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Asthma 2009: A Quick Primer


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Asthma 2009: A Quick Primer

  1. 1. Pediatric Asthma 101 : A Quick Primer Steve Marchbank, MD [email_address]
  2. 2. I. What is asthma? <ul><li>Chronic airway inflammation </li></ul><ul><li>Reversible airway constriction/airflow limitation </li></ul><ul><li>Airway hyperresponsiveness </li></ul><ul><li>Recurring symptoms over time, usually from a variety of triggers </li></ul>
  3. 3. OK… but what IS asthma? <ul><li>The first thing to remember (in pediatric or adult asthma) is that asthma can wear many ‘hats’ </li></ul><ul><li>and remember that…. Not everything that ‘wheezes’ is asthma, and not every asthmatic is ‘wheezing’ </li></ul>
  4. 4. Asthma Pathophysiology: 2 basic components <ul><li>Inflammation: Multiple contributing mechanisms and pathways; inflammation leads to tendency for bronchospasm & excessive mucous production </li></ul><ul><li>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 </li></ul>
  5. 5. So… what MIGHT be asthma? <ul><li>Recurrent cough (dry or loose) </li></ul><ul><li>Wheezing </li></ul><ul><li>Shortness of breath, chest tightness </li></ul><ul><li>Exercise intolerance </li></ul><ul><li>Sleep disturbance; cough at night </li></ul><ul><li>Colds ‘go to the chest’, and/or always last >10 days </li></ul><ul><li>‘ recurrent croup’ </li></ul><ul><li>constant throat-clearing </li></ul>
  6. 6. Diagnosis of Asthma <ul><li>History- pattern and recurrence of symptoms </li></ul><ul><li>Physical examination </li></ul><ul><li>Family History </li></ul><ul><li>Measurement/estimation of lung function (as age appropriate) </li></ul><ul><li>Evaluation of allergies/allergic status </li></ul><ul><li>Exclude alternative diagnoses </li></ul>
  7. 7. The “Three R’s” of asthma diagnosis <ul><li>Recurrence : symptoms recur over time </li></ul><ul><li>Reactivity : the symptoms brought on by a trigger </li></ul><ul><li>Responsive : symptoms ↓ in response to bronchodilators and/or anti-inflammatory agents (i.e. ICS) </li></ul>
  8. 8. What may only LOOK like pediatric asthma? (differential diagnoses) <ul><li>Allergic rhinitis/sinusitis </li></ul><ul><li>Large airway obstruction: tracheal FB, vocal cord dysfunction, vascular rings, laryngotracheomalacia, laryngeal webs, extrinsic (lymphadenopathy/tumor) </li></ul><ul><li>Small airway obstruction: viral bronchiolitis, obliterative bronchiolitis, CF, BPD (bronchopulmonary dysplasia), heart disease </li></ul><ul><li>Vocal cord dysfunction </li></ul><ul><li>Other: recurrent cough (non-asthmatic), chronic aspiration and/or severe GERD </li></ul>
  9. 9. Asthma Triggers <ul><li>Upper respiratory infection </li></ul><ul><li>Allergens: animal dander, dust mites, pollen, molds </li></ul><ul><li>Exercise </li></ul><ul><li>Smoke - cigarette, other </li></ul><ul><li>Temperature/humidity changes </li></ul><ul><li>Emotional stress- anxiety, fatigue, laughter, crying </li></ul><ul><li>Other: drugs, chemicals </li></ul>
  10. 10. How common is asthma? <ul><li>If neither parent has asthma, the incidence of asthma in the average child is 7-10% </li></ul><ul><li>~20% if one parent has asthma </li></ul><ul><li>~60% if both parents have asthma </li></ul><ul><li>Significant number of infants/toddlers hospitalized for RSV bronchiolitis go on to have asthma (somewhere between 30-50%) </li></ul>
  11. 11. II. Asthma Classification <ul><li>The most recent NAEPP (National Asthma Education & Prevention Program) Expert Panel Report 3 (2004) classifies asthma into the following: </li></ul><ul><ul><li>Mild intermittent </li></ul></ul><ul><ul><li>Mild persistent </li></ul></ul><ul><ul><li>Moderate Persistent </li></ul></ul><ul><ul><li>Severe Persistent </li></ul></ul><ul><li>Can be found online at: </li></ul>
  12. 12. The Big Picture….. Is asthma Intermittent or Persistent? <ul><li>The take-home message (in my opinion) of the most recent Expert Panel Report, and for the typical primary care provider is this: </li></ul><ul><ul><li>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 </li></ul></ul>
  13. 13. Intermittent vs. Persistent <ul><li>Intermittent Asthma </li></ul><ul><ul><li>symptoms  2 times/week </li></ul></ul><ul><ul><li>nighttime symptoms  2 nights/month </li></ul></ul><ul><ul><li>FEV 1 /PEF  80% predicted </li></ul></ul><ul><ul><li>PEF variability < 20% </li></ul></ul><ul><li>Persistent Asthma </li></ul><ul><ul><li>symptoms > 2 times/week </li></ul></ul><ul><ul><li>nighttime symptoms > 2 nights/month </li></ul></ul><ul><ul><li>FEV 1 /PEF variable (dependent on sub-type, mild/mod/severe) </li></ul></ul><ul><ul><li>PEF variability > 20% </li></ul></ul>
  14. 14. Why does the classification matter? <ul><li>The classification - intermittent or persistent - leads us to the proper management and treatment of asthma </li></ul><ul><li>The basics: </li></ul><ul><ul><li>intermittent asthma = bronchodilators as needed </li></ul></ul><ul><ul><li>persistent asthma = daily anti-inflammatory + bronchodilators as needed </li></ul></ul>
  15. 15. If you only remember ONE thing from this presentation… <ul><li>1. Persistent asthma = Daily , preventative anti-inflammatory asthma medication </li></ul><ul><li>2. The Gold-Standard for anti-inflammatory asthma medication is: inhaled corticosteroid </li></ul>
  16. 16. Summary <ul><li>Asthma is either intermittent OR persistent. Persistent asthma should be treated with daily anti-inflammatory medication, the gold standard for which is inhaled corticosteroid </li></ul>