Cme regarding peads asthma

1. BRONCHIAL ASTHMA
AND
STATUS ATHMATICUS
MUNIRAH
FARHANIM
SUPERVISOR: DR KENT

2. OUTLINE
• EPIDEMIOLOGY
• DEFINITION
• WHEN TO DIAGNOSE ASTHMA IN CHILDREN
• MANAGEMENT OF CHRONIC ASTHMA
• MANAGEMENT OF ACUTE ASTHMA
• ASTHMA EDUCATION

3. DEFINITION
• Chronic airway inflammation leading to increase airway
responsiveness that leads to:
- recurrent episodes of wheezing
- shortness of breath
- chest tightness
- cough
• Variable airflow obstruction that is often reversible either
spontaneously or with treatment
• >20% improvement of Peak Expiratory Flow Rate (PEFR) in response
to bronchodilator

4. When to diagnose asthma in children?
• A diagnosis of asthma is largely based on symptoms pattern
combined with clinical history and physical findings. Presence of
atopy, or strong family history of asthma may be predictive.
• However, if absence these conditions does not exclude asthma

5. CLINICAL HISTORY PHYSICAL EXAMINATIONS
Current symptoms
Pattern of symptoms
Precipitating factors
Present of treatment
Previous hospital admission
Typical exacerbations
Impact on life style
History of atopy
Response to prior treatment
Prolonged URTI symptoms
Family history
SIGNS OF CHRONIC ILLNESS :
Harrison’s sulcus
Hyperinflated chest
Eczema / dry skin
Hypertrophied turbinates
SIGNS IN ACUTE
EXACERBATION :
Tachypnea
Wheeze, rhonchi
Hyperinflated chest
Accessory muscles usage
Cyanosis
Drowsiness
Tachycardia

6. ECZEMA
INCREASE AP
DIAMETER
HARRISON’S
SULCUS
HYPERINFLAT
ED LUNGS

7. PRECIPITATING FACTOR ATOPY
 VIRAL INFECTION
 ALLERGENS EXPOSURE
 SMOKE
 DUST
 FUR
 COLD / HOT WEATHER
 COLD DRINKS
 EMOTIONS
 EXERCISE
 ECZEMA
 ALLERGIC RHINITIS
 CONJUNCTIVITIS

8. The possibility of those with negative index not becoming
asthmatic by 6 years old was 95% whereas those with a
positive index have a 65% chance of becoming asthmatic by 6
years old

9. EPISODIC WHEEZERS
(viral induced wheeze)
MULTIPLE TRIGGER
WHEEZERS
Children who only
wheeze with viral
infections and are well in
between of episodes
Children who have
discrete exacerbations
and also symptoms in
between these episodes

10. THINK OF OTHER DIAGNOSIS IF:
• Early presentation
• Failure to thrive
• Focal lung pathology/ persistent lung signs
• Cardiovascular signs
• Vomiting or regurgitation
• Chronic wet cough
• Not responding to anti-asthma medication
• Clubbing, cyanosis

11. COMMON DIFFERENTIAL DIAGNOSIS
• Chronic Lung Disease (CLD) of infancy or BPD
• Recurrent aspiration pneumonia (Gastro Esophageal Reflux Disease
(GERD), swallowing incoordination)
• Tuberculosis
• Bronchiectasis
• Immunodeficiency

12. NEWLY DIAGNOSED
ASTHMA

15. ASTHMA CONTROL

18. REMOVAL OF CARPET IN THE
HOUSE
GET RID OF CATS & ETC
FREQUENT LAUNDERING OF
BEDDING, CURTAINS WITH HOT
WATER
STOP SMOKING
AVOIDANCE OF ANY SMOKE
EXERCISE OR ACTIVITY SHOULD
NOT BE LIMITED
BUT TAKING B2 AGONIST PRIOR
TO STRENOUS EXERCISED WILL
HELP
PREVENTION

19. TREATMENT OF ASTHMA
LONG TERM GOALS
To achieve good control of symptoms
and maintain normal activity levels
To minimize future risk of exacerbation,
fixed airflow limitations and side effect

20. Controller : used for regular maintenance treatment,
reduce airway inflammation, control symptoms and
reduce risks of exacerbation
Reliever : for relief during worsening
asthma/exacerbation, also used for short term
prevention of EIA
Add on therapy in patients with severe asthma :
persistent symptoms despite optimize treatment
with high dose controller meds

21. RELIEVER
- to relieve bronchospasm and improve
symptoms
1. Beta 2 agonist
- Most effective bronchodilators
- Therapeutic effect felt within few minutes of inhalation
- Side effect : tremor, tachycardia
- Eg
• Salbutamol (ventolin)
• Terbutaline (bricanyl)
• Fenoterol (berotec)
• Salmeterol (serevent)

22. 2. Anticholinergic drug
- Longer duration of action
- Few side effects
- Eg : ipratropium bromide (atrovent)
3. Methyxanthines
- Narrow therapeutic windows
- Eg :
• Neulin SR
• Euphylline

23. RELIEVER

24. 1. Corticosteroid
- Main prophylactic drug
-oral/inhalation
-Eg
Beclomethasone diproprionate
Budesonide
2. Sodium chromoglycate
-No significant side effect
CONTROLLER – anti inflammatory
- to treat airway inflammation and bronchial
hyperresponsiveness, to prevent attacks

25. PREVENTER

29. CONTROL BASED ASTHMA MANAGEMENT CYCLE
ASSESS
ADJUST
TTEATMENT
REVIEW
RESPONSE
- Diagnosis
- Symptoms control & risk factor
- Inhaler technique and adherence
- Patient preference
- Asthma medications
- Non pharmacological strategies
- Treat modifiable risk factors
- Symptoms
- Exacerbations
- Side effect
- Patient satisfaction
- Lung function

30. STEPWISE APPROACH TO CONTROL SYMPTOMS
& MINIMIZE FUTURE RISK

31. DAYTIME SX
NOCTURNAL SX
EXERCISED INDUCED SX
NEED FOR RELIEVER
ANY VISIT TO ED OR
CLINIC FOR
NEBULISATION?
ACCESS THE
TECHNIQUE USE OF
MDI / EASYHALER
ANY ABSENCE FROM
SCHOOL BECAUSE OF
ASTHMA?
EVERY CLINIC VISIT, WHAT
SHOULD WE ASK ?
ANY SIDE EFFECTS
FROM
MEDICATIONS?

32. Review treatment
every 3 months and if
control sustained for
at least 4-6 months ,
consider gradual
treatment reduction
Access patient after 1
month of initiation of
treatment and if
control is not
adequate, consider
step up after looking
into factors
Consider stepping up if
uncontrolled
symptoms/exacerbation
s (check inhaler
technique, adherence
first )
Consider stepping down
if symptoms controlled
for 3months & low risk
for exacerbations
(stopping ICS is not
advised)

33. Cessation of smoking
Physical activity
Avoid occupational exposure
Avoid medications that make
asthma worse
NON PHARMACOLOGICAL
INTERVENTIONS

34. Acute Exacerbation
of Bronchial Asthma

35. Assessment of severity (initial acute
assessment)
Diagnosis
- Symptoms : cough, wheezing, breathlessness, pneumonia
Triggers
- food, weather, exercise, infection, emotion, drugs,
aeroallergens
Severity
- RR, colour, respiratory effort, conscious level

37. Status asthmaticus/acute severe asthma
• Life-threatening
asthma
• Medical emergency
• Poorly responsive to
standard therapeutic
measures
Characterized by:
- Hypoxemia
- Hypercarbia
- Secondary
respiratory
failure
Risk of acute respiratory failure  death

38. Criteria for admission
• Failure to respond to standard home treatment
• Failure of those mild/moderate acute asthma to respond to
nebulized β2-agonist
• Relapsed within 4 hours of nebulized β2-agonist
• Severe acute asthma

43. Asthma
education

48. Mechanism of asthma medications
Reliever Preventer
Use when needed
• Use to relieve airway
constriction.
• Improves acute symptoms of
asthma attacks

49. WHEN TO USE RELIEVER

50. Possible side effects of preventers & how to minimize them
(fluticasone/ budesonide)
• Infrequently preventers
may cause local side
effect such as oral
candidiasis infection.
Other side effects are
rare.
• Patients are advised to
rinse out their mouth
with water after using
the medication

51. Inhaler Technique for
children
1)spacer device with/without
face mask
2)Easyhaler / accuhaler

52. Steps on how to use an inhaler with chamber and
mask
Step 1: Check for the
expiry date and
correct medication

53. Step 2: Visually
check for foreign
objects before each
use
Step 3: Remove the
mouthpiece cover
from the inhaler

54. Step 4: Insert inhaler
to the adapter of the
chamber
Step 5: While holding the chamber
with the inhaler, firmly shake the
inhaler 5 times in an up-and-down
motion
(as the above diagram)

55. Step 6: Apply mask
to face and ensure
that there is a good
seal
Step 7:
-Press inhaler.
-Breathe normally 10 breaths
- Ensure a closed seal of nose and
mouth

56. Step 5
Step 6
Step 7
Wait 30 seconds to 1
minute before the
second puff . Repeat
step 5-7.
Step 8 : Gargle mouth
and throat after using
preventer

57. Steps on how to use an easyhaler
Step 1: Remove the powder
inhaler from the laminated pouch
Step 2: Insert the powder inhaler
into the protective cover.
Preparing the powder inhaler for first use:

58. Step 1:
-Remove the dust cap
- hold device upright
Step 2: Shake the device
prior to each dose.
Delivering the medication:

59. Step 3:
-Press the device only ONCE
until a “CLICK” sound is heard.
-Keep holding the device in the
upright position.
Step 4: Breathe in and out
normally, away from the
mouthpiece.

60. Step 5: Place the mouthpiece between
lips and close tightly around the
mouthpiece. Breathe in forcefully and
deeply through the mouth only
Step 6: Remove the
inhaler from mouth and
hold breath for 10 seconds

61. Wait 30 seconds to 1 minute before
the second puff . Repeat step 2-6.
Step 8 : Gargle mouth and throat
after using preventer
Put the dust cap back on
the mouthpiece. Store
Easyhaler® in a dry
place

62. CLEAN AND CARE FOR INHALERS &
SPACERS
• Clean weekly with tap water
• No sharing of spacer device and medication
• Store spacer device and medication in a
clean container
• REMEMBER to bring your inhaler/spacer
during every clinic appointment for technique
reassessment.

63. HOW TO CLEAN YOUR SPACER
STEP 1: DISASSEMBLE
THE PRODUCT
STEP 2: SOAK AND
RINSE IN CLEAN WARM
WATER

64. HOW TO CLEAN YOUR SPACER
STEP 3: AIR DRY IN
STANDING POSITION
STEP 4: REASSEMBLE
THE PRODUCT

70. Aims of asthma management :
1. Maintenance of normal activities including the
ability to exercise
2. No absence from school
3. No visits to the emergency department or any
hospitalization due to asthma exacerbation
4. No mortality
5. No side effects from medication

71. THANK YOU