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Flashcards in ASTHMA IN CHILDREN Deck (24):
1

What is the differential diagnosis for wheezing in a child? For each diagnosis give a sign that might distinguish it from asthma.

Asthma

Cystic fibrosis - failure to thrive, productive cough, finger clubbing

Aspiration associated with gastro-oesophageal reflux - vomiting

Central airway disease - Inspiratory stridor with wheeze

Laryngeal problems - Abnormal voice

Inhaled foreign body - sudden onset

Postviral wheeze - recent URTI in children under 2

2

What features increase the probability that a wheezing child has asthma?

Episodes are frequent and recurrent

Worse at night or in the early morning

Occur in response to, or are worse after, exercise or other triggers such as exposure to pets, cold or damp air, or with emotions or laughter.

Occur even when the person has not got a cold (coryzal illness)

Another atopic disorder (hayfever, eczema).

Family history of atopy

Wheeze is widespread and bilateral

Prolonged expiration

Increased respiratory rate

3

You are a FY2 on a GP rotation. A mother presents to you with her 6 year old child Tim. You take a history and decide that there is a high probability that Tim is suffering from asthma. What should you do now?

Start Tim on a trial of treatment.

Explain difference between reliever and preventive therapy.

Take a baseline peak expiratory flow and compare it to his predicted.

4

What factors help determine what a child’s predicted peak flow should be?

Age

Height

Weight

BMI

Gender

Whether they have used a peak flow meter before

Children need to be six years or over to do a reliable peak flow. Additionally, if children have never used one before, a one-off reading when they are unwell will not be very reliable!

5

What is the first line management of chronic asthma in children regardless of age?

Salbutamol inhaler

6

You prescribe salbutamol inhaler with a spacer for Tim a 6 year old with newly diagnosed asthmatic. He comes back 3 weeks later. What are the indications for proceeding to the next step in the management of chronic asthma?

Having symptoms three times weekly or more

Awakening with symptoms one night a week or more

Having an exacerbation in the past 2 years

Using their inhaled beta2-agonist three times weekly or more

7

You prescribe salbutamol inhaler with a spacer for Tim a 6 year old with newly diagnosed asthmatic. He comes back 3 weeks later and his symptoms do not seem to have improved enough with the reliever. What is the next step in the management of chronic asthma in someone of his age group (5-12)?

Inhaled corticosteroids - beclometasone 200-400 micrograms per day normally across two doses

8

Tim is a 6 year old with asthma. He has a salbutamol inhaler and has recently been started on inhaled steroids. However, he is not tolerating these particularly well. What might you prescribe for Tim instead of the inhaled corticosteroids?

Leukotriene receptor antagonist - monteleukast.

9

Tim is a 6 year old with asthma. He has a salbutamol inhaler and is also on 200 micrograms of inhaled steroids BD. He comes back to surgery with his mother complaining that he is still experiencing some symptoms. What is the next step in the management of chronic asthma in someone of his age group (5-12)?

Consider starting Long-acting beta2-agonists (LABA) if symptoms are still uncontrolled when using an ICS at 400 micrograms/day.

10

Tim is a 6 year old with asthma. He has a salbutamol inhaler and is also on 200 micrograms of inhaled steroids BD. He was recently also given a LABA to try as he was still experiencing symptoms, however this doesn't seem to have helped much. What is the next step in the management of chronic asthma in someone of his age group (5-12)?

Stop LABA, consider leukotriene receptor antagonist or theophyline

11

Tim is a 6 year old with asthma. He has a salbutamol inhaler and is also on 200 micrograms of inhaled steroids BD as well as monteleukast. He is still experiencing symptoms. What is the next step in the management of chronic asthma in someone of his age group (5-12)?

Increased inhaled corticosteroids to 400 micrograms BD (800/day)

12

Tim is a 6 year old with asthma. You recently increased his dose of inhaled corticosteroid therapy from 400 micrograms a day to 800 micrograms a day. He is still experiencing symptoms. What is the next step in the management of chronic asthma in someone of his age group (5-12)?

Refer to specialist care

13

You prescribe salbutamol inhaler with a spacer for Alice a 3 year old with newly diagnosed asthmatic. She comes back 3 weeks later and her symptoms do not seem to have improved enough with the reliever. What is the next step in the management of chronic asthma in someone of his age group (under 5)?

Inhaled corticosteroids - beclometasone 200-400 micrograms per day normally across two doses

14

Alice is a 3 year old with asthma. She has a salbutamol inhaler and has recently been started on inhaled steroids. However, she is not tolerating these particularly well. What might you prescribe for Alice instead of the inhaled corticosteroids?

Leukotriene antagonists - monteleukast

Should only be given to children older than 2

15

Alice is a 3 year old with asthma. She has a salbutamol inhaler and is also on 200 micrograms of inhaled steroids BD. She is tolerating these well but is still experiencing symptoms. What is the next step in the management of chronic asthma in someone of his age group (under 5)?

Consider starting Leukotriene antagonists - monteleukast if symptoms are still uncontrolled when using an ICS at 400 micrograms/day.

Should only be given to children older than 2

16

Alice is a 3 year old with asthma. She has a salbutamol inhaler and is also on 200 micrograms of inhaled steroids BD and monteleukast. However, she is still experiencing symptoms. What is the next step in the management of chronic asthma in someone of his age group (under 5)?

Refer to specialist care

17

What factors are known to trigger asthma exacerbations?

Passive smoking

Cold air

Exercise

Viral infections

Emotion

Allergens

18

What is the dose of rescue prednisolone for children with an exacerbation of their asthma?

Under 1 years old: 1-2 mg/kg/day

1-5 years old: 20mg/day

Above 5 years old: maximum 40mg/day

19

With regard to an acute asthma attack in children, what are the criteria for a moderate asthma attack, rather than a severe or life threatening attack?

Sats more than or equal to 92%

PEF of more than or equal to 50%

Able to talk

Heart rate of less than or equal to 125 bpm

Respiratory rate of less than or equal to 30 bpm

20

With regard to an acute asthma attack in children, what are the criteria for a severe asthma attack, rather than either a moderate or a life threatening attack?

Sats of less than 92% (debate as to whether this is life threatening or severe)

PEF of between 33 and 50% of best or predicted

Too breathless to talk

Heart rate of more than 125 bpm

Respiratory rate of more than 30 bpm

Use of accessory muscles

21

With regard to an acute asthma attack in children, what are the criteria for a life threatening asthma attack, rather than a severe attack?

Sats of less than 92%

PEF of less than 33%

Silent chest

Poor respiratory effort

Agitation

Altered consciousness

Cyanosis

22

A child presents with signs and symptoms consistent with a severe asthma attack and is started on nebulised salbutamol and ipratropium with high flow oxygen. An hour later after her third dose of nebulised salbutamol you decide that she is not improving. What is the next step in the management of this child?

Obtain IV access

Send off U&Es

Do an ABG

IV salbutamol with ECG monitoring

IV fluids containing potassium

IV hydrocortisone

23

A child presents with signs and symptoms consistent with a severe asthma attack and is started on nebulised salbutamol and ipratropium with high flow oxygen. An hour later after her third dose of nebulised salbutamol you decide that she is not improving. You give her IV salbutamol and IV hydrocortisone. You reassess her after a short while and find that there has been no real improvement. What is the next step in the management of this child?

This is now considered life threatening and you need to activate the paediatric emergency protocol calling 2222.

She needs IV magnesium sulphate with BP monitoring

If still poor response, consider IV aminophylline

24

A child came in earlier this afternoon with a severe asthma attack. Fortunately you managed to successfully treat her and she is looking and feeling much better. What do you now need to find out about her general asthma control?

MAILS-IT

Medications - inhalers, technique, compliance, steroids

Atopy - other symptoms (eczema, hayfever), family history

Inpatient admissions - ITU/HDU

Life affects - missed school, exercise tolerance

Smoking - parents or siblings at home

Interval symptoms - cough at night, sleep disturbance,

Triggers - cold, dust, exercise, pollen, pets