Pediatric Asthma
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1. The document discusses the diagnosis and management of asthma including defining features, triggers, pathophysiology, diagnostic testing, severity assessment, treatment guidelines, and medications. 2. Asthma is characterized by recurrent episodes of airflow obstruction, bronchial hyperresponsiveness and inflammation. Onset most often occurs before age 5 and is influenced by viral infections, allergens, exercise and stress. 3. Treatment involves a stepwise approach adding or increasing control medications based on impairment, symptoms and exacerbation risk. Recommended medications include inhaled corticosteroids, long-acting beta-agonists, leukotriene modifiers and omalizumab.
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Pediatric Asthma
- 5. •70-80% before 5 years of age Onset • only 1/3rd of all wheezers have asthma Progression
- 8. Early phase : immediate response Late-phase : 6 to 24 hours
- 9. Consistent with Asthma Not consistent with asthma
- 10. Major Risk Factors Minor Risk Factors Parental Asthma Allergic Rhinitis Wheezing without URTI Eczema Eosinophilia >4% Loose Index Stringent Index 1 episode of wheezing in 3 years + 1 major > 3 episode of wheezing in 3 years + 1 major 1 episode of wheezing in 3 years + 2 Minor > 3 episode of wheezing in 3 years + 2 Minor Conclusion: Conclusion 2.6-5.5 times likely to have asthma 4.3 – 9.8 times likely to have asthma
- 11. Viral Associated wheeze Early Onset Asthma Febrile Episodes Afebrile episodes No Personal Atopy Positive Personal Atopy No Family history of atopy Positive Family history of atopy Variable response to bronchodilators Predictable response to bronchodilators
- 13. History Of presenting Illness Age • Birth • Early infancy • Early Childhood • Adolescents Associated symp. • Choking • Fever • Feeding onset • New or recurrent Temporal Pattern • Episodic or persistent Control of wheeze • Difficult to control Past Medical History • Recurrent pneumoniae • Neurodegenerative disease Birth History • Antenatal Antenatal USS. • Natal Preterm Family history • Atopy
- 15. General Examination: Denny morgan lines allergic salute Clubbing Erythematous conjuntiva Growth Charts : Weight: Underweight Length: Short stature Head circumference: Macro or microcephaly Vital Signs Temperature: fever Systemic Examination: Skin: Urticaria Eczema ENT: Boggy turbinates Rhinorrhea Polyps Stridor CNS: Features of neurodegenerative diseases Chest: Increased AP Local vs generalized Inspiratory vs expiratory
- 17. PFTs (diagnostic) CXR (Rule out other causes) RAST Other: CBC Sweat Chloride , immunoglobulins,Viral screen Barium Swallow
- 18. FEV1 FEV1/FVC FEF25-75 FVC Flow volume Loop
- 19. PFTs Result TLC Increased or normal RV Increased FVC Reduced
- 20. PFTs Result FEV1 Reduced FEV1/FVC Reduced FEF25-75 Reduced
- 23. 1. recurrent episodic symptoms of airflow obstruction 2. Airway flow obstruction is at least partially reversible by administration of a bronchodilator. 3. Alternative diagnoses are excluded Symptoms are often worse at night or on waking Symptoms occur variably over time and vary in intensity Symptoms are often triggered by exercise, laughter, allergens, virus
- 24. Cystic fibrosis FBA Vascular ring Immune dysregulation Swallowing dysfunction GERD
- 25. • Minimal need <2/wk for SABA • Maintenance of normal daily activities Reduction in impairment • Prevention of recurrent exacerbations • minimal or no adverse effects of drugs Reduction of risk
- 28. Intermittent Persistent Mild Moderate Severe Asthma Severity is classified into 3 categories:
- 30. signs and symptoms pulmonary function quality of life exacerbations adherence to treatment medication side effects
- 32. COMPONENETS OF SEVERITY SEVERITY INTERMITTENT PERSISTENT MILD MODERATE SEVERE IMPAIRMENT DAY <2 times/ week >2 times/ week DAILY FREQUENT SABA USE <2 times/ week >2 times/ week DAILY FREQUENT NIGHT <2 times/ MONTH >2 times/ MONTH >5 times/ MONTH FREQUENT ACTIVITY NONE MINOR SOME EXTREME >80% >60 <60% LUNG FUNCTION >5YEARS FEV1% PREDICTED >80% FEV1/FVC RATIO >85 >80% >75 <75% >12y = NORMAL NORMAL REDUCED 5% REDUCED 5% RISK EXACERBATIONS <2TIMES /YEAR >2TIMES /YEAR
- 34. COMPONENETS OF CONTROL CONTROL WELL NOT WELL VERY POOR IMPAIRMENT DAY <2 times/ week >2 times/ week FREQUENT SABA USE <2 times/ week >2 times/ week FREQUENT NIGHT <2 times/ MONTH >2 times/ MONTH >5 times/ MONTH ACTIVITY MINOR SOME EXTREME >60% <60% LUNG FUNCTION >5YEARS FEV1% PREDICTED >80% FEV1/FVC RATIO >80% >75 <75% RISK EXACERBATIONS <2TIMES /YEAR >2TIMES /YEAR
- 44. COMPONENETS OF SEVERITY SEVERITY INTERMITTENT PERSISTENT MILD MODERATE SEVERE RECOMMENDED STEPS FOR INTIATING THERAPY STEP1 STEP2 0-4 y STEP3 STEP3 5-11y STEP3 STEP3-4 >12y STEP3 STEP4-5 CONSIDER SHORT DOSE OF STEROIDS
- 45. Step: Step1 Step2 Step3 Step4 Step5 Step6 0-4y P SABA prn Low ICS Medium ICS Medium ICS + LABA or LTRA High ICS +LABA or LTRA High ICS +LABA or LTRA+steroids A LTRA 5-11y P SABA prn Low ICS Medium ICS or Low dose ICS + LABA, LTRA Medium ICS+LABA or LTRA High ICS +LABA or LTRA High ICS +LABA or LTRA+steroids A LTRA theophylline theophylline theophylline theophylline >12y P SABA prn Low ICS Medium ICS or Low dose ICS +LABA or LTRA Medium ICS+LABA or LTRA High ICS +LABA or LTRA High ICS +LABA or LTRA+steroids A or LTRA Theophylline, Zileuton Theophylline, Zileuton Omalizumab Omalizumab
- 47. 3. leukotriene modifiers, 4. mast cell stabilizers i.e Cromolyn 5. Omalizumab
Editor's Notes
- It is omnipresent. But the Greatest proportion in developed nations
- 1: Respiratory Viral Infection Environmental allergens : Outdoor allergens: pollen, grass pollen, weed pollen, molds Indoor allergens: animal dander, dust mites, cockroach, indoor molds, mouse Irritants: Environmental tobacco, smoke Air, pollutants (eg, ozone, sulfur dioxide),Particulate matter (eg, wood or coal burning smoke) Mycotoxins, Endotoxin, Dust Occupational exposure (eg, farm and barn exposure, formaldehyde, cedar, paint fumes, others) Cold, dry air Exercise
- 100 genetic loci have been identified high-affinity IgE receptors T-cell antigen receptor interleukin-4 gene Other : ADAM-33 , B agonist receptor polymorphism
- Bronchoconstriction and Bronchopspasm Recruitment of immune cells which cause epithelial cell damage
- The most common symptoms that arouse a suspicion of asthma are intermittent and repetitive episodes of cough and noisy breathing or wheezing triggered by respiratory infections, allergen or irritant exposure, exercise, or play, with symptoms often awakening the child at night Nonspecific symptoms may include self-imposed limitation of physical activities, genera Recurrent “croup” in an older child or frequent “clinical pneumonias” or “bronchitis” may also alert the pediatrician to consider evaluating for possible asthmal fatigue, and difficulty keeping up with peers
- Birth: Congenital diaphragmatic hernias( neonatal), Bronchopulmonary dysplasia(Neonate) Early infancy: Vascular rings Early Childhood: Bronchiolitis , FBA Adolescents: Atypical pneumoniae and asthma New-onset: Previously healthy infant: bronchiolitis , incontext of urticaria , stridor: anaphylaxis Recurrent: URTI: Viral induced wheeze, Feeds: GERD, Atopy: asthma Episodic: viral induced wheeze, Persistent: Congenital airway abnormality: tracheomalacia, mediastinial mass Both: asthma Control: Recurrent wheeze is difficult to control Severe asthma or Cystic Fibrosis or anatomic abnormality Recurrent pneumoniae: immunodeficiency or Cystic fibrosis or ciliary dyskinesia Neurodegenerative : Swallowing dysfunction Antenatal: Congenital diaphragmatic hernia Preterm: intubated? BPD FH: Atopy: Asthma
- GE: DML: allergy Clubbing: CF Weight and Height: Chronic disorders: CF, Immunodeficiency HC: Neurodegenerative disease Temp: Pneumoniae, Urticaria: anaphylaxis Eczema: AR Boggy: AR Rhinorrhea: VIW PolypS: CF NDD: swallowing dysfuntion Local : FBA Localized: FBA, Endobronchial mass Generalized: Asthma Inspiratory: obstruction: FBA, Expiratory: Edema asthma, VIW, irritants
- PFTs: diagnostic, Reversibility, Hyperreactivity, CXR: If its new onset, worsening wheezing Hyperinflation: generalized: Asthma, CF, Bronchiolitis, Localized: FBA Cardiomegaly, Mediastinial masses radioallergosorbent test: Asthma to identify triggers sometime in difficult to treat cases Barium: TEF, GERD, vascular rings
- FVC = forced vital capacity = volume exhaled after maximal inspiration through to maximal expiration FEV1 = forced expiratory volume in 1 sec FEV1/FVC = ratio = percent exhaled within first second FEF25-75 = forced expiratory flow: the % exhaled between 25%-75% PEFR = peak expiratory flow rate: highest at first because of mechanical advantage and traction of airways; also a measure of effort AGE GENDER HEIGHT RACE
- exercise challenges, methacholine, cold air, and most recently, mannitol challenges performed only when the determination of asthma is difficult despite routine evaluation.
- Clinical diagnosis < 5 years , in whom PFTs cant be performed Recurrent: cough or wheeze And inclusion of FH or personal history of atopy So you don’t do PFTs to confirm
- Ciliary dyskinesia or cystic fibrosis: Symptoms and signs that are not consistent with chronicity of asthma, including failure to thrive, cyanosis, and clubbing, should alert the pediatrician to alternative diagnoses such as ciliary dyskinesia or cystic fibrosis. Foreign body aspiration : A baseline chest radiograph may help exclude other conditions that mimic asthma Vascular ring: barium swallow Immune dysregulation : White cell count and differential and quantitative immunoglobulins. GERD: Symptoms sometimes related to eating, vomiting Clinical,An upper gastrointestinal series
- SABA: nil to 1 time a week Activity: work, sport Exacerbations: <2 a year Adverse effect: minimise and reduce the dose as much as possible
- Spirometry: A baseline spirometry should also be performed once a year during follow-up evaluations Assessment of asthma control should not be based solely on individual single measurements and limited interactions
- Asthma control represents the degree to which manifestations of asthma are minimized and the goals of therapy are met, and should be used as a guide to either maintain or adjust therapy. Responsiveness refers to the ease with which prescribed therapy achieves asthma control the degree of control can change over time; thus, constant review of symptoms and treatment every 1 to 6 months is helpful Apart from the assessment of severity and control, the predisposition to risk for exacerbations should also be kept in mind. For instance, a child with intermittent asthma may not need daily controller medication based on the initial assessment of severity, but the child may still have an unexpectedly severe exacerbation triggered by, for example, a viral infection
- Asthma severity index and asthma control index basically contains the following parameters. Aim is to bring the symptoms to the intermittent range of asthma severity and Spirometry results to normal physiologic
- 1. Basic facts about asthma Differences between normal and asthmatic airway, preferably using models Links between airways inflammation, hyperreactivity, and bronchoconstriction 2. Environmental exposures Comorbid conditions 4. Also provide asthma plan for school
- Meds: taste, dosing schedule, difficulties with devices, side effects, and expense medication regimens tends to be suboptimal Patient:; misperception of disease severity, misunderstanding instructions Physician; failure to monitor patients regularly, and incorrect medication and dosage
- 1. Put your mattresses and pillows in special allergen-proof covers. Remove all animal products from bedding (e.g. feather pillows and down comforters). Wash your bedding every week in hot water 2. Keep the bathroom dry by using an exhaust fan or dehumidifier. Clean sinks, tubs and showers often with a bleach solution (1 part bleach, 3 parts water). Limit house plants as they are sources of dampness and mold. 3. During allergy season, use air conditioning instead of opening the windows at home and in the car. hange the air conditioner filter monthly. Shower or bathe after being outdoors 4. Keep pets outside, if possible. Keep them off the furniture. Keep pets out of the bedrooms. Bathe your pets weekl 5. Some medications, such as aspirin or beta blockers 6. These chemicals are found in wine, beer, shrimp, dried fruit and processed potatoes, and can cause breathing difficulty for many people with asthma. 7. Smoking and secondhand smoke irritate the lungs. Do not use wood burning stoves or fireplaces and avoid campfires 8. Perfumes, sprays and cleaning products 9. Strong emotions, such as anger and anxiety, can lead to changes in breathing that can cause asthma symptoms or make them worse 10. Take your asthma medicine as prescribed. Warm up by exercising slowly at first. Limit exercise if you are ill or if the weather is cold and dry.
- relief medication for quick relief of acute symptoms and exacerbations controller medication for long-term control of the underlying pathophysiologic mechanism of asthma inhaled corticosteroids (ICS), combination ICS and long-acting β-agonists (ICS-LABA), leukotriene receptor antagonists (LTRA),
- 5 y step 2-4 consider allergen immunotherapy SABA > 2 d / week should alert
- SABA:Excessive reliance on quick relievers has been associated with increased risk for death or worsening asthma. ipratropium: This agent decreases vagal tone (resulting in bronchodilation) Steroids: These drugs have broad anti-inflammatory effects and are usually used as a short 3- to 5-day course to gain initial control of asthma and to speed resolution of moderate or severe persistent exacerbation
- 1. Inhaled corticosteroids are recommended as the first-line treatment for most types of persistent asthma. inhibition of inflammatory cytokines and upregulation of β2-receptor responsiveness. improve pulmonary function, reduce the need for quick-relief medications, 2. are not intended for treating acute exacerbations or as monotherapy for persistent asthma up to 12 hours The FDA also specifies that LABAs should be discontinued when asthma control is achieved, and asthma should be maintained with controllers such as ICS 3. montelukast > 6mand zafirlukast,>5y that block LTD4 receptors, Zileuton >12y 4. they need to be administered frequently (4 times a day) and are not as efficacious as ICS or leukotriene antagonists 5. omalizumab : is an anti-IgE humanized monoclonal antibody that binds circulating IgE, thereby binding the high-affinity receptor and preventing IgE-mediated allergic responses and inflammatory cascade 6. administered every 2 to 4 weeks subcutaneously
- Issues to consider include the drug delivery device, dose level, formulation of the preparation, bioavailability, potency of the inhaled corticosteroid, and deposition either in the pulmonary system or in the gastrointestinal system
- Allergy shots work like a vaccine. Your body responds to injected amounts of a particular allergen, given in gradually increasing doses, by develop resistance to allergen
- Of great concern is that many of these fatal outcomes occur in children viewed as having mild disease.. Risk of death increase with Prior admissions to an intensive care unit, Prior intubation for asthma and sometimes when they have Difficulty perceiving airflow obstruction or its severity, Use of more than 1 canister per month