The document discusses asthma triggers and diagnosing asthma. It provides information on the most common indoor asthma triggers like dust mites, pet dander, cockroaches, mold, and tobacco smoke. It notes that diagnosing asthma requires identifying recurrent symptoms like coughing, wheezing, and shortness of breath that are at least partially reversible with treatment. The diagnosis can be challenging for young children as lung function tests are difficult.

2. Dr. Ashraf El Adawy
Consultant Chest Physician
TB TEAM EXPERT – WHO
Egypt

3. Asthma triggers

4. ©2004 Children’s
Hospital and Health
System / FAM Allies.
are things that make
asthma worse.
Remember, everyone is different!
Triggers …

5. 3 kinds of
asthma triggers
Allergens
Infections
Irritants

6. Common Asthma Triggers
Allergens
Molds
Dust Mites
Animals
Pollen
Food
Pests
(cockroaches)
Irritants
Secondhand smoke
Strong odors
Ozone
Chemicals/cleaning
compounds

7. Other asthma triggers
Viral respiratory infections
o Colds
o Flu
Exercise
Changes in weather
o Cold air
o Wind
o Humidity

8. Indoor Air Pollution
A Major Health Concern
Most people spend 90% of their time indoors
Toxin levels indoors may be higher than
outdoors because of energy tight buildings
Most of the common asthma triggers are
found indoors

9. 5 Most Common Indoor
Environmental Triggers
Secondhand Smoke
Dust Mites
Mold
Pets/Animals
Cockroaches

10. Animal allergens
Dust mites
Cockroach allergens
Indoor fungi
Tobacco smoke
5 Most Common Indoor Environmental Triggers

11. • Too small to be seen
• Found almost everywhere!
• Live in soft bedding
• Feed on dead skin cells
• Mites and mite droppings
can be asthma triggers
• Live in warm, humid places
Dust Mites

16. Pet Dander

18. This trigger’s dander and saliva
make asthma worse.
Dogs and cats

24. Secondhand Smoke

25. Evidence suggests an association
between environmental tobacco
smoke exposure (ETS) 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.

28. Other Indoor Triggers
Household Products
Vapors from cleaning
solvents (non-water
based), paint, liquid
bleach, mothballs,
glue
Spray deodorants,
perfume
bleach, pesticides,
oven cleaners, drain
openers, aerosol
spray products

36. This pollutant can make allergic
responses more severe. Diesel air pollution

38. ‫بالفحم‬ ‫الشوي‬ ‫دخان‬

39. ‫بالفحم‬ ‫الشوي‬ ‫دخان‬

43. Combustion Appliances
 Nitrogen dioxide is an
odorless gas that can
irritate your eyes, nose,
and throat and may
cause shortness of
breath. This gas can
come from the use of
appliances that burn
fuels, such as gas,
wood, and kerosene

44. 44

51. 51

52. 52

53. 53

54. Dust of book depo-
sitories

56. Triggers: Food Allergies

65. What Can Make Asthma Worse?
• Changes in
weather and
temperature
• Infections in the upper
airways, such as colds
• Physical expressions of
strong feelings (crying or
laughing hard, yelling)
Not all factors affect all people. It’s important to identify what affects
a particular student’s asthma.

66. § ß-Blockers
Exposure to sensitizing drugs
§ Aspirin and NSAIDS
§ ACE inhibitors

67. Diagnosis of Asthma
67

68. What is Asthma?
A disease that:
 Is chronic
 Produces recurring episodes of breathing
problems
– Coughing
– Wheezing
– Chest tightness
– Shortness of breath

69. Make the asthma diagnosis
 Episodic airflow obstruction
 Airflow obstruction is at least partially
reversible
 Alternative diagnoses are excluded
Inflammation causes recurrent episodes of coughing,
wheezing, breathlessness, and chest tightness. These
episodes are usually associated with widespread but
variable airflow obstruction that is often reversible either
spontaneously or with treatment.
-- NAEPP EPR3 2007 Definition of asthma

70. The prevalence or rate of
asthma is …… On the rise or increasing

72. 72

73. 73

75. Allergic Disease is Epidemic
H O W C O M M O N A R E A L L E R G I E S ?
One in five Americans – 55 million people – have
allergies to airborne triggers such as pollen, mold, dust
mites or animal dander.
VERY

76. 76

77. Changes in the prevalence of allergic diseases
combinations in 6-7 yrs old children
Kudzyte et al. Pediatric Pulmonology and Allergology 2004
A+ADAR+AD
0
0.5
%
1994-95 y
2001-02 y
A+AR+AD A+AR
*
* *
*p<0.05
ISAAC (International Study of Asthma and Allergy in Childhood)

78. Changes in the prevalence of allergic diseases
combinations in 13-14 yrs old children
Kudzyte et al. Pediatric Pulmonology and Allergology 2004
A+ADAR+AD
0
0.5
%
1994-95 y
2001-02 y
A+AR+AD A+AR
*
*
*p<0.05
1.0
ISAAC (International Study of Asthma and Allergy in Childhood)

80. We need to be proactive and
not just reactive

81. Diagnosis of Asthma
History of Recurrent Symptoms
*Wheeze Cough Shortness of breath
Rule Out Other Causes of Symptoms
Document Presence of Airflow Obstruction
● Spirometry ● PEFR
Demonstrate Reversibility of Obstruction/Symptoms

83. A correct diagnosis of asthma is essential if
appropriate drug therapy is to be given.
Asthma symptoms may be intermittent and their
significance may be overlooked by patients and
physicians
Asthma symptoms may be non-specific, result in
misdiagnosis , This is particularly true among
children, and lead to inappropriate treatment.

84. Asthma Diagnosis
 By history, the patient must meet three criteria:
─ Symptoms of asthma occur in response to an
allergen , trigger or airway irritant (airway
hyperreactivity)
─ Repeated episodes of symptoms (recurrence)
─ Response to treatment (reversibility) measured
objectively by spirometry with a significant
increase postbronchodilator or relief of symptoms

85. Symptoms of Bronchial Asthma
Bronchial asthma is episodic
•In-between attacks patients especially
young ones may be asymptomatic
The common symptoms are:
Cough Wheezing Tightness Dyspnea
85

87. Diagnosis of Asthma
Detailed medical history
– Cough
 Nocturnal
 Seasonal
 Related to workplace
 Related to specific activity
– Recurrent wheeze
– Recurrent dyspnea
– Recurrent chest tightness
– Triggers (allergic and non-allergic)

88. o Symptoms that suggest asthma include wheezing,
dyspnea, chest tightness, or cough in the
following circumstances
(1) with exposure to cold air
(2) after exercise
(3) during respiratory infections
(4) following inhalant exposures in the workplace
(5) after exposure to allergens and other asthma
triggers.

89. Not All That Wheezes Is Asthma…
-Foreign body
- Upper airway diseases
- Enlarged lymph nodes or tumor
- Vocal cord dysfunction
- Aspiration/GERD
- COPD
- CHF
- PE
- Drug reaction/side effect

90. Asthma Does Not Always Wheeze…
√ Chronic or nocturnal cough with
awakenings
√ Exercise induced symptoms
√ Chest tightness
√ Viral induced symptoms

91. Wheezes are heard more commonly during
expiration because the airways normally narrow
during this phase of respiration.
Wheezing during expiration alone is generally
indicative of milder obstruction than if present
during both inspiration and expiration, which
suggests more severe airway narrowing.

92.  In contrast, the absence of wheezing in an
asthmatic may indicate either improvement of the
bronchoconstriction or severe, widespread airflow
obstruction.
 The latter suggests that the airflow rates are too low
to generate wheezes or the viscous mucus is
obstructing large regions of the peripheral airways.
 Increasing exhaustion and a "silent chest" are
ominous signs of respiratory muscle fatigue and
failure

93. Asthma – To Wheeze or Not
To Wheeze
Asthma does not always present with classic
wheezing, chest tightness and cough.
Sometimes, only the cough is present and we call
this Cough Variant Asthma.
Some people only get symptoms when they
exercise and we call this Exercise Induced
Asthma.

94. When cough is the only asthma symptom, this is
known as cough variant asthma (CVA).
People with cough-variant asthma often have no
other "classic" asthma symptom, such as
wheezing or shortness of breath

95. √ Wheezing does not always indiciate asthma and
vice versa - you can have an asthma attack
where wheezing is not the main symptom.
√ Coughing can sometimes be the main symptom
of an asthma attack (but again, a persistent
cough does not necessarily mean he has
asthma)

96. A chronic cough is defined as one that lasts
longer than 8 weeks. There are many causes of
chronic cough in nonsmoking adults.
Asthma, gastroesophageal reflux disease, post-
nasal drip and post-infectious cough are the
most common causes.
Asthma is believed to be responsible for 24% to
29% of these persistent coughs

97.  Absence of symptoms at the time of
the examination does not exclude
the diagnosis of asthma

98. Is it Asthma?
√ Recurrent episodes of wheezing
√ Troublesome cough at night
√ Cough or wheeze after exercise
√ Cough, wheeze or chest tightness after
exposure to airborne allergens or pollutants
√ Colds “go to the chest” or take more than 10
days to clear
√ Symptoms improved by appropriate asthma
treatment?

99.  Several studies have demonstrated that
patients’ symptom reports are unreliable
indicators of airflow limitation
 Poor perception of the severity of asthma on the
part of the patient and health care professional
has been cited as a major factor causing delay
in treatment and thus may contribute to
increased severity and mortality from asthma
exacerbations.
 However, this is not the case with all patients

100. 10
0

101. Asthma diagnosis in children
Asthma is the Most Common Chronic Illness
of Childhood
Asthma is Underdiagnosed and therefore
Undertreated in Infants and Children

102.  There should be an identifiable
trigger usually a viral infection
 Airways obstruction is reversible
with bronchodilators
 Usually more than 3 episodes
TO DIAGNOSE ASTHMA IN INFANTS
THINK OF THE “3R”
Reactivity
Reversibility
Recurrence
Finder Curr. Probl. Pediatr. 1999

103. A diagnosis of asthma should be considered if
more than 3 episodes of reversible bronchial
obstruction have been documented within
the previous 6 months.

104. Diagnosis of Asthma in Children 5 Years
and Younger
Asthma diagnosis in this age group is difficult
Respiratory symptoms (wheezing and cough) also
common in children without asthma
Not possible to routinely assess airflow limitation
(spirometry)
Lung function testing is of limited use because of
practical difficulties obtaining reliable results.

105. Diagnosis of Asthma in Children 5 Years
and Younger
No tests provide a diagnosis with certainty but the
following may be useful adjuncts in a diagnostic
decision:
Therapeutic trial with inhaled glucocortiosteroid
and rapid-acting β2-agonists for 8-12 weeks
Tests for atopy

106. Asthma should be suspected in any infant with
recurrent wheezing and coughing episodes.
Diagnosis is often only possible through long-
term follow-up, observations of the child´s
response to bronchodilator and/or anti-
inflammatory treatment and consideration of
the extensive differential diagnoses.

108. In children 5 years and younger, the diagnosis of
asthma has to be based largely on clinical
judgment and an assessment of symptoms and
physical findings.
A useful method for confirming the diagnosis in this
age group is a trial of treatment with SABA and ICS.
Marked clinical improvement during the treatment
and deterioration when treatment is stopped
supports a diagnosis of asthma.

109. <5 years: clinical judgement and response
to asthma treatment may be the only
reliable means for diagnosing asthma
Spirometry for children >5 years
Asthma in children < 5 years

110. Natural History of Childhood Wheeze
Age (Years)
WheezingPrevalence
Non-atopic
wheezers
Transient early
wheezers
IgE-associated
wheeze/asthma
0 3 6 11
Martinez. J Allergy Clin Immunol 1999;104:S169-S174.

111. 1
1
1
Wheezing phenotypes in children
12 Longitudinal birth cohorts
Original Tucson Group (Taussig L et al 1985)

113. Wheezing phenotypes
 Episodic wheezing and cough is very common
even in children who do not have asthma and
particularly in those under age 3.
 Three categories of wheezing have been described
in children 5 years and younger:
1. Transient early wheezing
2. Persistent early-onset wheezing (before age 3).
3. Late-onset wheezing/asthma.

114. Transient early wheezing
Commonest form of wheeze
Decrease lung function at birth
The pattern of respiratory symptoms starting
in the first year of life.
Generally, transient wheezing in infants is
not associated with a family history of
asthma or allergic sensitization - Non Atopic
No airway hyper-responsiveness

115. Transient early wheezing
Transient early wheezing, is often outgrown in
the first 3 years - characteristically resolves
around the age of 3
Transient early wheezing, is often associated
with prematurity & male gender &,Teenage
pregnancy and parental maternal smoking ,
as well as postnatal exposure to tobacco
smoke..

116. OR for asthma in the first 5 years of life
Smoking
mother
only
1.3
MATERNAL AND GRANDMATERNAL SMOKING PATTERNS
ARE ASSOCIATED WITH EARLY CHILDHOOD ASTHMA
Li YF Chest 2005
3 –
2 –
1 –
0
1.8
 338 children
with asthma
diagnosed
in the first 5
years of life
 570 control
subjects
Grandmaternal
only smoking
during the
mother’s fetal
period
Grandmaternal
and maternal
smoking
2.6

117. Early Wheeze group had lower lung function
than any other group shortly after birth(before
the first wheezing episode)
Continued to have slightly lower function than
predicted into young adulthood,suggesting
their airways are anatomically smaller than
average
They may be at increased risk of COPD if they
become smokers themselves
Transient early wheezing

118.  European Community Respiratory Health Survey
participants aged 20–45 years randomly selected from
general populations.
 Spirometry in 1991–3 (n=13,359) and
9 years later (n=7,738).
Early life origins of chronic obstructive
pulmonary disease Svanes Thorax 2010;65:14–20
•Maternal asthma
•Paternal asthma
•Childhood asthma
•Maternal smoking and
Childhood respiratory infections
defined as
‘‘childhood
disadvantage
factors’’.

119. THE ADULT INCIDENCE OF ASTHMA AND RESPIRATORY
SYMPTOMS BY PASSIVE SMOKING IN UTERO OR IN
CHILDHOOD Skorge AJRCCM 2005
 Between 1985 and
1996/1997 an 11-year
community cohort
study on the
incidence of asthma
 3.786 subjects
OR ratio for adult
onset asthma
3 –
2 –
1 –
0
3
Smoking mother

120. REGULAR SMOKING AND ASTHMA INCIDENCE IN
ADOLESCENTS Gilliland AJRCCM 2006; 174: 1094
 2,609 children with no
lifetime history of
asthma or wheezing
 Followed annually
in schools
 Regular smoking was
defined as smoking 300
cigarettes in the year
 New cases of physician-
diagnosed asthma
RR FOR NEW ONSET
OF ASTHMA
3.9
4 –
3 –
2 –
1 –
0
In children smoking
>300 cigarettes/year

121. RR FOR NEW ONSET
OF ASTHMA
8.8
10-
8 –
6 –
4 –
2 –
0
In children smoking
>300 cigarettes/year and
exposed to maternal smoking
during gestation
REGULAR SMOKING AND ASTHMA INCIDENCE IN
ADOLESCENTS Gilliland AJRCCM 2006; 174: 1094
 2,609 children with no
lifetime history of
asthma or wheezing
 Followed annually
in schools
 Regular smoking was
defined as smoking 300
cigarettes in the year
 New cases of physician-
diagnosed asthma

123. Persistent early-onset wheezing (before age 3).
These children typically have recurrent episodes
of wheezing associated with acute viral
respiratory infections,
The cause of the episode is usually the
respiratory syncytial virus in children younger
than age 2, while other viruses predominate in
older preschool children.
Symptoms continue beyond the age of six
Persistent Nonatopic Wheezers
Viral-associated wheeze

124. Ceases in adolescence
The symptoms normally persist through school
age and are still present at age 12 in a large
proportion of children
Have no evidence of atopy and, have no family
history of atopy.
Of all the children who continue to wheeze after
the age of 3 years, 40% belong to this second
phenotype.
Persistent Nonatopic Wheezers

125. Unlike children with transient wheezing, these
children are born with lung function that is similar
to that of the control group and that remains
statistically normal up to the age of 18 years, but
they show bronchial hyperresponsiveness to
methacholine - Airway hyper-responsiveness
Nonatopic wheezers have normal lung function
in early life & reduced in later life
Persistent Nonatopic Wheezers

126. – Late-onset wheezing/asthma:
80% before the age of 6yr (esp before 3yr)
Symptoms persist into childhood and adult life.
Atopic background, often with eczema
 Children with recurrent wheeze at school age
commonly also have a parental history of asthma, or
have signs of atopy, like eczema or allergic rhinitis,
or have at least one positive skin prick test for an
inhaled allergen.
Atopic wheezer/ asthma.

127. Children with persistent 'atopic' wheezing who
develop asthma in later childhood, more often
have their first episode of wheeze after the first year
of life, discrete attacks with symptom-free intervals,
symptoms that worsen at night, frequent symptoms,
a family history of asthma, elevated serum IgE and
peripheral blood eosinophilia. Furthermore they
may respond to bronchodilators and
corticosteroids.
Increased symptoms with increasing age
Lung function normal at birth but deteriorates with
recurrent symptoms
Atopic wheezer/ asthma

128. Lung function according to wheezing history at 6 years
Early infancy 6 years of age
V max of FRC (ml/s)
V max of FRC (ml/s)
never early late persistent never early late persistent
wheezerswheezers
Martinez NEJM 1995; 332: 133
-
-
-
-


-
-
-
-


-
-
-
-
-
- -
-



160 -
140 -
120 -
100 -
80 -
60 -
40 -
20 -
0
1400 -
1300 -
1200 -
1100 -
1000 -
900 -
800

129. 12
9
We have a
long way to
go!

130.  The following categories of symptoms are
highly suggestive of a diagnosis 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, and
symptoms that persist after age 3.

131. OUTCOME OF INFANT WHEEZING
Low birth weight
Pregnancy smoking
Male Sex
Affluence
Atopy
Low maternal age (first born)
Infant wheeze
With viral infection alone With various precipitants
Remission in 80%
?? COPD in adults
Persistent asthma (with or
without evidence of atopy) in
50-60%

132. Spectrum of disorders
Birth 1 year 5 years Adolescence

133. Spectrum of disorders
Birth 1 year 5 years Adolescence
Bronchiolitis Pre-school wheeze Asthma in school children

134. Spectrum of disorders
Birth 1 year 5 years Adolescence
Bronchiolitis Pre-school wheeze School children
RSV, adeno,
rhino
50:50 atopic 90:10 atopic

137. 0
20
40
60
80
100
Infant wheeze Infant wheeze
with atopic
parent (s)
Infant wheeze +
atopic eczema
and/or other
food allergies
Infant wheeze +
atopic parent +
positive skin prick
test + raised sIL-2R
20%
40%
50%
90%
% OF INFANTS SUBSEQUENTLY
DEVELOPING ASTHMA

138. 13
8

139. 13
9

140. 14
0

141. 14
1

142. 14
2

143. 14
3

144. Asthma in young infants
 Most common cause
of wheezing in infants
and young children is
viral respiratory tract
infection
but
 strongest predictor
for wheezing
continuing into
asthma is atopy

145. • Different phenotypes of childhood
asthma
- Virus associated wheeze
- Post-bronchiolitis wheeze
- Atopy associated wheeze
• Asthma in more than 50% begins <3
years
Asthma is not one disease

146. In the vast majority of cases asthma has its
onset in childhood.
In a proportion of asthmatic children,
asthma remits in adolescence or early
adulthood and the severity of asthma tracks
significantly with age.

147. Complete remission of childhood asthma may
be the exception rather than the rule.
Patients with asthma in clinical remission
should be monitored with periodic assessment
of lung function, bronchial responsiveness, and
other markers of inflammation.

148. „... there is a belief among general
practitioners and paediatricians that
children grow out of asthma.“
Issues in Adolescent Asthma.
Thorax 1996; 51 (Supplement 1)
Childhood asthma
„... it is often not the asthma that is
outgrown but the paediatrician.“

149. Do all children who wheeze
have asthma?
 No. Most children who develop wheezing
after age 5 have asthma.
 However, diagnosis of asthma in children 5
years and younger presents a particularly
difficult problem.

150.  Episodic wheezing and cough are also
common in children who do not have
asthma, particularly in children younger
than age 3 .
 The younger the child, the greater the
likelihood that an alternative diagnosis may
explain recurrent wheeze.
Do all children who wheeze
have asthma?

151.  Although there is the possibility of overtreatment,
episodes of wheezing may be shortened and
reduced in intensity by effective use of anti-
inflammatory medications and bronchodilators
rather than antibiotics.
Do all children who wheeze
have asthma?

153. “No great thing is created
suddenly.”
Epictetus