Asthma/ Wheeze and children Sanarya Namuq 16/09/2018

Objectives Pre lecture Quiz Definition of Asthma Viral induced wheeze Severity of asthma Management Stepwise management of chronic asthma Indications of referral Results of quiz 16/09/2018

Measurement of peak flow Pre-test A 6 year old girl presents to your surgery with shortness of breath and wheeze. Her heart rate is 120 beats per minute, her respiratory rate is 28 breaths per minute, and her oxygen saturations are 94% on air. She is able to talk in sentences. How would you grade the severity of her exacerbation? Mild to moderate Moderate to severe Life threatening A 7 year old boy with known asthma presents with shortness of breath and wheeze. He can talk in full sentences, his heart rate is 125 beats per minute, his respiratory rate is 25 breaths per minute, and his oxygen saturations are 95% on air. What investigation should you do? Blood gas Chest x ray Measurement of peak flow You see a 4 year old girl with a mild exacerbation of her asthma. She is afebrile, her respiratory rate is 30 breaths per minute, her heart rate is 130 beats per minute, and her oxygen saturations are 94% on air. You give her a salbutamol inhaler via a spacer. What should you do next? Refer her to hospital immediately by ambulance Refer her to hospital as a routine admission Assess her response to the salbutamol inhaler What is the best method of delivering a beta 2 agonist to a 7 year old child with an exacerbation of their asthma that is mild-moderate in severity? By nebuliser By pressurised metered dose inhaler and spacer By pressurised metered dose inhaler without a spacer A 12 year old girl who is known to have asthma presents to the emergency department with shortness of breath and wheeze. Her oxygen saturations are 88% on air, heart rate 140 beats per minute, and respiratory rate 40 breaths per minute. She has very poor air entry bilaterally and is becoming increasingly agitated. On the basis of the above, how would you grade the severity of her exacerbation? Mild moderate Moderate severe 16/09/2018

Intravenous aminophylline In a child with a life threatening exacerbation of asthma which of the following is the first choice for intravenous treatment? Intravenous salbutamol or magnesium sulphate (bolus followed by infusion) Intravenous aminophylline An 8 year old boy presents to your surgery because he is having frequent exacerbations of his asthma needing multiple courses of oral steroids. His current medications are terbutaline 500 µg as required (via a turbohaler) and a combination inhaler containing budesonide and formoterol (100/6 1 puff twice daily. What should you do next? Add in a daily steroid tablet Refer to a respiratory paediatrician Increase the budesonide/formoterol inhaler 100/6 to 2 puffs twice daily A 4 year old boy has frequent exacerbations of his asthma that occur with viral upper respiratory tract infections. He has a nocturnal cough between exacerbations. He currently uses a salbutamol inhaler (with a spacer and facemask) as required. He needs to use this daily. What should you do next? Add in oral theophylline Add in a beclometasone inhaler 100 µg twice daily Add in a long acting beta 2 agonist 16/09/2018

Definition   Asthma is a chronic inflammatory disease of the airways, associated with widespread, variable outflow obstruction. Features: Wheeze Cough Difficulty breathing Chest tightness The outflow obstruction reverses either spontaneously or with medications. 16/09/2018

Viral induced wheeze: Episodes of wheezing, cough and difficulty breathing associated with viral upper respiratory tract infections (URTIs) with no persisting symptoms. Common in infants and preschool children Most, however, will have stopped having recurrent symptoms by school entry. 16/09/2018

Asthma more likely Asthma less likely . More than one of: Wheeze. Cough. Difficulty breathing. Chest tightness. Symptoms only occurring in conjunction with colds; no interval symptoms. Particularly when: Frequent and recurrent symptoms. Worse at night and in the early morning. Occurring in response to stimuli/ triggers Isolated cough without wheeze or breathing difficulties. Personal history of atopy. History of productive cough. Family history of atopy or asthma. Normal respiratory examinations when symptomatic. Abnormal Peak flow Normal lung function tests (including peak flow) when symptomatic. History of symptom or lung function improvement after adequate therapy No response to asthma treatment . 16/09/2018

Severity 2 to 5 years Over 5 years Mild- Moderate SpO2 ≥92% on air Mild respiratory distress Respiratory rate ≤40/min HR ≤140/min Able to talk and feed SpO2 ≥92% on air PEFR ≥50% best or predicted Respiratory rate ≤30/min HR ≤125/min Able to talk Moderate-Severe SpO2 <92% on air Too breathless to feed or talk Respiratory rate >40/min HR >140 /min Use of accessory muscles SpO2 <92% on air PEFR <33 to 50% best or predicted Respiratory rate >30/min HR >125/min Use of accessory muscles Life-threatening SpO2 <92% on air plus any of: Cyanosis Silent chest Poor respiratory effort Fatigue or exhaustion Agitation or reduced level of consciousness SpO2 <92% on air plus any of: Cyanosis Silent chest Poor respiratory effort Fatigue or exhaustion PEFR <33% best or predicted Agitation or reduced level of consciousness 16/09/2018

16/09/2018

so you should not request them routinely so you should not request them routinely. Patients need a chest x ray if there is subcutaneous emphysema, persisting unilateral signs suggesting pneumothorax, lobar collapse, or consolidation and/or life threatening asthma not responding to treatment 16/09/2018

Management of chronic asthma 16/09/2018

Adult and child over 5 years Step 1—Mild intermittent asthma Start inhaled short-acting beta2 agonist Step 2—Regular preventer therapy Start the inhaled corticosteroid at a dose appropriate to severity of disease and adjust to the lowest effective dose Adult and child over 12 years: 200–800 micrograms/day beclometasone dipropionate  Child 5–12 years: 200–400 micrograms/day beclometasone dipropionate  Step 3—Initial add-on therapy Consider adding a regular inhaled long-acting beta2 agonist (LABA) such as formoterol fumarate or salmeterol to be used in conjunction with an inhaled corticosteroid If the patient is gaining some benefit from addition of a LABA but control is inadequate then continue the LABA and increase dose of inhaled corticosteroid to top end of inhaled standard-dose corticosteroid range. If there is no response to the LABA, discontinue and increase dose of inhaled corticosteroid. If control is still inadequate, start a trial of either a leukotriene receptor antagonist (montelukast,) Step 4—Persistent poor control Increase dose of inhaled corticosteroid Add a leukotriene receptor antagonist , Adult and child over 12 years: up to 2000 micrograms/day beclometasone dipropionate  Child 5–12 years: up to 800 micrograms/day beclometasone dipropionate  Before proceeding to step 5, refer Step 5— Add regular oral corticosteroid (prednisolone, as single daily dose) at lowest dose continue high-dose inhaled corticosteroid

Child under 5 years Step 1—Mild intermittent asthma   Inhaled short-acting beta2 agonist Step 2—Regular preventer therapy Consider adding regular standard-dose inhaled corticosteroid If the child is unable to take an inhaled corticosteroid, a leukotriene receptor antagonist (such as montelukast) is an effective first-line preventer Child under 5 years: 200–400 micrograms/day beclometasone dipropionate  Step 3—Initial add-on therapy  In children 2–5 years, add a leukotriene receptor antagonist if not added during step 2. If a leukotriene receptor antagonist was added at step 2, reconsider addition of standard-dose inhaled corticosteroid In children under 2 years then refer Step 4—Persistent poor control  Refer child to respiratory paediatrician

Stepping down Patient should be maintained at the lowest possible dose of inhaled corticosteroid. Reductions should be considered every three months, decreasing the dose by approximately 25–50% each time. Reduce the dose slowly as patients deteriorate at different rates. 16/09/2018

Indiations for Referral Diagnosis unclear Symptoms present from birth or a perinatal lung problem. Excessive vomiting Severe URTI. Nasal polyps. Unexpected clinical findings (eg, focal chest signs, abnormal cry or voice, dysphagia, stridor). Failure to respond to conventional treatment (especially corticosteroids above 400 micrograms/day). Frequent use of oral steroids. 16/09/2018

Results 16/09/2018

Measurement of peak flow 1.A 6 year old girl presents to your surgery with shortness of breath and wheeze. Her heart rate is 120 beats per minute, her respiratory rate is 28 breaths per minute, and her oxygen saturations are 94% on air. She is able to talk in sentences. How would you grade the severity of her exacerbation? Mild to moderate Moderate to severe Life threatening 2.A 7 year old boy with known asthma presents with shortness of breath and wheeze. He can talk in full sentences, his heart rate is 125 beats per minute, his respiratory rate is 25 breaths per minute, and his oxygen saturations are 95% on air. What investigation should you do? Blood gas Chest x ray Measurement of peak flow 16/09/2018

Refer her to hospital immediately by ambulance 3.You see a 4 year old girl with a mild exacerbation of her asthma. She is afebrile, her respiratory rate is 30 breaths per minute, her heart rate is 130 beats per minute, and her oxygen saturations are 94% on air. You give her a salbutamol inhaler via a spacer. What should you do next? Refer her to hospital immediately by ambulance Refer her to hospital as a routine admission Assess her response to the salbutamol inhaler 4.What is the best method of delivering a beta 2 agonist to a 7 year old child with an exacerbation of their asthma that is mild-moderate in severity? By nebuliser By pressurised metered dose inhaler and spacer By pressurised metered dose inhaler without a spacer 16/09/2018

Intravenous aminophylline 5.A 12 year old girl who is known to have asthma presents to the emergency department with shortness of breath and wheeze. Her oxygen saturations are 88% on air, heart rate 140 beats per minute, and respiratory rate 40 breaths per minute. She has very poor air entry bilaterally and is becoming increasingly agitated. On the basis of the above, how would you grade the severity of her exacerbation? a.Mild moderate Moderate severe Life threatening In a child with a life threatening exacerbation of asthma which of the following is the first choice for intravenous treatment? Intravenous salbutamol or magnesium sulphate (bolus followed by infusion) Intravenous aminophylline 16/09/2018

a.Add in a daily steroid tablet Refer to a respiratory paediatrician 7.An 8 year old boy presents to your surgery because he is having frequent exacerbations of his asthma needing multiple courses of oral steroids. His current medications are terbutaline 500 µg as required (via a turbohaler) and a combination inhaler containing budesonide and formoterol (100/6 1 puff twice daily. What should you do next? a.Add in a daily steroid tablet Refer to a respiratory paediatrician Increase the budesonide/formoterol inhaler 100/6 to 2 puffs twice daily 8.A 4 year old boy has frequent exacerbations of his asthma that occur with viral upper respiratory tract infections. He has a nocturnal cough between exacerbations. He currently uses a salbutamol inhaler (with a spacer and facemask) as required. He needs to use this daily. What should you do next? a.Add in oral theophylline Add in a beclometasone inhaler 100 µg twice daily Add in a long acting beta 2 agonist 16/09/2018

References BMJ NICE BNF Emergency medicine 16/09/2018

THANK YOU ANY Q 16/09/2018