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![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](https://image.slidesharecdn.com/8-180524153647/85/8-had-and-tb-44-320.jpg)
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- 1. Childhood asthma GETA .B(MD) 08/05/2018
- 2. Out line • Definition •Epidemiology • Etiology / Risk factors • Natural history & pathogenesis • Clinical presentation • Laboratory studies • Treatment
- 3. CHILDHOOD ASTHMA • Definition Asthmais 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 2006National 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% ofall 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 determinedbut 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
- 8. Triggers • Viruses • Dust •Allergens (pollen) • Cold Air • Cigarette smoke • Exercise • Stress/emotional • Animals
- 9. Early Childhood RiskFactors for Persistent Asthma • Parental asthma • Allergy – Atopic dermatitis – Allergic rhinitis – Food allergy – Inhalant allergen sensitization – Food allergen sensitization • Severe lower respiratory tract infection – Pneumonia – Bronchiolitis requiring hospitalization • Wheezing apart from colds • Male gender • Low birth weight • Environmental tobacco smoke exposure
- 10. AHR - airways hyperresponsiveness ETS- environmental tobacco smoke Etiology and pathogenesis of asthma
- 11. MAJOR CRITERIA MINORCRITERIA 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 duringthe 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 inlater 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 isan 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 • Approximately80% 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 • Daytimesymptoms, 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 FunctionTesting • 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 exhalednitric 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 - Chestradiogram • Findings consistent with asthma, such as – hyperinflation, – peribronchial thickening, and – mucoid impaction with atelectasis. – Complications
- 29. Radiology – chestCT • 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 • NationalAsthma 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
- 31. The key elementsto optimal asthma management
- 32.
- 33. Managing Asthma inChildren
- 34. Asthma management 1. Regularassessment & 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. Controlof 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. ASTHMAPHARMACOTHERAPY • 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 ADULTSAND 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
- 45. Managing Children (≤5Yr)with Acute or Chronic Asthma
- 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 treatmentevery 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 controlis 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
- 50. Managing Asthma inChildren >5Yr of Age
- 51. Managing Asthma inChildren >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 inChildren >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 andTheir 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 andTheir Management … mgt The optimal management of a child comprehensive assessment • Focused history • Clinical assessment • Risk factors for asthma morbidity & death • Treatment
- 55. Asthma Exacerbations andTheir 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 ofAsthma 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 ofAsthma 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 ofAsthma 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 ofAsthma 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 ofAsthma 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 ofAsthma 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 ofAsthma 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 ofAsthma 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 ofAsthma 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 ofAsthma Exacerbations Interventions for status asthmaticus 1. Supplemental oxygen, 2. frequently or continuously administered inhaled bronchodilator And 3. Systemic corticosteroid therapy
- 66. Hospital Management ofAsthma 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 ofAsthma 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 ofAsthma 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
- 69. Childhood Tuberculosis GETA .B(MD) 07/05/2018
- 70. outline • Epidemiogy • Etiology •Transmission • pathogenesis • Clinical Manifestation • Diagnosis • Managment • Prevention
- 71. Epidemiology • one-third ofworld 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 are22 high burden countries acounted for 82% of all estimated case worldwide . • Ethiopia is the 7th burdened country.
- 73. Etiology • Mycobacterium tuberculosiscomplex. –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 isperson 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 – Poorlyventilation – Overcrowding – Intimacy Younger children (<7yr) rarely infect others M.Bovies transmited by ingestion of cow milk.
- 76. Continuing • The riskof infection of susceptible individual is high with close,prolonged,indoor exposure to aperson with sputum positive pulmonary TB.
- 77. Pathogenesis • lung isportal 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 TBoccurs 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 Agload 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
- 81. Continuing • Extrapulmonary – TBlymphadenities – pleural TB – TB pericardities – CNS TB • Stage 1 • stage 2 • stage 3
- 82. Continuing • Common permanentdisabilities 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 TB2RHZE/4RH • Nutritional Rehablitation • Sceaning of the family(index case, other contacts). • follow up(Adherance,responce,drug side effact)
- 86. Continuing • Steroid inTB 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.
- 87. prevention • Ventilation • Earlydiagnosis and treatment
- 88.