Resp - asthma

Question 1

What are the clinical chest signs that indicate asthma?

Answer 1

Chest movement:
Reduced, but hyperinflated.
Use of accessory muscles.
Chest wall retraction.

Hyperresonant on percussion

Wheeze

Question 2

What are the 2 patterns of wheezing

Answer 2

Transient early wheezing

Persistent recurrent wheezing

Question 3

What is the typical history of transient early wheezers? (wheezy bronchitis)

Answer 3

Episodic, triggered by virus.
Usually resolves by age 5.
Most pre-school children with wheeze (associated with small airway diameter)

Mimics asthma

Question 4

Which virus causes the majority of infective asthma exacerbations?

Answer 4

rhinovirus

Question 5

Which aspects of the history increase the probability of an asthma diagnosis?

Answer 5

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

Question 6

What are Harrison sulci?

Answer 6

Depressions at the base of thorax, associated with muscular insertion of diaphragm.

In chronic obstructive airway disease, such as asthma

Question 7

How does bronchiolitis present?

Answer 7

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

Question 8

What is croup? Which organisms cause it?

Answer 8

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

Question 9

Which are the prevalent years for croup?

Answer 9

6 months to 6 years

Peak in 2nd year

Question 10

What are the typical features of croup?

Answer 10

Barking cough
Harsh stridor
Hoarseness
Preceded by fever and coryza

It is possible to have recurrent croup, possibly related to atopy

Question 11

Which non-respiratory condition may cause cough and wheeze?

Answer 11

Aspiration of feeds, due to GORD.

May cause cough and wheeze can can mimic asthma

Question 12

What is step 1 in managing asthma? (<5yrs)

Answer 12

Mild, intermittent.

Inhaled SABA as required.
Consider inhaled iptratropium bromide.

Question 13

What is step 2 in managing asthma? (<5yrs)

Answer 13

Regular preventer. (if 3 or more SABA per week)

Add inhaled steroid (200-400micrograms per day)
Or LTRA if steroid CI

Question 14

What is step 3 in managing asthma? (<5yrs)

Answer 14

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)

Question 15

What is step 1 in managing asthma? (5-12yrs)

Answer 15

Inhaled SABA as required

Question 16

What is step 2 in managing asthma? (5-12yrs)

Answer 16

Regular preventer. (if 3 or more SABA per week)

Add inhaled steroid (200-400micrograms per day)

Question 17

What is step 3 in managing asthma? (5-12yrs)

Answer 17

(Add-on therapy)
Add LABA
Assess its effect and possibly increase steroid dose.

If still no response, add-on LTRA, or SR theophylline

Question 18

What is step 4 in managing asthma? (5-12yrs)

Answer 18

Increase inhaled corticosteroid up to 800 microgram/day

Question 19

What is step 5 in managing asthma? (5-12yrs)

Answer 19

Use daily steroid tablet (low dose first, then up till 800micrograms/day)

Refer to respiratory paediatrician

Question 20

What are the criteria for complete asthma control?

Answer 20

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

Question 21

What are features of a severe asthma attack?

Answer 21

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

Question 22

What should be measured in all children acutely presenting to hospital with asthma?

Answer 22

Oxygen saturation
<92% implies severe or life-threatening

Do peak flow routinely in school aged children

Question 23

Name the mainstay of acute asthma management

Answer 23

SABA
Inhaled steroid
O2

Question 24

What is given in an acute asthma attack with O2 sats >92% and PF >50% and no severe features?

Answer 24

SABA via spacer.
2-4 puffs, increase by 2 puffs 2 min to 10 puffs if required

Consider oral prednisolone.
Reassess in 1 hour

Question 25

What is the management of acute ashtma, if there are signs and symptoms of severe disease?

Answer 25

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

Question 26

What is the initial management of life-threatening acute asthma?

Answer 26

Nebulised SABA PLUS iptratropium bromide

IV hydrocortisone
Discuss with senior clinician
Repeat bronchodilators every 20-30 minutes

Question 27

How is reponse to treatment in an exacerbation monitored?

Answer 27

RR
HR
O2 sats
Peak flow

Question 28

If patient is responsive to bronchodilators in an acute attack, what are the next steps?

Answer 28

Continue bronchodilators 1-4h prn
Discharge when stable on 4-h treatment.

Continue oral prednisolone for up to 3 days

Question 29

What is the management of a child with acute exacerbation who is UNRESPONSIVE to bronchodilators?

Answer 29

PICU
Consider CXR and blood gases

IV salbutamol or aminophylline (unless already on oral theophylline)

Consider bolus of IV magnesium sulphate

Question 30

What advise is important for the parents about how to manage their asthmatic child?

(INCOMPLETE)

Answer 30

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.

Question 31

How do inhaled corticosteroids work in asthma?

Answer 31

Reduce inflammation

Takes days to weeks until maximum benefit is achieved

Question 32

How do LTRAs work in asthma?

Answer 32

Oral intake

Block leukotriene which is an inflammatory mediator

Question 33

Advise a parent on how to care for a child with asthma?

Answer 33

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

Question 34

Explain the use of an MDI (metered dose inhaler)

Answer 34

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.