Case 5 - wheeze Flashcards
(14 cards)
Presentation of asthma in children
- Dry chronic cough and polyphonic wheeze
- Wosens with exercise
- Difficulty with exercise
- Worse at night
Monitoring efficacy of inhalers in children under 5
- Symptom based asthma action plans
- Clinic review after 6 weeks
(peak flow and LFT are unreliable in those under 5)
What to check if symptoms of asthma are well managed and then are not
- Check concordance
- Check inhaler technique
- Exclude other causes
Management of exacerbation of asthma
If moderate:
* Inhaled beta 2 agonists
* Consider oral steroids for 3-5 days
Severe:
* O2
* Nebulised salbutamol
* Nebulised ipratropium bromide
Additional options if not responding to initial management of acute asthma exacerbation
- IV magnesium sulfate
- IV salbutamol
- IV aminophylline
How often are salbutamol inhaler puffs given for moderate exacerbation of asthma?
Give via spacer
* 10 puffs every 2 hours - give 10 puffs initially, ait 30-60s between each puff
* 10 puffs every 4 hours
* 6 puffs every 4 hours
* 4 puffs every 6 hours
Management for life threatening asthma
- HDU/ITU input
- Consider intubation and ventilation early
Risk factors for severe asthma
- Previous near fatal asthma - ventilation or resp acidosis
- Previous admission for asthma, esp in last year
- Requiring 3 or more classes of asthma medication
- Heavy use of SABA
- Repeated ED attendences for asthm carer
- Brittle asthma
Stepwise management of chronic asthma in children - from case notes
Step 1 –
* As needed salbutammol inhaler
* Consider monitored initiation of treatment with very low to low dose ICS.
Step 2 -
* Regular preventer:
* = Very low (paediatric) dose inhaled corticosteroid (ICS).
Step 3 – Initial add-on therapy:
* Very low (paediatric) dose ICS plus:
* In children >5 years old add inhaled LABA or LTRA
* In children <5 years old add LTRA
Step 4 –
* Additional controller therapies:
* Consider: Increasing ICS to low dose – or –
* In children >5 years old adding LRTA or LABA.
* If no response to LABA, consider stopping LABA
Step 5 – Specialist therapies:
Refer patient for specialist care.
Asthma severity scoreer
Managment of asthma in over 12s
- AIR - ICS + formoterol
- Low dose MART
- Moderate dose MART
- Secialist referra if FeNo and eosinophils raised
- Add LTRA or LAMA (+MART)
- specialist referral
Management of asthma in 5-11
- Twice daily paediatric low dose ICS + SABA
Then asess ability for MART regime:
If yes: - don’t need SABA
* Paediatric low dose MART
* Moderate dose
* Refer
If not: - need SABA
* LTRA (+ICS)
* LABA (+ICS)
* Moderate dose ICS and LABA (+/- LTRA)
Management asthma under 5s
- 8-12 week trial paeds low dose ICS + SABA
- If do not resolve - refer
If resolve:
* Consider stopping
* If recur - restart ICS + SABA
* Consider another trial without
* If recur - LTRA (+SABA and ICS)
Inhaled steroids and growth
- Can slightly reduce growth velocity
- Up to 1cm in adult height long term
- Dose dependent
- But poorly controlled asthma can result in needing oral steroids more often = greater effect
