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Approach to Chronic wheezing & asthma an update 2013

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Approach to Chronic wheezing & asthma an update 2013

  1. 1. ” Approach to Chronic Wheezing & Asthma Mostafa Moin MD Professor of Allergy & Clinical Immunology Immunology , Asthma & Allergy Research Institute ( IAARI ) Children Medical Center Tehran University of Medical Sciences 2013
  2. 2. The Prevalence of Wheezing in Pre-School Children “ a continuous, high pitched musical sound coming from the chest” Prevalence (%) 80 Wheezing ≥50% 70 Atopic (n=94) Non-atopic (n=59) 60 50 Cough : 100% 40 30 20 10 0 1 2 3 4 5 6 7 8 9 10 11 12 13 Age (years) Illi S, von Mutius E, Lau S, et al. Perennial allergen sensitisation early in life and chronic asthma in children: a birth cohort study. Lancet. 2006;368(9537):763–770
  3. 3. Worldwide Prevalence of Asthma
  4. 4. A systemic review of recent asthma surveys in Iranian children Ch Resp.Dis , 2009:6(2):109-14
  5. 5.    ISAAC        
  6. 6. Asthma Predictive Index 77% Predictive Identify high risk children (2 and 3 yr of age): ≥3-4 wheezing episodes in the past year (at least one must be MD diagnosed) PLUS One major criterion OR • Parent with asthma • Atopic dermatitis • Aero-allergen sensitivity Two minor criteria • Food sensitivity • Eosinophilia (≥4%) • Wheezing not related to infection Modified from: Castro-Rodriguez JA, Holberg CJ, Wright AL, et al. A clinical index to define risk of asthma in young children with recurrent wheezing. Am J Respir Crit Care Med. 2000;162(4 Pt 1):1403–1406
  7. 7. Diagnostic approach 1 - Clinical suspicion! 2 - History with focus on symptom patterns 3 - Physical examination for signs of asthma & allergies 4 - Confirm diagnosis with objective measurement of pulmonary function(Spirometry) 5 - Allergy testing 6 – Other possibly useful tests 7– Clinical response to treatment 9
  8. 8. 1 - Clinical Suspicion Suspect Asthma!  Suspect asthma in patients who have      repeated diagnoses of respiratory illnesses as : Reactive airway diseaes Bronchitis Previous health records Croup are Pneumonia impotant! Bronchiolitis Always maintain a high index of suspicion for asthma. 10
  9. 9. Diagnostic approach 1 - Clinical suspicion! 2 - History with focus on symptom patterns 3 - Physical examination for signs of asthma & allergies 4 - Confirm diagnosis with objective measurement of pulmonary function(Spirometry) 5 - Allergy testing 6 – Other possibly useful tests 7– Clinical response to treatment 11
  10. 10. Key History Points         Symptoms Pattern of Symptoms Precipitating Factors (Triggers) Development of Disease Living Situation Disease Impact Patient`s Perception Family & Medical History 12
  11. 11. 2 - Clinical history : Wheezing Asthma? Wheezing with URIs is very common in small children but :  Many of these children will not develop asthma.  Asthma medications may benefit patients who wheeze whether or not they have asthma. All that wheezes is not asthma & many asthmatics do not wheeze! 13
  12. 12. 2 - Clinical history : Cough - Asthma? Consider asthma in children with:  Recurrent episodes of cough with or without wheezing  Nocturnal awakening because of cough  Cough that is associated with exercise/play Cough may be the only symptom Present in patients with asthma(CVA) 14
  13. 13. Exercise Induced Bronchospasm(Asthma)
  14. 14. 2 - Clinical history : Asthma triggers Respiratory Infections Drugs: NSAIDS Beta blockers Irritants Endocrine Weather changes Cold air Airway Inflammation Pets Additives Environment Exercise Emotion
  15. 15. Diagnostic approach 1 - Clinical suspicion! 2 - History with focus on symptom patterns 3 - Physical examination for signs of asthma & allergies 4 - Confirm diagnosis with objective measurement of pulmonary function(Spirometry) 5 - Allergy testing 6 – Other possibly useful tests 7– Clinical response to treatment 17
  16. 16. 3 - Physical Examination  Respiratory examination • Evidence for obstructive respiratory disease • -R.R , R.distress , Chest deformity, Cough , Wheeze ,… May be normal in patients with asthma  General examination • Evidence for atopic disease : -A.rhinitis , A.dermatitis , Siusitis , Adenoids.. • Absence of clubbing 18
  17. 17. Chronic Severe Asthma
  18. 18. Chronic Severe Asthma
  19. 19. Allergic Rhinitis
  20. 20. Eczema – Allergic Dermatitis
  21. 21. Diagnostic approach 1 - Clinical suspicion! 2 - History with focus on symptom patterns 3 - Physical examination for signs of asthma & allergies 4 - Confirm diagnosis with objective measurement of pulmonary function(Spirometry) 5 - Allergy testing 6 – Other possibly useful tests 7– Clinical response to treatment 25
  22. 22. 4 - Pulmonary Function Tests Peakflometry
  23. 23. 4 - Pulmonary Function Tests Peak-flowmetry
  24. 24. 4 - Peakflometry Curves
  25. 25. 4 - Pulmonary Function Tests Spirometry
  26. 26. 4 - Pulmonary Function Tests Spirometry
  27. 27. 4 - Pulmonary Function Tests Spirometry   FEV1 < 80% predicted FEV1 /FVC ratio <80% Spirometry may be normal in mild or well- controlled asthma   PFM : More useful for monitoring PFT : Preferred for diagnosis 31
  28. 28. 4 - Bronchoprovocation (Reversibility of obstruction) Findings consistent with asthma include: Bronchodilator Challenge Test : -12% or greater increase in FEV1 (≥200 cc) -Inhaled or oral corticosteroids may be required to demonstrate reversibility Absence of response does not exclude asthma. 32
  29. 29. 4 - Bronchoprovocation (Bronchial Hyperreactivity) Exercise Challenge Test : Findings consistent with asthma include: 15% or greater decrease in FEV1  Methacholine challenge Test : Findings consistent with asthma include: 20% or greater decrease in FEV1 A negative result does not exclude the Dx. of asthma. 33
  30. 30. Diagnostic approach 1 - Clinical suspicion! 2 - History with focus on symptom patterns 3 - Physical examination for signs of asthma & allergies 4 - Confirm diagnosis with objective measurement of pulmonary function(Spirometry) 5 - Allergy testing 6 – Other possibly useful tests 7– Clinical response to treatment 34
  31. 31. 5 - Allergy Testing  Evidence for allergy common in pediatric patients with asthma. May help guide environmental control  Skin testing (prick &/or intradermal)  the “gold standard.”  In vitro (RAST) testing an alternative in some situtions.  Eosinophils in blood & nasal secretions 35
  32. 32. 5 – Allergy Skin testing (prick)
  33. 33. 5 - Eosinophilia ( Blood , Nasal secretions )
  34. 34. Diagnostic approach 1 - Clinical suspicion! 2 - History with focus on symptom patterns 3 - Physical examination for signs of asthma & allergies 4 - Confirm diagnosis with objective measurement of pulmonary function(Spirometry) 5 - Allergy testing 6 – Other possibly useful tests 7– Clinical response to treatment 38
  35. 35. 6 - Other Possibly Useful Tests (To exclude other diseases)       Chest x-ray (not in every exacerbation!) Sinus x-ray Sweat chloride (polyp) pH probe , Barium swallow , Sonography Rhinolaryngoscopy Bronchoscopy 39
  36. 36. Acute Severe Asthma
  37. 37. Acute sinusitis
  38. 38. Diagnostic approach 1 - Clinical suspicion! 2 - History with focus on symptom patterns 3 - Physical examination for signs of asthma & allergies 4 - Confirm diagnosis with objective measurement of pulmonary function(Spirometry) 5 - Allergy testing 6 – Other possibly useful tests 7– Clinical response to treatment 42
  39. 39. 7 - Clinical response to RX. Therapeutic trial of :  SABA (eg Salbutamol) or  ICS (eg Beclomethasone) or OCS (PredniSone) and then assessment of the response to Rx. Steroids should be prescribed on a case by case basis, particularly in severe attacks and the practise of prescribing them unnecessarily should be stopped.
  40. 40. Remember…!   The diagnosis of asthma in children is a clinical one. Based on recognizing a characteristic pattern of episodic symptoms in the absence of an alternative explanation BTS guideline 2008
  41. 41. Clinical Features that Increase the Probability of Asthma : More than one of the following symptoms:     wheeze, cough, difficulty breathing, Chest - tightness, particularly if these symptoms:     Are frequent and recurrent Are worse at night and in the early morning Are worse with triggers: exercise ,exposure to pets, cold or damp air, emotions or laughter 45 Occur apart from colds
  42. 42. Clinical Features that Increase the Probability of Asthma Cont,d:  Personal history of atopic disorder   Family history of atopic disorder and /or asthma  Widespread wheeze heared on auscultation  History of improvement in symptoms or lung function in response to adequate therapy 46
  43. 43. Clinical Features that Decrease the Probability of Asthma:        Isolated cough in the absence of wheeze or difficulty breathing History of moist cough Prominent dizziness, light-headedness, peripheral tingling Repeatedly normal PE of chest when symptomatic Normal spirometry or PFM when symptomatic No response to a trial of asthma therapy Clinical features pointing to alternative diagnosis 47
  44. 44. Clinical Features Pointing to Another Diagnosis! Failure to gain weight  Clubbing  Fatty stools  Productive sputum  Other chest findings eg crackles, unequal BS  Inspiratory noises  Barking cough  Early onset rhinorhoea  GERD symptoms  Absence of nocturnal symptoms  48
  45. 45. Chronic rhinosinusitis Acute bronchiolitis GERD Differential Diagnosis <5 Yr Foreign body aspiration Cardiac asthma Vascular ring
  46. 46. Pneumonia Cystic fibrosis Tuberculosis Differential Diagnosis Bronchopulmonary dysplasia <5 Yr PCD Immune deficiency
  47. 47. Hyperventilation syndrome Upper airway obstruction & CHF Differential Diagnosis >5 Yr-Adults Paranchymal lung disease COPD F.B Vocal cord dysfunction
  48. 48. Co-morbid Conditions that Affect Asthma Rhinitis / Sinusitis GERD ASA/NSAID sensitivity Anxiety / Depression & Noncompliance  Obesity  Sleep Apnea limitations  Financial  ABPA
  49. 49. Clinical Picture of Bronchiolitis        Mild Upper Respiratory Tract Infection for 2-3 days Gradual onset of Respiratory Distress Paroxysmal Spasmodic Cough Wheezes Dyspnea Irritability + - Feeding difficulty due to tachypnea
  50. 50. Differences between Bronchiolitis and Asthma 1-Asthma is not common in the first year.  2- The following may favors the diagnosis of Asthma: - 1-Positive family history, 2-repeated attacks, 3-markedly prolonged expiration, 4-onset may be sudden without preceding URT infection, 5-there will be eosinophilia and 6-favourable response to bronchodilators. 
  51. 51. A chest X-ray demonstrating lung hyperinflation with a flattened diaphragm and bilateral atelectasis in the right apical and left basal regions in a 16-day- old infant with Severe bronchiolitis
  52. 52. FOREIGN BODY
  53. 53. FOREIGN BODY ASPIRATION Clinical picture First phase Immediately following the incident Choking, gagging, coughing, wheezing, and/or stridor Associated temporary cyanotic episode Second phase Asymptomatic period Can last from minutes to months following the incident Third phase Renewed symptomatic period Airway inflammation or infection occurs Of cough, wheexing(mayb e unilateral), fever, sputu m production, and occasionally, hemoptys is
  54. 54. FOREIGN BODY ASPIRATION Expiratory chest radiograph in a 12-month-old- boy with a 2-month history of wheezing demonstrates continued hyperlucency and hyperexpansion of the right hemithorax. A greater mediasstinal shift is noted toward the left lung field. A corn kernel was removed from the patients right mainstem bronchus during bronchoscopy.
  55. 55. GERD and wheezes? Signs and symptoms:       Frequent or recurrent vomiting GERD Frequent or persistent cough Hearburn, gas, abdominal pain Colic (Frequent crying and fussiness) Aspiration Regurgitation and re-swallowing Feeding problem wet burp or Frequent hiccups
  56. 56. GERD and wheezes? Signs and symptoms:        Recurrent choking or gagging Poor sleep habits typically with frequent waking Arching their necks and back during or after eating Frequent ear infections or sinus congestion Poor growth Breathing problems Recurrent wheezing
  57. 57. Endoscopy - Inflammation
  58. 58. The Goals of Asthma Therapy Reduce Impairment      Prevent symptoms Require infrequent use of short- acting beta2- agonists(≤2 days/ week) Maintain (near) “normal” pulmonary function Maintain normal activity levels Meet patients and families expectation of and satisfaction Reduce Risk    Prevent recurrent exacerbations of asthma and minimize the need for ED visits or hospitalizations Prevent progressive loss of lung function Provide optimal pharmacotherapy with minimal or no adverse effects
  59. 59. Stepwise Management of Asthma Global Initiative for Asthma (GINA). Revised 2009. Available at: www.ginasthma.org.
  60. 60. Stepwise Management of Asthma Begin Rx. by severity: STEP 4 & 5 Severe Persistent -- Sx‘sN: Continuous D: Cont... STEP 3 Moderate Persistent -Sx‘s : N >1w – D : Daily STEP 2 Mild Persistent -- Sx„s : N>2m D >2w Severity Classified by  Symptoms(Sx‟s)  Activity levels  Exacerbations  FEV1/PEFR  PEFR variability STEP 1 Intermittent -- Sx„s : N<2m D<2w Note ! Severity is classified before therapy begins!
  61. 61. Stepwise Management of Asthma by severity : *At all levels patient should have a SABA prn Step 5: Severe Persistent High-dose ICS + LABA + Oral CS Step 4 : Severe Persistent Medium dose ICS + LABA Step 3: Moderate Persistent Low -dose ICS+ LABA Step 2: Mild Persistent Low -dose ICS , LTAs 2nd line Step 1: Intermittent No daily medicines , SABA p.r.n. Pharmacological management. Thorax 2003; 58 (Suppl I): i1-i92
  62. 62. Stepwise Management of Asthma Global Initiative for Asthma (GINA). Revised 2009. Available at: www.ginasthma.org.
  63. 63. 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.
  64. 64. Step-up Therapy  Indications: Symptoms, need for quick-relief medication, exercise intolerance, decreased lung function.   May need a short course of oral steroids. Continue to monitor:   Follow and reassess every 1–6 months Step down when appropriate.
  65. 65. LEVEL OF CONTROL controlled REDUCE Stepwise Management of Asthma TREATMENT OF ACTION maintain and find lowest controlling step consider stepping up to gain control uncontrolled Exacerbation DECREASE INCREASE partly controlled step up until controlled Treat exacerbation INCREASE TREATMENT STEPS STEP STEP STEP STEP STEP 1 2 3 4 5
  66. 66. Pitfalls in Asthma Treatment If good control is not achieved ! Consider possible contribution of :  Adverse environmental/allergen exposures  Co-morbidities  Poor technique  Poor adherence to therapy (Non–Compliance)
  67. 67. Identify Precipitating Factors & Co-morbid Conditions! Precipitating Factors     Allergens Irritants (eg, environmental, tobac co smoke) Respiratory viruses Medications , sulfites, infections GERD=gastroesophageal reflux disease. OSA=obstructive sleep apnea. ABPA=allergic bronchopulmonary aspergillosis. Co-morbid Conditions        GERD Rhinosinusitis Rhinitis OSA Obesity ABPA Stress, Depression, and Psychosocial Factors
  68. 68. Pitfalls in Asthma Treatment Poor technique! Drug Delivery Options  Metered dose inhalers (MDI)  Dry powder inhalers (Rota haler)  Dry powder compressed for Disc haler  Spacers / Holding chambers  Nebulizers
  69. 69. Common Pitfalls in Management of Asthma Late &/or mis-diagnosis Late &/or mis-therapy Poor perception of symptoms Poor adherence Poor knowledge(patient & family) Poor relation between the patient , physician & family Prolonged exposure to triggers Smoking or exposure to ETS Poverty Psycho-social problems
  70. 70. Pitfalls in Asthma Treatment ONLY INHALATION THERAPY! All asthma drugs should ideally be taken through the inhaled route!
  71. 71. Asthma Devices Turbuhaler DPI Metered Dose inhaler MDI Diskus DPI
  72. 72. Spacer devices / masks
  73. 73. Inhalation Devices Rotahaler Dry powder Inhaler Metered dose inhaler or MDI Spacer Space halers
  74. 74. Why use a Spacer with an Inhaler? Inhaler alone When an inhaler is used alone, medicine ends up in the mouth, throat, stomach and lungs. Inhaler used with spacer device When an inhaler is used with a spacer device, more medicine is delivered to the lungs.
  75. 75. Ask the patient to demonstrate to you the technique
  76. 76. Spacer with mask
  77. 77. Rotahaler technique of use
  78. 78. Therapy to avoid! Sedatives & hypnotics Cough syrups & Mucolytics Anti-histamines (routinely!) Antibiotics (routinely!) Corticosteroid injections (routinely!) Combination tablets Immunosuppressive drugs Chest physiotherapy Immunotherapy Maintenance oral prednisone >10mg/day
  79. 79. Conclusions :         Good asthma control Risk factor control Compliance Inhaler technique Step up/down treatment as appropriate Suitable treatment for acute exacerbation Patient & Family Education:… Be always up-to-date!
  80. 80. -
  81. 81. National Asthma Guideline
  82. 82. THANKS

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