Asthma/ Wheeze and children - PowerPoint Presentation

1. Asthma/ Wheeze and children Sanarya Namuq16/10/20161

2. Pre lecture QuizDefinition of AsthmaViral induced wheezeSeverity of asthmaManagementStepwise management of chronic asthma Indications of referralResults of quiz Objectives 16/10/20162

3. Pre-testA 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 moderateModerate to severeLife threateningA 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 gasChest x rayMeasurement of peak flowYou 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 ambulanceRefer her to hospital as a routine admissionAssess her response to the salbutamol inhalerWhat 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 nebuliserBy pressurised metered dose inhaler and spacerBy pressurised metered dose inhaler without a spacerA 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 moderateModerate severeLife threatening16/10/20163

4. 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 aminophyllineAn 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 tabletRefer to a respiratory paediatricianIncrease the budesonide/formoterol inhaler 100/6 to 2 puffs twice dailyA 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 theophyllineAdd in a beclometasone inhaler 100 µg twice dailyAdd in a long acting beta 2 agonist16/10/20164

5.  Asthma is a chronic inflammatory disease of the airways, associated with widespread, variable outflow obstruction.  Features: WheezeCoughDifficulty breathingChest tightnessThe outflow obstruction reverses either spontaneously or with medications. Definition 16/10/20165

6. 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.Viral induced wheeze: 16/10/20166

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 flowNormal lung function tests (including peak flow) when symptomatic.History of symptom or lung function improvement after adequate therapyNo response to asthma treatment .16/10/20167

8. 2 to 5 yearsOver 5 yearsMild- ModerateSpO2 ≥92% on airMild respiratory distressRespiratory rate ≤40/minHR ≤140/minAble to talk and feedSpO2 ≥92% on airPEFR ≥50% best or predictedRespiratory rate ≤30/minHR ≤125/minAble to talkModerate-SevereSpO2 <92% on airToo breathless to feed or talkRespiratory rate >40/minHR >140 /minUse of accessory musclesSpO2 <92% on airPEFR <33 to 50% best or predictedRespiratory rate >30/minHR >125/minUse of accessory musclesLife-threateningSpO2 <92% on air plus any of:CyanosisSilent chestPoor respiratory effortFatigue or exhaustionAgitation or reduced level of consciousnessSpO2 <92% on air plus any of:CyanosisSilent chestPoor respiratory effortFatigue or exhaustionPEFR <33% best or predictedAgitation or reduced level of consciousness16/10/20168Severity

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10. 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 treatment16/10/201610

11. Management of chronic asthma 16/10/201611

12. Adult and child over 5 yearsStep 1—Mild intermittent asthmaStart inhaled short-acting beta2 agonist Step 2—Regular preventer therapyStart 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 therapyConsider adding a regular inhaled long-acting beta2 agonist (LABA) such as formoterol fumarate or salmeterol to be used in conjunction with an inhaled corticosteroidIf 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 controlIncrease 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 12

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 preventerChild 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 corticosteroidIn children under 2 years then refer Step 4—Persistent poor control Refer child to respiratory paediatrician13

14.  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.16/10/201614Stepping down

15. Diagnosis unclearSymptoms present from birth or a perinatal lung problem.Excessive vomitingSevere 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.16/10/201615Indiations for Referral

16. Results 16/10/201616

17. 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 16/10/201617

18. 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 ambulanceRefer her to hospital as a routine admissionAssess 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 spacerBy pressurised metered dose inhaler without a spacer 16/10/201618

19. 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 severeLife 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 16/10/201619

20. 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 paediatricianIncrease 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 dailyAdd in a long acting beta 2 agonist 16/10/201620

21. BMJNICEBNFEmergency medicine 16/10/201621References

22. THANK YOU ANY Q16/10/201622