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Approach To A Child With Asthma

Approach To A Child With Asthma






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    Approach To A Child With Asthma Approach To A Child With Asthma Presentation Transcript

    • APPROACH TO ACHILD WITH ASTHMA By: Dr.S.Krishnapradeep Registrar (Paed),SBSCH,Peradeniya
    • WHAT IS ASTHMA? It is a chronic inflammatory disorder of the airways characterized by an obstruction to airflow, which may be completely or partially reversible with or without specific therapy.
    • COMPONENTS OF ASTHMA1. Airway inflammation2. Bronchial hyper-responsiveness (BHR)3. Bronchospasm
    • Disability-adjusted life year for asthma per 100,000 inhabitants in 2004 DALY = YLL + YLD"Death and DALY estimates for 2004 by cause for WHO Member States: Persons, allages“.World Health Organization. 2002. Retrieved 2009-11-12.
    • EPIDEMIOLOGY 300 million individuals are effected. 15 million disability-adjusted life-years are lost and 250,000 deaths are reported. 150,000 paediatric hospitalizations. Before puberty M:F = 3:1 During adolescence M= F In majority, asthma develops before age 5 years, and in more than half before age 3 years.
    • ETIOLOGY Geneticso Hundreds of genes are associatedo 20p13 is associated with bronchial hyper responsivenesso Risk of transmission greater through mother than father Foodo In 25% triggered by foodo Common foods are peanut, milk, egg and tree nutso Fish-oil 3 fatty acid supplementation has no benefit
    • ETIOLOGY…….. Infectionso Rhinovirus & RSV are the most common causeso Low production of IFN-ß was noted in patients with asthmao Rhinovirus isolated in wheezing infants is the strongest predictor for wheezing after 3rd year of life Pests & petso Dust, house dust mites, furry & feathered pets and endotoxins from gram negative bacteria play a role
    • ETIOLOGY…….. Obesityo ↑ BMI increases the risk Tobacco smokingo Parental smoking odds ratio 1:21 for asthmao Parental smoking causes high BHR at 1 month of age & lower lung function at 6 years Other causeso Paracetamol usage,Rhinitis
    • ETIOLOGY- THE HYGEINEHYPOTHESIS Children reared on farms have a lower incidence of asthma. Exposure to allergenic factors since newborn period encourages tolerance to common aeroallergens. The immune system of the newborn is skewed toward TH2 cytokine generation . Over time, environmental stimuli activate TH1 responses and bring the TH1/TH2 relationship to an appropriate balance. Anderson WJ, Watson L. Asthma and the hygiene hypothesis. N Engl J Med. May 24 2001;344(21):1643-4.
    • PATHOPHYSIOLOGY Interactions between environmental and genetic factors result in airway inflammation Airway inflammation → loss of normal balance between two "opposing" populations of T helper (Th) lymphocytes. Th1 → IL-2 and IFN-α → help cellular defense. Th2 → generates cytokines → mediate allergic inflammation.
    • PATHOPHYSIOLOGY………… Chronic inflammation of the airways → increased BHR → bronchospasm and airway obstruction Airway obstruction → increased resistance to airflow → decreased expiratory flow rates → air trapping and hyperinflation. Hyperinflation → alteration in pulmonary mechanics → increases the work of breathing → ventilation perfusion mismatch
    • CLINICAL FEATURES Wheeze Cougho Chestyo Repetitiveo Nocturnal/early morningo Precipitated by exercise/crying Breathlessness Chest tightness
    • COUGH Cough is an early symptom in childhood asthma which can be overlooked for years if the airway obstruction has not been severe enough to produce wheezing. National guidelines for management of asthma 2007;112
    • GRADING OF ASTHMASTEP DAY SYMPTOMS NIGHT FEV1 & PEF SYMPTOMSMILD ≤ 2times/week ≤ 2times/month FEV1 or PEF<80%INTERMITTENT PEF variability <20%MILD > 2times/week >2times/month FEV1 or PEF<80%PERSISTENT Less than 1time/day More than PEF variability 20- 2times/mo 30%MODERATE 1 time/day > 1 time/week FEV1 or PEF 60-80%PERSISTENT PEF variability >30%SEVERE continuous frequent FEV1 or PEF <60%PERSISTENT PEF variability >30%
    • DIAGNOSIS Primarily clinical Look for key features Consideration & exclusion of alternative diagnoses Expect improvement with bronchodilators If management ineffective -Question the diagnosis Objective tests are difficult to perform
    • CAUSES FOR RECURRENTWHEEZING1. Intra bronchial foreign body2. Recurrent lower respiratory tract infections3. Mediastinal masses & Vascular rings4. Heart failure5. Gastro oesophageal reflux6. H-type tracheo oesophageal fistula7. Immune deficiency8. Loeffler syndrome9. Cystic fibrosis & Ciliary dyskinesia
    • OBJECTIVE TESTS Possible in children over 5 years Variability of Peak expiratory flow (PEF) and Forced expiratory volume in first second (FEV1) Percentage variability=(highest-lowest) × 100 highest
    • OBJECTIVE TESTS PEFo Low than predictedo 20 % change after bronchodilator or exercise FEV1o Low than predictedo Improvement by ≥ 12% after bronchodilatoro Worsening by ≥ 15% after exerciseo AM to PM variation ≥ 20%o FEV1/FVC < 0.8
    • OTHER INVESTIGATIONS CXRo During initial diagnosiso Severe life threatening episode HYPERSENSITIVITY TESTSo RAST & allergic skin testso Not available in SLo Trigger factor to be detected
    • MANAGEMENTGoals of Management Minimal or no symptoms Minimal or no exacerbation Minimal or no need of relievers FEV1 or PEF over 80% of predicted Minimal or no adverse effects from medications Normal activities and rare school absences Optimum growth Minimal effect on family members
    • NON PHARMACOLOGICALMANAGEMENTPrimary prevention Breast feeding Exposure to allergens/infections at early age Avoiding maternal smokingNo clear benefits with…… Avoidance of postnatal exposure Modified infant formula Vit C , fish oil Journal of Paediatrics 2001;139:261-6 Journal of Tropical Paediatrics 2001;47:142-5
    • NON PHARMACOLOGICAL MANAGEMENT…………. Secondary prevention  Avoid identified allergens  Avoid smoking, air pollution  ObesityNo clear benefits with…….. Alternative medicine Generalized dietary restrictions Goats milk New England J medicine 1990;323:502-7 Clin Exp allergy 1999;29;905-11
    • PHARMACOLOGICALMANAGEMENT  Long term management  Management of an acute exacerbation
    • STEPWISE LONG TERMMANAGEMENT STEPS DAILY MEDICATION MILD INTERMITTENT No daily medication MILD PERSISTENT •Low dose inhaled steroids •Sustained release theophylline •Leukotriene receptor antagonists •Ketotifen MODERATE PERSISTENT •Medium dose inhaled steroids OR Low dose inhaled steroids + long acting ß2 agonists SEVERE PERSISTENT •High dose inhaled steroids + long acting ß2 agonists •May need oral steroids
    • STEPWISE LONG TERMMANAGEMENT  Step down theory  Step up theory  Referring steps
    • INHALER DEVICES < 2 years -MDI + Baby haler 2-3years -MDI + Spacer device + face mask 3-5 years- MDI + Spacer device 5-8 years -MDI + Spacer device or DPI > 8 years- MDI or DPI
    • EVIDENCE BASED PRACTICE Combination inhalers- steroid and long acting beta agonists The new inhaled steroids - CICLESONIDE and MOMETASONE FUROATE The extra fine HYDROFLUOROALKANE BECLOMEHASONE Leukotiriene antagonists- MONTELUKAST Mononoclonal antibodies against IgE - OMALIZUMAB Immunotherapy Perera B J C .Paediatric respirology 2010 Perera B J C.Modern reinements in prophylaxis of wheezing 2011
    • SEVERITY OF ACUTE EXACERBATIONSYMPTOMS MILD MODERATE SEVERECONSCIOUSNES No No Confused/drowsySRECESSIONS No Minimal Moderate/severeSpO2 >94% 94-90% <90%SPEECH sentences phrases Words/unablePULSE <2yr = <110 <2yr = 110-130 <2yr= >130 >2yr = <100 >2yr = 100-120 >2yr= >120RESPIRATORY <2yr= <50 <2yr= 50-60 <2yr= >60RATE >2yr= <40 >2yr= 40-50 >2yr= >50CYANOSIS absent absent presentWHEEZE variable Moderately loud Often quietPEFR >60% <50% <40%
    • MANAGEMENT OF SEVERE ATTACK Observe in the acute side/HDU High flow oxygen Nebulise with Salbutamol• every 15 mins or continuous Nebulise with Ipratropium• initially every 20 mins, then 6 hourly If no response exclude pneumothorax, heart failure Steroids• effects appear after 4 hours
    • MANAGEMENT OF SEVERE ATTACK….. If deteriorating, exhausted or confused admit to ICU IV Fluids to correct hydration IV Aminophyllineo bolus 5-10 mg/kg if was not on theophylline within 24 hours, maintenance 1mg/kg/hro can cause arrythmia, seizures, vomiting IV Salbutamolo bolus 5µg/kg over 10 mins, maintenance 0.5-1µg/kg/mino can cause hypokalemia
    • MANAGEMENT OF SEVEREATTACK….. IV Magnesium sulphateo Bolus 40-100 mg/kg for 20mins,maintenance 30mg/kg/hro Causes arrythmia, hypotension, vomiting Indications for mechanical ventilationo Worsening life threatening asthmao Severe exhaustiono Impending respiratory failureo PCO2>60mmHg, PO2<50mmHgo Worsening metabolic acidosis
    • EVIDENCE BASED PRACTICE In acute asthma MDI+spacer is equally effective as nebulisers. Addition of inhaled anti-cholinergics to beta agonists has proven benefit IV Aminophylline is useful than IV Salbutamol The place of IV Magnesium Sulphate is still not well established, but several studies show it to be beneficial. Perera B J C .Paediatric respirology 2010 Perera B J C.Modern reinements in prophylaxis of wheezing 2011
    • SUMMARY Asthma is a Multifactorial disease Correct diagnosis is the cornerstone in management Choosing the best drug combination, best mode of administration and correct technique will reduce the morbidity. Death due to Asthma is definitely preventable with the timely diagnosis and management of the life threatening episode