asthma management in children

Question 1

is there a cure for asthma

Answer 1

no, only palliation/spontaneous resolution

Question 2

goals of treatment

Answer 2

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)

Question 3

measuring control of asthma (SANE)

Answer 3

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

Question 4

treatment decisions (possible change)

Answer 4

are symptoms being controlled
is treatment being taken
will changing the treatment help

Question 5

what to do if asthma is well controlled

Answer 5

no change or reduce treatment

Question 6

what to do if asthma isn’t well controlled

Answer 6

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

Question 7

step up step down approach

Answer 7

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

Question 8

use of steroids in childhood asthma

Answer 8

child hood asthma is very steroid sensitive
chronic/maintenance: ICS
acute treatment: oral steroid

Question 9

classes of medication

Answer 9

SABAs
ICS
oral steroids

add ons:
long acting beta2 agonists (LABA)
leukotriene receptor agonists
theophyllines

Question 10

inhaled corticosteroids

Answer 10

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)

Question 11

2016 BTS/SIGN guidelines

Answer 11

one figure for all children
ICS doses overlap w/ adults
acknowledges areas of uncertainty when ICS aren’t sufficient

Question 12

contrast w/ adult treatment

Answer 12

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

Question 13

step 2 - regular preventer

Answer 13

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)

Question 14

add on preventer - LABA

Answer 14

useful for patients w/ lots of exertional symptoms
DO NOT USE W/O ICS
use as fixed dose inhaler (one inhaler w/ both medications)

Question 15

add on preventer - LTRA

Answer 15

montelukast only
1/3 respond well, 1/3 respond slightly, 1/3 dont respond at al
better adherence than inhalers
granules for reluctant toddlers

Question 16

step 3 - inital add on preventer

Answer 16

add on LABA/LTRA (BTS/SIGN)
add on LTRA (NICE)
increase ICS dose (GINA)

ADD ON LABA WHEN PATIENT ISNT RESPONDING TO ICS

Question 17

severe asthma management

Answer 17

refer to specialist

generally due to lack of compliance w/ inhalers or not taking them properly

Question 18

delivery systems

Answer 18

MDI/spacer
DPIs
nebulisers

Question 19

MDI/spacer

Answer 19

<5% lung deposition w/o spacer
= 20% lung deposition w/ spacer
shake inhaler between puffs and wash spacer monthly to reduce static

Question 20

what do spacers do

Answer 20

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

Question 21

DPIs

Answer 21

licensed in over 5s
under 8s can’t use them
20% lung deposition

Question 22

nebulisers

Answer 22

not indicated for day-to-day use
MDI spacer vs nebuliser:
quieter, quicker, valve mechanism, don’t break down, portable, cheaper

Question 23

deposition w/ infants

Answer 23

loosely fitting face mask - 0.1%
crying during inhalation - 1%, lots ends up in stomach
quietly inhaling - 8%

Question 24

non-medicinal intervention

Answer 24

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)

Question 25

mild acute asthma treatment

Answer 25

SABA via spacer

SABA via spacer + prednisolone

Question 26

moderate acute asthma treatment

Answer 26

marked increased RR and increased work of breathing
SABA via neb + prednisolone
SABA and ipratropium via neb and prednisolone

Question 27

advantage of nebuliser over spacer

Answer 27

neb is superior for moderate asthma treatment

delivers large amounts of salbutamol to buccal mucosa where it can be absorbed

Question 28

severe acute asthma treatment

Answer 28

IV salbutamol
IV aminophylline
IV magnesium (neb) - same effects as hydrocortisone 
IV hydrocortisone 
intubate and ventilate

Question 29

when are IV steroids given

Answer 29

when child is vomiting, hypoxic or in a coma

Question 30

things to look for in acute asthma

Answer 30

HR and RR
work of breathing 
O2 sats
ability to complete sentences
confusion 
air entry