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ASTHMA IN CHILDHOOD dr. Ery Olivianto, SpA Dr. dr. Wisnu Barlianto, SpA(K) Prof. Dr. dr. HMS. Chandra Kusuma, SpA(K) Child Health Department Faculty of Medicine Brawijaya University Saiful Anwar General Hospital

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Old paradigma (1860) Paroxysmal dyspnoea Contraction of smooth muscle bronchodilator New paradigma (1950) Inflammatory disorder Corticosteroids Holgate ST. J Allergy Clin Immunol 2011;128:495-505

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Definitions Asthma is a chronic inflammatory disorder of the airways associated with airway hyperresponsiveness and airflow obstruction that is often reversible either spontaneously or with treatment WAO. White Book on Allergy, 2011

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Epidemiology World Health Organisation estimate 300 million individuals have asthma worldwide Current rising trends this will reach 400 million by 2025 Approximately 250,000 people die prematurely each year from asthma Prevalence in the 13-14 year olds ranging from 2.1% to 32.2% Prevalence in the 6-7 year olds was similar to those in the older children with prevalence of wheezing varying from 4.1%-32.1% Indonesia: 2.6% - 17.4% WAO. White Book on Allergy, 2011 Pedoman Nasional Asma Anak, 2004

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Asthma GeneticAllergensInfection Tobacco smoke PollutantsNutritionIrritantsExerciseWeatherStress Bacharier LB, et al,. Allergy 2008: 63: 534

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Inflammatory and immune cells involved in asthma Barnes PJ. Nat Rev Immunol 2010;8:183-192

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Asthma inflammatory cascade Bernstein D. Pediatric for Medical Students 3 rd Ed, 2011

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Asthma phenotypes Infant (0-2 years old)Preschool children (3-5 years old)School children (6-12 years old)Adolescents Bacharier LB, et al,. Allergy 2008: 63: 534

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Infantile asthma Asthma affecting infant aged < 2 years 3 or more episodes of marked expiratory wheezing within the previous 6 months Bacharier LB, et al,. Allergy 2008: 63: 534

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Hypothetical yearly prevalence for recurrent wheezing phenotypes in childhood Leung DM. Pediatric Allergy 2 nd Ed, 2010

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Modified Asthma Predictive Index for children (Tucson Children's Respiratory Study, Tucson, Arizona). Through a statistically optimized model for 2- to 3-year-old children with frequent wheezing in the past year, one major criterion or two minor criteria provided 77% positive predictive value and 97% specificity for persistent asthma in later childhood Leung DM. Pediatric Allergy 2 nd Ed, 2010

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Asthma phenotypes in children > 2 years Bacharier LB, et al,. Allergy 2008: 63: 534

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Entry point of asthma diagnosis: Recurrent Wheezing and/or Chronic Recurrent Cough Pedoman Nasional Asma Anak, 2004

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Diagnosis Cough and/or Wheeze Clinical history Physical examination Mantoux test Suggestive of asthma: Episodic Nocturnal Seasonal Exertional Atopic Indeterminate features or suggestive of alternative diagnosis Neonatal onset Failure to thrive Chronic infection Vomiting/choking Focal lung or CVS signs If possible frequent peak flow measurements : Reversibility (20%) Variability (20%) Consider Chest and sinus x rays Lung function Bronchial challenge and/or Bronchodilator response

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.. Consider : Sweat test Immune function Ciliary & Reflux studies Bronchodilator response No response Response WD/ Asthma Assess severity and etiology Review diagnosis and compliance if poor response to treatment + ve - ve Alternative diagnosis and treatment Chest x ray if more than mild episodic disease Trial of antiasthma treatment Consider asthma as an associated problem Not asthma Pedoman Nasional Asma Anak, 2004

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Differential diagnosis of wheezing in children Nishimuta T. Allergology International 2011;60:147-169

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Bernstein D. Pediatric for Medical Students 3 rd Ed, 2011

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Classification of Asthma in Children Chronic Infrequent episodic asthma Frequent episodic asthma Persistent asthma Acute Mild attack Moderate attack Severe attack Pedoman Nasional Asma Anak, 2004

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Classification of disease Clinical parameters and lung function Infrequent episodic asthma Persistent asthma Frequent episodic asthma Freq of attacks< 1x /monthDaily> 1x /month Duration of attacks < 1 week Daily >1 week Between episodes No symptoms Frequent nocturnal symptoms Symptoms (+) Sleep and activity NormalAffectMay affect Physical examNormalAbnormalMay affect ControllerNo needSteroid/combination Lung function (No attacks) PEF/FEV1 >80% PEF/FEV1 15%> 50%> 30% Pedoman Nasional Asma Anak, 2004

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Asthma managements Chronic asthma Long term management Reliever & Controller Acute asthma Attack management Reliever Pedoman Nasional Asma Anak, 2004

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Asthma managements Chronic asthma Long term management Algorithm diagnosis & treatment Acute asthma Attack management Algorithm attack management Pedoman Nasional Asma Anak, 2004

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Asthma medication Controller drug to control asthma ie attack or symptom not easily emerge Inhaled steroid LABA, ALTR Reliever drug to relieve asthma attack or symptoms -agonist Xanthine anticholinergic Pedoman Nasional Asma Anak, 2004

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23 Long term treatment 2 -agonist or theophylline inhaled/oral intermittently Add sodium cromoglicate Replace with low dose inhaled steroids Continue 2 -a or/and theophylline inhaled/oral intermittently 6-8 weeks >3 doses / week 6-8 weeks response (-) Infrequent Episodic Symptoms Frequent episodic Symptoms 3-6 months Evaluation 3-6 months response (+) 6-8 weeks response (-) 3-6 months response (+)

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24 Consider : Long acting 2 -agonists, or Slow release 2 -agonists, or Slow release theophyllines Increase dose of inhaled steroid Add oral steroids 6-8 weeks respons (-) Persistent Symptoms 3-6 months respons (+) 6-8 weeks respons (-) 3-6 months respons (+) 6-8 weeks respons (-) 3-6 months respons (+) Pedoman Nasional Asma Anak, 2004

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> 2 days/week Need for reliever/rescue Nocturnal symptoms or awakening None (less than twice/week, typically for short periods of the order of minutes and rapidly relieved by use of a rapid-acting bronchodilator) Limitations of activities >Twice a week Daytime symptoms: wheezing, cough, difficult breathing Uncontrolled (>3 features of partly con- trolled present in any week) Partly controlled (any measure present in any week) Controlled Characteristic None (child is fully active, plays and runs without limitation or symptoms) None (including no nocturnal coughing during sleep) < 2 days/week (typically for short periods of the order of minutes and rapidly relieved by use of a rapid-acting bronchodilator (coughs during sleep or wakes with cough, wheezing, and/or difficult breathing) Any > 2 days/week Any (cough, wheeze or difficulty breathing,during exercise, play or laughing) (typically last minutes or hours or recur, but partially or fully relieved by a rapid-acting bronchodilator >Twice a week Any (cough, wheeze or difficulty breathing,during exercise, play or laughing) (coughs during sleep or wakes with cough, wheezing, and/or difficult breathing) Any Levels of Asthma Control in Children 5 years or youngers GINA, 2009

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Assessment of severity MildModerateSevere Respiratory arrest imminent BreathlessWalking Can lie down Talking Infant-softer Shorter cry Difficult feeding Prefers sitting At rest Infant stops feeding Hunched forward Talks inSentencesPhrasesWords AlertnessMaybe agitated Usually agitated Drowsy or confused Respiratory rate Increased Often >30x/min

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Normal rates of breathing in awake children: Age Normal rates

Pulsus paradoxus Absent