

A

high pitched whistling sound when breathing out

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22
Q

What are the 4 types of asthma?

A
  • recurrent wheezing
  • chronic asthma
  • exercise induced
  • September epidemic
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23
Q

What is the primary cause of recurrent wheezing?

A

viral illness

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24
Q

When does recurrent wheezing usually present?

A

early childhood

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25
Q

When does chronic asthma present?

A

later childhood

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26
Q

What is chronic asthma typically associated with?

A

allergies

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27
Q

What is exercise induced asthma?

A

intermittent symptoms exacerbated by physical activity

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28
Q

When does September epidemic usually present?

A

school age children

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29
Q

What type of wheezing is recurrent wheezing associated with?

A

non-atopic

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30
Q

What type of wheezing is chronic asthma associated with?

A

atopic

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31
Q

What is the September epidemic?

A
  • stress associated with return to school?
  • high levels of environmental allergens in late summer
  • more exposure to RVIs
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32
Q

At what age is the Pulmonary Function Test appropriate?

A

≥ 5 years

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33
Q

What is the PFT used for?

A

excluding other diseases

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34
Q

Why is the PFT not valid in children under 5?

A
  • short attention span

- limited coordination

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35
Q

What are the types of inhalers?

A
  • metered dose inhaler
  • breath-actuated dry powder inhaler
  • nebulizer
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36
Q

DPIs are ideal for young children because they are the easiest to use. (T/F)

A

False, young children often cannot generate enough strength in the breath to inspire the powder down into the lungs

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37
Q

Which is better for children, MDI + spacer or nebulizer?

A

both are equally safe and effective

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38
Q

What are the facets of care for pediatric asthma?

A
  • classification of asthma severity
  • daily management
  • exacerbation management
  • therapy adjustment
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39
Q

What are the main goals of therapy in pediatric asthma?

A
  • reduce impairment

- reduce risk

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40
Q

How do we reduce impairment in pediatric asthma?

A
  • prevent symptoms
  • infrequent use of rescue medications
  • maintain near normal PFT
41
Q

What is considered “infrequent use” of rescue medications?

A

≤ 2 days per week

42
Q

How do we reduce risk in pediatric asthma?

A
  • prevent recurrent exacerbations and hospitalizations

- minimize ADRs

43
Q

Describe Step 1 of asthma management for 0-4 year olds.

A

SABA PRN

44
Q

In whom is Step 1 asthma therapy appropriate?

A

Intermittent asthma

45
Q

Describe Step 2 of asthma management for 0-4 year olds.

A

Preferred: low dose ICS
Alternate: cromolyn or montelukast

46
Q

In whom is Step 2 asthma therapy appropriate?

A

Mild Persistent asthma

47
Q

Describe Step 3 of asthma management for 0-4 year olds.

A

medium dose ICS

48
Q

In whom is Step 3 asthma therapy appropriate?

A

Moderate Persistent Asthma

49
Q

Describe Step 4 of asthma management for 0-4 year olds.

A

medium dose ICS + LABA or montelukast

50
Q

Describe Step 5 of asthma management for 0-4 year olds.

A

high dose ICS + LABA or montelukast

51
Q

Describe Step 6 of asthma management for 0-4 year olds.

A

high dose ICS + LABA or montelukast + oral systemic corticosteroids

52
Q

In whom is Step 4 asthma therapy appropriate?

A

Moderate Persistent Asthma

53
Q

In whom is Step 5 asthma therapy appropriate?

A

Severe Persistent Asthma

54
Q

In whom is Step 4 asthma therapy appropriate?

A

Severe persistent asthma

55
Q

Describe Step 1 of asthma management for 5-11 year olds.

A

SABA PRN

56
Q

Describe Step 2 of asthma management for 5-11 year olds.

A

Preferred: Low-dose ICS
Alternative: cromolyn, LTRA, Nedocromil, or Theophylline

57
Q

Describe Step 3 of asthma management for 5-11 year olds.

A

EITHER
Low-dose ICS + LABA/LTRA/Theophylline
-or-
medium dose ICS

58
Q

Describe Step 4 of asthma management for 5-11 year olds.

A

Preferred: Medium dose ICS + LABA
Alternative: Medium dose ICS + LTRA/theophylline

59
Q

Describe Step 5 of asthma management for 5-11 year olds.

A

Preferred: high dose ICS + LABA
Alternative: high dose ICS + LTRA/theophylline

60
Q

Describe Step 6 of asthma management for 5-11 year olds.

A

Preferred: High dose ICS + LABA + oral corticosteroids
Alternative: High dose ICS + LTRA/theophylline +oral corticosteroids

61
Q

Before continuing on the the next step, what should always be checked?

A
  • adherence
  • environmental control
  • management of comorbidities
62
Q

What are the key points of patient education with pediatric asthma?

A
  • asthma action plan
  • peak flow monitoring
  • symptom monitoring
  • adherence
  • correct inhaler techniques
63
Q

What are the key points of the management of pediatric asthma?

A
  • patient education
  • control of environmental factors
  • vaccinations
64
Q

At what point should you consider stepping down therapy in pediatric asthma?

A

well controlled for > 3 months

65
Q

What are the anti-inflammatory agents used for pediatric asthma?

A
  • inhaled corticosteroids
  • oral corticosteroids
  • mast cell stabilizers
  • leukotriene modifiers
66
Q

Why would you want to use a SABA?

A
  • provide relief of acute symptoms
  • drug of choice for intermittent asthma
  • prevention and management of EIA
67
Q

What are the SABA agents?

A
  • albuterol sulfate
  • levalbuterol
  • pirbuterol acetate
68
Q

Why would you want to use a LABA?

A
  • patients requiring scheduled β₂ agonists
  • moderate to severe asthma
  • adjunct to anti-inflammatory agents
  • assists primarily with nocturnal symptoms
69
Q

What are the LABA agents?

A
  • formoterol fumigate
  • salmeterol xinafoate
  • *fluticasone propionate/salmeterol xinafoate (Advair)
  • *budsonide/formoterol fumigate
  • combo with ICS
70
Q

What is the mainstay therapy for asthma management?

A

ICS

71
Q

What are the ICS agents?

A
  • beclomethasone
  • budsonide
  • ciclesonide
  • flunisolide
  • fluticasone proprionate
  • mometasone furonate
  • triamcinolone acetone
72
Q

Do ICSs make children shorter?

A

Average of 1.2 cm difference (minimal)

73
Q

Why would you want to use a Leukotriene Receptor Antagonist (LTRA)?

A
  • long-term control and prevention of asthma exacerbations

- added to therapy due to minimal ADRs and easy admin.

74
Q

What is status asthmaticus?

A

condition of a patient in progressive respiratory failure due to asthma, in whom conventional forms of therapy have failed

75
Q

What are the pharmacotherapy options for status asthmaticus?

A
  • systemic corticosteroids
  • bronchodilators
  • magnesium
  • terbutaline
  • ketamine
  • methylxanthines
76
Q

Describe systemic corticosteroid use in status asthmaticus.

A
  • drug of choice
  • burst therapy for 3 - 10 days has minimal ADRs
  • long term dosing (combined with decreased ICS use)
    • daily (lowest possible dose
    • every other day
    • combined with ICS
    • replace ICS
77
Q

What are the systemic corticosteroid agents?

A
  • dexamethasone
  • methylprednisolone
  • prednisolone
  • prednisone
78
Q

Which systemic corticosteroid agent solution contains alcohol?

A
  • dexamethasone

- prednisolone

79
Q

In status asthmaticus, what are the bronchodilating agents?

A
  • albuterol inhalation

- ipratropium bromide

80
Q

What is the dosage of MDI albuterol in status asthmaticus?

A

4 - 8 puffs every 20 minutes x 3 doses

81
Q

What is the dosage of nebulizer albuterol in status asthmaticus?

A

2.5 mg q 20 minutes x 3 doses

82
Q

What category does ipratropium bromide belong?

A

anticholinergic bronchodilator

83
Q

There is no benefit to adding ipratropium bromide to β₂ agonist or corticosteroid therapy. (T/F)

A

True

84
Q

How does magnesium treat status asthmaticus?

A

inhibits smooth muscle contraction by inhibiting calcium uptake causing bronchodilation

85
Q

How is magnesium dosed in status asthmaticus?

A

25 - 75 mg/kg IV over 15 - 30 minutes

86
Q

What are the ADRs of magnesium therapy?

A
  • flushing
  • nausea
  • hypotension
87
Q

What is terbutaline?

A

systemic β₂ agonist

88
Q

What is the dose of terbutaline in status asthmaticus?

A

10 mcg/kg IV load

0.4 - 10 mcg/kg/min continuous infusion

89
Q

What are the ADRs of terbutaline?

A
  • HTN
  • nervousness
  • tachycardia
90
Q

In what situation might terbutaline be used?

A

patient is in such a state that inhaled β₂ agonists cannot be introduced into the lungs

91
Q

Which route of administration with terbutaline minimizes ADRs?

A

SQ

92
Q

What are the methylxanthine agents?

A

aminophylline

93
Q

What is the dose of aminophylline in status asthmaticus?

A

6 mg/kg IV load

0.5 - 1.2 mg/kg/hr IV

94
Q

What are the target serum concentrations of aminophylline?

A

5 - 10 mcg/ ml

95
Q

What is the therapeutic result of low serum concentrations of aminophylline?

A

anti-inflammatory and immune-modulary

96
Q

What is the therapeutic result of high serum concentrations of aminophylline?

A

asthma MOA

97
Q

How does ketamine treat status asthmaticus?

A

NMDA receptor antagonist that reduces airway resistance via bronchodilation

98
Q

At what stage of status asthmaticus is ketamine to be used?

A

last line

99
Q

What is the dose of ketamine in status asthmaticus?

A

1 - 2 mg/kg loading

6 - 10 mcg/kg/min continuous infusion

967 Block 3 - Pulmonary (3 decks)

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