2. Objectives in 2015
How to pick up wheezy infants who may
develop persistent asthma ?
How to treat children with a high risk of
developing asthma ?
Possible asthma preventive strategies.
3. What is Asthma?
Chronic inflammatory disorder
of the airways
Characterized by
– Airway inflammation
– Airflow obstruction
– Airway hyper responsiveness
http://health.allrefer.com/health/asthma-normal-versus-asthmatic-bronchiole.html
Cookson W. Nature 1999; 402S: B5-11
4. What Causes Asthma?
Asthma is a complex trait
– Genetic and environmental factors
– Viral infections
– Appears early in life and severity remains constant
Multiple interacting genes
5. Potential Risk Factors
Host factors
– Genetic predisposition
– Atopy
– Airway hyper
responsiveness
– Gender
– Race / Ethnicity
Environmental factors
– Indoor allergens
– Outdoor allergens
– Tobacco smoke
– Air pollution
– Respiratory infections
– Socioeconomic status
– Family size
– Diet and drugs
– Obesity
Masoli M, et al. The Global Burden of Asthma: Executive Summary of the GINA Dissemination
Committee Report. Allergy 2004; 59: 469-78.
6. Pediatric Asthma
Childhood asthma is not a single disease
Most cases of asthma start in the preschool years
More common in kids with atopic dermatitis and
food allergy during their first 1-2 years of life
With rare exceptions, no single allergen causes
childhood asthma
No currently available medicine changes the
course of the disease
7. Pediatric Asthma
Differs with Adults
Lung growth affected during development.
Children have smaller airway size and
lower inspiratory flow rates.
Difficulty with objective lung function
testing in smaller kids.
8. Pediatric Asthma
Wheezing in Young Children
Transient Early Wheezing
Recurrent wheezing episodes in first years of
life.
Low lung functions, History of Prematurity
Can have severe episodes, requiring
hospitalizations.
Resolves by age 3-5 years.
[ Low Lung function: children improve within a few years and
"outgrow" their asthma ]
9. Pediatric Asthma
Wheezing in Young Children
Non-atopic Wheezing
Viral-induced asthma.
Onset with Lower Respiratory Tract Infection
< 1 year age, i.e. RSV.
Improves by early adolescence.
10. Pediatric Asthma
Wheezing in Young Children
Atopic Wheezing
Presents in 2nd-3rd year of life.
Personal/Family history of ATOPY.
Episodic wheezing.
Normal lung function in infancy but reduced
by age 6 years.
Leads to Persistent asthma
11. Prevalenceofwheeze
Age Years
Martinez Pediatrics 2002;109:362
Transient early wheeze
Non-atopic viral
induced wheeze
Atopic asthma
0 3 6 11
Pre-school “Asthma phenotypes”
Wheezing is common in young children but is it asthma?
12. The prevalence of childhood asthma has continued to
increase on the Indian subcontinent over the past 10 yrs
ISAAC Phase 3 Thorax 2007;62:758
13. Prevalence studies on asthma from India
Study Population Age (yrs) Definition /
Methodology
Prevalence
(%)Region Group No.
Children
2. Shah (2000) Multicentric Schools 37171
31697
13-14
6-7
Self reported,
(ISAAC)
3.7
4.5
3. Awasthi (2004) North (L) Schools 3000 13-14
6-7
do 3.3
2.3
4. Mistry (2004) North ( C) Schools 575 13-14 Q. wheezing 12.5
5. Chakravarthy (2002) South (TN) Field 855 < 12 Q.Diagnosed
asthma
5
6. Chhabra (1998) North (D) Schools 2609 4-17 Q; Current 11.6
7. Paramesh (2002) South (B) Schools 6550 6-15 16.6
8. Gupta (2001) North (C ) Schools 9090 9-20 IUATLD based
validated Q
2.3
B = Bangalore; C = Chandigarh; D = Delhi; IUATLD = International Union Against Tuberculosis & Lung Disease; ISAAC = International Study on
Allergies and Asthma in Children; L = Lucknow; M = Mumbai; P = Patna; Q = Questionnaire; ECRHS = European Community Respiratory Health
Survey; TN = Tamil Nadu
14. Prevalence of asthma
> 300 million asthmatics in world
[ More than population of Russia ]
> 30 million asthmatics in India
Significant economic burden
Total asthma costs > Cost of TB & HIV
combined
18. Asthma Predictive Index (API)
The Asthma Predictive Index is a useful tool for
predicting asthma in young children
To differentiate “Early wheezers” from
“Persistent wheezers” or children who will
develop asthma
API is the basis for the NHLBI recommendations
for Initiating Long-term Controller Therapy in
Young Children (0-4 years)
95% of - ve by API do not have asthma.Source:Journal of allergy and clinical immunology [0091-6749] Castro Rodriguez, Jose
yr:2010 vol:126
19. Asthma Predictive Index
> 4 episodes/yr of wheezing lasting more than 1 day
affecting sleep in a child with one MAJOR or two
MINOR criteria
Major criteria
– Parent with asthma
– Physician diagnosed atopic dermatitis
Minor criteria
– Physician diagnosed allergic rhinitis
– Eosinophilia (>4%)
– Wheezing apart from colds
1Adapted from Castro-Rodriquez JA, et al. AJRCCM 2000; 162: 1403
20. Once “Asthma” Diagnosis Made
Identify precipitating factors
Identify co morbid conditions
Assess the patient/families knowledge
Classify asthma severity using the
Guidelines from the NHLBI (Expert Panel)
21. Spirometry
Feasible in children > 6 years of age
Monitoring Asthma and efficacy of treatment
Measures FVC, FEV 1 and FEV1/FVC Ratio
Normal values for children available on the basis
of height, gender and ethnicity.
5/12/2015 21
22. Spirometry
Airflow Limitation:
Low FEV1
FEV1/ FVC ratio < 0.80
Bronchodilator response to β-agonist:
Improvement in FEV1 ≥ 12%
Exercise challenge:
Worsening of FEV1 ≥ 15%
5/12/2015 22
25. Peak Expiratory Flow (PEF) Meters
Allows patient to assess status of his/her asthma
Patient should know his/her personal best PEF score
Daily peak flow or FEV1 AM-PM variation < 20%
26. Peak Flow Charts
People with moderate
or severe asthma
should take readings:
– Every morning
– Every evening
– After an
exacerbation
– Before inhaling
certain medications
Source: “What You and Your Family Can Do About Asthma” by the Global Initiative For Asthma
Created and funded by NIH/NHLBI
29. Role of early diagnosis
Majority of asthma starts in childhood.
> 75 % had first symptom b4 6 yrs.
Early diagnosis is key component of
effective asthma management.
Spirometry not possible in < 6 yrs.
? User friendly means of diagnosis &
management in preschool children.
30. Exhaled Nitric Oxide
NO is produced by all tissues including lung
& under Th2 cytokine IL3 control.
eNO is non invasive way of assessing
airway inflammation.
Easy, quick, pt friendly, Repeatly measured
Elevated eNO indicates uncontrolled airway
inflammation Initiate ICS
31. Exhaled Nitric Oxide
? Tailoring of ICS dose on eNO
Optimum discriminating level of eNO was
47 ppb.
> 33 ppb : highly predictive of +ve ICS
response.
< 22 ppb : successful discontinuation of ICS
32. Asthma: Goals of Treatment
Control chronic and nocturnal symptoms
Maintain normal activity levels and exercise
Maintain near-normal pulmonary function
Prevent acute episodes of asthma
Minimize emergency (ED) visits and
hospitalizations
Avoid adverse effects of asthma medications
Global Initiative for Asthma. GINA workshop report: global strategy for asthma management and
prevention. Available at: http://www.ginasthma.org. Accessed October 13, 2006.
33. Classifying Asthma Severity in
Children
Break down into intermittent, mild,
moderate, or severe persistent asthma
depending on symptoms of impairment and
risk
Once classified, use the 6 steps depending
on the severity to obtain asthma control
with the lowest amount of medication
34.
35. Assessing Asthma Severity
Use Impairment and Risk criterion
Impairments are
– Symptoms: night time symptoms, reliever use
(SABA), miss school/work, quality of life, ACT
screen
– Lung function- spirometry (FEV 1), eNO
Risks are
– Recurrent exacerbations including ED visits and
hospitalization (may be normal between events)
– Use of oral steroids
– At times, hard to differential between impairment and risk
36. Steps of Therapy
Step 1: intermittent use SABA
Step 2: low dose ICS or LTRA or cromolyn
Step 3: moderate dose of ICS
Step 4: moderate dose of ICS and add either LTRA
or LABA ( if > 4yrs )
Step 5: high dose ICS and LTRA or LABA ( if > 4yrs )
Step 6: high dose ICS and LTRA or LABA ( if > 4yrs )
plus oral steroids
Consult asthma specialist if step 3 or higher
37. Asthma Therapy in Children 0-4 Yrs
Treatment is often in the form of a
therapeutic trial
– Monitor response over 4-6 weeks
» If no response, stop therapy and reevaluate
for other diagnosis
» If a clear positive response for at least 3
months indicates good asthma control.
38. Maintaining Control
Monitor every 3-6 months if stable
If stable at 3 months, try to reduce therapy
(usually by 25-50%)
ICS are safe even in the young at mild to moderate
doses with only a slight decrease in growth
velocity.
Higher doses have been shown to affect growth,
cause cataracts and reduce bone density
Response to therapy is very important in this age
group !
39. NHLBI Guidelines for Initiating Long-term
Controller Therapy in Young Children (0-4 years)
To reduce impairment in children who have
Consistently required reliever treatment
more than 2 times/wk for greater than 4 wks
Should be considered for reducing risk in
young children who have 2 exacerbations
requiring systemic steroids within 6 mths
45. Inhaled Corticosteroid
ICS is preferred treatment alone or in combination
for all persistent categories of asthma
Safe when use is properly monitored
Reduces asthma symptoms, bronchial hyper
reactivity, exacerbations and hospitalizations, need
for rescue medications
Improves lung function, quality of life
May prevent airway remodeling …This is Probably no
longer true
46. ICS Are More Effective at Decreasing Asthma
Exacerbations Than Anti-leukotriene Agents
Results not affected by type of medication, methods, analysis, publication status or
funding source. Insufficient evidence in children.
* No exacerbations reported
Maspero
Baumgartner
Busse
Hughes (BUD)*
Hughes (FP)
Laviolette*
Skalky
Williams
Bleecker
Busse
Fixed Effects
Pooled Relative Risk
0.1 -15 -10 -5 0 +5 +10 +15 +10
Relative Risk (95% CI)
Ducharme FM, BMJ 2003; 326: 621
Favors anti-leukotrienes Favors inhaled glucocorticoids
1
Kim
1.6
47. FDA Approved preventive
Therapies
ICS nebulizer solution (1-8 years)
ICS MDI for all ages
ICS DPI (4 years of age and older)
LABA and LABA/ICS combination DPI and MDI
(4 years of age and older)
Montelukast chewables (2-4 years),
granules (down to 6 mths of age)
Cromolyn sodium nebulizer (2 years and older)
48. Role of Environmental Interventions
Single allergen reduction
not effective
“…Treatment by means of
allergen avoidance
requires the definition of
what patients are allergic
to, and additional
measures beyond the use
of mattress covers and
education”
Thomas Platts-Mills
http://health.allrefer.com/health/asthm
a-common-asthma-triggers.html
50. A Potential Gap in Communications
Asthma Practices- Patients and Doctors Perspectives
0
20
40
60
80
100
Developed
Written Action
Plan
Prescribed
Peak Flow
Meter
Given Lung-
Function Test
Scheduled
Follow-up Visits
Shown Inhaler
Use
%ofPatientsandDoctors
Base: All patients (unweighted N=2509), all doctors (unweighted N=512).
27%
70%
28%
83%
35%
70%
55%
92% 90%
97%Patient
Doctor
1Adapted from http://www.asthmainamerica.com/slides/powerpoint/slide27.ppt
51. Asthma Prevention
There has been remarkable progress in
pharmacotherapy, education and
environmental measures in treating asthma
However, no single action has been
demonstrated to decrease the risk of
developing asthma
Prevention will depend on factors influencing
the development and progression of asthma
52. Asthma Prevention
Reduce exposure to ETS even in utero
Encourage vaginal delivery
Exclusive breast feeding for 6 mths
Avoid broad spectrum antibiotics in 1st yr
Reduce exposure to house dust mites
Reduce indoor & outdoor pollution
Reduce exposure to pets / mould
53. Asthma Prevention
Preventing asthma attack
– Identify & avoid triggers
– Written down asthma plan
– Flu & Pneumonia vaccines
– Keep track of asthma symptoms & level of
control
– Early identification & t/t of acute asthma attack
54. Beyond 2015
To develop interventions which initiated before
the development of the first asthma-like
symptoms, will prevent progression of airway
dysfunction.
Asthma-related airway remodeling occur mainly
during the preschool years; blocking the processes
that cause these changes will drastically reduce
persistent asthma
55. Beyond 2015
Early genetic and phenotypic markers are needed
to target children with confirmed asthma, so that
specific therapies can be introduced to prevent
their progression.
In children with milder persistent asthma,
intermittent, SABA-linked controller therapy may
be as effective as daily therapy with ICS, and will
be much more acceptable for parents and children
alike.
56.
57. The bottom line
In problematic cases of childhood asthma,
rather than escalating treatment, a systematic
approach is needed
- review of the diagnosis
- adherence, ability to take drugs correctly
- child’s environment
58. If diagnostic doubt or failure to respond
adequately to a low dose ICS
- prompt referral to specialist
Asthma is a disease that kills, even in
children with “mild” asthma, and care must
be seen in that context
59. Any ED visit
- is a marker of future risk
- prompt urgent review of trigger
- whether the attack was appropriately managed
Non-adherence to treatment, overuse of
SABA, and underuse of ICS are common
problems that should be routinely tackled
60. Failure of regular asthma review is a factor
in asthma related deaths and for children a
routine review should be done every three
months.
When specialist services are also involved,
good communication is essential;
particularly after an acute asthma attack
