Asthma in ChildrenDiagnosis dan ManagementRoni NaningDepartement of Child HealthFaculty of MedicineUniversitas Gadjah Mada Yogyakarta

A 7-year old girl presents to an outpatient clinic Has history of wheezing and rhinitis since infancy. Over the past 2 years her symptoms have worsened. Complains of coughing and short of breath daily Claims to awaken at least once a week in the middle of the night by these symptoms. A case of Mareta

History of medication:Salbutamol puffer daily and requires monthly refills. In the past year she has had 4 courses of prednisone

Family history: maternal asthma

Physical examination findings: inflamed nose, mild wheezing, otherwise unremarkable.

What makes you think this is ASTHMA ?

SUSPECT ASTHMA IF:Intermittent wheezing, cough, dyspnea.Increased rate of breathing.Symptoms worse at night and in early morning.History of medicationHistory of maternal asthmaAssociated with triggers

What is asthma? Various definition of asthma is used across countries

The history.REVERSIBLE AIRFLOW OBSTRUCTION SPONTANEOUSLY OR UNDER TREATMENTBRONCHIAL HYPERRESPONSIVENESS CHRONIC CONDITION, RECURRENT BRONCHOSPASM, NARROWING AIRWAY DUE TO STIMULIAIRWAY INFLAMMATORY LESION, CELLULAR INFILTRATE, SUBMUCOSAL WALL OEDEMA, FIBROSIS1950:1960:1970:1990:

PNAA Asthma DefinitionRecurrent wheezing and/or cough with tendsepisodic, at night/early morning (nocturnal),has triggers such as physical activity,reversible either spontaneously or withtreatment, and has asthma history or otherallergy in patient /family.PNAA : Pedoman Nasional Asma Anak, 2004

A condition in which episodic wheezing and/or cough occurred in a clinical setting where asthma was likely and other, rarer condition had been excludedInternational Pediatric Asthma Consensus Group. Arch Dis Child 1992;67:240-8

International Pediatric Consensus Statement on the Management of Childhood Asthma Recurrent wheezing and/or persistent coughing in a setting where asthma is likely and other rarer condition has been excludedWarner et al. Pediatr Pulmonol 1998;25:1-71989:1992:1998:

National Asthma Council (Australia, 2006)chronic inflammatory disorder of the airways which causes recurrent episodes of wheezing, breathlessness, chest tightness and coughing. These episodes are reversible with appropriate treatment

Global Initiative for Asthma (GINA) 2011 Asthma is a chronic inflammatory disorder of the airway in which many cells and celluler elements play a role.

The chronic inflammation is associated with airway hyperesponsioveness which leads to recurrent episodes of wheezing, coughing, and shortness of breath.

The episodes are associated with widespread but variable airflow obstruction that is often reversible either spontaneously or with treatment.

Epidemiology Asthma is a problem worlwide, around 300 million individuals are affectedProblems in determine the burden of asthma in childrena lack of uniform definition of asthmadifferent methods (population, measurement) among studiesa lack of objective measurement the use of lung function test ?

are likely to have asthma (United States) On average, 3 children in a classroom of 30

are likely to have asthma(Australia)On average, 10 children in a classroom of 40

Pediatric asthma prevalence in Indonesia Djajanto (Jakarta,91) 6 12 yrs 16,4% Naning (Yogya, 1991) 6 12 yrs 4,8% Rosmayudi (Bandung,93) 6 12 yrs 6,6% Dahlan (Makasar, 1996) 6 12 yrs 17,4% Arifin (Palembang, 1996) 13 15 yrs 5,7% Rosalina I (Bandung,1997) 13 15 yrs 2,6% Rochman (Yogya, 1998) junior HS 10,5% Kartasasmita (Bandung,2002) 6 7 yrs 3,0% 13 14 yrs 5,2% Rahajoe (Jakarta,2002) 13 14 yrs 6,7%

Emergency department visits for asthma per 100 people with asthma, by age group and sex, New South Wales and Victoria, July 1999 to June 2004 (AIHW, 2005)

Hospital separations for asthma per 100,000 population, by age group, Australia, 19932005 (AIHW, 2005)

an attempt to standardize the methodology and definition Measured a prevalence of current wheeze Have you (has your child) had wheezing or whistling in the chest in the past 12 months? International study on Asthma & Allergies in Childhood (ISAAC)

Phase 1 (1992-1998)Phase 3 (1999-2004)6-7 year age group4.1% - 32.1%2.8% 22.2%13-14 year age group2.1% - 35.1%3.4% - 31.2%

MORTALITYRare and preventableAnnual death rate from asthma international (age 5-34 yo): 0.5 to 2.0/100,000 75% of these have occurred in children aged 5-14 years (Sears, 1991)Australia (age 5-34 yo): 0.37/100,000US (age 0-17 yo): 0.3/100,000

Mechanisms Underlying the Definition of Asthma

Risk Factors(for development of asthma)

INFLAMMATIONAirwayHyperresponsivenessAirflow Obstruction Risk Factors/trigger (for exacerbations)Symptoms

www.nature.com/nri/journal/v2/n2/images/nri725-f1.gifImmunopathophysiology of Asthma

Features of Asthma

What is your differential diagnosis ?

Recurrent wheezing can be caused by:BronchiolitisPneumoniaCystic FibrosisCardiac diseaseGERDForeign body aspirationCongenital malformation of intrathoracic airway

Major :Atopic dermatitisParental asthmaSkin test (+) foraeroallergens

Minor :Allergic rhinitisWheeze apart of coldEosinophils >4%Skin test (+) foringestion allergenRecurrent wheeze

Asthma if:2 major and/or1 major + 2 minor

Taussig LM, et al.JACI 2003; 111:661-675

What is your work up?

Asthma diagnosisHistory and patterns of symptomsPhysical examinationMeasurements of lung functionMeasurements of allergic status to identify risk factors

History takingDoes the child have:Recurrent episodes of wheezing ?Troublesome cough at night ?Cough, wheeze or chest tightness after exposure to the triggers (e.g. exercise, airborne allergens or pollutants) ?Colds go to the chest or take more than 10 days to clear ?Symptoms improved by appropriate asthma treatment ?

Physical examinationTachypnoeaProlonged ExpirationAccessory musclesWheezeHyperinflationIncrease AP diameter

Peak flow meterSpirometryLung Function Test

Bronchodilator test in asthma: FEV1 improves > 12% after administration of bronchodilator

How would you classify Mareta's asthma severity ?

Patterns of asthma in childreninfrequent episodic~ 65-75%frequent episodic~ 20-25%persistent~ 5-10%

Infrequent episodic asthmaepisodes 6-8 weeks or more apartattacks generally not severesymptoms rare in between attacksnormal examination and lung function between attacks> 6 weeks

Frequent episodic asthma

attacks < 6 weeks apartattacks more troublesomeminimal or no symptoms between attacksnormal examination and lung function between attacksoften seasonal (winter months)< 6 weeks

Persistent asthmasymptoms between attackssleep disturbance > 1 night/weekexercise induced wheeze / limitationuse of beta2 agonists > 3 times per week abnormal lung function between attacks

Chronic asthma parameters

ClinicalparameterInfrequentepisodicFrequentepisodicPersistentfrequency< 1x /month> 1x /monthfrequentsymptomduration< 1 week1 weekalmost all the timebetween attackno symptomfew symptomsday & night symptomssleep & activitynot disturbeddisturbedvery disturbedPhys exam whenno attacknormalfew signsnever in normalconditioncontrollernot neededneed, non steroidneed, steroidlung function testPEF/FEV1 >80%PEF/FEV1 60-80%PEF/FEV1 15%< 30%< 50%

Chronic asthma

1. Infrequentepisodic asthma

2. Frequentepisodic asthma

3. Persistentasthma Acute asthma

1. Mild asthmaattack

2. Moderate asthmaattack

3. Severe asthmaattackPediatric Asthma classification

What is the best way to treat Mareta today?

Component of patient managementDevelop patient/doctor partnershipIdentify and reduce exposure to risk factorsAssess, treat, and monitor asthmSpecial Consideration

Develop patient/doctor partnership

2. Identify and reduce exposure to risk factors

Asma Triger

3. Assess, treat, and monitor asthma

ManagementNon-pharmacologicalAllergen avoidanceHouse dust mitePetsPassive smoke exposure

Pharmacological

Steps of asthma treatment

1. Avoidance of trigger(s)

2. Avoidance of trigger(s)

3. Avoidance of trigger(s)4. Drug(s)a. Reliever

b. Controller

Asthma medication To relieve asthma symptoms - attack As needed medication If the symptom relieve, stop No package system

To control asthma inflammation Long term medication, months - years Evaluated regularly, Dose adjusment: maintain, increase,decreaseReliever

drug

(pereda)

Controller

drug

(pengendali)

3. Assess, treat, and monitor asthmaPharmacologic treatment of asthma in childrenInfrequent episodeReliever as neededPersistent reliever as neededController : inhaled corticosteroidOral corticosteroid

Frequent episodeReliever as neededController : inhaled corticosteroid

Reliever drugInhalation: Nebulizer or MDI + spacer Reliever inhalation drug:

2 agonist: salbutamol, terbutaline,fenoterol, procaterol

Anti-cholinergic: ipratropium bromide

2 agonist + anti-cholinergic

Systemic steroid (oral, injection)

Inhaled steroid ???Xanthin: aminophylline, theophylline

ControllerIf symptoms / attack frequently appear,i.e. in Frequent episodic asthma orPersistent asthma

Mechanism: to control airwayinflammation, reduce the airway hyper-reactivity, not easily triggered

Long term medication, continously,months up to years

Controller drug

attack

symptom

MPI

AsthmaMPI: Triggerminimal light,persistent singleinflammation

inflammationTriggerheavy,combination

Controller drugInhaled C-Steroid:fluticasonebudesonidemometason etriamsinolone

LABA: salmeterol formoterolCombination: ICS + LABAAnti-leukotrien: montelukast zafirlukast

Manage asthma exacerbations Asthma exacerbation:Episodes of rapidly progressive increase in shortness of breath, cough, wheezing or chest tightness or some combination of these symptomsCharacterized by decrease of expiratory airflow PEF or FEV1

The severity of asthma attack

MildModerateSevereRespiratory arrest imminentBreathlessWalking

TalkingInfant softer shorter cry; difficulty feedingAt rest Infants stop feedingCan lie downPrefers sittingHunched forward Talks inSentencesPhrasesWordsAlertnessMay be agitatedUsually agitatedUsually agitatedDrowsy or confusedRespiratory rateIncreasedIncreasedOften > 30 / minNormal rates of breathing in awake children: Age Normal rate < 2 mo < 60 x / min 2 12 mo < 50 x / min 1 5 y < 40 x / min 6 8 y < 30 x / min

MildModerateSevereRespiratory arrest imminentAccessory muscles and suprasternal retractionsUsually notUsuallyUsuallyParadoxical thoraco-abdominal movementWheeze Moderate, often only end expiratoryLoudUsually loudAbsence of wheezePulse / min< 100100 - 120> 120BradycardiaGuides to limits of normal pulse rate in children Infants 2 12 mo - Normal rate < 160 x / min Preschool 1 2 years < 150 x / min School age 2 8 years < 110 x / min

MildModerateSevereRespiratory arrest imminentPulsus paradoxusAbsent< 10 mmHgMay be present10- 25 mmHgOften present> 25 mmHg (adult)20 40 mmHg (child)Absence suggests respiratory muscle fatiguePEFafter initial bronchodilator % predicted or% personal best Over 80%Approx. 60-80%< 60% predicted or personal best (< 100 L/min adults)orResponse lasts < 2 hPaO2 (on air)*NormalTest not ussually necessary> 60 mmHg< 60 mmHg

Possible cyanosisAnd/orPaCO2 (on air)*< 45 mmHg< 45 mmHg> 45 mmHg; possible respiratory failure

GINA, 2002 (revised)

MildModerateSevereRespiratory arrest imminentSaO2 % (on air)*> 95 %91 95 %< 90 %Hypercapnia (hypoventilation) develops more readily in young children than in adults and adolescentsThe presencce of several parameters, but not necessarily all, indicates the general classification of the exacerbation* Note: kilopascals are also used internationally; conversion would be appropriate in this regard

Ped acute asthma algorithm

Clinic / ER

Asses attack severity

1st management nebulitation -agonis 3x, 20 min interval3rd nebulitation + anticholinergicModerate attack(nebulization 2-3x,partial response) give O2 asses: moderate ODC IV lineMild attack(nebulization 1x,complete response) persist 1-2 hr:discharge symptom reappear:Moderate attackSevere attack(nebulization 3x,no response) O2 from the start IV line asses: Severe -hospitalized CXR

One Day Care (ODC) Oxygen therapy Oral steroid Nebulized / 4-6 hour Observe 8-12 hours,if stable discharge Poor response in 12h, admissionAdmission room Oxygen therapy Treat dehydration andacidosis Steroid IV / 6-8 hours Nebulized / 2-4 hours Initial aminophylline IV,then maintenance Nebulized 4-6x good response per 4-6 h If stable in 24 hours discharge Poor response ICUDischarge give -agonist(inhaled/oral) routine drugs viral infection:oral steroid Outpatient clinic in24-48 hoursNotes: In severe attack, directly use -agonist + anticholinergic If nebulizers not available, use adrenalin SC 0.01 ml/kg/times with maximal dose 0.3 ml/timesOxygen therapy 2-4 l/min should be early treatment in moderateand severe attack

Longterm management

Chronic asthma parameters

ClinicalparameterInfrequentepisodicFrequentepisodicPersistentfrequency< 1x /month> 1x /monthfrequentsymptomduration< 1 week1 weekalmost all the timebetween attackno symptomfew symptomsday & night symptomssleep & activitynot disturbeddisturbedvery disturbedPhys exam whenno attacknormalfew signsnever in normalconditioncontrollernot neededneed, non steroidneed, steroidlung function testPEF/FEV1 >80%PEF/FEV1 60-80%PEF/FEV1 15%< 30%< 50%

Algoritma tatalaksana jangka panjang< 3x(-)6-8 minggu, responsObat pereda: -agonis kerja cepat(hirupan/oral) dan/atau teofilin oral bila perluAsma episodik jarang

Tambahkan obat pengendali:Dosis rendah ICS 100-200 atau kromolin hirupan*)Asma episodik sering

Obat pengendali dengan steroid hirupanDosis 200-400 mgObat pereda: diberi bila perlu6-8 minggu, respons(-)PENGHINDARANStepup1-3 bl1-3 bl1-3 bl

Naikkan dosis steroid hirupan >800 mgTambahkan steroid oralCatatan :*) Ketotifen/cetirizin dapat ditambahkan pada pasien asma yang disertai rinitis 6-8 minggu, respons(-)ICS 400-600 mg Tambahan salah satu obat : -agonis kerja panjang -agonis lepas terkendali Teofilin lepas lambat AntileukotrinAsma persistenPENGHINDARANStepdown1-3 bl1-3 bl1-3 bl

Inhaler devices

MDIMDI+SpacerMDI+Spacer (baby haler)Nebulizer

Choosing inhaler devices for children with asthma

When it doesnt seem right!( inadequate response to appropriate dose of ICS )non-adherence / poor techniqueconsider risk benefitmisinterpretation of respiratory symptoms as asthmacheck the diagnosis

Level of Asthma controll Characteristic

Day symptoms

Limitation of activities

Nocturnal symptom/awakening

Need for reliever/rescue treatment

Lung function (PEF or FEV1)

ExacerbationsControll (all of the following)

None (twice or less/week)

None

None

None (twice or less/week)

Normal

NonePartly controll (any measure present in any week)

More than twice/week

Any

Any

More than twice/week

< 80% predict or personal best (if known)

One or more/yearUncontrolled

Three or more features or partly controlled asthma present in any week

One in any week

Asthma attacksStable asthma(No attack)Infrequent episodicFrequent episodicPersistentReliever (+)Controller (-)Reliever (+)Controller (+)Reliever (+)Controller (+)Assess the severity of attacksAssess class of diseaseEDUCATION and AVOIDANCE

Thanks for your attention

************www.nature.com/nri/journal/v2/n2/images/nri725-f1.gif**************************