Asthma 2009: A Quick Primer

Pediatric Asthma 101 : A Quick Primer Steve Marchbank, MD [email_address]

I. What is asthma?
Chronic airway inflammation
Reversible airway constriction/airflow limitation
Airway hyperresponsiveness
Recurring symptoms over time, usually from a variety of triggers

OK… but what IS asthma?
The first thing to remember (in pediatric or adult asthma) is that asthma can wear many ‘hats’
and remember that…. Not everything that ‘wheezes’ is asthma, and not every asthmatic is ‘wheezing’

Asthma Pathophysiology: 2 basic components
Inflammation: Multiple contributing mechanisms and pathways; inflammation leads to tendency for bronchospasm & excessive mucous production
Bronchoconstriction: Multiple biochemical pathways; bronchospasm means the air doesn’t flow as easily, which can give cough, wheeze, SOB, sleep disturbance, etc. Airway hyperresponsiveness to a variety of triggers & reversible airway obstruction/constriction

So… what MIGHT be asthma?
Recurrent cough (dry or loose)
Wheezing
Shortness of breath, chest tightness
Exercise intolerance
Sleep disturbance; cough at night
Colds ‘go to the chest’, and/or always last >10 days
‘ recurrent croup’
constant throat-clearing

Diagnosis of Asthma
History- pattern and recurrence of symptoms
Physical examination
Family History
Measurement/estimation of lung function (as age appropriate)
Evaluation of allergies/allergic status
Exclude alternative diagnoses

The “Three R’s” of asthma diagnosis
Recurrence : symptoms recur over time
Reactivity : the symptoms brought on by a trigger
Responsive : symptoms ↓ in response to bronchodilators and/or anti-inflammatory agents (i.e. ICS)

What may only LOOK like pediatric asthma? (differential diagnoses)
Allergic rhinitis/sinusitis
Large airway obstruction: tracheal FB, vocal cord dysfunction, vascular rings, laryngotracheomalacia, laryngeal webs, extrinsic (lymphadenopathy/tumor)
Small airway obstruction: viral bronchiolitis, obliterative bronchiolitis, CF, BPD (bronchopulmonary dysplasia), heart disease
Vocal cord dysfunction
Other: recurrent cough (non-asthmatic), chronic aspiration and/or severe GERD

Asthma Triggers
Upper respiratory infection
Allergens: animal dander, dust mites, pollen, molds
Exercise
Smoke - cigarette, other
Temperature/humidity changes
Emotional stress- anxiety, fatigue, laughter, crying
Other: drugs, chemicals

How common is asthma?
If neither parent has asthma, the incidence of asthma in the average child is 7-10%
~20% if one parent has asthma
~60% if both parents have asthma
Significant number of infants/toddlers hospitalized for RSV bronchiolitis go on to have asthma (somewhere between 30-50%)

II. Asthma Classification
The most recent NAEPP (National Asthma Education & Prevention Program) Expert Panel Report 3 (2004) classifies asthma into the following:
Mild intermittent
Mild persistent
Moderate Persistent
Severe Persistent
Can be found online at: http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm

The Big Picture….. Is asthma Intermittent or Persistent?
The take-home message (in my opinion) of the most recent Expert Panel Report, and for the typical primary care provider is this:
Once you have established the diagnosis of asthma, you should then CLASSIFY it based on the frequency of recurrence (most importantly) and severity of symptoms, as being either intermittent or persistent

Intermittent vs. Persistent
Intermittent Asthma
symptoms  2 times/week
nighttime symptoms  2 nights/month
FEV 1 /PEF  80% predicted
PEF variability < 20%
Persistent Asthma
symptoms > 2 times/week
nighttime symptoms > 2 nights/month
FEV 1 /PEF variable (dependent on sub-type, mild/mod/severe)
PEF variability > 20%

Why does the classification matter?
The classification - intermittent or persistent - leads us to the proper management and treatment of asthma
The basics:
intermittent asthma = bronchodilators as needed
persistent asthma = daily anti-inflammatory + bronchodilators as needed

If you only remember ONE thing from this presentation…
1. Persistent asthma = Daily , preventative anti-inflammatory asthma medication
2. The Gold-Standard for anti-inflammatory asthma medication is: inhaled corticosteroid

Summary
Asthma is either intermittent OR persistent. Persistent asthma should be treated with daily anti-inflammatory medication, the gold standard for which is inhaled corticosteroid

Asthma 2009: A Quick Primer

by Steve Marchbank

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