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ASTHMA - LECTURE Assessing Dyspnoeic Child History o Normal Hx, past treatment, dosages, method of delivery, previous hospitalisations,

ICU, ED Exam o Normal SaO2 in children: >95% o Normal RR: 1-5 yrs (20-30), 5-10 yrs (15-25), 10-16 yrs (15-20) o LOC/level of alertness o Speech o Signs of distress: subcostal/intercostal recession, nasal flaring, tracheal tug, head bobbing, grunting, accessory muscle uses, increased RR. o Chest: air entry, wheeze, stridor, bronchial breath sounds, symmetry, Harrisons sulcus o Others: Liver ptosis Investigations o Resp function: not usually done in children, unreliable unless >6 yrs old o Bloods: FBC, EUCs o Challenge tests: generally not done o Allergy tests: RAST test o CXR: do not perform if presenting during an acute asthma attack, but should be done in a child presenting with 1st episode of suspected asthma e.g might find incidentally a foreign body and other extrinsic causes of wheezing other than asthma e.g mediastinal lymphomas, increased mediastinum, congenital diaphragmatic hernia, cyst. Also perform if suspecting pneumothorax, pneumonia, suspected severe/life threatening asthma or if uncertain of diagnosis

DDX for Wheeze CF Suppurative Lung Disease e.g Bronchiectasis Transient infant wheezing Bronchiolitis Obliterans Cardiac Failure Vocal cord dysfunction Foreign body

Factors suggestive of Asthma Diagnosis Especially if seasonal/recurrent, worse at night or in the morning, triggered by exercise, infections, or irritants. Response to bronchodilators

Asthma Treatment 1. 2. 3. 4. Relievers Preventers to reduce frequency and severity and prevent symptoms between attacks Symptom Controllers Combination Therapy

Relievers Beta2-agonists o E.g (Ventolin/Salbutamol (blue), Airomir, Respolin, Asmol, Bricanyl (Terbutaline). o When inhaled, they should provide relief within 10 minutes. These medications also come in tablets and syrups, but take longer to work and the larger dose means children may have more SFx, including slight tremors, increase in HR, nervousness, excitability.. o Salbutamol - IV salbutamol is not more efficacious than inhaled. IV improves outcome if given early in servere asthma unresponsive to inhaled salbutamol. Oral should not be used. Weaning salbutamol usually done 4th hourly 6th hourly BD cease. Anti-Cholinergics o E.g Ipratropiu Bromide (Atrovent) o These are often given in combination with medictions such as ventolin to increase their effectiveness. Atrovent may take up to 30 mins to work so should not be taken along if in resp distress. They are used more commonly for other lung conditions e.g COPD. SFx include dry mouth, agitation if taken in excessive doses, glaucoma. Theophylline (Nuelin tablets or syrup) o Low toxic, therapeutic index but used if resistant to other drugs. It has bronchodilator, anti-inflammatory, and positive chronotropic and ionotropic effect (so increases BP, renal blood flow. Aminophylline (compound of theophylline with ethylenediamine)- IV aminophylline improves spirometry and symptoms but not length of hospital stay, nor need for inhaled bronchodilator therapy. It may cause increased vomiting.

Preventers Corticosteroids o Steroids reduce mucous and inflammation and increase the effectiveness of bronchodilators. Use of corticosteroids within the first hr for acute asthma in the ED reduces admission rates, most notably in those with more severe asthma. A short course of corticosteroids in an acute exacerbation of asthma significantly reduces the relapse rate. The efficacy of inhaled vs systemic vs combined inhaled and systemic is not proven. Corticosteroids are usually stopped after 3 days. Types o Inhaled corticosteroids: Flixatide, Pulmicort, Qvar o Oral Corticosteroids:(Prednisone,Prednisolone, Redipred, Predmix). Oral steroids are most commonly used in short courses during episodes of wheezing not controlled with reliever medication. They also increase the effectiveness of reliever medication. They work within hours, but may take dyas or weeks to get benefit from them. SFx include increased appetite, facial edema, weight gain, slow growth, hypertension, behavioural changes. These do not occur if taken for less than 2 weeks. Also if taken long term, live vaccines should be given with caution esp polio, measles, rubella. Some viral infections e.g chickenpox may be more severe in children taking prednisolone/prednisone. o IV Corticosteroids: Hydrocortisone SFx of inhaled corticosteroids o High doses associated with growth suppression although max of 1cm and is non progressive o Adrenal suppression o Thrush Leukotriene antagonists (Montelukast, Zafirlukast) o These may be used as additional treatment in children with troublesome asthma who continue to have symptoms of asthma who continue to have symptoms of asthma despite corticosteroids or those with exercse induced asthma. Come in tablet form so good preventer in those who struggle with inhalers or prefer not to use them. o SFX: headache, gastrointestinal upsets. Na Cromoglycate (Intal, Intal Forte)/Nedocromil Na (Tilade) o These work within minutes, but may take up to several weeks before full effect of medication is noticed. These only work when taken regularly over months and are not helpful as a relieving medication during an acute asthma attack. They prevent asthma symptoms instead. o SFx : minor throat irritation, cough, nausea, headaches, cough Anti-immunoglobulin therapy Macrolides

Symptom Controllers Long acting beta agonist (LABAs e.g Salmeterol, Eformeterol). o These are used in patients who experience regular asthma symptoms despite using inhaled corticosteroids or regular oral corticosteroids. They work for 12 hours but because they dont treat the underlying inflammation, they should be used in addition to preventer medication. These also have the possibility of tachyphylaxis: decreased upregulation of receptors decreased effect over time, and hence not given as monotherapy.

Combination Seretide (preventer fluticasone + symptom controller salmeterol) Symbicort (Preventer budesonide + Symptom controller eformoterol) o Because these medications are taken twice a day using an inhaler over a long period of time, combining the two makes it easier to take. Note: that first line for children requiring a prevent should be inhaled corticosteroid at an appropriate dose.

Devices Small volume spacer Large volume spacers Nebuliser MDI with spacer: as effective as nebulise in mild to moderate asthma. MDI spaces may be better tolerated by some children and use of a spacer offers the advantage of facilitating family education in spacer use while the child is in hospital, which may assist with long term home management. MDIs with spacers produce outcomes that are at least equivalent to nebuliser delivery. Holding chambers could have some advantages compared to nebulisers for children with acute asthma including shorter length of stay in emergency and lower pulse rates. Equivalent efficacy is obatinaed with an MDI doser around 1/6 of that used in nebulisation. Therefore 4-6 x 100 microgram doses via MDI is equivalent to 2.5mg via nebuliser and 8-12 x 100 micrograms via MDI is equivalent to 5mg nebulised. Accuhaler: from 6-8 yrs Turbohaler

Note: - All children with life threatening or persisting severe asthma will require consultation with senior medical officers (local, NETS or your local retrieval service, or tertiary referral centre) and transfer to a Childrens hospital.