asthma management in children Flashcards
(30 cards)
is there a cure for asthma
no, only palliation/spontaneous resolution
goals of treatment
minimal symptoms during day/night minimal need for reliever medication no attacks no limitation of physical activity normal lung function (FEV1 and/or PEF >80% predicted/best)
measuring control of asthma (SANE)
Short acting beta agonist /wk: if used >3 days, poorly controlled, = 2 days is well controlled
Absence from school/nursery
Nocturnal symptoms/wk: waking 1 night/wk = poor control
Exertional symptoms/wk
treatment decisions (possible change)
are symptoms being controlled
is treatment being taken
will changing the treatment help
what to do if asthma is well controlled
no change or reduce treatment
what to do if asthma isn’t well controlled
not taking treatment
not taking treatment correctly
(if either of the above 2, dont change treatment)
not asthma - stop asthma treatment
none of the above - increase asthma treatment
step up step down approach
started on low dose ICS - severe may respond to minimal treatment
review after 2mths - no routine test to monitor progress
no change is easier than step down if symptoms have responded
need an inhaler holiday (easter) - given inhaler, take a break when not at school/nursery to see if symptoms resolve
use of steroids in childhood asthma
child hood asthma is very steroid sensitive
chronic/maintenance: ICS
acute treatment: oral steroid
classes of medication
SABAs
ICS
oral steroids
add ons:
long acting beta2 agonists (LABA)
leukotriene receptor agonists
theophyllines
inhaled corticosteroids
very useful for diagnosis
very effective and safe
not much +ve effect when going from middle - high dose but many more adverse effects (heigh suppression, oral thrush, adrenocortical suppression - esp w/ fluticasone, hypertension, cataracts)
2016 BTS/SIGN guidelines
one figure for all children
ICS doses overlap w/ adults
acknowledges areas of uncertainty when ICS aren’t sufficient
contrast w/ adult treatment
max dose ICS 800 microg (<12y/o), 2000 in adults
no oral beta2 tablet in children
LTRA 1st line preventer in <5s (not used in adults)
no LAMAs (long acting muscarinic antagonists, only used for adults currently)
only 2 biologicals in children, many more options in adults
step 2 - regular preventer
diagnostic test
beta 2 agonist: >2days/wk, symptomatic (>/= 3 days/wk or waking 1 night/wk)
exacerbations of asthma in the last 2 yrs
start w/ v low dose of ICS (or LTRA in <5s)
add on preventer - LABA
useful for patients w/ lots of exertional symptoms
DO NOT USE W/O ICS
use as fixed dose inhaler (one inhaler w/ both medications)
add on preventer - LTRA
montelukast only
1/3 respond well, 1/3 respond slightly, 1/3 dont respond at al
better adherence than inhalers
granules for reluctant toddlers
step 3 - inital add on preventer
add on LABA/LTRA (BTS/SIGN)
add on LTRA (NICE)
increase ICS dose (GINA)
ADD ON LABA WHEN PATIENT ISNT RESPONDING TO ICS
severe asthma management
refer to specialist
generally due to lack of compliance w/ inhalers or not taking them properly
delivery systems
MDI/spacer
DPIs
nebulisers
MDI/spacer
<5% lung deposition w/o spacer
= 20% lung deposition w/ spacer
shake inhaler between puffs and wash spacer monthly to reduce static
what do spacers do
hold the dose and allows the patient to breathe it in at their own pace
easier for children to use than co-ordinating breathing w/ pressing inhaler
DPIs
licensed in over 5s
under 8s can’t use them
20% lung deposition
nebulisers
not indicated for day-to-day use
MDI spacer vs nebuliser:
quieter, quicker, valve mechanism, don’t break down, portable, cheaper
deposition w/ infants
loosely fitting face mask - 0.1%
crying during inhalation - 1%, lots ends up in stomach
quietly inhaling - 8%
non-medicinal intervention
stop tobacco smoke exposure
remove environmental triggers
diet (evidence -ve)
alter humidity (no evidence, air ionisers increase cough)
weight reduction (no evidence that it reduces asthma in children)
