Copy of Copy of Asthma

Asthma in children
Asthma
-Immune Inflammatory, toxins, infections, inhaled substances.
Activates mast cells, lymphocytes. t- leukocytes, macrophages, eosinophis.


Assess severity
Moderate

Able to talk in sentences
Sp0² ≥ 92%
PEF ≥ 50% best or predicted
Heart rate ≤ 140 child aged 2-5 years
≤ 125 child aged > 5 years
Resps ≤ 40/min child aged 2-5 years
≤ 30/min child aged > 5 years

First line treatment

Salbutamol
Prednisolone
Ipratroprium Bromide (Atrovent)

contraction smooth muscle
oedema as capillary walls dilate and leak
inc secretions
dec mucous clearance
epthelial cells shred and mix with mucous forming thick plugs
Inflammation
Bronchial hyper-responsiveness
Bronchospasm

What do we see?
Wheezy
Chest tightness
Changes in respiratory rate
Decreased oxygen saturations
Recession (use of accessory muscles)
Decreased air entry on auscultation
Not able to talk in sentences
Coughing
Cyanosis
Tired, lethargic, exhausted
Looking anxiety, fearful, frightened
“Tripod” position, prefer to sit upright
PEFR reduced (if old enough to perform test)

Acute severe
Can’t complete sentences in one breath or to breathless to talk or feed
Sp0² < 92%
PEF 33-50% best or predicted
Pulse > 140 child aged 2-5 years
> 125 child aged > 5 years
Resps > 40 breaths/min aged 2-5 years
> 30 breaths/min aged > 5 years

Life threatening
Silent chest
Cyanosis
Poor respiratory effort
Hypotension
Exhaustion
Confusion
Sp0² < 92%
PEF < 33% best or predicted

Second line treatment
IV Salbutamol
IV Magnesium
IV Aminphylline
IV Hydrocortisone

Features that inc probability
More than one of the following:
wheeze, cough, difficulty breathing,
tight chest
Symptoms are frequent and recurrent
Worse at night and early morning
Worse after exercise or exposure to
allergens
Family history of atopic disorder
Personal history of atopic disorder
Widespread wheeze on chest
auscultation
Response to therapy or
improvement of symptom
Lowering the probability
Symptoms occur with colds only
History of a moist cough
Normal physical examination when symptoms present
Normal PEFR
No response to medicine trial
Clinical features indication differential diagnosis

Meds
Beta² Agonists
Bronchodilators
First line treatment for asthma
Nebuliser or spacer and in HDU IV

Salbutamol; Terbutaline; Salmeterol (long acting)
Side effects: tachycardia, tremors, headache, lowers potassium.
Can be repeated every 20-30mins


Antimuscarinic Bronchodliator
(Ipratropium Bromide “Atrovent”)
Blocks muscarinic receptors in the broncthi therefore reduces smooth muscle contraction
Reduces mucus secretion
Dose can be repeated in acute asthma every 20-30 mins for the first 2 hour
s


Corticosteroids

Ant-inflammatory plus
enhance actions of
beta²adrenoceptors

Under the age of 5,
the use of leukotriene
receptor antagonists,
1st add on choice
over inhaled
steroids.


Leukotrine Receptor Antagonists
(“Montelukast”)

Inhibits leukotrienes, act on the
receptors of bronchial smooth muscle

Added into treatment plans for persistant poor control and after alonger acting bronchodilator has been trialled, not used for acute exacerbation

In children under 5 years who cannot take inhaled
steroids, these may be used as an alternative

Should be used alongside steroid therapy

Meds
Meds
Physiology
Meds
https://www.brit-thoracic.org.uk/standards-of-care/guidelines/btssign-british-guideline-on-the-management-of-asthma/
https://www.nice.org.uk/guidance/qs25
http://dontforgetthebubbles.com/asthma-medical-management/

A 9 year old boy is rushed into ED with what is clearly a severe exacerbation of his asthma. His sats are 80%, his RR is 60-70 and he is not looking great. You can hear some air entry with a bit of wheeze. He clearly needs some good treatment and he needs it quickly. Which drugs you choose? What is the evidence for asthma treatment and what are the principles of managing the critical asthmatic?

http://emergencymedicineireland.com/2013/05/the-crashing-asthmatic/

http://www.thecochranelibrary.com/view/0/browse.html?cat=ccochlungsasthmaacute
https://www.nice.org.uk/guidance/conditions-and-diseases/respiratory-conditions/asthma