Resp - asthma Flashcards
What are the clinical chest signs that indicate asthma?
Chest movement:
Reduced, but hyperinflated.
Use of accessory muscles.
Chest wall retraction.
Hyperresonant on percussion
Wheeze
What are the 2 patterns of wheezing
Transient early wheezing
Persistent recurrent wheezing
What is the typical history of transient early wheezers? (wheezy bronchitis)
Episodic, triggered by virus.
Usually resolves by age 5.
Most pre-school children with wheeze (associated with small airway diameter)
Mimics asthma
Which virus causes the majority of infective asthma exacerbations?
rhinovirus
Which aspects of the history increase the probability of an asthma diagnosis?
Symptoms worse at night and early in the morning.
Symptoms have triggers (exercise, pets, cold air, emotions)
Interval symptoms (between acute exacerbations)
Personal or family history of atopic disease (eczema, rhinoconjunctivitis, food allergy)
Positive response to asthma therapy
What are Harrison sulci?
Depressions at the base of thorax, associated with muscular insertion of diaphragm.
In chronic obstructive airway disease, such as asthma
How does bronchiolitis present?
Age 1-9 months
Poor feeding, apnoea, dry cough.
Laboured breathing: chest recession, hyperinflation, fine end-insp crackles, wheeze, liver displaced downwards
Apnoea, cyanosis, resp failure
What is croup? Which organisms cause it?
laryngotracheobronchitis
Mucosal inflammation and increased secretions.
Oedema of the subglottic area is potentially dangerous.
Parainfluenza viruses most often, but can also be RSV and influenza
Which are the prevalent years for croup?
6 months to 6 years
Peak in 2nd year
What are the typical features of croup?
Barking cough
Harsh stridor
Hoarseness
Preceded by fever and coryza
It is possible to have recurrent croup, possibly related to atopy
Which non-respiratory condition may cause cough and wheeze?
Aspiration of feeds, due to GORD.
May cause cough and wheeze can can mimic asthma
What is step 1 in managing asthma? (<5yrs)
Mild, intermittent.
Inhaled SABA as required.
Consider inhaled iptratropium bromide.
What is step 2 in managing asthma? (<5yrs)
Regular preventer. (if 3 or more SABA per week)
Add inhaled steroid (200-400micrograms per day)
Or LTRA if steroid CI
What is step 3 in managing asthma? (<5yrs)
If inhaled steroid taken 200-400micrograms/day, consider adding LTRA
(or the other way around)
If <2 years old, go to step 4 (refer to resp paediatrician)
What is step 1 in managing asthma? (5-12yrs)
Inhaled SABA as required
What is step 2 in managing asthma? (5-12yrs)
Regular preventer. (if 3 or more SABA per week)
Add inhaled steroid (200-400micrograms per day)
What is step 3 in managing asthma? (5-12yrs)
(Add-on therapy)
Add LABA
Assess its effect and possibly increase steroid dose.
If still no response, add-on LTRA, or SR theophylline
What is step 4 in managing asthma? (5-12yrs)
Increase inhaled corticosteroid up to 800 microgram/day
What is step 5 in managing asthma? (5-12yrs)
Use daily steroid tablet (low dose first, then up till 800micrograms/day)
Refer to respiratory paediatrician
What are the criteria for complete asthma control?
No daytime symptoms No night time awakening No need for rescue medication No asthma attacks No exacerbations No limitations on activity inlcuding exercise
Normal lung function (FEV and PEF > 80% predicted)
Minimal side effects from medication
What are features of a severe asthma attack?
Wheeze and tachypnoea (poor guide to severity)
Increasing tachycardia
Accessory muscle use, chest recession
Presence of marked pulsus paradoxus (difference between systolic and diastolic pressure on inspiration and expiration)
If breathlessness interferes with talking!
Cyanosis, fatigue, drowsiness and silent chest indicate life-threatening
What should be measured in all children acutely presenting to hospital with asthma?
Oxygen saturation
<92% implies severe or life-threatening
Do peak flow routinely in school aged children
Name the mainstay of acute asthma management
SABA
Inhaled steroid
O2
What is given in an acute asthma attack with O2 sats >92% and PF >50% and no severe features?
SABA via spacer.
2-4 puffs, increase by 2 puffs 2 min to 10 puffs if required
Consider oral prednisolone.
Reassess in 1 hour
What is the management of acute ashtma, if there are signs and symptoms of severe disease?
Oxygen via facemask to achieve normal saturations
10 puffs of SABA via spacer or nebulised
Oral prednisolone or IV hydrocortisone
Repeat bronchodilators every 20-30 as needed
Nebulised
What is the initial management of life-threatening acute asthma?
Nebulised SABA PLUS iptratropium bromide
IV hydrocortisone
Discuss with senior clinician
Repeat bronchodilators every 20-30 minutes
How is reponse to treatment in an exacerbation monitored?
RR
HR
O2 sats
Peak flow
If patient is responsive to bronchodilators in an acute attack, what are the next steps?
Continue bronchodilators 1-4h prn
Discharge when stable on 4-h treatment.
Continue oral prednisolone for up to 3 days
What is the management of a child with acute exacerbation who is UNRESPONSIVE to bronchodilators?
PICU
Consider CXR and blood gases
IV salbutamol or aminophylline (unless already on oral theophylline)
Consider bolus of IV magnesium sulphate
What advise is important for the parents about how to manage their asthmatic child?
(INCOMPLETE)
Increasing cough, wheeze, breathlessness, difficulty walking, talking, sleeping or decreasing relief from bronchodilators indicate poorly controlled asthma. Good to measure peak flow at home.
Inhaler technique.
How do inhaled corticosteroids work in asthma?
Reduce inflammation
Takes days to weeks until maximum benefit is achieved
How do LTRAs work in asthma?
Oral intake
Block leukotriene which is an inflammatory mediator
Advise a parent on how to care for a child with asthma?
Follow ACTION PLAN (eg. what to give, avoiding triggers, recognize flare-ups)
Daily vs. quick relief medicines
Identify and avoid triggers (dust pollen, mold, weather, flu)
Make sure to get yearly flu vaccine
Asthma diary and peak flow meter are good for recognizing flare-ups early
Change in mood, breathing, or feeling funny may be EARLY signs!
Can then adjust the medicines
Always have a quick relief medicine and call emergency when needed
Explain the use of an MDI (metered dose inhaler)
Take cap off, Shake device for 5 sec Exhale completely, away from the device. Tilt head back and straighten head. Inhale deeply while pressing the top button of the inhaler and making a tight seal. Hold breath for 10 seconds. Then exhale slowly.
Repeat after 30 seconds if another dose is needed
Most paediatric inhalers need to be prepared, and then no button is pressed.
