02-06 Slides Asthma

Pediatric Asthma
The Approach to the Wheezing Child
With Dr. Brian Alverson
Neuer Nutzer, ssemwogererethaddeus@gmail.com

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Learning Objectives
• Build a differential diagnosis for a wheezing child.
• Learn important historical points to these children.
• Perfect your physical exam skills in evaluating a

wheezing child.
• Learn appropriate workup and treatment of wheezing

children.

The Wheezing Child Ours
Child
6 years Runny nose
Congestion
Wheezing on exam
In moderate respiratory distress

Cough
What is your medical diagnosis?

What Is the Difference Between Stridor and Wheezing?
Pathology

What Is Wheezing?
Pathology

What Causes Wheezing?
0 1 year 1 4 years > 5 years High-yield

• Bronchiolitis • Viral-induced wheeze • Asthma
• BPD • Vocal cord dysfunction
• Early asthma
• Foreign body • Hypersensitivity
• Foreign body pneumonitis
• Aspiration
• Anatomic • Cystic fibrosis • Allergic
abnormalities of the bronchopulmonary
airway aspergillosis

What Questions Should You Ask?
Signs & Symptoms
• At what age did wheezing begin?
• Episodic or persistent?
• Sudden onset or gradual?
• Associated triggers?
• Has it responded to albuterol in the past?

Signs & Symptoms
• Events per week?
• Nighttime awakenings?
• Interference with normal activity?

• Systemic steroids in the last year?
• Previous hospitalizations?
• Previous visits to an intensive care unit?

Signs & Symptoms
History of prematurity?
Chris Sternal-Johnson, Lyra, https://flic.kr/p/6sgnga,

Neuer Nutzer, CC BY 2.0, Flickr
ssemwogererethaddeus@gmail.com
Key Physical Exam Findings
Clinical Presentation
Overall appearance and respiratory distress
Respiratory rate and lung exam
Heart rate and cardiac exam
Exam of liver
Allergic stigmata, other findings like

failure to thrive or clubbing

Diagnosing Asthma?
Diagnosis
• Spirometry with postbronchodilator

response may be obtained as a test to
establish the asthma diagnosis.
•
diagnosis.
• Consider allergy testing or pulmonary

function testing only in children
> 5 years old!
Faria AC, Lopes AJ, Jansen

Neuer Nutzer,JM, Melo PL, https://openi.nlm.nih.gov/detailedresult.php?img=PMC2760559_1475-925X-8-22-
1&query=Spirometry&it=ph&lic=by&req=4&npos=13,
© www.lecturio.com | This document PubMed, CCby
is protected BYcopyright.
2.0
Diagnosing Asthma?
Diagnosis
• For child with previous diagnosis of

asthma, no labs or radiology is
indicated.
• For hospitalized children with no

history of wheezing, a CXR may help
distinguish between foreign body,
asthma, or another condition.
Faria AC, Lopes AJ, Jansen

Neuer Nutzer,JM, Melo PL, https://openi.nlm.nih.gov/detailedresult.php?img=PMC2760559_1475-925X-8-22-
1&query=Spirometry&it=ph&lic=by&req=4&npos=13,
© www.lecturio.com | This document PubMed, CCby
is protected BYcopyright.
2.0
Treating Asthma
Management
For the acute exacerbation:

Treating Asthma
Management
For the acute exacerbation:
Counsel
Albuterol Steroids about
triggers

Treating Asthma
Management
Other agents you may see used:
Ketamine,
Avoid
Magnesium Terbutaline inhalational
intubation!
agents

The Hospitalized Child
Management
Cont. Q2 Q4
• May be in the ICU • Treat every 2 hours • Almost ready to be
setting discharged
• Use asthma scores
• Continuous NEB of to monitor • Discharge if:
albuterol • No O2
• Q4 x 2
• No respiratory
distress

Preventing Asthma Exacerbations
Diagnosis
Categories of asthma Questions to ask
• Intermittent • Nighttime awakening?
• Mild persistent • Frequency of albuterol use?
• Moderate persistent • Interference with normal activity?
• Severe persistent • Systemic steroids used this year?

Preventing Asthma Exacerbations
Diagnosis
Severity Intmt Mild Pers Mod Pers Sev Pers
Symptoms? 2 day/wk 2 6 day/wk Daily All day
Awakening? 2 night/mo 3 4 night/mo > 1 night/wk Every night High-yield
Albuterol? 2 day/wk 2 6 day/wk Daily All day
Interfere? None Minor Some Extreme
Steroids? 1 time/yr > twice per year

Choosing your Controller
Management
Worst symptom documented above determines severity

Intermittent Mild Moderate Severe persistent
persistent persistent
2 puffs
5 11 years 1 puff Fluticasone 1 puff Fluticasone 110 mcg
Albuterol PRN Fluticasone 44
old 110 BID BID ± Montelukast
BID
Fluticasone/Salmeterol
2 puffs 115 mcg/21 mcg 2 puff
1 puff Fluticasone
12+ years old Albuterol PRN Fluticasone 44 BID vs. Fluticasone
110 BID
BID 110mcg 2 puff BID +
Montelukast

If the Child Is Already on a Controller
Management
More Is the child taking

Increase
education No the controller Yes
controller
appropriately?

Common Questions About Asthma
A patient is admitted to the hospital with an asthma exacerbation.

What medicine is most likely to prevent him from bouncing back
to the hospital?
A. Albuterol
B. Steroids
C. Magnesium
D. Terbutaline

A patient is admitted to the hospital with an asthma exacerbation.

What medicine is most likely to prevent him from bouncing back
to the hospital?
A. Albuterol
B. Steroids
C. Magnesium
D. Terbutaline

A 7-year-old uses albuterol three times a week and has night-time

coughing that wakes him up twice a week. He takes his low-dose
to do?
A. Put him on a long-acting beta-agonist twice daily as monotherapy
B. Give him more albuterol and use it more frequently
C. Increase his inhaler to moderate dose fluticasone
D. Admit him to the hospital for pulmonary function tests

A 7-year-old uses albuterol three times a week and has night-time

coughing that wakes him up twice a week. He takes his low-dose
fluticasone, two puffs twice a day and is compliant. the best thing
to do?
A. Put him on a long-acting beta-agonist twice daily as monotherapy
B. Give him more albuterol and use it more frequently
C. Increase his inhaler to moderate dose fluticasone
D. Admit him to the hospital for pulmonary function tests

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Pediatric Asthma

The Approach to the Wheezing Child

With Dr. Brian Alverson

Neuer Nutzer, ssemwogererethaddeus@gmail.com

• Build a differential diagnosis for a wheezing child.

• Learn important historical points to these children.

• Perfect your physical exam skills in evaluating a

• Learn appropriate workup and treatment of wheezing

Neuer Nutzer, ssemwogererethaddeus@gmail.com

In moderate respiratory distress

What is your medical diagnosis?

Neuer Nutzer, ssemwogererethaddeus@gmail.com

Neuer Nutzer, ssemwogererethaddeus@gmail.com

Neuer Nutzer, ssemwogererethaddeus@gmail.com

0 1 year 1 4 years > 5 years High-yield

Neuer Nutzer, ssemwogererethaddeus@gmail.com

• At what age did wheezing begin?

• Has it responded to albuterol in the past?

Neuer Nutzer, ssemwogererethaddeus@gmail.com

• Events per week?

• Interference with normal activity?

• Previous visits to an intensive care unit?

Neuer Nutzer, ssemwogererethaddeus@gmail.com

Chris Sternal-Johnson, Lyra, https://flic.kr/p/6sgnga,

Overall appearance and respiratory distress

Respiratory rate and lung exam

Heart rate and cardiac exam

Allergic stigmata, other findings like

Neuer Nutzer, ssemwogererethaddeus@gmail.com

• Spirometry with postbronchodilator

• Consider allergy testing or pulmonary

Faria AC, Lopes AJ, Jansen

• For child with previous diagnosis of

• For hospitalized children with no

Faria AC, Lopes AJ, Jansen

For the acute exacerbation:

Neuer Nutzer, ssemwogererethaddeus@gmail.com

For the acute exacerbation:

Neuer Nutzer, ssemwogererethaddeus@gmail.com

Other agents you may see used:

Neuer Nutzer, ssemwogererethaddeus@gmail.com

Neuer Nutzer, ssemwogererethaddeus@gmail.com

Categories of asthma Questions to ask

• Intermittent • Nighttime awakening?

• Mild persistent • Frequency of albuterol use?

• Moderate persistent • Interference with normal activity?

• Severe persistent • Systemic steroids used this year?

Neuer Nutzer, ssemwogererethaddeus@gmail.com

Severity Intmt Mild Pers Mod Pers Sev Pers

Symptoms? 2 day/wk 2 6 day/wk Daily All day

Awakening? 2 night/mo 3 4 night/mo > 1 night/wk Every night High-yield

Albuterol? 2 day/wk 2 6 day/wk Daily All day

Interfere? None Minor Some Extreme

Steroids? 1 time/yr > twice per year

Neuer Nutzer, ssemwogererethaddeus@gmail.com

Worst symptom documented above determines severity

Neuer Nutzer, ssemwogererethaddeus@gmail.com

More Is the child taking

Neuer Nutzer, ssemwogererethaddeus@gmail.com

A patient is admitted to the hospital with an asthma exacerbation.

Neuer Nutzer, ssemwogererethaddeus@gmail.com

A patient is admitted to the hospital with an asthma exacerbation.

Neuer Nutzer, ssemwogererethaddeus@gmail.com

A 7-year-old uses albuterol three times a week and has night-time