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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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Question 2Question 2
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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Question 4Question 4
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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ThankThank--youyou
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