Regarding the management of an 8-month-old child with moderate severity bronchiolitis and a background history of an allergy to nuts, which ONE of the following is INCORRECT?
Answer: B Salbutamol has been shown in a Cochrane review to be ineffective in the management of bronchiolitis. It found bronchodilators other than adrenaline had no effect on the rate of hospitalization or other longer term outcomes although it may produce small short-term improvements.83 The American Academy of Pediatrics still advocates the use of salbutamol as a trial in infants with a history of response to bronchodilator or a strong family history of asthma or atopy, in the age group over 6 months, despite a paucity of evidence in its favour. The small potential benefit of routine short-acting bronchodilator treatment must be weighed against the potential negative effects associated with these agents.
A transient decrease in saturation is common after the administration of a bronchodilator, as its first effect is on the pulmonary vasculature, which causes vessel dilation, while the airway remains bronchconstricted with poor airflow. This results in a worsening of the ventilation-perfusion mismatch, albeit transiently, until the airway also dilates to improve airflow to the now already dilated capillary bed, ultimately improving gaseous exchange.
Steroids are of no benefit in bronchiolitis. Another Cochrane review determined that systemic corticosteroids have no impact on clinical scores, admission rates, length of stay or readmission rates and should not be used routinely in the management of bronchiolitis.
Three percent hypertonic saline may be useful. Four small trials assessed in a 2008 Cochrane review, have shown to improve clinical scores and reduce the length of stay. This supports a beneficial adjunctive role for hypertonic saline in the treatment of bronchiolitis. However, there is not enough data to make an evidence-based recommendation.
References:
A 4-year-old child presents to the ED with acute asthma. Examination reveals an oxygen saturation of 90% on room air with obvious accessory muscle use and quiet chest.
Which ONE of the following is the BEST answer?
Answer: B: Assessing the severity of presenting signs and symptoms during an acute asthma episode is crucial in determining the initial management strategy (see table below). This child satisfies the criteria for severe/ life-threatening asthma and requires immediate management with oxygen and continuous nebulized salbutamol and three doses of nebulized ipratropium. Current trends in life-threatening asthma management support the use of intravenous salbutamol as well as concurrent or subsequent use of intravenous magnesium sulfate. Aminophylline has fallen out of favour in recent years due to its poor side effect profile (specifically nausea and vomiting), despite the fact that studies have shown good efficacy in the management of acute severe and life-threatening asthma. For this reason it is usually recommended only in the intensive care setting. There is no role for empiric antibiotics when sepsis is not suspected. Most exacerbations of asthma will be viral induced.
INITIAL ASSESSMENT OF ACUTE ASTHMA IN CHILDREN:
Source: National Asthma Council Australia. Managing acute asthma in children. In: Asthma management handbook 2006; Table 5, p. 44. Online. Available: http://www.nationalasthma.org.au/cms/images/stories/amh2006_web_5.pdf; May 2011.
*Any of these features indicates that the episode is severe. The absence of any feature does not exclude a severe episode. These tests are usually not used in the assessment of acute asthma in children.
**Children under 7 years old are unlikely to perform PEF or spirometry reliably during an acute episode.
Reference:
Regarding an 18-month-old child presenting to the ED with recurrent episodes of mild wheezing and no history of atopy, which ONE of the following is the BEST answer?
Answer: D: Wheezing is common in children with the highest incidence in preschool children. Epidemiological studies have demonstrated three different phenotypes; the majority of children will stop wheezing before the age of 3 (transient wheezers), some will wheeze beyond this age (persistent wheezers) and a small group will only start wheezing at 3 years of age (late onset wheezers). Few children continue to wheeze beyond 6 years.
In infants, wheezing is often not due to asthma but rather due to acute viral bronchiolitis or transient early wheeze. Therefore, the response to inhaled bronchodilators is not generally as beneficial as in older children. Young children aged 2–5 years usually do not have classical asthma but rather a viral-induced wheeze associated with a respiratory tract infection. These children are well in-between episodes, are non-atopic and have a good prospect of outgrowing the tendency to wheeze in later childhood. The standard approach for these patients is to use bronchodilators as needed. Neither inhaled nor oral steroids appear to be helpful. Leukotriene receptor antagonists (LTRA) may be useful both as a long-term preventive agent and as an ‘episode modifier’.
From the author’s perspective, the simplest approach to wheeze in children is to categorize by age:
All of these groups still require the exclusion of other pathologies such as heart failure, foreign body aspiration, gastroesophageal reflux disease (GERD), suppurative lung disease, atypical pneumonia, cystic fibrosis and structural abnormalities to ensure the wheeze is not due to an organic cause. This exclusion of other causes can be done with careful history taking and good clinical examination.
An 8-year-old girl has a history of intermittent wheezing episodes responding to salbutamol as well as a dry cough on most nights of the week. Her growth and development is normal.
Which ONE of the following is the most appropriate answer?
Answer: C: This girl has symptoms suggestive of asthma. She would be classified as persistent asthma due to her interval symptoms and would benefit from preventer medication. Exclusion of other causes of wheeze is an important consideration. This girl is unlikely to have a chronic lung disease such as cystic fibrosis or bronchiectasis as there is no evidence of FTT and no productive sputum. Nevertheless, a CXR is indicated due to the chronic nature of her symptoms, as well as formal lung function testing to confirm an obstructive lung disease pattern.
In the majority of children, the diagnosis of asthma is based on a history of recurrent or persistent wheeze in the absence of any other apparent pathology. Cough, shortness of breath, or both often accompany wheeze due to asthma. A history of associated eczema, urticaria or a history of asthma in a first-degree relative supports the diagnosis. In young children, asthma can be confirmed by a clinical response to an inhaled bronchodilator. In children aged ≥7 years, spirometry can be used reliably to confirm the diagnosis.
Classification of childhood asthma is based mainly on the clinical pattern (see Table below). The pattern of asthma determines the need for preventive therapy in children. Children with intermittent, infrequent asthma can be managed with bronchodilators as needed. They do not require any long-term preventive medications. However, children of any age with frequent intermittent or persistent asthma will require preventative medication that is effective in reducing asthma attacks. In children with frequent intermittent and mild persistent asthma, inhaled cromones, oral leukotriene receptor antagonists (LTRAs) or low-dose inhaled corticosteroids (ICS) are recommended. For children with moderate-to-severe persistent asthma, an ICS is the preferred option. Long-acting beta2 - agonists (LABAs) can be prescribed in children in combination with ICS (salmeterol in children >5 years or eformoterol in children >12 years). However, there is limited evidence for their efficacy and safety in children. The National Asthma Council Australia suggests a stepwise approach to drug therapy in children – starting treatment at the step most appropriate to the level of asthma severity and step up or down as necessary. The goal is to decrease treatment to the least medication necessary to maintain control.
CLASSIFICATION OF ASTHMA IN CHILDREN OVER 5 YEARS OLD:
Source: National Asthma Council Australia. Managing acute asthma in children. In: Asthma management handbook 2006; Table 2, p. 14. Online. Available: http://www.nationalasthma.org.au/cms/images/stories/amh2006_web_5.pdf; May 2011.
*Predicted values are based on age, sex and height.
**Difference between morning and evening values.
A fully immunized 2-year-old child presents to the ED with a chronic cough for 5 weeks following a coryzal illness. The child appears well and clinical examination is unremarkable.
Answer: D: This child most likely has post viral cough syndrome with irritation of her upper airways, activation of cough receptors and therefore worse coughing at night (due to cold air, and lying flat with upper airway secretions causing irritation). Symptomatic management with upper airway soothing agents such as honey or warm drinks may be of benefit, although the course is usually 4–8 weeks with spontaneous resolution in time. Pneumonia is unlikely, as this child appears completely well. Cough can be the predominant symptom of asthma, but it is extremely rare for cough to be the only symptom. When cough is due to asthma, it is usually accompanied by some wheeze and episodes of shortness of breath.
Most children with chronic cough require some diagnostic work-up including a CXR, sputum examination and a nasopharyngeal aspirate polymerase chain reaction (NPA-PCR) for pertussis or other specific viral testing. Exclusion of pertussis by NPA-PCR, empiric treatment with azithromycin and a screening CXR are usual initial steps in the ED. The most important management point is reassurance to parents after thorough clinical assessment, with an end point at 2 months of ongoing symptoms requiring referral to a respiratory clinician for more complicated work-up, including tests for cystic fibrosis, aspiration syndromes and gastroesophageal reflux.
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