Pediatrics
A 3-year-old child is a known asthmatic who usually has 1 acute exacerbation each month.
The acute symptoms are relieved by nebulizer therapy at the Emergency Department or the nearby health centre. Which of the following should be included in the daily management?
Explanation
Core Concept: Asthma is a chronic inflammatory disorder of the airways causing variable expiratory airflow limitation. A child requiring emergency or urgent care for asthma exacerbations more than twice a month, or experiencing symptoms frequently, has persistent asthma and requires daily controller therapy to reduce airway inflammation.
Clinical Presentation:
- Classic symptoms: Recurrent episodes of wheezing, breathlessness, chest tightness, and coughing (often worse at night or early morning). Symptoms are triggered by viral infections, allergens, exercise, or cold air.
- Complications: Status asthmaticus (life-threatening exacerbation), airway remodeling, sleep disturbance, and impaired physical activity/growth.
Diagnosis:
- First-line diagnostic plan/tool: Clinical history and physical examination. In children > 5 years, spirometry demonstrating reversible airway obstruction (FEV1/FVC ratio < lower limit of normal, improving with bronchodilators).
- Most accurate (gold standard) diagnostic test: Spirometry (pulmonary function testing) with bronchodilator reversibility testing.
Management:
- Acute management: Short-acting beta-agonists (SABA, e.g., albuterol) for quick relief of symptoms. Systemic corticosteroids and ipratropium bromide for moderate-to-severe exacerbations.
- Gold standard long-term/definitive management: Daily inhaled corticosteroids (ICS, e.g., inhaled budesonide or fluticasone) are the first-line controller therapy for persistent asthma in children. Leukotriene receptor antagonists (e.g., montelukast) are an alternative but less effective. Regular follow-up and asthma action plans are essential.