Pediatric Asthama

1. Paediatric Asthma
Dr Rossa Brugha
Clinical Research Fellow
11th February 2014
April 2010

2. Paediatric asthma
• What is asthma in childhood?
• Pathology, signs and symptoms
• Diagnosis
• Principles of asthma management
• Self management
• Pharmacotherapy
• Assessing control
• What’s new

3. The scale of the problem
0
5
10
15
20
25
30
Eczema Rhinitis Asthma Wheeze
1973
1988
2003
%
of
12
yr.
olds
Burr et al Thorax
2006;61:296-9

4. Changes in the Prevalence of Diagnosed Asthma and Asthma Symptoms over Time in Children and Young Adults.
Eder W et al. N Engl J Med 2006;355:2226-2235.
The scale of the problem

5. Asthma vs preschool wheeze
Asthma
• Above age 5
• Approx 1 in 11 children
• Inflammatory condition
• Responds to inhaled
corticosteroids
Preschool wheeze
• Age 1-5
• Approx 1 in 3 children
• ‘Episodic viral’ wheeze
– Wheeze only with viral
infections
– No evidence for ICS
• ‘Multi-trigger’ wheeze
– URTIs plus other triggers eg
exercise, smoke, allergens
• Only give oral prednisolone in
subgroup of those requiring
admission
See: Bush A, Grigg J, Saglani S. Managing wheeze in preschool children. BMJ 2014; 348

6. What is Asthma? A clinical diagnosis
• There is no agreed definition, no known
cause
• Genetic susceptibility plus environmental
trigger:
• 1st degree relative increases risk
• Identical environments in siblings with
and without asthma
• Time course/“double hit” of atopic
sensitization and viral infection eg hRV3;
1st year of life is crucial

7. Clinical features that increase the
probability of asthma
More than one of the following symptoms:
• Wheeze, cough, DIB, chest tightness,
particularly if symptoms:
–are frequent and recurrent
–are worse at night and in the early morning
–occur in response to, or are worse after,
exercise or other triggers, such as exposure
to pets, cold, damp air, or with
emotions/laughter

8. • Personal history of atopic disorder
• Family history of atopic disorder and/or
asthma
• Widespread wheeze heard on auscultation
• History of improvement in symptoms or lung
function in response to adequate therapy
Clinical features that increase the
probability of asthma

9. Clinical features that lower the
probability of asthma
• Symptoms with colds only, with no interval
symptoms
• Isolated cough in the absence of wheeze or
difficulty breathing
• History of moist cough
• Prominent dizziness, light-headedness,
peripheral tingling

10. Clinical features that lower the
probability of asthma
• Repeatedly normal physical examination of
chest when symptomatic
• Normal peak expiratory flow (PEF) or
spirometry when symptomatic
• No response to a trial of asthma therapy
• Clinical features pointing to alternative
diagnosis

11. Airway pathology in asthma
The hallmark of asthma is chronic airway inflammation
From: Bradding, P., Walls, A.F. & Holgate, S.T. (2006). The role of the mast cell in the pathophysiology of asthma.
J Allergy Clin Immunol 117, 1277–84

12. Airway pathology in asthma

14. Signs and symptoms
The result of airway inflammation is airway narrowing

16. Self management
• Avoid triggers
• Air pollution
• Passive (active) smoking
• Aeroallergens when/if possible
• Healthy diet
• Studies in adults and children have shown that
a high intake of fresh fruit and vegetables is
associated with fewer asthma symptoms and
better lung function

18. Self management
• Exercise
• Warm up and warm down
• Use bronchodilator pre-exercise
• Good evidence that exercise helps asthma
• Complementary treatments
• Buteyko breathing (a technique to control
hyperventilation) has been shown to reduce
symptoms

19. Pharmacotherapy
Steroids Montelukast
Monoclonal anti-IgE
(omalizumab, Xolair)
Lebrikizumab: anti IL-13
Mepolizumab: anti IL-5
Pascolizumab: anti IL-4

20. Management of chronic asthma

22. Asthma control test
• During the past 4 weeks:
1. How often did your asthma prevent you from getting
as much done at work, school or home?
2. How often have you had shortness of breath?
3. How often did your asthma (wheezing, coughing,
chest tightness, shortness of breath) wake you up?
4. How often have you used your reliever inhaler?
5. How would you rate your asthma control ?

23. Comorbidities
• Around 50% with asthma will have atopy
- Eczema
- Rhinitis
- Hayfever
• Antigen crossing via these sites can
persistently sensitise the immune system
• Important to optimise epithelial health
- Barriers (emollient)
- Immunomodulators (topical steroid)
- Symptom control (antihistamines)

24. What’s in the pipeline
• Phenotyping asthma
– Via SNPs eg leukotrienes and ALOX-5
• “Urine dip” for asthma
– By sputum leucocytes
– By exhaled breath cytokine pattern (Th1, Th2, Th17)
• Predicting exacerbations/inflammometry
– FeNO (probably not in children)
– Sputum eosinophil count (probably not in children)
– ACT score
– Peak flow fractals

25. Why phenotype?
• All that wheezes is not asthma
• Consider the approach to management of
other chronic inflammatory conditions in
childhood
– Joint arthropathies
– Inflammatory bowel disease

27. Asthma Review: Checklist
1. The right diagnosis
2. Check symptom control (ACT)
3. Ask about and address smoking (child and parent)
4. The right treatment at the right time (step-wise)
– Before initiating a new drug/step: check
compliance with existing therapies, inhaler
technique and try to eliminate trigger factors.
– Minimise side effects from treatment (i.e. growth
if on high dose ICS)
5. The right inhaler, correct technique
– Give inhaler training, ensure correct technique
before writing prescription

28. 6. The gold standard is MDI + spacer
7. Give Asthma education
– (repetition, reinforcement, signpost/give
resources)
8. All children should have an Asthma Plan
9. Promote self-management
– Compliance
10.Need regular review
– Annual review
– Review at 48-72 hrs and 30 days post
exacerbation/admission
Asthma Review: Checklist

29. NICE Quality standards QS25
• Statement 1. People with newly diagnosed asthma are diagnosed in
accordance with BTS/SIGN guidance.
• Statement 2. Adults with new onset asthma are assessed for occupational
causes.
• Statement 3. People with asthma receive a written personalised action
plan.
• Statement 4. People with asthma are given specific training and
assessment in inhaler technique before starting any new inhaler
treatment.
• Statement 5. People with asthma receive a structured review at least
annually.
• Statement 6. People with asthma who present with respiratory symptoms
receive an assessment of their asthma control.

30. NICE Quality Standards QS25
• Statement 7. People with asthma who present with an exacerbation of
their symptoms receive an objective measurement of severity at the time
of presentation.
• Statement 8. People aged 5 years or older presenting to a healthcare
professional with a severe or life-threatening acute exacerbation of
asthma receive oral or intravenous steroids within 1 hour of presentation.
• Statement 9. People admitted to hospital with an acute exacerbation of
asthma have a structured review by a member of a specialist respiratory
team before discharge.
• Statement 10. People who received treatment in hospital or through out-
of-hours services for an acute exacerbation of asthma are followed up by
their own GP practice within 2 working days of treatment.
• Statement 11. People with difficult asthma are offered an assessment by a
multidisciplinary difficult asthma service.

31. Useful learning resources
• Acute breathing difficulties:
http://abd.ocbmedia.com/home/
• Spotting the Sick child;
https://www.spottingthesickchild.com/
• Adult & Paed case studies:
http://real.educationforhealth.org/
• Itchy Sneezy Wheezy:
http://www.itchysneezywheezy.co.uk/
• Asthma UK http://www.asthma.org.uk/

32. Further reading
 BTS Guidelines 2011/12 http://www.brit-
thoracic.org.uk/guidelines/asthma-
guidelines.aspx
 Atopic Eczema in Children (NICE)
http://www.nice.org.uk/CG57
 BNF for Children 2011/12

33. Questions
April 2010

34. Summary
• Asthma is very common
• Large disease burden
• Morbidity & mortality
• Regular asthma review
– Assess control
– Assess technique
– Assess understanding, compliance/concordance
– Question the diagnosis