Asthma and/or Viral induced wheeze in a child Flashcards Preview

Year 5 - Paediatrics COPY > Asthma and/or Viral induced wheeze in a child > Flashcards

Flashcards in Asthma and/or Viral induced wheeze in a child Deck (28)
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1
Q

What are the criteria for a life threatening asthma attack (BTS/SIGN)?

A
  • SpO2 <92% (same as severe)
  • PEF <33% best or predicted
  • Silent chest
  • Poor respiratory effort
  • Agitation
  • Altered consciousness
  • Cyanosis

May not be able to complete sentences.

2
Q

What are the criteria for a severe asthma attack (BTS/SIGN)?

A
  • SpO2 < 92%
  • PEF 33-50% best or predicted
  • Too breathless to talk or feed

Heart rate

  • >125 (>5 years)
  • >140 (1-5 years)

Respiratory rate

  • >30 breaths/min (>5 years)
  • >40 (1-5 years)
  • Use of accessory neck muscles
3
Q

What is the management of asthma in children?

A

This applies for children <12 years old. Older children are treated as adults.

4
Q

Define asthma.

A

Asthma is a chronic respiratory disorder characterised by

  1. variable airway inflammation,
  2. airway obstruction,
  3. and airway hyper-responsiveness.

https://www.brit-thoracic.org.uk/document-library/guidelines/asthma/btssign-asthma-guideline-quick-reference-guide-2019/

5
Q

What is the epidemiology of paediatric asthma?

A

prevalent in UK, US(8.5%) and Australia

increasing prevalence

higher prevalence in prepubertal males and postpubertal females

6
Q

What factors are linked to increased prevalence of paediatric asthma?

A
  • Allergic sensitisation/atopic disease
  • Exposure to tobacco
  • Non-viral induced wheeze*
  • Respiratory infections in early childhood - RSV and hRV
  • Maternal stress
  • Pollution

*in response to emotion, weather, tobacco, exercise

7
Q

Describe the presenting symptoms of childhood asthma.

A
  • Intermittent wheeze (non-viral triggers)
  • Dry cough at night time
  • Responsiveness to medication
  • SOB on exertion

Wheeze and recurrent cough triggered by viral infections /weather /exercise

8
Q

What are the findings on examination in paediatric asthma?

A
  • Widespread polyphonic wheeze
  • Chest tighness/increased work of breathing - chest recessions/retractions, tachypnoea, accessory muscle usage
  • Atopic disease e.g. eczema
  • Chest wall deformity - Harrrison’s sulci or hyperinflation (uncommon)
9
Q

How does spirometry aid in the diagnosis of asthma in children?

A

Obstructive pattern seen

  • Decreased FEV1/FVC ratio - usually <0.90
  • Decreased mid-flow - MEF25 % of FVC or FEF25-75 % of FVC
  • Decreased FEV1
  • Spirometry is usually feasible in children >5years.
10
Q

How does response to bronchodilator on spirometry aid in the diagnosis of paediatric asthma?

A

Shows reversibility - >12% improvement in FEV1 is significant and suggestive of asthma

Lack of response usually signifies alternative diagnosis

11
Q

Can PEFR be used in the diagnosis of paediatric asthma?

A

No because of low sensitivity and dependance on effort.

12
Q

What tests (other than spirometry/medication reponse) can aid in the diagnosis of asthma?

A
  1. Airway challenge tests - decrease of 15-20% in FEV1 with challenge
  2. FeNO - fractional expired nitric oxide may be elevated
  3. Exercise challenge test - decrease in FEV1 >12% or in PEFR >15% is consistet with exercise-induced bronchocontriction. Measured at baseline and every 5min up to 20min. Done in children >6years.
  4. FBC - eosinophilia >4% assoc. with asthma
  5. Sputum culture
  6. Sweat test - chloride >60mmol/L on repeat samples is CF
  7. Bronchoscopy - exclude aspiration, tracheomalacia, bronchomalacia
  8. BAL - eosinophilia (>1.2%) or sputum eosinophilia (>3%)
  9. Electron micrograph ciliary studies - Kartagener’s syndrome
  10. Skin prick testing - atopy
13
Q

Give an example of a SABA.

A

Salbutamol

14
Q

Give an example of a LABA.

A

Salmeterol

15
Q

Give an example of a LRTA.

A

Leukotriene receptor antagonists are given orally

e.g. montelukast

16
Q

Give 2 examples of low/medium/high dose ICS.

A

Beclometasone

  • Low - 50-100mcg/day
  • Medium - 100-200mcg/day
  • High >200mcg/day

Budesonide

  • Low - 100-200mcg/day
  • Medium - 200-400mcg/day
  • High >400mcg/day (always more if nebulised)

Also: Fluticasone

17
Q

What class is tiotropium?

A

Long-acting muscarinic antagonist - can reduce exacerbations and be used as add-on therapy in children > 6 years.

18
Q

What mAbs can be used in treatment of paediatric asthma?

A
  1. Omalizumab - anti-IgE (stops basophil and eosinophil activation)
  2. Mepolizumab can also be used - anti-IL-5

These require specialist input.

19
Q

Which scoring system can be used to assess the severity of acute asthma in children?

A

PRAM score

20
Q

How do you distinguish between severe and life threatening asthma attack?

A

Life threatening is severe plus any of:

  • SaO2 < 92%
  • Silent chest / poor respiratory effort
  • Drowsy / restless / confused / agitated
  • Cyanosis / Exhaustion
21
Q

How do you treat moderate acute asthma?

A
  1. Burst therapy - salbutamol 100mcg x 10 puffs every 20 min for 1 hr
  2. and Dexamethasone - 0.6mg/kg single dose (max 16mg)
  3. Reassess every 30 min
  4. Improvement?
    1. If yes: reassess 1hourly and give salbutamol burst therapy every 1- 4 hours. If wheeze free for >3-4 hours then consider discharge.
    2. If no: add 20mcg of 4-8 puffs ipratropium bromide to burst therapy every hour and reassess (max 4 bursts)
22
Q

How do you treat severe acute asthma?

A
  1. Burst therapy - salbutamol 100mcg x 10 puffs AND ipratropium bromide 20mcg 4-8 puffs every 20 mins for 1 hour
  2. and Oxygen to maintain SaO2 >92%
  3. and Dexamethasone - 0.6mg/kg single dose (max 16mg)
  4. Reassess every 30 mins post burst therapy
  5. Improvement?
    1. If yes: give another burst therapy, then salbutamol 100mcg x 10 puffs every hour (max 4 times). If further imporvement then give salbutamol burst therapy every 2-4 hourly and ipratropium bromide 4-6 hourly
    2. If no: escalate
23
Q

How do you treat life threatening acute asthma?

A
  1. RESUS
  2. Senior medical review
  3. Oxygen to maintain SaO2 >92%
  4. IV access
  5. Nebulisers - salbutamol 2.5-5mg every 20 min + ipratropium bromide 125-500mcg
  6. Dexamethasone - oral or IV hydrocortisone
  7. IV magnesium sulfate - over 20mins 40mg/kg (over 2yrs; max 2g).
  8. IV salbutamol bolus - 5mcg/kg over 5 mins

Do not give aminophylline loading dose if already on theophylline

24
Q

Wheeze/asthma care pathway for children >1 years old

A
25
Q

How do you differentiate between viral induced wheeze and asthma?

A
26
Q

Why would you give montelukast before increasing beclamethasone dose in asthma? (from Capsule case)

A

Montelukast is safer and easier to give but it is not wrong to increase the steroid dose first.

Motelukast given before salmeterol. Usually you sould stop montelukast before giving salmeterol.

27
Q

In what position should the child be to give nebulisers?

A

MUST be vertically positioned, cannot be lying down.

28
Q

What is the definition of cyanosis?

A

Saturations <85% on air

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