Asthma

Question 1

How are children under 5 diagnosed with asthma?

Answer 1

Based on judgement of symptoms and clinical judgement.

Question 2

How are children 5 and over diagnosed with asthma?

Answer 2

Based on judgement of symptoms and clinical judgement, as well as spirometry.

Question 3

How is chronic asthma managed in under 5s?

Answer 3

1. SABA
2. 8-week trial of paediatric moderate dose ICS if symptoms at presentation indicate need for maintenance (symptoms 3x a week or causing waking at night), or if uncontrolled by SABA alone.
3. After 8 weeks, stop ICS and monitor symptoms.
   If symptoms did not resolve in trial review for other diagnosis.
   If symptoms resolved then reoccurred within 4 weeks of stopping, restart at paediatric low dose.
   If symptoms resolved but reoccurred beyond 4 weeks of stopping, repeat 8-week trial.

Question 4

How should acute asthma/ asthma attack be managed in under 5s?

Answer 4

2.5mg nebulised salbutamol via oxygen driven nebuliser, or pMDI salbutamol 1 puff every 30-60 seconds via a large-volume spacer.
Oxygen if sats <92%
Prednisolone 1-2mg/kg for up to 3 days or IV hydrocortisone if can’t swallow

If poor response to salbutamol: nebulised ipratropium bromide 250mcg every 20-30 mins for 2 hours, then every 4-6 hours.

If poor response: IV magnesium

Monitor PEFR

Question 5

How should chronic asthma be managed in 5-16 year olds?

Answer 5

1. SABA
2. Paediatric low dose ICS if symptoms at presentation indicate need for maintenance (symptoms 3x a week or causing waking at night), or if uncontrolled by SABA alone.
3. Add LTRA and review response in 4-8 weeks.
4. Stop LTRA and add LABA.
5. Change to MART regimen (ICS + LABA in 1 inhaler)
6. Increase ICS to paediatric moderate maintenance dose either in MART or with LABA.
7. Increase ICS to paediatric high maintenance dose OR add additional drug such as theophylline.

Question 6

What asthma drugs are used off-label in under 18s?

Answer 6

LTRAs
LABAs
MART - ICS + LABA

Question 7

How should acute asthma / asthma attack be managed in 5-16 year olds?

Answer 7

5mg nebulised salbutamol via 6l/min oxygen driven nebuliser OR pMDI salbutamol 1 puff every 30-60 seconds via a large volume spacer.
Oxygen if sats <92%
Prednisolone: <12 1-2mg/kg od (max 40mg) for up to 3 days. >12 40-50mg daily. If can’t swallow, IV hydrocortisone 100mg every 6 hours.

If poor response to salbutamol: nebulised ipratropium bromide 250mcg every 20-30 mins for 2 hours, then every 4-6 hours.

If poor response: IV magnesium

Monitor PEFR

Question 8

What should be considered when prescribing ICS?

Answer 8

Monitor height and weight of children on long term ICS treatment annually. If growth slows, refer to paediatrician.

Only beclomethasone is licensed in under 5s.

Prescribe beclomethasone by brand name as Clenil Modulute has a lower potency than Qvar which has a higher potency due to extre-fine particles.

Rinse mouth out after use and use spacer to avoid oral thrush.

Question 9

How would you explain to a parent/patient how to use a spacer with a mask?

Answer 9

child on parents lap facing them (infant) or sideways or facing away (if older). Older children can also stand or sit facing away on their own.
2. Sit/stand up straight with chin slightly up.
3. Put the inhaler into the back of the spacer so that it is facing the same way up as the mask.
4. Put mask on face to form a seal over nose and mouth.
5. Press inhaler an encourage child to breathe in out 5 times. If a large-volume spacer with a valve is used, a click will be heard with each breath.
6. Remove mask from face.
7. Wait 30 seconds to 1 minute, then repeat if another dose is required.
8. If using ICS, encourage them to swill some water or brush their teeth after using.

Question 10

How would you explain to a parent/patient how to use a spacer using the long-hold technique?

Answer 10

1. Sit/stand up straight with chin slightly up.
2. Put inhaler into the back of the spacer.
3. Ask to child to breath all the way out slowly.
4. Ask them to from a seal with their lips around the mouthpiece.
5. Press canister once and have them breathe in slowly and steadily until their lungs feel full.
6. Take the mouth piece out of their mouth, and encourage them to close their lips and hold their breath for 10 seconds.
7. Have them breathe out away from the inhaler.
8. Wait 30 seconds to 1 minute, then repeat if another dose is required.

Question 11

How would you explain to a parent/patient how to use a spacer using the tidal-breahing technique?

Answer 11

1. Sit/stand up straight with chin slightly up.
2. Put inhaler into the back of the spacer.
3. Ask them to from a seal with their lips around the mouthpiece.
4. Encourage them to start breathing in and out slowly.
5. Press canister once and have them breathe in and out 5 times.
6. Wait 30 seconds to 1 minute, then repeat if another dose is required.

Question 12

When would the tidal breathing technique be used instead of the long-hold spacer technique?

Answer 12

If the child can’t hold their breath for around 10 seconds or during an asthma attack.

Question 13

What is the mechanism of action of Montelukast?

Answer 13

Leukotriene receptor antagonist.
Binds to CysLT type 1 receptor to inhibit action of leukotriene C4, D4, and E3, thus decreasing inflammation and relaxing smooth muscle.

Question 14

What are some side effects of montelukast?

Answer 14

GI discomfort
URTI
Headache
Skin reactions
Neuropyschiatric reactions such as speech impairment or OCD.

Question 15

How do inhaled beta-2 agonists work?

Answer 15

Activate beta-2 receptors in the airways causing dilatation and smooth muscle relaxation.

Question 16

Name 2 SABAs.

Answer 16

Salbutamol and terbutaline.

Question 17

How long does it take SABAs to work?

Answer 17

Within 15 minutes.

Question 18

Name 2 LABAs.

Answer 18

Salmeterol and formoterol.

Question 19

What is the onset of action of LABAs?

Answer 19

Within 12 hours.

Question 20

When are beta-2 agonists contraindicated?

Answer 20

Hyperthyroidism - beta-2 agonists may stimulate thyroid activity.

Diabetes - rare risk of ketoacidosis but usually only with IV administration.

CVD - beta-2 agonists can cause arrythmias due to QT interval prolongation, as well as changes to BP and HR.

Question 21

Which medicines are contraindicated/used with caution in asthma?

Answer 21

NSAIDs - can cause bronchospasm.

Opioids - can cause respiratory depression.

Question 22

What are some common side effects of beta-2 agonists.

Answer 22

Headaches
Muscle cramps
Palpitations
Trembling

Question 23

What is the mechanism of action of muscarinic antagonists?

Answer 23

Inhibit M3 muscarinic receptors in the airways to block binding of Ach to decrease production of cGMP. This reduces smooth muscle contraction and promotes bronchodilation.

Question 24

Name one short-acting and one long-acting muscarinic antagonist.

Answer 24

SAMA - ipratropium.
LAMA - tiotropium.

Question 25

What are muscarinic antagonists contraindicated in?

Answer 25

Glaucoma Urinary outflow tract obstruction Cystic fibrosis

Question 26

What are some common side effects of muscarinic antagonists?

Answer 26

Cough Constipation Diarrhoea Dry mouth Headache

Question 27

How do inhaled corticosteroids work?

Answer 27

Switch off activated inflammatory genes via histone deacetylation. This results in decreased formation of cytokines, decreased microvascular permeability, inhibited influx of eosinophils in the lungs, and reduced bronchial hyper-responsiveness.

Question 28

What are some common side effects of ICSs?

Answer 28

Oral candidiasis (rinse mouth after use or use a spacer) Headaches Taste altered Voice altered

Question 29

Why should oral steroids such as prednisolone be avoided longterm?

Answer 29

Prolonged use can lead to: Adrenal suppression Increase risk of infection Ulcers Growth suppression

Question 30

What is theophylline?

Answer 30

Oral xanthine bronchodilator which competitively inhibits type III and type IV phosphodiesterase (PDE), the enzyme responsible for breaking down cyclic AMP in smooth muscle cells, possibly resulting in bronchodilation.