2. Out line
• Definition
• Epidemiology
• Etiology / Risk factors
• Natural history & pathogenesis
• Clinical presentation
• Laboratory studies
• Treatment
3. CHILDHOOD ASTHMA
• Definition
Asthma is a chronic, inflammatory disease of
lung airways characterized by:
• Symptoms of cough, wheezing, dyspnea, &
chest tightness that occur in paroxysms
• Airway narrowing, often reversible, and
• ↑se in the existing bronchial hyper-
responsiveness
4. Epidemiology
The CDC's 2006 National Health Interview Survey
estimated
• a lifetime asthma prevalence of 13.5%, and
prevalence of 9.6% among children ≤18yrs in
2009
– But ranges from 1.6 to 36.8 in different locale
5. Epidemio…
• 80% of all asthmatics report disease onset
prior to 6yr of age.
• Allergy in young children has emerged as a
major risk factor for the persistence of
childhood asthma.
6. Epidemiologic risk factors
• Gender – boys > girls (14 vs 10%) but in
adults F>M = 8.9 vs 5.6
• Race / ethnicity : high in African-Americans
& Puerto Ricans
• Socioeconomic status : more prevalent in
poor …
• Locale : urban > rural
7. Etiology
Not clearly determined but multifactorial
• Environmental exposures
– Recurrent viral infections of the airways
– Other airways exposures – tobacco smoke, indoor
allergens … and
• Inherent biological and genetic
vulnerabilities.
– More than 22 loci on 15 autosomal chromosomes
11. MAJOR CRITERIA MINOR CRITERIA
Parent asthma Allergic rhinitis
Eczema Wheezing apart from colds
Inhalant allergen
sensitization
Eosinophils ≥ 4%
Food allergen sensitization
Asthma Predictive Index for Children
For preschool age children with frequent wheezing in the
past year, one major criterion OR two minor criteria
provide a high specificity (97%) and positive predictive
value (77%) for persistent asthma into later childhood
12. Types of asthma
• There are 2 main types of childhood asthma:
(1) Recurrent wheezing in early childhood; and
(2) Chronic asthma associated with allergy that
persists into later childhood and often
adulthood
• A 3rd type typically emerges in females who
develop obesity and early-onset puberty (by
11yr of age).
13. Natural history
Wheezing during the first six years
1. intermittent symptoms at an early age - viral
illnesses
2. Later-onset with more persistent symptoms -
cxzed by
• Atopy and
• A positive family history of asthma, and
• Are at an increased risk for asthma later in life.
14. Natural history
Wheezing in later childhood
• Patients younger than 15years diagnosed with
severe asthma had, when compared to older
patients, significantly higher five-year rates of
improvement (80 vs 61%) and remission (23 vs
14%).
• Patients diagnosed with mild disease were
unlikely to develop severe disease within five
years, regardless of age
15. Pathophysiology
• Asthma is an inflammatory process
– mediated by helper T lymphocytes and
other immune cells.
• Airways inflammation is linked to
– AHR or hypersensitivity of airways
smooth muscle to numerous provocative
exposures that act as triggers,
16. Pathophysiology
• Airways inflammation…
– airways edema,
– basement membrane thickening – type IV
collagen,
– Desquamation of the epithelial lining,
– smooth muscle and mucous gland
hypertrophy, &
– mucus hypersecretion
17. Clinical manifestations
• Approximately 80% of children with asthma
develop symptoms before 5yrs of age
• Intermittent dry coughing & wheezing
• Breathlessness, chest tightness or pressure –
older
• Intermittent, nonfocal chest “pain” – younger
children.
18. Clinical manifestations
• Daytime symptoms, often linked with physical
activities or play
• Poor school performance and fatigue
– May be due to sleep deprivation from nocturnal
symptoms.
• Response to asthma medications
(bronchodilators)
• Symptoms can be triggered by numerous events
19. Clinical manifestations
PHYSICAL EXAMINATION
• Normal in the absence of an acute exacerbation.
• Abnormalities that may be observed include :
– An increased A-P diameter of the chest - air
trapping.
– Decreased air entry or wheezing on
auscultation.
– A prolonged expiratory phase on auscultation.
20. Clinical manifestations
• Crackles (or rales) and rhonchi
• Signs of rhinitis and sinusitis - nasal
discharge, inflamed nasal mucosa, sinus
tenderness,
• Eczema/atopic dermatitis.
• Nasal polyps (glistening, gray, mucoid
masses within the nasal cavities)
21. Laboratory findings
Pulmonary Function Testing
• Forced expiratory airflow measures
– in diagnosing and monitoring asthma and
– in assessing efficacy of therapy.
• Spirometry – for children > 6 yrs
22. • Spirometric volume-time
curves
1. FEV1 -
2. FVC - total volume of air
exhaled during a forced
expiratory effort.
• Note that subject 2's FEV1 &
FEV1/FVC ratio are smaller than
subject 1's --- airflow limitation.
• Also, subject 2's FVC is very
close to what is expected
Subject 1 – non-asthmatic
Subject 2 - asthmaric
23. Spirometry (in clinic)
1. Airflow limitation
• Low FEV1 (relative to percentage of predicted
norms)
• FEV1/FVC ratio <0.80
2. Bronchodilator response (to inhaled β-agonist)
• Improvement in FEV1 ≥12% or ≥200 mL*
3. Exercise challenge
• Worsening in FEV1 ≥15%*
4. Daily peak flow or FEV1 monitoring: day to day
and/or AM-to-PM variation ≥20%*
Lung Function Abnormalities in asthma
* Main criteria consistent with asthma
24. Laboratory findings
• Bronchoprovocation
• Can be helpful in diagnosis & management.
• inhaled methacholine, histamine, and cold or
dry air.
– The degree of AHR correlates with asthma severity
and airways inflammation.
• A negative study may exclude a diagnosis of
asthma
25. Laboratory findings
Exercise challenges
• aerobic exertion or “running” for 6–8 min
• identify children with exercise-induced
bronchospasm.
– FEV1 typically decreases during or after exercise by
>15%.
26. Laboratory findings
Measuring exhaled nitric oxide (FENO),
• a marker of airway inflammation in asthma,
Peak expiratory flow (PEF)
• PEF variation >20% is consistent with asthma
Allergy tests
Sweat chloride test
27. Radiology - Chest radiogram
• Findings consistent with asthma, such as
– hyperinflation,
– peribronchial thickening, and
– mucoid impaction with atelectasis.
– Complications
28.
29. Radiology – chest CT
• Bronchiectasis is clearly seen on CT scan and
• implicates an asthma masquerader such as
– cystic fibrosis,
– allergic bronchopulmonary mycoses
(aspergillosis),
– ciliary dyskinesias…
30. Asthma management
• National Asthma Education and Prevention
Program - NAEPP.
– 4 principle components to optimal asthma
mgt
1. Regular assessment & monitoring
2. Control of factors contributing to asthma
severity
3. Asthma pharmacotherapy
34. Asthma management
1. Regular assessment & monitoring
• Asthma checkups Every 2 - 4 wk until good
control
• 2 - 4 per yr to maintain good control
• Lung function monitoring
– Annually, or more often
35. Asthma mgt – regular ass’t
• Assess the optimal goals by determining the:
(1) frequency of asthma symptoms during the
day, at night, and with physical exercise;
(2) frequency of “rescue” SABA use and refills;
(3) number and severity of asthma exacerbations
since the last visit; and
(4) participation in school, sports, and other
activities
36. Asthma mgt – regular ass’t
Lung function testing (spirometry)
• PEF (Peak expiratory flow) monitoring at home if
– children with poor symptom perception,
– other causes of chronic coughing,
– moderate to severe asthma, or
– history of severe exacerbations
37. Asthma mgt – regular ass’t
PEF
• 80–100% of personal best - good control;
• 50–80% necessitates increased awareness
& Rx;
• <50% poor control & increased likelihood
of an exacerbation, requiring immediate
intervention.
• The NAEPP guidelines recommend at least
once-daily PEF monitoring
38. Asthma management
2. Control of factors contributing to asthma
severitiy
• Eliminate or reduce problematic
environmental exposures
• Treat co-morbid conditions: rhinitis, sinusitis,
gastroesophageal reflux
• Annual influenza vaccination
39. Asthma management
3. ASTHMA PHARMACOTHERAPY
• Long-term-control Vs quick-relief medications
• Classification of asthma severity
• Step-up, step-down approach
• Asthma exacerbation management
The “three strikes” rule for determining if an
asthmatic child should receive controller
therapy
40. Asthma mgt - pharmacotherapy
The “three strikes” rule
• If an asthmatic child
– has symptoms or uses quick-relief
medication at least 3 times per wk,
– awakens at night due to asthma at least 3x /
mo,
– requires a refill for a quick-relief inhaler
prescription at least 3 times per yr,
41. Asthma mgt - pharmacotherapy
The “three strikes” rule
• if an asthmatic child…
– experiences asthma exacerbations > 3x/ yr,
or
– requires short courses of systemic
corticosteroids >3 x/yr, then
• That patient should receive daily controller
therapy.
42. Asthma mgt - pharmacotherapy
Principles of Asthma Pharmacotherapy
• For younger children (<5 yr of age),
management is primarily based on symptoms
• A major objective of this approach is to
identify and treat all “persistent” asthma with
anti-inflammatory controller medication.
43. Asthma mgt - pharmacotherapy
Principles of Asthma Pharmacotherapy
• The classification of asthma severity is based
on the parameters:
(1) frequency of daytime and
(2) nighttime symptoms,
(3) degree of airflow obstruction by spirometry,
and/or
(4) PEF variability
44. CLASSIFN
STEP
DAYS WITH
SYMPTOMS
NIGHTS
WITH
SYMPTOMS
FOR ADULTS AND
CHILDREN AGE > 5 YEARS
WHO CAN USE A
SPIROMETER OR PEAK
FLOW METER
FEV1 or PEF[*] %
Predicted
Normal
PEF
Variability
(%)
Severe
persistent
4 Continual Frequent ≤60 >30
Moderate
persistent
3 Daily >1/wk >60–<80 >30
Mild
persistent
2
>2/wk, but <1/day
>2/mo ≥80 20–30
Mild
intermitte
nt
1 ≤2/wk <2/mo ≥80 <20
Classification of Asthma Severity
From NAEPP Expert Panel Report
NIH publication no: 02–5075
46. For all patients – quick relief
Bronchodilator as needed for symptoms:
-Preferred treatment:
-inhaled SABA by nebulizer or face mask and
space/holding chamber
-Alternative treatment: Oral β2-agonist
Managing Infants and Young Children (≤5Yr)
with Acute or Chronic Asthma
47. For all patients – quick relief
With viral respiratory infection
-Bronchodilator q 4–6 hr up to 24 hr;
-Consider systemic corticosteroid if exacerbation is
severe or history of previous severe exacerbations
-Use of SABA >2x/wk in intermittent asthma (daily, or
increasing use in persistent asthma) need to initiate
(increase) long-term-control therapy.
Managing Children (≤5Yr) with Acute or Chronic
Asthma
48. Step down
Review treatment every 1 to 6 mo;
a gradual stepwise reduction in treatment may
be possible.
Managing Infants and Young Children (≤5 Yr of
Age) with Acute or Chronic Asthma
49. ↑Step up
If control is not maintained,
Review patient medication technique, adherence, and
environmental control.
• Classify severity: assign patient to most severe step in
which any feature occurs.
• There are very few studies on asthma therapy for
infants.
• Gain control as quickly as possible (a course of short
systemic corticosteroids may be required)
Managing Infants and Young Children (≤5 Yr of Age) with
Acute or Chronic Asthma
51. Managing Asthma in Children >5Yr of Age
Quick Relief - All Patients
• inhaled SABA: 2–4 puffs as needed for symptoms.
• Intensity of treatment will depend on severity of
exacerbation;
•up to 3 treatments at 20-minute intervals or
•a single nebulizer treatment as needed.
• Course of systemic corticosteroids may be needed.
52. Managing Asthma in Children >5Yr of Age
Quick Relief All Patients
• Use of SABA >2 times/wk in intermittent asthma
(daily, or increasing use in persistent asthma)
need to initiate (increase) long-term-controller
NB: SABAs are the recommended quick-reliever
medications for symptoms and exercise
pretreatment for all asthma severity levels.
53. Asthma Exacerbations and Their
Management
Asthma exacerbations
• acute or subacute episodes of progressively
worsening symptoms and airflow obstruction.
• Obstruction can become extensive life-
threatening respiratory insufficiency.
54. Asthma Exacerbations and Their
Management
… mgt
The optimal management of a child
comprehensive assessment
• Focused history
• Clinical assessment
• Risk factors for asthma morbidity & death
• Treatment
55. Asthma Exacerbations and Their
Management
Acute asthma exacerbations mgt
• SABAs - increase pulmonary blood flow with
increasing dosage and frequency.
• When airways obstruction is not resolved with
SABA use,
• Ventilation-perfusion mismatch significant
hypoxemia, which can perpetuate
bronchoconstriction and further worsen the
condition.
56. Home Management of Asthma
Exacerbations
• written action plan - recognition & mgt of
exacerbations
• immediate treatment with “rescue” medication
– inhaled SABA, up to 3 treatments in 1 hr.
– A good response
• resolution of symptoms within 1 hr,
• no further symptoms over the next 4 hr, and
• improvement in PEF to at least 80% of
personal best.
57. Home Management of Asthma
Exacerbations
If the child has an incomplete response i.e
• persistent symptoms &/or PEF <80% of
personal best,
– a short course of oral corticosteroid therapy
(prednisone for 4 days)
– Contact clinician
58. Home Management of Asthma
Exacerbations
• For patients with severe asthma and/or
• a history of life-threatening episodes,
– providing an injectable form of epinephrine and
– portable oxygen at home should be considered.
59. Emergency Department
Management of Asthma
Exacerbations
Primary goals:-
• correction of hypoxemia,
• rapid improvement of airflow obstruction, and
• prevention of progression or recurrence of
symptoms.
Interventions are based on
• clinical severity on arrival,
• response to initial therapy, and
• risk factors associated with asthma morbidity &
60. Emergency Department
Management of Asthma
Exacerbations
Indications of a severe exacerbation include
• Signs of severe respiratory distress
• a silent chest with poor air exchange,
• severe airflow limitation (PEF or FEV1 <50% of
personal best or predicted values), and
• mental status changes
61. Emergency Department
Management of Asthma
Exacerbations
Initial treatment includes
• supplemental oxygen,
• inhaled SABA every 20 min for 1 hr, &, if
necessary,
• systemic corticosteroids - oral or IV.
Inhaled ipratropium may be added if no significant
response is seen with the 1st inhaled β-agonist
Rx.
62. Emergency Department
Management of Asthma
Exacerbations
• An IM injection of epinephrine in severe cases.
– Oxygen continued for at least 20 min after the
last injection to compensate for possible
ventilation-perfusion abnormalities caused by
SABAs.
• monitor clinical status, hydration, and
oxygenation
63. Emergency Department
Management of Asthma
Exacerbations
Discharge to home if there is
– sustained improvement in symptoms,
– normal physical findings,
– PEF >70% of predicted or personal best,
– an oxygen saturation >92% on room air for 4 hr.
Discharge medications
– inhaled β-agonist up to every 3–4 hr plus
– a 3–7 day course of an oral corticosteroid.
Optimize controller therapy - addition of ICS
64. Hospital Management of Asthma
Exacerbations
Indication – status asthmaticus
• moderate to severe exacerbations not
improving within 1–2 hr of intensive treatment
• high-risk features for asthma morbidity or
death.
• severe respiratory distress, and concern for
potential respiratory failure and arrest.
65. Hospital Management of Asthma
Exacerbations
Interventions for status asthmaticus
1. Supplemental oxygen,
2. frequently or continuously administered
inhaled bronchodilator And
3. Systemic corticosteroid therapy
66. Hospital Management of Asthma
Exacerbations
SAβAs -
• Adverse effects - tremor, irritability, tachycardia,
and hypokalemia.
• Thus, ongoing cardiac monitoring, & oximetry
Inhaled ipratropium bromide
• is often added every 6 hr if no remarkable
improvement
• synergistic effect in relieving severe
bronchospasm
• beneficial in patients with mucous hypersecretion
67. Hospital Management of Asthma
Exacerbations
Monitoring
• arterial blood gas, complete blood cell counts,
• serum electrolytes, and chest radiograph to
monitor for
– respiratory insufficiency,
– co-morbidities, infection, and/or
– dehydration.
• especially important in infants and young
children
68. Hospital Management of Asthma
Exacerbations
• Several therapies, including parenterally
administered
– epinephrine,
– β-agonists,
– methylxanthines,
– magnesium sulfate (25–75 mg/kg, maximum dose
2.5 g, intravenously over 20 min)
have demonstrated some benefit as adjunctive
therapies in severe status asthmaticus patients
71. Epidemiology
• one-third of world population is infected with
M.TB.
• There were an estimated 0.5million TB cse among
children<15yr old
• Theree were 74000 TB death among HIV negative
children
• Number of TB death is unacceptably high given
that most are preventable
72. Continuing
• There are 22 high burden countries acounted for
82% of all estimated case worldwide .
• Ethiopia is the 7th burdened country.
73. Etiology
• Mycobacterium tuberculosis complex.
–M.Tuberculosis
–M.Bovis
–M.Africanum
–M.Microti
–M.Cantti
• M.TB
– Most important cause of human Tuberculosis
– non spor forming,non motil,slow growing,obligat
aerobic,grow best 37-41 degree
74. Transmission
• Transmission is person to person(usually by air
born mucus droplet nucli.
• Rarely occurs by diract contact with an infected
discharge or contaminated fomite.
• Risk of transmission increase with index case:
• smear positive TB
• Extensive upper lobe infiltration
• Copious production of sputum
• Sever and forcefull cough
• Not treated
75. Continuing
• Enviroment
– Poorly ventilation
– Overcrowding
– Intimacy
Younger children (<7yr) rarely infect others
M.Bovies transmited by ingestion of cow milk.
76. Continuing
• The risk of infection of susceptible individual is
high with close,prolonged,indoor exposure to
aperson with sputum positive pulmonary TB.
77. Pathogenesis
• lung is portal of entry in more than 98%of the
case.
• Bacilli multiply initially within alveoli and
alveolar duct.
• Most cleared by macrophages.
• Primary complex formed through portal of
entry and regional lymphe nodes.
78. Continuing
• Disseminated TB occurs if
– circulating number of bacilli is large.
– Host immune response is inadequet.
• Cell mediated immunity developes 2-12wks
after infection along with tissue
hypersensitivity.
79. Clinical presentation
• Pulmonary
• Commonest 70%
• all lobes of lung are at equaly risk of initial
infection
• cough,Fever,night sweat anorexia
,decreased appetit
• Failur to thrive
• Common site of reactivation is apex of
upper lobe
80. Continuing
• when Ag load is small and tissue hypersensitivity
is high granuloma will formed
• when both Ag and sensitivity are high incomplit
tissue necrosis results in formation of caseous
material.
• When degree of tissue sensitivity is low it results
in diffuse reaction
82. Continuing
• Common permanent disabilities are
– Blindness
– Deafness
– Paraplagia
– Diabetic insipidus
– Mental retardation
• Diagnosis is mainly by high degree of
suspension .
83. Continuing
• GI/peritoneal TB
– Most commonly affected areas are ileum,jejunum
and appendex.
– Presentas abdominal pain, diarrhea/constipation.
– I.testinal obstruction.
• Renal TB
• Urin cultur positive in 80-90%..
• Bone and Joint TB.
• Cutaneus TB.
84. Diagnosis
• Sputum AFB
• Chest X-ray
• CBC
• Sputum cultur
• TB could be smear positive and smear negative
85. Managment
• Chemotherapy/Anti TB 2RHZE/4RH
• Nutritional Rehablitation
• Sceaning of the family(index case, other
contacts).
• follow up(Adherance,responce,drug side
effact)
86. Continuing
• Steroid in TB indication
– Meningities.
– pericardities.
– Adrenal inssufficiency.
– airway obstruction.
– Bilateral pleurl effusion with respiratory problem
• 60 mg/ day for 4 wk then tper every 1-2 wk.
• Indication of pyridoxin
– breast feed infants.
– severly malnourished children.
– HIV infected Children.
