DR. A.Mirshokraei NIOC Hospital Pediatrics Ward

Asthma in Children

DEFINITIONDefinition :

- Chronic inflammatory condition of the lung airways resulting in episodic airflow obstruction- AHR to provocative exposures

Asthma management• Reducing airway inflammation by:

Minimizing pro inflammatory environmental exposure, using daily controller anti inflammatory medication, controlling co morbid conditions that worsen asthma, less inflammation better asthma control and fewer exacerbations

Anyway exacerbations occur

BUT

Even the uncommon child with sever asthma can be managed to live

normally

RECURRENT WHEEZING EPISODES WITH COMMON RESPIRATORY VIRUSES(RSV,RHINOVIRUS,INFLUENZA,PARAINFLUENZA,ADENOVIRUS,HUMAN METAPNUMOVIRUS)

HOST FEATURES AFFECTING IMMUNOLOGIC HOST DEFENSE,INFLAMMATION/PREVIOUS VIRAL INFECTIONS MAINIFESTED AS PNUMONIA OR BRONCHIOLITIS REQUIRING HOSPITALIZATION UNDERLIE THE RECURRENT WHEEZING IN EARLY CHILDHOOD

OTHER AIRWAY EXPOSURES SUCH AS INDOOR AND HOME ALLERGENS,COLD AIR,STRONG ODORS,TOBACCO SMOKE,ALL INCREASE AHR

ALLERGEN ELLIMINATION SOMETIMES LEEDS TO CURE

EPIDEMIOLOGY Common etiology of emergency visits and school day

missing in childhood ,occasionally hospitalization and rare deaths specially in poverty ,urban living ,ethnic minorities

Increasing asthma prevalence worldwide(50% per decade)

Good correlation of asthma prevalence with allergic rhino sinusitis and atopic eczema and other allergies

More prevalence in high level urban modern families than suburban villagers

More than 80%of asthmatics reported getting the disease before 6 year

RECURRENT COUGHING/WHEEZING PATTERNS IN CHILDHOOD BASED ON

NATURAL HISTORY

CLINICS

TRANSIENT EARLY WHEEZINGCommon in early preschool yearsRecurrent coughing/wheezing primary

triggered by common respiratory viral INFTend to resolve during preschool yrs

without increasing risk of asthma later in life

Problems due to reduced airflow at birth suggestive of relative narrow airways improved by school yrs

Persistent Atopy Associated AsthmaBegins in early preschool yrsAssociated with atopy (eg atopic dermatitis in

infancy, allergic rhinitis, food allergy)Biologic factors e.g.: early inhalant sensitization,

increase serum IGE, increase blood eosinophills,High risk of persistence into later childhood and

adulthood lung function abnormalityThose with onset<3 yrs reduced air flow

by school yrsThose with later onset of symptoms or allergen

sensitizations unlikely persistence lung function abnormality later

Non-Atopic Wheezing

Wheezing ,coughing beginning in early life often with RSV INF resolves later in childhood without increasing risk of persistence asthma

Associated with bronchial hyper responsiveness near birth

Asthma with declining lung function

• Children with asthma with progressive increase in air flow limitation

• Associated with hyper inflation in childhood

• Male gender

Late onset asthma in females associated with obesity and early onset puberty Onset between 8_13 yrs Associated with early onset puberty and obesity Specific for females

Occupational type asthma in children

Children with asthma and occupational type exposure known to trigger asthma in adults in occupational settings

Types of Asthma

common clinical presentations of intermittent recurrent wheezing and/or coughing

Recurrent wheezing in early childhoodChronic asthma associated with allergyFemales 11 yrs with early onset puberty and

obesity

PathogenesisAirflow obstruction resulting fromI. Broncho constriction of bronchiolar smooth

muscle massII. Cellular inflammatory infiltrates and exudates

mostly Eosinophills(also N , M ,L ,mast cells ,basophiles)fill and obstruct airways and damage epithelium and induce desquamation into airway lumen mediated by T helper cells and other immune cells that produce pro allergic pro inflammatory cytokines(IL4,IL6,IL13)

III. Breach in normal immune regulatory process

RESULTAirway inflammationAHREdema basement membrane thickness sub

epithelial collagen depositionSmooth muscle and mucus gland

hypertrophy and mucus hyper secretion

Air obstruction

Clinical manifestations and diagnosisMost common intermittent dry cough and

expiratory wheezing

Shortness of breath and chest tightness in older children and adults

Intermittent non focal chest pain in younger children

Worsening of respiratory symptoms at night

Worsening of day time symptoms by activity

Continue….. Subtle symptoms such as self limitation of

activities ,general fatigue ,difficulty in keeping up with peers

Relief with aerosolized bronchodilators

Lack of improvement with bronchodilators and steroid is inconsistent with Asthma and should consider Asthma masquerading conditions!!!!

Hyper ventilation, intercostal retractions ,nasal flaring ,respiratory accessory muscle use

Its common not to hear the expiratory wheezing when Air flow is so limited before treatment

Asthma Triggers Common viral infections of the respiratory tract Aero allergens in sensitized asthmatics ,animal

dander ,dust mite ,molds ,indoor allergens ,cockroaches Seasonal aero allergens ,pollens(trees ,grasses ,weeds ,) Environmental tobacco smoke Air pollutants ,ozone ,so2,wood or coal

smoke ,endotoxin ,mycotoxin ,dust Strong or noxious odors or fumes ,perfume ,hair

spray ,cleaning agents Occupational exposure Cold air ,dry air Exercise Crying ,laughter ,hyperventilation Co morbid conditions Rhinitis ,Sinusitis ,GER

ClinicsHistory:Triggering symptoms by laughter ,cold air ,airway irritants

Exposures that induce airway irritation such as viral URTI Mycoplasma ,Chlamydia

Inhaled allergens All lead to AHR

Presence Of Risk Factors:

History of other allergies ,allergic Rhinitis, allergic Conjunctivitis ,atopic Dermatitis ,food allergies

Parental Asthma

Symptoms apart from cold

Continue…..No or minimal signs in routine visitsDry or persistent coughNormal chest findings unless wheezing when

asking to breath deeperQuick relief (10 MIN) after SABA useExpiratory wheezing ,prolonged expiratory phase

,decreased sounds in RT lower pos lobe due to regional hypoventilation owing to airway obstruction

Rales , ronchi ,crackles due to hyper secretionSegmental crackles and poor breath sounds

atelectasis?

Continue….

Labored respiration ,respiratory distress increased prolongation of expiration and wheezing in E and I

Poor air entry

Inter costal retractions ,nasal flaring ,supra and infra sternal retractions

And again in most sever forms expiratory wheezing does not appear until some broncho dilation

DDGERD Rhino sinusitis co morbid conditions with asthma

Recurrent aspiration in early life(tracheo broncho malacia ,TEF , foreign body ,CF ,BPD

VCD in older children and adolescents

Pulmonary Function Testing

LAB FINDINGS

Continue….

Forced expiratory airflow measures helpful in Diagnosis , assessing efficacy of therapy and monitoring Asthma in children specially in poor children who do not have PHE unless obstruction is sever

Valueablity of spirometric findings in children>6 yrs

3 efforts the highest is the peak

Reduced FEV FEV1/FVC <0.80 means significant obstruction

Improvement in FEV1 following beta 2 agonist > = 12% or 200 ml is consistent with Asthma

Peak flow meter

CXROften normal aside from subtle and

nonspecific findings of hyperinflation

Peribronchial thickening

Helping in diagnosis of Asthma differentials

Diagnosis of complications of Asthma exacerbations

Other tests such as allergy skin prick testing

Treatment

www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm

Asthma Treatment & Management has 4 components :1. Assessment and monitoring of disease

activity2. Provision to educate pt and family3. Identification and management of

precipitating factors and co morbid conditions

4. Appropriate selection of medication

Attainment of optimal Asthma control

Component 1

Asthma severity :intermittentPersistent: mild ,mod ,severeOnly once during patient initial evaluation

in pt who is not using a daily controller agent

Asthma control degree to which symptoms , on going functional impairments , risk of adverse events minimized and goals of therapy are met

Continue….1. Well controlled2. Not well controlled3. Very poor controlled

NIH guidelines for both severity and control for 3 age groups

1. 0-4 yrs2. 5-11 yrs3. =>12 yrs

Important

even in the absence of frequent symptoms infants and children whom have risk factors for asthma and 4 or more episodes of wheezing over the past yr which lasted more than 1 day or 2 or more exacerbations in the last 6 months requiring syst corticosteroids should be considered in the persistent group and hence receive long term controller therapy

Important Tips..Regular clinical visits every 2-6 weeks

Assessment of :

1. Pt symptoms frequency night and day2. Need for short acting inhaled b2 agonists

for quick relief3. Ability to engage in normal activities4. Air flow measures for>=5 yrs

Continue..Component 2 : pt educationComponent 3 : control of factors

contributing to asthma severity1. Environmental exposures2. Co morbid conditions Component 4 :principals of asthma

pharmacotherapy

Asthma MedicationSABA ICSLABALTRASYSTEMIC STEROIDSNONSTEROIDAL ANTIINFLAMMATORY

CROMOLYN AND NEDOCROMYLOXYGENANTICHOLINERGIC AGENTS

IPRATROPIUM BROMIDEANTIIMMUNOGLUBOLINE E

MANAGEMENT OF ASTHMA EXACERBATION(STATUS ASTHMATICUS)

RISK ASSESMENT ON ADMISSION

FOCUSED HISTORY

ONSET OF CURRENT EXACERBATIONFREQUENCY AND severity of daytime and night time symptoms and activity limitationFrequency of rescue bronchodilator useCurrent medication and allergiesPotential triggersHistory of systemic steroid courses, emergency department visists , hospitalization, intubation or life threatening episodes

Clinical assesment

Physical examination findings: vital signs, breathlessness, air movement, use of accessory respiratory muscles, retractions, anxiety level, alteration in mental statusPulse oximetryLung function(defer in pts with mod to severe distress or history of labile disease)

Treatment

Drugs and trade name Mechanism of action and dosing Cautions and adverse effects

Oxygen(mask or nasal canula)Inhaled short acting b2 agonistAlbuterol nebulized solution(5mg/ml concentratesAlbuterol MDILevabuterol

Treats hypoxiaBronchodilatorNeubolizer 0.15 mg/kg every 20 min for 3 doses as needed,then 0.15_0.3 mg/kg up t 10 mg every 1_4 hour as needed or up to 0.5 mg/kg/hr by continous neubolization2_8 puf up to every 20 min for 3 doses as needed then every 1 hr as needed

Monitor pulse oximetry to maintain o2 saturation>92%Cardiorespiratory monitoringDuring exacerbations,frequent or continuous use can cause pulmonary vasodilatation,v/q mistmatch and hypoxemiaAdverse effect palpitation, tachycardia, arrhythmia, tremor, hypoxemia Neubolizer:when giving concentrate forms,dilute with saline to 3 ml total neubolized volumeFor MDI use space/holding chamber

Systemic corticosteroidsPrednisolone tbMethyl prednisolonAnticholinergicsIpratropiumAtroventIpratropium with Albuterol

Anti inflammatory0.5_1 mg/kg every 6-8 hr for 48 hr , then 1-2 mg/kg day bid(max 60 mg/day)Short course burst for exacerbation 1-2 mg/kg/day qd or bid for 3-7 daysMucolitic/bronchodilatorNeubolizer 0.5 mg q6-8 hr (tid or qid) as needed MDI 2 paf qid1 vial by neubolizer qid

If pt has been exposed chickenpox or measles, consider passive immunoglobulin prophylaxis, also risk of complications with herspes simplex and TB

For daily dosing , 8 am administration minimizes adrenal suppression

Children may benefit from dosage tapering if course exceed 7 days Adverse effect monitoring: frequent therapy bursts risk numerous

corticosteroid adverse effects Should not be used as first line treatment added to b2 agonist

therapyNeubolizer may mix Ipratropium with Albuterol

QUICK RELIEF MEDICATION

SABAAnti cholinergic(ipratropium)

Short term systemic gluco corticoid

SABA Quick relief of asthma symptoms Relax airway smooth muscle prompt airflow↑ Repetitive or continuous SABA is the most effective means of

reversing air flow obstruction SABA should not be prescribed on a regular schedule because

concerns of possibility of deteriorating asthma control Frequent use of SABA is an indication of poor asthma control Preferred root is inhalation smaller dose , fewer side effects

more rapid on set of action Ipratropium Bromide as an adjunct to SABA in emergency

room reduces hospital admissions and improves lung function Systemic Glucocorticoids short oral course + SABA in

moderate to severe asthma exacerbation

LABASalmetrolShould be used in combination with inhaled corticosteroids and not as mono therapyExercise induces asthma in children >= 4

Yrs one inhalation 30 min prior to exerciseNo additional doses for PTs who are already

receiving it twice daily not recommended by NIH guidelines

LTRAMonteLukast ( singulair)Antihistaminic Leukotrien receptor antagonistAsthma ( not < 12 MO) and allergic rhinitis

( not < 6 MO) Morning dosing not evaluatedProphylactic and chronic treatment of asthmaExercise induced asthma in >= 15 YrsZafir Lukast : prophylactic and chronic

treatment of asthma

ICAMost potent anti inflammatory agents

available for the treatment of asthmaInhibiting most steps in the cascade of the

inflammatory response Benefits reducing bronchial hyper

responsiveness , prevention of late asthmatic response , enhanced lung function

Inhaled Glucocorticoids first line controller therapy for persistent asthma or those who require step 2

Prognosis35%of preschool children experience recurrent

coughing and wheezing,1/3 of them continue to have persistent asthma into later childhood and 2/3 improvement on their own through their teen yrs

Asthma severity by age 7-10 yrs is predictive of asthma persistence into adulthood

Children with mod to severe asthma and lower lung function are likely to have persistent asthma as adults

Children with milder asthma and N/R lung function are likely to improve over time or be periodically asthmatic

THANK YOU FOR YOUR ATTENTION