investigation asthma

7/27/2019 Investigation Asthma

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Investigation

Usually diagnosed from the history and examination and no investigations are needed.

History Taking

Current symptoms

Pattern of symptoms

Precipitating factors Present treatment

Previous hospital admission

Typical exacerbations

Home/ school environment

Impact on life style

History of atopy (allergy) Response to prior treatment

Prolonged URTI symptoms

Family history


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Sometimes, specific investigations are required to confirm the diagnosis, or explore

the severity and phenotype in more detail.

Pulmonary Function Testing:

I. Spirometry

II. Bronchoprovocation challenges (To see whether

your airway is hyper responsive)

III. Exercise challenges

IV. Peak expiratory flow (PFE). (Most children over 5years of age can use a peak flow meter)

Radiology: Chest Radiographs

Allergy testing (Skin-prick testing )


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Management

Management

Acute

Chronic


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Mild attacks can be usually treated at home if the patient is prepared and has

a personal asthma action plan.

Moderate and severe attacks require clinic or hospital attendance.

Asthma attacks require prompt treatment.

A patient who has brittle asthma, previous ICU admissions for asthma or with

parents who are either uncomfortable or judged unable to care for the child

with an acute exacerbation should be admitted to hospital.

Managing Acute Exacerbations


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Failure to respond to standard home treatment.

Failure of those with mild or moderate acute asthma

to respond to nebulized -agonists.

Relapse within 4 hours of nebulized - agonists.

Severe acute asthma.

Criteria for Admission


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Monitoring Acute Asthma Monitor pulse, color, PEFR, ABG and O2 Saturation. Close monitoring for at least 4 hours.

Hydration - give maintenance fluids.

Role of Aminophylline debated due to its potential toxicity. To be used with caution, in a

controlled environment like ICU.

IV Magnesium Sulphate : Consider as an adjunct treatment in severe exacerbations

unresponsive to the initial treatment. It is safe and beneficial in severe acute asthma.

Avoid Chest physiotherapy as it may increase patient discomfort.

Antibiotics indicated only if bacterial infection suspected.

Avoid sedatives and mucolytics.

Efficacy of prednisolone in the first year of life is poor.

On discharge, patients must be provided with an Action Plan to assist parents or

patients to prevent/terminate asthma attacks.


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Preventing Chronic Asthma

Identifying and avoiding the following common triggers

Environmental allergens

Cigarette smoke

Respiratory tract infections - commonest trigger in children.

Food allergy - uncommon trigger, occurring in 1-2% of children

Exercise


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Monitoring Chronic AsthmaDuring each follow up visit, three issues need to be assessed. They are:

Assessment of asthma control based on:

Interval symptoms.

Frequency and severity of acute exacerbation.

Morbidity secondary to asthma.

Quality of life.Peak Expiratory Flow Rate (PEFR) or FEV1 monitoring.

Compliance to asthma therapy:

Frequency.

Technique.

Asthma education:

Understanding asthma in childhood.

Reemphasize compliance to therapy.

Written asthma action plan.


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Primary school children : 13.8%

Children aged 13-14 : 9.6%

Adult ( self-reported) in National Health and Morbidity Survey

(NHMS) : 4.1%

Prevalence was higher in rural (4.5%) than in Urban areas (4.0%).However, another study was conducted by Universiti Putra

Malaysia in 2010 ,shows that prevalence of asthma among urban

children was the highest (5.7%), followed by industrial area

(5.2%), and rural children (4.6%).

Prevalence was also higher in those with lower educationalstatus (5.6%)and lower income (4.7%)

Epidemiology of Asthma Among Malaysian Children


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Grading of Acute Exacerbation

1. Diagnosis : symptoms (eg; cough, wheezing, breathlessness, pneumonia)

2. Triggering factors : food, weather, exercise, infection, emotion, drugs

3. Severity: respiratory rate, colour, respiratory effort, conscious level


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Parameter Mild Moderate Severe Life threatening

Breathless When walking When talking At rest

Infants: stop

feeding

Talks in Sentences Phrases words Unable to speak

Alertness Maybe agitated Usually agitated Usually agitated Drowsy/

confused/coma

Resp. Rate Normal to mildly

increased

Increased Markedly

increased

Poor resp effort

Accessory

Muscle usage/

retractions

Absent Present- moderate Present- severe Paradoxical

thoraco-

abdominal mov.

Wheeze Moderate, often only

end expiratory

Loud Usually loud Silent chest

SpO2 (on air) >95% 92-95% 160 (infants)

Bradycardia

PEFR1 >80% 60-80%


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Grading of Chronic Asthma

1. Based on severity

2. Based on levels of control

Classification Daytime

symptoms

Nocturnal

symptoms

FEV1/ PEFR (%)

Intermittent 1/week >2/month >80

Moderate persistent Daily >1/week >60-80

Severe persistent Continual daily Daily


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Category Clinical Parameters

Intermittent Daytime symptoms less than once a week

Nocturnal symptoms less than once a month

No exercise induced symptoms

Brief exacerbations not affecting sleep and

activity

Normal lung function

Persistent (Threshold for preventive treatment)

Mild Persistent Daytime symptoms more than once a week

Nocturnal symptoms more than twice a month

Exercise induced symptoms

Exacerbations > 1x/month affect sleep/activity

PEFR / FEV1 > 80%

Evaluation of the background of newly diagnosed asthma


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Continued..Moderate Persistent Daytime symptoms daily

Nocturnal symptoms more than once a week

Exercise induced symptoms

Exacerbations >2x/month affect sleep,

activity

PEFR/ FEV1 60-80%

Severe Persistent Daytime symptoms daily

Daily nocturnal symptoms

Daily exercise induced symptoms

Frequent exacerbations >2x/month affect

sleep, activity

PEFR/ FEV1 < 60%


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Asthma Severity based to Control Based

Proposed by *The Global Initiatives for Asthma (GINA).

Based on symptoms and 3 levels of control:

1. Well controlled

2. Partly control

3. Uncontrolled

*A medical guidelines organization which works with public health officials and health

care professionals globally to reduce asthma prevalence.


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Characteristics Controlled

All of the following:

Partly controlled

Any measure present

in any week

Uncontrolled

Daytime symptoms none >2/week

Limitation of

activities

None Any

Nocturnal

symptoms/

awakening

None Any >3 features of

partly controlled

asthma present in

any week

Need for reliever None >2/week

Lung function test None 1/ year One in any week

Level of Asthma Control (GINA 2006)


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Asthmatic Predictive Index

The possibility of those with negative index not becoming asthmatic by 6 years old

was 95% whereas those with a positive index have a 65% chance of becomingasthmatic by 6 years old.

Positive Index ( >3 wheezing episodes/ year during first 3 years

Plus one Major criteria or two Minorcriteria

Major criteria Eczema

Parental asthma

Positive aeroallergen skin test

Minor criteria Positive skin test

Wheezing without URTI

Eosinophillia (>4%)

A clinical index to define Risk of Asthma in young children with Recurrent Wheeze


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Treatment

Age (years) Oral MDI +Spacer

MDI + Mask+ Spacer

Dry PowderInhaler

8 - + + +

*MDI = metered-dose inhaler

Drug Therapy

Delivery System available & recommendation for diff. ages


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Treatment for Chronic Asthma

Management Based Control

Reduce Increase

STEP 1Intermittent STEP 2Mild

Persistent

STEP 3Moderate

Persistent

STEP 4Severe

Persistent

STEP 5Severe

Persistent

As needed

rapid acting

- agonists

As needed

rapid acting

- agonists

ControllerOptions

Select One Select One Add One / more Add One / both

Low dose

Inhaled

steroids

Low dose ICS + long acting

- agonists

Med / High dose

ICS + long acting

- agonists

Oral

Glucocorticoids

Lowest dose

Leukotriene

modifier

Med / High dose ICS Leukotriene

modifier

Anti-IgE

Low dose ICS + Leukotriene modifier SR Theophylline

Low dose ICS + SR Theophylline


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Drug Treatment

d i f h


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Drugs Used in Treatment of Acute Asthma

Drug Formulation Dosage

B2-agonists

(causes bronchodilation of

the small airways)

Salbutamol Nebulizer solution 5mg/ml or

2.5 mg/ml nebule

Intravenous

0.15 mg/kg/dose (max 5mg) or < 2

y/o : 2.5 mg/dose

> 2 y/o : 5.0 mg/dose

Cont: 500 mcg/kg/hour

Bolus: 5-10 mcg/kg over 10min

Infusion: 0.5-1.0 mcg/kg/min,

increase by 1.0 mcg/kg/min every

15min to a max of 20 mcg/kg/min

Terbutaline Nebuliser solution 10mg/ml,

2.5 mg/ml or 5 mg/ml respule

Parenteral

0.2-0.3 mg/kg/dose or

20kg : 5.0 mg/dose

5-10 mcg/kg/dose

Fenoterol Nebuliser solution 0.12-1.5 mg/dose


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Corticosteroid

Prednisolone oral 1-2 mg/kg/day in divided doses(for 3-7 days)

Hydrocortisone intravenous 4-5 mg/kg/dose 6 hourly

Methylprednisolone intravenous 1-2 mg/kg/dose 6-12 hourly

Other agents

Ipratropium bromide Nebuliser solution

(250 mcg/ml)

5 y/o : 500 mcg 4-6 hourly

Aminophylline Intravenous 6 mg/kg slow bolus (if not

previously on theophylline)

followed by infusion 0.5-1.0

mg/kg/hr

Montelukast Oral 4mg granules

5mg/ tablet on night chewable

10mg/tablet ON


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Relieving drugs

B2-agonists

Salbutamol Oral

Metered dose inhaler

Dry powder inhaler

0.15mg/kg/dose TDS-QID/PRN

100-200 mcg/dose QID-PRN

100-200 mcg/dose QID-PRN

Terbutaline Oral 0.075 mg/kg/dose TDS-QID/PRN

250-500 mcg/dose QID/PRN

500-1000 mcg/dose QID/PRN

(max 4000 mcg/daily)

Fenoterol Metered dose inhaler 200 mcg/dose QID/PRN

Ipratropium bromide Metered dose inhaler 40-60mcg /dose TDS/QID/PRN

Drugs Used in Treatment of Chronic Asthma


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Preventive drugs

Corticosteroid

Prednisolone Oral 1-2 mg/kg/day in divided doses

Beclomethasone

Diproprionate

Budesonide

Metered dose inhaler

Dry powder inhaler


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Long acting B2-agonist

Salmetrol Metered dose inhaler

Dry powder inhaler

50-100 mcg/dose BD

50-100 mcg/dose BD

Combination

Salmetrol / fluticasone Metered dose inhaler

Dry powder inhaler

25/50 mcg, 25/125mcg, 25/250mcg

50/100 mcg, 50/250mcg,

50/500mcg

Budesonide / formoterol Dry powder inhaler 160/4.5mcg, 80/4.5mcg

Antileukotrienes

(leukotriene modifier)

Montelukast Oral 4mg granules

5mg/tablet on night chewable

10mg/tablet ON


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Devices used

Pressured Metered Dose Inhaler (PMDI)

Used with spacer

Appropriate for all age groups

0-2 years use spacer and facemask

> 2 years use spacer alone

Spacer is recommended as it increases drug deposition in the lungs

Useful for acute asthma attacks when poor inspiratory effort may

impair the use of inhalers direct to the mouth


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Breath-Actuated Metered Dose Inhalers

> 6 years old

Useful for delivering beta-agonists when out and about in older children

Dont have to press canister to release the drug

Do not require a spacer

Medicine comes out automatically as the individual breathes in


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Steps for Use

1. Shake gently and remove the cap from the mouthpiece.

2. Hold the inhaler upright and flip open the lever or take off the cap.

If the inhaler is new or has not been used in the last 48 hours it must

be primed. Point the inhaler away from you. Lift the lever on top of

the canister. Push the test fire slide button on the bottom while holding the

inhaler upright. Lower the lever and repeat the steps to release the secondprime spray.

3. Tilt your chin up slightly and breathe out.

4. Place your lips around the mouthpiece and begin breathing in slowly.

5. Breathe in slowly through your mouth for 3 to 5 seconds. The inhaler

will release a puff of medicine.6. Hold your breath for 10 seconds and then breathe our slowly.

7. Close the flip lever and replace the cap over the mouthpiece.


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Dry Powder Inhaler

> 4 years old

Needs good inspiratory flow

Less efficient in severe asthma and an acute attack

Also used when children are out and about

Rely on the individuals force of inspiration

Medication is commonly held either in a capsule for manual loading or a

proprietary form (pellet) from inside the inhaler.

Once loaded or actuated, the operator puts the mouthpiece of the inhaler into

their mouth and takes a deep inhalation, holding their breath for 5-10 seconds


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