Paediatric

1. CHILDHOOD ASTHMA
PROF. DR. SAMIYA NAEEMULLAH
Diplomate American Board of Pediatrics
F.A.A.P. FCPS
Head of Department of Pediatrics
Rawalpindi Medical College

2. WHAT IS ASTHMA?
Asthma is:
Chronic Inflammatory
condition of the lung
airways resulting in
episodic airflow
obstruction

3. PRESENTATION
 Characterized by recurrent breathing problems
Manifests as
 Breathlessness
 Wheezing
 Chest tightness, and coughing

4. CONT…
Wheezing
Cough
“ All is not Asthma that wheezes”
“ Not all asthma wheezes”

5. Asthma symptoms vary from:
 Hour to hour
 Day to day
 Week to week
 Over months
 Worse at night and in the early hours of the morning.
 The severity of asthma also varies from individual to
individual.

6. CHILD FREE OF SYMPTOMS BETWEEN
ATTACKS
& NORMAL PHYSICAL EXAMINATION OF
CHEST

7. Who are affected by Asthma
 All ethnic groups.
 Socioeconomic levels.
 Ages
Asthma often develops during childhood.
50% under 1 year affected.
80-90% under 5 years

8. GENETICS
Asthma:
One parent affected:
25% chance
Both parents affected:
50% chance
10% if no F/H
Incidence in Twins:
Monozygotic 74%
Diazygotic 35%
All other allergies:
One parent affected:
50% chance
Both parents affected:
66% chance

9. Global burden of Asthma report
 On world Asthma day May 04, 2004 the
Global Initiative for Asthma 300 million
world wide.
 1998 statistics by NCHS (National Centre for
Health Statistics)
 8.65 million children (12.1%).
 3.8 million children have experienced an
asthma episode in US in preceding 12
months.

10.  Under Diagnosed & Under Treated Condition worldwide.
 Increasing incidence.
 Besides improvements in medication.
 In US 1982-1994 72%
 ISAAC (1.6 – 36.8%)

12. Pathogenesis
1. Airway Obstruction
Of small airways
2. Airway inflammation, Hyper responsiveness
Airway modelling
Asthmatic Airways
- number of mast calls
- activated eosinophils
- activated helper T-lymphocytes

13. The Lung Airways
Airways=
bronchi
alveoli

14. Normal
Smooth
muscle
Epithelial cells

15. What happens to the Airways in
Asthma?
Muscle contraction =
Bronchoconstriction
Constricted airway
Inflamed airway
Inflammation +
Constriction

16. ASTHMA TRIGGERS
 Common viral infections of respiratory tract
 Indoor allergens
• Dust mite
• Cockroaches
• Molds
• Animal dander

17. MITE

18. COCKROACH
Cockroaches: most important in urban environments.
Management with cleanliness, keeping food containers
sealed, etc.

21. Seasonal aero allergens


23.  Environmental tobacco smoke

24. Envoirnmental allergens:
 Tobacco smoke
 Strong odors
 Hair spray
 Cleansing agents
 Cold air
 Dry air
Air Pollutants:
 Dust
 Wood or coal burning smoke
 Ozone
 Sulphur-dioxide

25.  Exercise
 Crying, laughter , hyper ventilation
 Co-morbid
Rhinits
Sinusitis
Gastroesophageal reflux

26. DIAGNOSIS
History + physical examination
CBC – normal
Eosinophilia
Immunoglobulins
Sweat test
Mantoux test
Radiographs
Lung function test
Blood gases
Allergy skin testing
Rast

27. RADIOGRAPHS
CHEST
 Hyperinflation
 With peribronchial infiltrates
 Atelectasis
 Pneumomediastinum
 Pneumothorax (rare)
PARANASAL SINUSES

28. Lung functional abnormalities in
asthma
 Spirometry
 Air flow limitation
 Low FEV1 (relative to % of predicted norms)
 FEV1/ FVC ratio < 0.8
 Bronchodilator response to (inhaled 2 agonist)
 Improvement in FEV1 >12%
 Exercise challenge
 Worsening in FEV1 > 15%
 Peak flow morning to afternoon variation > 20%

29. FEV1/FVC = 0.57

33. CONDITIONS CONFUSED WITH
ASTHMA
 Aspiration of foreign body
 Vocal cord dysfunction
 Hyperventilation
syndrome
 Bronchiolitis
 Cystic fibrosis
 Bronchiectasis
 Habit cough
 Ciliary dyskinesis
 α- 1- Antitrypsin
deficiency

34. Asthmatics are classified as:
 Intermittent -
 Asthmatics who have symptoms that occur
with a cold from time to time.
 They often grow out of the disease.
 Persistent -
 Asthmatics having symptoms at least twice a week
during the day and twice a month during the night.
 These asthmatics are further classified as mild,
moderate, or severe.

35. Stepwise Approach for Managing Asthma:
Severity Classification (NAEPP)
Asthma Severity Days
Symptoms
Nights
Symptoms
Lung Functions
Step 1:
Mild Intermittent
< 3 per week
< once per
week
< 3 per mo
Not more
Than twice
FEV1 or PEF 
80% of predicted;
PEF variability
< 20%
Step 2
Mild Persistent ³>3 per week
3-4 per mo FEV or PEF 
80% of predicted;
PEF variability 20-
30%

36. Asthma
Severity
Days Symptoms Nights
Symptoms
Lung Functions
Step 3:
Moderate
persistent
Daily symptoms daily use
of short-d acting -
agonists
1 time per
wk
FEV1 or PEF
>60 and 80%
predicted; PEF
variability >30%
Step 4:
Severe
Persistent
Continual symptoms
limited physical activity
frequent exacerbations
Frequent FEV1 or PEF 60%
of predicted; PEF
variability >30%

37. Management and Prevention
 Develop patient/doctor partnership
 Identify and reduce exposure to risk factors
 Assess, treat and monitor asthma
 Manage asthma exacerbations
 Special considerations

38. Aim of partnership
 To give people with asthma the ability to control their
own condition and guidance from healthcare
professionals
 To discuss goals of treatment
 Develop written self management Action Plan

40. Patient Education
(“4 R”)
i. Reach agreement on goals
ii. Rehearsal
iii. Repetition
iv. Reinforcement

41. Identify and reduce exposure to risk
factors
 Prevent allergic sensitization prenatally
 Inhibit exposure to tobacco smoke prenatally and
postnatally
 Breast feeding
 Prevention from outdoor and indoor allergens
 Any other triggers
 Drugs ( aspirin and beta blockers )
 Influenza vaccination
 Obesity
 Emotional stress

42. Assess
Treat
Monitor asthma

43. Figure 4.3-1. Levels of Asthma Control
Characteristic Controlled
(All of the
Following)
Partly Controlled
(Any measure present in any
week)
Uncontrolled
Daytime symptoms None More than twice/week Three or
more features
of partly
controlled
asthma
present in
any week
Limitations of
activities
None Any
Nocturnal
symptoms/
awakening
None Any
Need for reliever /
rescue treatment
None (twice
or less/week)
More than twice/week
Lung function
(PEF or FEV1)
Normal <80% predicted or personal best
(if known)
Exacerbations None One or more/year* One in any
week

44. Management Approach Based On Control
Controlled
Maintain
and find lowest controlling step
Partly controlled Consider stepping up to gain control
Uncontrolled Step up until controlled
Exacerbation Treat as Exacerbation
Increase
Reduce

45. Asthma pharmacotherapy
 Long-term control versus quick-relief medications
 Classification of asthma severity for anti-inflammatory
pharmacotherapy
 Step-up, step-down approach
 Asthma exacerbation management

46. Asthma medications
 Quick relief medications
 “Relievers” “Rescue”
 Long term control medications
 “controllers”

48. RELIEVERS
1. Short acting inhaled 2 agonists
Salbutamol (100 µg) , Nebules(1ml=5mg)
Terbutaline
2. Inhaled anticholinergics
Ipratropium (Atem,atrovent, Nebules 250 µg)
Atropine
3. Adrenaline (Epinephrine)
4. Short acting theophylline
5. Short course systemic glucocorticoids
Prednisone
Methyl prednisone

49. Controllers
- Non steroidal anti-inflammatory agents
- Cromolyn sodium – Intal
- Inhaled glucocorticoids
- Beclomethasone
- Becotide (50 µg/puff),
- cleinal forte( 250 µg), Becloforte
- Budesonide Pulmicort (50 µg, 250 µg)
- Fluticasone Flixotide (50, 125, 250 µg)
- Triamcinolone Azmacort (200 µg)

50. - Sustained release Theophylline
- Long acting inhaled  agonists.
- Salmeterol,(Serevent) formoterol
- Long acting inhaled β2 agonist + Fluticasone
(Seretide 25/50, 25/125, 25/250)
Leukotriene modifiers
- Monteleukast (4mg, 5mg, 10mg)
- Zafirlukast

51. Figure 3-4. Estimated Daily Doses of inhaled
Glucocorticosteriods for children
Drug Low Daily
Dose(g)
Medium Daily
Dose (g)
High Daily Dose
(g)
Beclomethasone
dipropionate
100-200 >200-400 >400
Budesonide* 100-200 >200-400 >400
Ciclesonide* 80-160 >160-320 >320
Flunisolide 500-750 >750-1250 >1250
Fluticasone 100-200 >200-500 >500
Mometasone
furoate*
100-200 >200-400 >400
Triamcinolone
acetonide
400-800 >800-1200 >1200

52. THE “3 STRIKES” RULE
The child should receive controller therapy based on
NAEPP Guidelines
If an asthmatic child requires
 Quick-relief medication more than 3 times per week
 Awakens at night due to asthma more than 3 times per
month
 Requires refill for a quick-relief inhaler more than 3 times
per year

53. Or
Leukotriene
modifier
Or LABA
Leukotriene modifier
SR theophylline

54. RECOMMENDED MEDICATIONS BY LEVEL
OF SEVERITY
Step up-step down approach
Level of severity Long term control medications
Step 1
Intermittent
None necessary
Step 2
Mild persistent
Low dose inhaled steroids
Cromolyn, theophylline
Leukotriene modifier
Step 3
Moderate Persistent
Inhaled steriods + long acting inhaled 2
agonist
Inhaled steriod + leukotriene modifier
Step 4
Severe persistent
High dose inhaled steroids + long acting
2 agonist
-leukotrine modifier
-oral steriod

55. Under 5 years

56.  Maintain normal activity
 Regular school or daycare attendance
 Full participation in physical exercise, athletics, and
other recreational activities
 Prevent sleep disturbance
 Prevent chronic asthma symptoms
 Keep asthma exacerbations from becoming severe
 Maintain normal lung function
 Experience little to no adverse effects of treatment

57. Four Components of Optimal
Asthma Management
Regular assessment and monitoring
 Asthma check-ups
 Every 2-4 wk until good control is achieved
 2-4 per year to maintain good control
 Lung function monitoring
 Control on medication at any step for three months step
up or step down
 Review and followup

58. PROGNOSIS
 Ultimate remission depends on growth and cross-
sectional diameter of the airways
 50% of all asthmatic become symptom free with 10-20
years
 Onset between two years and puberty
Remission rate 50%
Children with severe asthma
Frequent hospitalizations and steroid dependent
disease
 95% become adult asthmatics

59. Prevention
1 ounce of prevention = 1 pound of cure

60.  Ludwig van Beethoven, composer
 Leonard Bernstein, conductor
 Bob Hope, entertainer
 Samuel Johnson, 18th century poet, critic, and writer
 John F. Kennedy, 35th president of the United States
 Peter the Great, 18th century Russian czar
 William Tecumseh Sherman, Civil War General
 Elizabeth Taylor, actress
 Charles Dickens, novelist
 Jim “Catfish” Hunter, baseball Hall of Famer
 Greg Louganis, Olympic diver
Did you know these famous people also suffered from,
or currently suffer from asthma?

61. Threshold concentrations of allergens
 10 ug/g dust of group I mite allergen
 8 ug/g dust of Fel d I,the major cat allergen
 10 ug/g dust of Can f I,the major dog allergen
 8 ug/g dust of cockroach allergen

62. Asthma Quiz: True or False?
1. Asthma is an emotional or psychological illness
2. All people with asthma have allergies.
3. A number of Olympic medallists have asthma.
4. Asthma can be cured.
5. Children outgrow asthma.
6. A family history is a good predictor of whether or not a child
develops asthma.
7. Some dog beeds, such as chihuahuas, are better for people with
asthma and allergies.
8. All pet allergies will be cleared from a room once a pet is
removed.
9. Secondhand smoke may cause the development of asthma in
preschool children.
10. People with asthma should avoid all known asthma triggers.

65. Management of acute severe
asthma attack
Home management
 Rescue medication inhaled short acting 2 agonist
 Salbutamol Nebulization 1 ml = 5 mg
 Three treatments in one hour or 4-8 puffs by inhaler/spacer
 Response to initial Treatment is:
Good
 Symptoms of subside and relief is sustained for 4 hours.
 PEF is greater than 80%
Action
 Continue 2 agonist every 3-4 hours for 1-2 days

66. Incomplete
 Symptoms decrease but return in less than 3 hours
 PEF is 60-80% predicted or personal best
Actions
 Add oral steriods
 Add inhaled anticholinergic
 Continue 2 agonist
 Consult clinician urgently
Poor
 PEF less than 60%
 Transport to hospital emergency

67. Hospital Management
Upon arrival to emergency room after rapid
cardiopulmonary assessment:
 Prompt Initiation of Oxygen therapy
 Salbutamol Nebulization (3 back to back
treatments/ 4-8 puffs by inhaler/spacer)
 Adrenaline s/c 0.01 mg/Kg can be used in
addition if no response

68.  Systemic glucocorticoid: Intravenous
methylprednisolone 1-2 mg/kg hydrocortisone
10mg/kg or IM route must be administered
 Reassessment in 1 hour
 If O2 saturation < 90, tachycardia shallow fast
breathing, altered sensorium admit PICU

69.  Continue O2
 2 agonist inhalation every 20 minutes or continuous
Nebulization 0.5 mg/kg maximum 15 mg/hr
 Anticholinergic Nebulization Ipratropium bromide 6
hourly
 Intravenous fluids 2/3 maintenance
 Intravenous Theophylline 6 mg/kg loading, 1 mg/kg
per hour
 Intravenous Steroids
 Intravenous 2 agonist 15 μg/kg over 15 min
 If not improving and exhausted lethargic showing
increasing mixed acidosis
 IV magnesium sulphate

70.  Intubation and ventilation
 Strictly avoid sedatives
 Nebulized 2 agonist on ventilator
 Inhaled Heliox

71. ACUTE SEVERE ASTHMA
signs & symptoms
 Cough
 Sounds tight
 Non-productive
 Wheezing
 Tachypnoea
 Dyspnoea
 Prolonged expiration
 Use of accessory muscles of respiration
 Cyanosis – hyperinflation
 Tachycardia – pulsus paradoxas

72.  Extreme respiratory distress
 Silent chest
 Wheezing comes after treatment
 Difficulty walking or talking
 Sitting up – hunched over
 Abdominal pain
 Liver
 Spleen
 Palpable
 Vomiting
 Sweating