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• Asthma is the most common chronic disease of childhood and the leading cause of childhood morbidity from chronic disease as measured by school absences, emergency department visits, and hospitalizations. • Asthma leads to recurrent episodes of wheezing, breathlessness, chest tightness and coughing (particularly at night or early morning). Clinical symptoms in children 5 years and younger are variable and non-specific. • Widespread, variable, and often reversible airflow limitation.
Asthma Inflammation – Cells and Mediators
Mechanism – Asthma Inflammation Source: Peter J. Barnes, MD
Factors Influencing the Development and Expression of Asthma Host factors – • Genetic 1. Genes predisposing to atopy 2. Genes predisposing to airway hyper responsiveness • Obesity • Sex
Environmental factors – • Allergens – 1. Indoor – Domestic mites, furred animals (dogs, cats, mice), cockroach allergens, fungi, molds, yeasts. 2. Outdoor – Pollens, fungi, molds, yeasts. • Infections (predominantly viral) • Occupational sensitizers • Tobacco smoke 1. Passive smoking 2. Active smoking • Indoor/Outdoor air pollution • Diet
Risk factors of Asthma in younger children • Sensitization to allergen. • Maternal diet during pregnancy and/ or lactation. • Pollutants (particularly environmental tobacco smoke). • Microbes and their products. • Respiratory (viral) infections. • Psychosocial factors.
Prevalence of Childhood asthma
The prevalence of childhood asthma has continued to increase on the Indian subcontinent over the past 10 yrs ISAAC Phase 3 Thorax 2007; 62: 758
Underdiagnosed/ Misdiagnosed Fear of steroids Acceptance of Asthma diagnosis/label Heterogenous Disease/varying phenotypes Heavy nebulisation Issues in Pediatric Asthma Cough or Wheeze Choice of right device Oral vs. Inhaled Lack of knowledge & time vs. more patients Poor patient/ parent education
Other Challenges • Most of the children are below 5 years of age, who cannot tell their problems • Parents are proxy story teller, who may mislead the doctor • PEF cannot be performed in children below 5 years of age • Fear of addiction to inhalation therapy • Physicians lack of knowledge and time
Clinical Features • Recurrent Wheeze • Recurrent Cough • Recurrent Breathlessness • Activity Induced Cough/Wheeze • Nocturnal Cough/Breathlessness • Tightness Of Chest Asthma by Consensus, IAP 2003
Symptomatology • Cough – 90% • Wheezing – 74% • Exercise induced wheeze or cough – 55% Ind J Ped 2002; 69: 309 -12
Typical features of Asthma • Afebrile episodes • Personal atopy • Family history of atopy or asthma • Exercise /Activity induced symptoms • History of triggers • Seasonal exacerbations • Relief with bronchodilators Asthma by Consensus, IAP 2003
When does Asthma begin? • By 1 year – 26% • 1 -5 years – 51. 4% • > 5 years – 22. 3% 77% Of Asthma Begins In Children Less Than 5 Years Ind J Ped 2002; 69: 309 -12
Tools to Diagnosis • Good History Taking (ASK) • Careful Physical Examination (LOOK) • Investigations (PERFORM) – above 5 years only CHILDHOOD ASTHMA by KHUBCHANDANI R. P. et al
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? CHILDHOOD ASTHMA by KHUBCHANDANI R. P. et al
History taking (Ask) • Does the child cough, wheeze, or develop chest tightness after exposure to airborne allergens or irritants e. g. smoke, perfumes, animal fur? • Does the child’s cold frequently ‘go to the chest’ or take more days to resolve? If than the 10 answer is ‘yes’ to any of the questions, a • diagnosis should considered Does the child of use asthma any medication when be symptoms occur? How often? • Are symptoms relieved when medication is used? CHILDHOOD ASTHMA by KHUBCHANDANI R. P. et al
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 CHILDHOOD ASTHMA by KHUBCHANDANI R. P. et al
What all features one should look for specifically? ü Dyspnea • Expiratory wheeze • Accessory muscle movement • Difficulty in feeding, talking, getting to sleep • Irritability CHILDHOOD ASTHMA by KHUBCHANDANI R. P. et al
What all features one should look for specifically? ü Cough • Persistent/ recurrent / nocturnal/ exercise-induced Associated conditions • Eczema • Allergic Rhinitis ü Weight/Height CHILDHOOD ASTHMA by KHUBCHANDANI R. P. et al
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 β 2 agonist • >15% decrease in PEFR after exercise • Diurnal variation > 10% in children not on bronchodilator OR >20% In children on bronchodilator 1. Asthma by Consensus, IAP 2003 2. CHILDHOOD ASTHMA by KHUBCHANDANI R. P. et al
How to rule out the mimics?
The Early Wheezer (< 3 Years) WALRI (wheeze associated lower respiratory tract infections) or Viral Associated wheeze Early onset asthma • Febrile episodes • Personal atopy absent • Family history of asthma / atopy absent • Variable response to bronchodilators • Afebrile episodes • Personal atopy present • Family history of asthma / atopy present • Predictable good response to bronchodilators Asthma by Consensus, IAP 2003
Bronchiolitis in children • Commonest cause of wheezing in children between 6 months to 3 years • Resembles asthma • Diagnosis essentially clinical • Common viruses causing bronchiolitis in children: – Respiratory syncytial virus (RSV)
Clinical manifestations of RSV disease • Rhinorrhoea • Pharyngitis • Cough • Low grade fever • Wheezing • Increased respiratory rate
Differential diagnosis Age Common Uncommon Rare Less than 6 months Bronchiolitis Aspiration pneumonia Asthma Gastro-esophageal Bronchopulmonary dysplasia Foreign body aspiration reflux Congestive heart failure Cystic fibrosis 6 months - Bronchiolitis 2 years Foreign body aspiration Aspiration pneumonia Congestive heart failure Asthma Bronchopulmonary dysplasia Cystic fibrosis Gastro-esophageal reflux 2 - 5 years Cystic fibrosis Gastro-esophageal reflux Viral pneumonia Asthma Foreign body aspiration Aspiration pneumonia Bronchiolitis Congestive heart failure Gastro-esophageal reflux IPAG 2007
Co morbid conditions • Allergic Rhinitis ü Colds, ear infections ü Sneezing in the morning ü Blocked nose, snoring, mouth breathing • Gastro esophageal reflux (GER) ü Nocturnal cough followed by vomiting • Eczema
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 International Primary Care Airways Group 2007
Early Childhood Asthma Diagnosis (below 6 years) Diagnostic Tool Findings that Support Diagnosis Differential diagnosis The diagnosis of asthma in children under age 6 is primarily one of exclusion. Physical examination If the child does not appear acutely ill and is growing, and there is no evidence specifically indicating another cause of symptoms, a trial of therapy is warranted. Trial of therapy (bronchodilators) Improvement with treatment supports a diagnosis of asthma. Frequent reassessment Health care professionals should always be prepared to reconsider the diagnosis if management is ineffective or if the clinical situation changes. IPAG 2007
Childhood Asthma Diagnosis (6 -14 years) IPAG 2007
Childhood Asthma Diagnosis (6 -14 years) IPAG 2007
NORDIC CONSENSUS Confirm Asthma if, If the child is having 3 attacks of airway obstruction in last 1 yr. If the child gets 1 attack of asthmatic symptoms after the age of 2 yrs. Irrespective of age in an attack in children with allergy (eczema, food allergy etc. ) or history of atopy. If the child does not become free of symptoms when infection has ceased or has persistent symptoms for more than a month. Respir Med. 2000; 94(4): 299 -327
IAP GUIDELINES 3 Or More Episodes Of Airflow Obstruction With Several Of The Following: • Afebrile Episodes • Personal Atopy Or Family H/O Atopy / Asthma • Nocturnal Exacerbations • Exercise/Activity Induced Symptoms • Trigger Induced Symptoms • Seasonal Exacerbations • Relief With Bronchodilators ± Oral Steroid Asthma by Consensus, The Indian Academy of Pediatrics 2003
GINA • 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 Global Initiative for Asthma 2008
GINA • A useful method for confirming the diagnosis of asthma in children 5 years and younger is a trial of treatment with shortacting 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 GINA 2008
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 standardised approach to the recording of presenting clinical features and the basis for a diagnosis of asthma British Thoracic Society 2008
Clinical features that increase the probability of asthma • More than one of the following symptoms: wheeze, cough, difficulty breathing, chest tightness, particularly if these symptoms: ◊ are frequent and recurrent ◊ are worse at night and in the early morning ◊ occur in response to, or are worse after, exercise or other triggers, such as exposure to pets, cold or damp air, or with emotions or laughter ◊ occur apart from colds • Personal history of atopic disorder • Family history of atopic disorder and/or asthma • Widespread wheeze heard on auscultation • History of improvement in symptoms or lung function in response to adequate therapy BTS 2008
Clinical features that lower the probability of asthma • Symptoms with colds only, with no interval symptoms • Isolated cough in the absence of wheeze or difficulty breathing • History of moist cough • Prominent dizziness, light-headedness, peripheral tingling • Repeatedly normal physical examination of chest when symptomatic • Normal peak expiratory flow (PEF) or spirometry when symptomatic • No response to a trial of asthma therapy • Clinical features pointing to alternative diagnosis BTS 2008
What do you understand by phenotypes? • Phenotypes “the visible properties of an organism that are produced by the interaction of genotype and the environment” -Webster’s New Collegiate Dictionary
Pre-school “Asthma phenotypes” Wheezing is common in young children but is it asthma? Prevalence of wheeze Atopic asthma Non-atopic viral induced wheeze Transient wheeze 0 3 6 Age Years 11 Martinez Pediatrics 2002; 109: 362
Asthma phenotypes in childhood Transient • linked with smoking during pregnancy • viral RTIs • not associated with atopy • remits by school age • Impaired lung function at birth
Asthma phenotypes in childhood Persistent • not associated with atopy: - associated with viral RTIs (RSV), - may remit during school age - LTRAs have been found to be beneficial • associated with atopy: - bronchial responsiveness, impaired lung function - parental history of asthma - most ongoing during school age
Classification of Asthma • The goal of the treatment is to achieve and maintain control for prolonged periods with due regard to the safety of treatment, potential for adverse effects, and the cost of treatment required to achieve this goal. • Assessment of asthma control should include control of the clinical manifestations, control of the expected future risk to the patient such as exacerbations, accelerated decline in the lung function, and side-effects of the treatment. • The achievement of good clinical control of asthma leads to reduced risk of exacerbations.
Characteristic Controlled Partly controlled (All of the following) (Any present in any week) More than Daytime symptoms None (2 or less / week) Limitations of activities None Any Nocturnal symptoms / awakening Need for rescue / “reliever” treatment Lung function# (PEF or FEV 1) *Any Exacerbation twice / week 3 or more features of partly controlled asthma More than None (2 or less / week) present in any week* twice / week < 80% predicted or Normal personal best (if known) on any day None One or more / year exacerbation should be prompt review of maintenance treatment to ensure that it is adequate. #Lung Uncontrolled function is not a reliable test for children 5 years and younger. 1 in any week GINA 2009
Levels of Asthma Control in Children 5 years and younger Characteristic Controlled (All of the following) Partly Controlled (Any measure present in any week) Uncontrolled (Three or more of features of partly controlled asthma in any week) Daytime symptoms – wheezing, cough, difficult breathing None (less than twice/week, typically for short periods of on the order minutes and rapidly relieved by use of a rapid-acting bronchodilator) More than twice/week (typically for short periods on the order minutes and rapidly relieved by use of a rapid-acting bronchodilator) More than twice/week (typically last minutes of hour or recur, but partially or fully relieved with rapid-acting bronchodilators) Limitation of activities None (child is fully active, plays and runs without limitation or symptoms) Any (may cough, wheeze, or have difficulty breathing during exercise, vigorous play or laughing) Nocturnal symptoms/ awakening None (no nocturnal coughing during sleep) Any (typically coughs during sleep/wakes with cough, wheezing and/or difficult breathing) Need for reliever/rescue treatment Less than/equal to 2 days/week > 2 days/week
• Examples of validated measures for assessing clinical control of asthma include – • Asthma Control Test (ACT) – www. asthmacontrol. com • Childhood Asthma Control test (C - Act) • Asthma Control Questionnaire (ACQ) – www. qoltech. co. uk/asthma 1. htm • Asthma Therapy Assessment Questionnaire (ATAQ) – www. ataqinstrument. com • Asthma Control Scoring System
Asthma Treatments • Classified into Controllers and Relievers • Controllers – medications to be taken on daily long term basis. • Relievers – medications to be used on as-needed basis to relieve symptoms quickly.
• Asthma treatment can be administered in different ways – inhaled, oral, or by injection. • Advantage of inhaled therapy - drugs are delivered directly into the airways, producing higher local concentrations with significantly less risk of systemic side effects. • Inhaled medications for asthma are available as pressurized MDIs, DPIs, soft mist inhalers and nebulized or ‘wet’ aerosols. • CFC inhaler devices are being phased out due to the impact of CFCs upon the atmospheric ozone layer, and are being replaced by HFA devices.
• Choosing an inhaler device for children with asthma *Age group Preferred device Alternative device Pressurized metered-dose inhaler Younger than 4 years plus dedicated spacer with face Nebulizer with face mask Pressurized metered-dose inhaler 4 -5 years plus dedicated spacer with Nebulizer with mouthpiece Dry powder inhaler or breath actuated pressurized metered. Older than 6 years dose inhaler or pressurized Nebulizer with mouthpiece metered-dose inhaler with spacer with mouthpiece *Based on efficacy of drug delivery, cost effectiveness, safety, ease of use, and convenience. GINA 2009
Asthma management and prevention • The goals for successful management of asthma are 1. Achieve and maintain control of symptoms 2. Maintain normal activity levels, including exercise 3. Maintain pulmonary function as close to normal as possible 4. Prevent asthma exacerbations 5. Avoid adverse effects from asthma medications 6. Prevent asthma mortality
Five interrelated components of therapy are required to achieve and maintain control of asthma- 1. Develop Patient/Doctor partnership 2. Identify and reduce exposure to risk factors 3. Assess, treat, and monitor asthma 4. Manage asthma exacerbations 5. Special considerations
Develop Patient/Doctor partnership • Effective management of asthma requires the development of a partnership between the person with asthma and the health care team. • Patients can learn to – 1. Avoid risk factors 2. Take medications correctly
3. Understand the difference between controller and reliever medications 4. Monitor their status using symptoms and, if relevant, PEF 5. Recognize signs that asthma is worsening and take action 6. Seek medical help as appropriate
• Education should be integral part of all interactions between health care professional and patients. • Using variety of methods such as discussions, demonstrations, written materials, group classes, video/audio tapes, dramas and patient support groups helps reinforce educational messages. • Health care professional and patients should prepare a written personal asthma action plan that is medically appropriate and practical. • Additional self-management plans can be found on – 1. www. asthma. org. uk 2. www. nhlbisupport. com/asthma/index. html 3. www. asthmaz. co. nz
Identify and reduce exposure to risk factors - • Measures to prevent the development of asthma and asthma exacerbations by avoiding or reducing exposure to risk factors should be implemented wherever possible. • Reducing patients exposure to some categories of risk factors improves the control of asthma and reduces medication needs.
Assess, Treat and Monitor Asthma – • The goal of asthma treatment can be reached in most patients through a continuous cycle that involves – assessing, treating and monitoring asthma. • Each patient should be assessed to establish his/her current treatment regimen, adherence to the current regimen, and level of asthma control. • Each patient is assigned to one of five treatment steps. • At each treatment step, reliever medication should be provided for quick relief of symptoms as needed.
• Inhaled medications are preferred because they deliver drugs directly to the airways where they are needed, resulting in potent therapeutic effects with fewer systemic side effects. • Inhaled medications for asthma are available as pressurized MDIs, breath actuated MDIs, DPIs and nebulizers. • Spacer devices make inhalers easier to use and reduce systemic absorption and side effects of ICS. • Patients should be demonstrated about the use of devices.
• Monitoring is essential to maintain control and establish the lowest step and dose of treatment to minimize cost and maximize safety. • If asthma is not controlled, step up the treatment. Improvement is generally seen within 1 month. • If asthma is partly controlled, consider stepping up treatment, depending more effective options available, safety and cost of possible treatment and patient’s satisfaction with the level of control achieved. • If controlled asthma is maintained for at least 3 months, step down with a gradual, stepwise reduction in treatment. The goal is to decrease treatment to the least medication necessary to maintain control.
Asthma management approach based on control for children 5 years and younger Asthma education, Environmental approach, and as needed rapid acting beta -agonists Controlled on as needed rapid Partly controlled on as needed acting beta 2 -agonists rapid acting beta 2 -agonists Uncontrolled or only partly controlled on low - dose inhaled glucocorticosteroid Controller options Continue as needed rapid acting Low – dose inhaled Double Low – dose inhaled beta 2 -agonists glucocorticosteroid Low – dose inhaled Leukotriene modifier glucocorticosteroid plus Leukotriene modifier
To summarize… Diagnosis • Asthma is an inflammatory illness • Diagnosis of asthma is clinical, and relies on history • All asthma does not wheeze • In children < 3 yrs, WALRI is an important differential diagnosis • 2 out of 3 children outgrow their asthma • A family history of asthma / atopy increases risk of asthma
To summarize… Long term management • Patient education is a very important part of asthma management • Drugs control, but do not cure asthma • Clinical grading over time, decides long term management plan • Mild intermittent asthma does not merit controllers • Inhaled steroids are mainstay of long term asthma management • Treatment should be stepped up or stepped down depending upon patient response