Paediatric Asthma notes and management

1. Pediatric Asthma
mr. okumu l
lazarusokumu@gmail.com
jkuat -2023

2. • Introduction
• Asthma is a chronic inflammatory disease of the airways,
characterized by recurrent episodes of airflow obstruction resulting
from edema, bronchospasm, and increased mucus production.
• Commonly associated with seasonal allergies (allergic rhinitis) and
eczema (atopic dermatitis), these three conditions form what is
known as the atopic triad.

3. • Patients who have asthma may experience a range of respiratory
symptoms, such as wheezing, shortness of breath, cough, and chest
tightness.
• There is a wide range in the frequency and severity of the symptoms,
but uncontrolled asthma and acute exacerbations can lead to
respiratory failure and death.

4. • Etiology
• The exact etiology of asthma remains unclear and appears to be
multifactorial.
• Both genetic and environmental factors seem to contribute. Positive
family history is a risk factor for asthma but is neither necessary nor
sufficient for the development of the disease.
• Multiple environmental exposures, both prenatal and during
childhood, are associated with the development of asthma.

5. • One of the most well-studied risk factors during the prenatal period is
maternal smoking, which does appear to increase the risk of
wheezing in childhood and likely increases risk for the development
of asthma.
• Other proposed prenatal risk factors include maternal diet and
nutrition, stress, use of antibiotics, and delivery via Cesarean section,
though studies regarding these have been less conclusive.

6. • Many childhood exposures have also been the target of research.
Tobacco smoke exposure appears to increase the risk of development
of asthma and is also a known trigger for exacerbations in those
already diagnosed with the disease.
• Other risk factors include animal, mite, mold, or other allergens, as
well as air pollutants.

7. • The role of many other proposed risk factors remains unclear, and studies are often
inconclusive or contradictory.
• The influence of breastfeeding and avoidance of nutritional allergens during
breastfeeding is controversial.
• Family size and structure have been proposed as a risk factor; an increase in family size
may be protective, though birth order seems less likely to be contributory.
• Low socioeconomic status has correlations with increased morbidity, though the
increased prevalence is a topic of debate.
• Viral lower respiratory infections and the use of antibiotics have been associated with
early childhood wheezing, but their role in causing persistent asthma is less clear.
• There has been a particular association with Respiratory syncytial virus (RSV) and
asthma, but not causation.
• Viral respiratory tract infections are known to trigger existent asthma.

8. • Epidemiology
• There are an estimated 300 million people who have asthma worldwide, with a significant
geographic variation of prevalence, severity, and mortality.
• According to the CDC, 8.4% (or over 6 million) of children in the United States have asthma.
• Asthma is a chronic disease that has a high morbidity rate and a comparatively low mortality rate
overall.
• It is the leading cause of chronic disease and missed school days in children.
• While asthma classically begins during childhood, and the incidence and prevalence are higher
during this period, it can occur at any time throughout life.
• Before puberty, the rate of asthma incidence, prevalence, and hospitalizations is higher in boys
than girls, though this reverses during adolescence.
• Severe asthma affects 5% to 15% of this population in the U.S. and world, with males being more
likely to have severe asthma in childhood (66%) and adolescence (57%).
• Studies have shown an increased in prevalence, rate of emergency department visits and
hospitalizations, and mortality in African American and Hispanic populations in the United States.

9. • Pathophysiology
• The pathophysiology of asthma involves the infiltration of inflammatory
cells, including neutrophils, eosinophils, and lymphocytes into the airway,
activation of mast cells, and damage to the epithelial cells.
• These inflammatory responses lead to the classic features of airway
swelling, increased mucus production, and bronchial muscle dysfunction,
which produce airway flow limitation and asthma symptoms.
• Remodeling, a term used to describe persistent changes in the airway
structure, can occur, ultimately leading to fibrosis, mucus hypersecretion,
epithelial cell injury, smooth muscle hypertrophy, and angiogenesis.

10. • History and Physical
• Classic symptoms of asthma include cough, wheezing, chest tightness, and
shortness of breath. Symptoms are often episodic and can become
triggered by numerous factors, including upper respiratory tract infections,
exercise, exposure to allergens, and airway irritants such as tobacco smoke.
They may also be worse at night.
• As previously discussed, there exists a classic triad of asthma, eczema, and
allergies, and it is worthwhile to elicit a personal or family history of these
components as young children may not have a formal diagnosis. In
children, the diagnosis of RAD (reactive airway disease) or recurrent WARIs
(wheezing associated respiratory infections) often precede a formal
diagnosis of asthma.

11. • During acute exacerbations, children may also have significantly increased
work of breathing or audible wheezing, which may be appreciated by
caregivers and prompt presentation for further evaluation. Information to
ascertain during these acute visits include:
• What interventions have taken place before arrival, e.g., nebulizer
treatments or rescue inhaler use
• If the child has been taking other asthma medications as prescribed,
• If the child has ever been hospitalized for asthma
• If the child has ever needed intubationadmission was required
• If the child has taken oral steroids for asthma exacerbations and if so, when

12. • Physical Examination
• The physical examination should focus on three main areas, which
will help to develop your differential diagnosis and identify co-morbid
conditions. These are general appearance, including state of nutrition
and body habitus, signs of allergic disease, and signs of respiratory
dysfunction.
• The physical examination may be completely normal, especially in a
child with well-controlled asthma who does not have an acute
exacerbation. Children may have increased nasal secretion, mucosal
swelling, or nasal polyps, consistent with allergic rhinitis. The skin
exam may reveal atopic dermatitis.

13. • Cough, prolonged expiratory phase, and wheezing, which may be
expiratory or inspiratory, are common respiratory exam findings in
asthmatic children with acute exacerbation. Children may experience
varying degrees of tachypnea and dyspnea. There may also be signs of
increased work of breathing (“belly breathing,” use of accessory
muscles, including subcostal, intercostal, or supraclavicular
retractions, nasal flaring), tripod positioning, inability to speak in full
sentences, or grunting. Of note, a child who was previously noted to
have significantly increased work of breathing by caregivers, but who
has now “tired out,” appears to be breathing at a normal rate, or who
becomes lethargic, may have impending respiratory failure.

14. • In a child with significant airway obstruction, there may come a point
at which wheezing may no longer be present. This absence of
wheezing indicates that the child is moving a minimal volume of air. A
child who develops altered mental status, appears truly lethargic,
becomes unresponsive, is cyanotic, or has a “silent chest” has signs of
impending respiratory failure and may rapidly decompensate to
respiratory arrest.
• Features such as digital clubbing, barrel chest, localized wheezing,
urticarial rash, or stridor may suggest other diagnoses or comorbid
conditions.

15. • Making the Diagnosis of Asthma
• A diagnosis of asthma should be a consideration when any of the
following indicators are present:
• Recurrent episodes of cough, wheezing, difficulty breathing, or
chest tightness
• Symptoms that occur at night or disrupt sleep
• Symptoms that appear to be triggered by upper respiratory tract
infections, exercise, exposure to animals, dust, mold, tobacco smoke,
aerosols, changes in weather, stress, strong emotional expression, or
menses

16. • In children who are at least five years of age and adults, pre- and
post-bronchodilator spirometry can help confirm the diagnosis.
• Baseline spirometry provides the following information FVC (Forced
vital capacity), FEV1 ( forced expiratory volume at 1 second),
FEV1/FVC, and F25-75 (the difference between the forced expiratory
volume at 25% and 75%).
• Assessment of the bronchodilator response begins with the baseline
spirometry followed by the administration of a short-acting
bronchodilator (most commonly, albuterol 2 to 4 puffs in adults and
older children).

17. • According to the ATS/ERS guidelines, reversibility is deemed
significant when there is a greater than 12 % improvement from
baseline or an increase of over 200 ml in FEV1.
• Peak flow meters are for monitoring asthma. A decline of 20 to 30%
or more from the patient's personal best may be indicative of an
impending or current exacerbation. A peak flow of less than 40% of
their best is indicative of severe exacerbation.

18. • Acute Exacerbation
• Children who present for an acute exacerbation should have a full set
of vitals collected. Overall clinical appearance should determine
whether they should escalate to a higher level of care.
• Asthma exacerbations are diagnosed clinically and do not require
laboratory or imaging studies routinely; it is appropriate to begin
treatment.

19. • It is appropriate to consider a chest X-ray in the following setting:
• First wheezing episode
• Asymmetric lung findings
• Unexplained fever
• Symptoms continue to worsen despite treatment
• The patient is critically ill

20. • A chest x-ray may reveal hyperinflated lungs and interstitial
prominence. If there is any focal consolidation, the patient should
also receive treatment for pneumonia.
• Other laboratory studies, including ABG, may also be considered in
patients if symptoms continue to worsen despite treatment or the
patient is critically ill; however, initial therapy with nebulizers should
not be delayed.

21. • Treatment / Management
• Non-pharmacologic Management
• Avoiding exposure to environmental factors that may provoke asthma
personal or second-hand tobacco smoke, food or drug triggers, and
pollutants and irritants is vital.
• Vitamin D deficiency has been noted to be highly prevalent in
patients with atopic disease.

22. • There has been evidence that vitamin D deficiency is contributory to
the disruption of the immune system and the worsening of reactive
airways.
• screening and appropriate supplementation may lead to an
improvement in atopic disease, including asthma.

23. • STEP Therapy for Asthma
• The preferred treatment option for intermittent asthma, as well as for
quick relief of asthma symptoms and the prevention of exercise-
induced bronchoconstriction is a short-acting beta-2 agonist. This is
referred to as STEP 1.
• Albuterol and levalbuterol are examples of short-acting
bronchodilators. They have a quick onset of action, within 5 to 15
minutes, and a duration of action of 4 to 6 hours.
• Their administration is most often by nebulizer or inhaler.

24. • STEPS 2-6 refer to options for persistent asthma. In each of these
steps, inhaled corticosteroids are a component of the preferred
treatment regimen.
• The preferred treatment for step 2 is a low-dose inhaled
corticosteroid (ICS).
• Montelukast can be an alternative. Montelukast is a leukotriene
receptor antagonist available in 4 mg granules, or 4 mg and 5 mg
chewable tablets, as well as in a 10 mg tablet formulation. Single
evening dosing prescribing is by age and FDA approved for asthma
control from 12 months of age.

25. • The preferred option for step 3 is a medium dose ICS in the 0 to 4-
year-old children.
• In the 5 to 11 year age group, the preferred option is either a
medium-dose ICS or a combination ICS + long-acting beta-agonist
(LABA) or leukotriene receptor antagonist (LTRA).
• For those ages 12 years through adulthood, the preferred choice is a
low dose of ICS + LABA or medium-dose ICS.

26. • There was a black-box warning on LABAs due to concerns about
increasing deaths in patients taking LABAs; however, according to
more recent studies, LABAs demonstrated safety when combined
with inhaled corticosteroids.
• LABA monotherapy is indeed associated with an increase in asthma-
related mortality and serious adverse events.
• Step 4 in the 0 to 4-year-old age range is a medium dose ICS + either a
LABA or montelukast.
• In ages, 5 to 11 years and 12 and above, a medium dose ICS + LABA is
the preferred option.

27. • Step 5 for 0-4 years is high dose ICS + either LABA or montelukast; in
5-11 years and 12 and above, a high dose ICS + LABA.
• EPR-3 also recommends consideration of omalizumab for ages 12
and above. Since the publication of these guidelines, Omalizumab has
received FDA approval for ages 6 years and above.
• Omalizumab is a monoclonal antibody indicated for moderate to
severe persistent asthma with objective evidence of perennial
aeroallergen sensitivity and inadequate control with ICS.

28. • Step 6 for ages 0-4 years is a high dose ICS + either LABA or
montelukast or oral corticosteroids; for ages 5-11 years – high dose
ICS + LABA + oral systemic corticosteroid; and for ages 12 and up, high
dose ICS + LABA + oral corticosteroid are preferred.
• Omalizumab may be a consideration for appropriate patients with
allergy.

29. • Theophylline is a medication that may be an alternative medication in
Steps 2 through 6. However, its use requires caution due to its narrow
therapeutic range and potential side effects, including diuresis,
tremors, and headaches.

30. • Asthma action plans are recommended for all patients with asthma.
These are individualized to and developed in partnership with each
patient.
• They include detailed directions on how to manage asthma with
instructions for when the patient is well, beginning to feel symptoms,
and in an acute exacerbation that necessitates medical evaluation.

31. • Management of Acute Exacerbations
• Initial management of a child who presents to the emergency department
with an acute asthma exacerbation includes bronchodilators and steroids.
• Albuterol:
• 2.5 - 5 mg of nebulized albuterol should be given as initial management
and can be re-dosed every 20 minutes.
• If the child is 5 years or older, 5 mg is the recommended dose. If a child is
experiencing significant respiratory distress and is declining between doses,
it may be re-dosed more frequently, or continuous nebulization of
albuterol may be required.

32. • Ipratropium:
• Dosing of 250 to 500 mcg of ipratropium should be co-administered with
albuterol for three doses in moderate to severe exacerbations.
• Corticosteroids:
• Oral and IV steroids have been demonstrated to have equivalent potency in
treating acute asthma exacerbations.
• Patients should be given prednisolone PO or methylprednisolone IV 1 to 2
mg/kg/day or dexamethasone 0.6 mg/kg PO or IV depending on their level
of respiratory distress and ability to swallow.
• Dexamethasone has been shown non-inferior to a short course of
prednisone or prednisolone for an acute exacerbation.

33. • Magnesium sulfate:
• If the child continues to experience respiratory distress, they should
receive magnesium sulfate at a dose of 50 mg/kg (up to 2 to 4 g) over
15 to 30 minutes.
• In exacerbations that are refractory to the above, epinephrine (1 per
1000 concentration) at a dose of 0.01 mg/kg or terbutaline at a dose
of 0.01 mg/kg, should be considered. These also have beta-agonist
properties and thus promote bronchodilation.

34. • Supplemental oxygen can be applied to maintain oxygen saturation
above 90 to 92%, and heliox can be considered to aid in delivering
oxygen to lower airways.
• If patients have been treated with all of the above and still are
experiencing respiratory distress, non-invasive positive pressure
ventilation should commence as it may alleviate muscle fatigue and
assist in maximizing inspiration.
• Intubation should be avoided in the asthmatic patient as there are
several associated risks.

35. • Intubation may aggravate bronchospasm, induce laryngospasm, and
increase the risk of barotrauma.
• Ketamine (at a dose of 1 to 2 mg/kg) is the preferred induction agent
due to bronchodilator effects; it is also unlikely to cause hypotension.
• If intubated, asthmatic patients may require deep sedation or
paralysis.

36. • Differential Diagnosis
• U pper Airway Diseases
• Allergic rhinitis and sinusitis
• Large Airway Obstruction
• Foreign body aspiration
• Vascular ring or laryngeal webs
• Laryngomalacia
• Tracheomalacia
• Lymphadenopathy
• Mass
• Epiglottitis

37. • Small Airway Obstruction
• Asthma
• Bronchiolitis/wheezing-associated respiratory infections
• Cystic fibrosis
• Bronchopulmonary dysplasia
• Cardiac disease

38. • Other Causes
• Congestive heart failure
• Gastroesophageal reflux disease
• Anaphylaxis
• Angioedema
• Chronic obstructive pulmonary disease(more likely in adults)
• Pulmonary embolism (more likely in adults)

39. ANY QUESTIONS ???
END
WE MADE IT !!