paediatric viral wheeze and asthma Flashcards by Laurence Forsyth

comparing moderate, severe and life-threatening asthma attacks in children:
how is the SpO2 affected

moderate >92%

severe- <92%

life-threatening- <92%

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comparing moderate, severe and life-threatening asthma attacks in children:
how is the PEF affected

moderate >50% best or predicted

severe- 33-50% best or predicted

life threatening- <33% best or predicted

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point about presenation of moderate asthma attacks

no features of severe attacks

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in severe asthma attacks in children:
how is the presentation 2

severe- too breathless to talk or feed

use of accessory neck muscles

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in life-threatening asthma attacks in children:
how is the presenation 5

silent chest

poor repsiratory effort

agitation

altered consciousness

cyanosis

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in severe asthma attacks in children:
heart rate in 1-5 yo and >5 yo

1-5 yo - >140

5>yo - >125

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in severe asthma attacks in children:
respiratory rate in 1-5yo and >5 yo

1-5yo >40

> 5yo >30

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mild to moderate asthma attack management 2

beta-2 agnoist via spacer
-if <3 yo use close fitting mask

1 puff every 30-60 secs up to max 10 puffs

symptoms not controlled-> repeat beta2-agnoist and refer to hospital

stroids
-oral pred 3-5days
2-5yo 20mg OD
>5 yo 30-40mg OD

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managment of severe /life threatening asthma attack

use mild/moderate managemnt
+
ipratropium bromide
+
nebulised magneiusm sulphate- specialist
+
Iv hydrocort
+
IV salbutamol
+
IV aminophyliine

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presenation of a child suggesting asthma diagnosis 8

episodic symptoms w intermittent exacerabtions

diurinal variability
-worse at night and early morning

dry cough w wheeze and SOB

typical triggers

atopic FHx

atopic personal Hx

bilateral wheeze on asculatation

symptoms imporve w bronchodilator

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presenation indicating a diagnoisis OTHER than asthma 5

wheeze only related to coughs and colds (MORE SUGGESTIVE OF VIRAL INDUCED WHEEZE)

isolated or productive cough

normal investiagtions

no response to treatment

unilateral wheeze-> focal lesion,inhaled foregin body or infection

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typical asthma triggers 5

dust

animals

cold air

exercise

smoke

food alergens (peanuts, shellfish or eggs)

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age of diagnoiss of asthma in children

not until they are at least 2 to 3 years old

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investiagtions for asthma diangosis 4

spirometry with reveristybility testing
-only in children >5yo

direct bronchial challenge test w histamine or methacholine

fractional exhaled nitric oxide (FeNO)

peak flow variability
-diary of peak flow measurements severeal times a day for 2-4 weeks

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prinicples of asthma managemnt in children 5

start at most apporpriate step for severeity of syx

review at regular intervals

step up and down ladder based on syx

aim to achieeve no syx or exacerabitons on lwoest dose and no of treatments

always check inhaler technqiue and adherence at each review

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medical therapy for asthma in under 5 yo
1st line 1

SABA

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medical therapy for asthma in under 5 yo
2nd line 2

SABA
+
low dose corticosteroid inhaler or leukotriene atnagonist (ie oral montelukast)

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medical therapy for asthma in under 5 yo
3rd line

SABA
+
low dose corticosteroid inhaler
+
leukotriene atnagonist (ie oral montelukast)

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medical therapy for asthma under 5yo

fourth line 1

rrefer to specalist

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medical therapy for asthma aged 5-12 yo

1st line

SABA

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medical therapy for asthma aged 5-12 yo

second line 2

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SABA

low dose coritosteroid inhaler

medical therapy for asthma aged 5-12 yo

third line 3

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saba

low dose cortico inhaler

LABA(salmeterol)
-only continue if patient has good response

medical therapy for asthma aged 5-12 yo

fourth line 4

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saba

MEDIUM dose cortico inhaler

LABA(salmeterol)
-only continue if patient has good response

consider adding:
-oral leukotriene receptor antagonist (montelukast)
-oral theophylline

medical therapy for asthma aged 5-12 yo

fifth line 4

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saba

HIGH dose cortico inhaler

LABA(salmeterol)
-only continue if patient has good response

consider adding:
-oral leukotriene receptor antagonist (montelukast)
-oral theophylline

medical therapy for asthma aged 5-12 yo sixth line 4

refer specalist

medical therapy for asthma aged >12 yo first line

SABA

medical therapy for asthma aged 5-12 yo seocnd line 2

SABA low dose corticosteriod inhaler

medical therapy for asthma aged >12 yo third line

saba low dose cortico inhaler LABA(salmeterol) -only continue if patient has good response

medical therapy for asthma aged >12 yo fourth line 4

saba MEDIUM dose cortico inhaler LABA(salmeterol) -only continue if patient has good response consider adding: -oral leukotriene receptor antagonist (montelukast) -oral theophylline -inhlaed LAMA (tiotropium)

medical therapy for asthma aged >12 yo fourth line 4

saba HIGH dose cortico inhaler LABA(salmeterol) -only continue if patient has good response consider adding: -oral leukotriene receptor antagonist (montelukast) -oral theophylline -inhlaed LAMA (tiotropium) -ORAL BETA AGONIST -REFER TO SPECALIST

important point regarding use of inhalred corticosteroids in children

parents can be worried that regular steroids can slow growth

growth in children and inhaled corticosetoid use

there is evidence that it slightly reduced growth -reduction is up to 1cm when used long term (for more than 12 months) -effects are dose-dependent -less of a problem with smaller doses It is worth putting this in context for the parent by explaining that these are effective medications that work to prevent poorly controlled asthma and asthma attacks that could lead to higher doses of oral steroids being given. Poorly controlled asthma can lead to a more significant impact on growth and development. The child will also have regular asthma reviews to ensure they are growing well and on the minimal dose required to effectively control symptoms.

inhaler technique without a spacer

Remove the cap Shake the inhaler (depending on the type) Sit or stand up straight Lift the chin slightly Fully exhale Make a tight seal around the inhaler between the lips Take a steady breath in whilst pressing the canister Continue breathing for 3 – 4 seconds after pressing the canister Hold the breath for 10 seconds or as long as comfortably possible Wait 30 seconds before giving a further dose Rinse the mouth after using a steroid inhaler

inhaler technique with a spacer

Assemble the spacer Shake the inhaler (depending on the type) Attach the inhaler to the correct end Sit or stand up straight Lift the chin slightly Make a seal around the spacer mouthpiece or place the mask over the face Spray the dose into the spacer Take steady breaths in and out 5 times until the mist is fully inhaled

define a viral induced wheeze

acute wheezy illness cuased by a viral infection

basic pathophys of viral induced wheeze

small children (under 3 yo) have small airways-> can encouter a virus (usually RSV or rhinovirus)-> develop small amount of inflammatino and oedema air flowing through narrow airways causes the wheeze and the restricted ventialation leads to respiratory distress

types of viruses causing viral induced wheeze-MOST COMMON (2)

RSV RHinovirus

association to viral induced wheeze (1)

family hisotry -alwasy enquire

factors of a viral induced wheeze that differentiate it from asthma 3

before 3yo no atopic history only occurs during viral infections

triggers of asthma compared to viral induced wheeze 5

whilst asthma can be triggered by viral or baterial infections -there are other triggers: -exercise -cold weather -dust -strong emotions

presenation of viral induced wheeze symptoms- 1 signs -2

SOB signs of respiratory distress expiratory wheeze throughout chest

focal wheeze in viral induced wheeze or asthma?

NO -these do not cause a focal wheeze so be wary anf investigate further for foreign body or tumour

management of viral induced wheeze?

same as acute asthma moderate: Nebulised beta-2 agonists (i.e. salbutamol 5mg repeated as often as required) Nebulised ipratropium bromide Steroids. Oral prednisolone or IV hydrocortisone. These are continued for 5 days Antibiotics if there is convincing evidence of bacterial infection Severe: Oxygen if required to maintain sats 94-98% Aminophylline infusion Consider IV salbutamol Life threatening: IV magnesium sulphate infusion Admission to HDU / ICU Intubation in worst cases – however this decision should be made early because it is very difficult to intubate with severe bronchoconstriction

ABGs in asthma and viral induced wheeze

respiratory alkalosis -as tachypnoea -> drop in CO2

noraml pCO2 or hypoxia in acute viral induced wheeze or asthma?

CONCERNING -indicates they are tiring and is a feature of life threatening asthma

respiratory acidosis in asthma or viral induced wheeze?

VERY BAD SIGN -due to high CO2

how to monitor response to treatment in acute asthma or viral induced wheeze 5

resp rate resp effort peak flow O2 sats chest auscultation

during an acute asthma attack or viral induced wheeze, when the patient is given salbutamol what needs to be monitored (2) and why

potatisum - can be lowered heart rate- can cause tachy

follow up after asthma attack 2

give them 'asthma action plan' -provdes clear plan for everything nthey need to know about their ashtma in one place -consider prescribing rescue pack (steroids) if they have another exacerabtion

when should patients be referred to respiratroy specialist after asthma attacks

after 2 attacks in 12 months

paediatric viral wheeze and asthma Flashcards

(50 cards)