Asthma

Question 1

Most common chronic disease of childhood

Answer 1

Asthma 15%

Question 2

Suggestive of asthma in children

Answer 2

1. Recurrent wheeze/cough that responds to bronchodilator therapy

Question 3

Confirmation of diagnosis

Answer 3

Good response to bronchodilators, either in symptom control or PEFR

Question 4

CXR findings

Answer 4

1. Hyperinflation due to air trapping
2. Collapse due to mucus plugging

Question 5

Goal of good asthma management

Answer 5

1. Reduction in symptoms
2. Normal activity
3. School attendance
4. Growth

Question 6

When should a MDI with spacer + face mask definitely be used

Answer 6

Younger than 5 years

Question 7

At what oxygen saturation should children be admitted to hospital

Answer 7

AT LESS THAN 92%

Question 8

Describe cough in asthma

Answer 8

1. Recurrent
2. Dry
3. Worse at night
4. Worse with exercise

Question 9

Describe wheeze in asthma

Answer 9

1. Expiratory
2. Triggered by viral
3. Responds to bronchodilators

Question 10

Triggers for shortness of breath

Answer 10

1. Exercise
2. Cold
3. Allergens
4. Smoke!!!

Question 11

Brief pathology overview

Answer 11

Environmental triggers cause broncho-constriction, mucosal oedema, excess mucus in genetically predisposed child Airway narrowing causes wheeze and SOB

Question 12

Assessing severity

Answer 12

1. Mild/Moderate

Walk, speak whole sentences in one breath

>94% oxygen saturation

2. Severe

Use of accessory muscles, intercostals, tracheal tug

Unable to complete sentences

Obvious respiratory distress

90-94% saturation

3. Life threatening

Reduced consciousness/collapse

Exhaustion

Cyanosis

<90% O2 sats

Poor respiratory effort

Soft/absent breath souds

Question 13

Suggestive of asthma in children

Answer 13

1. Recurrent wheeze/cough that responds to bronchodilator therapy, difficulty breathing, tightness, cough
2. Recur
3. Worse at night/mornign
4. Triggers->exercise, cold, pets
5. History of allergies, family history of allergies
6. Widespread wheeze on auscultation
7. Lung function + with bronchodilator

Question 14

Confirmation of diagnosis

Answer 14

1. Good response to bronchodilators, either in symptom control or PEFR
2. FEV1 before and 10-15 after bronchodilator, reversible +>12% for FEV1

Question 15

Investigations and significance

Answer 15

1. PEFR->record in PEF diary to monitor change, beta-2 agonist bronchodilator response, defined as a 12% or greater improvement in either FEV1 or FVC 10 to 15 minutes after inhalation of beta-2 agonist
2. CXR->Exclude pneumothorax in severe.
3. Avoid ++radiographs
4. Allergy test->skin prick most useful. Specific IgE to common inhaled allergens may identify allergens to avoid

Question 16

Goal of good asthma management

Answer 16

1. Reduction in symptoms Normal activity School attendance Growth

Question 17

Describe cough in asthma

Answer 17

Recurrent Dry Worse at night Worse with exercise

Question 18

Describe wheeze in asthma

Answer 18

Expiratory Triggered by viral Responds to bronchodilators

Question 19

Triggers for shortness of breath

Answer 19

Exercise Cold Allergens Smoke

Question 20

Evidence of poor asthma control (4)

Answer 20

1. Poor growth
2. Chronic chest deformity
3. Miss school
4. Frequent exacerbations

Question 21

Brief pathology overview

Answer 21

Environmental triggers cause broncho-constriction, mucosal oedema, excess mucus in genetically predisposed child Airway narrowing causes wheeze and SOB

Question 22

Assessing severity

Answer 22

1. Mild: -breathless, not distressed -PEFR reduced, still >50% 2. Severe: -too breathless to talk or feed -RR >50 bpm, >130 tachyC -PEFR

Question 23

History

Answer 23

1. Cough and wheeze?
2. Worse at night, dry cough
3. Triggers- exercise, viral, temperature
4. Acute exacerbations, severity, management
5. Affect on life, school, activity
6. Revleiver use?
7. Effectiveness?
8. Other atopic symptoms
9. Parental smoking

Question 24

Examination

Answer 24

1. In well controlled, may not have signs between exacerbations
2. Respiratory distress
3. Chest wall deformity->barrel chest, Harrison’s sulcus
4. Listen for wheeze
5. Features of atopy
6. Measure PEFR with hand held meter
7. Check height and weight->poorly controlled asthma shunts growth, as will overuse corticosteroids
8. Check inhaler technique

Question 25

Investigations and significance

Answer 25

PEFR-\>record in PED diary to monitor change. beta-2 agonist bronchodilator response, defined as a 12% or greater improvement in either FEV1 or FVC 10 to 15 minutes after inhalation of beta-2 agonist CXR-\>Exclude pneumothorax in severe. Avoid ++radiographs Allergy test-\>skin prick most useful. Specific IgE to common inhaled allergens may identify allergens to avoid

Question 26

Management overview categories (4)

Answer 26

1. Medications 2. Environmental control-\>avoid passive smoke, dust mites 3. Self monitoring of disease progress-\>PEFR, symptom diary, management plan 4. Education-\>all involved, inhaler technique, emergency management, asthma action plan

Question 27

Most important parameters in assessment of severity

Answer 27

1. General appearance/mental state 2. Work of breathing

Question 28

SpO2 considerations- to give or not

Answer 28

1. Oxygen may be required for low saturations, DO NOT give for wheeze or increased work of breathing. arterial oxygen saturation (SaO2) may be reduced in the absence of significant airway obstruction due to factors such as atelectasis and mucous plugging of airways. 2. SaO2 is purely a measure of oxygenation, which may be preserved in the presence of deteriorating ventilation (with CO2 retention).

Question 29

Mild severity and management

Answer 29

1. Mild Normal MS Subtle +WOB Talking in full sentences Salbutamol by MDI/spacer (dose below table) - give once (\<6, 6 puffs, \>6 12 puffs, and review after 20 mins. If non acute care-\>arrange transfer 3. Ensure device / technique appropriate. 4. Good response - discharge on B2-agonist as needed. 5. Poor response - treat as moderate-add ipratropium bromide (8 puffs \>6, 4 puffs \<6 every 20 minutes via mDI) 6. Oral prednisolone for acute episodes which do not respond to bronchodilator alone - 2 mg/kg (max 60 mg) initially, only continuing with 1 mg/kg daily for further 1-2 days if there is ongoing need for regular salbutamol. 7. Observe for 1 hour after breathing difficulty resolves 8. Post acute care Provide written advice on what to do if symptoms worsen. Consider overall control and family's knowledge. Ensure regular inhaled preventor if indicated Inhaler technique Spacer Interim asthma action plan 9. Arrange follow-up as appropriate. 10. Discharge pack

Question 30

What is in discharge pack

Answer 30

1. Review need for preventative treatment 2. Check inhaler technique 3. Family education 4. Prescription 5. Follow up-\> GP and pediatrician (4-6 weeks) 6. Written action plan 7. Communication with GP

Question 31

Review need for preventative

Answer 31

1. Intermittent asthma-\>regular preventor not recommended 2. Frequent intermittent, viral induced with frequent symptoms Monteleukast 5mg once daily, reasses response in 2-4 weeks \<2 years-\>sodium cromoglycate 3. Moderate to severe Regular low dose inhaled corticosteroid

Question 32

Couselling on use of puffer: reason, how it is given, benefits, how to use and care for

Answer 32

1. Your child has come to hospital for treatment of asthma. 2. If your child has had asthma before, he/she may have been given medicine through a nebuliser or "pump". 3. We now know that asthma medication given through a puffer and spacer relieves asthma symptoms just as well as a nebuliser. 4. Most children who come to hospital will now have their asthma medicine through an puffer and spacer. 5. The benefits of using an puffer and spacer are that it is: a) effective in relieving asthma symptoms, easy to use, portable, inexpensive, easy to care for 6. It is important to remember the following when using a puffer and spacer: puffer and spacer is better than using a puffer alone as more medication gets to the lungs where it is needed the number of puffs given in hospital is more than is usually given at home as the asthma is usually worse (in hospital your child will have 6 or 12 puffs of 'ventolin' at a time depending on his/her age) you and your child (if he/she is old enough) need to know how to use the puffer and spacer properly for the medication to work as well as it can (see over) you and your child (if he/she is old enough) need to know to care for the spacer

Question 33

Initial explanation of inhaler

Answer 33

1. Type of inhaler, purpose and when to use Inhaler contains set dose of medication 2. Aim is to get into the lungs 3. Drug is released by pressing the cannister/twisting as shown

Question 34

Steps for using the inhaler

Answer 34

1. Check expiration 2. SHake 3. Remove cap, see if clean 4. Sit/stand up straight 5. Hold inhaler upright with index and thumb 6. Breathe out completely 7. Seal mouth around 8. Simultaneously press down and breathe in slowly and deeply- aim for back of throat not tongue 9. Hold breath for 10 seconds 10. 10. Breath out slowly 11. Replace cap 12. Repeat after one minute if required

Question 35

Other advice when talking about inhaler

Answer 35

1. Seek help if symptoms not relieved 2. See GP if having side effects 3. Ask if any questions or concerns.

Question 36

Breathing with a spacer

Answer 36

How to use your Large Volume Spacer 1. Put together the spacer following the instructions that came with it. 2. Remove the protective cap from the puffer. 3. Shake the puffer well and insert (place) it firmly into the end of the spacer. 4. Place the mouth piece of the spacer in your mouth and put it between your teeth. Now, close your lips around the spacer mouth piece. Make sure your lips cover the entire mouth piece so there are no gaps. Hold the spacer level so that it does not tilt up or hang down. 5. Breathe out gently. 6. Press the puffer ONCE to release a dose of the medicine into the spacer. Do not remove the puffer. 7. Breathe in very slowly until you have taken a deep breath. You will hear a whistle sound if you are breathing in too fast. Hold your breath for a few seconds, then breathe out slowly and deeply through your mouth. 8. Breathe in and out 4 or 5 times (do not remove your mouth from the mouthpiece in between each breath - there is a 2 way valve system which will prevent any of the medication from escaping from the chamber).

Question 37

Care of the spacer

Answer 37

1. Clean once a week , or however often you feel it is dirty based on how often you use it 2. Wash with warm soap and water 3. Always leave to drip dry 4. Replace every 6-12 months

Question 38

Use of turbuhaler

Answer 38

1. To load the medication, you need to turn the base of the Turbuhaler all the way in one direction and then all the way back in the other direction. 2. If your child needs more than dose of medicine, twist the base again - first one way, then the other to load the next dose. 3. If your child is taking a preventer medicine, it is best if they clean their teeth or have a drink after using the medicine so that none stays in their mouth. 4. Talk to your doctor, pharmacist or nurse if you have any questions about these instructions. 5. If your child has to have regular medication every day ( such as a preventer) - it can be helpful to keep it with their tootbrush.

Question 39

Moderate severity and management

Answer 39

1. Salbutamol 2. Reassess 3. Ipratropium bromide 4. Consider add on therapy 5. Systemic corticosteroid 2mg/kg day 1, 1mg/kg day 2 and 3 6. Reassess after 1 hour 7. Nil issue-\>observe 1 hour, post-acute care: enducation, managing at home, oral prednisilone 3-5 days, preventer at home, inhaler technique, spacer, asthma action plan, F/U, GP 8. If ongoing breathing difficulty Admit Continue bronchoD + add on therapy-\> IV magnesium sulphate, I salbutamol, NIPPV

Question 40

Severe severity and management

Answer 40

1. Agitated/distressed Moderate-marked increased work of breathing accessory muscle use/recession. Tachycardia Marked limitation of ability to talk Note: wheeze is a poor predictor of severity. 2. Oxygen as above 3. Salbutamol by MDI/spacer - 1 dose (dose below) every 20 minutes for 1 hour; review ongoing requirements 10-20 min after 3rd dose. 4. If improving, reduce frequency. If no change, continue 20 minutely. 5. If deteriorating at any stage, treat as critical. Ipratropium by MDI/spacer - 1 dose (dose below) every 20 minutes for 1 hour only. 6. Aminophylline If deteriorating or child is very sick. Loading dose: 10 mg/kg i.v. (maximum dose 500 mg) over 60 min. 7. Unless markedly improved following loading dose, give continuous infusion (usually in ICU), or 6 hourly dosing (usually in ward). Drug doses 8. Magnesium sulphate 50% (500 mg/mL) Dilute to 200 mg/mL (by adding 1.5mls of sodium chloride 0.9% to each 1ml of Mg Sulphate) for intravenous administration 50 mg/kg over 20 mins 9. If going to ICU, this may be continued with 30 mg/kg/hour by infusion 10. Oral prednisolone (2 mg/kg); if vomiting give i.v. methylprednisolone (1 mg/kg) 11. Involve senior staff. 12. Arrange admission after initial assessment.

Question 41

Critical severity and management

Answer 41

1. Confused/drowsy, Maximal work of breathing accessory muscle use/recession, Exhaustion, Marked tachycardia, Unable to talk SILENT CHEST, wheeze may be absent if there is poor air entry. Involve senior staff. Be sure to arrange transfer if beyond management in that hospital 2. Oxygen 3. Continuous nebulised salbutamol (use 2 x 5mg/2.5L nebules undiluted) - see below re toxicity. 4. Nebulised ipratropium 250 mcg 3 times in 1st hr only, (20 minutely, added to salbutamol). 5. Methylprednisolone 1 mg/kg i.v. 6-hourly. 6. Aminophylline as above 7. Magnesium sulphate as above. 8. In ICU patients on Mg infusion, aim to keep serum Mg between 1.5 and 2.5mmol/L. 9. May also consider i.v. salbutamol. Limited evidence for benefit. 5 mcg/kg/min for one hour as a load, followed by 1-2 mcg/kg/min. 10. Intensive care admission for respiratory support (facemask CPAP, BiPAP, or intubation/IPPV) may be needed.

Question 42

Salbutamol toxicity

Answer 42

1. Beware salbutamol toxicity: tachycardia, tachypnoea, metabolic acidosis, hypokalemia 2. Can occur with both IV and inhaled therapy. 3. Lactate commonly high. 4. Consider stopping/reducing salbutamol as a trial if you think this may be the problem.

Question 43

Can aminophylline, salbutamol and magnesium be give by same IV line

Answer 43

No, need seperate

Question 44

Salbutamol dose

Answer 44

6 puffs if \<6 years old 12 puffs if \>6 years old

Question 45

Ipratropium dose

Answer 45

4 puffs if \<6 years 8 puffs if \>6 years

Question 46

Investigations

Answer 46

1. CXR not usually required 2. ABG and spirometry not required in immediate assessment

Question 47

When to consider discharge

Answer 47

Consider discharge when: 1. Assess patient for clinical improvement 1 hour following initial therapy and discharge if clinically well. If necessary, reassess again after 30 minutes 2. Adequate oxygenation - Oxygen saturation of less than 92 percent should not preclude discharge if patient is clinically well and has responded well to treatment 3. Adequate oral intake 4. Adequate parental education and ability to administer salbutamol via spacer

Question 48

Defining good asthma control

Answer 48

1. No limit on activity 2. No nocturnal symptoms 3. Good exercise tolerance 4. Minimal b2 agonist use 5. No severe attacks 6. No medication side effects 7. Near/normal lung function \>80%

Question 49

6 Step long term management

Answer 49

1. Assess severity 2. Achieve best lung function 3. Avoid triggers 4. Maintain best lung function 5. Individualised written asthma plan

Question 50

Reasons for suboptimal asthma management

Answer 50

1. Poor adherence 2. Inefficient use of inhaler 3. Procrastination introducing therapy 4. Patient fears 5. Doctor reluctance

Question 51

Long term management of intermittent and definition

Answer 51

Xweekly- \>6 weeks apart PEFR \> 80 SABA PRN

Question 52

Long term management of mild, and definition

Answer 52

1. weekly, Xevery day , \>2 monthly nocturnal , Regular imapact activity \>80% PEFR Regular inhaled CS or monteleukast (\>5) or sodium cromoglycate \<5 + SABA --\>2 SAβA 2–3 times daily

Question 53

Long term management of moderate

Answer 53

1. daily, weekly nocturnal, Other triggers, 60-80% SABA prn, LABA + Regular inhaled CS +dose or ICS + monteleukast

Question 54

Long term management of severe

Answer 54

1. Symptoms every day, Wakes frequently with cough/ wheeze, Chest tightness on waking, Limitation of physical activity 2. ICS high dose or ICS low + monteleukast or ICS low + LABA SABA PRN 3. Referral to specialist

Question 55

Options for LABA

Answer 55

1 eformoterol 12 micrograms by inhalation, twice daily OR 1 salmeterol 50 micrograms by inhalation, twice daily.

Question 56

Combination medication

Answer 56

1. fluticasone + salmeterol (Seretide) MDI: 50/25; 125/25; 250/25 mcg dose: adults, 2 inhalations bd; children 4–12, 2 inhalations bd 50/25 Accuhaler: 100/50; 250/50; 500/50 dose: adults, 1 inhalation bd; children 4–12, 1 inhalation bd 100/50 2. budesonide + eformoterol (Symbicort) Turbuhaler 100/6; 200/6; 400/12; 1–2 inhalations bd

Question 57

Exercise induced treatment

Answer 57

salbutamol 100 to 400 micrograms by inhalation, 5 minutes before exercise If frequent-\>monteleukast

Question 58

Common side effects of iCS

Answer 58

1. Oral candidiasis 2. Hoarse voice 3. Bronchial irritation/cough 4. Adrenal suppresion \>2000mcg

Question 59

What is contained in an asthma action plan

Answer 59

1. Medication taken every day 2. How to tell if asthma is getting worse 3. What to do when symptoms getting worse 4. What to do if having an asthma attack

Question 60

When my asthma is well controlled

Answer 60

1. No regular wheeze, or cough or chest tightness at night time, on waking or during the day 2. Able to take part in normal physical activity without wheeze, cough or chest tightness 3. Need reliever medication less than three times a week (except if it is used before exercise Take preventer, reliever and combination medication as usual

Question 61

When my asthma is getting worse

Answer 61

1. At the first sign of worsening asthma symptoms associated with a cold 2. Waking from sleep due to coughing, wheezing or chest tightness 3. Using reliever puffer more than 3 times a week (not including before exercise) Peak Flow\* between 60-80 Increase medication and see doctor about getting worse

Question 62

When my asthma is severe

Answer 62

1. Need reliever puffer every 3 hours or more often 2. Increasing wheezing, coughing, chest tightness 3. Difficulty with normal activity 4. Waking each night and most mornings with wheezing, coughing or chest tightness 5. Feel that asthma is out of control Peak Flow\* between \< 60 See doctor for advice

Question 63

How to recognise life threatening and manage

Answer 63

1. Dial 000 for an ambulance and/or 112 from a mobile phone if you have any of the following danger signs: • extreme difficulty breathing • little or no improvement from reliever puffer • lips turn blue and follow the Asthma First Aid Plan below while waiting for ambulance to arrive. 2. A serious asthma attack is also indicated by: • symptoms getting worse quickly • severe shortness of breath or difficulty in speaking • you are feeling frightened or panicked • Peak Flow\* below 60 Asthma First Aid Plan 1 Sit upright and stay calm. 2 Take 4 separate puffs of a reliever puffer (one puff at a time) via a spacer device. Just use the puffer on its own if you don’t have a spacer. Take 4 breaths from the spacer after each puff. 3 Wait 4 minutes. If there is no improvement, take another 4 puffs. 4. If little or no improvement CALL AN AMBULANCE IMMEDIATELY (DIAL 000 and/or 112 from mobile phone) and state that you are having an asthma attack. 5. Keep taking 4 puffs every 4 minutes until the ambulance arrives. 6. See your doctor immediately after a serious asthma attack.

Question 64

Option for exercise induced asthma, multiple allergen triggers

Answer 64

1. Sodium cromoglycate 2. Monleukast Also for children with nasal polyps, aspirin hypersensitivity, allergic asthma