- Host response to environment - Infection - Physiology abnormal before symptoms - It is a syndrome - Genetics (ADAM33, ORMDL3 (not all people with these genes have asthma))- interact with environment

Respiratory Flashcards by Katie Robertson

What should do if think its asthma and QoL is affected?

QoL affected confirm diagnosis with a trial of ICS

QoL not affected, watch and see

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What is asthma?

Chronic

Wheeze, Cough, SOB

Multiple triggers-although in children the predominant trigger is an URTI

Variable/reverisble

RESPONDS TO ASTHMA TX

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Is asthma a diagnosis of exclusion?

NOOOOO

Key words:
- Wheeze
- Variability
- Respond to treatment

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What causes asthma?

Host response to environment
Infection
Physiology abnormal before symptoms
It is a syndrome
Genetics (ADAM33, ORMDL3 (not all people with these genes have asthma))- interact with environment

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What are some asthma syndromes (multiple hits)?

All go into a final common pathway

Infant onset
Childhood onset
Adult onset
Exertional asthma
Occupational asthma

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Does allergy cause asthma?

Thats a nope (not directly related)

Primary epithelial (skin, airway, gut) abnormality results in:
1) Eczema/asthma etc
2) Allergy

Allergy then fuels (sensitisation) eczema/asthma etc

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Early environment causes childhood asthma: what are some of these interventions to change environments to reduce exposure?

Feeding (breast, late weaning
Allergen (ante- and post natal)
Smoking

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Is there a diagnostic test for asthma in children?

Tests can be useful (excluding>diagnosing)

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What makes spirometery useful?

Bronchodilator response to measure the lung function

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Asthma diagnosis tests (more for exclusion of other things?

Spirometry
BDR
FeNO
Peak flow

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Asthma diagnosis tests (more for exclusion of other things?

Spirometry
BDR
FeNO
Peak flow

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Why is it hard to diagnose asthma in <5s?

Uncertainty greatest in <5s

Tests not reliable in <5s

Tests not great anyway

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Does a cough variant asthma exist in children?

NOOOOOO

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Rattle of … & the whistle of …

Rattle of bronchitis and the whistle of asthma

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Do you get a Hx of SOB in asthma?

YES DUH

Sig resp difficult (<30% lung function)
Airway obstruction
‘Sooking’ in of ribs with wheeze

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What kind of cough is associated with asthma?

Dry
Nocturnal (just after falling asleep)
Exertional

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What is the treatment/diagnosis of asthma?

ICS for 2 months

Remember false positive responses-inhaler holiday

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What Hx do you ideally need to diagnose asthma (hindsight diagnosis)

Wheeze (with & w/o URTI)

SOB @ rest

Parental asthma

Responds to Tx

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What are the harms of a trial of treatment for asthma and what are the benefits?

Harm=0.5-1cm loss in height, oral thrush

Benefit=helps diagnosis and if symptoms respond it improves QoL & reduces risk of attacks

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What are the harms of a trial of treatment for asthma and what are the benefits?

Harm=0.5-1cm loss in height, oral thrush

Benefit=helps diagnosis and if symptoms respond it improves QoL & reduces risk of attacks

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Under 18 months respiratory symptoms are most likely infection and >5 most likely asthma but…?

If it sounds like asthma & responds to asthma Tx it is asthma regardless of age!

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Are asthma & VIW treated the same?

Yes-they are the same condition

Preschool children
Different shades of the same colour
Should be treated

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Is there a cure for asthma?

No, only palliation or spontaneous resolution

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How is control measured (what criteria)?

SANE

Short acting beta agonist/week
Absence school/nursery
Nocturnal symptoms/week
Exertional symptoms/week

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If patient has been symptom free for 3 months what might you consider in asthma?

Stepping down the treatment

What is the starting treatment for asthma?

Low dose ICS (severe may respond to minimal treatment) Review after 2 months (inhaler hol-easter)

ICS is the standard preventer so what is SABA?

Blue relieving medication

What is the max dose of ICS in <12 yo?

800microg

What is the first line preventer in <5s?

LTRA

What are the contrasts between child and adult asthma meds?

- No oral B2 tablet - No LAMAs - Only 2 biologics

When should a regular preventer of asthma be used?

- Diagnostic test - B2 agonists >2 days a week - Symptomatic 2 x a week or more or waking one night a week

What can oral steroids cause?

HT & Cataracts

Higher dose steroids (fluticasone in particular) can cause what?

Adrenocortical suppression

How are LABAs given?

Not used without ICS Used as a fixed dose inhaler

What leukotriene receptor agonist is given?

Montelukast only in children - Rule of thirds - Granules for reluctant todlers - Oral - better adherance

What should be added to an ICS if a patient is poorly controlled?

Add on a LABA but keep an open mind Additional add on therapies include increase ICS and LTRA

What are the 2 types of delivery system?

MDI/Spacer Dry powder device-licensed in over 5s-under 8s cant use them

How is a spacer of benefit?

<5% lung deposition w/o spacer <20% lung deposition with spacer MDI/spacer=4xMDI Shake=2x no shake Wash to reduce static charge=2x no wash Shake, wash and use spacer

Are nebulisers indicated for day to day use?

What is some other management for asthma that are not meds?

- Stop tobacco smoke exposure - Remove environmental triggers

What can air ionisers do?

Increase cough

How in an acute setting is it worked out what meds to give?

Look at RR, work of breathing and O2 saturations - Confusion - Air entry - Ability to complete sentences The level of treatment is determined by symptoms and sats (be guided by sats/oxygen requirement)

What should you do in acute asthma after you have started treatment?

Reassess in 1 hr Step up or down as appropriate

What is the difference in the use of steroids for chronic and acute asthma?

Chronic/maintenance= inhaled steroids (NOT oral) Acute= oral steroids

What are some side effects of Abx?

- Diarrhoea - Oral thrush - Nappy rash - Allergic reaction - Multi-resistance

What are some examples of anti-pyretics?

Paracetamol and ibuprofen for fever

Rhinitis is usually a self limiting condition but what could it be a predrome to?

- Pneumonia, bronchiolitis - Meningitis - Septicaemia

What is ottitis media?

Infection in the middle ear - Erythema - Bulging drum - Common and self limiting - Spontaneous rupture of drum - Abx Tx doesn't usually help

What is the secondary infection of otitis media?

Pneumococcus/H'flu

How is otitis managed?

- ANALGESIA - Abx may work >24hrs

With tonsilitis/pharyngitis how is it managed?

Throat swab-bacterial or viral Viral=nothing Bacterial=10 days penicillin (Don't use amoxycillin-EBV get rash)

What is characteristics of strep throat?

- Scarlet fever-faint pink rash - sandpaper like feel - Pallor around the mouth - Temp & poor energy

What is the treatment for croup (LTB)?

Oral dexamethasone Duration of croup 1-2 days

What are the signs and treatment of epiglottits?

- Stridor, drooling - Intubation & Abx

What is tracheitis, what is it caused by and how is it managed?

Fever, sick child-'croup which doesn't get better' Staph or strep invasive infection Augmentin

Bronchitis is an endobronchial infection where the child is very well but the parent is worried. How does it present?

- Loose rattly cough with URTI - Post tussive vomit-'glut' - Chest free of wheeze/creps - Haemophilus/pneumococcus - Mostly self limiting

What is the mechanism of bacterial bronchitis?

- Disturbed mucocilliary clearance-mild airway malacia, RSV/adenovirus Bacterial infection is secondary

What is the natural Hx of bacterial bronchitis?

- Lasts 4 weeks following an URTI - Third winter fine - Pneumococcus/H flu

How to manage persistent bacterial bronchitis?

Make the diagnosis-reassure-do not treat

What causes bronchiolitis (LRTI of infants) & how does it present?

Usually RSV-others incl. paraflu III, HMPV - Nasal stuffiness, tachypnoea, poor feeding - Crackles +/- wheeze Bronchiolitis is very predictable RSV for XMAS!! - <12 months old - One off (NOT recurrent) - Typical Hx

How do we investigate Bronchiolitis?

- NPA - Oxygen sats (severity) No routine need for CXR, Bloods & bacterial cultures

What are the main characteristics of a LRTI?

48 hrs, fever (>38.5), SOB, cough, grunting - Wheeze makes bacterial cause unlikely - Reduced or bronchial breath sounds

Only call pneumonia instead of LRTI if have...?

- Signs are focal (ie in one area (LLZ)) - Creps - High fever

Is CRX indicated in CAP?

NO, CXR & inflam markers are NOT 'routine'

What is the management for CAP?

- Nothing if symptoms are mild - Oral Amoxycillin 1st line - 2nd line=Oral macrolide - Only for IV if vomiting

When should oral Abx be used and not IV?

- Abx are indicated (48 hrs etc) - In non severe LRTI - When child is not vomiting

What is the difference between LRTI & Bronchiolitis?

LRTI= In all ages, more rapid onset of symptoms, fever Bronchiolitis=<12 months, 3 days before reach peak, fever rarely >38 degrees

Is pertussis common?

YES Vax reduces risk and severity

What are the symptoms of Pertussis?

- Coughing fits - Vomiting & colour change

What is empyema and what is it a complication of?

Complication of pneumonia Extension of infection into pleural space

How does empyema present and how is it treated?

Chest pain & very unwell Abx +/- drainage Good prognosis (in contrast with adults)