Paediatric Asthma

Dr Rossa BrughaClinical Research Fellow

11th February 2014

April 2010

Paediatric asthma

• What is asthma in childhood?• Pathology, signs and symptoms• Diagnosis• Principles of asthma management

• Self management• Pharmacotherapy• Assessing control•What’s new

The scale of the problem%

of 1

2 yr

. old

s

Burr et al Thorax 2006;61:296-9

Changes in the Prevalence of Diagnosed Asthma and Asthma Symptoms over Time in Children and Young Adults.

Eder W et al. N Engl J Med 2006;355:2226-2235.

The scale of the problem

Asthma vs preschool wheeze

Asthma• Above age 5• Approx 1 in 11 children• Inflammatory condition• Responds to inhaled

corticosteroids

Preschool wheeze• Age 1-5• Approx 1 in 3 children• ‘Episodic viral’ wheeze

– Wheeze only with viral infections

– No evidence for ICS• ‘Multi-trigger’ wheeze

– URTIs plus other triggers eg exercise, smoke, allergens

• Only give oral prednisolone in subgroup of those requiring admission

See: Bush A, Grigg J, Saglani S. Managing wheeze in preschool children. BMJ 2014; 348

What is Asthma? A clinical diagnosis

• There is no agreed definition, no known cause

• Genetic susceptibility plus environmental trigger: • 1st degree relative increases risk• Identical environments in siblings with

and without asthma• Time course/“double hit” of atopic

sensitization and viral infection eg hRV3; 1st year of life is crucial

Clinical features that increase the probability of asthma

More than one of the following symptoms:•Wheeze, cough, DIB, chest tightness, particularly if symptoms:– are frequent and recurrent– are worse at night and in the early morning–occur in response to, or are worse after,

exercise or other triggers, such as exposure to pets, cold, damp air, or with emotions/laughter

• Personal history of atopic disorder• Family history of atopic disorder and/or

asthma• Widespread wheeze heard on auscultation• History of improvement in symptoms or lung

function in response to adequate therapy

Clinical features that increase the probability of asthma

Clinical features that lower the probability of asthma

• Symptoms with colds only, with no interval symptoms

• Isolated cough in the absence of wheeze or difficulty breathing

• History of moist cough• Prominent dizziness, light-headedness,

peripheral tingling

Clinical features that lower the probability of asthma

• Repeatedly normal physical examination of chest when symptomatic

• Normal peak expiratory flow (PEF) or spirometry when symptomatic

• No response to a trial of asthma therapy• Clinical features pointing to alternative

diagnosis

Airway pathology in asthmaThe hallmark of asthma is chronic airway inflammation

From: Bradding, P., Walls, A.F. & Holgate, S.T. (2006). The role of the mast cell in the pathophysiology of asthma. J Allergy Clin Immunol 117, 1277–84

Airway pathology in asthma

Signs and symptomsThe result of airway inflammation is airway narrowing

Self management

• Avoid triggers• Air pollution• Passive (active) smoking• Aeroallergens when/if possible

• Healthy diet• Studies in adults and children have shown that

a high intake of fresh fruit and vegetables is associated with fewer asthma symptoms and better lung function

Self management

• Exercise• Warm up and warm down• Use bronchodilator pre-exercise• Good evidence that exercise helps asthma

• Complementary treatments• Buteyko breathing (a technique to control

hyperventilation) has been shown to reduce symptoms

PharmacotherapySteroids Montelukast

Monoclonal anti-IgE(omalizumab, Xolair)

Lebrikizumab: anti IL-13Mepolizumab: anti IL-5Pascolizumab: anti IL-4

Management of chronic asthma

Asthma control test

• During the past 4 weeks:1. How often did your asthma prevent you from getting

as much done at work, school or home? 2. How often have you had shortness of breath? 3. How often did your asthma (wheezing, coughing,

chest tightness, shortness of breath) wake you up? 4. How often have you used your reliever inhaler? 5. How would you rate your asthma control ?

Comorbidities• Around 50% with asthma will have atopy

- Eczema- Rhinitis- Hayfever

• Antigen crossing via these sites can persistently sensitise the immune system

• Important to optimise epithelial health- Barriers (emollient)- Immunomodulators (topical steroid)- Symptom control (antihistamines)

What’s in the pipeline

• Phenotyping asthma– Via SNPs eg leukotrienes and ALOX-5

• “Urine dip” for asthma– By sputum leucocytes– By exhaled breath cytokine pattern (Th1, Th2, Th17)

• Predicting exacerbations/inflammometry– FeNO (probably not in children)– Sputum eosinophil count (probably not in children)– ACT score– Peak flow fractals

Why phenotype?

• All that wheezes is not asthma• Consider the approach to management of

other chronic inflammatory conditions in childhood– Joint arthropathies– Inflammatory bowel disease

Asthma Review: Checklist1. The right diagnosis2. Check symptom control (ACT)3. Ask about and address smoking (child and parent)4. The right treatment at the right time (step-wise)– Before initiating a new drug/step: check compliance with

existing therapies, inhaler technique and try to eliminate trigger factors.

– Minimise side effects from treatment (i.e. growth if on high dose ICS)

5. The right inhaler, correct technique – Give inhaler training, ensure correct technique before

writing prescription

6. The gold standard is MDI + spacer7. Give Asthma education– (repetition, reinforcement, signpost/give resources)

8. All children should have an Asthma Plan9. Promote self-management – Compliance

10.Need regular review– Annual review– Review at 48-72 hrs and 30 days post

exacerbation/admission

Asthma Review: Checklist

NICE Quality standards QS25• Statement 1. People with newly diagnosed asthma are diagnosed in

accordance with BTS/SIGN guidance.• Statement 2. Adults with new onset asthma are assessed for occupational

causes.• Statement 3. People with asthma receive a written personalised action

plan.• Statement 4. People with asthma are given specific training and

assessment in inhaler technique before starting any new inhaler treatment.

• Statement 5. People with asthma receive a structured review at least annually.

• Statement 6. People with asthma who present with respiratory symptoms receive an assessment of their asthma control.

NICE Quality Standards QS25• Statement 7. People with asthma who present with an exacerbation of their

symptoms receive an objective measurement of severity at the time of presentation.

• Statement 8. People aged 5 years or older presenting to a healthcare professional with a severe or life-threatening acute exacerbation of asthma receive oral or intravenous steroids within 1 hour of presentation.

• Statement 9. People admitted to hospital with an acute exacerbation of asthma have a structured review by a member of a specialist respiratory team before discharge.

• Statement 10. People who received treatment in hospital or through out-of-hours services for an acute exacerbation of asthma are followed up by their own GP practice within 2 working days of treatment.

• Statement 11. People with difficult asthma are offered an assessment by a multidisciplinary difficult asthma service.

Useful learning resources• Acute breathing difficulties:

http://abd.ocbmedia.com/home/• Spotting the Sick child;

https://www.spottingthesickchild.com/• Adult & Paed case studies:

http://real.educationforhealth.org/• Itchy Sneezy Wheezy:

http://www.itchysneezywheezy.co.uk/• Asthma UK http://www.asthma.org.uk/

Further reading

BTS Guidelines 2011/12 http://www.brit-thoracic.org.uk/guidelines/asthma-guidelines.aspx

Atopic Eczema in Children (NICE)

http://www.nice.org.uk/CG57

BNF for Children 2011/12

Questions

April 2010

Summary• Asthma is very common• Large disease burden• Morbidity & mortality• Regular asthma review – Assess control– Assess technique– Assess understanding, compliance/concordance– Question the diagnosis