a review for diagnosis and management for suspect asthma in young children 小兒科專題討論 氣喘

1. Review-
Asthma in children 5Y
and younger

2. Q1 :
Recurrent Stridor+ bronchiolitis, 何時開始啟動asthma的診斷?
Q2 :
懷疑Asthma小孩,需要注意哪些red flags ?
Q3 :
憂心的爸媽, 現階段有哪些可以做的事?

3. Q1 :
Recurrent Stridor+ bronchiolitis, 何時開始啟動asthma的診斷?
Q2 :
懷疑Asthma小孩, 需要注意哪些red flags ?
Q3 :
憂心的爸媽, 現階段有哪些可以做的事?

4. Diagnosis – what the GINA said
“a history of respiratory symptoms such as
wheeze, shortness of breath, chest tightness
and cough that vary over time and in intensity,
AND
variable expiratory airflow limitation.”

5. • <5Y recurrent stridor/cough
• (lower airway infection)
• 合併有過敏體質
• 父母有氣喘病史
• 病史: 夜間咳嗽 誘發因子*
• 沒有專一的診斷工具
• Skin prick test
• Serum IgE test (false neg in < 3y)
• 仔細的D/D
-----------------5Y--------------
• Spirometry – PEF, flow-volume loop
• 避免過敏原
• SABA, beta2-agonist prn
• ICS, inh corticosteroid
• LTRA, leukotriene-R antagonist
• 遺傳 + 過敏原 + 環境
(smoke, 塵蟎, 母乳, 運動, 氣候)
Asthma

7. D/D
Infection Recurrent viral
respiratory
tract infections
Mainly cough, runny congested nose for
<10 days; wheeze usually mild; no
symptoms between infections
Tuberculosis fever unresponsive to normal antibiotics; poor
response to bronchodilators or inhaled
corticosteroids
Mechanical Foreign body
aspiration
CXR
Gastroesophage
al reflux
pH probe
Congenital Tracheomalacia, Congenital heart disease, Bronchopulmonary
dysplasia…

8. ----children 5 years and younger
• Recurrent wheezing occurs in a large proportion of
children <=5 years, typically with viral URI.
• more likely if…
• Wheezing or coughing that occurs with exercise,
laughing or crying in the absence of an apparent
respiratory infection
• A history of other allergic disease (eczema or allergic
rhinitis) or asthma in first-degree relatives
• Clinical improvement during 2–3 months of controller
treatment, and worsening after cessation.

9. Where to start?
• wheezing episodes are frequent or severe
 SABA + A trial of controller therapy
• <4 years : pressurized metered dose inhaler and
spacer, with face mask
• 4–5 year-old : mouthpiece

10. Q1 :
有Stridor表現的pneumonia, 或是反覆入院的
bronchopneumonia, 何時開始啟動asthma的診斷?
1. 受限於診斷公具 – spirometry, 難以在五歲前確診asthma
2. Recurrent stridor + atopy + family hx  暗示著asthma
3. 在症狀嚴重的小孩，測試2-3個月的ICS, 根據藥物反應調
整診斷

11. Q1 :
有Stridor表現的pneumonia, 或是反覆入院的
bronchopneumonia, 何時開始啟動asthma的診斷?
Q2 :
懷疑Asthma小孩, 需要注意哪些red flags ?
Q3 :
憂心的爸媽, 現階段有哪些可以做的事?

12. The word “exacerbation”
-- flare-up

13. Written action plan--
• The patient’s usual asthma medications
• When and how to increase medications, and start OCS
• How to access medical care if symptoms fail to respond

14. Written action plan--
• The patient’s usual asthma medications
• When and how to increase medications, and start OCS
• How to access medical care if symptoms fail to respond
Maintain dose
-Reliever
-Controller
Increase dose
-Reliever
-Controller
Start OCS
1–2
mg/kg/day
MAX 40mg
ER48H
FEV1 < 60%
急速惡化

15. As a doctor– 呼吸困難 意識不清
1.同時access與treatment
SABA + O2 supplement
RR + HR + SaO2 + (FEV1)
2. 一邊在心中D/D
heart failure, pulmonary embolism
inhaled foreign body
3. 安排後送or 會診
4. Keep SaO2>94, 嚴重時追加
oral steroid
inh ipratropium

16. Pay attention to --
• A history of near-fatal asthma requiring intubation and ventilation
• Hospitalization or emergency care for asthma in last 12 months
• Not currently using ICS, or poor adherence with ICS
• Currently using or recently stopped using OCS (this indicates the
severity of recent events)
• Over-use of SABAs, especially more than 1 canister/month
• Lack of a written asthma action plan
• History of psychiatric disease or psychosocial problems
• Confirmed food allergy in a patient with asthma
曾經很嚴重 最近很嚴重;
非常不配合 配合過頭了; 食物過敏

17. Q2 :
懷疑Asthma小孩, 需要注意哪些red flags ?
1. 症狀持續惡化, OCS後48H仍然沒有緩解
2. 症狀迅速惡化, 呼吸困難, 意識不清

18. Q1 :
有Stridor表現的pneumonia, 或是反覆入院的
bronchopneumonia, 何時開始啟動asthma的診斷?
Q2 :
懷疑Asthma小孩,需要注意哪些red flags ?
Q3 :
憂心的爸媽, 現階段有哪些可以做的事?

19. Asthma三部曲
• 基因的易感受性 – family history
• 過敏原的曝露
• 環境因素
二手菸 食物過敏 寵物 潮濕 黴菌

20. Q1 :
有Stridor表現的pneumonia, 或是反覆入院的
bronchopneumonia, 何時開始啟動asthma的診斷?
Q2 :
懷疑Asthma小孩,需要注意哪些red flags ?
Q3 :
憂心的爸媽, 現階段有哪些可以做的事?
-Asthma受限於診斷工具, 難以在五歲前確診
-recurrent cough w/ stridor + atopy + family hx
是asthma的前奏
-迅速發生的呼吸困難, 意識不清
-漸進性的症狀, oral steroid 仍無法緩解
- 降低對已知過敏原的暴露
- 降低誘發因子

21. Reference