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Chapter 2 Index
A. Evaluation by system:
1. General
2. HEENT 3.
Cardiopulmonary
--Heart Murmurs: When to Refer
--How to Feed Infants with Heart Disease
--Syncope in the Pediatric Age-Group
--Asthma: Classification and Management
--Asthma Medication |
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Exercise Induced Asthma (EIA)*
Incidence in children: 3-12% of the population; poverty a definite risk
factor
Incidence in children with diagnosed asthma: > 90%
Mechanism: Airway obstruction related to thermodynamic
events within the airway. Most people respond to exercise with
bronchodilation; opposite with EIA. Constriction leads to increased
respiratory effort, and therefore decreased FEV1 and PEFR (peak flow
expiratory flow rate).
Questions to ask in someone considering diagnosis of EIA:
- Does it bother you when you swim? Because of warmth and humidity
usually better then
- Is your endurance getting less? Get an “out of shape” label, even
though well-conditioned
- Is your endurance better in different seasons? Usually cold air makes
worse.
- Are you exposed to pollutants, smoke, etc?
- Do you cough whenever you start to exercise? Cough = wheeze
Diagnosis: When wheezing is not present:
- Is there associated sinus disease?
- Lab: Abnormal FEV1 or FVC; sometimes peak flow can be normal at time
of testing, but all should be followed with this at home.
- Exercise Challenge test: can be done by having child run in place for
10-15 minutes. Can also use the methacholine challenge tests, but not
likely to be available in the office. Can do following challenge test:
- do baseline peak flow test
- have exercise for 10-15 minutes by running in place
- do another peak flow test
- give inhaled albuterol, and compare peak flow tests
If still convinced that has EIA, and can not prove it this way, may need
to refer for PFTs.
Treatment:
1. General:
Increase physical conditioning; warm up longer before exercising; breathe
through nose rather than the mouth when exercising; however, normal
cardiovascular fitness does not protect against EIA.
2. Medications:
- Beta
agonists: drugs of choice: albuterol, metaproterenol, terbutaline,
salmeterol. Effective in 85-90% of patients. Salmeterol: >12 yrs old: give 2
puffs every 12 hours: longer duration; give 30 minutes before exercise;
that after 1 month, doesn’t last as many hours. Give short
acting 15 minutes before exercise.
- Anti-inflammatory: cromolyn prevents in 70-85% of patients. Give 10-45
minutes before exercise; Nedocromil sodium: combine with beta agonist
- Steroids:
not effective just prior to exercise; includes budesonide.
- Leukotriene-receptor
(Montelukast or Singulair): chewable tab once a day aged 6-12: works in most
patients, but 25% get no protection.
*Ref: Rupp:
Treating Exercise-Induced Asthma. The Physician and Sportsmedicine: Jan 96 NEJM
98;339: articles on salmeterol, montelukast, and editorial. (back
to the top)
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