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
Moderator : Dr. Seema And Dr. Sandesh
Presenter : Dr. Ajay
A chronic inflammatory disease of the airways
that develops under the allergens influence.
Bronchial hyper responsiveness and reversible
Manifests with attacks of dyspnea,
breathlessness, cough, wheezing, chest tightness
and sibilant rales more expressed at breathing-out.
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
• 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).
• 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)
• 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
Types of Childhood
• 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).
• 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
• Chronic inflammation• Smooth muscle hyperplasia, bronchial hyper responsiveness and
increased collagen deposition.
Asthma is primarily an inflammatory disease
Smooth muscle spasm
Activated mast cells and lymphocytes produce proinflammatory cytokines (histamine, leukotrienes, PAF), which
are increased in asthmatics’ airways and bloodstream
Irritable and damaged airway
Epithelial damage with exposed nerve endings
Hypertrophy of goblet cells and mucus gland
The irritable and inflamed airway is
susceptible to obstruction triggered by
Irritants including smoke
and Diagnosis :
(All wheeze is not asthma )
• Cough, productive or dry.
• Chest discomfort.
Pattern of symptoms
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
Peak expiratory flow rate [PEFR] .
• Key Points:
• • The diagnosis of asthma is based on the patient's medical history,
• 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
EVALUATION OF ASTHMA
EXACERBATION SEVERITY IN THE
URGENT OR EMERGENCY CARE
:SYMPTOMS AND SIGNS
EVALUATION OF ASTHMA EXACERBATION
SEVERITY IN THE URGENT OR EMERGENCY
CARE :FUNCTION ASSESSMENT
CHILDHOOD ASTHMA :
UPPER RESPIRATORY TRACT CONDITIONS
Nasal foreign body
MIDDLE RESPIRATORY TRACT CONDITIONS
Laryngotracheobronchitis (e.g., pertussis)*
Vocal cord dysfunction*
Vocal cord paralysis
Vascular ring, sling, or external mass compressing on the airway
Foreign body aspiration*
Chronic bronchitis from environmental tobacco smoke exposure*
• Pulmonary Function Testing:
• Spirometry: (feasible in
children > 6 yr of age )
LUNG FUNCTION ABNORMALITIES
• 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
Daily peak flow or FEV1
monitoring: day to day and/or amto-pm variation ≥20%*
(posteroanterior and lateral
views) in children with asthma
often appear to be normal.
Helpful in identifying
abnormalities that are hallmarks
of asthma masqueraders .
• Exercise challenges.
• In asthmatic patients, FEV1
typically decreases during or
after exercise by >15%
• Measuring exhaled nitric oxide
• Peak expiratory flow (PEF)
• The National Asthma Education and Prevention Program's Expert
Panel Report 3 (EPR3): Guidelines for the Diagnosis and Management
of Asthma 2007
Management of asthma have the
• (1) Assessment and monitoring.
• (2) Provision of education to parents for the self-management.
• (3) Identification and management of precipitating factors and co-morbid
• (4) Appropriate selection of medications.
• The long-term goal of asthma management
is attainment of optimal asthma control.
Regular Assessment and
Concept based on.
1. Asthma severity
2. Asthma control
3. Asthma Responsiveness
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:
Asthma control :
•It measures degree to which :
Ongoing functional impairments,
Risk of adverse events are minimized and
Goals of therapy are met.
• 1.well controlled
• 2.Not well controlled
• 3.Very poorly controlled
Assessing Asthma control and adjusting
Telling pathophysiology of asthma in plain language.
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.
Control of Factors Contributing to
• Eliminate or reduce problematic environmental exposures.
• Allergen exposure elimination or reduction in sensitized asthmatic patients:
• Animal danders
1. Dust mites
Other airway irritants
1.Wood- or coal-burning smoke
2.Strong chemical odors and perfumes
Treat co-morbid conditions:
Annual influenza vaccination (unless patient is egg-allergic)
Component 4: Principles of
• Goal of therapy is to reduce the components of both impairment and risk.
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
5.Meeting families expectations and satisfaction with asthma care.
1. Preventing recurrent exacerbations.
2. Reduced lung growth.
3. Medications’ adverse effects.
• 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
• 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
• Zileuton is less desirable alternative due to limited studies.
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
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
Step-down Therapy :
Step down once control is achieved:
After 2–3 months
25% reduction over 2–3 months
Every 1–6 months
Review medication use.
Objective monitoring (PEF or spirometry)
• Leukotriene modifiers
• Nonsteroidal anti-inflammatory agents
• Sustained-release theophylline.
• An anti-IgE preparation, omalizumab (Xolair) for children >12 yr old.
Risk assessment for corticosteroid
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)
≤ 1 risk factor
Low- to medium-dose ICS
1.Montor BP, weight,height.
3. Regular physical exercise
4. adequate dietary calcium and vitamin
5. Avoid smoking and alcohol.
1.if > 1 risk factor
3.At least 4 courses oral corticosteroid/yr
As above, plus
1.Yearly opthalmological evaluation.
2. Baseline bone densitometry (DEXA
1Chronic systemic corticosteroids
2. ≥ 7 oral corticosteroid burst
3. Very-high-dose ICS
As above, plus
2. Bone age assessment
5. Testosterone in males,Vit D, estradiol
in amenorrheic premenopausal
women,parathyroid hormone, and
Delivery Devices and Inhalation
1. Aerosolized form in a metered-dose inhaler.
2. Dry powder inhaler.
3. Suspension or solution form delivered via a nebulizer.
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
1.Popular because of their simplicity of use.
2. Albeit adequate inspiratory flow is needed
4. Spacers are not needed.
Mainstay of aerosol treatment for infants and young children
Need for a power source,
Inconvenience in that treatments take about 5 min, and expensive.
Potential for bacterial contamination.
• 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.
• Conventional anti-inflammatory interventions—the cornerstone of
• Early immunomodulatory intervention might prevent asthma
• 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.