Childhood asthma


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Pediatric Asthma
Epidemiology , compliance
asthma tests

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Childhood asthma

  1. 1. Presented byDr pankaj
  2. 2. • Asthma is the most common chronic disease of childhood and theleading cause of childhood morbidity from chronic disease asmeasured by school absences, emergency department visits, andhospitalizations.• Asthma leads to recurrent episodes of wheezing, breathlessness,chest tightness and coughing (particularly at night or early morning).Clinical symptoms in children 5 years and younger are variable andnon-specific.• Widespread, variable, and often reversible airflow
  3. 3. Factors Influencing the Developmentand Expression of AsthmaHost factors – Genetic1.Genes predisposing to atopy2. Genes predisposing to airway hyper
  4. 4. Environmental factors –Allergens –1. Indoor – Domestic mites, furred animals (dogs, cats, mice),cockroach allergens, fungi, molds, yeasts.2. Outdoor – Pollens, fungi, molds, yeasts.Infections (predominantly viral)Occupational sensitizersTobacco smoke1. Passive smoking2. Active smokingIndoor/Outdoor air pollutionDiet
  5. 5. Risk factors of Asthma in younger children• Sensitization to allergen.• Maternal diet during pregnancy and/ or lactation.• Pollutants (particularly environmental tobacco smoke).• Microbes and their products.• Respiratory (viral) infections.• Psychosocial
  6. 6. The prevalence of childhood asthma has continued toincrease on the Indian subcontinent over the past 10 yrsISAAC Phase 3 Thorax 2007;
  7. 7. Epidemiological trend BronchialAsthma Global Burden of AsthmaAround 300 m. patients (currently)Expected by 2025: 100 m. additionalLoss of DALYs : About 15 m./year(around 1% of all DALYs lost) Accounts for in every 250 deaths• Considerable economic costsThe UK has one of the highest prevalences for childhood asthmainternationally, with about 15% children affected.The prevalence is 8-10 times higher in developed countries than indeveloping
  8. 8. The prevalence of any wheeze over recent months (usually taken aswithin the last year) amongst children has risen from about 10% in the1960s to 20-30% in the 1990s. There is some evidence of a possibleflattening of this rise from the late 1990s onwards. An increasingpercentage of currently wheezing children also have a diagnosis ofasthma.There is still a significant morbidity associated with the disease,particularly severe childhood asthma, despite therapeutic advances.Prevalence is higher in lower socioeconomic groups in urban areas.There are gender differences. Boys are affected more before puberty (3times greater prevalence). Prevalence is equal in adolescence, butadult-onset asthma is more common in women.The increasing prevalence of asthma is mirrored by the increasingprevalence of childhood obesity. Prospective studies suggest thatobesity increases the risk of subsequent asthma, although theunderlying mechanisms are unclear, but obesity also increases theclinical severity of asthma and reduces quality of life for
  9. 9. The overall burden of Asthma in India is estimated atmore than 15 million .According to the study done by A.Anuradha1, V.LakshmiKalpana1,S.Narsingara. et al. The type of asthma isdistributed as cough-variant-asthma (50.83%), nocturnalasthma (17.5%), allergic asthma (20.83%) and occupationalasthma (10.83%). Regarding family history,59.16% showedgenetic predisposition irrespective of sex. Amongasthmatics, 20% were having atopicdermatitis. Twenty-five percent were smokers, 20% were alcoholics and44.16% were with diabetics.Advancing age, usual residence in urban area and lowersocio-economic status were associated with significantlyhigher odds of having asthma. The present study showsthat asthma is an important public health issue in
  10. 10. Asthma Burden in Developing countries (INDIA)1. Wide variations – High magnitude2. Increase in prevalence with rapid industrializationand urbanization3. High levels of pollution – important role4. Role of infections, smoking and under-nutrition5. Under diagnosis and under treatment6. Limited drug availability7. Difficulties of management at different levels ofhealth-care
  11. 11. Fear of steroidsHeavynebulisationChoice of rightdeviceOral vs. Inhaled Lack ofknowledge &time vs.more patientsPoor patient/parenteducationCough orWheezeHeterogenousDisease/varyingphenotypesAcceptance ofAsthmadiagnosis/labelUnderdiagnosed/MisdiagnosedIssues inPediatric
  12. 12. Other ChallengesMost of the children are below 5 years of age, who cannottell their problemsParents are proxy story teller, who may mislead the doctorPEF cannot be performed in children below 5 years of ageFear of addiction to inhalation therapyPhysicians lack of knowledge and
  13. 13. Clinical FeaturesRecurrent WheezeRecurrent CoughRecurrent BreathlessnessActivity Induced Cough/WheezeNocturnal Cough/BreathlessnessTightness Of ChestAsthma by Consensus, IAP
  14. 14. SymptomatologyCough – 90%Wheezing – 74%Exercise induced wheeze or cough – 55%Ind J Ped 2002;
  15. 15. Typical features of AsthmaAfebrile episodesPersonal atopyFamily history of atopy or asthmaExercise /Activity induced symptomsHistory of triggersSeasonal exacerbationsRelief with bronchodilators Asthma by Consensus, IAP
  16. 16. When does Asthma begin?By 1 year – 26%1-5 years – 51.4%> 5 years – 22.3%77% Of AsthmaBegins In ChildrenLess Than 5 YearsInd J Ped 2002;
  17. 17. Tools to DiagnosisGood History Taking (ASK)Careful Physical Examination (LOOK)Investigations (PERFORM) – above 5 years onlyCHILDHOOD ASTHMA by KHUBCHANDANI R.P. et
  18. 18. History taking (Ask)Has the child had an attack or recurrent episode ofwheezing (high-pitched whistling sounds when breathingout)?Does the child have a troublesome cough which isparticularly worse at night or on waking?Is the child awakened by coughing or difficult breathing?Does the child cough or wheeze after physical activity (likegames and exercise) or excessive crying?Does the child experience breathing problems during aparticular season?CHILDHOOD ASTHMA by KHUBCHANDANI R.P. et
  19. 19. History taking (Ask)Does the child cough, wheeze, or develop chest tightnessafter exposure to airborne allergens or irritants e.g. smoke,perfumes, animal fur?Does the child’s cold frequently ‘go to the chest’ or takemore than 10 days to resolve?Does the child use any medication when symptoms occur?How often?Are symptoms relieved when medication is used?CHILDHOOD ASTHMA by KHUBCHANDANI R.P. et alIf the answer is ‘yes’ to any of the questions,a diagnosis of asthma should be
  20. 20. Physical Examination (Look)General Attitude And Well BeingDeformity Of The ChestCharacter Of BreathingThorough Auscultation Of Breath SoundsSigns Of Any Other Allergic Disorders On TheBodyGrowth And Development StatusCHILDHOOD ASTHMA by KHUBCHANDANI R.P. et
  21. 21. What all features one should look for specifically?DyspneaExpiratory wheezeAccessory muscle movementDifficulty in feeding, talking, getting to sleepIrritabilityCHILDHOOD ASTHMA by KHUBCHANDANI R.P. et
  22. 22. What all features one should look for specifically?CoughPersistent/ recurrent / nocturnal/ exercise-inducedAssociated conditionsEczemaAllergic RhinitisWeight/HeightCHILDHOOD ASTHMA by KHUBCHANDANI R.P. et
  23. 23. How to rule out the mimics?
  24. 24. The Early Wheezer (< 3Years)Early onset asthmaAfebrile episodesPersonal atopy presentFamily history of asthma /atopy presentPredictable good response tobronchodilatorsWALRI (wheeze associatedlower respiratory tractinfections)or Viral Associated wheezeFebrile episodesPersonal atopy absentFamily history of asthma / atopyabsentVariable response tobronchodilatorsAsthma by Consensus, IAP
  25. 25. Bronchiolitis in childrenCommonest cause of wheezing in childrenbetween 6 months to 3 yearsResembles asthmaDiagnosis essentially clinicalCommon viruses causing bronchiolitis inchildren:Respiratory syncytial virus (RSV)
  26. 26. Clinical manifestations of RSV diseaseRhinorrhoeaPharyngitisCoughLow grade feverWheezingIncreased respiratory
  27. 27. Differential diagnosisAge Common Uncommon RareLess than6 monthsBronchiolitisGastro-esophagealrefluxAspiration pneumoniaBronchopulmonary dysplasiaCongestive heart failureCystic fibrosisAsthmaForeign body aspiration6 months -2 yearsBronchiolitisForeign bodyaspirationAspiration pneumoniaAsthmaBronchopulmonary dysplasiaCystic fibrosisGastro-esophageal refluxCongestive heart failure2 - 5 years AsthmaForeign bodyaspirationCystic fibrosisGastro-esophageal refluxViral pneumoniaAspiration pneumoniaBronchiolitisCongestive heart failureGastro-esophageal refluxIPAG
  28. 28.
  29. 29. Co morbid conditionsAllergic RhinitisColds, ear infectionsSneezing in the morningBlocked nose, snoring, mouth breathingGastro esophageal reflux (GER)Nocturnal cough followed by vomiting
  30. 30. Guidelines for confirmingChildhood Asthma
  31. 31. IPAG DiagnosisCharacterize the problemEstablish chronicityExclude non-respiratory or othercausesExclude infectious diseasesConsider patient’s ageUse diagnostic aidsInternational Primary Care Airways Group
  33. 33. Method – how to perform1. 4 normal breaths2. Inhale as deeply as possible3. Exhale to normal depth4. 3 normal breaths5. Exhale as much as possible6. 3 normal breaths7. Inhale as much as possible8. Exhale as fast andcompletely as possible9. 4 normal
  35. 35. What all investigations can be performed inasthmatic children? (PERFORM)Peak expiratory flow rate: It is highlysuggestive of asthma when:>15% increase in PEFR after inhaled shortacting β2 agonist>15% decrease in PEFR after exerciseDiurnal variation > 10% in children not onbronchodilator OR>20% In children on bronchodilator1. Asthma by Consensus, IAP 20032. CHILDHOOD ASTHMA by KHUBCHANDANI R.P. et
  36. 36. Early Childhood Asthma Diagnosis(below 6 years)Diagnostic Tool Findings that Support DiagnosisDifferentialdiagnosisThe diagnosis of asthma in children under age 6 is primarilyone of exclusion.PhysicalexaminationIf the child does not appear acutely ill and is growing, andthere is no evidence specifically indicating another cause ofsymptoms, a trial of therapy is warranted.Trial of therapy(bronchodilators)Improvement with treatment supports a diagnosis ofasthma.FrequentreassessmentHealth care professionals should always be prepared toreconsider the diagnosis if management is ineffective or ifthe clinical situation changes.IPAG
  37. 37. Childhood Asthma Diagnosis (6-14 years)IPAG
  38. 38. Childhood Asthma Diagnosis (6-14 years)IPAG
  39. 39. NORDIC CONSENSUSConfirm Asthma if,If the child is having 3 attacks of airway obstruction inlast 1 yr.If the child gets 1 attack of asthmatic symptoms afterthe age of 2 yrs.Irrespective of age in an attack in children withallergy (eczema, food allergy etc.) or history of atopy.If the child does not become free of symptoms wheninfection has ceased or has persistent symptoms formore than a month.Respir Med. 2000;94(4)
  40. 40. IAP GUIDELINES3 Or More Episodes Of Airflow Obstruction With SeveralOf The Following:• Afebrile Episodes• Personal Atopy Or Family H/O Atopy / Asthma• Nocturnal Exacerbations• Exercise/Activity Induced Symptoms• Trigger Induced Symptoms• Seasonal Exacerbations• Relief With Bronchodilators ± Oral SteroidAsthma by Consensus, The Indian Academy of Pediatrics
  41. 41. GINA The following symptoms are highly suggestive of adiagnosis of asthma: frequent episodes of wheeze (more than once a month) activity-induced cough or wheeze nocturnal cough in periods without viral infections absence of seasonal variation in wheeze symptoms that persist after age 3 A simple clinical index based on: presence of a wheeze before the age of 3 presence of one major risk factor (parental history ofasthma or eczema) or two of three minor risk factors(eosinophilia, wheezing without colds, and allergicrhinitis) has been shown to predict the presence ofasthma in later childhoodGlobal Initiative for Asthma
  42. 42. GINAA useful method for confirming the diagnosis of asthma inchildren 5 years and younger is a trial of treatment withshort-acting bronchodilators and inhaledglucocorticosteroidsChildren 4 to 5 years old can be taught to use a PEF meter,but to ensure reliability parental supervision is requiredUse of spirometry and other measures recommended forolder children such as airway responsiveness and markers ofairway inflammation is difficult and several require complexequipment making them unsuitable for routine useGINA
  43. 43. BTS Initial assessment of children suspected of havingasthma should be based on: presence of key features in the history and clinical examination careful consideration of alternative diagnoses Using a structured questionnaire may produce a morestandardised approach to the recording of presentingclinical features and the basis for a diagnosis of asthmaBritish Thoracic Society
  44. 44. Clinical features that increase the probability of asthmaMore than one of the following symptoms: wheeze, cough, difficultybreathing, chest tightness, particularly if these symptoms:◊ are frequent and recurrent◊ are worse at night and in the early morning◊ occur in response to, or are worse after, exercise or other triggers,such as exposure to pets, cold or damp air, or with emotions orlaughter◊ occur apart from coldsPersonal history of atopic disorderFamily history of atopic disorder and/or asthmaWidespread wheeze heard on auscultationHistory of improvement in symptoms or lung function in response toadequate therapyBTS
  45. 45. Clinical features that lower the probability of asthmaSymptoms with colds only, with no interval symptomsIsolated cough in the absence of wheeze or difficulty breathingHistory of moist coughProminent dizziness, light-headedness, peripheral tinglingRepeatedly normal physical examination of chest when symptomaticNormal peak expiratory flow (PEF) or spirometry when symptomaticNo response to a trial of asthma therapyClinical features pointing to alternative diagnosisBTS
  46. 46. Asthma management and preventionThe goals for successful management of asthma are1. Achieve and maintain control of symptoms2. Maintain normal activity levels, including exercise3. Maintain pulmonary function as close to normal as possible4. Prevent asthma exacerbations5. Avoid adverse effects from asthma medications6. Prevent asthma
  47. 47. Five interrelated components of therapy are required to achieveand maintain control of asthma-1. Develop Patient/Doctor partnership2. Identify and reduce exposure to risk factors3. Assess, treat, and monitor asthma4. Manage asthma exacerbations5. Special
  48. 48. Develop Patient/Doctor partnership -Effective management of asthma requires the development of apartnership between the person with asthma and the health careteam.Patients can learn to –1. Avoid risk factors2. Take medications
  49. 49. 3. Understand the difference between controller and relievermedications4. Monitor their status using symptoms and, if relevant, PEF5. Recognize signs that asthma is worsening and take action6. Seek medical help as
  50. 50. Education should be integral part of all interactions between health careprofessional and patients.Using variety of methods such as discussions, demonstrations, writtenmaterials, group classes, video/audio tapes, dramas and patient supportgroups helps reinforce educational messages.Health care professional and patients should prepare a written personalasthma action plan that is medically appropriate and practical.Additional self-management plans can be found on –1.
  51. 51. Assess, Treat and Monitor Asthma –The goal of asthma treatment can be reached in most patientsthrough a continuous cycle that involves – assessing, treating andmonitoring asthma.Each patient should be assessed to establish his/her currenttreatment regimen, adherence to the current regimen, and level ofasthma control.Each patient is assigned to one of five treatment steps.At each treatment step, reliever medication should be provided forquick relief of symptoms as
  52. 52. Monitoring is essential to maintain control and establish the lowest step anddose of treatment to minimize cost and maximize safety.If asthma is not controlled, step up the treatment. Improvement is generallyseen within 1 month.If asthma is partly controlled, consider stepping up treatment, dependingmore effective options available, safety and cost of possible treatment andpatient’s satisfaction with the level of control achieved.If controlled asthma is maintained for at least 3 months, step down with agradual, stepwise reduction in treatment. The goal is to decrease treatmentto the least medication necessary to maintain
  53. 53. To summarize…Asthma is an inflammatory illnessDiagnosis of asthma is clinical, and relies on historyAll asthma does not wheezeIn children < 3 yrs, WALRI is an important differential diagnosis2 out of 3 children outgrow their asthmaA family history of asthma / atopy increases risk of
  54. 54. To summarize…Patient education is a very important part of asthma managementDrugs control, but do not cure asthmaClinical grading over time, decides long term management planMild intermittent asthma does not merit controllersInhaled steroids are mainstay of long term asthma managementTreatment should be stepped up or stepped down depending uponpatient responseLong term
  55. 55. Thank