Childhood asthma

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  • Based on observational studies, it is the opinion of the Expert Panel 2 that the initiation of long-term control therapy should be considered in infants and young children who have had more than 3 episodes of wheezing in the past year that have lasted more than 1 day and affected sleep, and who have risk factors for the development of asthma (parental history of asthma or physician-diagnosed atopic dermatitis or 2 of the following: physician-diagnosed allergic rhinitis, wheezing apart from cold, peripheral blood eosinophilia). This is in addition to previously recommended indications for starting long-term control therapy—ie, in infants and young children requiring symptomatic treatment more than 2 times per week or experiencing severe exacerbations less than 6 weeks apart.
  • Once asthma is brought under control, consideration should be given to stepping down therapy by either decreasing dosage (eg, of an inhaled corticosteroid) or eliminating part of the combination therapy. An adequate period should be given for the maintenance of asthma control before considering stepping down, however. This is somewhat arbitrary, but it is generally recommended that symptomatic control for at least (in milder asthma) 2 to 3 months after initial therapy should be maintained prior to consideration of stepping down. Stepping down may include the possibility of decreasing the frequency of medication as a way to enhance adherence and decrease dosage at the same time. Asthma is a dynamic and often fluctuating disorder that may require step-up and step-down therapy periodically. The entire step-up and step-down process implies the need for regular monitoring of patients, the frequency of which is dictated by the stability of asthma and degree of asthma control possible. Reassessment includes carefully eliciting evidence of symptomatic control and measuring airflow objectively. Although symptoms can reflect lung functions, it is important to emphasize the imperfect relationship between airflow limitation and symptoms, with a wide range among the patient population of perceived degree of airflow limitation. Review of adherence, the ability to use medication properly, and other aspects of therapy are also important on a repeated basis.PEFR = peak expiratory flow rate
  • Childhood asthma

    1. 1. CHILDHOOD ASTHMA • • Moderator : Dr. Seema And Dr. Sandesh Presenter : Dr. Ajay
    2. 2. Definition : • A chronic inflammatory disease of the airways that develops under the allergens influence. • Bronchial hyper responsiveness and reversible obstruction. • Manifests with attacks of dyspnea, breathlessness, cough, wheezing, chest tightness and sibilant rales more expressed at breathing-out.
    3. 3. ETIOLOGY : Respiratory exposures : • 1.Inhaled allergens, • 2. respiratory viral infections, and • 3. chemical and biologic air pollutants - environmental tobacco smoke. Genetics : More than 100 genetic loci have been linked to asthma. Important ones are : • 1. Proinflammatory genes (the interleukin [IL]-4 gene cluster on chromosome 5). • 2. ADAM-33 (member of the metalloproteinase family) • 3. The gene for the prostanoid DP receptor. • 4. Genes located on chromosome 5q31 (possibly IL-12). Environment : • Common respiratory viruses, including respiratory syncytial virus, rhinovirus, influenza virus, adenovirus, parainfluenza virus, and human metapneumovirus. • Indoor and home allergen exposures • Tobacco smoke and air pollutants (ozone, sulfur dioxide)
    4. 4. Epidemiology : • In 2007, 9.6 million children (13.1%) had been diagnosed with asthma . Boys 14% vs girls10% • An increase in asthma prevalence of about 50% per decade. • More prevalent in 1. Modern metropolitan locales and 2. More affluent nations. • In contrast, children living in rural areas of developing countries and farming communities are less likely to experience asthma and allergy, although childhood asthma in less affluent nations seems more severe.
    5. 5. Predictors of Asthma : Major : 1. Parent asthma. 2. Eczema.(Atopic Dermatitis) 3. Inhalant allergen sensitization. Minor: 1.Allergic rhinitis. 2. Wheezing apart from colds. 3. ≥4% eosinophils. 4. Food allergen sensitization.
    6. 6. Types of Childhood Asthma : • There are 2 main types of childhood asthma: • (1) recurrent wheezing in early childhood, primarily triggered by common viral infections of the respiratory tract, and • (2) chronic asthma associated with allergy that persists into later childhood and often adulthood. • A 3rd type of childhood asthma typically emerges in females who experience obesity and early-onset puberty (by 11 yr of age).
    7. 7. Pathophysiology : • Chronic inflammatory disorder. Airway hyper responsiveness and airflow limitations. Acute bronchoconstriction, airway edema, mucous plug formation and airway remodeling. • Immediate and delayed responses Early phase-mast cell mediators (Histamine, leukotrienes, prostaglandins and thormboxanes) Late phase- cytokines (eosinophils, basophils, lymphocytes and mast cells) • Chronic inflammation• Smooth muscle hyperplasia, bronchial hyper responsiveness and increased collagen deposition.
    8. 8. Asthma is primarily an inflammatory disease Smooth muscle spasm Airway edema Mucous plugging
    9. 9. Inflammatory cytokines Activated mast cells and lymphocytes produce proinflammatory cytokines (histamine, leukotrienes, PAF), which are increased in asthmatics’ airways and bloodstream
    10. 10. Irritable and damaged airway Hypersecretion Epithelial damage with exposed nerve endings Hypertrophy of goblet cells and mucus gland
    11. 11. The irritable and inflamed airway is susceptible to obstruction triggered by : Allergens Infections Irritants including smoke Exercise Emotional stress GE reflux Drugs Other factors
    12. 12. Clinical manifestation and Diagnosis : Symptoms • Wheezing. (All wheeze is not asthma ) • Breathlessness. • Cough, productive or dry. • Chest discomfort. Pattern of symptoms • Perennial/seasonal. • Episodic/continual. • Diurnal. Severity of symptom classification • Number of symptom episodes per week • Number of nocturnal symptoms per month • Objective measures of lung function (forced expiratory volume in one second [FEV1], Peak expiratory flow rate [PEFR] .
    13. 13. Diagnosis: • Key Points: • • The diagnosis of asthma is based on the patient's medical history, physical examination. • Pulmonary function tests and laboratory test results. • Other historical components • • Emergency department visits and hospitalization • • Medication use (especially oral steroids) • • Lung function, PEFR variability • • Associated comorbidities, e.g., rhinitis, sinusitis, gastroesophageal reflux (GERD)
    14. 14. EVALUATION OF ASTHMA EXACERBATION SEVERITY IN THE URGENT OR EMERGENCY CARE :SYMPTOMS AND SIGNS
    15. 15. EVALUATION OF ASTHMA EXACERBATION SEVERITY IN THE URGENT OR EMERGENCY CARE :FUNCTION ASSESSMENT
    16. 16. DIFFERENTIAL DIAGNOSIS OF CHILDHOOD ASTHMA : UPPER RESPIRATORY TRACT CONDITIONS Allergic rhinitis* Chronic rhinitis* Sinusitis* Nasal foreign body MIDDLE RESPIRATORY TRACT CONDITIONS Laryngotracheobronchomalacia* Laryngotracheobronchitis (e.g., pertussis)* Vocal cord dysfunction* Vocal cord paralysis Tracheoesophageal fistula Vascular ring, sling, or external mass compressing on the airway (e.g., tumor) Foreign body aspiration* Chronic bronchitis from environmental tobacco smoke exposure*
    17. 17. D/Diagnosis (cont.) • LOWER RESPIRATORY TRACT CONDITIONS Bronchopulmonary dysplasia (chronic lung disease of preterm) Viral bronchiolitis* Gastroesophageal reflux* Causes of bronchiectasis: Cystic fibrosis Bronchiolitis obliterans Pulmonary eosinophilia, Churg-Strauss vasculitis Pulmonary hemosiderosis Pneumonia Pulmonary edema (e.g., congestive heart failure) Medications associated with chronic cough(ach inhibitors) β-Adrenergic antagonists
    18. 18. Laboratory Findings: • Pulmonary Function Testing: • Spirometry: (feasible in children > 6 yr of age ) 1. FEV1 2.FVC 3.FEV1/FVC LUNG FUNCTION ABNORMALITIES IN ASTHMA • Spirometry (in clinic): Airflow limitation: Low FEV1 (relative to percentage of predicted norms) FEV1/FVC ratio <0.80 Bronchodilator response (to inhaled β-agonist): Improvement in FEV1 ≥12% and ≥200 mL* Exercise challenge: Worsening in FEV1 ≥15%* Daily peak flow or FEV1 monitoring: day to day and/or amto-pm variation ≥20%*
    19. 19. PEF Monitoring :
    20. 20. Radiolo gy Chest radiographs (posteroanterior and lateral views) in children with asthma often appear to be normal. Helpful in identifying abnormalities that are hallmarks of asthma masqueraders . • Aspiration pneumonitis, • Bronchiolitis obliterans • Atelectasis, • Pneumomediastinum, • Pneumothorax
    21. 21. Laboratory findings(cont.) • Bronchoprovocation challenges. • Exercise challenges. • In asthmatic patients, FEV1 typically decreases during or after exercise by >15% • Measuring exhaled nitric oxide (FENO), • Peak expiratory flow (PEF) monitoring.
    22. 22. Treatment : • The National Asthma Education and Prevention Program's Expert Panel Report 3 (EPR3): Guidelines for the Diagnosis and Management of Asthma 2007
    23. 23. Management of asthma have the following components: • (1) Assessment and monitoring. • (2) Provision of education to parents for the self-management. • (3) Identification and management of precipitating factors and co-morbid conditions. • (4) Appropriate selection of medications. • The long-term goal of asthma management is attainment of optimal asthma control.
    24. 24. Component 1: Regular Assessment and Monitoring Concept based on. 1. Asthma severity 2. Asthma control 3. Asthma Responsiveness
    25. 25. Asthma Severity : • Assessing asthma severity directs the initial level of therapy. Two general category are made. 1. Intermittent asthma. 2. Persistent asthma. Sub group are: 1. Mild 2. Moderate 3 Severe
    26. 26. Classification of asthma severity contd :
    27. 27. Asthma control : •It measures degree to which : • • • • • Symptoms, Ongoing functional impairments, Risk of adverse events are minimized and Goals of therapy are met. Classification • 1.well controlled • 2.Not well controlled • 3.Very poorly controlled
    28. 28. Assessing Asthma control and adjusting therapy:
    29. 29. Recommended action for Treatment:
    30. 30. Component 2: Patient Education 1. 2. 3. 4. Telling pathophysiology of asthma in plain language. Reassurance. Parental education regarding asthma triggers. Maintaining proper record of child's symptoms, sleep disturbance ,absence from school due to illness, medication required. 5. Making parents understand how medicines work and side effect. 6. PEF monitoring at home . 7. Self-monitoring and self-management skills . 8. Written asthma management plan. 9. Regular follow-up visits . 10. Adherence to treatment.
    31. 31. Component 3: Control of Factors Contributing to Asthma Severity • Eliminate or reduce problematic environmental exposures. • Allergen exposure elimination or reduction in sensitized asthmatic patients: • Animal danders 1. Dust mites 2. Cockroaches 3.Molds Other airway irritants 1.Wood- or coal-burning smoke 2.Strong chemical odors and perfumes Treat co-morbid conditions: 1. Rhinitis 2.Sinusitis 3.GERD Annual influenza vaccination (unless patient is egg-allergic)
    32. 32. Component 4: Principles of Asthma Pharmacotherapy • Goal of therapy is to reduce the components of both impairment and risk. • Impairment: 1.Preventing chronic symptoms. 2.Allowing infrequent need of medications 3.Maintaining “normal” lung function, 4.Maintaining normal activity levels including physical activity and school attendance, 5.Meeting families expectations and satisfaction with asthma care. Risk : 1. Preventing recurrent exacerbations. 2. Reduced lung growth. 3. Medications’ adverse effects.
    33. 33. Notes: • The stepwise approach is meant to assist, not replace, the clinical decision. • If alternative treatment is used and response is inadequate, discontinue it and use the preferred treatment before stepping up. • If clear benefit is not observed within 4-6 wks consider adjusting therapy or alternative diagnosis. • Clinicians who administer omalizumab should be prepared and equipped to treat anaphylaxis that may occur. • Theophylline is a less desirable alternative due to the need to monitor serum concentration levels • Zileuton is less desirable alternative due to limited studies.
    34. 34. Infants and Young Children— When to Start Controllers >3 episodes of wheezing in the last year, and Parental history of asthma or physician diagnosis of eczema Or 2 of the following:  Physician diagnosis of allergic rhinitis, wheezing apart from colds, peripheral eosinophilia  Courses of oral steroids more often than every 6 weeks  Symptoms >2 times per week, nocturnal symptoms >2 times per month
    35. 35. Step-down Therapy : Step down once control is achieved: After 2–3 months 25% reduction over 2–3 months Follow-up monitoring: Every 1–6 months Assess symptoms. Review medication use. Objective monitoring (PEF or spirometry) Review medication.
    36. 36. Long-Term Controller Medications : • ICS • LABA • Leukotriene modifiers • Nonsteroidal anti-inflammatory agents • Sustained-release theophylline. • An anti-IgE preparation, omalizumab (Xolair) for children >12 yr old.
    37. 37. Dosage for long term controller medication:
    38. 38. Dosage contd :
    39. 39. Dosage contd.
    40. 40. Risk assessment for corticosteroid therapy: Risk Factos 1.Presence of other chronic illness(es). 2. Medications (corticosteroids, anticonvulsants, heparin, diuretics). 3. Low body weight. 4. Family history of osteoporosis. 5 .Significant fracture history disproportionate to trauma. 6. Recurrent falls. 7. Impaired vision. 8. Low dietary calcium and vitamin D intake, and 9. Lifestyle factors (decreased physical activity, smoking, and alcohol)
    41. 41. Conditions Recommendations LOW RISK ≤ 1 risk factor Low- to medium-dose ICS 1.Montor BP, weight,height. 3. Regular physical exercise 4. adequate dietary calcium and vitamin D. 5. Avoid smoking and alcohol. Medium risk 1.if > 1 risk factor 2.High-dose ICS 3.At least 4 courses oral corticosteroid/yr As above, plus 1.Yearly opthalmological evaluation. 2. Baseline bone densitometry (DEXA scan) High risk 1Chronic systemic corticosteroids 2. ≥ 7 oral corticosteroid burst treatments/year 3. Very-high-dose ICS As above, plus 1.DEXA scan. 2. Bone age assessment 3.CHG 4.S.Ca+2,Po+4,ALP. 5. Testosterone in males,Vit D, estradiol in amenorrheic premenopausal women,parathyroid hormone, and osteocalcin.
    42. 42. Delivery Devices and Inhalation Technique: 1. Aerosolized form in a metered-dose inhaler. 2. Dry powder inhaler. 3. Suspension or solution form delivered via a nebulizer.
    43. 43. MDI : 1. Simple and inexpensive 2. Decrease the coordination required to use MDIs 3. Improve the delivery of inhaled drug 4. Minimize the risk of propellant-mediated adverse effects (thrush) 5. No waiting time between puffs of medication is needed DPI 1.Popular because of their simplicity of use. 2. Albeit adequate inspiratory flow is needed 3. Breath-actuated 4. Spacers are not needed. Nebulizer Mainstay of aerosol treatment for infants and young children Advantage: simple technique Disadvantages Need for a power source, Inconvenience in that treatments take about 5 min, and expensive. Potential for bacterial contamination.
    44. 44. Prognosis : • Recurrent coughing and wheezing occurs in 35% of preschool-aged children. Of these, approximately one third continue to have persistent asthma into later childhood, and approximately two thirds improve on their own through their teen years. • Asthma severity by the ages of 7-10 yr of age is predictive of asthma persistence in adulthood. • Children with moderate to severe asthma and with lower lung function measures are likely to have persistent asthma as adults.
    45. 45. Prevention : • Conventional anti-inflammatory interventions—the cornerstone of asthma control. • Early immunomodulatory intervention might prevent asthma development. • Nonpharmacotherapeutic measures with numerous positive health benefits,which might reduce the development of Asthma : 1.Avoidance of environmental tobacco smoke. 2.Prolonged breastfeeding (>4 mo). 3.An active lifestyle. 4. A healthy diet.
    46. 46. Thank you

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