DrSTSA
Wheeze A high-pitched whistling/musical sound produced by    the passage of air through narrowed airways/ bronchi   Loud...
Wheezing in Children Episodic wheezing and cough are common in children Infants and young children (<3 years) are especi...
Pathogenesis of Wheezing
Wheeze Acute    Inhaled foreign body    Acute infection    Acute allergic reaction Recurrent    Respiratory System  ...
Categories of Wheezing in children<5 years Transient early wheezing Persistent early-onset wheezing            Late-ons...
Transient early wheezing Result from small airways being obstruct due to  inflammation secondary to viral infections. ↓ ...
Non atopic wheezing Have normal lung function in early life Lower respiratory illness due to viral infection  leads to ↑...
Ig E-mediated wheezing             (atopic asthma) Lung function – normal at birth Recurrent wheeze develops with allerg...
Other causes of recurrent wheezein infancy Recurrent aspiration of feeds Cystic fibrosiso Inhaled foreign body Congenit...
History TakingWheeze   Age of onset   Duration-Acute or recurrent   Precipitating factors     URTI symptoms     Conta...
 Pattern of symptoms    Daytime/ nocturnal symptoms    Exercise induced Severity    On any medication? Types?    Rel...
 Systemic Review    General condition - LOA, LOW    Atopy - angioedema, allergic rhinitis, allergic     conjunctivitis,...
 Birth History    Antenatal: intrauterine infection    Intrapartum: Prematurity    Postnatal: Prolonged labour, NNJ, c...
Physical Examination General condition: alert, conscious, drowsiness, irritability Signs of respiratory distress    Sit...
 Hands    Clubbing of fingernails    Peripheral cyanosis Head    Ears – inflammation, discharge    Nose – nasal disc...
Respiratory System Inspection    Use of accessory muscles : suprasternal, intercostal retraction    Harrison’s sulcus  ...
 Auscultation    Respiratory        Air entry        Prolonged inspiratory or expiratory phase        Vesicular breat...
Investigations1.       Laboratory            FBC : to look for infection, eosinophilia            BUSE : hydration statu...
Bronchial Asthma
Asthma (Protocol) Chronic airway inflammation leading to ↑ airway responsiveness that leads to recurrent episodes of whee...
Pathophysiology                                                       GeneticEnvironmental factors                        ...
Risk factors   Allergic rhinitis   Atopic dermatitis   Allergy- food   Bronchiolitis,Pneumonia   Severe LRTI   Male...
History taking Current symptoms Pattern of symptoms Precipitating factors Prolonged URTI Symptom Present Treatment P...
Physical Exam:Growth & nutrition                                Signs of acute exacerbation:                              ...
Tests for Diagnosis and Monitoringof Asthma Spirometry – FEV1 and FVC PEFR    To confirm the diagnosis of asthma ( impr...
Peak Flow Meterhttp://www.nhs.uk/Pathways/asthma/Pages/Diagnosis.aspx
Management of acute asthma Assessment of Severity Initial (Acute assessment)  Diagnosis - Symptoms e.g. cough, wheezing, ...
Criteria for Admission Failure to respond to standard home treatment Failure of those with mild or moderate acute asthma...
Monitor vital s/-   Pulse,SpO2 ,colour,ABG,PEFRDefinitive Treatment1. O2 therapy (SpO2 >95%)2. Bronchodilator therapy    •...
GINA 2009…..Under 5
>5 years
Upon Discharge Review asthma medications Provide Asthma Action Plan   How to recognize worsening asthma   How to treat...
Asthma Education To provide the person with asthma, their family and other  caregivers with suitable information and trai...
Prevention Identifying and avoiding the following common triggers may be useful   Environmental allergens (house dust mi...
Assessment of level of controlManagement based on controlDrug therapy –types,dosages,delivery
 Assessment of severity        Classification based on frequency, chronicity and severity of          symptoms        M...
Management of Chronic Asthma Goal:    Achieve and maintain control of symptoms    Maintain normal activity levels, incl...
Treatment of Chronic asthma
Chronic asthmaNOTE:1. Patients should commence treatment at the step most   appropriate to the initial severity.   A short...
Drugs        Nebulizer        MDI        Nebulizer        MDI        MDI        Oral,IV        Oral
 Delivery Systems
Pressurized metered-            dose inhaler                        DryNebulizer               powder                     ...
GINA 2009……Under 5
…..GINA2009 (> 5 years)
GINA 2009
Monitoring Assessment during follow-up    Assess severity    Response to treatment       Interval symptoms       Freq...
References Pediatric Protocols Illustrated Textbook of Pediatric GINAReport 2009 GINA_Under 5 Report 2009 Nelson Text...
Asthma Lecture
Asthma Lecture
Asthma Lecture
Asthma Lecture
Asthma Lecture
Asthma Lecture
Asthma Lecture
Asthma Lecture
Asthma Lecture
Upcoming SlideShare
Loading in …5
×

Asthma Lecture

1,480 views

Published on

Published in: Health & Medicine
0 Comments
1 Like
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
1,480
On SlideShare
0
From Embeds
0
Number of Embeds
3
Actions
Shares
0
Downloads
69
Comments
0
Likes
1
Embeds 0
No embeds

No notes for slide
  • Continuous ossilation,E&gt;I coz airway nlly dilate during I,,absence in severe cond:--therefore poor guide to severity
  • Airway narrowing start fm inflamm;of bronchus/bronchiolesaccumula ;of cells(N,L,E)congestion/oedemanarrowing of wall of bronch,hypertrophy of s/m ,cell produce↑mucous,plug formation
  • Older age- Pul parasitic infestation,Hypersensitivitypneumonitis,T.B,Immunedef,Pciliarydyskinesia
  • Dry&amp; moist =p’ia,Nocturnal = asthma
  • Evidence of poor wt gain suggests Immune def,CF and GOR
  • Chronic inflamm;is precipitated by E and G .Bronchoconstriction is strongly linked to airway hyper-responsiveness to *-irritentexposure,cold/dry air ..etc..Inflamm mediators – E,Cytokines,chemokines, NK ,mast cells(proinflamm cells)inflamm process
  • LFT=spirogram(FEV1,FVC,..)PEF,Flow-volume-loopFEV1/FVC =0.8(80%) useful in determin:ofobst and restrict d/sPEFR morning /evening variation &gt;20% is consistent with asthma,morning dip is s/- of (worsening)uncontrolled asthma
  • Spirometric findings
  • DX,Severityass,Response to Tx, Compliance,PEFR diary
  • Attend school regularly,can participate in sport,sleep well without disturbance
  • Leucotriene synthesis inhibitors-Zilueton,L receptor antagonist- Monteleukast/Zafirleukast
  • Na dichromoglycate=MDI
  • Aerochamber= spacer
  • Asthma Lecture

    1. 1. DrSTSA
    2. 2. Wheeze A high-pitched whistling/musical sound produced by the passage of air through narrowed airways/ bronchi Louder during expiration A manifestation of lower respiratory tract obstruction Site of obstruction may be anywhere from the intrathoracic trachea to the small bronchi or large bronchioles Sound is generated by turbulence in larger airways that collapse with forced expiration
    3. 3. Wheezing in Children Episodic wheezing and cough are common in children Infants and young children (<3 years) are especially prone to wheezing
    4. 4. Pathogenesis of Wheezing
    5. 5. Wheeze Acute  Inhaled foreign body  Acute infection  Acute allergic reaction Recurrent  Respiratory System  Asthma  Other causes* • Non-respiratory system  Heart failure (left to right shunts)  GERD (milk inhalation)
    6. 6. Categories of Wheezing in children<5 years Transient early wheezing Persistent early-onset wheezing Late-onset wheezing
    7. 7. Transient early wheezing Result from small airways being obstruct due to inflammation secondary to viral infections. ↓ lung function from birth Risk factors: mother smoking during and/ or after pregnancy and prematurity Common in ♂ Resolves by 5 years old
    8. 8. Non atopic wheezing Have normal lung function in early life Lower respiratory illness due to viral infection leads to ↑ wheezing during the 1st 10 years of life. cause less severe persistent wheezing symptoms improve during adolescence
    9. 9. Ig E-mediated wheezing (atopic asthma) Lung function – normal at birth Recurrent wheeze develops with allergic sensitisation  ↑ blood Ig E & positive skin prick tests to common allergens Persistence of symptoms & ↓ lung function later in childhood. Risk factors:  Positive family history  Allergy  History of eczema
    10. 10. Other causes of recurrent wheezein infancy Recurrent aspiration of feeds Cystic fibrosiso Inhaled foreign body Congenital abnormality of lung, airway or heart Idiopathic Cow’s milk protein intolerance
    11. 11. History TakingWheeze  Age of onset  Duration-Acute or recurrent  Precipitating factors  URTI symptoms  Contact with URTI patient  Triggers for asthma - ( A,V,C,D,E,F)  History of atopy  Associated symptoms  Rapid breathing  Cough- dry or productive? Sputum colour?  Chest tightness  Nausea or vomiting  Cyanosis
    12. 12.  Pattern of symptoms  Daytime/ nocturnal symptoms  Exercise induced Severity  On any medication? Types?  Relieved with medication  Restriction of daily activities  Sleep disturbances
    13. 13.  Systemic Review  General condition - LOA, LOW  Atopy - angioedema, allergic rhinitis, allergic conjunctivitis, eczema, urticaria Past Medical History  Number of admission to the hospital  Number of admission due to similar problem  Last admission due to similar problem  Duration of stays  Medication given and discharge medication  History of prolonged URTI symptoms
    14. 14.  Birth History  Antenatal: intrauterine infection  Intrapartum: Prematurity  Postnatal: Prolonged labour, NNJ, congenital pulmonary disease Immunization History Family History  Asthma  Atopy  CHD  Cystic fibrosis Social History  School performance  Daily activities  Social interaction  Anyone smoking at home  Location of house  Environment condition: Pets, flower, dust Drug and Allergy History
    15. 15. Physical Examination General condition: alert, conscious, drowsiness, irritability Signs of respiratory distress  Sitting propped up  Shortness of breath  Use of accessory muscles  Audible wheeze  Central cyanosis Vital signs Anthropometry measurements O2 therapy: : nasal prong, face mask, high-flow mask, nebulizer Speech: sentences, phrases or words
    16. 16.  Hands  Clubbing of fingernails  Peripheral cyanosis Head  Ears – inflammation, discharge  Nose – nasal discharge  Throat - inflammation, tonsil enlargement  Tongue – central cyanosis Neck  Lymph nodes  Tracheal shift
    17. 17. Respiratory System Inspection  Use of accessory muscles : suprasternal, intercostal retraction  Harrison’s sulcus  Chest deformities  pectus carinatum  Pectus cavum  Hyperinflacted chest  Signs of atopy : eczema, dry skin Palpation  Trachea shift ( older child)  Chest expansion  Vocal Fremitus  Apex beat Percussion : HyperresonancePercussion is usually normal unless there are foreign body, lung collapse, mediasternal masses
    18. 18.  Auscultation  Respiratory  Air entry  Prolonged inspiratory or expiratory phase  Vesicular breath sound  Added sounds : Rhonchi or crepitations  Cardiovascular  S1 and S2  Additional sounds Palpation of abdomen - hepatomegaly
    19. 19. Investigations1. Laboratory  FBC : to look for infection, eosinophilia  BUSE : hydration status, fluid maintenance  ABG : to look for respiratory failure if severe condition  Throat swab or sputum for culture and sensitivity2. Imaging  Chest X-Ray  Foreign body  Pneumothorax, lobar collapse, mass  Infection3. Bronchoscopy
    20. 20. Bronchial Asthma
    21. 21. Asthma (Protocol) Chronic airway inflammation leading to ↑ airway responsiveness that leads to recurrent episodes of wheezing, breathlessness, chest tightness and coughing particularly night / early morning. often associated with widespread but variable airway obstruction that is often reversible either spontaneously or with treatment.
    22. 22. Pathophysiology GeneticEnvironmental factors predisposition Bronchial inflammation Bronchial hyperactivity + trigger Trigger factors:* factors • Common viral infections of resp: tract •Allergens Oedema •Cig smoking,Coldair,Chemic al irritants Bronchoconstriction •Dust ↑ mucus production •Exercise,Emotional upset •Food Airways narrowing Symptoms: cough , wheeze , breathlessness & chest tightness
    23. 23. Risk factors Allergic rhinitis Atopic dermatitis Allergy- food Bronchiolitis,Pneumonia Severe LRTI Male LBW Exposure to tobacco smoke Parental Asthma
    24. 24. History taking Current symptoms Pattern of symptoms Precipitating factors Prolonged URTI Symptom Present Treatment Previous hospital admission Response to prior Treatment Typical exacerbations History of atopy Home/school environment Impact on lifestyle: school, sports, sleep Family history
    25. 25. Physical Exam:Growth & nutrition Signs of acute exacerbation: • Drowsiness,fatigue • Tachypnoea • Tachycardia • Hyperinflated chestSigns of chronic illness: • Accessory muscles • Cyanosis • Harrison sulci • Pulsus paradoxus • Hyperinflated chest • Prolonged expiratory phase, wheeze • Eczema/dry skin • Silent chest • Hypertrophied turbinates • Rhonchi
    26. 26. Tests for Diagnosis and Monitoringof Asthma Spirometry – FEV1 and FVC PEFR  To confirm the diagnosis of asthma ( improvement of >15% after bronchodilator)  useful for assessing the severity of asthma  response of the patient to therapy  Normal value are available & relate to height  To identify environmental (including occupational) causes of asthma symptoms Skin prick test with allergens Exercise challenge
    27. 27. Peak Flow Meterhttp://www.nhs.uk/Pathways/asthma/Pages/Diagnosis.aspx
    28. 28. Management of acute asthma Assessment of Severity Initial (Acute assessment)  Diagnosis - Symptoms e.g. cough, wheezing, breathlessness  Triggering factors - Food, weather, exercise, infection, emotion, drugs, aeroallergens • Severity - Respiratory rate, colour, respiratory effort, conscious level
    29. 29. Criteria for Admission Failure to respond to standard home treatment Failure of those with mild or moderate acute asthma to respond to nebulised β2-agonists Relapse within 4 hrs of nebulised β2-agonists Severe acute asthma
    30. 30. Monitor vital s/- Pulse,SpO2 ,colour,ABG,PEFRDefinitive Treatment1. O2 therapy (SpO2 >95%)2. Bronchodilator therapy • β2-agonists • Ipratropium bromide • Aminophylline3. Maintenance therapySupportive Treatment1.Hydration & fluid maintenance2.+/- antibiotics(ONLY if bacterial infection suspected)
    31. 31. GINA 2009…..Under 5
    32. 32. >5 years
    33. 33. Upon Discharge Review asthma medications Provide Asthma Action Plan  How to recognize worsening asthma  How to treat worsening asthma  How & when to seek medical attention Schedule regular follow-ups to monitor asthma control
    34. 34. Asthma Education To provide the person with asthma, their family and other caregivers with suitable information and training so that they can keep well and adjust treatment according to a medication plan developed with the health care professional Asthma Education should include :  What is asthma?  Types of treatment available  Drugs – “relievers” & “controllers”  Inhalation devices – how to use them  Trigger factors and how to avoid them  Personal Asthma Action Plan
    35. 35. Prevention Identifying and avoiding the following common triggers may be useful  Environmental allergens (house dust mites, animal dander, insects, mould and pollen)  Cigarette smoking  Respiratory tract infections  Food allergy – uncommon trigger, occurring in 1-2% of children  vigorous exercise –should not restrict
    36. 36. Assessment of level of controlManagement based on controlDrug therapy –types,dosages,delivery
    37. 37.  Assessment of severity  Classification based on frequency, chronicity and severity of symptoms  Management according to severity: Daytime Limitatio Nocturnal Need for Lung Exacerba symptoms of symptoms/ reliever function tions activites awakening tests sControlled None None None None None NoneAll of thefollowing:Partly >2 / week Any Any 2/week <80% ≥1 a yearcontrolled predictedany measure orpresent in personalany wk bestUncontroll ≥3 features of partly controlled asthma present in any week 1/weeked
    38. 38. Management of Chronic Asthma Goal:  Achieve and maintain control of symptoms  Maintain normal activity levels, including exercise  Maintain pulmonary function as close to normal as possible  Prevent asthma exacerbations  Avoid adverse effects from asthma medications  Prevent asthma mortality
    39. 39. Treatment of Chronic asthma
    40. 40. Chronic asthmaNOTE:1. Patients should commence treatment at the step most appropriate to the initial severity. A short rescue course of prednisolone may help establish control promptly.2. Explain to parents and patient about asthma and all therapy3. Ensure both compliance and inhaler technique optimal before progression to next step.4. Step-up; assess patient after 1 month of initiation of treatment and if control is not adequate, consider step-up after looking into factors as in 35. Step-down; review treatment every 3 months and if control sustained for at least 4-6 months, consider gradual treatment reduction.
    41. 41. Drugs Nebulizer MDI Nebulizer MDI MDI Oral,IV Oral
    42. 42.  Delivery Systems
    43. 43. Pressurized metered- dose inhaler DryNebulizer powder inhaler
    44. 44. GINA 2009……Under 5
    45. 45. …..GINA2009 (> 5 years)
    46. 46. GINA 2009
    47. 47. Monitoring Assessment during follow-up  Assess severity  Response to treatment  Interval symptoms  Frequency and severity of acute exacerbation  Morbidity secondary to asthma  Quality of life  PER monitoring on each visit  Compliance  Frequency, technique, reason and excuses  Education  Technique, factual information, written action plan, PEF monitoring may not be practical for all asthmatics but is essential especially for those have poor perception of symptoms and those with life threatening attacks
    48. 48. References Pediatric Protocols Illustrated Textbook of Pediatric GINAReport 2009 GINA_Under 5 Report 2009 Nelson Textbook of Pediatric 18th Edition, chapter 381

    ×