by dr hisham alrabty pefdiatrics consultant and pulmonologist in tripoli children hospital libya

2. By Dr Hisham Alrabty
Pediatric consultant and pulmonologist
Tripoli teaching children hospital

3. There is no global consensus concerned
asthma diagnosis in children.
There is no a single test diagnostic to
asthma in children whatever was blood
,skin or imaging(radiological).
Asthma can be diagnosed in children aged
less than 2 years with exclusion of other
causes of recurrent wheeze like GERD.
Facts:

4. To diagnose asthma in children
you should pass by next steps:
Good history.
Clinical examination.
Some investigational procedures(peak
flow metry).

5. Personal history of asthma or allergy.
Recurrent wheeze and shortness of breath.
Bronchodilator use as nebulizer or syrup.
History of previous admission because of wheeze.
History of chronic cough certainly at night.
History of breathlessness on exercise.
Patient has eczema or AR.
Symptoms relieved by bronchodilators.
Symptoms exacerbated by cold last more than 10 days.
Symptoms got worse by either animal
dander,emotion,dust,smoke,drugs,dust mite.
from gina asthma booklet
History:

6. Signs of respiratory distress:
tachypnea.
Wheeze.
Flaring alae nasii.
Cyanosis.
Chest indrawings.
Decreased air entry.
Rhonchi +/- rales.
Silent chest.
Hypoxia.
Clinical examination:

7. **By detailed history and clinical
evaluation we could diagnose
asthma in children in more than
95% of cases, the remaining 5% of
cases we could seek help of some
investigation/s .

8. It should not be done on routine basis for
each asthma episode only when we suspect
patient could have complication like
pneumothorax.
Chest x ray:
CBC:
High IgE and eosinophilia indicate the child is
allergic.

9. Hyper inflated chest

10. Results of pulmonary function testing are not reliable
in patients younger than 5 years.
In young children (3-6 y) and older children who are
unable to perform the conventional spirometry
maneuver, newer techniques, such as measurement
of airway resistance using impulse oscillometry
system, are used.
By which measurement of airway resistance before
and after a dose of inhaled bronchodilator may help
to diagnose bronchodilator-responsive airway
obstruction.
Pulmonary Function Tests:

11. impulse oscillometry system

12. In a typical case, an obstructive defect is present in
the form of normal forced vital capacity (FVC),
reduced forced expiratory volume in 1 second (FEV1),
and reduced forced expiratory flow more than 25-75%
of the FVC (FEF 25-75).
Documentation of reversibility of airway obstruction
after bronchodilator therapy is central to the
definition of asthma.
FEF 25-75 is a sensitive indicator of obstruction and
may be the only abnormality in a child with mild
disease.
Spirometry:

13. Patients with chronic persistent asthma
may have hyperinflation, as evidenced by an
increased total lung capacity (TLC) at
Plethysmography.
Increased residual volume (RV) and
functional residual capacity (FRC) with
normal TLC suggests air trapping.
Airway resistance is increased when
significant obstruction is present.
Plethysmography:

14. Plethysmography

15. It could be measured before and after dose
of inhaled bronchodilator and if there were
improvement by 15% , it is asthma.
It can be used as monitor for asthma
control.
Peak expiratory flow merty:

16. In patient has history of exercise induced symptoms this
test could be done to establish diagnosis of asthma.
Done in kids age more than 6 yrs.
Baseline spirometry followed by exercise on treadmill or
bicycle till heart rate reaches 60% of predicted maximum
under monitor of ECG and pulse oxymeter.
Then spirometry done at 3.5,10,15 and 20 min interval.
Then assess reversibility of airway obstruction by
neb.bronchodilator.
Exercise challenge:

17. Either by use of inhaled methacholine or
histamine to induce wheeze in suspected
patient and they should be done by
experienced personnel in specialized labs.
It is neither applicable nor practical
certainly in children.
Positive response is 20% fall in FEV1.
Asthma provocative tests:

18. Either specific igE level in blood or skin
brick test both are done to recognize
the allergen/s patient is sensitized to,
in patients do not respond to
maximum treatment of chromic
asthma, both are not diagnostic.
Allergen detecting tests:

19. Measuring the fraction of exhaled nitric oxide
(FeNO) has proved useful as a noninvasive
marker of airway inflammation, in order to
guide adjustment of the dose of inhaled
corticosteroids.
in some patients, the FeNO rose before
significant exacerbations of the asthma.
Due to the high cost of equipment, FeNO
measurement is used primarily as a research
tool at present.
Fraction of Exhaled Nitric Oxide Testing:

20. Measuring the level of interleukin-5 in
exhaled breath condensate is a possible way
of titrating asthma progress, according to
one study.
In a longitudinal study of 40 asthmatic
children aged 6-16 years, asthma control
score and level of interleukin-5 were
significant predictors of an asthma
exacerbation..
Measuring the level of interleukin-5:

21. It will reveal infiltration with inflammatory cells,
narrowing of airway Lumina, bronchial and
bronchiolar epithelial denudation and mucus plugs.
Thickened basement membrane and airway
remodeling in form of severe subepithelial fibrosis
and smooth muscle hypertrophy or hyperplasia in
severe cases of chronic asthma.
Histological findings:

22. Like chest CT,
MRI, bronchoscopy, gatrograffin
study, sweat test, 24 ph
monitoring… all done to exclude
other causes of recurrent wheeze.
Other investigations:

23. Major criteria:
Parent with asthma.
Physician diagnosed atopic dermatitis.
Minor criteria:
Physician diagnosed allergic rhinitis.
Eosinophilia (>4%).
Wheezing apart from colds.
If the child has more than 4 episodes of wheezing per
year lasting more than 1 day affecting sleep with one
MAJOR or two MINOR criteria.
It is asthma upto this index…
Asthma Predictive Index:

24. Conclusively asthma
is still clinical based
diagnosis.