A detailed approach to asthma in Children

1. Approach to asthma in children

2. objectives
o Differntial diagnosis
o Introduction to asthma+ 1slide epidemiology and CRADLE not asthma+ signs and symptoms also nocturnal
cough
o Prevention (CDC slides)
o Diagnostic approaches+ FeNO joke
o Quick relief
o Long term treatment
o Modified asthma predictive index
o Asthma action plan

4. Asthma is the most common
chronic disease of childhood in
industrialized countries.

5. Pathophysiology
• Type 1 heypersensitivity, IgE
mediated
• Associated with eosinophilia
• +eczema, allergic rhinitis
• Cells:
mast cells, eosinophils, T lymphocytes,
neutrophils
• chemical mediators:
histamine, leukotrienes, platelet-activating
factor, bradykinin
• chemical mediators:
histamine, leukotrienes,
platelet-activating factor, bradykinin

6. cough
SOB
Chest
tightness
wheeze
Asthma
Presentation of Asthma:
Studies of asthma's natural history have shown that almost 80%
of cases begin during the first 6 years of life. The symptoms of
pediatric asthma in this age group are varied and not specific to
asthma making the diagnosis challenging. The primary
symptoms of asthma in infancy and early childhood include
cough, both dry and productive (albeit young children rarely
expectorate), wheeze, shortness of breath, and work of
breathing. Asthma symptoms are a result of airway
inflammation, bronchospasm, airway edema, and airway
mucous gland hypertrophy.
Interestingly, these symptoms can also present with a multitude
of other pediatric diseases including respiratory tract infections
and congenital airway anomalies posing a diagnostic challenge.
It is well-established that asthma in this age group is frequently
under-diagnosed and undertreated
Ref: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6603154/

7. Rhinosinusitis
Aspirin
GERD
Can aggravate asthma

8. Features that favor the diagnosis of asthma:
 Intermittent episodes of wheezing that usually are the result of a common trigger
 Seasonal variation
 Family history of asthma and/or atopy
 Good response to asthma medications

9. Doesn‘t include ASTHMAAA!

10. Laboratory and imaging studies
• Spirometry
• Peak flow measures
• Allergy skin testing
• Radioallergosorbent test (RAST)
• Chest radiograph
• Exhaled nitric oxide analysis
• enzyme-linked immunosorbent assay (ELISA), are
generally less sensitive in
defining clinically pertinent allergens, are expensive,
and time consuming.

12. Spirometry
 monitor response to treatment
 assess degree of reversibility with
therapeutic intervention
 measure the severity
of an asthma exacerbation
 older than 5 y. o.

13. Radiographic Studies
A chest x-ray should be performed with the first episode of asthma or with
recurrent episodes of undiagnosed cough or wheeze to exclude anatomic
abnormalities.
 Repeat chest x-rays are not needed with new episodes unless there is fever
(suggesting pneumonia) or localized findings on physical examination.
 In mild asthma, the chest radiograph is normal
In more severe, signs of air trapping may be seen:
• hyper lucency
• flattening of the diaphragms
• increased AP diameter
• horizontal positioning of the ribs

15. Pulmonary Function Test:
• Spirometry (usually feasible in children >5 yr of age )
many of whom can have near-normal or even supra-
normal airflow despite having the other hallmarks of
moderate to severe disease.
• exhaled nitric oxide (FENO)
• Peak expiratory flow (PEF) monitoring

16. Lung Function Abnormalities in Asthma:
 Airflow limitation
Low FEV1 (relative to percentage of predicted norms)
FEV1/FVC ratio <0.80
 Bronchodilator response to inhaled β-
agonist )Improvement in FEV1 ≥12% or ≥200 mL(
 Exercise challenge Worsening in FEV1 ≥15%
 Daily peak flow or FEV 1 monitoring: day to day
and/or AM-to-PM variation ≥20%

17. Peak Flow Meter
 A device used to measure how air flows from your lungs in one “fast blast.”
 Children with poor symptom perception
 Other causes of chronic coughing in addition to asthma
 Moderate to severe asthma
 History of severe asthma
 Assess objectively airflow as an indicator of asthma control

18. treatment

21. Reducing Exposure to House Dust Mites
• Use bedding encasements
• Wash bed linens weekly
• Avoid down fillings
• Limit stuffed animals to
those that can be washed
• Reduce humidity level
(between 30% and 50%
relative humidity per EPR-
3)
Source: “What You and Your Family Can Do About Asthma” by the Global Initiative For
Asthma Created and funded by NIH/NHLBI, 1995
Reference: CDC

22. Reducing Exposure to
Environmental Tobacco Smoke
Evidence suggests an
association between
environmental tobacco smoke
exposure and exacerbations of
asthma among school-aged,
older children, and adults.
Evidence shows an association
between environmental tobacco
smoke exposure and asthma
development among pre-school
aged children.
Reference: CDC

23. Reducing Exposure to Cockroaches
Remove as many water and food sources as
possible to avoid cockroaches.
Reference: CDC

24. Reducing Exposure to Pets
• People who are allergic to pets should not have them in the
house.
• At a minimum, do not allow pets in the bedroom.
Reference: CDC

25. Reducing Exposure to Mold
Eliminating mold and the moist conditions that permit
mold growth may help prevent asthma exacerbations.
Reference: CDC

26. Other Asthma Triggers
Air pollution
Trees, grass, and weed pollen
Reference: CDC

30. PROGNOSIS
For some children, symptoms of wheezing with respiratory
infections subside in the preschool years, whereas others
have more persistent asthma symptoms. Prognostic
indicators for children younger than 3 years of age who
are at risk
for persistent asthma are known as the Modified Asthma
Predictive Index for children (Table 78.5). Atopy is the
strongest predictor for wheezing continuing into persistent
asthma