This document discusses childhood asthma, including its definition, risk factors, diagnosis, and treatment. Key points include: - Asthma is a chronic inflammatory airway disorder characterized by variable airflow obstruction and airway hyperresponsiveness. - Risk factors include genetic predisposition, obesity, allergens, infections, and tobacco smoke. - Diagnosis is based on symptoms like recurrent wheezing and cough, as well as response to bronchodilators. Spirometry can help diagnose in children over 5. - Treatment involves bronchodilators, inhaled corticosteroids, and other controllers. Correct inhaler technique is important for effective treatment.

1. CHILDHOOD ASTHMA Dr. Imran Masood, PhD
drimranmasood@iub.edu.p
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2. DEFINITION
The National UK guidelines (BTS/SIGN,2009) define asthma as
‘a chronic inflammatory disorder of the airways which occurs in susceptible
individuals; inflammatory symptoms are usually associated with widespread but
variable airflow obstruction and an increase in airway response to a variety of
stimuli’.

3. FACTORS INFLUENCING THE
DEVELOPMENT AND EXPRESSION
OF ASTHMA
Host factors
Genetic
Genes predisposing to atopy
Genes predisposing to airway hyper responsiveness
Obesity
Sex

4. Environmental factor
Allergens
Indoor - domestic mites, furred animals (dogs, cats, mice), cockroach allergens, fungi,
molds, yeasts.
Outdoor – pollens, fungi, molds, yeasts.
Infections (predominantly viral)
Occupational sensitizers
Tobacco smoke
Passive smoke
Active smoke
Indoor/outdoor air pollution

5. RISK FACTORS OF ASTHMA IN
YOUNGER CHILDREN
•Sensitization to allergens
•Maternal diet during pregnancy
•Pollutants (particularly environmental tobacco smoke)
•Microbes and their products
•Respiratory (viral) infections
•Psychosocial factors

6. ISSUES IN CHILDHOOD
ASTHMA
•Underdiagnosed/misdiagnosed
•Acceptance of asthma diagnosis/label
•Heterogeneous disease/varying phenotypes
•Cough or wheeze
•Poor patient/parent education
•Lack of knowledge and time vs. more patients
•Oral vs inhaled
•Choice of right device
•Heavy nebulization
•Fear of steroids

7. OTHER CHALLENGES
•Most of the children are below 5 years of age, who cannot tell their problems.
•Parents are proxy story tellers, who may mislead the doctor.
•PEF cannot be performed in children below 5 years of age.
•Fear of addiction to inhalational therapy.
•Physicians lack of knowledge and time.

8. CLINICAL FEATURES
•Recurrent wheeze
•Recurrent cough
•Recurrent breathless
•Activity induced cough/wheeze
•Nocturnal cough/breathlessness
•Tightness of chest

9. SYMPTOMATOLOGY
Cough-90%
Wheezing-74%
Exercise induced wheeze or cough-55%

10. TYPICAL FEATURES OF
ASTHMA
•Afebrile episodes
•Personal atopy
•Family history of atopy or asthma
•Exercise or activity induced asthma
•History of triggers
•Seasonal exacerbations
•Relief with bronchodilators

11. TOOLS TO DIAGNOSIS
Good history taking (ASK)
Careful physical examination (LOOK)
Investigations (PERFORM) – above 5 years only

12. HISTORY TAKING (ASK)
Has the child had an attack or recurrent episode of wheezing (high-pitched whistling
sounds when breathing out)?
Does the child have a troublesome cough which is particularly worse at night or on
waking?
Is the child awakened by coughing or difficult breathing?
Does the child cough or wheeze after physical activity (like games and exercise) or
excessive crying?
Does the child experience breathing problems during a particular season?

13. Does the child cough, wheeze, or develop chest tightness after exposure to airborne
allergens or irritants e.g. smoke, perfumes, animal fur?
Are symptoms relieved when medication is used?
If the answer is ‘yes’ to any of the questions, a diagnosis of asthma should be
considered

14. PHYSICAL EXAMINATION
(LOOK)
General Attitude And Well Being
Deformity Of The Chest
Character Of Breathing
Thorough Auscultation Of Breath Sounds
Signs Of Any Other Allergic Disorders On The Body
Growth And Development Status

15. WHAT ALL FEATURES ONE
SHOULD LOOK FOR
SPECIFICALLY?
Dyspnea
Expiratory wheeze
Accessory muscle movement
Difficulty in feeding, talking, getting to sleep
Irritability
Cough
Persistent/ recurrent / nocturnal/ exercise induced

16. Associated conditions
Eczema
Allergic Rhinitis
Weight/Height

17. IDENTIFYING COMORBIDITIES
Co-morbid condition
Allergic Rhinitis
Colds, ear infections
Sneezing in the morning
Blocked nose, snoring, mouth breathing
Gastro esophageal reflux (GER)
Nocturnal cough followed by vomiting
Eczema

18. GUIDELINES FOR CONFIRMING
CHILDHOOD ASTHMA DIAGNOSIS
IPAG Diagnosis
Characterize the problem
Establish chronicity
Exclude non-respiratory or other causes
Exclude infectious diseases
Consider patient’s age
Use diagnostic aids

19. SPIROMETRY
Spirometry is a pulmonary function test that measures the volume of air an
individual inhales or exhales as a function of time.
How to perform?
1. 4 normal breaths
2. Inhale as deeply as possible
3. Exhale to normal depth
4. 3 normal breaths
5. Exhale as much as possible
6. 3 normal breaths
7. Inhale as much as possible
8. Exhale as fast and completely as possible
9. 4 normal breaths

20. ROLE OF SPIROMETRY IN
ASTHMA
Helps to make diagnosis.
Assess degree of airflow obstruction.
To predict whether obstruction is reversible.
Aids in management of asthma.
To monitor progression of disease.

21. WHAT ALL INVESTIGATIONS CAN BE PERFORMED
IN ASTHMATIC CHILDREN? (PERFORM)
Peak expiratory flow rate: It is highly suggestive of asthma when:
>15% increase in PEFR after inhaled short acting β2 agonist
>15% decrease in PEFR after exercise
Diurnal variation > 10% in children not on bronchodilator
OR >20% In children

25. GINA GUIDELINES
The following symptoms are highly suggestive of a diagnosis of asthma:
frequent episodes of wheeze (more than once a month)
activity-induced cough or wheeze
nocturnal cough in periods without viral infections
absence of seasonal variation in wheeze
symptoms that persist after age 3
 A simple clinical index based on:
presence of a wheeze before the age of 3
presence of one major risk factor (parental history of asthma or eczema) or two of three
minor risk factors (eosinophilia, wheezing without colds, and allergic rhinitis) has been
shown to predict the presence of asthma in later childhood

26. A useful method for confirming the diagnosis of asthma in children 5 years and younger is a trial of
treatment with short-acting bronchodilators and inhaled glucocorticosteroids.
Children 4 to 5 years old can be taught to use a PEF meter, but to ensure reliability parental
supervision is required.
Use of spirometry and other measures recommended for older children such as airway responsiveness
and markers of airway inflammation is difficult and several require complex equipment making them
unsuitable for routine use.
BTS
Initial assessment of children suspected of having asthma should be based on:
• presence of key features in the history and clinical examination
• careful consideration of alternative diagnoses
• Using a structured questionnaire may produce a more standardized approach to the recording of
presenting clinical features and the basis for a diagnosis of asthma

27. TREATMENT
Type of drug Drug
Bronchodilators
ß2-agonists (relievers) Salbutamol, terbutaline
anti cholinergic Ipratropium bromide
bronchodilators
Preventive/prophylactic treatment
inhaled steroids Beclomethasone, Fluticasone,
Mometasone
Long acting Salmeterol, formoterol
ß2-bronchodialators
methylxanthines theophylline
leukotrienes inhibitors Montelukast
oral steroids Prednisolone
Anti-IgE injections omalizumab

29. INHALERS
Inhaled drugs may be administered via a variety of devices, chosen
according to the child’s age and preference:
• Pressurized metered dose inhaler (pMDI) and spacer.
– Appropriate for all age groups: 0–2 years, spacer and facemask;
>2 years, spacer alone
– A spacer is recommended for all children as it increases drug
deposition to the lungs
– Useful for acute asthma attacks when poor inspiratory effort may
impair the use of inhalers direct to the mouth
• Breath-actuated metered dose inhalers (e.g. Auto haler, Easibreath):
6+ years. Less coordination needed than a pMDI without spacer.
Useful for delivering βagonists when ‘out and about’ in older children

30. • Dry powder inhaler: 4+ years. Needs a good inspiratory
flow, therefore less good in severe asthma and during
an asthma attack. Also easy to use when ‘out and
about’ in older children
• Nebulizer: any age. Only used in acute asthma where
oxygen is needed in addition to inhaled drugs;
occasionally used at home as part of an acute
management plan in those with rapid onset severe asthma
(brittle asthma).
Many children fail to gain the benefit of their treatment
because they cannot use the inhaler correctly. This must
be demonstrated and the child’s ability to use it
checked. In young children, parents need to be skilled in
assisting their child to use the inhaler correctly. Assessing
and reassessing inhaler technique is vital to good
management and should be a routine part of any review.