Asthma Edited

8/8/2019 Asthma Edited

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ASTHMA INASTHMA IN

PAEDIATRICSPAEDIATRICS

Adapted from sourceAdapted from source


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ASTHMAASTHMA


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3am phone call3am phone call


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ASTHMAASTHMA

Reversible bronchoconstrictionReversible bronchoconstriction

Smooth muscle contractionSmooth muscle contraction

Increase mucus secretionIncrease mucus secretion


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AsthmaAsthma


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Morbidity/MortalityMorbidity/Mortality

0.9/100,000 deaths for children aged 50.9/100,000 deaths for children aged 5--19 (very few


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HISTORYHISTORYTHIS EPISODE:THIS EPISODE:

Duration & nature of symptomsDuration & nature of symptoms

WheezeWheeze

CoughCough

Chest tightness/BreathlessnessChest tightness/Breathlessness

Treatments used (relievers/puffers)Treatments used (relievers/puffers)

PREVIOUS EPISODES:PREVIOUS EPISODES:

History of asthma symptoms &History of asthma symptoms & frequency of brochodilator usefrequency of brochodilator use

Severity & patternSeverity & pattern

Infrequent episodic, frequent episodic, persistentInfrequent episodic, frequent episodic, persistent

Interval symptoms:Interval symptoms:

Sleep disturbanceSleep disturbance

Early morning symptomsEarly morning symptoms

Exercise induced cough or wheezeExercise induced cough or wheeze


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EXAMINATIONEXAMINATIONVITAL:VITAL:

** General appearance/mental state** General appearance/mental state

** Work of breathing** Work of breathing

Respiratory rateRespiratory rate

Accessory muscle use/recessionAccessory muscle use/recession

Prolonged expiratory phaseProlonged expiratory phase HyperinflationHyperinflation

HELPFUL:HELPFUL:

Initial SaO2 in airInitial SaO2 in air

Heart rate

Heart rate Ability to talkAbility to talk

LESS RELIABLELESS RELIABLE

Wheeze intensityWheeze intensity

Pulsus paradoxusPulsus paradoxus

Peak expiratory flow rates are not reliablePeak expiratory flow rates are not reliable


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INVESTIGATIONSINVESTIGATIONS

Chest xChest x--ray:ray: Generally not required. Consider if:Generally not required. Consider if:

Concerns of complicationsConcerns of complications AtelecastsisAtelecastsis

PneumothoraxPneumothorax

PneumomedistinumPneumomedistinum PneuonniaPneuonnia

Signs:Signs: Fever > 38.5oCFever > 38.5oC

Focal examination findings (rales/decreased air entry)Focal examination findings (rales/decreased air entry)

Extreme tachypnea or tachycardiaExtreme tachypnea or tachycardia

Lack of response to asthma therapy to look for other processLack of response to asthma therapy to look for other processthat may mimic asthmathat may mimic asthma vascular ring; foreign body aspirationvascular ring; foreign body aspiration


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INVESTIGATIONSINVESTIGATIONS

Cap/arterial blood gases:Cap/arterial blood gases:

Children in respiratory distress with normal or elevated pCO2 areChildren in respiratory distress with normal or elevated pCO2 areat risk of imminent respiratory failure.at risk of imminent respiratory failure.

HOWEVER.HOWEVER.

Arterial blood gas (& spirometry) rarely required in childrenArterial blood gas (& spirometry) rarely required in children

Distressing and can cause a child with respiratory compromiseDistressing and can cause a child with respiratory compromiseto deteriorate furtherto deteriorate further

Child's clinical state is more important in guiding therapyChild's clinical state is more important in guiding therapy


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DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSIS

Cystic FibrosisCystic Fibrosis

Primary Ciliary DyskinesiaPrimary Ciliary Dyskinesia

Chronic bronchitisChronic bronchitis

Structural abnormalityStructural abnormality Vocal cord dysfunctionVocal cord dysfunction

Foreign bodyForeign body

Cardiac failureCardiac failure

HyperventilationHyperventilation--anxietyanxiety

Exertional dyspnoeaExertional dyspnoea AspirationAspiration


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AsthmaAsthma -- mildmild

Assessment:Assessment: * Normal mental state* Normal mental state

* Subtle or no accessory muscle use/recession* Subtle or no accessory muscle use/recession

SaO2 > 95% in air.SaO2 > 95% in air.

Able to talk normallyAble to talk normally

Management:Management: SalbutamolSalbutamol by MDI/spacerby MDI/spacer((dosedose)) -- once and review after 20 mins.once and review after 20 mins.

Salbutamol dose:Salbutamol dose: 6 puffs if < 6 years old,12 puffs if >6 years old6 puffs if < 6 years old,12 puffs if >6 years old

Good responseGood response -- discharge on B2discharge on B2--agonist as needed.agonist as needed.

Poor responsePoor response -- treat as moderate.treat as moderate. Consider oralConsider oral prednisoloneprednisolone (1 mg/kg daily for1(1 mg/kg daily for1--3 days)3 days)

Ensure device / technique appropriateEnsure device / technique appropriate

Written advice on what to do if symptoms worsenWritten advice on what to do if symptoms worsen

Follow upFollow up


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AsthmaAsthma -- moderatemoderate

ASSESMENTASSESMENT

* Normal mental state* Normal mental state

* Some accessory muscle use/recession* Some accessory muscle use/recession

SaO2 92SaO2 92--95% in air95% in air

May be reduced in absence of significant airway obstruction byMay be reduced in absence of significant airway obstruction byfactors such as atelectasis & mucous pluggingfactors such as atelectasis & mucous plugging

TachycardiaTachycardia

Some limitation of ability to talkSome limitation of ability to talk

MANAGEMENTMANAGEMENT O2O2 if saturation is < 92%if saturation is < 92%

SalbutamolSalbutamol by MDI/spacerby MDI/spacer -- 1 dose every1 dose every 20 ms for1 hour ;20 ms for1 hour ;review 10review 10--20 min after 3rd dose ?admission vs discharge20 min after 3rd dose ?admission vs discharge

PrednisolonePrednisolone (1 mg/kg daily for 3 days)(1 mg/kg daily for 3 days)


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AsthmaAsthma -- severesevereASSESSMENTASSESSMENT *Agitated/distressed*Agitated/distressed

* Moderate* Moderate--marked accessory muscle use/recessionmarked accessory muscle use/recession

SaO2SaO2 < 92% in air< 92% in air

TachycardiaTachycardia

Marked limitation of ability to talkMarked limitation of ability to talk

MANAGEMENTMANAGEMENT

OxygenOxygen

SalbutamolSalbutamol by MDI/spacerby MDI/spacer-- 1 dose1 dose ((dosedose)) everyevery 20 minutes for120 minutes for1hour.Review onhour.Review on--going requirements 10going requirements 10--20 min after 3rd dose20 min after 3rd dose

If improving reduce frequencyIf improving reduce frequency If no change continue 20 minutelyIf no change continue 20 minutely

If deteriorating at any stage treat as criticalIf deteriorating at any stage treat as critical

OralOral prednisoloneprednisolone (1 mg/kg daily)(1 mg/kg daily)

If vomiting give i.v.If vomiting give i.v.methylprednisolonemethylprednisolone

Ipratropium(Atrovent)Ipratropium(Atrovent)by MDI/spacerby MDI/spacer

(20mcg/puff:(20mcg/puff: 4 puffs if < 6 years old,4 puffs if < 6 years old, 8 puffs if >6 years old8 puffs if >6 years old


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AsthmaAsthma -- criticalcriticalASSESSMENTASSESSMENT

* Confused/drowsy* Confused/drowsy

* Maximal accessory muscle use/recession. Exhaustion* Maximal accessory muscle use/recession. Exhaustion

SaO2 < 90% in airSaO2 < 90% in air

Marked tachycardiaMarked tachycardia

Unable to talkUnable to talk

MANAGEMENTMANAGEMENT

OxygenOxygen

Continuousneb salbutamolContinuousneb salbutamol

Nebulised ipratropiumNebulised ipratropium 25

0mcg 3 times in

1st hr only (2

025

0mcg 3 times in

1st hr only (2

0minutely, added to salbutamol)minutely, added to salbutamol)

MethylprednisoloneMethylprednisolone 1 mg/kg i.v.61 mg/kg i.v.6--hourly.hourly.

Aminophylline:Aminophylline: If deteriorating or child is very sickIf deteriorating or child is very sick Loading dose:Loading dose: 10 mg/kg i.v. (max 500 mg) over60 min10 mg/kg i.v. (max 500 mg) over60 min

Unless markedly improved, follow with continuous infusion or6Unless markedly improved, follow with continuous infusion or6

hourly dosinghourly dosing


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AsthmaAsthma -- criticalcritical

Magnesiumsulphate:Magnesiumsulphate:

50% Mg Sulphate50% Mg Sulphate -- 0.1ml/kg (50mg/kg) over 20 mins, then0.1ml/kg (50mg/kg) over 20 mins, then0.06ml/kg/hr (30mg/kg/hour) by infusion0.06ml/kg/hr (30mg/kg/hour) by infusion

Aim to keep serum Mg between 1.5 and 2.5mmol/LAim to keep serum Mg between 1.5 and 2.5mmol/L

IV Salbutamol:IV Salbutamol:

5 mcg/kg/min for1hr as a load, followed by 15 mcg/kg/min for1hr as a load, followed by 1--2 mcg/kg/min.2 mcg/kg/min.

Beware toxicity: tachycardia, tachypnoea, metabolic acidosis.Beware toxicity: tachycardia, tachypnoea, metabolic acidosis.

Lactate commonly highLactate commonly high

Aminophylline, magnesiumAminophylline, magnesium & salbutamol must be given via& salbutamol must be given viaseparate IV lines.separate IV lines.

Intensive care admission for respiratory support (facemask CPAP,Intensive care admission for respiratory support (facemask CPAP,

BiPAP, or intubation/IPPV) may be needed.BiPAP, or intubation/IPPV) may be needed.


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GlucocorticoidsGlucocorticoids

SYSTEMICSYSTEMIC

Pred/methylpredPred/methylpred 1mg/kg1mg/kg

Decrease airway inflammation & secretionsDecrease airway inflammation & secretions

Relative CI: Hypersensitivity reactions; Varicella infections;Relative CI: Hypersensitivity reactions; Varicella infections;HSV keratitis (balance severity of bronchospasm vs risk)HSV keratitis (balance severity of bronchospasm vs risk)

INHALED (e.g: Pulmicort)INHALED (e.g: Pulmicort)

No role in paediatric acute asthma exacerbation!No role in paediatric acute asthma exacerbation!

Neither in addition to, or instead of, systemic glucocorticoidsNeither in addition to, or instead of, systemic glucocorticoids


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Magnesium SulphateMagnesium Sulphate

InexpensiveInexpensive

Minimal side effectsMinimal side effects

Readily availableReadily available

Useful in severe asthma that fails to respond to conventionalUseful in severe asthma that fails to respond to conventional

therapy of salbutamol & corticosteroidstherapy of salbutamol & corticosteroids


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??Other??Other

ANTIBIOTICSANTIBIOTICS

No benefit in acute asthma exacerbationsNo benefit in acute asthma exacerbations

May be necessary if coMay be necessary if co--existing infectionsexisting infections

(pneumonia/sinusitis)(pneumonia/sinusitis)

CHEST PHYSIOTHERAPYCHEST PHYSIOTHERAPY

No benefitNo benefit

May subject child to unnecessary stressMay subject child to unnecessary stress


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ASTHMAASTHMA -- CLASIFICATIONCLASIFICATION

Infrequent episodic (70Infrequent episodic (70--75%)75%)

attacks > 6 weeks apartattacks > 6 weeks apart

no symptoms between attacksno symptoms between attacks

normal examination and lung function between attacksnormal examination and lung function between attacks often seasonal (winter months)often seasonal (winter months)

By 10yo 40% will have stopped wheezing altogether, mayBy 10yo 40% will have stopped wheezing altogether, mayhave persistent bronchial hyperreactivityhave persistent bronchial hyperreactivity

Majority have little if no symptoms in adults life. A smallMajority have little if no symptoms in adults life. A smallnumber may have more troublesome symptoms as adults.number may have more troublesome symptoms as adults.

Usually normal interval PFTsUsually normal interval PFTs


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ASTHMAASTHMA -- CLASIFICATIONCLASIFICATION

Frequent episodic: (20Frequent episodic: (20--25%)25%)

Attacks < 6 weeks apartAttacks < 6 weeks apart

No interval symptomsNo interval symptoms

Often seasonal (winter months)Often seasonal (winter months)

Usually starts prior to age 3Usually starts prior to age 3

Initially viral URTIs are triggerInitially viral URTIs are trigger

By age 6/7 exercise, allergens, weatherBy age 6/7 exercise, allergens, weather

2020--30% will have an abnormal FEV1 during childhood, but only30% will have an abnormal FEV1 during childhood, but only

about 15% in adulthoodabout 15% in adulthood


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ASTHMAASTHMA CLASIFICATIONCLASIFICATION

Persistent asthma (5Persistent asthma (5--10%)10%)

25% wheeze prior to 6/1225% wheeze prior to 6/12

Often worst between 8Often worst between 8--14 yrs14 yrs

Usually persistently abnormal PFTsUsually persistently abnormal PFTs

5% will become totally wheeze free in adult life,15% trivial,5% will become totally wheeze free in adult life,15% trivial,

>50% have very frequent or persistent asthma>50% have very frequent or persistent asthma

Small proportion will develop irreversible airways obstruction inSmall proportion will develop irreversible airways obstruction in

adulthoodadulthood


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PREVENTERSPREVENTERS

Consider preventive treatment if:Consider preventive treatment if:

There are frequent acute episodes orThere are frequent acute episodes or

Chronic symptomsChronic symptoms

More than one disturbed night per weekMore than one disturbed night per week Difficulty participating in physical activitiesDifficulty participating in physical activities

Or bronchodilator use on more than one day per weekOr bronchodilator use on more than one day per week


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SteroidsSteroids

Fluticasone (Flixotide): Recommended starting dose is 200 ug/dayFluticasone (Flixotide): Recommended starting dose is 200 ug/dayin 2 divided dosesin 2 divided doses

Side effects:Side effects:

Oral candidiasisOral candidiasis PharyngitisPharyngitis

Hoarse voiceHoarse voice

Marked adrenal suppression said to occur with doses >1500ugMarked adrenal suppression said to occur with doses >1500ugper day (750 ug of fluticasone)per day (750 ug of fluticasone)

GrowthGrowth effect on growth is said to occur mainly in the firsteffect on growth is said to occur mainly in the firstyear of treatment, with gradual catch up , and no significantyear of treatment, with gradual catch up , and no significanteffect on adult heighteffect on adult height

No effect seen on bone mineral density with long term inhaledNo effect seen on bone mineral density with long term inhaledcorticosteroidscorticosteroids


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LongactingLongacting

bronchodilatorsbronchodilators LABA: Salmeterol (Serevent)LABA: Salmeterol (Serevent)

Combination with ICSCombination with ICS

SeretideSeretide

SymbicortSymbicort


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LEUKTORIENE RECEPTOR ANTAGONISTSLEUKTORIENE RECEPTOR ANTAGONISTS

Singulair;Singulair; available as a chewable tabletavailable as a chewable tablet

Mild persistent asthmaMild persistent asthma

Not as effective as ICS though ?role as steroid sparing agentNot as effective as ICS though ?role as steroid sparing agent

Role in allergic rhinitis & nasal polypsRole in allergic rhinitis & nasal polyps

No role in acute asthma exacerbationNo role in acute asthma exacerbation


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DISCHARGEDISCHARGE

Each child should have a written action planEach child should have a written action plan

Observe inhaler technique before dischargeObserve inhaler technique before discharge

Advise parents to return if the patients condition deteriorate or ifAdvise parents to return if the patients condition deteriorate or ifthere is no significant improvement within 48 hoursthere is no significant improvement within 48 hours


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CRITERIA FOR ADMISSIONCRITERIA FOR ADMISSION

(1) Salbutamol more of then 2(1) Salbutamol more of then 2--3 hours3 hours

(2) Not improved after administration of systemic glucosteroids(2) Not improved after administration of systemic glucosteroids

(3) Oxygen requirement(3) Oxygen requirement

Other considerations:Other considerations:

A history of rapid progression of severity in past exacerbationsA history of rapid progression of severity in past exacerbations

Poor adherence with outpatient medication regimenPoor adherence with outpatient medication regimen

Inadequate access to medical careInadequate access to medical care Poor social support at homePoor social support at home


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TRICKY QUESTIONSTRICKY QUESTIONS

Question 1Question 1

If a child has infrequent episodic asthmaIf a child has infrequent episodic asthmaassociated with viral respiratoryassociated with viral respiratoryinfections, would inhaled corticosteroidsinfections, would inhaled corticosteroidsdecrease the frequency and severity ofdecrease the frequency and severity ofthe exacerbations?the exacerbations?


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Answer: No!Answer: No!

Benefits are well established for use of maintenanceBenefits are well established for use of maintenance

ICS in persistent asthmaICS in persistent asthma

Well documented in adults and children that lowWell documented in adults and children that lowdose maintenance ICS reduces the number ofdose maintenance ICS reduces the number ofasthma exacerbations by ~45%asthma exacerbations by ~45%

NEJMNEJM2000: 343:10542000: 343:1054

In children with infrequent episodic asthma,In children with infrequent episodic asthma,maintenance ICS does not reduce the frequency ormaintenance ICS does not reduce the frequency orseverity of viral respiratory infection inducedseverity of viral respiratory infection induced

exacerbations of asthmaexacerbations of asthma


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If a child is not on an inhaledIf a child is not on an inhaled

corticosteroid, would commencing themcorticosteroid, would commencing them

at the start of a viral respiratory infectionat the start of a viral respiratory infection

reduce the risk or severity of anreduce the risk or severity of anexacerbation of asthma?exacerbation of asthma?


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No!No!

High dose ICS at the commencement of a viralHigh dose ICS at the commencement of a viralrespiratory infection does not reduce the needrespiratory infection does not reduce the needfor intervention with oral corticosteroids orfor intervention with oral corticosteroids orhospitalisation in asthma exacerbationhospitalisation in asthma exacerbation


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QUESTION 3QUESTION 3

If a child with frequent interval symptomsIf a child with frequent interval symptoms

is put on ICS will the frequency andis put on ICS will the frequency and

severity of viral respiratory infectionseverity of viral respiratory infection

associated exacerbations be reduced?associated exacerbations be reduced?


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Yes!Yes!

Use of inhaled corticosteroids in a childUse of inhaled corticosteroids in a child

with frequent interval symptoms willwith frequent interval symptoms will

reduce the frequency and severity of viralreduce the frequency and severity of viral

respiratory infection associatedrespiratory infection associatedexacerbations in addition to the beneficialexacerbations in addition to the beneficial

effect on interval symptomseffect on interval symptoms


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If a child is on inhaled corticosteroidsIf a child is on inhaled corticosteroids

would increasing the dose during a viralwould increasing the dose during a viral

respiratory infection decrease the risk orrespiratory infection decrease the risk or

severity of exacerbation?severity of exacerbation?


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No!No!

The available evidence shows noThe available evidence shows no

reduction in risk or severity ofreduction in risk or severity of

exacerbations with a doubled dose ofexacerbations with a doubled dose of

inhaled corticosteroids during a viralinhaled corticosteroids during a viralrespiratory infection.respiratory infection.


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QUESTION 5QUESTION 5

Do oral corticosteroids given with viral respiratoryDo oral corticosteroids given with viral respiratory

infections (or at the onset of an exacerbation)infections (or at the onset of an exacerbation)reduce the risk or severity of an exacerbation?reduce the risk or severity of an exacerbation?


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Yes!Yes!

Administration of oral corticosteroids atAdministration of oral corticosteroids at

home early in a viral respiratory infectionhome early in a viral respiratory infection

induced exacerbation of asthma isinduced exacerbation of asthma is

effective in reducing the severity/risk ofeffective in reducing the severity/risk ofthe exacerbation.the exacerbation.


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AsthmaAsthma -- ResourcesResources

You:You:

http://www.rch.org.au/clinicalguide/cpg.cfm?http://www.rch.org.au/clinicalguide/cpg.cfm?

doc_id=5251doc_id=5251

Parents:Parents:

http://www.rch.org.au/kidsinfo/factsheets.cfmhttp://www.rch.org.au/kidsinfo/factsheets.cfm

?doc_id=3714?doc_id=3714 http://www.nationalasthma.org.au/http://www.nationalasthma.org.au/


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