Session 18

Define acute diarrhea.

Diarrhea (at least three liquid stools per day) that lasts for 14 days or less.

Note: a patient without diarrhea does not have gastroenteritis. Acute diarrhea is an extremely common
problem-most child under 5 have one diarrheal illness per year. Almost all cases of acute diarrhea are
self-limiting, do not require any specific intervention, and no interventions will shorten the course of
illness.

The majority of acute diarrhea cases in developed countries are caused by…………a……………. infections.
The single most common cause is ………b………..followed by ………c………….

a) Viral infections

b) Rotavirus

c)Norovirus

Identify red flags in acute diarrhea.

Bloody diarrhea (dysentery) – essentially no viral infections cause bloody diarrhea, so it’s presence
effectively rules out viral infections as cause. Seen with Campylobacter, E. coli H7:0157 (EHEC), and
Shigella infections, as well as Entamoeba histolytica (Entamoeba is extremely rare to acquire in a
developed country, without a history of travel).

Recent antibiotic use or hospitalization – risk factor for Clostridium difficile infection. An absence of
recent antibiotic use or hospitalization is a strong negative predictor for C. diff infection.

Recent travel to a developing country – the prevalence of bacterial and parasitic causes of acute
diarrhea are much higher in developing countries than developed countries. As a result, recent travel to
one increases the probability that a patient’s acute diarrhea may be due to a bacterial or parasitic
cause.

High fever (>38.5) or septic appearance -Increases the probability of bacterial infection or serious
illness.

Immunocompromised patients –higher risk of having a bacterial or parasitic cause. More likely to get
sicker from a given pathogen.

Large volume diarrhea (>12 episodes a day) – increases the probability that the cause is not a viral
infection

Duration of diarrhea more than one week – most viral causes have symptom resolution by a week.
Thus, symptoms lasting longer than this increase the probability of bacterial or parasitic infection (such
as Giardia).

Ingestion of raw seafood – Vibrio parahaemolyticus is essentially only contracted by eating raw
seafood (especially oysters). Thus, an absence of this effectively rules it out.
Hypovolemia – as manifested by hypotension or tachycardia. This is a moderate predictor for non-viral

causes

What does it mean to use a “red flag approach” to diagnosing?

A red flag approach means that we only purse further investigation or treatment in patients who have
at least one red flag. All other patients receive supportive care and reassurance.

Describe partial illness scripts for Campylobacter, Salmonella, E. coli O157:H7 (EHEC), Enterotoxin E.
coli (ETEC, travellers diarrhea), Cholera, Vibrio parahemolytica, Shigella, Clostridium difficle, Giardia.

*Note the illness scripts below are from UMlearn.

ROTOVIRUS

Prevalence: most common

Risk factors: age 6-24 months. Spread by fomites. Person to person spread.
Positive predictors: fever and vomiting. Lasts 3-8 days. Watery diarrhea.
Confirmatory/rule out tests: not easily available
Prognosis: Can cause death-mostly in developing countries. Usually it has full recovery in a week.
Prognosis c tx: excellent if dehydration treated.

NOROVIRUS

Prevalence: second most common (12%)

Risk factors: transmission by fomites. Occurs in outbreaks.
Positive predictors: vomiting, watery diarrhea, low fever, lasts 1-3 days
Confirmatory/rule out tests: not easily available
Prognosis: usually excellent prognosis

CAMPYLOBACTER

Prevalence: common among bacterial causes. 0.5% of Americans per year.

Risk factors: transmission person to person and in water/food. Travel.
Positive predictors: abdominal pain, fever, malaise. Headache. Bloody diarrhea.
Confirmatory/rule out tests: Stool bacteria culture.

SALMONELLA

Risk factors: transmitted food. Travel.

Positive predictors: Fever, abdominal pain, and abdominal tenderness.
Confirmatory/rule out tests: stool bacteria culture.

E. COLI O157:H7

Risk factors: shed in cattle feces.

Positive predictors: bloody diarrhea
Confirmatory/rule out tests: stool bacteria culture
Prognosis: causes Hemolytic Uremic Syndrome

ENTEROTOXIC E. COLI (ETEC, traveller’s diarrhea)

Risk factors: travel to developing countries

Positive predictors: watery diarrhea
Prognosis: prognosis is good with or without treatment
Prognosis c tx: course is shortened by a little with treatment

CHOLERA

Risk factors: travel. Contaminated water.

Positive predictors: Extremely voluminous watery diarrhea.
Prognosis: life-threatening
Prognosis c tx: Prognosis with treatment including fluid replacement, is excellent

VIBRIO PARAHEMOLYTICAS

Prevalence: 0.001% of Americans per year

Risk factors: undercooked seafood

SHIGELLA

Risk factors: travel to developing countries. Person to person, fomites, food/water spread.
Positive predictors: can be short period of watery diarrhea, to bloody stools with fever, abdominal pain,
and tenderness.
Confirmatory/rule out tests: stool bacteria culture

CLOSTRIDIUM DIFFICLE

Risk factors: outbreaks in health care institutions. Occurs after antibiotic use, especially clindamycin.
Confirmatory/rule out tests: stool for C. diff. toxin
Prognosis: Can be life threatening.

PARASITES AS A GROUP

Prevalence: 1-8% of acute diarrhea in developed countries

Confirmatory/rule out tests: stool for ova and parasites
Treatment: most with antibiotics

GIARDIA
Prevalence: most common parasite in developed countries
Confirmatory/rule out tests: stool for ova and parasites
*Most common parasitic cause of acute diarrhea in MB. Treat with antibiotics.

HYPONATREMIA

Positive predictors: severe dehydration, altered levels of consciousness

Negative predictors: lack of severe dehydration
Confirmatory/rule out tests: serum sodium

Estimate the degree of dehydration in a child based on physical exam findings.

EUVOLEMIC TO MILD DEHYDRATION

Fluid deficit is less than 5% body weight or less than 50mL/kg body weight in infants; less than 3% body
weight or less than 30mL/kg body weight in older children.
• Mental status: alert
• Eyes: not sunken
• Tears: present
• Heart rate: normal
• Pulses: normal
• Breathing: normal
• Mouth and tongue: moist
• Capillary refill: normal
• Extremities: warm
• Skin pinch: instant recoil
• Drinks normally when offered water, not thirsty
• Urine output reported as normal to decreased

MODERATE DEHYDRATION
Fluid deficit is 5-10% body weight or 50-100mL/kg body weight in infants; 3-6% body weight or 30-60
mL/kg body weight in older children.
• Mental status: normal, fatigued or restless, irritable
• Eyes: slightly sunken
• Tears: decreased
• Heart rate: normal to increased
• Pulses: normal to decreased
• Breathing: normal to fast
• Mouth and tongue: dry
• Capillary refill: prolonged
• Extremities: cool
• Skin pinch: recoil in less than 2 seconds
• Thirsty and eager to drink
• Urine output reported as decreased
If they are 4% dehydrated this translates to 500ml ish.

Describe measures that are effective in preventing the spread of acute gastroenteritis.

Hand washing, cook food thoroughly/practice safe food handling, keep sick children away from daycare,
practice proper hygiene, water purification, safe diaper changing and disposal, vaccines against
rotavirus.

Identify the most likely cause of acute diarrhea in a child.

Rotavirus has historically been the most common cause of acute viral gastroenteritis in children. Non-
viral enteritis pathogens (bacteria/parasites) account for approximately 30% of cases of acute
gastroenteritis in children.

Identify when investigations and specific management are required for a child with acute diarrhea.

Acute viral gastroenteritis is usually self-limited and is treated with supportive measures (fluid repletion
and unrestricted diet). Most immune-competent children >1 with typical findings of acute
gastroenteritis do not require laboratory evaluation.

Children with acute viral gastroenteritis may need hospitalization if they show signs of: shock, severe
volume depletion, moderate volume depletion with refusal of oral fluids, clinical deterioration,
intractable or bilious vomiting, failure of oral rehydration, neurologic abnormalities, possibility of other
severe illness or condition.

Laboratory investigations may be warranted in children who require intravenous hydration or who have
an atypical presentation.
• Serum electrolytes are suggested for children requiring intravenous hydration
• CBC is suggested if hemolytic uremic syndrome is suspected
• Fecal leukocytes may be warranted if bacterial gastroenteritis or inflammatory bowel disease is
suspected
• Inflammatory markers in the serum (ex. C-reactive protein)/stool suggest inflammatory rather
than viral cause
• Stool samples for C. diff., examination for ova and parasites
• Urinalysis and urine culture if UTI is suspected

Describe the medical management of a child with dehydration from acute gastroenteritis.

Monitor serum electrolytes, BUN, and creatinine.

Treat mild to moderate dehydration with oral rehydration therapy.
Treat severe dehydration (>10% volume loss) with emergent IV therapy 20ml/kg of isotonic saline, and
once stable oral rehydration therapy.
What investigations should be considered in patients with acute gastroenteritis and at least one of the
red flag symptoms?

• Routine stool culture for Salmonella, Shigella, E. coli O157: H7.

• C diff. stool toxin assay.
• Giardia test (stool microscopy or stool antigen detection assay)
• CBC, urinalysis/renal function tests, electrolytes

What are some cases of bacterial caused diarrhea in which antibiotics would and would not be
prescribed?

Antibiotics are used for acute bacterial diarrhea when a patient has invasive bacterial infections (like
sepsis), cholera with severe dehydration, or salmonella in an immunocompromised or malnourished
patient.
Antibiotics are generally contraindicated in E. coli O157: H7 cases due to an increased risk of hemolytic
uremic syndrome (HUS), and in uncomplicated Salmonella enteritis due to prolonged bacterial shedding.

Session 19
Describe illness scripts for the following causes of acute dyspnea: COPD exacerbation, secondary
spontaneous pneumothorax, community acquired pneumonia, acute pulmonary edema secondary to
CHF, pulmonary embolism, panic attack, chemical aspiration pneumonitis.
Note that the illness scripts below are the one’s Dr. Guinn posted on UMlearn following the session.

COPD (chronic): progressive, partially reversible airway obstruction disease

Prevalence: 5% of US population
Risk factors: smoking more than 10 to 40 pack years
Positive predictors: chronic cough, sputum production. Weak predictors: wheezing, and chest tightness,
hyperinflation on exam, wheezes, decreased breath sounds, barrel shaped chest, CXR changes
Negative predictors: lack of smoking history
Confirmatory tests: spirometry FEV1/FVC less than 0.7 AND FEV1 <80% predicted, incompletely
reversible with bronchodilator
Rule out test: spirometry
Prognosis: gradual worsening expected. COPD is a leading cause of death.
Prognosis c tx: smoking cessation delays death.

COPD exacerbation: sudden worsening of symptoms of COPD

Prevalence: common
Risk factors: severe COPD
Positive predictors: increase in cough, sputum or dyspnea. Change in colour of sputum. Wheeze,
tachypnea, increased work of breathing, altered level of consciousness
Confirmatory tests: definition-an acute event characterized by a worsening of the patient’s respiratory
symptoms that is beyond normal day-to-day variations and leads to a change in medication
Prognosis: Can be life threatening.
Prognosis c tx: 3-9% mortality in hospitalized patients.

SPONTANEOUS PNEUMOTHORAX: formation of small sacs of air in lung tissue that rupture causing air
to leak into the pleural space.

Prevalence: uncommon
Risk factors: COPD, risk higher with worse disease
Positive predictors: Chest pain. Large pneumothorax: decreased chest excursion, diminished breath
sounds, absent fremitus, and hyper resonance to percussion on the affected side. Subcutaneous
emphysema may be present.
Confirmatory tests: CXR
Rule out tests: CXR can rule out reasonably well. CT is better for very small pneumothoraxes
Prognosis: Can be life threatening
Prognosis c tx: Good response to evacuation of pneumothorax with chest tube and further tx if needed

PNEUMONIA (community acquired)

Prevalence: common
Risk factors: age, immune compromise, chronic respiratory conditions
Positive predictors: cough, fever, tachycardia, crackles on exam, pleuritic chest pain, sputum, chills,
rigors, vomiting and diarrhea, altered mental status, WBC 15-30
Negative predictors: lack of tachypnea over 24 bpm (sensitivity of 50-70%), lack of fever (sensitivity of
80%)
Confirmatory tests: CXR is reference standard in clinically plausible patients
Rule out tests: CXR is reference standard
Prognosis: can be life threatening
Prognosis c tx: good response to treatment

CHF (chronic)

Prevalence: common
Risk factors: older age, coronary artery disease, hypertension
Positive predictors: dyspnea, orthopnea, edema, RUQ pain from hepatic congestion, fatigue, weakness,
tachyarrhythmias especially atrial fibrillation, displaced apical impulse, elevated JVP, cardiomegaly on
CXR, strong predictors=pulsus alternans, S3 or S4 or both, BNP (brain natriuretic peptide >400 pg/ml
Negative predictors: normal EKG makes systolic heart failure unlikely (98%=negative predictive value),
BNP <100 pg/ml)

ACUTE PULMONARY EDEMA SECONDARY TO CHF

Prevalence: common
Positive predictors: cough, peripheral edema, chest discomfort, crackles, wheezing, tachycardia,
hypertension, S3 or S4 or both, new or changed murmur, elevated JVP, T wave inversions, QT
prolongation, B type Natriuretic peptide
Confirmatory tests: CXR, echocardiogram
Rule out tests: CXR does not rule out acute decompensated heart failure, but it does rule out pulmonary
edema.
Prognosis: Can be life threatening
Prognosis c tx: Good response to treatment

PULMONARY EMBOLISM: blockage of an artery in the lungs

Prevalence: uncommon
Risk factors: immobilization for three or more days, or surgery in previous four weeks, previous DVT/PE,
active malignancy
Positive predictors: pleuritic chest pain, cough, calf/thigh pain/swelling, wheeze, hemoptysis, onset of
dyspnea within seconds or minutes, tachypnea, crackles, jugular venous distension
Confirmatory tests: CT pulmonary angiogram or high probability VQ scan, or MR pulmonary angiogram
(rarely available)
Rule out tests: d dimer in low or moderate risk patients
Prognosis: can be life threatening
Prognosis c tx: good response to treatment

PANIC ATTACK: abrupt onset of intense fear or discomfort

Prevalence: common, 12-month prevalence showed that 2-3% of population had panic attacks
Risk factors: women: men =2:1, prevalence falls after age 60, depression, anxiety, life stresses
Positive predictors: spontaneous, discrete recurrent, non-triggered episodes of intense fear that lasts
for several minutes to an hour. An abrupt surge of intense fear or intense discomfort that reaches a
peak within minutes, and during which time four or more of the following 13 symptoms occur:
Palpitations, Pounding heart or accelerated heart rate, Sweating, Trembling or shaking, Sensations of
shortness of breath or smothering, Feelings of choking, Chest pain or discomfort, Nausea or abdominal
distress, Feeling dizzy, unsteady, light-headed, or faint, Chills or heat sensations, Paresthesia (numbness
or tingling sensations), Derealizations (feeling of unreality) or depersonalization (being detached from
oneself), Fear of losing control or “going crazy”, Fear of dying.
Negative predictors: hypoxemia
Confirmatory tests: DSM 5 criteria are the reference standard. It assumes organic causes have been
ruled out.
Rule out tests: None
Prognosis: No danger from the attack even though it feels horrible to the patient. However, panic
decreases quality of life and increases chronic risk of suicide

ASPIRATION PNEUMONITIS: inhaling toxic substances, usually gastric substances into the lungs

Prevalence: extremely common in subclinical form but otherwise only common in at risk populations
Risk factors: reduced consciousness, dysphagia, mechanical airway disruption
Positive predictors: abrupt onset of symptoms with prominent dyspnea, fever (usually low grade),
cyanosis and diffuse crackles on lung auscultation, severe hypoxemia and infiltrates on chest imaging
involving dependent pulmonary segments.
Confirmatory tests: CXR after two hours
Prognosis: high mortality rate
Prognosis c tx: Improved with supportive care.

Diagnose the most likely cause of acute dyspnea in a patient.

We did this in tutorial, look at the tutor notes/student notes if need to review. Use the illness scripts
above to design a differential. Things to remember:
• For the sake of this course assume that a normal chest x-ray rules out pneumonia or pulmonary
edema
• An elevated D-dimer alone is insufficient for the diagnosis of PE

Describe and use the SBAR tool to verbally communicate patient information to another healthcare
provider.

SBAR (Situation, background, assessment, and recommendations or request) is an alternative template

to an SOAP note for verbal communication. The main benefit of SBAR over SOAP for verbal
communication is that the very first piece of information you are telling someone is contextual.

Example:

Situation: I have a consult for a patient with hepatic encephalopathy who requires admission to
hospital.
Background: Mr. I is a 72 year old man with a history of alcoholic cirrhosis who presented to hospital
with 2 days of worsening weakness and confusion.
Assessment: He is vitally stable, and afebrile. He has asterixis on exam. He seems to have ascites
as well. His bloodwork showed that his hemoglobin is lower than usual.
Recommendations (or Requests): I think he needs admission to treat his hepatic encephalopathy, as
well as to look for possible causes of it, such as spontaneous bacterial peritonitis, or a GI bleed.

Session 20

Describe illness scripts for the following causes of acute cough in children: common cold, foreign body
aspiration, asthma exacerbation, pneumonia, croup, bronchiolitis, bacterial tracheitis, pertussis.

*Note the illness scripts below are the ones provided on UMlearn following tutorial

ASTHMA EXACERBATION
Prevalence: Common. Overall prevalence 1-18%.
Risk factors: Family history of asthma, personal history of eczema.
Positive predictors: Wheezing is a strong positive predictor. History of chronic symptoms with acute
worsening-especially if symptoms are seasonal or associated with triggers such as environmental
exposures, exercise, cold, or air. Other predictors: nocturnal cough, breathlessness, chest tightness or
pressure, tachypnea, hypoxemia, accessory muscle use, indrawing/retractions
Confirmatory tests: spirometry, documentation of reversible obstruction
Prognosis: extremely variable from barely symptomatic
Prognosis c tx: very good response to treatment.

COMMON COLD

Prevalence: most common by far ~90%, 6-8 colds/year

Risk factors: exposure to children, especially daycare, stress, smoking exposure, fall and winter season
Positive predictors: runny nose, nasal congestion, headache, sneezing, fever, abnormal middle ear
pressure, pharyngeal erythema, anterior cervical lymphadenopathy
Negative predictors: high fever, chest signs on exam, ill looking, oral ulcers, hemoptysis
Confirmatory tests: viral cultures are rarely done
Prognosis: mild illness, up to 2 weeks

BRONCHIOLITIS: infection of bronchioles

Prevalence: Common
Risk factors: age <2years, fall and winter season
Positive predictors: rhinorrhea and other common cold symptoms, wheezing, crackles, mild fever, CXR
findings, tachypnea, intercostal indrawing/retractions, prolonged expiration
Confirmatory tests: reference standard: common cold like symptoms and wheezing without another
diagnosis in a 12-24 month old.
Rule out tests: age >24 months
Prognosis: self limited, usually mild, but occasionally life threatening
Prognosis c tx: good response to treatment with supportive care

PNEUMONIA

Prevalence: Common
Positive predictors: fever (higher fever=more predictive), tachypnea (most sensitive and specific
finding), increased work of breathing, occasionally pleuritic chest pain, ill looking, indrawing/retractions,
altered mental status, nasal flaring, crackles, wheezes, increased WBC, increased C reactive protein
Negative predictors: lack of tachypnea
Confirmatory tests: CXR, can also be diagnosed clinically if classic findings
Prognosis: good prognosis with treatment

CROUP: swelling and narrowing of respiratory tract

Prevalence: common
Risk factors: children aged 3months-3years. Rare after age 6. Family history/personal history, smoking
exposure, fall and winter season.
Positive predictors: stridor is a strong positive predictor, characteristic barking, brassy, or seal like
cough is a very strong predictor. Other predictors include hoarseness, nasal discharge, and coryza,
fever, lasting less than 3 days. The degree of stridor, tachypnea, and indrawing are measures of severity.
Hypoxemia marks very severe disease.
Confirmatory tests: characteristic cough is a very strong predictor
Prognosis: usually mild and self limited but can be life-threatening
Prognosis c tx: good response to treatment

BACTERIAL TRACHEITIS: bacterial caused infection of the trachea

Prevalence: rare. 0.1 cases per 100,000 children per year

Risk factors: age <6 years
Positive predictors: usually common cold like symptoms for 1-3 days first before severe illness. Then
experience stridor, high fever, and respiratory distress. Other predictors: neck pain, orthopnea, choking,
dysphagia, dysphonia, syncope. Should be suspected in children presenting with acute onset of airway
obstruction in the setting of viral respiratory infection and in children with laryngotracheitis who are
febrile, toxic-appearing, and have a poor response to treatment with nebulized epinephrine or
glucocorticoids
Confirmatory/rule out tests: bronchoscopy
Prognosis: life-threatening
Prognosis c tx: much better with treatment

ASPIRATED FOREIGN BODY

Prevalence: uncommon. One death per 100, 000 children under age 4 per year.
Risk factors: age <3 years
Positive predictors: strong positive predictor: sudden onset. Respiratory distress, cyanosis, altered level
of consciousness, cough, tachypnea, stridor, wheeze, decreased air entry/breath sounds, hemoptysis.
Fever if delayed diagnosis. CXR findings.
Negative predictors: lack of witnessed choking (sensitivity 76-92%)
Confirmatory/rule out tests: bronchoscopy
Prognosis: life-threatening
Prognosis c tx: much better with treatment

PERTUSSIS

Prevalence: rare
Risk factors: personal contacts
Positive predictors: catarrhal stage is like the common cold for first 1-2 weeks. Paroxysmal stage 2-8
weeks-a long series of cough without inspiration, ending with gagging/vomiting or apnea/cyanosis-
sometimes ending with a “whoop” i.e. sudden deep inspiration. Whooping in 80% of cases but less in
vaccinated patients. Increased WBC.
Confirmatory tests: CDC case definition: cough >2 weeks AND one of: paroxysm of cough, inspiratory
whoop, post tussive vomiting, apnea/cyanosis AND contact with lab confirmed case. Nasopharyngeal
PCR/culture/serology also confirms.
Prognosis: life-threatening in many cases. More so in young infants. 1% mortality rate in infants under 6
months.
Prognosis c tx: supportive care improves prognosis.

Diagnose the most likely cause of acute cough in a child.

We did this in the tutorial, use the illness scripts above.

Session 21
Define a clinical practice guideline.

Clinical practice guidelines are an attempt for the medical community to both standardize our practice
choices and to incorporate the best available evidence into those choices. Guidelines are not rules that
are assigned by an authority. They are expert advice on how to best apply evidence. Guidelines consist
of a series of specific recommendations directed at practicing physicians on how they should investigate
and manage care. Since these recommendations are expected to be based on relevant evidence that is
referenced, clinical practice guideline is tertiary literature.

Evaluate a guideline by the standards of the Institute of Medicine.

STANDARD 1: ESTABLISHING TRANSPARENCY: The process by which a clinical practice guideline is

developed and funded should be detailed explicitly and publicly accessible.

STANDARD 2: MANAGEMENT OF CONFLICT OF INTEREST: Avoid conflicts of interest when possible and
identify them when avoidance is not possible.

STANDARD 3: GUIDELINE DEVELOPMENT GROUP COMPOSITION: The group developing the guideline
should be multidisciplinary and balanced, comprising of a variety of methodological experts and
clinicians, and populations expected to be affected by the guideline.

STANDARD 4: CLINICAL PRACTICE GUIDELINE-SYSTEMATIC REVIEW INTERSECTION: Clinical practice

guideline developers should use systematic reviews that meet standards set by the Institute of Medicine

STANDARD 5: ESTABLISHING EVIDENCE FOUNDATIONS FOR AND RATION STRENGTH OF

RECOMMENDATIONS. Ex. GRADE criteria.
STANDARDS 6, 7, 8: The recommendations should be clear, measurable, externally reviewed by relevant
stakeholders through a structured transparent process, and updated regularly.

Describe a detailed illness script for pediatric asthma including differentiating the following levels of
asthma severity:
Mild intermittent asthma (controlled asthma), mild persistent asthma, moderate persistent asthma,
severe persistent asthma, and status asthmaticus. Describe the treatment appropriate to each level of
asthma severity.

Prevalence: common chronic childhood disorder, 12% of kids in Canada

Risk factors: allergens, stress, obesity, low socioeconomic status, pollution, smoking/second hand
smoke
Positive predictors: cough, dyspnea, wheeze (asthma triad)

MILD INTERMITTENT ASTHMA (controlled asthma)

Symptoms present: ≤ 2 days/week and ≤ 2 nights/month
Preferred treatment: no daily medication required

MILD-PERSISTENT ASTHMA
Symptoms present: >2 days/week, but <1/day, and > 2 nights/month. Minor limitations in normal
activity
Preferred treatment: low dose inhaled corticosteroid
Alternative treatments: in patients <5 years, cromolyn or a leukotriene receptor antagonist may be
used; nedocromil and sustained-release theophylline are additional alternatives that can be used in
patients older than 5 years

MODERATE-PERSISTENT ASTHMA
Symptoms present: daily and more than 1 night/week. Limitation in daily activity
Preferred treatment (patients ≤ 5 years): low-dose ICS and inhaled LABA; or monotherapy with a
medium-dose ICS; a medium-dose ICS with inhaled LABA in patients with recurring severe exacerbations
Preferred treatment (patients > 5 years): low-dose or medium dose ICS and inhaled LABA; the dose of
ICS may be increased and LABA added in patients with recurring severe exacerbations

Identify and apply the GRADE 1A and 1B recommendations of the 2012 CTS Pediatric asthma
guideline.

From the background readings: YOU ARE REQUIRED TO KNOW ALL THE PEDIATRIC GRADE1A AND 1B
RECOMMENDATIONS FROM THIS GUIDELINE AND IDENTIFY HOW TO APPLY THEM TO A PATIENT CASE.

1. Recommendation 2B
a. Initiation of adjunct therapy in children with asthma uncontrolled despite adherence to
a medium dose of ICS (GRADE 1A)
 2. Recommendation 3B
a. In children with asthma not achieving control despite adherence to a low dose of ICS,
we recommend increasing to a medium dose of ICS (GRADE 1A)
3. Recommendation 4A
a. Do NOT recommend the use of an ICS/LABA combination as a reliever in lieu of a fast-
acting beta agonist as a reliever in individuals 16 years of age and over with mild
intermittent asthma or no maintenance controller therapy (GRADE 1B)
4. Recommendation 4B
a. Recommend use of a SABA instead of either a LABA (GRADE 1A) or an ICS/LABA
combination inhaler (GRADE 1B) as a reliever in individuals with mild intermittent
asthma or no maintenance controller therapy
5. Recommendation 6A
a. We recommend daily ICS in lieu of starting intermittent ICS at the onset of an episode
of acute loss of asthma control in patients with mild persistent asthma (GRADE 1B)
6. Recommendation 6B
a. We recommend that the safest and minimal effective ICS dose be prescribed to
minimize side effects in all age groups, particularly in children to address the concern
regarding growth velocity (GRADE 1B).

Identify criteria for endotracheal intubation.

There are two firm criteria for intubation:

1. Hypoxemia despite supplemental oxygen
2. The loss of a patent airway protected by normal reflexes. This includes stupor and coma.

These two firm criteria each have a softer version i.e. threatened hypoxemia, and threatened loss of
airway.