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CHILDHOOD ASTHMA
DIAGNOSIS &
MANAGMENT
Dr. Virendra Kumar Gupta
Assistant Professor
Department Of Pediatric Gastroentero-
hepatology & Liver Transplantation
NIMS Medical College &
Hospital , Jaipur
Story of rahul
An 4-year-old boy rahul was brought by
his mother for recurrent cough for last 1
year, his cough gets worse at night and he
coughs a lot after running or laughing.
She also reported that he frequently had
colds which “went to the chest”.
Definition of asthma
 Asthma is a Chronic inflammatory condition of the
airways characterized by airway
hyperresponsiveness to a variety of stimuli,
manifesting as recurrent obstruction which is
reversible either spontaneously or by medication.
WHEN TO SUSPECT ASTHMA
1.Frequent episodes of wheezing.
2.Cough or wheeze after exercise.
3.Cough particularly in night during periods
without viral infection.
4.Symptoms that persists after the age 3yrs
Consider asthma if any the following signs or
symptoms are present:
WHEN TO SUSPECT ASTHMA contd…
5.Symptoms occur or worsen in the presence
of:
• Aeroallergens
• Exercise
• Pollens
• Respiratory infections (viral)
• Strong emotional stress
• Tobacco smoke
6.Childs cold repeatedly “cough goes to the
chest” and takes more than 10 days to clear
up
7.Symptoms improve when asthma
medications are given
Clinical presentations of asthma
patient
Clinical presentation of asthma child may be
from absolutely normal during routine visit
to severe symptomatic during acute
exacerbation.
During acute episode
Child may have
• Difficult Breathing
• Coughing
• Audible Wheezing
• Chest tightness
On examination
Hunched position / squatting
Fatigued, anxious, sweating
watery/glassy eyes
Flared nostrils
Cyanosed,Tachyponea,Tachycardia
Intercostal and tracheostrenal retraction to feeble
chest movement
On auscultation loud expiratory wheeze to silent
chest
absolutely normal sensorium to agitated
Childhood asthma diagnosis and management
Factors that Influence Asthma
Development and Expression
Host Factors
 Genetic
- Atopy
- Airway
hyperresponsiveness
 Gender
 Obesity
 Emotional factors
 Race/ ethnicity
 Environmental
Factors
 Indoor allergens
 Outdoor allergens
 Occupational sensitizers
 Tobacco smoke
 Air Pollution
 Respiratory Infections
 Diet and drugs
 Family size
 Socioeconomic status
Recognition of asthma triggers and avoiding them including smoking is
the first step towards controlling asthma
TRIGGERS
Trigger Factors are things that set off or start asthma
Can vary from person to person. An asthma attack can be induced by direct irritants
(allergens)
Factors that Exacerbate Asthma
 Allergens
 Respiratory infections
 Exercise and hyperventilation
 Weather changes
 Sulfur dioxide
 Food, additives, drugs
How to Diagnose
asthma
 History and patterns of symptoms
1. Frequent episodes of wheezing(i.e.> once a month)
2. Cough or wheeze after exercise .
3. Cough particularly in night during periods without viral
infection
4. Symptoms occur or worsen in the presence of trigger
5. Childs cold repeatedly “cough goes to the chest” and takes
more than 10 days to clear up.
6. Symptoms improve when asthma medications are given
7. Family h/o atopy /asthma
8. Personal h/o atopy
9. Seasonal exacerbations
Asthma Diagnosis contd…
Investigations:
 LAB investigations
 CBC/DLC
 ABG
 Allergy test
 Chest x ray
Investigations help to rule out alternate diagnose, not
to prove asthma
Asthma Diagnosis (investigation) contd…
Spirometry-
 Use spirometry to establish
airflow obstruction:
 FEV1/FVC < 80% predicted
indicate significant airflow
obstruction
 FEV1/FVC 60%-80%-moderate
airflow obstruction
 FEV1/FVC < 60% severe airflow
obstruction
 Use spirometry to establish
reversibility:
 FEV1 increases >12% and at
least 200 mL after using a short-
acting inhaled beta2-agonist
 Exercise challenge/challenge
to methacholine -Worsening in
FEV1 ≥15%[*]
Differential diagnosis of asthma
Before labeling any patient as bronchial asthma we should
exclude condition which simulate asthma-
 Congenital Anomalies with airway impingement: Vascular
rings, tracheobronchial obstruction, mediastinal mass
 Bronchopulmonary dysplasia
 Cystic fibrosis
 Gastroesophageal reflux
 Aspiration
 Foreign Body Aspiration
 Heart Failure
 Sinusitis and allergic rhinitis
 Bronchiolitis /WALRI
 Pertussis
 Tuberculosis
 Immune system Disorders
How to confirm
No gold standard test to diagnose
Diagnosis is Essentially Clinical
Lung function tests are occasional
helpful
Other causes of recurrent cough
should be ruled out
WHEN TO LABEL
Three or more episodes of reversible airflow
obstruction
with several of these:(most accepted defination
including WHO )
1.Afebrile episodes
2.Nocturnal exacerbations
3.Family h/o atopy /asthma
4.Personal h/o atopy
5.Exercise/activity induced symptoms
6.Trigger induced symptoms
7.Seasonal exacerbations
8.Relief with bronchodilators/steroids
The early wheezer (<3 years)
WALRI
 Febrile episode
 Personal atopy
absent
 Family history of
asthma atopy absent
 Variable response to
bronchodilator
Early onset sthma
 Afebrile episodes
 Personal atopy
present
 Present
 Predictable good
response
Early Childhood Risk Factors for
Persistent Asthma
 Parental asthma
 Allergy
 Allergic rhinitis
 Atopic dermatitis
 Food allergy
 Inhalant allergen sensitization
 Food allergen sensitization
 Severe respiratory infection
 Pneumonia
 Bronchiolitis requiring hospitalization
 Wheezing apart from cold
 Environmental exposure to tobacco
 Low birth weight
Genetic risk factor for asthma
 Multiple interacting genes
 At least 20 distinct chromosomal regions
with linkage to asthma and asthma related
traits have been identified: Chromosome
5q , ADAM33 , PHF11
 Asthma / atopy in family
sibling –doubles risk
one parent –doubles risk
both parent –triples risk
Asthma Predictive Index For
Children
Major criteria
•Parent asthma
•Atopy
•Inhalant allergen
sensitisation
MINOR CRITERIA
• Allergic rhinits
• Wheezing apart
from Colds
• Eosinophils >4%
• Food Allergen
sensitization
ONE MAJOR OR TWO MINOR CRITERIA PROVIDE A
HIGH SPECIFICITY (97%) & POSITIVE PREDICTIVE
VALUE (77%) FOR PERSISTANT ASTHMA IN TO
LATER CHILDHOOD.
Identify Co morbid conditions
 ALLERGIC rhino sinusitis
- Morning sneezing, blocked nose, snoring , mouth
breathing
 Adenoidal hypertrophy
-Frequent Colds ,ear infections, blocked nose, snoring ,
mouth breathing
 Gastro esophageal reflux
-Nocturnal cough followed by vomiting
 OBESITY
- asthma patients who are overweight or obese that weight
loss, in addition to improving overall health, might also
improve their asthma control
Classification of asthma
At one point of time-
Used to Classify acute exacerbation of asthma to
decide the severity and drug to be used to control acute
attack(reliever medication)
1. Mild
2. Moderate
3. Severe
Classification of asthma contd…
over a period of time to decide the need and
choice of long term controller medications
Old classification
1. Mild intermittent
2. Mild persistent
3. Moderate persistent
4. Severe persistent
New GINA classification
1. Controlled
2. partly controlled
3. Uncontrolled
OLD CLASSIFICATION OF ASTHMA
(from NAEPP expert panel report. Guide line for asthma diagnosis
management-updates 2002)
based on symptoms, frequency of episodes, functional impairment and
objective measure of pulmonary function
CLASSIFICATION STEP DAYS WITH
SYMP
NIGHT
WITH
SYMP
PEF
OR
FEV1
PEF
VARIA
BILITY
Severe persistent 4 continual Frequent <60 >30
Moderate
persistent
3 Daily > 1/ wk >60-
<80
>30
Mild persistent 2 > 2/ wk but < 1
time/day
> 2
/month
>80 20-30
Mild intermittent 1 < 2/ wk < 2
/month
>80 <20
PEFR or FEV1 is applicable for children over 5 year of age and
adult.
New GINA classification based on
Levels of Asthma Control
Characteristic
Controlled
(All of the following)
Partly controlled
(Any present in any week)
Uncontrolled
Daytime symptoms
None (2 or less
days / week)
More than
twice / week
3 or more
features of
partly
controlled
asthma
present in
any week
Limitations of
activities
None Any
Nocturnal
symptoms /
awakening
None Any
Need for rescue /
“reliever” treatment
None (2 or less /
week)
More than
twice / week
Lung function
(PEF or FEV1)
Normal
< 80% predicted or
personal best (if
known) on any day
Exacerbation None One or more / year 1 in any week
This is simple easy to remember even by patient
Treatment
 Regular Assessment and Monitoring
 Patient Education
 Control of Factors Contributing to Asthma
Severity
 Pharmacotherapy
 Asthma Exacerbations and Their
Management
Identify and Reduce Exposure to Risk Factors
 To improve control of asthma and reduce
medication needs, patients should take steps to
avoid the risk factors that cause their asthma
symptoms
 Avoidance measures that improve control of
asthma and reduce medication needs are:
 Tobacco smoke: Stay away from tobacco smoke.
Patients and parents should not smoke.
 Drugs, foods, and additives: Avoid if they are
known to cause symptoms.
 Occupational sensitizers: Reduce or, preferably,
avoid exposure to these agents.
Identify and Reduce Exposure to Risk
Factors contd…
Reasonable avoidance measures that can be recommended
but have not been shown to have clinical benefit:
• House dust mites: Wash bed linens and blankets weekly in
hot water and dry in a hot dryer or the sun. Encase pillows
and mattresses in air-tight covers (If possible, use vacuum
cleaner with filters).
• Animals with fur:. Remove animals from the home (Use air
filters)
• Cockroaches: Clean the home thoroughly and often. Use
pesticide spray—but when patient is not at home.
• Outdoor pollens and mold: Close windows and doors and
remain indoors when pollen and mold counts are highest.
• Indoor mold: Reduce dampness in the home; clean any
damp areas frequently
Pharmacotherapy of asthma
(Drugs)
Relievers
 For treatment of
bronchospasm and to
relieve acute attack
Preventers or
controller
 For long term control
of inflammation and to
prevent further attack
Reliever Medications
 Rapid-acting inhaled β2-agonists
 Systemic glucocorticosteroids
 Anticholinergics
 Theophylline
 Short-acting oral β2-agonists
Preventers/controller medication
Inhaled
 Corticosteroids (ICS)
 Long acting B2
agonist
 Cromolyn sodium
Oral
 Leucotriene
antagonist
 Theophylline – SR
 Oral prednisolone
Short-acting beta2-agonists
slective beta-2 agonist:
salbutmol, levosalbutamol, terbutaline.
Non slective beta 2 agonist:-adrenaline
Short-acting beta2-agonists are available in inhaled, pill,
liquid, and injectable forms. The inhaled form is available in
metered-dose inhalers (MDIs) and as a liquid for
compressor-driven nebulizers.
 Short-acting beta2-agonists are bronchodilators. They
relax the muscles lining the airways that carry air to the
lungs (bronchial tubes) within 5 minutes, increasing airflow
and making it easier to breathe. They relieve asthma
symptoms for 3 to 6 hours. They do not control the
inflammation
Short-acting beta2-agonists
 Short-acting beta2-agonists are used to:
 Provide quick relief of symptoms during asthma attacks.
 Prevent asthma symptoms before exercise.
 Treat symptoms in intermittent asthma.
 Common side effects
 Headache and dizziness.
 Nausea, vomiting, and diarrhea.
 Anxiety.
 Nervousness or tremor (such as unsteady, shaky
hands).
LABA
 Not used as relievers
 Never use alone
 Used with ICS for synergistic effects/steroid
sparing effects
 Useful in nocturnal/Exercise induced
symptoms
 Used only in children >4years
 Salmeterol / Formoterol-not much to choose
 Duration of action 12 to 24 hours
 Use for mod/severe persistant asthma
LABA
 Formoterol:
Mdi:12 µg/puff
Dpi/rota cap:12µg/cap
Dose: 1 to 2 puff/rota cap/day od/bd
 Salmeterol:
Mdi:25 µg/puff
Dpi/rota cap:50 µg/cap
Dose: 1 to 2 puffs/caps od/bd
ICS
 Anti inflammatory effect evident in 2-3 weeks
 Local side effects can be minimized by
spacer/gargling
 Systemic side effects negligible
 Most children are controlled with medium doses.
 In prolonged high doses-monitor growth and eyes
 Near 20% velocity reduction of growth in 1st yr of
treatment, then growth normalizes in case of
routinely recommended inhaled doses
Completely inactivated during first pass
metabolism so has minimum side effects
ICS
Side effects :
Local – Oral candidiasis, dysphonia
Systemic : Adrenal suppression, Effects on bone
and linear growth
Long-term treatment with inhaled
glucocorticosteroids has not been shown to be
associated with any increase in osteoporosis
or bone fracture
Studies including a total of over 3,500 children
treated for periods of 1 – 13 years have found
no sustained adverse effect of inhaled
glucocorticosteroids on growth
Beclomethasone 200-500 100-200 >500-1000 >200-400 >1000 >400
Budesonide 200-400 100-200 400-800 >200-400 >800 >400
Budesonide-Neb
Inhalation Suspension
250-500 >500-1000 >1000
Ciclesonide 80 – 160 80-160 >160-320 >160-320 >320-1280 >320
Flunisolide 500-1000 500-750 >1000-2000 >750-1250 >2000 >1250
Fluticasone 100-250 100-200 >250-500 >200-500 >500 >500
Mometasone furoate 200-400 100-200 > 400-800 >200-400 >800-1200 >400
Triamcinolone acetonide 400-1000 400-800 >1000-2000 >800-1200 >2000 >1200
Drug Low Daily Dose (g) Medium Daily Dose (g) High Daily Dose (g)
> 5 y Age < 5 y > 5 y Age < 5 y > 5 y Age < 5 y
Estimate Comparative Daily Dosages for
Inhaled Glucocorticosteroids by Age
ICS Formulation
Inhaled medications for asthma are
available as
1. pressurized metered-dose inhalers
(pMDIs),
2. breath-actuated MDIs,
3. dry powder inhalers (DPIs)-rota cap
4. nebulizers-respule
Long term oral steroids
 Use limited to severe persistent asthma
 Minimal possible doses
 Alternate morning doses preferred
 Prednisolone – best option
 Side effects :Excessive weight gain,
hypertension, osteoporosis, decreased
linear growth, metabolic derangement and
catarcts
Leukotrine antagonists
 Leukotrine antagonist may be considered as
mono therapy in mild persistent asthma where
child parent refused for inhalation therapy but
certainly inferior to ICS
 Add on in moderate to severe asthma
 Weak anti inflammatory effect
 Exercise induced asthma
 Montelukast > 6 months
 Zafirlukast>6 yrs
 S/E : headache, abd pain, vivid dreams,
Churgg Strauss Syndrome(eiosinophilic
vasculitis) rarely.
Leukotrine antagonists contd…
 Montelukast:
 4,5,10 mg tabs available
 dose: 2-5 yrs:4 mg/day
 5-12 yrs:5 mg/day
 >12 yrs:10 mg/day
Theophylline
 Anti inflammatory / immunomodulator effect
 Inhibitor of phosphodiesterase
 Adjunct therapy for mod/severe persistent asthma
 MOA : Smooth muscle relaxant, bronchodilator, respiratory
stimulant,diaphragmatic muscle contractlity improver
 Disadvantage:-Low theraptic index

 S/E :gastric irritation, GI h’age, CNS sym- agitation, convulsions,
coma, resp failure
 100,150,200,300 mg tab available
 Dose; 5 to 15 mg/kg/day in 2 divided doses
Treating to Achieve Asthma
Control
 Those patient who are newly diagnosed asthma is
categorised according to old classification and
treatment is started accordingly.
 Then monitoring and follow up is done according to
new GINA classification.
 At each treatment step, reliever medication should
be provided for quick relief of symptoms as needed
 At Steps 2 through 5, patients also require one or
more regular controller medications, which keep
symptoms and attacks from starting.
 If asthma is not controlled on the current treatment
regimen, treatment should be stepped up until
control is achieved.
For newly diagnosed patient treatment is started
according to old classification
CATEGORY symptoms/day
Symptoms/night
STEP TREATMENT
Mild
intermittent/
Exercise
induced asthma
≤2days/week
≤2night/mo
1 No daily medication reqd. In case of severe
exacerbations, a course of systemic CS
recommended and sos SABA
Mild persistent
asthma
>2 d/mo but<1ep/d
>2 night/mo
2 Low dose inhaled CS and SABA sos
Alt:,Leukotriene modifier,SR theophylline
Cromolyn , nedocromiL,
Moderate
persistent
asthma
Daily
>1 night/week
3 Low to medium dose inhaled CS
And long acting inhaled beta agonists
For younger children mod to high dose inhaled
steroid is better
Alt : ,Leukotriene modifier, theophylline
Cromolyn, nedocromiL
Severe
persistent
asthma
continual
frequent
4 High dose inhaled CS
and Long acting beta agonists add one or more
Leukotriene modifier, theophylline Cromolyn,
nedocromiL if needed.
Oral CS- short course (2mg/kg/day) max 60
Childhood asthma diagnosis and management
Step 1 – As-needed reliever medication
 Patients with occasional daytime symptoms of
short duration( mild intermittent asthma)
 A rapid-acting inhaled β2-agonist is the
recommended reliever treatment
 When symptoms are more frequent, and/or
worsen periodically, patients require regular
controller treatment (step 2 or higher)
Treating to Achieve Asthma Control
Childhood asthma diagnosis and management
Step 2 – Reliever medication plus a single
controller
 for mild persistent asthma- treatment is started at
this step
 A low-dose inhaled glucocorticosteroid is recommended
as the initial controller treatment for patients of all ages
 Alternative controller medications include leukotriene
modifiers appropriate for patients unable/unwilling to
use inhaled glucocorticosteroids
Treating to Achieve Asthma Control
Childhood asthma diagnosis and management
Step 3 – Reliever medication plus one or two
controllers
 For moderate persistent asthma treatment is started at
this step
 For children, increase to a medium-dose inhaled
glucocorticosteroid
 For adults and adolescents, combine a low-dose inhaled
glucocorticosteroid with an inhaled long-acting β2-
agonist either in a combination inhaler device or as
separate components
 Inhaled long-acting β2-agonist must not be used as
monotherapy
Treating to Achieve Asthma Control
Childhood asthma diagnosis and management
Step 4 – Reliever medication plus two or more
controllers
 For severe persistent asthma treatment is
started at this step
 Selection of treatment at Step 4 depends
on prior selections at Steps 2 and 3
 Where possible, patients not controlled on
Step 3 treatments patient should be
referred to a health professional with
expertise in the management of asthma
Treating to Achieve Asthma Control
Step 4 – Reliever medication plus two or more controllers
 Medium- or high-dose inhaled glucocorticosteroid
combined with a long-acting inhaled β2-agonist
 Medium- or high-dose inhaled glucocorticosteroid
combined with leukotriene modifiers
 Low-dose sustained-release theophylline added
to medium- or high-dose inhaled
glucocorticosteroid combined with a long-acting
inhaled β2-agonist
Treating to Achieve Asthma Control
Childhood asthma diagnosis and management
Treating to Achieve Asthma Control
Step 5 – Reliever medication plus additional controller options
 Addition of oral glucocorticosteroids to other
controller medications may be effective but
is associated with severe side effects
 Addition of anti-IgE treatment to other
controller medications improves control of
allergic asthma when control has not been
achieved on other medications
controlled
partly controlled
uncontrolled
exacerbation
LEVEL OF CONTROL
maintain and find lowest
controlling step
consider stepping up to
gain control
step up until controlled
treat as exacerbation
TREATMENT OF ACTION
TREATMENT STEPS
REDUCE INCREASE
STEP
1
STEP
2
STEP
3
STEP
4
STEP
5
REDUCEINCREASE
Clinical Control OF Asthma
 No (or minimal)* daytime symptoms
 No limitations of activity
 No nocturnal symptoms
 No (or minimal) need for rescue medication
 Normal lung function
 No exacerbations
_________
* Minimal = twice or less per week
Monitoring to Maintain Asthma Control
 When control has been achieved, ongoing monitoring is
essential to:
 - maintain control
- establish lowest step/dose of treatment to minimize cost
and maximize safety.
 Typically, patients should be seen one to three months
after the initial visit, and every three months thereafter .
 After an exacerbation, follow-up should be offered within
two weeks to one month.
 Asthma control should be monitored by the health care
professional and by the patient
Monitoring to Maintain Asthma
Control
At each visit, ask the questions to decide
adequacy of treatment
 is the asthma management plan meeting
expected goals?
 is the patient using inhalers, spacer, or peak flow
meters correctly?
 is the patient taking the medications and
avoiding risk factors according to the asthma
management plan?
 does the patient have any concerns?
Adjusting medication:
stepping up treatment
 Generally, improvement should be seen within 1
month.
 If asthma is not controlled on the current treatment
regimen, step up treatment.
 But first review the patient’s medication technique,
compliance, and avoidance of risk factors.
 If asthma is partly controlled, consider stepping up
treatment, depending on whether more effective
options are available, safety and cost of possible
treatment options, and the patient’s satisfaction with
the level of control achieved.
Monitoring to Maintain Asthma Control
Treating to Maintain Asthma Control
Stepping down treatment when asthma is controlled
 When controlled on medium- to high-dose inhaled
glucocorticosteroids: 50% dose reduction at 3 month
intervals
 When controlled on low-dose inhaled
glucocorticosteroids: switch to once-daily dosing
 Monitoring is still necessary even after control is
achieved, as asthma is a variable disease; treatment
has to be adjusted periodically in response to loss of
control as indicated by worsening symptoms or the
development of an exacerbation
Acute Exacerbations
 Exacerbations of asthma (asthma attacks)
are episodes of a progressive increase in
shortness of breath, cough, wheezing, or
chest tightness, or a combination of these
symptoms. .
 It is graded as mild, moderate, severe
exacerbation.
Management of Acute asthma:
Steps:
(1)Assessment of severity
(2)Initiation of therapy
(3)Assessment of response
(4)Modification of therapy or additional threapy
CLINICAL ASSESSMENT OF
SEVERITY:
 HISTORY
 PHYSICAL EXAMINATION
 OBJECTIVE ASSESSMENT
 LABORATORY STUDIES
IDENTIFICATION OF LIFE
THREATING ATTACK /RED
FLAG SIGNS
1. Unable to talk or cry or speak in words only
2. Cyanosis
3. Feeble chest movement
4. Absent breath sound
5. Fatigue or exhaustion
6. Agitated
7. Altered sensorium
8. Oxygen saturation < 92 %
Pulmonary Score Index
Score Respiratory rate
<6 years >6 years
Wheezing Accessory
muscle
Sternomastoid
activity
0 <30 <20 None None
1 31 - 45 21 – 35 Terminal
expiration with
stethoscope
Questionable
increase
2 46 – 60 36 – 50 Entire expiration
with stethoscope
Apparently
increase
3 >60 >50 During inspiration
& expiration
without
stethoscope*
Maximum
activity
Pulmonary Score Index
Score 0 – 3
mild
* If no wheezing due
to minimal air
exchange score >3
4 – 6
moderate
>6
severe
Those children whose score >6 should be admitted to
Pediatric ICU.
Initial Assessment
History, Physical Examination, PEF or FEV1
Initial Therapy
Bronchodilators , O2
Incomplete/Poor Response
Add Glucocorticosteroids
Good Response Poor Response
Discharge Admit to Hospital
Respiratory Failure
Admit to ICU
If Stable,
Discharge to
Home
Observe for at
least 4 hour
Good
Response
Emergency Department Management
Acute Asthma
Home treatment of acute
exacerbation (PS score ≤3)
 SA ß2 agonist 4-6 puff (actuation) given one puff q2
minutes through MDI ±SPACER±FACE MASK-
every 20 minute in 1st a hour.
 If symptoms improved or PEFR gets better then,
inhalation can be continued on Salbutamol 4- 6
hourly and plan for visit to treating physician.
 If response ill sustained (<4 hours) start 1st dose of
rescue steriod.
 Seek medical attention on the same day if inhaled
SABA is required for symptoms relief more
frequently than 3 hourly or for more than 24 hours.
Emergency Room management
PS 4-6 (Moderate)
•O2
•SA β2 AGONIST
nebulise with salbutamol 0.1-0.15mg/kg in 3cc NS over 5-10
min every 20 min.×3times 1st hour with 6-8L/min central
oxygen.
(or Continuous nebulization with salbutamol@: 0.1-0.5mg/kg/hr)
OR
MDI ± spacer ±Mask 1 puff q2min till 6puff reached
Give 6 puff like this every 20 min in 1st hour
OR
(If Inhaled therapy not available)
•Adrenaline /Terbutaline 0.01mg/kg sc q 20 min x 3
•Commence / Continue rescue steroid
•Continuous Assessment every one hour for 3-4 hours
E Room management contd….
ASSESSMENT OF RESPONSE TO INITIAL THREAPY:
After 3 doses of bronchodilator and oxygen therapy asses child if
GOOD RESPONSE:
 Free of wheeze, without any breathlessness
 Heart rate and respiratory rate decrease.
 Auscultation: minimal or no ronchi and PEFR or FEV1 improve
to more than 80% of the predicted or personal best.
 if response sustained >4 hours after last treatment at room
air.
 Plan will be:
1. Discharge with Patient education
2. Continue inhaled Beta 2 every 4-6 hours till symptoms abate.
3. continue oral steriods for 3-7 days .
E Room management contd….
PARTIAL RESPONSE:
 Breathlessness or wheezing reduced but still present
 Physical examination:1.HR and RR above physiologic levels.
2.Pulsus paradoxus of 10-15 mm hg
3.O2 saturation 91-95%.
4.PEFR 50-80% of predicted normal.
Child who have shown partial response to initial therapy
having distress may be continued inhalation therapy with
ß2 agonist as frequent as every 20 minutes, even
continuously without side effect for next 2 hours.
if Ipratropium not added at onset of therapy it can started be
at the end of 1st hour.
E Room management contd….
PARTIAL RESPONSE:
 Who have minimal symptoms after initial
therapy could be given inhalation every 2-4
hours.
 if child have improved on the on continuation of
above therapy for about 2 hours he can
observed 4 hours if response sustained 4 hours
then discharge with proper advice.
 if not responding(PS>3), response is illsustained
shift to ward / ICU
WARD MANAGEMENT OF ASTHMA
• Continue oxygen
•Start IV fluids, IV / Orals steriods
• Rescue Steroids are
IV Hydrocortisone (5-10 mg/kg) q 6 hr or
IV Methylprednisolone (1-2 mg/kg)q 6 hr or
IV / IM Dexamethasone (0.1-0.2 mg/kg) q 6 hr.
Oral prednisolone 1-2 mg/kg for 3-7 days
•Nebulie with SA β2 hourly/ back to back
•Ipratopium neb q 20 min x 3 and then q 6 hrs
if child is stable(PS score 4-6) on above therapy we can wait on
same therapy for at least 6-8 hours before intensification of therapy.
WARD MANAGEMENT OF ASTHMA
CONTD….
 Intensify the therapy by adding iv bronchodilator:
Magnesium sulphate, Aminophylline, Terbutaline infusion,
as per need if not improving
 But before intensification check that all the treatment
advised and oxygen was being given
 Magnesium sulphate
dose- 25 -50 mg/kg in 1: 10 dilution of NS &
infusion over ½ hour-single dose
 Aminophylline
Loading dose 5 mg/kg slow IV diluted in 5% dextrose
f/b 0.4-1 mg/kg/hr
WARD MANAGEMENT OF ASTHMA
CONTD….
 Terbutaline
- initial bolus of 5-10μg /kg over 10 min
- f/b 2-10 μg/kg/hr by infusion
 Discontinue neb β2 agonist at higher infusion rate
 Dissolve 1 ml (500 μg) in 50 ml 5% dextrose
(1ml of solution = 10 μg terbutaline)
• Monitor SaO2 and Serum K+
• CBC, X- Ray chest only to identify complications.
• No subjective or objective improvement child is
detoriating (PS SCORE >6) shift to ICU.
Indication for transfer of child in ICU
 depend upon status of child at time of
presentation and response to therapy
Indication
• life threatening attack
• severe distress
• shown poor response to therapy
• develop sign of impending respiratory failure
during therapy like hypoxia hpercarbia (PS
SCORE >6)
ICU MANAGEMENT
ICU Management
Continue
1. Oxygen
2. Inhaled short acting Beta agonist every 60 min or
continuous + inhaled Anticholinergics.
3. continue systemic rescue steroids.
4. Continue intensified ward plan/ intensify therapy by
adding bronchodilator: - Magnesium sulphate
Aminophylline, Terbutaline infusion.
5. Continuous monitoring with pulse oximetry and repeated
ABG are mandatory since most of these patient are not in
condition to perform PEFR
6. If indicated intubate child and start mechanical ventilation
ICU MANAGEMENT CONTD….
Indication of mechanical ventilation are:
 Failure of maximum pharmacotherapy
 Pao2<60 ,Paco2 >50
 Minimal chest movements
 Minimal air exchange
 Severe chest retractions
 Deterioration of mental status
 Respiratory/ cardiac arrest
ICU MANAGEMENT CONTD….
 Stabilize with 100% O2 with bag and mask
 Do suction and nasogastric decompression
 Premedication with atropine and local anesthetic
before intubation
 Ideal sedative is iv ketamine (midazolam/fentanyl) in
dose of 1 to 3 mg/kg.
 Paralysis with vecuronium bromide in a dose of 0.2 to
0.3 mg/ kg if required.
 Volume cycled ventilators is preferred with low RR ( 8
to 12 / min) and long expiratory time (i:e ratio 1:3 to
1:4), PEEP should be minimal and isnpiratoy flow rate
should be kept high to improve gas exchange.
 Tidal volume of 10 to 12 ml/kg and PIP less than of 40
to 50 cm of water should be maintained
ICU MANAGEMENT CONTD….
 Throughout ventilation ß2 agonist are nebulised into
isnpiratoy circuit of ventilator if not responding can
nebulise with halothane1-1.5%,isoflurane 1%
 Once PaCO2 value fall less than 45 mmHg and PIP
less than 35 cm H2O or no bronchospasm on
auscultation muscle paralysis can be stopped.
 As muscle function return to normal patient can be
put on spontaneous ventilation if child maintain
PaCO2< 45 mmHg child can be extubated.
 During recovery phase of asthma, frequency of
inhalation therapy should reduced gradually, and
shifted to oral medication.
Stepping down acute care
 Follow the principle “last in first out”
o Discontinue terbutaline/aminophylline drip in 24
hrs
o Discontinue ipratropium neb in 24-48 hrs
o Reduce nebulisation with SA β2 agonist to q 2-4
hrly and then q 4-6 hrly
o Replace IV rescue steriod  Oral steroid
Discharge Criteria
 Pulmonary score index < 3
 Sleep well at night
 Feeding well
 Appears comfortable
 Receiving less frequent β2 agonist
SEASONAL ASTHMA
 Is retrospective diagnosis-based on h/o in last
2-3 years, asthma attack start with onset of
particular season and persist during that season
till allergen persist otherwise child is normal
remaining part of year.
 Child can be started on maintenance treatment
2 weeks in advance of start of season.
 Medications are given as per the severity of
asthma
 Child should be examined again after
discontinuing meds after season is over
EXERSIZE INDUSED ASTHMA
 Managed by SABA/LABA/LTRAS
 Short acting B agonists are given just
before activity as they have short duration
of action
 Long acting bronchodilators/leukotriane
receptor antagonists can be given in the
morning
Prognosis
 The prognosis for asthma vary from child to child
 First thing we have to explain to
attainder/caregiver that asthma is controllable
disease if adequately treated not curable
diseases.
 60% of children will symptom free after the age
10 year as airway size increase with growth of
child but still they should under continuous
monitoring they can have repeat attack any time
in life so they can not declared cured. especially
for children with mild disease.
inhalation therapy
How do you initiate inhalation therapy?
4 steps
1. Explain advantage of inhalation therapy
2. Dispel myths and fear
3. Select appropriate device
4. demonstrate how to use selected device
Advantage of inhalation therapy
Inhaled oral
Route direct Indirect
Dosage smaller higher
Onset of action rapid slow
Adverse effect mild or none greater
Smaller doses, target delivery, quicker action,
lesser side effect.
Less Drug
Without Side effects
Straight into the
Lungs
Advantage of inhalation therapy
Salbutamol 4 mg Tabs 40 Puffs of Salbutamol Inhaler
Dispelling myths and fear
 Is inhalation therapy strong? NO
Emphasize micro organism
 is inhalation therapy ‘addictive? NO
None of drug cause dependence
 Is inhalation therapy expensive ? NO
Initially but not ultimately
 Is inhalation therapy easy to use in children YES
First choice, but not last resort !!!
When given by inhaled route how
much drug does one get
Inhaler Device
 MDI with spacer
 Metered dose inhaler
(MDI)
 Dry powder inhaler
 Nebulizer
Delivery
10-15%
5-10%
5-10%
1-5%
The right device
Criteria for selection
 Age
 Controller use
 Acute episodes
Selecting the right device
Age
 < 3 years – MDI + Spacer + mask
 >3 years – MDI + Spacer
 >6 years – MDI +Spacer
- Dry powder inhaler (DPI) is an
option
MDI + spacer is the most versatile device
Selecting the right device
 Controller regimen
• Moderate to high dose ICS
Use MDI + spacer instead of DPI even in
older children
Selecting the right device
 Acute episodes
• Home – MDI + spacer ±mask /DPI
• Hospital – MDI + spacer ±mask
- nebuliser in severe episodes
Do not use DPI in moderate / severe
exacerbations
 Demonstrate how to use selected devices
MDI
 The MDI is a device that delivers a specific and pre-
metered amount of medication to the lungs, in the
form of an aerosol spray that is inhaled by the
patient.
 Two types
-pressure actuated MDI (pMDI)
-breath actuated MDI (bMDI)
pMDI
pMDI)-they require coordination between actuation and
inhalation
How to Use a Spray Inhaler
Teach patients (and parents) how
to use inhaler devices.
Different devices need different
inhalation techniques.
 Give demonstrations and
illustrated instructions.
 Ask patients to show their
technique at every visit.
Health-care provider should
evaluate inhaler technique at each
visit.
 If an inhalant is not having much
effect, it could mean the person is
not using it properly or it is blocked
or empty.
Demonstration of pMDI
Click on icon to play Animation
Application
Breath actuated MDI(bMDI)
Breath actuated MDI (bMDI)-this is
advance over pMDI. bMDI overcome
the problem coordination between
actuation and inhalation. It is actuated
at low isnpiratoy flow rate
Demonstration how to use bMDI
spacer
 Spacers(some time also called as holding chamber) are
devices that hold the medication for few seconds after it
has been released from the MDI.
Role of spacer
 Spacers overcome coordination problem of actuation
and inhalation
 Increase delivery of drug to lung
 can reduce potential side effects.
 Dilute taste of inhaled spray
 eliminate cold Freon effect
When using MDI, Spacer is must
Type of spacer
Small volume vs large volume
Valved vs non valved
Polyamide vs polycarbonate
Spacers
Inhal ers
Spacers
Click on icon to play
animation
How to clean spacer
 they should cleaned once every 15 days
 open the lock, separate two halves of
spacer.
 Pace under simple tape water over 1-2
minute.
 put in clean place to become dry
Baby mask with spacer
Baby mask make it easy to deliver inhaled medicine in children younger 3 years.and
those who have difficulty in good seal of lips
it is made up of soft silicon and reusable.
equiped with exhalation vent.
Dry powder inhalation device(DPIs)
 DPIs, as their name implies, dispense
medication as dry powder formulation without
the use of propellant as in MDI.
 DPIs disperse medication as dry powder(2-5
µm) without use of propellant.
 DPIs are breath actuated so no coordination
problem between actuation and inhalation.
 Used above 6 years
 Two types
-unit dose DPIs( rotahaler and revoliser)
-multi dose DPIs(multihaler)
Rotahaler(single dose DPI device)
Technique of use of Rotahaler DPI devices
Click on icon to play
animation
A pplication
Rotahaler should
clean twice a
week. Separate
two halves of
rotahaler keep in
running tape
water over 1-2
minute. Put at
clean place to
become dry.
How to clean DPI
 Rotahaler should clean twice a week.
 Separate two halves of rotahaler.
 keep in running tape water over 1-2
minute.
 Put at clean place to become dry.
 Revolizer should clean once a week
Revolizer(single dose DPI device)
Revolizer(single dose DPI device)
The Revolizer is new generation patient friendly dry
powder inhaler device that is easy to use.
Technique of use of Revolizer DPI devices
Simply open the Revolizer, insert the rotacap, shut the
device and inhales
Multihaler(multi dose DPI device)
How to use multihaler
Advantage of multihaler
Nebuliser
 Nebulizer is device used for converting a liquid
drug into a fine mist which inhaled directly into the
lungs via face mask or mouth piece.
 Nebulisation chamber are small plastic device into
which drug solution is placed.
 The device is driven by compressor
(electric/battery operated)or oxygen.
 Gas flow of 6-8 L/min is normally required to drive
the nebuliser.
 Drug inhalation is accomplished by normal tidal
breathing over 5-10 minutes.
Nebuliser
Childhood asthma diagnosis and management
Advantage of nebuliser
 No efforts required ;needs only tidal
breathing.
 A large dose of drug can be administered
simply and effectively.
Indication of nebuliser -
emergency treatment of acute severe asthma
 Delivery of drug in diseases like cystic
fibrosis
 home treatment for patient who are too ill,
short of breath, or otherwise unable to use
hand-held inhalers.
FILLING YOUR NEBULISER
 Plug the compressor unit into the mains. Connect the
tubing from the compressor unit to the bottom of the
nebuliser chamber.
 Unscrew the top of the nebuliser chamber. Open the vial
of drug solution by twisting off the top. Measure out the
correct amount of drug solution and pour into the
nebuliser chamber.
 Sometimes you may need to dilute the drug solution.
Add normal saline to make total solution 3-5ml which is
required in the nebuliser chamber for it to work properly.
 Screw on the top of the nebuliser chamber and attach
the face mask or mouthpiece to the top of the chamber.
USING YOUR NEBULIZER
 Place the facemask over patient mouth and
nose and place the strap over your head.
 Sit up, well supported, in a chair or in bed and
keep the nebulizer chamber upright.
 Switch the compressor unit on and breath in and
out as normal. Relax whilst using nebuliser. .
 Nebulisation usually completed in 5-10 minute.
A small amount of solution may be left in the
nebuliser at this stage, but this is normal.
 Switch off the compressor unit and disconnect
the nebuliser chamber from the tubing.
CLEANING NEBULISER
 Each time you use it, wash the nebuliser chamber in
warm soapy water and then rinse thoroughly with clean
water. Do not use a brush to clean the nebuliser
chamber as you may damage it.
 Reconnect the nebuliser chamber to the tubing and blow
air from the compressor unit through it for a few
seconds. This will dry the nebuliser chamber and tubing.
Disconnect the nebuliser chamber from the tubing and
allow it to dry completely. Disconnect the tubing from the
compressor unit.
 Once a week, rinse the nebuliser chamber with a dilute
solution of Milton or a special nebuliser cleaner. Rinse
the nebuliser chamber with clean water and then dry as
before.
 Tubing and nebulisation chamber should be replaced
every six months or so.
Factors Involved in Non-Adherence
 Medication Usage
 Difficulties associated with
inhalers
 Complicated regimens
 Fears about, or actual
side effects
 Cost
 Distance to pharmacies
 Non-Medication
Factors
 Misunderstanding/lack of
information
 Fears about side-effects
 Inappropriate expectations
 Underestimation of severity
 Attitudes toward ill health
 Cultural factors
 Poor communication
Never overuse Reliever
 More reliever needed, worse the asthma
 Maximum recommended dose of
nebulised salbutamol at a time is 10 mg
 Overdosage : tachycardia with rates up to
200 beats per minute and arrhythmias
 Cardiac arrest and even death
If your patient needs to use a reliever
medication every day, or even more
than three or four times a week,
preventive/controller medication must
be added to the treatment plan
The Peak Flow Meter
• Useful to show
reversibility and &
Monitoring of treatment
• like a thermometer for
asthma to measure PEFR
• Economical handy
instrument
• Builds confidence in
treatment
• Gives objective values
• One ‘hard, fast blow’
Click on icon to start Animation
PEAK EXPIRATORY FLOW RATE
MONITORING
 Home monitoring ; for moderate to severe persistent asthma
 Normal PEFR ranges are determined by patient's age, gender
and height
 Zone classification
GREEN ( DOING WELL ) PEFR 80 -100% ;clear , no symptoms; can
do usual activities
YELLOW (ASTHMA GETTING WORSE)
PEFR 50-80%;cough,wheeze,chest tightness, shortness of
breath; waking at night due to asthma; can do some, but not all
activities
RED (MEDICAL ALERT) PEFR < 50 %;very short breath; cannot do
usual activities
Doxofylline
 Doxofylline is long acting oral methylxanthine derivative.
 Doxofylline is phosphodiesterase inhibitors has antitussive
and bronchodilator affects
 Unlike other xanthines, doxofylline lacks any significant
affinity for adenosine receptors and does not produce
stimulant effects..
Indication
 For maintenance therapy in Asthma and COPD.
Side Effects
 it has shown similar efficacy to theophylline but with
significantly less side effects.
Dosages
 Children-6mg/kg/dose bd.
 Adult:400mg od to tds.
Acebrophylline
 ambroxol-theophylline-7-acetate
 has 3 actions namely bronchodilation,
mucoregulation & anti-inflammatory action.
Indicatio
 asthmatic bronchitis, Acute & Chronic bronchitis.
Contraindication
 Hypersensitivity to ambroxol, theophylline,acebrophylline
 Patient with hemodynamic instability,hypotensionand
arrhythmias.
 Patient with renal and liver disorder.
Acebrophylline
Side Effects
Epigastric pain
 Unlike other xanthine derivatives it has minimum side
effects like palpitations & tachycardia.
Dosage
 In children 2-3 years is 2mg/kg/day two divided doses
 In children 3-12 years dose is 2-3.5mg/kg/day two
divided doses
 1 cap 100mg bd two week
 Available as cap. 100mg,syrup100 ml (1ml-10mg)
Bambuterol
 oral LABA
 prodrug of terbutaline (Bambec and Oxeo)
Indications
 Used in chronic persistent asthma as controller
 It should not be used single therapy.
Contraindications
 pregnancy, seriously impaired liver function.
Adverse effects
 similar to that of Salbutamol
Dose- oral 10/20 mg od.
Recommended above 12 years of age
Allergen-specific Immunotherapy
 Greatest benefit of specific immunotherapy using
allergen extracts has been obtained in the treatment of
allergic rhinitis
 The role of specific immunotherapy in asthma is limited
(anti IgE, Omalizumab)
 Specific immunotherapy should be considered only after
strict environmental avoidance and pharmacologic
intervention, including inhaled glucocorticosteroids, have
failed to control asthma
 Perform only by trained physician
OMALIZUMAB
Humanised monoclonal Anti IGE
MOA:-
It binds to IgE antibody and reduces the amount of
free IgE available to mast cells, basophils and
other cells.
Indication
Add ON therapy for moderate to severe asthma
Dosage:-
 150-375 mg intradermal or subcutaneous every 2-4
Weeks children > 12 yr age
side effects:-
Hypersensitivity
risk of increased incidence of parasitic infection and
malignancy
Disadvantage:- costly
Newer drugs in asthma control
Altrakincept:
 IL-4 receptor antagonist which have important role
in pahogenesis of asthma
 Soluble recombinant IL-4 receptor which acts as an
antagonist in vivo inactivates naturally occurring IL-4
without mediating cellular activation.
 Nebulized form of IL-4R has a serum half-life of 1 week.
Single dose of IL-4 R, 1500 mcg. per week, appears safe
 and effective in moderate asthma.
Mepolizumab:
 anti IL-5 antibody.
 It has been postulated to decrease eosinophil infiltration
and is particularly useful in hypereosinophilic syndromes.
Dose being 750mg/dose iv. for 3 infusions.
Suplatast tosilate:
 It is a Dimethyl sulphonium compound
 It selectively inhibits Th-2 cytokines.
 There is a notable drop in the average number of
infiltrating eosinophils and CD4+ cells.
dosage:-100 mg tds.
Efalizumab:
 It is a humanized IgG1 mAb against the lymphocyte
function antigen-1 (LFA-1) . Blocking of LFA-
1/intercellular adhesion molecule interactions could
inhibits the development of allergen-induced cellular
inflammatory response that inhibit the late asthmatic
response
Newer drugs in asthma control
Newer drugs in asthma control
Resquimod:
 Resiquimod is a new immune response modifier
from the family of imidazoquinolineamines.
 It inhibits allergen induced Th-2 response, airway
inflammation and airway reactivity.
 Has antiviral activity can used ingenital warts, herpes
genitalis and molluscumcontagiosum.
 can be administered topically and orally
IDEC -152
 IgG1 anti-CD23 antibody
 in patients with mild-to-moderate persistent allergic
asthma.
Ciclesonide, Rofleponide
 On site activated steroids: e.g..
Ciclesonide, Rofleponide (under study).
 Soft steroids: They have improved local,
topical selectivity and have much less
steroid effect outside target area.
Pranlukast
 Newer generation of leukotriene receptor antagonist
 Pranlukast is a cysteinyl leukotriene receptor-1
antagonist.
 This drug works similarly to montelukast.
 appear to be equally effective
 It is currently under clinical trials
Advantage of various drug fixed combination
Advantages
 Simpler dosage schedule improves compliance and
therefore improves treatment outcomes
 Reduces inadvertent medication error
 Less expensive than single ingredient drugs
 Potential for drug abuse can be minimized by using one
drug of the combination for this purpose.
 Eliminates drug shortages by simplifying drug storage
and handling, and thus lowers risk of being “out of stock”
Advantage of various drug fixed combination
 Only 1 expiry date simplifies dosing
(single products may have different expiry
dates)
 Procurement, management and handling
of drugs is simplified
 Lower packing and shipping costs
 Side effects are reduced by using one
drug of the combination for this purpose
Disadvantage of various drug fixed
combination
 Dosing is inflexible and cannot be regulated to
patient’s needs (each patient has unique
characteristics such as weight, age,
pharmacogenetics, co-morbidity, that may alter
drug metabolism and effect).
 If a patient is allergic or has a side-effect to 1
component,the FDC must be stopped and
replaced by separate inhaIer
 incompatible pharmacokinetics is irrational
because of different elimination ½ lives of
individual components
Various drug combination
formulation
Inhaler (foracort-100)
Inhaler (foracort-200)
Inhaler (foracort-400)
DPI (rotacap-200)
DPI (rotacap-200)
DPI (rotacap-400)
formetrol+budesonide
 6mcg+100mcg
 6mcg+200mcg
 6mcg+400mcg
 6mcg+200mcg
 6mcg+200mcg
 6mcg+400mcg
Various drug fixed combination
Inhaler(maxiflow-125)
Inhaler(maxiflow-250)
DPI(maxiflow-100)
DPI(maxiflow-250)
Inhaler(fullform-100)
Inhaler(fullform-200)
DPI(Fullform-200)
DPI(Fullform-400)
Fluticasone+formoterol
 125mcg+6mcg
 250mcg+6mcg
 100mcg+6mcg
 250mcg+6mcg
beclomethasone+Formoterol
 100mcg+6mcg
 200mcg+6mcg
 200mcg+6mcg
 400mcg+6mcg
Formulation
Various fixed drug combination
formulation
 Respule(Duolin)
 Inhaler(Duolin)
 DPI(Duolin)
Levosalbutamol+ipratropium
 1.25mg+500mcg/2.5ml
 50mcg+25mcg/puff
 100mcg+50mcg/rotacap
There are some of irrational combination in market
like-Aerocort inhaler /rotacap contain
beclomethasone and Levosalbutamol one controller
medication and other is reliever medication which is
irrational combination
“Be alert to the faults of patients
which make them lie about their
taking of the prescribed medicines,
and when things go wrong,
refusing to confess that they have
not been taking their medicine.”
- Hippocrates, ‘The Father of Medicine’, 200 BC
THANKS

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Childhood asthma diagnosis and management

  • 1. CHILDHOOD ASTHMA DIAGNOSIS & MANAGMENT Dr. Virendra Kumar Gupta Assistant Professor Department Of Pediatric Gastroentero- hepatology & Liver Transplantation NIMS Medical College & Hospital , Jaipur
  • 2. Story of rahul An 4-year-old boy rahul was brought by his mother for recurrent cough for last 1 year, his cough gets worse at night and he coughs a lot after running or laughing. She also reported that he frequently had colds which “went to the chest”.
  • 3. Definition of asthma  Asthma is a Chronic inflammatory condition of the airways characterized by airway hyperresponsiveness to a variety of stimuli, manifesting as recurrent obstruction which is reversible either spontaneously or by medication.
  • 4. WHEN TO SUSPECT ASTHMA 1.Frequent episodes of wheezing. 2.Cough or wheeze after exercise. 3.Cough particularly in night during periods without viral infection. 4.Symptoms that persists after the age 3yrs Consider asthma if any the following signs or symptoms are present:
  • 5. WHEN TO SUSPECT ASTHMA contd… 5.Symptoms occur or worsen in the presence of: • Aeroallergens • Exercise • Pollens • Respiratory infections (viral) • Strong emotional stress • Tobacco smoke 6.Childs cold repeatedly “cough goes to the chest” and takes more than 10 days to clear up 7.Symptoms improve when asthma medications are given
  • 6. Clinical presentations of asthma patient Clinical presentation of asthma child may be from absolutely normal during routine visit to severe symptomatic during acute exacerbation.
  • 7. During acute episode Child may have • Difficult Breathing • Coughing • Audible Wheezing • Chest tightness On examination Hunched position / squatting Fatigued, anxious, sweating watery/glassy eyes Flared nostrils Cyanosed,Tachyponea,Tachycardia Intercostal and tracheostrenal retraction to feeble chest movement On auscultation loud expiratory wheeze to silent chest absolutely normal sensorium to agitated
  • 9. Factors that Influence Asthma Development and Expression Host Factors  Genetic - Atopy - Airway hyperresponsiveness  Gender  Obesity  Emotional factors  Race/ ethnicity  Environmental Factors  Indoor allergens  Outdoor allergens  Occupational sensitizers  Tobacco smoke  Air Pollution  Respiratory Infections  Diet and drugs  Family size  Socioeconomic status
  • 10. Recognition of asthma triggers and avoiding them including smoking is the first step towards controlling asthma TRIGGERS Trigger Factors are things that set off or start asthma Can vary from person to person. An asthma attack can be induced by direct irritants (allergens)
  • 11. Factors that Exacerbate Asthma  Allergens  Respiratory infections  Exercise and hyperventilation  Weather changes  Sulfur dioxide  Food, additives, drugs
  • 12. How to Diagnose asthma  History and patterns of symptoms 1. Frequent episodes of wheezing(i.e.> once a month) 2. Cough or wheeze after exercise . 3. Cough particularly in night during periods without viral infection 4. Symptoms occur or worsen in the presence of trigger 5. Childs cold repeatedly “cough goes to the chest” and takes more than 10 days to clear up. 6. Symptoms improve when asthma medications are given 7. Family h/o atopy /asthma 8. Personal h/o atopy 9. Seasonal exacerbations
  • 13. Asthma Diagnosis contd… Investigations:  LAB investigations  CBC/DLC  ABG  Allergy test  Chest x ray Investigations help to rule out alternate diagnose, not to prove asthma
  • 14. Asthma Diagnosis (investigation) contd… Spirometry-  Use spirometry to establish airflow obstruction:  FEV1/FVC < 80% predicted indicate significant airflow obstruction  FEV1/FVC 60%-80%-moderate airflow obstruction  FEV1/FVC < 60% severe airflow obstruction  Use spirometry to establish reversibility:  FEV1 increases >12% and at least 200 mL after using a short- acting inhaled beta2-agonist  Exercise challenge/challenge to methacholine -Worsening in FEV1 ≥15%[*]
  • 15. Differential diagnosis of asthma Before labeling any patient as bronchial asthma we should exclude condition which simulate asthma-  Congenital Anomalies with airway impingement: Vascular rings, tracheobronchial obstruction, mediastinal mass  Bronchopulmonary dysplasia  Cystic fibrosis  Gastroesophageal reflux  Aspiration  Foreign Body Aspiration  Heart Failure  Sinusitis and allergic rhinitis  Bronchiolitis /WALRI  Pertussis  Tuberculosis  Immune system Disorders
  • 16. How to confirm No gold standard test to diagnose Diagnosis is Essentially Clinical Lung function tests are occasional helpful Other causes of recurrent cough should be ruled out
  • 17. WHEN TO LABEL Three or more episodes of reversible airflow obstruction with several of these:(most accepted defination including WHO ) 1.Afebrile episodes 2.Nocturnal exacerbations 3.Family h/o atopy /asthma 4.Personal h/o atopy 5.Exercise/activity induced symptoms 6.Trigger induced symptoms 7.Seasonal exacerbations 8.Relief with bronchodilators/steroids
  • 18. The early wheezer (<3 years) WALRI  Febrile episode  Personal atopy absent  Family history of asthma atopy absent  Variable response to bronchodilator Early onset sthma  Afebrile episodes  Personal atopy present  Present  Predictable good response
  • 19. Early Childhood Risk Factors for Persistent Asthma  Parental asthma  Allergy  Allergic rhinitis  Atopic dermatitis  Food allergy  Inhalant allergen sensitization  Food allergen sensitization  Severe respiratory infection  Pneumonia  Bronchiolitis requiring hospitalization  Wheezing apart from cold  Environmental exposure to tobacco  Low birth weight
  • 20. Genetic risk factor for asthma  Multiple interacting genes  At least 20 distinct chromosomal regions with linkage to asthma and asthma related traits have been identified: Chromosome 5q , ADAM33 , PHF11  Asthma / atopy in family sibling –doubles risk one parent –doubles risk both parent –triples risk
  • 21. Asthma Predictive Index For Children Major criteria •Parent asthma •Atopy •Inhalant allergen sensitisation MINOR CRITERIA • Allergic rhinits • Wheezing apart from Colds • Eosinophils >4% • Food Allergen sensitization ONE MAJOR OR TWO MINOR CRITERIA PROVIDE A HIGH SPECIFICITY (97%) & POSITIVE PREDICTIVE VALUE (77%) FOR PERSISTANT ASTHMA IN TO LATER CHILDHOOD.
  • 22. Identify Co morbid conditions  ALLERGIC rhino sinusitis - Morning sneezing, blocked nose, snoring , mouth breathing  Adenoidal hypertrophy -Frequent Colds ,ear infections, blocked nose, snoring , mouth breathing  Gastro esophageal reflux -Nocturnal cough followed by vomiting  OBESITY - asthma patients who are overweight or obese that weight loss, in addition to improving overall health, might also improve their asthma control
  • 23. Classification of asthma At one point of time- Used to Classify acute exacerbation of asthma to decide the severity and drug to be used to control acute attack(reliever medication) 1. Mild 2. Moderate 3. Severe
  • 24. Classification of asthma contd… over a period of time to decide the need and choice of long term controller medications Old classification 1. Mild intermittent 2. Mild persistent 3. Moderate persistent 4. Severe persistent New GINA classification 1. Controlled 2. partly controlled 3. Uncontrolled
  • 25. OLD CLASSIFICATION OF ASTHMA (from NAEPP expert panel report. Guide line for asthma diagnosis management-updates 2002) based on symptoms, frequency of episodes, functional impairment and objective measure of pulmonary function CLASSIFICATION STEP DAYS WITH SYMP NIGHT WITH SYMP PEF OR FEV1 PEF VARIA BILITY Severe persistent 4 continual Frequent <60 >30 Moderate persistent 3 Daily > 1/ wk >60- <80 >30 Mild persistent 2 > 2/ wk but < 1 time/day > 2 /month >80 20-30 Mild intermittent 1 < 2/ wk < 2 /month >80 <20 PEFR or FEV1 is applicable for children over 5 year of age and adult.
  • 26. New GINA classification based on Levels of Asthma Control Characteristic Controlled (All of the following) Partly controlled (Any present in any week) Uncontrolled Daytime symptoms None (2 or less days / week) More than twice / week 3 or more features of partly controlled asthma present in any week Limitations of activities None Any Nocturnal symptoms / awakening None Any Need for rescue / “reliever” treatment None (2 or less / week) More than twice / week Lung function (PEF or FEV1) Normal < 80% predicted or personal best (if known) on any day Exacerbation None One or more / year 1 in any week This is simple easy to remember even by patient
  • 27. Treatment  Regular Assessment and Monitoring  Patient Education  Control of Factors Contributing to Asthma Severity  Pharmacotherapy  Asthma Exacerbations and Their Management
  • 28. Identify and Reduce Exposure to Risk Factors  To improve control of asthma and reduce medication needs, patients should take steps to avoid the risk factors that cause their asthma symptoms  Avoidance measures that improve control of asthma and reduce medication needs are:  Tobacco smoke: Stay away from tobacco smoke. Patients and parents should not smoke.  Drugs, foods, and additives: Avoid if they are known to cause symptoms.  Occupational sensitizers: Reduce or, preferably, avoid exposure to these agents.
  • 29. Identify and Reduce Exposure to Risk Factors contd… Reasonable avoidance measures that can be recommended but have not been shown to have clinical benefit: • House dust mites: Wash bed linens and blankets weekly in hot water and dry in a hot dryer or the sun. Encase pillows and mattresses in air-tight covers (If possible, use vacuum cleaner with filters). • Animals with fur:. Remove animals from the home (Use air filters) • Cockroaches: Clean the home thoroughly and often. Use pesticide spray—but when patient is not at home. • Outdoor pollens and mold: Close windows and doors and remain indoors when pollen and mold counts are highest. • Indoor mold: Reduce dampness in the home; clean any damp areas frequently
  • 30. Pharmacotherapy of asthma (Drugs) Relievers  For treatment of bronchospasm and to relieve acute attack Preventers or controller  For long term control of inflammation and to prevent further attack
  • 31. Reliever Medications  Rapid-acting inhaled β2-agonists  Systemic glucocorticosteroids  Anticholinergics  Theophylline  Short-acting oral β2-agonists
  • 32. Preventers/controller medication Inhaled  Corticosteroids (ICS)  Long acting B2 agonist  Cromolyn sodium Oral  Leucotriene antagonist  Theophylline – SR  Oral prednisolone
  • 33. Short-acting beta2-agonists slective beta-2 agonist: salbutmol, levosalbutamol, terbutaline. Non slective beta 2 agonist:-adrenaline Short-acting beta2-agonists are available in inhaled, pill, liquid, and injectable forms. The inhaled form is available in metered-dose inhalers (MDIs) and as a liquid for compressor-driven nebulizers.  Short-acting beta2-agonists are bronchodilators. They relax the muscles lining the airways that carry air to the lungs (bronchial tubes) within 5 minutes, increasing airflow and making it easier to breathe. They relieve asthma symptoms for 3 to 6 hours. They do not control the inflammation
  • 34. Short-acting beta2-agonists  Short-acting beta2-agonists are used to:  Provide quick relief of symptoms during asthma attacks.  Prevent asthma symptoms before exercise.  Treat symptoms in intermittent asthma.  Common side effects  Headache and dizziness.  Nausea, vomiting, and diarrhea.  Anxiety.  Nervousness or tremor (such as unsteady, shaky hands).
  • 35. LABA  Not used as relievers  Never use alone  Used with ICS for synergistic effects/steroid sparing effects  Useful in nocturnal/Exercise induced symptoms  Used only in children >4years  Salmeterol / Formoterol-not much to choose  Duration of action 12 to 24 hours  Use for mod/severe persistant asthma
  • 36. LABA  Formoterol: Mdi:12 µg/puff Dpi/rota cap:12µg/cap Dose: 1 to 2 puff/rota cap/day od/bd  Salmeterol: Mdi:25 µg/puff Dpi/rota cap:50 µg/cap Dose: 1 to 2 puffs/caps od/bd
  • 37. ICS  Anti inflammatory effect evident in 2-3 weeks  Local side effects can be minimized by spacer/gargling  Systemic side effects negligible  Most children are controlled with medium doses.  In prolonged high doses-monitor growth and eyes  Near 20% velocity reduction of growth in 1st yr of treatment, then growth normalizes in case of routinely recommended inhaled doses Completely inactivated during first pass metabolism so has minimum side effects
  • 38. ICS Side effects : Local – Oral candidiasis, dysphonia Systemic : Adrenal suppression, Effects on bone and linear growth Long-term treatment with inhaled glucocorticosteroids has not been shown to be associated with any increase in osteoporosis or bone fracture Studies including a total of over 3,500 children treated for periods of 1 – 13 years have found no sustained adverse effect of inhaled glucocorticosteroids on growth
  • 39. Beclomethasone 200-500 100-200 >500-1000 >200-400 >1000 >400 Budesonide 200-400 100-200 400-800 >200-400 >800 >400 Budesonide-Neb Inhalation Suspension 250-500 >500-1000 >1000 Ciclesonide 80 – 160 80-160 >160-320 >160-320 >320-1280 >320 Flunisolide 500-1000 500-750 >1000-2000 >750-1250 >2000 >1250 Fluticasone 100-250 100-200 >250-500 >200-500 >500 >500 Mometasone furoate 200-400 100-200 > 400-800 >200-400 >800-1200 >400 Triamcinolone acetonide 400-1000 400-800 >1000-2000 >800-1200 >2000 >1200 Drug Low Daily Dose (g) Medium Daily Dose (g) High Daily Dose (g) > 5 y Age < 5 y > 5 y Age < 5 y > 5 y Age < 5 y Estimate Comparative Daily Dosages for Inhaled Glucocorticosteroids by Age
  • 40. ICS Formulation Inhaled medications for asthma are available as 1. pressurized metered-dose inhalers (pMDIs), 2. breath-actuated MDIs, 3. dry powder inhalers (DPIs)-rota cap 4. nebulizers-respule
  • 41. Long term oral steroids  Use limited to severe persistent asthma  Minimal possible doses  Alternate morning doses preferred  Prednisolone – best option  Side effects :Excessive weight gain, hypertension, osteoporosis, decreased linear growth, metabolic derangement and catarcts
  • 42. Leukotrine antagonists  Leukotrine antagonist may be considered as mono therapy in mild persistent asthma where child parent refused for inhalation therapy but certainly inferior to ICS  Add on in moderate to severe asthma  Weak anti inflammatory effect  Exercise induced asthma  Montelukast > 6 months  Zafirlukast>6 yrs  S/E : headache, abd pain, vivid dreams, Churgg Strauss Syndrome(eiosinophilic vasculitis) rarely.
  • 43. Leukotrine antagonists contd…  Montelukast:  4,5,10 mg tabs available  dose: 2-5 yrs:4 mg/day  5-12 yrs:5 mg/day  >12 yrs:10 mg/day
  • 44. Theophylline  Anti inflammatory / immunomodulator effect  Inhibitor of phosphodiesterase  Adjunct therapy for mod/severe persistent asthma  MOA : Smooth muscle relaxant, bronchodilator, respiratory stimulant,diaphragmatic muscle contractlity improver  Disadvantage:-Low theraptic index   S/E :gastric irritation, GI h’age, CNS sym- agitation, convulsions, coma, resp failure  100,150,200,300 mg tab available  Dose; 5 to 15 mg/kg/day in 2 divided doses
  • 45. Treating to Achieve Asthma Control  Those patient who are newly diagnosed asthma is categorised according to old classification and treatment is started accordingly.  Then monitoring and follow up is done according to new GINA classification.  At each treatment step, reliever medication should be provided for quick relief of symptoms as needed  At Steps 2 through 5, patients also require one or more regular controller medications, which keep symptoms and attacks from starting.  If asthma is not controlled on the current treatment regimen, treatment should be stepped up until control is achieved.
  • 46. For newly diagnosed patient treatment is started according to old classification CATEGORY symptoms/day Symptoms/night STEP TREATMENT Mild intermittent/ Exercise induced asthma ≤2days/week ≤2night/mo 1 No daily medication reqd. In case of severe exacerbations, a course of systemic CS recommended and sos SABA Mild persistent asthma >2 d/mo but<1ep/d >2 night/mo 2 Low dose inhaled CS and SABA sos Alt:,Leukotriene modifier,SR theophylline Cromolyn , nedocromiL, Moderate persistent asthma Daily >1 night/week 3 Low to medium dose inhaled CS And long acting inhaled beta agonists For younger children mod to high dose inhaled steroid is better Alt : ,Leukotriene modifier, theophylline Cromolyn, nedocromiL Severe persistent asthma continual frequent 4 High dose inhaled CS and Long acting beta agonists add one or more Leukotriene modifier, theophylline Cromolyn, nedocromiL if needed. Oral CS- short course (2mg/kg/day) max 60
  • 48. Step 1 – As-needed reliever medication  Patients with occasional daytime symptoms of short duration( mild intermittent asthma)  A rapid-acting inhaled β2-agonist is the recommended reliever treatment  When symptoms are more frequent, and/or worsen periodically, patients require regular controller treatment (step 2 or higher) Treating to Achieve Asthma Control
  • 50. Step 2 – Reliever medication plus a single controller  for mild persistent asthma- treatment is started at this step  A low-dose inhaled glucocorticosteroid is recommended as the initial controller treatment for patients of all ages  Alternative controller medications include leukotriene modifiers appropriate for patients unable/unwilling to use inhaled glucocorticosteroids Treating to Achieve Asthma Control
  • 52. Step 3 – Reliever medication plus one or two controllers  For moderate persistent asthma treatment is started at this step  For children, increase to a medium-dose inhaled glucocorticosteroid  For adults and adolescents, combine a low-dose inhaled glucocorticosteroid with an inhaled long-acting β2- agonist either in a combination inhaler device or as separate components  Inhaled long-acting β2-agonist must not be used as monotherapy Treating to Achieve Asthma Control
  • 54. Step 4 – Reliever medication plus two or more controllers  For severe persistent asthma treatment is started at this step  Selection of treatment at Step 4 depends on prior selections at Steps 2 and 3  Where possible, patients not controlled on Step 3 treatments patient should be referred to a health professional with expertise in the management of asthma Treating to Achieve Asthma Control
  • 55. Step 4 – Reliever medication plus two or more controllers  Medium- or high-dose inhaled glucocorticosteroid combined with a long-acting inhaled β2-agonist  Medium- or high-dose inhaled glucocorticosteroid combined with leukotriene modifiers  Low-dose sustained-release theophylline added to medium- or high-dose inhaled glucocorticosteroid combined with a long-acting inhaled β2-agonist Treating to Achieve Asthma Control
  • 57. Treating to Achieve Asthma Control Step 5 – Reliever medication plus additional controller options  Addition of oral glucocorticosteroids to other controller medications may be effective but is associated with severe side effects  Addition of anti-IgE treatment to other controller medications improves control of allergic asthma when control has not been achieved on other medications
  • 58. controlled partly controlled uncontrolled exacerbation LEVEL OF CONTROL maintain and find lowest controlling step consider stepping up to gain control step up until controlled treat as exacerbation TREATMENT OF ACTION TREATMENT STEPS REDUCE INCREASE STEP 1 STEP 2 STEP 3 STEP 4 STEP 5 REDUCEINCREASE
  • 59. Clinical Control OF Asthma  No (or minimal)* daytime symptoms  No limitations of activity  No nocturnal symptoms  No (or minimal) need for rescue medication  Normal lung function  No exacerbations _________ * Minimal = twice or less per week
  • 60. Monitoring to Maintain Asthma Control  When control has been achieved, ongoing monitoring is essential to:  - maintain control - establish lowest step/dose of treatment to minimize cost and maximize safety.  Typically, patients should be seen one to three months after the initial visit, and every three months thereafter .  After an exacerbation, follow-up should be offered within two weeks to one month.  Asthma control should be monitored by the health care professional and by the patient
  • 61. Monitoring to Maintain Asthma Control At each visit, ask the questions to decide adequacy of treatment  is the asthma management plan meeting expected goals?  is the patient using inhalers, spacer, or peak flow meters correctly?  is the patient taking the medications and avoiding risk factors according to the asthma management plan?  does the patient have any concerns?
  • 62. Adjusting medication: stepping up treatment  Generally, improvement should be seen within 1 month.  If asthma is not controlled on the current treatment regimen, step up treatment.  But first review the patient’s medication technique, compliance, and avoidance of risk factors.  If asthma is partly controlled, consider stepping up treatment, depending on whether more effective options are available, safety and cost of possible treatment options, and the patient’s satisfaction with the level of control achieved. Monitoring to Maintain Asthma Control
  • 63. Treating to Maintain Asthma Control Stepping down treatment when asthma is controlled  When controlled on medium- to high-dose inhaled glucocorticosteroids: 50% dose reduction at 3 month intervals  When controlled on low-dose inhaled glucocorticosteroids: switch to once-daily dosing  Monitoring is still necessary even after control is achieved, as asthma is a variable disease; treatment has to be adjusted periodically in response to loss of control as indicated by worsening symptoms or the development of an exacerbation
  • 64. Acute Exacerbations  Exacerbations of asthma (asthma attacks) are episodes of a progressive increase in shortness of breath, cough, wheezing, or chest tightness, or a combination of these symptoms. .  It is graded as mild, moderate, severe exacerbation.
  • 65. Management of Acute asthma: Steps: (1)Assessment of severity (2)Initiation of therapy (3)Assessment of response (4)Modification of therapy or additional threapy
  • 66. CLINICAL ASSESSMENT OF SEVERITY:  HISTORY  PHYSICAL EXAMINATION  OBJECTIVE ASSESSMENT  LABORATORY STUDIES
  • 67. IDENTIFICATION OF LIFE THREATING ATTACK /RED FLAG SIGNS 1. Unable to talk or cry or speak in words only 2. Cyanosis 3. Feeble chest movement 4. Absent breath sound 5. Fatigue or exhaustion 6. Agitated 7. Altered sensorium 8. Oxygen saturation < 92 %
  • 68. Pulmonary Score Index Score Respiratory rate <6 years >6 years Wheezing Accessory muscle Sternomastoid activity 0 <30 <20 None None 1 31 - 45 21 – 35 Terminal expiration with stethoscope Questionable increase 2 46 – 60 36 – 50 Entire expiration with stethoscope Apparently increase 3 >60 >50 During inspiration & expiration without stethoscope* Maximum activity
  • 69. Pulmonary Score Index Score 0 – 3 mild * If no wheezing due to minimal air exchange score >3 4 – 6 moderate >6 severe Those children whose score >6 should be admitted to Pediatric ICU.
  • 70. Initial Assessment History, Physical Examination, PEF or FEV1 Initial Therapy Bronchodilators , O2 Incomplete/Poor Response Add Glucocorticosteroids Good Response Poor Response Discharge Admit to Hospital Respiratory Failure Admit to ICU If Stable, Discharge to Home Observe for at least 4 hour Good Response Emergency Department Management Acute Asthma
  • 71. Home treatment of acute exacerbation (PS score ≤3)  SA ß2 agonist 4-6 puff (actuation) given one puff q2 minutes through MDI ±SPACER±FACE MASK- every 20 minute in 1st a hour.  If symptoms improved or PEFR gets better then, inhalation can be continued on Salbutamol 4- 6 hourly and plan for visit to treating physician.  If response ill sustained (<4 hours) start 1st dose of rescue steriod.  Seek medical attention on the same day if inhaled SABA is required for symptoms relief more frequently than 3 hourly or for more than 24 hours.
  • 72. Emergency Room management PS 4-6 (Moderate) •O2 •SA β2 AGONIST nebulise with salbutamol 0.1-0.15mg/kg in 3cc NS over 5-10 min every 20 min.×3times 1st hour with 6-8L/min central oxygen. (or Continuous nebulization with salbutamol@: 0.1-0.5mg/kg/hr) OR MDI ± spacer ±Mask 1 puff q2min till 6puff reached Give 6 puff like this every 20 min in 1st hour OR (If Inhaled therapy not available) •Adrenaline /Terbutaline 0.01mg/kg sc q 20 min x 3 •Commence / Continue rescue steroid •Continuous Assessment every one hour for 3-4 hours
  • 73. E Room management contd…. ASSESSMENT OF RESPONSE TO INITIAL THREAPY: After 3 doses of bronchodilator and oxygen therapy asses child if GOOD RESPONSE:  Free of wheeze, without any breathlessness  Heart rate and respiratory rate decrease.  Auscultation: minimal or no ronchi and PEFR or FEV1 improve to more than 80% of the predicted or personal best.  if response sustained >4 hours after last treatment at room air.  Plan will be: 1. Discharge with Patient education 2. Continue inhaled Beta 2 every 4-6 hours till symptoms abate. 3. continue oral steriods for 3-7 days .
  • 74. E Room management contd…. PARTIAL RESPONSE:  Breathlessness or wheezing reduced but still present  Physical examination:1.HR and RR above physiologic levels. 2.Pulsus paradoxus of 10-15 mm hg 3.O2 saturation 91-95%. 4.PEFR 50-80% of predicted normal. Child who have shown partial response to initial therapy having distress may be continued inhalation therapy with ß2 agonist as frequent as every 20 minutes, even continuously without side effect for next 2 hours. if Ipratropium not added at onset of therapy it can started be at the end of 1st hour.
  • 75. E Room management contd…. PARTIAL RESPONSE:  Who have minimal symptoms after initial therapy could be given inhalation every 2-4 hours.  if child have improved on the on continuation of above therapy for about 2 hours he can observed 4 hours if response sustained 4 hours then discharge with proper advice.  if not responding(PS>3), response is illsustained shift to ward / ICU
  • 76. WARD MANAGEMENT OF ASTHMA • Continue oxygen •Start IV fluids, IV / Orals steriods • Rescue Steroids are IV Hydrocortisone (5-10 mg/kg) q 6 hr or IV Methylprednisolone (1-2 mg/kg)q 6 hr or IV / IM Dexamethasone (0.1-0.2 mg/kg) q 6 hr. Oral prednisolone 1-2 mg/kg for 3-7 days •Nebulie with SA β2 hourly/ back to back •Ipratopium neb q 20 min x 3 and then q 6 hrs if child is stable(PS score 4-6) on above therapy we can wait on same therapy for at least 6-8 hours before intensification of therapy.
  • 77. WARD MANAGEMENT OF ASTHMA CONTD….  Intensify the therapy by adding iv bronchodilator: Magnesium sulphate, Aminophylline, Terbutaline infusion, as per need if not improving  But before intensification check that all the treatment advised and oxygen was being given  Magnesium sulphate dose- 25 -50 mg/kg in 1: 10 dilution of NS & infusion over ½ hour-single dose  Aminophylline Loading dose 5 mg/kg slow IV diluted in 5% dextrose f/b 0.4-1 mg/kg/hr
  • 78. WARD MANAGEMENT OF ASTHMA CONTD….  Terbutaline - initial bolus of 5-10μg /kg over 10 min - f/b 2-10 μg/kg/hr by infusion  Discontinue neb β2 agonist at higher infusion rate  Dissolve 1 ml (500 μg) in 50 ml 5% dextrose (1ml of solution = 10 μg terbutaline) • Monitor SaO2 and Serum K+ • CBC, X- Ray chest only to identify complications. • No subjective or objective improvement child is detoriating (PS SCORE >6) shift to ICU.
  • 79. Indication for transfer of child in ICU  depend upon status of child at time of presentation and response to therapy Indication • life threatening attack • severe distress • shown poor response to therapy • develop sign of impending respiratory failure during therapy like hypoxia hpercarbia (PS SCORE >6)
  • 80. ICU MANAGEMENT ICU Management Continue 1. Oxygen 2. Inhaled short acting Beta agonist every 60 min or continuous + inhaled Anticholinergics. 3. continue systemic rescue steroids. 4. Continue intensified ward plan/ intensify therapy by adding bronchodilator: - Magnesium sulphate Aminophylline, Terbutaline infusion. 5. Continuous monitoring with pulse oximetry and repeated ABG are mandatory since most of these patient are not in condition to perform PEFR 6. If indicated intubate child and start mechanical ventilation
  • 81. ICU MANAGEMENT CONTD…. Indication of mechanical ventilation are:  Failure of maximum pharmacotherapy  Pao2<60 ,Paco2 >50  Minimal chest movements  Minimal air exchange  Severe chest retractions  Deterioration of mental status  Respiratory/ cardiac arrest
  • 82. ICU MANAGEMENT CONTD….  Stabilize with 100% O2 with bag and mask  Do suction and nasogastric decompression  Premedication with atropine and local anesthetic before intubation  Ideal sedative is iv ketamine (midazolam/fentanyl) in dose of 1 to 3 mg/kg.  Paralysis with vecuronium bromide in a dose of 0.2 to 0.3 mg/ kg if required.  Volume cycled ventilators is preferred with low RR ( 8 to 12 / min) and long expiratory time (i:e ratio 1:3 to 1:4), PEEP should be minimal and isnpiratoy flow rate should be kept high to improve gas exchange.  Tidal volume of 10 to 12 ml/kg and PIP less than of 40 to 50 cm of water should be maintained
  • 83. ICU MANAGEMENT CONTD….  Throughout ventilation ß2 agonist are nebulised into isnpiratoy circuit of ventilator if not responding can nebulise with halothane1-1.5%,isoflurane 1%  Once PaCO2 value fall less than 45 mmHg and PIP less than 35 cm H2O or no bronchospasm on auscultation muscle paralysis can be stopped.  As muscle function return to normal patient can be put on spontaneous ventilation if child maintain PaCO2< 45 mmHg child can be extubated.  During recovery phase of asthma, frequency of inhalation therapy should reduced gradually, and shifted to oral medication.
  • 84. Stepping down acute care  Follow the principle “last in first out” o Discontinue terbutaline/aminophylline drip in 24 hrs o Discontinue ipratropium neb in 24-48 hrs o Reduce nebulisation with SA β2 agonist to q 2-4 hrly and then q 4-6 hrly o Replace IV rescue steriod  Oral steroid
  • 85. Discharge Criteria  Pulmonary score index < 3  Sleep well at night  Feeding well  Appears comfortable  Receiving less frequent β2 agonist
  • 86. SEASONAL ASTHMA  Is retrospective diagnosis-based on h/o in last 2-3 years, asthma attack start with onset of particular season and persist during that season till allergen persist otherwise child is normal remaining part of year.  Child can be started on maintenance treatment 2 weeks in advance of start of season.  Medications are given as per the severity of asthma  Child should be examined again after discontinuing meds after season is over
  • 87. EXERSIZE INDUSED ASTHMA  Managed by SABA/LABA/LTRAS  Short acting B agonists are given just before activity as they have short duration of action  Long acting bronchodilators/leukotriane receptor antagonists can be given in the morning
  • 88. Prognosis  The prognosis for asthma vary from child to child  First thing we have to explain to attainder/caregiver that asthma is controllable disease if adequately treated not curable diseases.  60% of children will symptom free after the age 10 year as airway size increase with growth of child but still they should under continuous monitoring they can have repeat attack any time in life so they can not declared cured. especially for children with mild disease.
  • 89. inhalation therapy How do you initiate inhalation therapy?
  • 90. 4 steps 1. Explain advantage of inhalation therapy 2. Dispel myths and fear 3. Select appropriate device 4. demonstrate how to use selected device
  • 91. Advantage of inhalation therapy Inhaled oral Route direct Indirect Dosage smaller higher Onset of action rapid slow Adverse effect mild or none greater Smaller doses, target delivery, quicker action, lesser side effect.
  • 92. Less Drug Without Side effects Straight into the Lungs Advantage of inhalation therapy Salbutamol 4 mg Tabs 40 Puffs of Salbutamol Inhaler
  • 93. Dispelling myths and fear  Is inhalation therapy strong? NO Emphasize micro organism  is inhalation therapy ‘addictive? NO None of drug cause dependence  Is inhalation therapy expensive ? NO Initially but not ultimately  Is inhalation therapy easy to use in children YES First choice, but not last resort !!!
  • 94. When given by inhaled route how much drug does one get Inhaler Device  MDI with spacer  Metered dose inhaler (MDI)  Dry powder inhaler  Nebulizer Delivery 10-15% 5-10% 5-10% 1-5%
  • 95. The right device Criteria for selection  Age  Controller use  Acute episodes
  • 96. Selecting the right device Age  < 3 years – MDI + Spacer + mask  >3 years – MDI + Spacer  >6 years – MDI +Spacer - Dry powder inhaler (DPI) is an option MDI + spacer is the most versatile device
  • 97. Selecting the right device  Controller regimen • Moderate to high dose ICS Use MDI + spacer instead of DPI even in older children
  • 98. Selecting the right device  Acute episodes • Home – MDI + spacer ±mask /DPI • Hospital – MDI + spacer ±mask - nebuliser in severe episodes Do not use DPI in moderate / severe exacerbations
  • 99.  Demonstrate how to use selected devices
  • 100. MDI  The MDI is a device that delivers a specific and pre- metered amount of medication to the lungs, in the form of an aerosol spray that is inhaled by the patient.  Two types -pressure actuated MDI (pMDI) -breath actuated MDI (bMDI)
  • 101. pMDI pMDI)-they require coordination between actuation and inhalation
  • 102. How to Use a Spray Inhaler Teach patients (and parents) how to use inhaler devices. Different devices need different inhalation techniques.  Give demonstrations and illustrated instructions.  Ask patients to show their technique at every visit. Health-care provider should evaluate inhaler technique at each visit.  If an inhalant is not having much effect, it could mean the person is not using it properly or it is blocked or empty. Demonstration of pMDI
  • 103. Click on icon to play Animation Application
  • 104. Breath actuated MDI(bMDI) Breath actuated MDI (bMDI)-this is advance over pMDI. bMDI overcome the problem coordination between actuation and inhalation. It is actuated at low isnpiratoy flow rate Demonstration how to use bMDI
  • 105. spacer  Spacers(some time also called as holding chamber) are devices that hold the medication for few seconds after it has been released from the MDI. Role of spacer  Spacers overcome coordination problem of actuation and inhalation  Increase delivery of drug to lung  can reduce potential side effects.  Dilute taste of inhaled spray  eliminate cold Freon effect When using MDI, Spacer is must
  • 106. Type of spacer Small volume vs large volume Valved vs non valved Polyamide vs polycarbonate
  • 108. Spacers Click on icon to play animation
  • 109. How to clean spacer  they should cleaned once every 15 days  open the lock, separate two halves of spacer.  Pace under simple tape water over 1-2 minute.  put in clean place to become dry
  • 110. Baby mask with spacer Baby mask make it easy to deliver inhaled medicine in children younger 3 years.and those who have difficulty in good seal of lips it is made up of soft silicon and reusable. equiped with exhalation vent.
  • 111. Dry powder inhalation device(DPIs)  DPIs, as their name implies, dispense medication as dry powder formulation without the use of propellant as in MDI.  DPIs disperse medication as dry powder(2-5 µm) without use of propellant.  DPIs are breath actuated so no coordination problem between actuation and inhalation.  Used above 6 years  Two types -unit dose DPIs( rotahaler and revoliser) -multi dose DPIs(multihaler)
  • 112. Rotahaler(single dose DPI device) Technique of use of Rotahaler DPI devices
  • 113. Click on icon to play animation A pplication Rotahaler should clean twice a week. Separate two halves of rotahaler keep in running tape water over 1-2 minute. Put at clean place to become dry.
  • 114. How to clean DPI  Rotahaler should clean twice a week.  Separate two halves of rotahaler.  keep in running tape water over 1-2 minute.  Put at clean place to become dry.  Revolizer should clean once a week
  • 116. Revolizer(single dose DPI device) The Revolizer is new generation patient friendly dry powder inhaler device that is easy to use. Technique of use of Revolizer DPI devices Simply open the Revolizer, insert the rotacap, shut the device and inhales
  • 118. How to use multihaler Advantage of multihaler
  • 119. Nebuliser  Nebulizer is device used for converting a liquid drug into a fine mist which inhaled directly into the lungs via face mask or mouth piece.  Nebulisation chamber are small plastic device into which drug solution is placed.  The device is driven by compressor (electric/battery operated)or oxygen.  Gas flow of 6-8 L/min is normally required to drive the nebuliser.  Drug inhalation is accomplished by normal tidal breathing over 5-10 minutes.
  • 122. Advantage of nebuliser  No efforts required ;needs only tidal breathing.  A large dose of drug can be administered simply and effectively. Indication of nebuliser - emergency treatment of acute severe asthma  Delivery of drug in diseases like cystic fibrosis  home treatment for patient who are too ill, short of breath, or otherwise unable to use hand-held inhalers.
  • 123. FILLING YOUR NEBULISER  Plug the compressor unit into the mains. Connect the tubing from the compressor unit to the bottom of the nebuliser chamber.  Unscrew the top of the nebuliser chamber. Open the vial of drug solution by twisting off the top. Measure out the correct amount of drug solution and pour into the nebuliser chamber.  Sometimes you may need to dilute the drug solution. Add normal saline to make total solution 3-5ml which is required in the nebuliser chamber for it to work properly.  Screw on the top of the nebuliser chamber and attach the face mask or mouthpiece to the top of the chamber.
  • 124. USING YOUR NEBULIZER  Place the facemask over patient mouth and nose and place the strap over your head.  Sit up, well supported, in a chair or in bed and keep the nebulizer chamber upright.  Switch the compressor unit on and breath in and out as normal. Relax whilst using nebuliser. .  Nebulisation usually completed in 5-10 minute. A small amount of solution may be left in the nebuliser at this stage, but this is normal.  Switch off the compressor unit and disconnect the nebuliser chamber from the tubing.
  • 125. CLEANING NEBULISER  Each time you use it, wash the nebuliser chamber in warm soapy water and then rinse thoroughly with clean water. Do not use a brush to clean the nebuliser chamber as you may damage it.  Reconnect the nebuliser chamber to the tubing and blow air from the compressor unit through it for a few seconds. This will dry the nebuliser chamber and tubing. Disconnect the nebuliser chamber from the tubing and allow it to dry completely. Disconnect the tubing from the compressor unit.  Once a week, rinse the nebuliser chamber with a dilute solution of Milton or a special nebuliser cleaner. Rinse the nebuliser chamber with clean water and then dry as before.  Tubing and nebulisation chamber should be replaced every six months or so.
  • 126. Factors Involved in Non-Adherence  Medication Usage  Difficulties associated with inhalers  Complicated regimens  Fears about, or actual side effects  Cost  Distance to pharmacies  Non-Medication Factors  Misunderstanding/lack of information  Fears about side-effects  Inappropriate expectations  Underestimation of severity  Attitudes toward ill health  Cultural factors  Poor communication
  • 127. Never overuse Reliever  More reliever needed, worse the asthma  Maximum recommended dose of nebulised salbutamol at a time is 10 mg  Overdosage : tachycardia with rates up to 200 beats per minute and arrhythmias  Cardiac arrest and even death
  • 128. If your patient needs to use a reliever medication every day, or even more than three or four times a week, preventive/controller medication must be added to the treatment plan
  • 129. The Peak Flow Meter • Useful to show reversibility and & Monitoring of treatment • like a thermometer for asthma to measure PEFR • Economical handy instrument • Builds confidence in treatment • Gives objective values • One ‘hard, fast blow’ Click on icon to start Animation
  • 130. PEAK EXPIRATORY FLOW RATE MONITORING  Home monitoring ; for moderate to severe persistent asthma  Normal PEFR ranges are determined by patient's age, gender and height  Zone classification GREEN ( DOING WELL ) PEFR 80 -100% ;clear , no symptoms; can do usual activities YELLOW (ASTHMA GETTING WORSE) PEFR 50-80%;cough,wheeze,chest tightness, shortness of breath; waking at night due to asthma; can do some, but not all activities RED (MEDICAL ALERT) PEFR < 50 %;very short breath; cannot do usual activities
  • 131. Doxofylline  Doxofylline is long acting oral methylxanthine derivative.  Doxofylline is phosphodiesterase inhibitors has antitussive and bronchodilator affects  Unlike other xanthines, doxofylline lacks any significant affinity for adenosine receptors and does not produce stimulant effects.. Indication  For maintenance therapy in Asthma and COPD. Side Effects  it has shown similar efficacy to theophylline but with significantly less side effects. Dosages  Children-6mg/kg/dose bd.  Adult:400mg od to tds.
  • 132. Acebrophylline  ambroxol-theophylline-7-acetate  has 3 actions namely bronchodilation, mucoregulation & anti-inflammatory action. Indicatio  asthmatic bronchitis, Acute & Chronic bronchitis. Contraindication  Hypersensitivity to ambroxol, theophylline,acebrophylline  Patient with hemodynamic instability,hypotensionand arrhythmias.  Patient with renal and liver disorder.
  • 133. Acebrophylline Side Effects Epigastric pain  Unlike other xanthine derivatives it has minimum side effects like palpitations & tachycardia. Dosage  In children 2-3 years is 2mg/kg/day two divided doses  In children 3-12 years dose is 2-3.5mg/kg/day two divided doses  1 cap 100mg bd two week  Available as cap. 100mg,syrup100 ml (1ml-10mg)
  • 134. Bambuterol  oral LABA  prodrug of terbutaline (Bambec and Oxeo) Indications  Used in chronic persistent asthma as controller  It should not be used single therapy. Contraindications  pregnancy, seriously impaired liver function. Adverse effects  similar to that of Salbutamol Dose- oral 10/20 mg od. Recommended above 12 years of age
  • 135. Allergen-specific Immunotherapy  Greatest benefit of specific immunotherapy using allergen extracts has been obtained in the treatment of allergic rhinitis  The role of specific immunotherapy in asthma is limited (anti IgE, Omalizumab)  Specific immunotherapy should be considered only after strict environmental avoidance and pharmacologic intervention, including inhaled glucocorticosteroids, have failed to control asthma  Perform only by trained physician
  • 136. OMALIZUMAB Humanised monoclonal Anti IGE MOA:- It binds to IgE antibody and reduces the amount of free IgE available to mast cells, basophils and other cells. Indication Add ON therapy for moderate to severe asthma Dosage:-  150-375 mg intradermal or subcutaneous every 2-4 Weeks children > 12 yr age side effects:- Hypersensitivity risk of increased incidence of parasitic infection and malignancy Disadvantage:- costly
  • 137. Newer drugs in asthma control Altrakincept:  IL-4 receptor antagonist which have important role in pahogenesis of asthma  Soluble recombinant IL-4 receptor which acts as an antagonist in vivo inactivates naturally occurring IL-4 without mediating cellular activation.  Nebulized form of IL-4R has a serum half-life of 1 week. Single dose of IL-4 R, 1500 mcg. per week, appears safe  and effective in moderate asthma. Mepolizumab:  anti IL-5 antibody.  It has been postulated to decrease eosinophil infiltration and is particularly useful in hypereosinophilic syndromes. Dose being 750mg/dose iv. for 3 infusions.
  • 138. Suplatast tosilate:  It is a Dimethyl sulphonium compound  It selectively inhibits Th-2 cytokines.  There is a notable drop in the average number of infiltrating eosinophils and CD4+ cells. dosage:-100 mg tds. Efalizumab:  It is a humanized IgG1 mAb against the lymphocyte function antigen-1 (LFA-1) . Blocking of LFA- 1/intercellular adhesion molecule interactions could inhibits the development of allergen-induced cellular inflammatory response that inhibit the late asthmatic response Newer drugs in asthma control
  • 139. Newer drugs in asthma control Resquimod:  Resiquimod is a new immune response modifier from the family of imidazoquinolineamines.  It inhibits allergen induced Th-2 response, airway inflammation and airway reactivity.  Has antiviral activity can used ingenital warts, herpes genitalis and molluscumcontagiosum.  can be administered topically and orally IDEC -152  IgG1 anti-CD23 antibody  in patients with mild-to-moderate persistent allergic asthma.
  • 140. Ciclesonide, Rofleponide  On site activated steroids: e.g.. Ciclesonide, Rofleponide (under study).  Soft steroids: They have improved local, topical selectivity and have much less steroid effect outside target area.
  • 141. Pranlukast  Newer generation of leukotriene receptor antagonist  Pranlukast is a cysteinyl leukotriene receptor-1 antagonist.  This drug works similarly to montelukast.  appear to be equally effective  It is currently under clinical trials
  • 142. Advantage of various drug fixed combination Advantages  Simpler dosage schedule improves compliance and therefore improves treatment outcomes  Reduces inadvertent medication error  Less expensive than single ingredient drugs  Potential for drug abuse can be minimized by using one drug of the combination for this purpose.  Eliminates drug shortages by simplifying drug storage and handling, and thus lowers risk of being “out of stock”
  • 143. Advantage of various drug fixed combination  Only 1 expiry date simplifies dosing (single products may have different expiry dates)  Procurement, management and handling of drugs is simplified  Lower packing and shipping costs  Side effects are reduced by using one drug of the combination for this purpose
  • 144. Disadvantage of various drug fixed combination  Dosing is inflexible and cannot be regulated to patient’s needs (each patient has unique characteristics such as weight, age, pharmacogenetics, co-morbidity, that may alter drug metabolism and effect).  If a patient is allergic or has a side-effect to 1 component,the FDC must be stopped and replaced by separate inhaIer  incompatible pharmacokinetics is irrational because of different elimination ½ lives of individual components
  • 145. Various drug combination formulation Inhaler (foracort-100) Inhaler (foracort-200) Inhaler (foracort-400) DPI (rotacap-200) DPI (rotacap-200) DPI (rotacap-400) formetrol+budesonide  6mcg+100mcg  6mcg+200mcg  6mcg+400mcg  6mcg+200mcg  6mcg+200mcg  6mcg+400mcg
  • 146. Various drug fixed combination Inhaler(maxiflow-125) Inhaler(maxiflow-250) DPI(maxiflow-100) DPI(maxiflow-250) Inhaler(fullform-100) Inhaler(fullform-200) DPI(Fullform-200) DPI(Fullform-400) Fluticasone+formoterol  125mcg+6mcg  250mcg+6mcg  100mcg+6mcg  250mcg+6mcg beclomethasone+Formoterol  100mcg+6mcg  200mcg+6mcg  200mcg+6mcg  400mcg+6mcg Formulation
  • 147. Various fixed drug combination formulation  Respule(Duolin)  Inhaler(Duolin)  DPI(Duolin) Levosalbutamol+ipratropium  1.25mg+500mcg/2.5ml  50mcg+25mcg/puff  100mcg+50mcg/rotacap There are some of irrational combination in market like-Aerocort inhaler /rotacap contain beclomethasone and Levosalbutamol one controller medication and other is reliever medication which is irrational combination
  • 148. “Be alert to the faults of patients which make them lie about their taking of the prescribed medicines, and when things go wrong, refusing to confess that they have not been taking their medicine.” - Hippocrates, ‘The Father of Medicine’, 200 BC
  • 149. THANKS