yes

2. Outlines
• Introduction
• Epidemiology
• Etiology
• Types of Childhood Asthma
• Clinical Manifestation and Diagnosis
• Differential diagnosis
• Management
• Prognosis

3. Introduction
• Asthma is a common, non communicable disease of the lungs
affecting both children and adults.
• It is a chronic inflammatory condition of the lung airways resulting in
episodic airflow obstruction.
• Airway inflammation is associated with airway hyperreactivity or
bronchial hyperresponsiveness (BHR), which is defined as the
inherent tendency of the airways to narrow in response to a variety of
stimuli.
• It has a global impact on health care utilization, quality of life, and
mortality.

4. EPIDEMIOLOGY
• Is among the most common causes of childhood
• Emergency department visits
• Hospitalizations
• Missed school days
• More common in
• Boys Vs girls = 15% Vs 13%
• Low socioeconomic status
• 18% of all children living from poor families
compared to 12% of children in families not
classified as poor
4

5. • There’s an increased in asthma prevalence approximately
50% per decade.
• Prevalence of current wheeze in
• 6-7 yr : 2.4-37.6%
• 13-14 yr old children : 0.8-32.6%
• Children living in rural areas of developing countries and
farming communalities with domestic animals are less
likely to experience asthma and allergy
5

6. Etiology and pathogenesis of asthma
• The cause of childhood asthma has not been determined
• A combination of environmental exposures and inherent biologic and
genetic susceptibilities has been implicated.
• Susceptible host immune responses to common airways
exposures stimulation of prolonged, pathogenic inflammation
aberrant repair of injured airways tissues Lung dysfunction
(AHR, reduced airflow) airway remodeling develop.
• These pathogenic processes in the growing lung during early life
adversely affect airways growth and differentiation, leading to altered
airways at mature ages.
• Once asthma has developed, ongoing inflammatory exposures appear to
worsen it, driving disease persistence and increasing the risk of severe
exacerbations.

7. Etiology and pathogenesis of asthma

9. I. Recurrent Weezers
• Primarily triggered by common respiratory viral infections
• Usually resolves during the preschool/lower school years
II. Chronic asthma
• Usually associated with allergy
• Persists into later childhood and often adulthood
A. Based on the natural courses
9

10. I. Intermittent
II. Persistent
A. Mild
B. Moderate
C. Sever
I. Well controlled
II. Not well controlled
III. Very poorly controlled
B. Based on severity
C. Based on control
10

11. I. Easy-to-treat:
• Well controlled with low levels of controller therapy
II. Difficult-to-treat
• Well controlled with multiple and/or high level of
controller therapies
III. Exacerbators
• Despite being well controlled, continue to have severe
exacerbations
IV. Refractory asthma
• Continue to have poorly controlled asthma despite
multiple and high levels of controller therapies
D. Based on Rx response and medication
requirements
11

12. Wheeze
• Is a continuous & musical sound that originates from oscillations of
air in narrowed airways.
• Mostly heard in expiration due to critical airway obstruction.
• Sign of intra-thoracic obstruction.

13. • The most likely diagnosis in children with recurrent wheezing is
asthma, regardless of the age of onset, evidence of atopic disease,
precipitating causes, or frequency of wheezing
• In addition to asthma, new-onset acute wheezing suggests
infection or sudden airway obstruction, whereas
• Chronic or recurrent wheezing may be caused by;-
• Congenital abnormalities,
• Cardiac disease,
• Aspiration syndromes,
• Impaired immunologic defenses, or
• Underlying pulmonary disease.

14. Acute wheezing (hours to days)
• In addition to asthma, acute onset of wheezing in a child is most often
caused by;-
• An infectious process or
• The most common cause of acute wheezing in infants <2 years is
viral bronchiolitis, usually due to respiratory syncytial virus
(RSV).
• Other viruses include
• Rhinovirus
• Parainfluenza virus and
• Metapneumovirus
• Foreign body aspiration (FBA).

15. Wheezing type in childhood.
• Transient early wheezer
• One episode or few episodes of wheezing.
• No further episodes beyond 3 years.
• No wheeze at 6 yrs, later
• Without increased risk for asthma in later life.

16. • Persistent atopy-associated wheezer
• Begins in early preschool.
• Wheezing < 3, at 6 yrs & Later
• Highest risk for persistence into later childhood and adulthood.
• Non-atopic wheezer = late
• No wheeze at 3 yrs, wheezing at 6yrs no wheezing later .
• Wheeze during viral infections and continue to have recurrent airway
obstruction during early school years.
• Resolves in later childhood without increased risk of persistent asthma.

18. Clinical manifestations
• History of recurrent episodes of wheezing, cough, breathlessness (SOB),
limitation of activity,
• Findings on examination may include:
• Prolonged expiratory phase, with audible expiratory wheeze
• Hyperinflation of the chest
• Reduced air entry
• General signs of respiratory distress:
Tachypnea, nasal flaring, lower chest indrawing (subcostal
retractions)
• Improvement with administration of bronchodilators (reversible)
• An increased A-P diameter of the chest - air trapping.

19. Asthma symptoms in children
Intermittent dry coughing and expiratory wheezing are the most
common chronic symptoms of asthma.
Intermittent, nonfocal chest pain( )
Day time symptoms(often linked with physical activities (exercise-
induced) or play)
 Self-imposed limitation of physical activities
General fatigue (possibly resulting from sleep disturbance)
 Difficulty in keeping up with peers in physical activities.
Shortness of breath and chest congestion and tightness(more in older
cildren and adults)

20. Cont...
Decreased breath sounds in some of the lung fields,are consistent with
regional hypoventilation caused by airways obstruction.
 Rhonchi and crackles (or rales ) can sometimes be heard, resulting
from excess mucus production and inflammatory exudate in the
airways.
The combination of segmental crackles and poor breath sounds can
indicate lung segmental atelectasis that is difficult to distinguish from
bronchial pneumonia and can complicate acute asthma management.

21. Diagnosis
• A combination of
Clinical history of the of cough, wheeze, and
breathlessness varying over time and
Associated identifiable
Supplemented by that

22. Diagnosis

23. Diagnosing Asthma in Young Children –
• > 4 episodes/yr of wheezing
lasting >1 day affecting sleep in a
child with one MAJOR or two
MINOR criteria
• Major criteria
– Parent with asthma
– Physician diagnosed atopic
dermatitis
– Airway allergens
• Minor criteria
– Physician diagnosed allergic
rhinitis
– Eosinophilia (>4%)
– Wheezing apart from colds
– Food allergy
• High specificity 97%
and positive predictive
value 77% for
persistent asthma into
later childhood.

24. Laboratory Findings
Pulmonary Function Testing
Can help to confirm the diagnosis of asthma and to determine disease
severity.
Helpful in children with asthma who are poor perceivers of airflow
obstruction,or
when physical signs of asthma do not occur until airflow obstruction is severe
Forced expiratory airflow measures are helpful in diagnosing and monitoring
asthma and in assessing efficacy of therapy.
Many asthma guidelines promote spirometric measures of airflow and lung
volumes during forced expiratory maneuvers as standard for asthma
assessment.

25. Spirometry
• Helpful objective measure of airflow limitation
• Essential assessment tool in children who are at risk for severe asthma
exacerbations and those who have poor perception of asthma
symptoms.
• Valid spirometric measures depend on a patient's ability to properly
perform a full, forceful, and prolonged expiratory maneuver, usually
feasible in children >6yr old

26. Bronchoprovocation challenges
• Can be helpful in diagnosing asthma and optimizing asthma
management
• Asthmatic airways are hyperresponsive and therefore more sensitive to
inhaled methacholine, mannitol, and cold or dry air.
• The degree of AHR to these exposures correlates to some extent with
asthma severity and airways inflammation.
• Their use is rarely practical in general practice.

27. Exhaled Nitric Oxide (FeNO)
• Is a noninvasive measure of allergic airways inflammation used in
clinical settings.
• Nitric oxide (NO) is a marker of allergic/eosinophilic inflammation.
• Children as young as 5 yr can perform this test.
• FeNO can
Substantiate the diagnosis of asthma,
Complement the assessment of asthma control,
Predict response to inhaled corticosteroid (ICS) therapy,
Assess adherence with ICS therapy,
Predict loss of control with ICS tapering, and
Predict future asthma exacerbations.

28. Radiology
• CXR - normal, hyperinflation and peribronchial thickening
- Rule out other causes
- Pick complications
• Other tests such as allergy testing to assess sensitization to inhalant
allergens, help with the management and prognosis of asthma.

29. Spirometry :
Airflow limitation
Low FEV1
FEV1 /FVC ratio <0.80
Bronchodilator response increase in FEV1 >12%
predicted FEV1 >10%
Exercise challenge: Worsening in FEV1 ≥15%
Daily PEF or
FEV1 monitoring
day-to-day and/or
AM -to-PM variation ≥20%*
Exhaled nitric oxide
(FeNO)
>20 ppb
Lung Function Abnormalities in Asthma and
Assessment of Airway Inflammation

30. Components of asthma Management
(1) Assessment and monitoring of disease activity;
(2) Education to enhance patient and family knowledge and skills for self-
management;
(3) Identification and management of precipitating factors and comorbid
conditions that worsen asthma; and
(4) Appropriate selection of medications to address the patient's needs.
The long-term goal of asthma management is attainment of optimal
asthma control

31. 1. Regular Assessment and Monitoring
• Are based on the concepts of
A. Asthma severity,
B. Asthma control, and
C. Responsiveness to therapy and Assessing future risk of adverse
outcomes

32. Asthma severity and control assessment
• Classification of asthma severity and control is based on the domains of
impairment and risk
I. Risk- refers to the likelihood of developing severe asthma exacerbations
For ≥5 yrs old,
2 exacerbations requiring oral corticosteroids in 1 yr, and
For ≤ 5yrs old children who have risk factors for asthma (see earlier)
and
 4 or more episodes of wheezing over the past year that lasted longer
than 1 day and affected sleep, or 2 or more exacerbations in 6 month
requiring systemic corticosteroids, qualifies them as having persistent
asthma.
II. Impairement-consists of an assessment of the patient's recent symptom

33. cont..
• Asthma symptom control
• Frequency of symptoms (days/week)
• Night symptoms
• Level of activity
• Reliever use

34. Assessing Asthma Severity and Initiating Treatment for Patients
Who Are Not Currently Taking Long-Term Control medications
CLASSIFICATION OFASTHMA SEVERITY
INTERMITTENT PERSISTENT
Mild Moderate Sever
COMPONENTS OF SEVERITY
Impairement
Daytime symptoms ≤2 days/wk >2 days/wk but not Daily Daily Throughout the day
night time
symptoms
age 0-4yrs 1-2×/mo 3-4×/mo >1×/wk
age ≥5yrs ≤2×/mo 3-4×/mo >1×/wk but not nightly Often 7×/wk
Short-acting β2agonist use forsymptoms
(not forEIB prevention)
≤2 days/wk >2 days/wk but not daily, and not
more than 1× on any day
Daily Several times per
day
Interference with
normal activity
None Minor limitation Some limitation Extreme limitation
lung
functi0n
and FEV1
/FVC
ratio
FEV1 % predicted,
age ≥5 yr
Normal FEV1 b/n
exacerbations>80% predicted ≥80% predicted
60–80% predicted <60% predicted
age 5-11 yrs >85% >80% 75-80% <75%
age≥ 12 yrs Normal Normal Reduced 5% Reduced >5%
risk
Exacerbations requiring systemic corticosteroids
Age 0-4yrs 0-1/yr ≥2 exacerbations in 6 mo requiring systemic CS or
≥4 wheezing episodes/yr lasting >1 day and risk factors for persistent asthma
age≥5 yrs 0-1/yr ≥2/yr

35. cont...

36. Assessing Asthma Control and Adjusting
Theraphy in Children

37. cont..

38. Assessing future risk of adverse outcomes

39. 2. Patient Education
• Basic facts about asthma
• Good asthma control
• Management of exacerbations
• Inhalant medication technique
• Risk and benefits of drugs
• Written action plan
• Follow up

40. Delivery Devices and Inhalation Technique
MDI WITH SPACER DEVIVES
 Recommended for the administration of all MDI
medications,
 Are simple and inexpensive tools that
 (1) decrease the coordination required to use MDIs,
especially in young children;
 (2) improve the delivery of inhaled drug to the lower
airways; and
 (3) minimize the risk of drug and propellant-mediated
oropharyngeal adverse effects (dysphonia and thrush).
Inhaled medications
are delivered in aerosolized form in a MDI, as a DPI formulation, or
In a suspension form delivered via a nebulizer.

41. Dry powder inhaler devices
Are popular because of their simplicity of use,
Are breath-actuated devices (the drug comes out
only as it is breathed in)
Spacers are not needed.
Adequate inspiratory flow is needed
Mouth rinsing is recommended after ICS use to
remove ICS deposited on the oral mucosa and
reduce the swallowed ICS and the risk of thrush.

42. Nebulizers
Are the mainstay of aerosol treatment for infants and young children.
An advantage of using nebulizers is the simple technique required of
relaxed breathing.
The preferential nasal breathing, small airways, low tidal volume, and
high respiratory rate of infants greatly increase the difficulty of inhaled
drug therapy targeting the lung airways.
Disadvantages of nebulizers include
Need for a power source
Inconvenience in that treatments take about 5 min,
Expense, and
Potential for bacterial contamination.

43. HOW TO USE INHALLER
S-Shake well before each use(for about 5 seconds)
P-Prime befere frist use
O-take a deep breath out
R-Rest the inhaller(mask) in the mouth & close your lips arrond it
T-take a deep breath in as you press down the inhaler
T-Ten seconds of holding your breath

44. 3. Control Environmental Factors and
Comorbid Conditions

45. 4. Principles of Asthma Pharmacology
• The main stays of theraphy are directed at these the two
pathophysiologic aspects of the disease
Bronchodiletors for bronchospasm and
Steroids for the inflamation.
• The recommendations for initial therapy are based on assessment of
asthma severity, while level of control determines any modifications
of treatment in children who are already using controller therapy.

46. cont...
• The goals of therapy are to achieve a well-controlled state by reducing the
components of both
 Impairment
• preventing or minimizing symptoms,
• infrequently needing quick-reliever medications,
• maintaining “normal” lung function and normal activity levels) and
 Risk
• preventing recurrent exacerbations
• reduced lung growth, and medication adverse effects).

47. cont...
• A major objective of this approach is to identify and treat all
“persistent” and inadequately controlled asthma with antiinflammatory
controller medication.
• The preferred treatment for all patients with persistent asthma is ICS
therapy, as monotherapy or in combination with adjunctive therapy.
• The type(s) and amount(s) of daily controller medications to be used
are determined by the asthma severity and control rating.

48. Antigen
omalizumab
mast cell stablizers
 Cromoglycate
 Nedocromil
 Ketotifen
LT synthesis inhibitors
 Corticosteroids
 zileuton
LT receptor antagonsts
 Zafrilukast
 montelukast
Bronchodilators
 salbutamol
 ipratropium
 theophyline

49. There are 6 treatment steps
Treatment step 1
Intermittent asthma
 Treatment is simply the use of a SABA as needed for symptoms and
for pretreatment in those with exercise-induced bronchospasm
• Low-dose ICS therapy is the treatment of choice for all children at
treatment
Treatment Step 2
Mild persistent asthma.
Alternative medications include a
Leukotriene modifying agent (montelukast),
Nonsteroidal antiinflammatory drugs (cromolyn,nedocromil), and
 Theophylline.

50. Treatment Step 3
Moderate persistent asthma
 There are 4 co-equal choices for the treatment:
1)Medium dose ICS,
2) Combination low-dose ICS and
3) Inhaled long-acting β2-agonist (LABA) ,
4) Leukotriene receptor antagonist (LTRA) , or theophylline.

51. Treatment Step 4
Moderate persistent asthma
Treatment is medium-dose ICS/LABA combination.
Alternatives include medium-dose ICS with either theophylline or an
LTRA or medium-dose ICS plus either an LABA

52. Treatment Steps 5 and 6
Severe persistent asthma
Children should receive combination high-dose ICS plus LABA.
Long-term administration of oral corticosteroids as controller
therapy is effective but is rarely required.
A rescue course of systemic corticosteroids may be necessary at
any step for very poorly controlled asthma

53. 5.Assessment and Management of Exacerbations
• Are acute or subacute episodes of progressively worsening symptoms
and airflow obstruction.
• Characteristically vary among individuals but tend to be similar in the
same patient.
• Severe asthma exacerbations, resulting in respiratory distress, hypoxia,
hospitalization, and respiratory failure, are the best predictors of future
life-threatening exacerbations or a fatal asthma episode.

54. cont...
• A severe exacerbation of asthma that
is termed status asthmaticus .
• Immediate management of an asthma exacerbation involves a rapid
evaluation of the severity of obstruction and assessment of risk for
further clinical deterioration .
• For most patients, exacerbations improve with frequent
bronchodilator treatments and a course of systemic (oral or
intravenous) corticosteroid.

55. Home Management of Asthma Exacerbations
• Written asthma action plans include:
• The patient’s usual asthma medications
• When/how to increase reliever and controller or start OCS
• How to access medical care if symptoms fail to respond

56. Emergency Department Management of
Asthma Exacerbations
The primary goals of asthma management include:
 Correction of hypoxemia,
Rapid improvement of airflow obstruction, and
Prevention of progression or recurrence of symptoms.
Interventions are based on clinical severity on arrival, response to initial
therapy, and presence of risk factors associated with asthma morbidity and
mortality

57. Hospital Management of Asthma Exacerbations
For patients with severe exacerbations that do not adequately improve
within 1-2hr of intensive treatment
High-risk features for asthma morbidity or death.
Supplemental oxygen,
Frequent or continuous administration of an inhaled bronchodilator

58. Hospital Management of Asthma Exacerbations
Admission to an intensive care unit (ICU) is indicated for
patients with severe respiratory distress,
 poor response to therapy, and
concern for potential respiratory failure and arrest.
Several therapies, including
parenteral β-agonists, magnesium sulfate and inhaled heliox
(helium and oxygen mixture) as adjunctive therapies
Parenteral (SC, IM, or IV)epinephrine or terbutaline sulfate in
patients with life threatening obstruction that is not responding
to high doses of inhaled β-agonists, because inhaled medication
may not reach the lower airway
Intubation and mechanical ventilation may become necessary in
ICU

61. Special Management Circumstances

63. PROGNOSIS
Recurrent coughing and wheezing occurs in 35% of preschool-age
children
One third continue to have persistent asthma into laterchildhood, and
 Two thirds improve on their own through their teen years.
 Asthma severity by ages 7-10 yr is predictive of asthma persistence in
adulthood.
Children with moderate to severe asthma and with lower lung function
measures are likely to have persistent asthma as adults.
Children with milder asthma and normal lung function are likely to
improve over time, with some becoming periodically asthmatic (disease-
free for months to years);
Complete remission for 5 yr in childhood is uncommon.

64. Reference
Nelson 21st ed.
Up-to-date 21.6
Internet