Preschool wheezy children


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Preschool wheezy children

  1. 1. Preschool Wheezy Children Gamal Rabie Agmy, MD, FCCP Professor of chest Diseases, Assiut university
  2. 2. Definition of Asthma  A chronic inflammatory disorder of the airways  Many cells and cellular elements play a role  Chronic inflammation is associated with airway hyperresponsiveness that leads to recurrent episodes of wheezing, breathlessness, chest tightness, and coughing  Widespread, variable, and often reversible airflow limitation
  3. 3. Asthma Inflammation: Cells and Mediators Source: Peter J. Barnes, MD
  4. 4. Mechanisms: Asthma Inflammation Source: Peter J. Barnes, MD
  5. 5. Asthma Inflammation: Cells and Mediators Source: Peter J. Barnes, MD
  6. 6. Asthma Pathobiology Smooth Muscle Dysfunction • • • • Bronchoconstriction Bronchial Hyperreactivity Hypertrophy/Hyperplasia Inflammatory Mediator Release Airway Inflammation • Inflammatory Cell Infiltration/Activation • Mucosal Edema • Cellular Proliferation • Epithelial Damage • Basement Membrane Thickening Symptoms/Exacerbations
  7. 7. Pathology of Asthma
  8. 8. Factors that Exacerbate Asthma       Allergens Respiratory infections Exercise and hyperventilation Weather changes Sulfur dioxide Food, additives, drugs
  9. 9. Factors that Influence Asthma Development and Expression Host Factors  Genetic - Atopy - Airway hyperresponsiveness  Gender  Obesity Environmental Factors  Indoor allergens  Outdoor allergens  Occupational sensitizers  Tobacco smoke  Air Pollution  Respiratory Infections  Diet
  10. 10. Is it Asthma?  Recurrent episodes of wheezing  Troublesome cough at night  Cough or wheeze after exercise  Cough, wheeze or chest tightness after exposure to airborne allergens or pollutants  Colds “go to the chest” or take more than 10 days to clear
  11. 11. 90% of the asthma problem is not seen: The inflammation!!! Bronchospasm= 10%
  12. 12. Symptoms When this disappears… Have we eliminated this? Underlying disease
  13. 13. Pediatric Asthma Not all wheezing is asthma Wheezing occurrences in children: - single episode in 30% to 50% of children before 5 yr of age - 40% who wheeze before 3 yr of age continue at 6 yr (“persistent wheezers”) - 50% of infants who wheeze once will wheeze again within several months
  14. 14. Wheezing in Children - Phenotypes
  15. 15. Childhood asthma phenotypes
  16. 16. Childhood asthma phenotypes *A 2012 study described 2 "new" phenotypes for young children with wheezing: "boys atopic multiple-trigger" and "girls nonatopic uncontrolled wheeze". JACI, 2012. *Toward a definition of asthma phenotypes in childhood: early viral wheezers, multitrigger wheezers (MTWs), and nonatopic uncontrolled wheezers (NAUWs). Some children have “allergic bronchitis” rather than “asthma”. JACI, 2012.
  17. 17. Diagnosing Asthma in Young Children – Asthma Predictive Index • Major criteria – Parent with asthma • > 4 episodes/yr of – Physician diagnosed wheezing lasting atopic dermatitis more than 1 day affecting sleep in a • Minor criteria child with one MAJOR – Physician diagnosed or two MINOR criteria allergic rhinitis – Eosinophilia (>4%) – Wheezing apart from colds 1Adapted from Castro-Rodriquez JA, et al. AJRCCM 2000; 162: 1403
  18. 18. Modified Asthma Predictive Index (API)
  19. 19. Cough-variant asthma Cough-variant asthma presents as dry cough at night. It worsens with exercise (EIA) and nonspecific triggers (cold air). Cough-variant asthma responds to asthma therapy with ICS. Cough-variant asthma is diagnosed with pulmonary function testing (PFTs) with response to bronchodilator. The most common cause of chronic cough in children is cough-variant asthma.
  20. 20. Guidelines National Heart, Lung, and Blood Institute (NHLBI) guidelines for diagnosis and management of asthma Key concepts: - severity dictates therapy - - distinction between intermittent and persistent asthma - - "rule of 2s” - - 4 levels of asthma severity - intermittent; 3 sublevels of persistent - - inhaled corticosteroids (ICS) preferred for all levels of persistent asthma - - use of asthma action plans - - spirometry recommended
  21. 21. Rule of 2s - if symptoms are present for more than 2 days per week or for more than 2 nights per month, asthma categorized as persistent. - Within this category, disease must be classified as mild, moderate, or severe. However, as severity of asthma not constant, must monitor patients for changes; as severity changes, therapy should change too. - The category of “mild intermittent” asthma was eliminated in the 2007 guidelines - now it is just called “intermittent” asthma.
  22. 22. The concepts of “impairment”, “risk”, and “control” were introduced in the 2007 guidelines: - impairment - refers to symptoms - - risk - refers to likelihood that the patient will eventually have exacerbation of asthma and present to emergency department (ED) or hospital, or need course of oral corticosteroids - - control - refers to the level of patient’s asthma control
  23. 23. Classification of asthma severity - impairment domain - daytime and nighttime symptoms (rule of 2's), use of short-acting beta-agonist (SABA), interference with normal activities - - risk domain - number of exacerbations per year (if more than 2, daily controller medication is needed). Increased risk is conferred by parental history of asthma or history of eczema. - Childhood Asthma Control Test (ACT) is validated down to age 4 yr. Adult ACT questionnaire should be used for teenagers (cutoff age is 11 years).
  24. 24. Treatment steps - step 1 - SABA as needed – - step 2 - low-dose ICS monotherapy vs. leukotriene receptor antagonist (LTRA) - - step 3 - low-to-medium dose ICS plus long-acting betaagonist (LABA) - - step 4 - high-dose ICS therapy plus LABA and (if needed) systemic corticosteroids. Omalizumab (Xolair; anti-IgE antibody) is prescribed before placing patient on daily oral corticosteroids.
  25. 25. “Rule of 2s” to determine level of control - daytime symptoms more than 2 days/wk - rescue β2 -agonist use more than 2 times per week - nighttime symptoms more than 2 nights/mo - more than 2 rescue β2-agonist canisters/yr
  26. 26. Step Down or Step Up When to step down therapy? If patient is well-controlled for 3 mo, consider stepping down therapy. When to step up therapy? If the patient is not wellcontrolled, step up therapy and re-evaluate in 2 to 6 wk. If the patient is very poorly controlled, step up therapy 2 steps, consider short course of steroids, and reassess in 2 wk.
  27. 27. When to consider long-term ICS treatment - positive API and more than 3 wheezing episodes in previous 12 mo lasting more than 1 day and affecting sleep - consistent requirement for SABA treatment (more than 2 times/wk, on average, over 1-2 mo); 2 exacerbations in 6 mo requiring oral corticosteroids
  28. 28. Treatmnt
  29. 29. Inhaled corticosteroid Relative binding affinity for glucocorticoid receptor (GR): mometasone = fluticasone > budesonide > triamcinolone. Relative anti-inflammatory potency: mometasone fluticasone > budesonide = beclomethasone triamcinolone. = >
  30. 30. Severe asthma - differential diagnosis and management
  31. 31. Foreign Body Aspiration
  32. 32. Radiographic Signs of Pneumomediastinum Subcutaneous emphysema Thymic sail sign Pneumoprecardium Ring around the artery sign Tubular artery sign Double bronchial wall sign Continuous diaphragm sign Extrapleural sign Air in the pulmonary ligament
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