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Jackie Lou C. Acha
Clinical Clerk
Department of Pediatrics- OPD
Asthma
 A chronic inflammatory condition of the lung airways
resulting in episodic airflow obstruction
 Chronic inflamma...
Asthma
 AHR leads to recurrent episodes of
 Wheezing
 breathlessness
 Chest tightness
 Coughing, at night or in early...
Epidemiology
 One of the most common chronic diseases
 ~300 M individuals affected worldwide
 Prevalence increasing in ...
Risk Factors for Asthma
Environment
-Allergens
-Infections
-Microbes
-Pollutants
-Stress
Biological and
Genetic Risk
-Immu...
Host factors + Environmental
factors
ASTHMA
Asthma Predictive Index
 Identify high risk children (2 and 3 years of age):
 ≥4 wheezing episodes in the past year
(at ...
Pathophysiology
Clinical Manifestations
 Dry coughing
 Expiratory wheezing
 Chest tightness
 Dyspnea
commonly provoked by physical exe...
Diagnosis
 History and patterns of symptoms
 Physical examination
 Measurements of lung functions
 Measurements of all...
History and Patterns of Symptoms
 Wheezing – high pitched whistling sounds when
breathing out
 History of any of the fol...
History and Patterns of Symptoms
 Symptoms occur or worsen at night, awakening the
patient
 Symptoms occur or worsen in ...
History and Patterns of Symptoms
 Symptoms occur or worsen in the presence of
 Animals with fur
 Aerosol chemicals
 Ch...
 Symptoms respond to anti-asthma therapy
 Patient’s cold go to the chest or take more than 10 days
to clear up
Physical Examination
 During routine clinic visits
 No abnormal signs
 Normal chest examination
 Deeper breaths can so...
Common viral infections of the respiratory
tract Aeroallergens in sensitized asthmatics
Animal dander
Indoor allergens
Dus...
UPPER RESPIRATORY TRACT
CONDITIONS
Allergic rhinitis[*]
Chronic rhinitis[*]
Sinusitis[*]
Adenoidal or tonsillar hypertroph...
Asthma Severity Classification
Levels of Asthma Control
Characteristic Controlled Partly controlled
(Any present in any week)
Uncontrolled
Daytime sympto...
Classification of Severity of Asthma
Exacerbation
Treatment
 The choice of treatment should be guided by:
 Level of asthma control
 Current treatment
 Pharmacological p...
Controller Medications
 Inhaled glucocorticosteroids
 Leukotriene modifiers
 Long-acting inhaled β2-agonists
 Systemic...
Estimate Comparative Daily Dosages for
Inhaled Glucocorticosteroids by Age
Drug Low Daily Dose ( g) Medium Daily Dose ( g)...
Reliever Medications
 Rapid-acting inhaled β2-agonists
 Systemic glucocorticosteroids
 Anticholinergics
 Theophylline
...
Component 4: Asthma Management and Prevention Program
Allergen-specific Immunotherapy
 Greatest benefit of specific immun...
controlled
partly controlled
uncontrolled
exacerbation
LEVEL OF CONTROL
maintain and find lowest
controlling step
consider...
Step 1 – As-needed reliever medication
 Patients with occasional daytime symptoms of
short duration
 A rapid-acting inha...
Step 2 – Reliever medication plus a single
controller
 A low-dose inhaled glucocorticosteroid is
recommended as the initi...
Step 3 – Reliever medication plus one or two
controllers
 For adults and adolescents, combine a low-dose
inhaled glucocor...
Additional Step 3 Options for Adolescents and Adults
 Increase to medium-dose inhaled
glucocorticosteroid (Evidence A)
 ...
Step 4 – Reliever medication plus two or more controllers
 Medium- or high-dose inhaled glucocorticosteroid
combined with...
Treating to Achieve Asthma Control
Step 5 – Reliever medication plus additional controller options
 Addition of oral gluc...
Treating to Maintain Asthma Control
 When control as been achieved, ongoing
monitoring is essential to:
- maintain contro...
Treating to Maintain Asthma Control
Stepping down treatment when asthma is controlled
 When controlled on medium- to high...
Treating to Maintain Asthma Control
Stepping down treatment when asthma is controlled
 When controlled on combination inh...
Treating to Maintain Asthma Control
Stepping up treatment in response to loss of control
 Rapid-onset, short-acting or lo...
Prevention
 hygiene hypothesis
 naturally occurring microbial exposures in early life
might drive early immune developme...
Thank you..
Bronchial Asthma in Children
Bronchial Asthma in Children
Bronchial Asthma in Children
Bronchial Asthma in Children
Bronchial Asthma in Children
Bronchial Asthma in Children
Bronchial Asthma in Children
Bronchial Asthma in Children
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Bronchial Asthma in Children

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Group didactics regarding Bronchial Asthma in Children.
Source: GINA guidelines, Nelson's Textbook of Pediatrics 19th ed.

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Bronchial Asthma in Children

  1. 1. Jackie Lou C. Acha Clinical Clerk Department of Pediatrics- OPD
  2. 2. Asthma  A chronic inflammatory condition of the lung airways resulting in episodic airflow obstruction  Chronic inflammation => heightened twitchiness of airways => Airways hyperresponsiveness (AHR) to provocative exposures
  3. 3. Asthma  AHR leads to recurrent episodes of  Wheezing  breathlessness  Chest tightness  Coughing, at night or in early morning  symptoms are usually associated with widespread but variable airflow obstruction that is generally reversible either spontaneously or with treatment
  4. 4. Epidemiology  One of the most common chronic diseases  ~300 M individuals affected worldwide  Prevalence increasing in many countries  Major cause of school/work absence
  5. 5. Risk Factors for Asthma Environment -Allergens -Infections -Microbes -Pollutants -Stress Biological and Genetic Risk -Immune -Lung -Repair Age
  6. 6. Host factors + Environmental factors ASTHMA
  7. 7. Asthma Predictive Index  Identify high risk children (2 and 3 years of age):  ≥4 wheezing episodes in the past year (at least one must be MD diagnosed) PLUS OR One major criterion • Parent with asthma • Atopic dermatitis • Aero-allergen sensitivity  Two minor criteria • Food sensitivity • Peripheral 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
  8. 8. Pathophysiology
  9. 9. Clinical Manifestations  Dry coughing  Expiratory wheezing  Chest tightness  Dyspnea commonly provoked by physical exertion and airways irritants (e.g., cold and dry air, environmental tobacco smoke)
  10. 10. Diagnosis  History and patterns of symptoms  Physical examination  Measurements of lung functions  Measurements of allergic status to identify risk factors
  11. 11. History and Patterns of Symptoms  Wheezing – high pitched whistling sounds when breathing out  History of any of the following  Cough, worse particularly at night  Recurrent wheeze  Recurrent difficult breathing  Recurrent chest tightness
  12. 12. History and Patterns of Symptoms  Symptoms occur or worsen at night, awakening the patient  Symptoms occur or worsen in a seasonal pattern  Patient has eczema, hay fever, or a family history of asthma or atopic diseases
  13. 13. History and Patterns of Symptoms  Symptoms occur or worsen in the presence of  Animals with fur  Aerosol chemicals  Changes in temperature  Domestic dust mites  Drugs (aspirin, beta blockers)  Exercise  Pollen  Respiratory infections  Smoke  Strong emotional expression
  14. 14.  Symptoms respond to anti-asthma therapy  Patient’s cold go to the chest or take more than 10 days to clear up
  15. 15. Physical Examination  During routine clinic visits  No abnormal signs  Normal chest examination  Deeper breaths can sometimes elicit otherwise undetectable wheezing  During asthma exacerbations  Expiratory wheezing  Prolonged expiratory phase  Decreased breath sounds in some of the lung fields  Crackles and rhonchi (excess mucous production)  Labored breathing and respiratory distress (retractions, nasal flaring
  16. 16. Common viral infections of the respiratory tract Aeroallergens in sensitized asthmatics Animal dander Indoor allergens Dust mites Cockroaches Molds Seasonal aeroallergens Pollens (trees, grasses, weeds) Seasonal molds Environmental tobacco smoke Air pollutants Ozone Sulfur dioxide Particulate matter Wood- or coal-burning smoke Endotoxin, mycotoxins Dust Asthma Triggers Strong or noxious odors or fumes Perfumes, hairsprays Cleaning agents Occupational exposures Farm and barn exposures Formaldehydes, cedar, paint fumes Cold air, dry air Exercise Crying, laughter, hyperventilation Co-morbid conditions Rhinitis Sinusitis Gastroesophageal reflux
  17. 17. UPPER RESPIRATORY TRACT CONDITIONS Allergic rhinitis[*] Chronic rhinitis[*] Sinusitis[*] Adenoidal or tonsillar hypertrophy Nasal foreign body MIDDLE RESPIRATORY TRACT CONDITIONS Laryngotracheobronchomalacia[*] Laryngotracheobronchitis (e.g., pertussis)[*] Laryngeal web, cyst, or stenosis 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[*] Toxic inhalations Differential Diagnosis of Childhood Asthma LOWER RESPIRATORY TRACT CONDITIONS Bronchopulmonary dysplasia (chronic lung disease of preterm infants) Viral bronchiolitis[*] Gastroesophageal reflux[*] Causes of bronchiectasis: Cystic fibrosis Immune deficiency Allergic bronchopulmonary mycoses (e.g., aspergillosis) Chronic aspiration Immotile cilia syndrome, primary ciliary dyskinesia Bronchiolitis obliterans Interstitial lung diseases Hypersensitivity pneumonitis Pulmonary eosinophilia, Churg-Strauss vasculitis Pulmonary hemosiderosis Tuberculosis Pneumonia Pulmonary edema (e.g., congestive heart failure) Medications associated with chronic cough Acetylcholinesterase inhibitors β-adrenergic antagonists
  18. 18. Asthma Severity Classification
  19. 19. Levels of Asthma Control Characteristic Controlled Partly controlled (Any present in any week) Uncontrolled Daytime symptoms None (2 or less / week) More than twice / week 3 or more features of partly controlled asthma present in any week Limitations of activities None Any Nocturnal symptoms / awakening None Any Need for rescue / “reliever” treatment None (2 or less / week) More than twice / week Lung function (PEF or FEV1) Normal < 80% predicted or personal best (if known) on any day Exacerbation None One or more / year 1 in any week
  20. 20. Classification of Severity of Asthma Exacerbation
  21. 21. Treatment  The choice of treatment should be guided by:  Level of asthma control  Current treatment  Pharmacological properties and availability of the various forms of asthma treatment  Economic considerations Cultural preferences and differing health care systems need to be considered
  22. 22. Controller Medications  Inhaled glucocorticosteroids  Leukotriene modifiers  Long-acting inhaled β2-agonists  Systemic glucocorticosteroids  Theophylline  Cromones  Long-acting oral β2-agonists  Anti-IgE  Systemic glucocorticosteroids
  23. 23. Estimate Comparative Daily Dosages for Inhaled Glucocorticosteroids by Age Drug Low Daily Dose ( g) Medium Daily Dose ( g) High Daily Dose ( g) > 5 y Age < 5 y > 5 y Age < 5 y > 5 y Age < 5 y Beclomethasone 200-500 100-200 >500-1000 >200-400 >1000 >400 Budesonide 200-600 100-200 600-1000 >200-400 >1000 >400 Budesonide-Neb Inhalation Suspension 250-500 >500-1000 >1000 Ciclesonide 80 – 160 80-160 >160-320 >160-320 >320-1280 >320 Flunisolide 500-1000 500-750 >1000-2000 >750-1250 >2000 >1250 Fluticasone 100-250 100-200 >250-500 >200-500 >500 >500 Mometasone furoate 200-400 100-200 > 400-800 >200-400 >800-1200 >400 Triamcinolone acetonide 400-1000 400-800 >1000-2000 >800-1200 >2000 >1200
  24. 24. Reliever Medications  Rapid-acting inhaled β2-agonists  Systemic glucocorticosteroids  Anticholinergics  Theophylline  Short-acting oral β2-agonists
  25. 25. Component 4: Asthma Management and Prevention Program Allergen-specific Immunotherapy  Greatest benefit of specific immunotherapy using allergen extracts has been obtained in the treatment of allergic rhinitis  The role of specific immunotherapy in asthma is limited  Specific immunotherapy should be considered only after strict environmental avoidance and pharmacologic intervention, including inhaled glucocorticosteroids, have failed to control asthma  Perform only by trained physician
  26. 26. controlled partly controlled uncontrolled exacerbation LEVEL OF CONTROL maintain and find lowest controlling step consider stepping up to gain control step up until controlled treat as exacerbation TREATMENT OF ACTION TREATMENT STEPS REDUCE INCREASE STEP 1 STEP 2 STEP 3 STEP 4 STEP 5 REDUCEINCREASE
  27. 27. Step 1 – As-needed reliever medication  Patients with occasional daytime symptoms of short duration  A rapid-acting inhaled β2-agonist is the recommended reliever treatment (Evidence A)  When symptoms are more frequent, and/or worsen periodically, patients require regular controller treatment (step 2 or higher) Treating to Achieve Asthma Control
  28. 28. Step 2 – Reliever medication plus a single controller  A low-dose inhaled glucocorticosteroid is recommended as the initial controller treatment for patients of all ages (Evidence A)  Alternative controller medications include leukotriene modifiers (Evidence A) appropriate for patients unable/unwilling to use inhaled glucocorticosteroids Treating to Achieve Asthma Control
  29. 29. Step 3 – Reliever medication plus one or two controllers  For adults and adolescents, combine a low-dose inhaled glucocorticosteroid with an inhaled long- acting β2-agonist either in a combination inhaler device or as separate components (Evidence A)  Inhaled long-acting β2-agonist must not be used as monotherapy  For children, increase to a medium-dose inhaled glucocorticosteroid (Evidence A) Treating to Achieve Asthma Control
  30. 30. Additional Step 3 Options for Adolescents and Adults  Increase to medium-dose inhaled glucocorticosteroid (Evidence A)  Low-dose inhaled glucocorticosteroid combined with leukotriene modifiers (Evidence A)  Low-dose sustained-release theophylline (Evidence B) Treating to Achieve Asthma Control
  31. 31. Step 4 – Reliever medication plus two or more controllers  Medium- or high-dose inhaled glucocorticosteroid combined with a long-acting inhaled β2-agonist (Evidence A)  Medium- or high-dose inhaled glucocorticosteroid combined with leukotriene modifiers (Evidence A)  Low-dose sustained-release theophylline added to medium- or high-dose inhaled glucocorticosteroid combined with a long-acting inhaled β2-agonist (Evidence B) Treating to Achieve Asthma Control
  32. 32. Treating to Achieve Asthma Control Step 5 – Reliever medication plus additional controller options  Addition of oral glucocorticosteroids to other controller medications may be effective (Evidence D) but is associated with severe side effects (Evidence A)  Addition of anti-IgE treatment to other controller medications improves control of allergic asthma when control has not been achieved on other medications (Evidence A)
  33. 33. Treating to Maintain Asthma Control  When control as been achieved, ongoing monitoring is essential to: - maintain control - establish lowest step/dose treatment
  34. 34. Treating to Maintain Asthma Control Stepping down treatment when asthma is controlled  When controlled on medium- to high-dose inhaled glucocorticosteroids: 50% dose reduction at 3 month intervals (Evidence B)  When controlled on low-dose inhaled glucocorticosteroids: switch to once-daily dosing (Evidence A)
  35. 35. Treating to Maintain Asthma Control Stepping down treatment when asthma is controlled  When controlled on combination inhaled glucocorticosteroids and long-acting inhaled β2- agonist, reduce dose of inhaled glucocorticosteroid by 50% while continuing the long-acting β2-agonist (Evidence B)  If control is maintained, reduce to low-dose inhaled glucocorticosteroids and stop long-acting β2-agonist (Evidence D)
  36. 36. Treating to Maintain Asthma Control Stepping up treatment in response to loss of control  Rapid-onset, short-acting or long- acting inhaled β2-agonist bronchodilators provide temporary relief.  Need for repeated dosing over more than one/two days signals need for possible increase in controller therapy
  37. 37. Prevention  hygiene hypothesis  naturally occurring microbial exposures in early life might drive early immune development away from allergen sensitization, persistent airways inflammation, and remodeling Other measures: avoidance of environmental tobacco smoke (beginning prenatally) prolonged breastfeeding (>4 mo) an active lifestyle and a healthy diet
  38. 38. Thank you..

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