This document provides an overview of asthma including its definition, epidemiology, etiology, pathogenesis, diagnosis, treatment, control, prognosis and prevention. Some key points include: - Asthma is a chronic inflammatory airway disease characterized by wheezing, breathlessness and coughing. - It affects over 235 million people worldwide and is a common cause of childhood morbidity. - It has a multifactorial etiology involving genetic and environmental factors such as allergens and irritants. - Diagnosis involves assessing symptoms, performing pulmonary function tests and ruling out other potential conditions. - Treatment involves reliever medications for exacerbations and controller medications for long-term control.

2. Contents
• Definition
• Epidemiology
• Etiology
• Pathogenesis
• Diagnosis (H/O – Exam – Inv – D.D )
• TTT
• Control
• Prognosis
• Prevention
• Special types
• Summary & Home messages

3. References
• Nelson textbook
• UpToDate
• AAP
• BTS
• NAEPP
• GINA
• SINA

4. Definition
• It is a chronic inflammatory disease of the
airways with the following clinical features:
• Episodic and/or persistent symptoms of
airway obstruction as wheezing,
breathlessness, chest tightness and coughing
particularly at night.
• Bronchial hyperresponsiveness to triggers
• Bronchial good responsiveness to ttt
• Alternative diagnoses are excluded

5. Epidemiology
• Asthma is the most common chronic disease of
childhood and the leading cause of childhood
morbidity from chronic disease as measured by
school absences, ER visits, and hospitalizations.
• Worldwide about 235 million person have
asthma.
• 9.6 million child (13.1%) had been diagnosed
with asthma.
• -Approximately 250,000 people die per year from
asthma

6. Prevelance

7. Incidence
• Poor : non poor = 2:1
• Till puberty Boys : Girls = 2:1
• Adulthood Women : men = 2:1
• Reasons for sex-related differences are unclear and
unexplained.
• Possible explanations include:
● Hormonal causes
● increased prevalence of atopy in young boys compared to girls
(ie, evidence of IgE sensitization to allergens).
● relative small airway size in boys compared to girls with
increased risk of wheezing after viral respiratory infections in
young boys compared to girls.

8. When does asthma begin?
• By 1 year – 25%
• 1-5 years – 50%
• Approximately 75% of all asthmatic patients
report disease onset prior to 5 yr of age.
> 5 years – 25%

9. Etiology
• Although the cause of childhood asthma has not
been determined
• Research implicates that it is multifactorial due to
combination of :
• Genetic vulnerabilities (Family H/O)
• Environmental exposure (Inducers – Triggers)
• Associated Comorbid conditions (GERD,Atopy)
{Allergic Rhinitis ,Allergic conjunctivitis,
dermatitis,eczema,Food allergy}

10. Inducers Triggers
Mechanism Inhaled Allergen Inhaled Irritant
Example Animal (Household pets
as cats & dogs furs)
Household dust and mites
Pollens (from grass , tress , weeds)
Molds
Smoke (cigarette – factory)
Strong fumes (cars – factory – truck)
Chemicals (air – food)
Dust
Cold air
Common Cold & other Viral infections
Exercise
Stress
Onset delayed Immediate
course 7 – 8 hrs 1 hr
Duartion long Short
Prevention Avoidance Avoidance
TTT Desensitization -----

11. House dust mite

13. AHR

15. History
• Intermittent dry cough
• Wheezing
• Shortness of breath and chest tightness
• Intermittent, nonfocal chest pain.
• Respiratory symptoms can be worse at night
• Daytime symptoms, often linked with physical
activities or exercise.
• limitation of physical activities, general fatigue.

16. Symptomatology
• Cough – 90%
• Wheezing – 74%
• Exercise induced symptoms (wheeze or cough)
– 55%

17. Examination
Signs in acute exacerbation
• •Respiratory Distress : 4 grades
• Tachypnea, Working Alae nasai
• Retractions
• Grunting
• Cyanosis, Drowziness, Coma.
• •Ausculation :
• Prolonged expiration
• Expiratory Wheeze
• Decreased air entry (Silent Tight chest)
Signs of chronic illness
• Hyperinflated chest (Barrel-shaped chest)
• Harrison’s sulci

18. Investigations
• PFTs
• Spirometry FEV1 or PEF
• feasible in children > 5 yr of age.

19. Spirometry changes with
BDs & Exercise

20. Role of spirometry
• Help to make diagnosis
• Assess degree of airflow obstruction and
disease severity.
• Predict whether obstruction is reversible or
not
• Aids in management of asthma
• Monitor progression of disaese

21. pH 7.31
PaCO2 50.3 mmHg
O2 sat 92.7%
PaO2 86 mmHg
HCO3 22.3 mEq/L
BE/BD -1.3 mEq/L
ABG

22. CXR
• often appear to be normal, or nonspecific
findings of hyperinflation and peribronchial
thickening.
• hyperinflation in asthma can mimic
pneumothorax.
• Also complications and co morbidities can be
looked.

23. Skin prick test
− When suspected Atopy :
− Risk factors :
− +ve family history
− Clinical markers :
− Atopic dermatitis & Eczema
− Lab markers :
• Peripheral blood and tissue eosinophilia
•  Serum total IgE
•  specific IgE

24. Skin prick test
• Number of allergens
• Patient exposure
(residence + occupation)
• Quality of allergens
(purification + standardization)
• Results Interpretation
(positive or negative)
• With clinical correlation

25.  Lower respiratory :
 Asthma
 Chronic respiratory infection T.B
 Bronchietasis
 CF
 PCD = IC$
 BPD
 ILD
 ID $
 CHD
 Recurrent Aspiration syndromes
 GERD
 Cow milk ptn Allergy
 Upper respiratory :
 Allergic Rhinitis
 Sinusitis
 Adenoid
 Nasal F.B
 Middle respiratory :
 Congenital malformation (laryngeal
web, cyst, stenosis, TOF, vascular
ring)
 Vocal cord dysfunction
 Laryngotracheobroncho/malacia
 F.B
D.D of chronic recurrent cough

26. D.D of chronic recurrent cough by age
Age Common Uncommon Rare
< 6 m GERD
Bronchiolitis
Aspiration pneumonia
BPD
CF
H.F
F.B
Asthma
6 m – 2 y Bronchiolitis
F.B
Aspiration pneumonia
BPD
CF
GERD
Asthma
H.F
2 – 5 y Asthma
F.B
Viral Pneumonia
CF
Aspiration pneumonia
Bronchiolitis
H.F
GERD

27. How to rule out mimics ?

28. Asthma LRTIs behave like Asthma
WALRI
RAD
AHR
Febrile episodes In viral induced yes
Personal H/O of Atopy yes No
Family H/O of Atopy or Asthma yes No
Exercise induced symptoms yes No
Trigger induced symptoms yes No
Seasonal exacerbations yes yes
Nocturnal exacerbations yes No
BD Response Good Variable

29. • These viral infections that behave like Asthma
is very common especially in small infants &
children.
• It occurs in 30 % of preschool-aged children.
All wheezes is not asthma

30. Factors predictive of progression from infantile
wheezing to asthma in school age
• Wheezing requiring hospitalization in first
year of life.
• Wheezing onset after 2 years of age.
• Asthma predictive index 

31. Asthma predictive index
Episodes of Wheezing
PLUS
Or
1 Major
Criterion
• Parent with
asthma
• Dermatitis,
Eczema
• Aeroallergic
sensitivity
2 Minor
Criteria
• Wheezing
not related
to infection
• Eosinophilia
•Food Allergy
1 episode  Loose index : 55% likelihood of persistent asthma
2 episode  Moderate index : 65% likelihood of persistent asthma
3 episode  Strong index : 75% likelihood of persistent asthma

32. Cough variant asthma
• Consider asthma in children with cough if :
• Colds every time “go to the chest”
• Colds take more than 2 weeks to clear.
• Recurrent episodes of cough (with or without
wheezing)
• Nocturnal awakening because of cough
• Cough that is associated with exercise/play
• Cough with good response to asthma ttt
All asthma is not wheezy
Cough may be the only symptom
present in patients with asthma

33. BTS clinical features
that lower the probability of asthma
• Symptoms with common colds only, with no interval
symptoms
• History of moist cough
• Repeatedly normal chest examination when symptomatic
• Repeatedly normal PFTs when symptomatic
• No response to a trial of asthma therapy
• Atypical history pointing to
• Atypical Clinical features alternative
diagnosis.

34. Atypical history
– Onset of symptoms in the neonatal period
(BPD)
– History of M.V in the neonatal period (BPD)
– Wheezing associated with feeding; vomiting
(GERD)
– The sudden onset of coughing or choking
(FB)
– Stridor (Malacia)
– Steatorrhea (CF)

35. Atypical clinical features
– FTT (CF – ID $)
– Clubbing (CF – ILD)
– Murmur (CHD)
– Fixed monophonic/asymmetric wheeze
(Sequestration)
– Fixed or focal finding on CXR (Sequestration)

36. Exclude specific conditions by specific Inv
 Structural problems or F.B : Laryngoscopy &
bronchoscopy
 GERD: Ba swallow, pH probes, endoscopes
 PCD: nasal ciliary motility, Exhaled NO, EM, saccharine
test
 BPD , Bronchiectasis: HRCT scan, BAL
 CF: sweat Cl test, nasal potentials, genotypes
 ILD : Lung Biopsy
 ID syndromes: Ig subtypes, lymphocytes & neutrophil
function, HIV
 CHD: echo, angiography
 TB: mantoux test, induced sputum/ gastric lavage/ BAL
Culture, microscopy & PCR

37. Management of asthma
• Parents's education to enhance the parents's
knowledge and skills for self-management
with written action plan.
• Identification and management of
precipitating factors and associated co-morbid
conditions that may worsen asthma.
• Assessment and treatment of acute asthma
exacerbations.
• Long term control therapy.

38. Classifying acute asthma exacerbation
Profound
(Impending R.F)
SevereModerateMild
At rest/leaning forwardAt rest/Sits uprightAt restwalkingDyspnea
nonewordsphrasessentencesspeech
confusedagitatednormalnormalConsciousness
Tight silent chest++++++Wheezes
paradoxical++++++Accessory ms
undetermined++++++RR
bradycardia> 140< 140< 110HR
< 85< 9090 – 95> 95Spo2
> 45> 42< 42< 40PCo2
< 25< 4040 – 70> 60 – 70PEF in > 5 y
Consider ETTPICUHospitalHomemanagement

39. • Inhaled SABA
• < 12 yr: 2.5 mg & > 12 yr: 5 mg
• Inhaled Ipratropium
• < 12 yr: 250 mic & > 12 yr: 500 mic
• Combination has synergestic effect
• Via Nebulizer : it deliver high-dose therapy
• We can use Inhaler if Neb is not available
• 2.5 mg from SABA in Nebs = 6 -12 puffs of MDI
Quick Relief of acute asthma exacerbation

40. • Assess response to treatment after 15 minutes.
• Repeat SABA + Ipratropium every 20 minutes up
to 3 times in the 1st hour
• If still no response  Systemic steroids
• With Continous SABA Nebs
Monitoring of side-effects of SABA :
irritability, tremor, tachycardia ,hypokalemia

41. Systemic steroids
• AAP  Oral prednisolone 2mg/kg/day
IV Methylprednisolone 2mg/kg/day
• BTS  Oral prednisone 2mg/kg/day
IV Hydrocortisone 4mg/kg/dose Q6
IV only for children who are unable
to take oral medication

42. Additional therapy
• if no improvement on previous measures :
• But needs continous monitoring in PICU :
 S.C Adrenaline
• 0.01 ml/kg/dose (diluted 1/1000 ) (max 0.3 ml) (may
repeated again)
• Stop immediately if tachycardia.
 IV Mgso4
• 50mg/kg over 30 min (Single dose ) (max 2.5 gm)
• Stop immediately if hypotension.

43. Additional therapy
 IV Aminophylline
• loading dose 10 mg/kg over 60 min (max 500 mg)
• Then continuous infusion 0.7 – 1.1 mg/kg/hour
• Stop immediately if tachycardia, convulsion.
 IV infusion SABA
• Stop immediately if tachycardia, convulsion.
 Salbutamol
• loading dose 5 – 15 mic/kg over 15 min (max 250 mic)
• Then continuous infusion 1 – 5 mic/kg/min
 Terbutaline
• loading dose 2 – 10 mic/kg over 15 min (max 250 mic)
• Then continuous infusion 0.1 – 0.2 mic/kg/min

44. Nonstandard therapy
• Heliox — a mixture of helium and O2 that enhances beta-
agonist delivery because the lower gas density will result in
lower flow resistance with greater response & earlier
discharge from the hospital.
• The NAEPP guidelines suggest combined administration of
beta-agonists with heliox in patients with life-threatening
exacerbations or who are not responding to conventional
therapy.
• However, the use of heliox should not delay intubation once it
is considered necessary.
• Ketamine — it is the drug of choice to provide sedation and
analgesia before intubating a child with life-threatening
exacerbations , due to its BD effect.

45. Nonrecommended therapy
• Antibiotics
•are not beneficial.
• Oseltamivir
• are not beneficial.
• Oral BD
• not recommended except if inhaled BD is not available.
• LTRAs
• are not effective in acute asthma exacerbations
• Inhaled Steroids
• are not as effective as systemic steroids for severe acute
asthma exacerbations
• should not be used as a substitute.
• Do not stop & Do not double dose of ICS during prescription
of systemic steroids for severe acute asthma exacerbations.

46. Goals of long-term control
• Maintain control of symptoms
• Maintain normal activity levels, including
exercise
• Maintain normal PFTs as possible
• Avoid adverse effects from asthma
medications
• Prevent asthma exacerbations
• Prevent asthma morbidity and mortality
Drugs control asthma only , but do not cure

47. Indications of long-term control
• ≥ 2 use of SABA in 1 week
• ≥ 2 use of systemic steroids in 6 months
• ≥ 4 exacerbations in 1 year

48. Long-term control medications
• ICS (is the backbone) including :
• Budesonide (Pulmicort) (any age) Nebs/MDI/DPI
• Fluticasone (Flixotide) (≥ 2 y) MDI/DPI
• Combination Fluticasone + LABA Salmeterol
(Seretide/Respira) (≥ 4 y) MDI/DPI
• Combination Budesonide + LABA Formoterol
(Symbicort) (≥ 4 y) DPI
• Ciclesonide (Alvesco) (≥ 12 y) MDI

49. ICS

50. Devices
• 1st 2 y  Nebs
• 2 – 5 y  MDI + Spacer + facial mask
• 5 – 8 y  MDI + Spacer + mouth piece
• > 8  MDI without Spacer or DPI
Nebs at Any age

51. Devices

52. Other long-term control medications
• LABA’s : Salmeterol , Formoterol > 4 y
• Methylxanthines: SR Theophylline > 5 y
• LTRA as Montelukast sach/tab: > 1 y
Zafirlukast tab: > 12 y
• Mast cell stabilizer as Cromolyn > 2 y
• Monoclonal Abs : > 12 y
Anti IgE (Omalizumab)
IL-5 inhibitors (mepolizumab, benralizumab)
IL-4 inhibitors (dupilumab)

53. Offlabel therapy
• LTRA
• > 6 m instead of 1 y
• Cromolyn
• > 1 y instead of 2 y
• Antihistaminics
• > 1 y instead of 2 y
• LABA
• > 2 y instead of 4 y
• Monoclonal Abs
• > 6 y instead of 12 y

54. New cases
Or
Patients not on control therapy

55. Classifying asthma severity
0 – 4 y

56. Classifying asthma severity
5 – 11 y

57. Classifying asthma severity
≥ 12 y and Adults

58. Old cases
Or
Patients already on control
therapy

59. Classifying asthma control
UncontrolledPartially controlledControlled
Any 3 of
poorly
controlled
present in
any week
> 2/week< 2/weekDay symptoms/Week
AnyNoneNight symptoms/Week
AnyNoneLimited physical activity
> 2/week< 2/weekQuick relief ttt/Week
> 1/yearNoneExacerbation /year
< 80 %NormalPEF in > 5 y

60. Controlled 3 m
Partially controlled 4 – 6 w
Uncontrolled 4 – 6 w
Exacerbation
LEVEL OF CONTROL
Maintain for 3 m and step down
Step up 1 step until controlled
Step up 2 steps until controlled
Quick Relief
TREATMENT OF ACTION
TREATMENT STEPS
REDUCE INCREASE
STEP
1
STEP
2
STEP
3
STEP
4
STEP STEP
5 6

61. Stepwise approach
0 – 4 y (LTRA)
Alternative :
Low-dose
ICS +
Montelukast

62. Stepwise approach
5 – 11 y (LABA & Theophylline)

63. Stepwise approach
≥ 12 y and Adults (Monoclonal Abs)

64. Stepwise approach
• Stepping up :
• if asthma partially controlled or uncontrolled for 4–6 weeks
• Important: first check for common causes (incorrect inhaler
technique, poor compliance, symptoms not due to asthma)
• Stepping down :
• if asthma controlled for 3 months
• reduce ICS doses (usually by 25-50%).
• till reach each patient’s minimum effective dose, that controls both
symptoms and exacerbations.
• Then shifted to single daily dose.
• Then stop other controllers as LTRA/LABA/Theophylline
• F/U
• 4-6 weeks after initiation of treatment, then every 3 months
• After an exacerbation, within 1 week.

65. Most certainly yes..
By the time she
reaches 12 years of
age Doctor.. will my
daughter asthma
improve ???

66. • Yes, by the time she reaches …. y.
• No, it’s a lifelong disease & therapy.
• May be, what is most important is to
reach the lowest dose of anti-
inflammatory therapy adequately
controlling the disease.

67. Prognosis
• 2 out of 3 children their asthma will improve.
• Asthma severity by the ages of 10 yr of age is
predictive index of asthma persistence in
adulthood :
• Children with mild asthma and normal PFTs are
mostlikely to improve over time, with some of
them become periodically asthmatic (disease
free for months to years)
• Children with moderate to severe asthma and
with impaired PFTs are mostlikely to have
persistent asthma as adults.

68. Prevention
• Several non pharmacotherapeutic measures
might reduce the development of asthma as :
• Prolonged exclusive breastfeeding for 6 m
• healthy diet
• active lifestyle , exercise

69. Special types of asthma
• Paracetamol is the safest antipyretic to avoid
Aspirin-induced asthma.
• SABA before exercise is better to avoid Exercise-
induced asthma.
• Intermittent asthma does not need controllers
and and treat as step 1.
• Seasonal asthma may not need controllers ; treat
as uncontrolled asthma in the season & treat as
step 1 rest of the year after the season.

70. Summary & Home messages
• Asthma is an inflammatory illness exacerbates with
infections.
• Diagnosis of asthma is clinical, and relies on history.
• A family history of asthma / atopy increases risk of
asthma.
• In children < 3 yrs, Asthma likes is an important D.D.
• All asthma is not wheezey & All wheezes is not
asthma.

71. Summary & Home messages
• Patient education is a very important part of
asthma management.
• Clinical grading, decides long term control plan.
• Treatment should be stepped up or down
depending upon patient response.
• ICS is the mainstay of long term asthma control.
• 2 out of 3 children their asthma will improve.
• Drugs control asthma only , but do not cure.

72. Thank You