overview of childhood asthma

8/14/2019 Overview of childhood asthma

1/159

1

Overview ofChildhoodAsthma

Dr Mazen QUISAIBATY


2/159

2

INTRODUCTIONChallenges in Asthma

Children The natural history and comorbidities

Diagnosis

Drugs:: Efficacy/Safety

UsingtheDrugs

Thelackofdataonnewtherapies

Developing New GuidelineDeveloping New Guideline


3/159

3


4/159

4

www.brit-thoracic.org.ukwww.brit-thoracic.org.uk

www.ginasthma.orgwww.ginasthma.org

www.sign.ac.ukwww.sign.ac.uk

wwwwww..thoracicthoracic..orgorgwww.nhlbi.nih.gov/guidelines/www.nhlbi.nih.gov/guidelines/

asthma/asthgdln.htmasthma/asthgdln.htm


5/159

5

AA

BB

CC

DD

Grade AGrade A Randomized clinicalRandomized clinical

trials andtrials and High-quality evidenceHigh-quality evidence

Levels of EvidenceLevels of Evidence


6/159


7/159

7

AA

BB

CC

DD



Grade BGrade B Randomized clinicalRandomized clinical

trials buttrials but Moderate -qualityModerate -quality

evidenceevidence

Grade CGrade C Nonrandomized clinicalNonrandomized clinical

trials andtrials and Low-quality evidenceLow-quality evidence



8/159

8

AA

BB

CC

DD



Grade BGrade B Randomized clinicalRandomized clinical

trials buttrials but Moderate -qualityModerate -quality

evidenceevidence

Grade CGrade C Nonrandomized clinicalNonrandomized clinical

trials andtrials and Low-quality evidenceLow-quality evidence

Grade DGrade D Panel consensusPanel consensus



9/159

9

How do patients present?


10/159

10

Phenotype of wheezingillnesses

Non-atopic Childhood Asthma:Non-atopic Childhood Asthma:1.1. Transient wheezingTransient wheezing

2.2. Persistent wheezingPersistent wheezing

AtopicChildhood Asthma


11/159

11

Phenotype of wheezingillnesses

Non-atopic Childhood Asthma:Non-atopic Childhood Asthma:1.1. Transient wheezingTransient wheezing

2.2. Persistent wheezingPersistent wheezing

AtopicAtopicChildhood AsthmaChildhood Asthma

N t i Childh d


12/159

12

Non-atopic ChildhoodAsthma Transient

wheezing 30-50% ofpreschool children have at

least one episode

Which is often outgrown in the first 3years

This is often associated with:

1. Prematurity

2. Parental smoking


13/159

13

Non-atopic Childhood AsthmaPersistent wheezing (before age 3)

Recurrent episodes of wheezingRecurrent episodes of wheezing

associated with acute viral respiratoryassociated with acute viral respiratory

infectionsinfections No evidence of atopy

No family history of atopy.

Their symptoms normally persist through schoolage and are still present at age 12 in a large

proportion of children


14/159

14


Recurrent episodes of wheezingRecurrent episodes of wheezing

associated with acute viral respiratoryassociated with acute viral respiratory

infectionsinfectionsNo evidence of atopyNo evidence of atopy

No family history of atopyNo family history of atopy.

Their symptoms normally persist through schoolage and are still present at age 12 in a large

proportion of children


15/159

15


Recurrent episodes of wheezing

associated with acute viral respiratory

infections

No evidence of atopy

No family history of atopy.

Their symptoms normally persist throughTheir symptoms normally persist throughschool age and are still present at age 12school age and are still present at age 12

in a large proportion of childrenin a large proportion of children


16/159

16


CausesRespiratory Syncytial VirusRespiratory Syncytial Virus in childrenin children

younger than age 2younger than age 2

Other viruses predominate in childrenOther viruses predominate in childrenages 2-5ages 2-5

Smaller airway dimensionsSmaller airway dimensions

Silverman M, ed. Childhood asthma and other wheezSilverman M, ed. Childhood asthma and other wheezining disorders. 2nd ed.g disorders. 2nd ed.

London: Hodder Arnold, 2002London: Hodder Arnold, 2002


17/159

17


Is more common than non-atopicchildhood asthma

85% ofschool aged children with asthma

are atopic


18/159

18


This commonly presents as the schoolaged child

who complains of:

1. Episodic wheeze

2. Cough

3. Shortness of breath

Evidence of atopy, such as eczema and hayfever

Likely of family history of atopy.


19/159

19



who complains of:

1. Episodic wheeze

2. Cough

3. Shortness of breath Evidence of atopy, such as eczema and hay

fever Likely of family history of atopy.


20/159

20



who complains of:

1. Episodic wheeze

2. Cough


Evidence of atopy, such as eczema andhay fever



21/159

21



who complains of:

1. Episodic wheeze2. Cough


Evidence of atopy, such as eczema andhay fever



22/159

22

Diagnosi

s ofAsthma


23/159

23

Diagnosis of Asthma

Frequent episodesof wheeze(more than once amonth)

Activity-induced cough or wheeze Nocturnal cough in periods without viral

Infections

Absence of seasonal variation in wheeze Symptoms that persist after age 3


24/159

24

Simple Clinical Index that

predict the presence ofasthma in

later childhood


25/159

25

A simple clinical index

Presence of a wheeze before the age of 3

and the presence of one major riskfactor:

1. Parental history of asthma

2. Parental history of Eczema


26/159

26

Presence of a wheeze before the age of 3

and the presence oftwo from three

minor risk factors:

1. Eosinophilia

2. wheezing without colds3. Allergic rhinitis

A simple clinical index


27/159

27

Alternative causes ofrecurrent wheezing

1.1. Chronic rhino-sinusitisChronic rhino-sinusitis

2.2. Gastroesophageal refluxGastroesophageal reflux

3.3. Recurrent viral lower respiratory tract infectionsRecurrent viral lower respiratory tract infections

4.4. Cystic fibrosisCystic fibrosis

5.5. Bronchopulmonary dysplasiaBronchopulmonary dysplasia6.6. TuberculosisTuberculosis

7.7. Congenital malformation causing narrowing of theCongenital malformation causing narrowing of theintrathoracic airwaysintrathoracic airways

8.8. Foreign body aspirationForeign body aspiration9.9. Primary ciliary dyskinesia syndromePrimary ciliary dyskinesia syndrome

10.10. Immune deficiencyImmune deficiency

11.11. Congenital heart diseaseCongenital heart disease


28/159

28

Tests for diagnosis andmonitoring


29/159

29

In children 5 yearsand younger

The diagnosis of asthma has to be basedThe diagnosis of asthma has to be based

largely on:largely on:Clinical judgment:

2. History

3. Symptoms4. physical findings


30/159

30

In children 5 yearsand younger

Trial of

treatment with

SABA and ICS

Marked clinicalMarked clinicalimprovementimprovement

during theduring the

treatmenttreatment And deteriorationAnd deterioration

when it iswhen it is

stoppedstopped

Supports aSupports a

diagnosis ofdiagnosis of

asthmaasthma

I hild 5


31/159

31

In children over 5 yearsand older

Peak expiratory flow monitoring

PFM is useful to establishPFM is useful to establish diurnaldiurnal

variationvariation and theand the severity ofseverity of


32/159

32

Skin Prick Tests


33/159

33

Other Tests

Pulmonary function testsPulmonary function tests( Reversibility of( Reversibility of

FEV1 more than 15% afterFEV1 more than 15% afterininhalation of ahalation of abronchodilator)bronchodilator)

MeasurMeasurining total serum IgEg total serum IgE

Chest radiographyChest radiography


34/159

34

AsthmaMedications


35/159

35

Short-Acting inhaled 2-Agonists

(SABA) Ev. A

Systemic GlucoCorticoSteroids

(SGCS) Ev. D

Long-Acting inhaled 2-

Agonists (LABA) Ev. A

Theophylline (THEO) Ev .B

Leukotriene Modifiers (LM) Ev

A

Inhaled gluCocorticoSteroids(ICS) Ev. A

AsthmaMedications

Reliever Medications

Controller Medications


36/159

36


(SABA) Ev. A


(SGCS) Ev. D




Leukotriene Modifiers (LM) Ev

A


AsthmaMedications




37/159

37


(SABA) Ev. A


(SGCS) Ev. D




Leukotriene Modifiers (LM)

Ev A

Inhaled gluCocorticoSteroids

(ICS) Ev. A

AsthmaMedications




38/159

38


(SABA) Ev. A


(SGCS) Ev. D





Ev A


AsthmaMedications




39/159


40/159

40

Short-Acting inhaled 2-

Agonists

(SABA) Ev. A


(SGCS) Ev. D





Ev A


(ICS) Ev. A

AsthmaMedications




41/159

41

Short-Actinginhaled 2-Agonists

(SABA) Ev. A


(SGCS) Ev. D





Ev A


(ICS) Ev. A

AsthmaMedications




42/159

42Anticholinergics

Short-Actinginhaled 2-

Agonists(SABA) Ev. A


(SGCS) Ev. D





Ev A


(ICS) Ev. A

AsthmaMedications



n a e


43/159

43

n a egluCocorticoSteroids

(ICS)

Inhaled glucocorticosteroids are the mosteffective controller therapy in all ages

Evidence A in LongTermasthmaManagement


44/159

44

InhaledgluCocorticoSteroids (ICS)

The benefits of ICS include:

1. Reduced bronchialhyperresponsiveness

2. Prevention of the late asthmatic

response

3. Enhanced lung function

Estimate Comparative Daily Dosages for


45/159

45


Inhaled Glucocorticosteroids by Age

Drug Low Daily Dose (g) Medium Daily Dose (g) High Daily Dose (g)> 5 y Age < 5 y > 5 y Age < 5 y > 5 y Age < 5 y

>1000>500-

1000250 -500

Budesonide-NebInhalation Suspension

>1000 >400600-1000 >200-400200-600 100-200Budesonide

>800-1200 >400> 400-800 >200-400200-400 100-

200Mometasone furoate

>2000 >1200>1000-2000 >800-1200400-1000 400-

800

Triamcinolone

acetonide

>500 >500>250-500 >200-500100-250 100-

200Fluticasone

>2000 >1250>1000-2000 >750-1250500-1000 500-

750Flunisolide

>320-1280 >320>160-320 >160-32080 160 80-160Ciclesonide

>1000 >400>500-1000 >200-400200-500 100-200Beclomethasone



46/159

46


Inhaled Glucocorticosteroids by Age

Drug Low Daily Dose (g) Medium Daily Dose (g) High Daily Dose (g)> 5 y Age < 5 y > 5 y Age < 5 y > 5 y Age < 5 y

>1000>500-

1000250 -500

Budesonide-Neb

Inhalation Suspension

>1000 >400600-1000 >200-400200-600 100-200Budesonide

>800-1200 >400> 400-800 >200-400200-400 100-

200Mometasone furoate

>2000 >1200>1000-2000 >800-1200400-1000 400-

800

Triamcinolone

acetonide

>500 >500>250-500 >200-500100-250 100-

200Fluticasone

>2000 >1250>1000-2000 >750-1250500-1000 500-

750Flunisolide

>320-1280 >320>160-320 >160-32080 160 80-160Ciclesonide

>1000 >400>500-1000 >200-400200-500 100-200Beclomethasone

I h l d


47/159

47

InhaledgluCocorticoSteroids (ICS)

Use of ICS does not induce remission ofUse of ICS does not induce remission ofasthma, and symptoms return whenasthma, and symptoms return when

treatment is stoppedtreatment is stopped

n a e


48/159

48

n a egluCocorticoSteroids

(ICS)No EvidenceNo Evidence

Maintenance or Intermittent low-dose (ICS)Maintenance or Intermittent low-dose (ICS)

PreventingPreventing Non-atopic Childhood AsthmaNon-atopic Childhood Asthma


49/159

49

LeukotrieneModifiers(LM)

Evidence A in LongTermasthmaManagement


50/159


51/159

51


One multicenter, randomized, double-blind, parallel-group study

Examined children (aged 2 to 5 years) (approximately270 children per group)

Intermittent asthma associated with viral infections andminimal asthma symptoms between exacerbations

Children were given Montelukast or placebo andfollowed for 12 months

Bisgaard, H, Zielen, S, Garcia-Garcia, ML, et al. Montelukast reduces asthmaexacerbations in 2- to 5-year-old children with intermittent asthma. Am JRespir Crit Care Med 2005; 171:315.


52/159


53/159

53



Examined infants (aged 2 to 5 years) (approximately 270children per group)


Children were given Montelukast or placebo andfollowed for 12 months



54/159

54



Examined infants (aged 2 to 5 years) (approximately 270children per group)


infants were given Montelukast orplacebo and followedfor 12 months



55/159

55


Montelukast significantly:

Reduced the rate of asthma

exacerbations by 32 % compared withplacebo (from 2.3 episodes per year to 1.6)

Decreased the use of ICSby 30%

Bisgaard, H, Zielen, S, Garcia-Garcia, ML, et al. Montelukast reduces asthma

exacerbations in 2- to 5-year-old children with intermittent asthma. Am J Respir

Crit Care Med 2005; 171:315.


56/159

56


Montelukast significantly:

Reduced the rate of asthma

exacerbations by 32 % compared withplacebo (from 2.3 episodes per year to 1.6)

Decreased the use of ICSby 30%

Bisgaard, H, Zielen, S, Garcia-Garcia, ML, et al. Montelukast reduces asthma

exacerbations in 2- to 5-year-old children with intermittent asthma. Am J Respir

Crit Care Med 2005; 171:315.


57/159


58/159

58

DOSING

10 mg/dayAdolescents >14 years

and Adults

5 mg/day6-14 years

4 mg/day6 months to 5 years

Montelukast


59/159

59

Theophylline

A few studies in infants 5 years andyounger suggest some clinical benefit

The efficacy is less than that of low-dose

ICS


60/159

60

Theophylline

The side effects are more pronouncedEvidence B inLongTermasthma

Management in children adolescents and

adults

Long Acting inhaled 2


61/159

61

Long-Acting inhaled 2-Agonists (LABA)

Evidence A in LongTermasthmaManagement in children adolescents and

adults:

Control of chronic symptoms

Prevent nocturnal symptoms

Exercise-induced bronchoconstriction



62/159

62


The effect of (LABA) has not yet beenadequately studied in infants 5 years and

younger



63/159

63


Recent studies in adults have shown anincrease in the relative risk of death from

asthma with the use of salmeteroll


64/159

64

Inhalation

50 mcg / 12

hours

> 4 years oldSalmeterol

inhalation

12 mcg / 12hours

> 5 years oldFormoterol

Long-Acting inhaled 2-Agonists LABA



65/159

65

g Agonists(SABA)

Evidence A:

Relief bronchospasm during acute

exacerbations of asthma

Pretreatment of exercise-induced

bronchoconstriction

Salbutamol, Terbutaline, Fenoterol, Reproterol,And Pirbuterol.



66/159

66

g Agonists(SABA)

Evidence A:

1. Relief bronchospasm during acute

exacerbations of asthma2. Pretreatment of exercise-induced

bronchoconstriction

Salbutamol, Terbutaline, Fenoterol,Reproterol, And Pirbuterol.


67/159


68/159



69/159

69

g Agonists(SABA)

Evidence also exists of reducedEvidence also exists of reducedprotection against exercise inducedprotection against exercise induced

asthmaasthma

Bisgaard H, Szefler S. Long actBisgaard H, Szefler S. Long actiningg LancetLancetagonists andagonists and

paediatric asthmapaediatric asthma

A ti h li i


70/159

70

Anticholinergics

In Acute Asthma

B. Reliever medication but less effectivethan SABA

C. Not recommended for long-term

management of asthma in children

Rodrigo G, Rodrigo C, Burschtin O. A meta-analysis of the effects of ipratropium bromide in

adults with acute asthma. Am J Med1999;107(4):363-70/McDonald NJ, Bara AI.Anticholinergic therapy for chronic

asthma in children over two years of age. Cochrane DatabaseSyst Rev2003(3):CD003535

A ti h li i


71/159

71

Anticholinergics

A. The combination between SABA &Anticholinergics:

1. Significant Improvement in pulmonaryfunction

2. Significantly reduces the risk of hospital

admission

Rodrigo G, Rodrigo C, Burschtin O. A meta-analysis of the effects of ipratropium bromide in

adults with acute asthma. Am J Med1999;107(4):363-70/McDonald NJ, Bara AI.Anticholinergic therapy for chronic

asthma in children over two years of age. Cochrane DatabaseSyst Rev2003(3):CD003535


72/159

AsthmaAsthma


73/159

73

SuccessfulSuccessful

AsthmaAsthmaManagementManagement

ManagementManagementandand

PreventionPrevention

AsthmaAsthmaM t d


74/159

74

PharmacologicPharmacologic

TherapyTherapy





Patient educationPatient educationAsthmaAsthma

M tM t dd


75/159

75

to createto create

a partnershipa partnership

betweenbetween

clinicianclinician

& patient& patient


TherapyTherapy





RoutineRoutineAsthmaAsthma

M tM t dd


76/159

76

RoutineRoutine

Monitoring ofMonitoring of

Symptoms &Symptoms &

Lung FunctionLung Function

Patient educationPatient education

to createto create


betweenbetween

clinicianclinician& patient& patient


TherapyTherapy





PreventionPreventionAsthmaAsthma

M tM t dd


77/159

77

PreventionPreventionTrigger factorsTrigger factors

coco--morbidmorbid

conditionsconditions

RoutineRoutine

Monitoring ofMonitoring ofSymptoms &Symptoms &

Lung FunctionLung Function


to createto create


betweenbetween

clinicianclinician

& patient& patient

PharmacologicPharmacologicTherapyTherapy






78/159


79/159


80/159

80

Initial Evaluation before treatment to classifyAsthma Severity

Treating for 4-6 weeksto achieve control: 5 steps

Pharmacologic Therapy


81/159

81

Total evaluation after treatment to identify the

Level of Control





82/159

82

Treatment Modification : Step up or Step down


Level of Control





83/159

83

Adequate management ofExacerbation



Level of Control





84/159

84



Classification of asthma severity before treatment (0-


85/159

85

Several

times

per day

Activity

SABA use for

symptom control

Nighttime

awakeningsImpairment

Extremely

limited

Some

limitation

Minor

limitationNone

Daily>2 days/week

but not daily>2

days/week

>1x/week3-

4x/month1-2x/month0

Daily

Moderate>2 days/week

but not daily

Mild

Persistent

Severe> 2

days/week

Intermittent

Throughout

the daySymptoms


4 years of age(

Components of severity



86/159

86

Several

times

per day

Activity

SABA use for

symptom control

Nighttime


Extremely

limited

Some

limitation

Minor

limitationNone

Daily>2 days/week

but not daily>2

days/week

>1x/week3-

4x/month1-2x/month0

Daily


but not daily

Mild

Persistent

Severe> 2

days/week

Intermittent

Throughout

the daySymptoms

Classification of asthma severity before treatment (0

4 years of age(



87/159



88/159

88

Several

times

per day

Activity

SABA use for

symptom control

Nighttime


Extremely

limited

Some

limitation

Minor

limitationNone

Daily>2 days/week

but not daily>2

days/week

>1x/week3-

4x/month1-2x/month0

Daily


but not daily

Mild

Persistent

Severe> 2

days/week

Intermittent

Throughout

the daySymptoms


4 years of age(




89/159

89

Several

times

per day

Activity

SABA use for

symptom control

Nighttime


Extremely

limited

Some

limitation

Minor

limitationNone

Daily>2 days/week

but not daily>2

days/week

>1x/week3-

4x/month1-2x/month0

Daily


but not daily

Mild

Persistent

Severe> 2

days/week

Intermittent

Throughout

the daySymptoms


4 years of age(


ModerateIntermittent SevereMild


90/159

90

0-1/year

Exacerbations of any severity may occur in patients in any

severity category may be related to FEV 1 in children 5-11 years

of age

Frequency and severity may fluctuate over time

Consider severity and interval since last exacerbation

2 exacerbations in 6

months requiring oral

systemic

corticosteroids or 4 wheezing

episodes/1 year lasting

>1 day AND risk

factors for persistent

asthma

2/year in children 5-11

years of age

Exacerbations

requiringoral

systemic

corticosteroids

Risk



91/159

91

0-1/year



of age





systemic



>1 day AND risk


asthma


years of age

Exacerbations

requiringoral

systemic

corticosteroids

Risk



92/159

92

0-1/year



of age





systemic



>1 day AND risk


asthma


years of age

Exacerbations

requiringoral

systemic

corticosteroids

Risk



93/159

93

0-1/year


severity category may be related to FEV1 in children 5-11 years

of age





systemic



>1 day AND risk


asthma


years of age

Exacerbations

requiringoral

systemic

corticosteroids

Risk


94/159

94

FEV 1 80 %

Normal FEV 1

between

exacerbations

FEV 1 >80 %predicted

FEV 1/FVC

>85 %

ModerateMild

Persistent

SevereIntermittent

Classification of asthma severity before treatment

(5-11

years

of

age)

Lungfunction

Ph l i Th


95/159

95





96/159

96

As needed Short-acting

inhaled 2-agonist(SABA)

Indicated in all agegroups

Evidence A

Step 1IntermittentAsthma


97/159

97

Step 2Step 2

MildMildAsthmaAsthma

Preferred

Low-dose ICSLow-dose ICS

Evidence AEvidence A

AlternativeMontelukast

Evidence A

Indicated in all age groups


98/159

98

Step 2Step 2

Mild AsthmaMild Asthma

PreferredLow-dose ICSLow-dose ICS


AlternativeMontelukastMontelukast

EvidenceEvidenceAA

Indicated in all age groups

Stepwise approach for managing asthma


99/159

99

Step 3Step 3

Moderate & Severe AsthmaModerate & Severe Asthma

Medium-dose ICSMedium-dose ICSEvidence AEvidence A


in children 0- 4 years of age



100/159

100

Step 4Step 4Moderate & SevereModerate & Severe

AsthmaAsthma

Medium-dose ICSMedium-dose ICS


LABALABA

EvidenceEvidenceAA

Montelukast

EvidenceA





101/159

101


AsthmaAsthma

Medium-dose ICSMedium-dose ICS


LABALABA

EvidenceEvidenceAA

MontelukastMontelukast

EvidenceEvidenceAAOrOr

PreferredPreferred





102/159

102

Step 5Step 5Severe AsthmaSevere Asthma

HighHigh-dose ICS-dose ICS


LABALABA

EvidenceEvidenceAA

Montelukast

EvidenceA





103/159

103


HighHigh-dose ICS-dose ICS


LABALABA

EvidenceEvidenceAA


EvidenceEvidenceAAOrOr

PreferredPreferred



Stepwise approach for managing asthma in children


104/159

104

SABA ICS -DoseDrugs

Stepwiseapproachformanagingasthmainchildren

0-4 years of age



105/159

105

1

Intermittent

SABA ICS -Dose

3

Moderate- Severe

542Steps

SevereMildSeverity

Drugs


0-4 years of age



106/159

106

LABA

Immunotherapy

Montelukast

HighMediumMedium

Montelukast

Low

1

Intermittent

SABA ICS -Dose

3

Moderate- Severe

542Steps

SevereMildSeverity

Drugs


0-4 years of age



107/159

107

LABA ???

Immunotherapy

Montelukast

HighMediumMedium

Montelukast

Low

1

Intermittent

SABA ICS -Dose

3

Moderate- Severe

542Steps

SevereMildSeverity

Drugs


0-4 years of age



108/159

108

LABA???

Immunotherapy

Montelukast

HighMediumMedium

Montelukast

Low

1

Intermittent

SABA ICS -Dose

3

Moderate- Severe

542Steps

SevereMildSeverity

Drugs


0-4 years of age

Stepwise approach for managing asthma in

Children older than 5 years Adolescents and


109/159

109


AsthmaAsthma

Low-dose ICSEvidence A

LABA

EvidenceA

MontelukastEvidenceA

SR-Theo

EvidenceB

Medium- dose ICS High dose ICSHigh dose ICS

Children older than 5 years, Adolescents and

Adults




110/159

110


AsthmaAsthma

Low-dose ICS

Evidence A

LABA

EvidenceA

Montelukast

EvidenceA

SR-Theo

EvidenceB

Medium- dose ICSMedium- dose ICS High dose ICSHigh dose ICS


Adults




111/159

111


AsthmaAsthma



LABALABA

EvidenceEvidenceAA

MontelukastEvidenceA

SR-Theo

EvidenceB

Medium- dose ICSMedium- dose ICS High dose ICSHigh dose ICS


Adults

PreferredPreferred




112/159

112


AsthmaAsthma



LABALABA

EvidenceEvidenceAA


EvidenceEvidenceAA

SR-Theo

EvidenceB

Medium- dose ICSMedium- dose ICS

OrOr

High dose ICSHigh dose ICS


Adults

PreferredPreferred




113/159

113


AsthmaAsthma



LABALABA

EvidenceEvidenceAA


EvidenceEvidenceAA

SR-TheoSR-Theo

EvidenceEvidenceBB

Medium- dose ICSMedium- dose ICS

OrOr

High dose ICSHigh dose ICS

OrOr


Adults

PreferredPreferred


114/159



115/159

115


AsthmaAsthma

Medium -dose ICS plusMedium -dose ICS plus

LABALABA


Evidence AEvidence ASR-TheoSR-Theo

EvidenceEvidence BB-/+-/+

High-doseHigh-doseICSICSplusplus

LABALABA


Adults



116/159

116


MediumMedium

dose ICS plusdose ICS plus

LABALABA



EvidenceEvidence BB

OralOral

GlucocorticosteroidsGlucocorticosteroids

low doselow dose Evidence DEvidence D

Anti-IgE

Evidence A

High-dose ICS plusHigh-dose ICS plus

LABALABA


Adults


C


117/159

117


MediumMedium

dose ICS plusdose ICS plus

LABALABA



EvidenceEvidence BB

-/+-/+OralOral

GlucocorticosteroidsGlucocorticosteroids

low doselow dose Evidence DEvidence D

Anti-IgEAnti-IgE


High-dose ICS plusHigh-dose ICS plus

LABALABA


Adults

Stepwise approach for managing asthma in Children older than 5 years, Adolescents and

Adults


118/159

118

+/- AntiIgE

Oral

Glucocorticosteroids

lowdose

5

SR-Theo

Montelukast

LABA

Medium or High

+/- SR-Theo

Montelukast

LABA

SR-Theo

Montelukast or

Immunotherapy

Medium or HighMedium or

High

LABA or

Low

Moderate- Severe

43

Severe

ICS

Immunotherapy in Children older thanAd l d Ad l


119/159

119

5 years, Adolescents and Adults

For steps 2-4 is basedFor steps 2-4 is based

onon Evidence BEvidence B for:for:HouseHouse--dustdust mitesmites

Animal dandersAnimal danders

PollensPollens

Immunotherapy in Children older than5 Ad l t d Ad lt


120/159

120


Evidence isEvidence is

strongeststrongest forfor

immunotherapy withimmunotherapy with

single allergenssingle allergens

Immunotherapy in Children older than5 Ad l t d Ad lt


121/159

121


The role of allergy inThe role of allergy in

asthma is greater inasthma is greater in

childrenchildren than inthan in

adultsadults



122/159

122


Level of Control


Treatingto achieve control: 5 steps


Le el Of ControlLevel Of Control


123/159

123

ExacerbationExacerbation

Level Of ControlLevel Of Control



124/159

124

UncontrolledUncontrolled





125/159

125

Partly ControlledPartly Controlled






126/159

126

ControlledControlled

Partly ControlledPartly Controlled




UncontrolledPartly controlled

( )

Controlled

Levels of Asthma ControlLevels of Asthma Control


127/159

127

Uncontrolled(Any present in any week)(All of the following)


(A t i k)

Controlled


Characteristic


128/159

128

Uncontrolled(Any present in any week)(All of the following)

Daytime symptoms

Characteristic


(A t i k)

Controlled


Characteristic


129/159

129

(Any present in any week)(All of the following)

Limitations of

activities

Daytime symptoms


130/159


(Any present in any week)

Controlled

(All f th f ll i )


Characteristic


131/159

131


Need for rescue /

reliever treatment

Nocturnal symptoms /awakening

Limitations of

activities

Daytime symptoms



Controlled

(All f th f ll i )


Characteristic

Characteristic


132/159

132


Lung function

(PEF or FEV1)

Need for rescue /

reliever treatment


Limitations of

activities

Daytime symptoms

Lung function

(PEF or FEV1)

Need for rescue /

reliever treatment


Limitations of

activities

Daytime symptoms


133/159


134/159

134

None (2 or less / week)


135/159

135

NONO


136/159

Limitations Of Activities


137/159

137


138/159

138

None (2 or less / week)

Typical Spirometric (FEV1)

Tracings


139/159

139

Tracings

11Time (sec)22 33 44 55

FEV1

Volume

Normal SubjectNormal Subject

Asthmatic (After Bronchodilator)Asthmatic (After Bronchodilator)

Asthmatic (Before Bronchodilator)Asthmatic (Before Bronchodilator)

Note: Each FEV1 curve represents the highest of three repeat measurements

NormalNormal


140/159

140

NoE

xacerbation


141/159


142/159



Controlled

(All of the following)


Characteristic


143/159

143

( y p y )(All of the following)

None (2 or less /week)

None

None

None (2 or less /

week)

Normal

None

More thantwice / week

Any

Any

More than

twice / week

< 80% predicted or

personal best (if known)

on any day

One or more / year 1 in any week

3 or more

features of

partly

controlled

asthma

present in any

week

Exacerbation

Lung function

(PEF or FEV1)

Need for rescue /

reliever treatment


Limitations of

activities

Daytime symptoms



144/159

144



Level of Control



Treatment Modification


145/159

145

STEP

1

S

TEP

2

STEP

3

STEP

4

STEP

5

Step upStep up

afterafter

weeks 4-6weeks 4-6

ofof

TreatmentTreatment

Step downStep down

AfterAfter

months 3-6months 3-6

ofof

TreatmentTreatment



146/159

146

Adequate management ofExacerbation



Level of Control




147/159

147


co bidmorbid

AsthmaAsthma




148/159

148

coco--morbidmorbid



TherapyTherapy



Prevention


149/159

149

CoCo--morbid conditionsmorbid conditions Trigger factorsTrigger factors

Influenza VaccinationInfluenza Vaccination

Chronic Rhino-Sinusitis


150/159

150

RecurrentMilk

Gastroesopha


151/159

151

Milk

Aspirationgeal Reflux

Trigger factorsTrigger factors


152/159

152

Prevention /InfluenzaVaccination


153/159

153

Vaccination


coco-morbidmorbid

AsthmaAsthma




154/159

154

coco--morbidmorbid



to createto create


betweenbetween

clinicianclinician

& patient& patient


TherapyTherapy



Patient Education


155/159

155


156/159


coco--morbidmorbid

AsthmaAsthma




157/159

157

coco--morbidmorbid


RoutineRoutine

Monitoring ofMonitoring of

Symptoms &Symptoms &Lung FunctionLung Function

Patient educationPatient educationto createto create


betweenbetween

clinicianclinician

& patient& patient


TherapyTherapy



out neMonitoring


158/159

158

Exacerbation

Lung function

(PEF or FEV1)

Need for rescue /

reliever treatment

Nocturnal symptoms /

awakening

Limitations of

activities

Daytime symptoms

Adequate use ofspacers / neublizer

Peak Flow Meter

Co-morbidconditions

Level of control

Treatment

StepStep


159/159

overview of childhood asthma

Documents