Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Good morning, everyone. My name is Caroline Delahanty. I'm a consultant pediatrician, and I was going to talk to you today on the diagnosis and management of asthma in Children. But I'm also going to talk about pre pre five weeks because they're a very difficult group to know if they've got true asthma or if they are purely Children that are getting a lot of recurrent viral infections and are sensitized. But we'll see as we go through the the slides. I don't have a slide of a clinical history, but I'm going to start. But we'll bring in some histories and talk about typical presentations as we go through. Okay, so I'm going to ask people to put in the chat or to shout out what are the typical symptoms of childhood asthma? This isn't a trick question. I promise anyone have any thoughts? What's the obvious symptom of childhood asthma? What do you need to be there to give a diagnosis of asthma? Okay, shortness of breath. Brilliant, absolutely wheezing. Yes, we's needs to be there. If you don't have, we's you probably don't have it. OK, cyanosis is being blue would obviously be a pre terminal uh, event. And you need to be given that child oxygen and managing acutely. But we will also come in. Okay. I love the allergy to dust. So a hist in your history You are going to be asking about history of a choppy because that will make childhood asthma much more common. Much more likely So. History of atopic disease Coffin? Absolutely. And frequent. Coffee coffin, episodic coffin. And we ask about night coffin in particular. Okay. Thank you very much. Right. I will hide the chant if I can. Now. Okay. So you know, it's always happened Every time I try to do something right, it may have to stop chairing. Go back in chairing, I'm afraid. Stop Share. Bear with me. I'm going to re share because my computer is stuck. And then once we re share, we should be okay. Okay. So asthma by definition, is a chronic respiratory disease presenting with wheeze, cough, shortness of breath. Ok, I think it's fair to say it can be difficult to diagnose, particularly in the under fives where we can't perform spyrometry and detailed lung function testing. It's very common. It's felt to have a prevalence of around 14% worldwide. But what's concerning is that Children continue to die of asthma, and every I think it's every five years. The UK audits asthma deaths and what's disappointing is that there are avoidable factors. There were warning factor. There were warning signs that the child's control was sub optimal. So we're going to talk about all these things I want to talk about triggers. What are your common asthma triggers? Um, a lot of these you will know, obviously viral respiratory in tract infections. So if they're getting into currents, respiratory infection, they are as a result of the pathology of Broncho constriction, more likely to generate that histamine response and Bronco constrict there. Al Viola and they're brand bronch. I. We know exercise can be a trigger. So actually, in the history, particularly at clinic, you'll ask about Do they cough or wheeze during exercise? We know cold mornings can affect Children. High humidity, the damp cold, um, so changes in temperature. But it tends to be that cold change in temperature, not the hot change in temperature. But Children that are Pollin triggered will be worse in spring and summer, when the grass pollens and the tree pollens are around. Someone mentioned in the the chat around dust. So dust mites. So get damp Dustin, as opposed to dry dust in to get to stop spraying around the house. I'm not sure how evidence based it is, but the generic advice about damp Dustin is something that we use and asking parents to Hoover if they think their child is particularly sensitive. And Hoover the bed mattress mold. Actually, I should have put up a recent headlines. So in the UK recently, there has been a coroner's inquest into a child that died in poor housing, died of asthma, and actually the and the parents had reported to the housing that there was a lot of damp. There was a lot of mold was making the child more and well requesting to be rear housed. And actually, the coroner said it was a factor in that child's death, which is then going to lead on to pressure, putting more pressure on housing authorities to make sure the housing is of appropriate standards. Environmental pollutants. So air pollution. We know Children under five if they are pushed in a buggy in a push tray, and they pushed on a high traffic street. The exhaust fumes are coming out to that at that child's level because it's low down and will be triggering their asthma. So again, in the UK there there are campaigns to stop Children walking to school on busy roads and to think about re routing your walk and going elsewhere. And also trying to reduce traffic on roads with primary schools so environmental pollutants is very important. Second hand smoke exposure, like the parents will always say, Oh, we smoke outside. We don't smoke inside, but that smoke is still on a child. Still, the child is still having access to that. Smoke it still to the parental hair. It sticks to their clothing, and it is a trigger for their asthma. So encouraging the parents to give up smoking is really important and getting them help. So pets and animals always a difficult one. But your child may be allergic to the cat or the dog. Think about it. I think the interesting one and laughter can do it. It's not always if a child is crying, they start to trigger wheeze by not controlling their breathing, but the same with laughter. Actually, If you're tickling a child, you can. You know that play. That emotion of happiness can actually trigger our asthma, and it's I'm not sure we know. Is it the breathing pattern or is it? Is the actual Broncho constriction that happens as well, but they need to be able to control their breathing drugs. Remember, we don't recommend non steroidal anti inflammatory drugs, so things like ibuprofen, which can be used as an antipyretic and beta blockers. We wouldn't want to put a child with migraine where we may wish to choose propranolol on, too. If they have asthma, we would avoid that drug because the risk of bronchial constriction, gastroesophageal reflux is always a difficult one. It's classed as an asthma trigger, but remember, it's a differential diagnosis as well. So I'm not sure I buy that, but I left it in because it is on a lot of the guidelines. Okay, tell your history you've got this child in clinic. What are you going to ask them? You've established that they've got we's recurrent episodes, not just a single episode single episode you're going to put down to a viral illness. They have a history of recurrent episodes of We's Shortness of Breath and Cough. Um, often, when you ask them, they'll say that they're coughing is worse overnight or early morning. If they go out in their cup, the cold there or exercise these can make things worse. You'll ask them about you know where they triggered by tickling by laughter by crying. What happens to their breathing at that point? Do you hear any wheeze? But your Then you're going to ask about predisposing risk factors? Do they have? Does the child have eczema, allergic rhinitis, hay fever? Or is there any history of nasal polyps? Is there a history in close family relatives? So ask about the the child's history and asked about family history. Ask about the family history of asthma. We do always ask about smoking because we want to have that opportunistic approach to supporting the family, to give up smoking and identifying. It's a risk factor to the family. Be clear premature birth, because if your preterm your valve Eola development may well, we'll have changed, particularly if you've had chronic lung disease bronchopulmonary dysplasia. So the alveolus car in the al viola sensitization is different. They are more at risk having got over their oxygen dependency to go on to get childhood asthma, ask about housing, ask about mold dampness and ask about exposure to air pollution. Because you may be able to give them that generic advice that I just said, Don't push the little one in. You know, Don't walk them to school on a busy traffic street. Can you go a street behind to get to the school? So ask about air pollution exposure. Legislation isn't in place for it in the UK to stop traffic around schools. There is safety legislation about reducing speed, but that's not because of asthma. Okay, I wish I had this flying in, but I'm going to just take I appreciate you seen it, But does anybody want to pop in the chapter? Claudia, you're going to have to read them out to me, because if I go into the chat, I'll block my screen again. What would make you think it's not asthma in the history when you're asking about the history because there's always a differential diagnosis isn't there which we're going to come on to what fact? What clinical symptoms would suggest. Actually, I don't think this is asthma. We have in the chat history of cough and weeds with food history of cough and wheeze and after food after food. Okay. Yeah, Good one. So that would suggest potential aspiration, pneumonia and unsafe swallow. So absolutely. Or even gastroesophageal reflex. So excellent suggestion. Okay, I'm going to move on to what I'm going to want to forensic. She ate in with this family. Little family in clinic is if mom tells me the symptoms being present from birth, cause I'm going to ask her When did this start? And she's probably going to say they had a bad infection. Um, it started after that. Maybe, but it absolutely should not be present from birth. If a child has a newborn cough, they've probably got a problem with their airway. They may have severe Laurinda Malaysia. They may have an abnormal airway that's making them cough. They could have cystic fibrosis, but they could have primary celery dyskinesia, but they will not have asthma. So daily. Simple, frequent symptoms from birth or daily symptoms from birth. In particular, it's not asthma. So frequent or daily, wet, moist sounding or productive cough asthma. You shouldn't be bringing up sputum. Right. So this makes me think about bronchitis. Okay. If a child is clubbed when you examine them, it's not asthma. Okay, So that suggests clubbing happens as a result of chronic hypoxia. Asthmatics are not chronically hypoxic. Chest wall deformity you'd want to think. Oh, I wonder if they have an intro. Thoracic deformity. Do they have a cystic hydro? Mama, Let's have a look. You'd want to start thinking about doing X rays because we don't X ray for asthma. We may do in the very acute situation to exclude pneumothorax or secondary infection, but we don't X ray as a primary diagnostic tool. Failure to thrive, asthma Children should thrive. Every child that comes into clinic remember, you want to do a hate height and weight If they've got heart murmur. Remember, cardiac failure can present with wheeze. So if they've got heart murmur, is it the heart? Is it congestive cardiac failure that's causing cough, wheeze, shortness of breath. So heart murmurs you're going to do an echo. You're going to think about it now exactly what someone said. The choking the vomitin, um, symptoms after food, food spillage, unsafe swallow. You're going to think about aspirate the current episodes of Aspiration Pneumonia when you listen to the chest, particularly in the chronic stage, if you heard asymmetrical chest findings. So if you've got a fixed wheeze on one side, actually, does anybody want to put in the chat what that would suggest Because it's a lovely diagnosis. Fixed. We's one side. Would it be obstruction? Absolutely foreign body aspiration causing obstruction or a congenital unilateral to keel abnormality causing obstruction? Have you got a stenosis? But foreign body, particularly if it's new onset and we do see it actually. So yeah, so obstruction now lost where I am, right stride Oh, as well, as well as if you've got Strider. It's an airway problem, isn't it? Remember, Stridor is inspiratory noise on inspiration, breathing in such as croup. If it's acute, if it's chronic, it's an airway problem. Again, we's is that prolonged sound on expiration. So one striders inspiratory wheeze is expiration. If you have persistent ear, nose or Sinus infections, you know is the mum. Does the mom really know what wheezes or is she thinking more of upper airway transmitted noises? Great, difficult, you know, Is she thinking more that the child has to use no fashioned term catarrh at the airway. Noise is, um, equally persistent infections. Do they have an immune deficiency? But I would expect that child to be failing to thrive. So it's not just one little bit to remember. Recurrent ear and throat and recurrent nasal infections, coughs. Colds are very common in Children family history of unusual chest disease. So if Mom tells you I've got I've got alpha one antitrypsin deficiency, I have cystic fibrosis. You're going to think, Oh, actually, I need to scream the child. It can be inherited. Or if the clinical picture is much worse than what you find when you examine or your spyrometry, your investigative spyrometry that you can do over the age of five suggests. Okay, I've probably just spoken about some of these differentials, but this is an example of some of the differentials. They're not all here, so cystic fibrosis symptoms would be should be present from birth. That there's a bit of a uh, sometimes is when the staff, local glorious or the haemophilus influenza gets into that chest that you start to really see the symptoms of cystic fibrosis. So if it's not necessarily from birth, but slightly later, but within the first year of life. But symptoms present from birth Finger Club in family history of cystic fibrosis wait faltering because remember, they should have malabsorption from the pancreatic dysfunction or any gastrointestinal symptoms. I would always ask about diarrhea, color of stools in an asthma consultation in your system. Review very quickly, because quite often you've only got 15 minutes in clinic very quickly. Just say, Are there any bowel problems? Primary Celery dyskinesia symptoms are present from birth. Remember, this is when the celery do not brush properly to expel the mucus, to carry the mucus up from the lungs down the nose and pause. You know, natural clearing. We're not brushing all the time. They are disconnect ick. They don't have good motility. Dyskinesia is abnormal motility, isn't it? So our natural, silly, sillier hairs that line all our respiratory tract are not brushing properly. Some mucus can build up, so the child has to actively cough or the baby has to cough. Or they will present with pneumonias, obviously again persistent cough. And they can be very nasal. But very michael peril peril int not clear nasal. So difficult because allergic rhinitis and asthma you get nasal symptoms, but just think from character cyst. If a child is bringing up sputum, if you have signs such as bronchial breathing or crepitations localized to suggest bronchiectasis iss, you could well have growth faltering, actually as well. Gastroesophageal reflux, disease or aspiration. We've mentioned, um, and then laryngeal dysfunction, stride or abnormal cry in a baby if they have a week cry. So there are differentials, and our role is to find the differentials. Okay, this is a complicated side and sort of repeat it. Actually, I like this one because I felt it was clearer than the UK asthma guideline one. Actually, this is from the New Zealand, uh, pediatric asthma protocol guideline, if that makes sense, so let's take it down. We've got plenty of time. Let's take it time. So you're asking about the child with respiratory symptoms? Are the symptoms typical of asthma? Okay, so we're here. I hope you can see my pointer. So if they're typical and this is in a preschool, 124 particularly difficult group, okay? Because the problem is they catch lots of viral infections and they get their airways become sensitized. Okay, so if you think just think diagrammatically I should have put a slide of diagrammatic. So a baby. Okay, a 10 month old if it catches a viral infection. If it catches bronchiolitis, for example. Okay. Which is in this country Very much RSB driven. But any virus can do it. Their airways they will res because they have a narrow, looming airway which is getting filled up with mucus and then they're pushing air through it. And you get that whistling Xperia Torrey sound Think of it. If you blow into a whistle that is a narrow blooming pipe, you get a whistle, you get an extra sound. You get that wheezy chest. If you try to blow through a big drainpipe, you don't get that extra sound because it's it's bigger you. It's more difficult when you're exhaling out to set up wheeze in asthma. Remember, the path of physiology is Broncho constriction of the smooth muscles. To make the pipe smaller in the 1 to 4 year olds is not necessarily that they're Bronco constricting. Their reason because they're pipe is small anyway, right and by pipe, I mean, they're bronch i their pipe there. Bronchi are smaller anyway. They're getting filled with mucus to make them smaller, and then we're getting the wheeze, so they're not necessarily Broncho constriction. But their reason. And you can't tell because you can't give them a dilator and then assess them with spyrometry. What they're what's happening if they've got reversibility. So the other definition of asthma from a path of physiology, point of view and I haven't put slide in I'm sorry. It's remember it's reversible Broncho constriction by relaxation of the smooth muscle. I'm sorry I've not got slide about that. So you have a 1 to 4 year old whose moms saying they're having recurrent episodes of wheeze cough and they can be short of breath when they're running around. So what you're going to do is try to get a feel for how often is this happening Now, she says, if we come down this chart, it's happening frequently or every 6 to 8 weeks, or it's severe flare ups with viral illness that the child is hit in hospital because they are so easy. What she also tells you is that they're having symptoms. Sorry, I keep losing this right They're having symptoms between the viral illnesses or flare ups. So it started to suggest actually, this could be asthma. Compare it to the other side here when it's infrequent, and it's only with the viral illness and there's no severe flare ups. They're not going into hospital. They seem to be much milder, and they're well in between. So if you come back down this side, we're suspecting preschool, asthma and what we would suggest with this chill, these Children is to give a trial of asthma therapy, including a trial of a preventer, an inhaled corticosteroid, and we would label them as preschool asthma. But we're going to keep an open mind because in 50% of the cases were going to be wrong. They were just infantile toddler ease, and they're going to get better. Okay, but we're going to watch them after three months and see if they if they improved. And if there's an improvement after three months, we tend to suggest try weaning the medication and see what happens. But leave them with their acute treatment plan of the salbutamol to use in the infrequent one child who didn't have intermediate symptoms. What you're going to do is label them as infrequent preschool Louise or Todd Louise and just suggest that they use salbutamol. Beta agonist reliever as required. But watch see how they go. What we do need to remember is that preschool wheeze is common because of the recurrent viral infections. Because of the anatomy of their airway, they're not necessarily Broncho constriction. But factors such as Isma, etcetera are going to increase your chances that they've truly got asthma. Okay, this is the UK sign the UK British Thoracic Society 2019 asthma chart. I didn't think it was as clear which. So I preferred the other one. Um but this is, uh this is not doing preschool here. So again, in your history, look for your recurrent episodes of symptoms. Your symptom variability. Remember, nocturnal cough, early morning cough, early morning wheeze, uh, absence of symptoms of the alternative diagnosis, which we've covered. I am repeating myself, but I think it's really important, you know, ideally, you want to hear the wheeze, or that the g P has seen them during an acute episode, which is likely for them to have got to secondary pediatrics. And they've recorded we's because what Mom thinks is we may not be. We could be group. It could be lots of different things. It could be upper airway transmitted sounds. You want the personal history of H P and if you can, you want the child to have done a peak flow the recording. But really we find it's only reliable. In fact, above the age of seven, we find even the 5 to 7 year olds difficult with peak peak flow monitors. But if you can show that when they're unwell, their peak expiry torrey flow rate drops or if they're early morning that diurnal variation and peak flow that is helpful and the peak flow should drop by, at least they say greater than 12%. But if you think 15% for the maths, it's easy. If you think their asthma, you're going to come down here and you're going to initiate treatment. Okay, so you're going to start them on their inhales core to corticosteroid as a preventer, and you're going to give them a treatment plan of when and how to use the salbutamol. Okay, if they're using the salbutamol more than three times a week, you don't have your preventer, your prophylaxis correct. You are going to follow them up and you're going to assess the response. If you're in a clinical setting where you can do spyrometry that validates your diagnosis. If the age of the child is appropriate, I think sometimes access to spyrometry can be restricted. But I think it's really important to think about it, particularly if you're struggling to get the child under control. So I wouldn't necessarily do it in someone who's a good responder with a good history. But I would do it if I'm struggling to achieve control. So the tests for Broncho constriction are reversibility. Obviously you do spyrometry sorry. You give them a bronchodilator and you assess their bronchodilator response. You do a peak flow charts get them. They can do this at home. Or like I've got challenge tests here. We don't do histamine challenge tests to trigger broncho constriction, but obviously I think in very challenging cases, it may be appropriate. Yeah, do I bleed them? But you could consider looking for you eosinophilia response. You could consider skin prick testing to identify allergens. Sorry, but think about your differentials. I'm going to move on and leave that slide and talk about treatment. You know, I may have to run away and get a drink of water. I'll leave you with outside. I'll be seconds. Okay, so this is the child 1 to 4. The first thing I'm going to point out is this little picture in my top right hand corner. As I look at my screen, I'm showing you a child with the correct inhaler technique. She is using a spacer. Okay? And we're going to come onto that. I want to try and show you a video of it at the end. But what I don't want to see is an inhaler going straight into the mouth. They swallow it, they don't. It doesn't get to the lungs. You must use a spacer if you take one message away. Any treatment is with the spacer. So your symptom relief is obviously my bottom line. Here. My salbutamol. Beta agonist Reliever. 1 to 2 puffs, as needed. Fine. Honest. I always give two puffs, but this is the New Zealand data. So you're going to give them symptom relief plan for mild wheeze. Say two puffs if they moderately wheezy five puffs. If they're having a severe asthma attack. Ask them to do 10 puffs. They can repeat this after two hours, but if it doesn't actually, they can repeat it straight away. But if they're repeating it straight away, they need to go and get help. But if they're finding that they haven't to do it like, I think it's okay to do 12 hours. But if they then having to do it more than four hourly, they need to be seen or if it lasts for more than 24 hours. But two puffs when a child is going out to play or if they've come in from nursery there easy or they've got a cold, you know, let them use their salbutamol inhaler if you're putting them onto maintenance preventer. Okay, remember, you've got different options. If you think they're an infrequent preschool, Wheezer, you're not going to give them any therapy. But if you think they're getting frequent or they've had severe episodes, you're going to give them a low dose inhaled corticosteroid. I see s stands for in inhaled corticosteroid. We use budesonide quite typically, but there are lots of options out there. There is Pulmicort. There is Podesta Naide. There's beclomethasone whatever inhaled corticosteroid you have access to. Then if their symptoms are not controlled, you see them in clinic and they're still reporting. They're not to know coffin. They're wheezing. They're using the beta agonist three times a week. Um, because ideally, you want them to not be using it or occasionally using it. If they're using it, you haven't got your control. And certainly if they're using it three times a week, then we would say you need to step up so we would add a In the 1 to 4 year group, we would add a montelukast. So an anti histamine driver, first of all, But if you're still not under control, they need to be seen in the specialist clinic. Always check inhaler technique. Okay, Inhaler technique is really important. Quite often, what the specialist clinics do is the asthma nurse provides education. And that's what makes the difference. Is not the drugs we all have access to the same drugs, the education and the training. Okay, I'm going to slip skip this slide because I've shown you the asthma pathway. But it's previously from the UK. This is the New Zealand version I think it's easier to understand the principles are the same. You've taken the history. If the history is typical, your initiating treatment you're diagnosing and you're evaluating the response. After three months, if the history is not typical, you consider other diagnosis. What you can do, though, in the 5 to 11 year olds is you can actually do spyrometry and peak flow monitoring so you can get objective data. Okay, I put this up because we're going to talk about acute asthma treatments. We've made our diagnosis. We now have to treat. We're going to talk about Acute and we're gonna talk about chronic. I have a picture of a child and an adult. The adult is put in the device straight into the mouth. We do not recommend that in Children, and in fact, even in adults they prefer, particularly when they're at home to you, they get. We know we get better delivery with spacer. A child has a spacer so that that's an aero chamber. But there are different types, and that child is using a mask, and it will be a metered dose inhaler. It's not turbo inhaler that they're fitting into the end you have to match your inhaler and your spaces. Okay, this is asthma diagnosis. And how are we going to treat? So I appreciate there's a little bit of repetition, but repetition is good. So you're going to use. So you've got your trying to get my I think I'm down the bottom on this blue bar going across. You will use your short acting beta agonist as required, but you will consider moving up my step diagram if they're using three doses a week or more. So if they use it, if they're reaching for their blue in their salbutamol inhaler three times a week, you haven't got your prophylaxis, your preventer, Correct. We start with preventive preventer once we pass that infrequent, short lived wheeze, and we've got regular symptomatology. We start with the regular preventer. We use very low dose inhaled corticosteroids. Okay. And if that doesn't work, we then they come back to clinic. We then need to think about an add on therapy. And there's options. You can go either way, and I think it depends on your symptomatology. Actually, you can either add add on if they're greater than five. You can add on a long acting beta agonist or leucotriene agonist. So you can either give them, um, a long acting salmeterol, for example. And the beauty of this is, sometimes you can use a combined inhaler with the inhaled corticosteroid, Um, or you can add on a single dose of a leukotriene antagonist to inhibit histamine in Children less than five. We don't tend to use the long acting beta agonist. We use the leucotriene agonist, and then after that, our next stage would be to increase the dose of steroids. So instead of going low dose, we'd go moderate dose instead of having them sitting at 100. We'd put them up to 200 mix twice a day, and then we'd go up to 400 mix twice a day. But if you're getting up into the big doses, make sure you've got spyrometry and you've got a specialist nurse involved. So that's our chronic treatment. Let's go on to the acute child that comes into hospital. You're working in the emergency department, and a child comes in known to have asthma. It's come in very acutely, wheezy and coffin, and what you're finding is your quick assessment. Can that child talk to you, right? Can they speak in sentences, or can they only manage phrases? So if they can talk to you in sentences, right. I'm going to say this is a 12 year old to make it easy. That child can speak to you in sentences and say, I've been to school today. Okay? Am wheezy. You know, maybe she had an art and that get made her easy as well. Although that's complicating things. Um, so you want to know? Can they complete sentences or are they too breathless to talk or in a little one too breathless to feed? They won't suck their bottle. They won't drink. They don't want to eat. Look at their heart rate. Okay, Because you want, you know, put take their pulse. If the pulse is greater than 140 in a 1 to 5 year old, I would say they're quite they're very bad if it's greater than 125 in greater than a five year old. That is concerns too tacky. Cardia is a concern. And also tack it near given news and measurements there, I'm going to put a saturation on them. Reverse hypoxia. You know you're going to give them oxygen. I know you think? Well, if the bronchoconstricted will the oxygen get in, but some will get in, so give them oxygen. Take their saturations. Right. So acute severe asthma, which requires are nebulized treatment, is going to go on to talk about the treatment. Would they would be hypoxic. They will be unable to talk. They will be very wheezy or they may in fact be wear the silent chest. If they can't get airing, you're not going to hear the wheeze until you open up the chest. So be very aware. The silent chest. Okay, Life threatening would obviously be if they're looking exhausted. If they're cyanosed, if they've got low BP, if they've got that silent chest I've just mentioned or if they've got very poor respiratory effort, they are so hype hoppsy, they've dampened their respiratory effort. And if they're confused, you're going to need to intubate and ventilate this child. This child, the accused of severe child, you can probably still turn around the life threatening. You need a needle test. Okay, So the acute severe child, the men to try turning them around, go to give them oxygen. If they're hypoxic, I'm also going to give them a better agonist. Okay, In that acute severe child, I would give that via nebulizer. But if it was mild to moderate, we's actually we use a spacer. We think it is equally effective. But what it really does is it teaches the parents. This is what we do. This is what you should be doing at home before you bring the child to us while you're getting your transport ready. So we would give them the beta agonist in mild to moderate asthma. Okay, They're not tachycardic. They will be a bit tight. Apneic, actually, To be fair, they probably may have a mild high cardia, but you'll just look at them. They can still talk to you, or they just don't look too bad. You're going to give them if they're hitting hospital, you're going to give them 10 puffs. If they're very mild at home, you may give them between two and five, but once they're acutely severe, you're going to nebulize them with salbutamol. You will consider adding, Certainly if you do two nebulizers and we often do to nebulizers back to back is what our treatment is so we literally just get the nursing team to say give them to nebulizers. And actually, we are DePetro me, um broke up bromide. That may not be the same around the world. Okay, but what we do need to do is take the inflammatory burden down and everyone around the world would give oral prednisolone in a moderate to severe. Not a mild, a mild. You may try to manage with justice salbutamol, but you'd give oral prednisolone. The problem with oral prednisolone is it takes four hours to work. It's not immediate acting if they're very severe there. That child that described on the previous child, the previous slide, actually in an accident and emergency you can reach for your nebulized magnesium as a muscle relaxant. It's been a bit life changing, actually in the management of asthma, it's quite knew there was something called the magnetic trial where they tried showed that nebulized magnesium is a very powerful Bronco dilator or if they're very bad, you're going to give intravenous magnesium. If you're using intravenous magnesium, you may be your you know that your next steps, if it doesn't work, is intensive care. But intravenous. Magnesium is also a very powerful, uh, smooth muscle. Bronchodilator used a lot in adults as well, so adult medicine is the same. All this is the same as with adult medicine. Actually, I'm not sure the adults are using the nebulized magnesium. You know, I've gone on Okay, I want to talk about inhaler technique, and I am going to go over time. I'm sorry, Claudia, but I think it's really important because I want everyone to know that they must assess inhaler technique because if it's not right, your child's not going to get better. M. D. I write metered dose inhaler with a spacer is the preferred option. We may in a child who's nine years and above offer them an easy breathe, activated device or other devices that they can have in their jacket pocket at school, etcetera. But in all young Children, and when they're in the house, or if they're acutely unwell, it is the spacer they required. You must shake the inhaler to get the particles right. So the first thing and you assess the actually I don't have an inhaler device, but I'm going to shake it. I'm then going to I'm going to have connected it to my volume Attic. I'm going to get the charge. Breathe out. Ask them to breathe out, and then I'm going to put it on their face. It doesn't matter so much. You don't always have to get them to breathe out if you're using the spacer. But certainly if you were using a breath activated device, you breathe out first so that your next breath in is a big breath going into the lungs. Um, to get better delivery. Okay, press inhaler into device to press the inhaler and then breathe in slowly and we count. We asked parents to count five breaths. So to watch the abdomen move in a young child or what? The chest move, whatever is easy. Remember, that device takes a minimum of 30 seconds to refill, so you can't just go 12, okay, You have to go one 30 seconds before I give Puff 25 breaths. Does not take 30 seconds. You need to be counting. Okay? There is a YouTube video, and I'm going to try to be what I'm gonna do. I'm gonna show the last slide, and then I'm going to show a YouTube video. So the key messages of this tour right? Uh, start with a bit of a bold statement. Pediatric asthma outcomes, despite medical intervention, are still poor that many deaths are preventable, and it's normally education and identifying the child that is not well controlled. One of the deaths we had. Actually, when we looked back, that child had come into hospital and I'd actually told them he had converted. He wasn't running around the football pitch anymore. He was now playing in goals because he didn't want to run. Okay, that was there in the history. But what happened? Unfortunately, because he was discharged home without his preventive treatment being escalated. He was acutely treated, but he didn't get the preventer escalation. Um, it's like it's just avoid. It was an avoidable death, wasn't it? If we had escalated the preventive treatment, we could have prevented his death. Okay, I've shown you the challenges of asthma diagnosis and the differentials. You review it follow up to make sure it's correct. Asthma attacks should be viewed as never events, because if they're having an attack, you need to get it into your mind. This is not normal. I should have prevented this. I've got my preventive strategy wrong. But if they do have an attack, you must do a post attack review to optimize your maintenance therapy and prevent future attracts attacks. Education is key. We also have a standard from asthma UK and some of the UK bodies to say that people should the Children should have a personalized asthma written plan. The parents should be told what to do. When? When do they step up? What are their child's symptoms? Increasing cough, increasing shortness of breath, These signs of an inter current viral infection. Step up your blue inhaler. Right. I am going to stop chairing. And if I'm going to stop sharing that and then what I'm gonna do, if that's okay, I'm going to show you a video. Uh, right. If I can share again, right share screen. Yeah, right. I'm gonna see. I don't know if this is gonna work. Uh, doctor, you need to share audio as well because we can't hear Oh, there should be an option to share audio where share screen is right. Hang on. Let me stop sharing. Sorry. Right. Claudia, you're gonna have to talk me through this because I think I am share in audio. Um, sure. Then maybe you can just post the link in the chat as well. Okay. The links on that last slide, right? Okay. So you can't hear my audio? Obviously. No, unfortunately, uh, that's very annoying. I will put the link in the chat. Um, should I try again? Yeah, we can give it another try. We've got five minutes left. Hang on. Ok, so I'm in settings on this Subtitles I wonder if I put subtitles on Got subtyping so Oh, no, We can't hear it, but I can't I don't know what else can. Okay, right. Thank you. That was a clear video summarizing what you said. I'm very sorry about that. I'll post you the link, but the link is also on the on the side on their slide. Any questions? We have none in the chat we have. Thank you's in the chat. If anyone has a question, please feel free to a mute in the last two minutes remaining. Thank you. And thank you, Doctor. Yeah, I'm sorry I went over, but I think that video is really clear on how to teach a parent how to do it. All right, I'll post that link in the chat again. Thank you. I've closed the feedback form in the chat as well, and the certificate is now on the chat, so please download before the lecture ends and the doctor will place the link for the video now. Thank you. I'm with every question. Why is it that magnesium is in last week search, uh, management of, uh, actually, do we catch that? I said, why is magnesium the last restart? I'll type it right now. Okay. Why is magnesium the last response? Um, toxicity. I am assuming. Actually, we always use it at the end. We always use the beta agonist. Um, and we we keep magnesium to the end. We probably using less aminophylline than what we used to and using more magnesium, particularly in the older child. In the under fours. I think we still don't have the data on magnesium, but you can get toxicity. It can affect your BP. Um, if you give intravenous magnesium, you don't feel you feel very shaky, don't you? You see it in the I guess I'm comparing it because a lot of the moms with who are delivering prematurity get magnesium, and they say they don't feel well. They also get a lot of shaking, so I think it's just not as well tolerated, but it's very, very good. Broncodilator you use it in preeclampsia as well, don't you too? Uh, calm the neurotransmitter system and to lower the BP. Thank you, doctor. And thank you, everyone for your engagement. And I would have to end election lowers. The next lecture is starting. Okay. Thank you. Have to see you soon, Doctor. Thank you.