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

1. Jackie Lou C. Acha
Clinical Clerk
Department of Pediatrics- OPD

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. 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. Epidemiology
 One of the most common chronic diseases
 ~300 M individuals affected worldwide
 Prevalence increasing in many countries
 Major cause of school/work absence

6. Risk Factors for Asthma
Environment
-Allergens
-Infections
-Microbes
-Pollutants
-Stress
Biological and
Genetic Risk
-Immune
-Lung
-Repair
Age

7. Host factors + Environmental
factors
ASTHMA

8. 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

9. Pathophysiology

10. 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)

11. Diagnosis
 History and patterns of symptoms
 Physical examination
 Measurements of lung functions
 Measurements of allergic status to identify risk factors

12. 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

13. 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

14. 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

15.  Symptoms respond to anti-asthma therapy
 Patient’s cold go to the chest or take more than 10 days
to clear up

16. 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

17. 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

18. 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

19. Asthma Severity Classification

21. 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

22. Classification of Severity of Asthma
Exacerbation

23. 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

24. Controller Medications
 Inhaled glucocorticosteroids
 Leukotriene modifiers
 Long-acting inhaled β2-agonists
 Systemic glucocorticosteroids
 Theophylline
 Cromones
 Long-acting oral β2-agonists
 Anti-IgE
 Systemic glucocorticosteroids

25. 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

26. Reliever Medications
 Rapid-acting inhaled β2-agonists
 Systemic glucocorticosteroids
 Anticholinergics
 Theophylline
 Short-acting oral β2-agonists

27. 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

28. 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

31. 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

33. 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

35. 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

36. 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

38. 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

40. 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)

41. Treating to Maintain Asthma Control
 When control as been achieved, ongoing
monitoring is essential to:
- maintain control
- establish lowest step/dose treatment

42. 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)

43. 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)

44. 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

45. 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

46. Thank you..