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

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 16/09/2018

10. 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

11. Management of chronic asthma
16/09/2018

12. 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

13. 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

14. 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

15. 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

16. Results
16/09/2018

17. 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

18. 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

19. 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

20. 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

21. References
BMJ NICE BNF Emergency medicine
16/09/2018

22. THANK YOU
ANY Q
16/09/2018