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ASTHMA IN CHILDHOOD

ASTHMA IN CHILDHOOD. dr . Ery Olivianto, SpA Dr. dr . Wisnu Barlianto, SpA (K) Prof . D r . d r. HMS. Chandra K usuma , SpA (K) Child Health Department Faculty of Medicine Brawijaya University Saiful Anwar General Hospital. Holgate ST. J Allergy Clin Immunol 2011;128:495-505.

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ASTHMA IN CHILDHOOD

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  1. ASTHMA IN CHILDHOOD dr. Ery Olivianto, SpA Dr. dr. Wisnu Barlianto, SpA(K) Prof. Dr. dr. HMS. Chandra Kusuma, SpA(K) Child Health Department Faculty of Medicine Brawijaya University Saiful Anwar General Hospital

  2. Holgate ST. J Allergy ClinImmunol 2011;128:495-505

  3. Definitions • Asthma is a chronic inflammatory disorder of the airways associated with airway hyperresponsiveness and airflow obstruction that is often reversible either spontaneously or with treatment WAO. White Book on Allergy, 2011

  4. Epidemiology • World Health Organisationestimate 300 million individuals have asthma worldwide • Current rising trends this will reach 400 million by 2025 • Approximately 250,000 people die prematurely each year from asthma • Prevalence in the 13-14 year olds ranging from 2.1% to 32.2% • Prevalence in the 6-7 year olds was similar to those in the older children with prevalence of wheezing varying from 4.1%-32.1% • Indonesia: 2.6% - 17.4% WAO. White Book on Allergy, 2011 PedomanNasionalAsmaAnak, 2004

  5. Bacharier LB, et al,. Allergy 2008: 63: 5–34

  6. Inflammatory and immune cells involved in asthma Barnes PJ. Nat Rev Immunol 2010;8:183-192

  7. Asthma inflammatory cascade Bernstein D. Pediatric for Medical Students 3rd Ed, 2011

  8. Asthma phenotypes Bacharier LB, et al,. Allergy 2008: 63: 5–34

  9. Infantile asthma • Asthma affecting infant aged < 2 years • 3 or more episodes of marked expiratory wheezing within the previous 6 months Bacharier LB, et al,. Allergy 2008: 63: 5–34

  10. Hypothetical yearly prevalence for recurrent wheezing phenotypes in childhood Leung DM. Pediatric Allergy 2nd Ed, 2010

  11. Modified Asthma Predictive Index for children (Tucson Children's Respiratory Study, Tucson, Arizona). Through a statistically optimized model for 2- to 3-year-old children with frequent wheezing in the past year, one major criterion or two minor criteria provided 77% positive predictive value and 97% specificity for persistent asthma in later childhood Leung DM. Pediatric Allergy 2nd Ed, 2010

  12. Asthma phenotypes in children > 2 years Bacharier LB, et al,. Allergy 2008: 63: 5–34

  13. Entry point of asthma diagnosis: Recurrent Wheezing and/or Chronic Recurrent Cough PedomanNasionalAsmaAnak, 2004

  14. Diagnosis Cough and/or Wheeze Clinical history Physical examination Mantoux test • Indeterminate features or suggestive • of alternative diagnosis • Neonatal onset • Failure to thrive • Chronic infection • Vomiting/choking • Focal lung or CVS signs • Suggestive of asthma: • Episodic • Nocturnal • Seasonal • Exertional • Atopic • If possible frequent peak flow • measurements : • Reversibility (20%) • Variability (20%) • Consider • Chest and sinus x rays • Lung function • Bronchial challenge and/or • Bronchodilator response

  15. ….. Consider : • Sweat test • Immune function • Ciliary & Reflux studies Bronchodilator response No response Response WD/ Asthma - ve + ve Assess severity and etiology Chest x ray if more than mild episodic disease Alternative diagnosis and treatment Trial of antiasthma treatment Consider asthma as an associated problem Not asthma Review diagnosis and compliance if poor response to treatment PedomanNasionalAsmaAnak, 2004

  16. Differential diagnosis of wheezing in children Nishimuta T. AllergologyInternational 2011;60:147-169

  17. Bernstein D. Pediatric for Medical Students 3rd Ed, 2011

  18. Chronic Infrequent episodic asthma Frequent episodic asthma Persistent asthma Acute Mild attack Moderate attack Severe attack Classification of Asthma in Children PedomanNasionalAsmaAnak, 2004

  19. Clinical parameters and lung function Infrequent episodic asthma Frequent episodic asthma Persistent asthma Freq of attacks < 1x /month > 1x /month Daily Duration of attacks < 1 week >1 week Daily Between episodes No symptoms Symptoms (+) Frequent nocturnal symptoms Sleep and activity Normal May affect Affect Physical exam Normal May affect Abnormal Controller No need Steroid/combination Steroid/combination Lung function (No attacks) PEF/FEV1 >80% PEF/FEV1 60-80% PEF/FEV1 <60% Variability 20-30% Variability (attacks) >15% > 30% > 50% Classification of disease PedomanNasionalAsmaAnak, 2004

  20. Chronic asthma Long term management Reliever & Controller Acute asthma Attack management Reliever Asthma managements PedomanNasionalAsmaAnak, 2004

  21. Chronic asthma Long term management Algorithm diagnosis & treatment Acute asthma Attack management Algorithm attack management Asthma managements PedomanNasionalAsmaAnak, 2004

  22. Controller drug to control asthma ie attack or symptom not easily emerge Inhaled steroid LABA, ALTR Reliever drug to relieve asthma attack orsymptoms -agonist Xanthine anticholinergic Asthma medication PedomanNasionalAsmaAnak, 2004

  23. Long term treatment 2-agonistor theophylline inhaled/oral intermittently Infrequent Episodic Symptoms 6-8 weeks >3 doses / week 3-6 months Evaluation Add sodium cromoglicate 6-8 weeks response (-) 3-6 months response (+) Frequent episodic Symptoms Replace with low dose inhaled steroids Continue 2-a or/and theophylline inhaled/oral intermittently 6-8 weeks response (-) 3-6 months response (+)

  24. 6-8 weeks respons (-) 3-6 months respons (+) • Consider : • Long acting 2-agonists, or • Slow release 2-agonists, or • Slow release theophyllines Persistent Symptoms 6-8 weeks respons (-) 3-6 months respons (+) Increase dose of inhaled steroid 3-6 months respons (+) 6-8 weeks respons (-) Add oral steroids PedomanNasionalAsmaAnak, 2004

  25. Levels of Asthma Control in Children 5 years or youngers Controlled Characteristic Partly controlled (any measure present in any week) Uncontrolled (>3 features of partly con- trolled present in any week) >Twice a week >Twice a week Daytime symptoms: wheezing, cough, difficult breathing None (less than twice/week, typically for short periods of the order of minutes and rapidly relieved by use of a rapid-acting bronchodilator) (typically last minutes or hours or recur, but partially or fully relieved by a rapid-acting bronchodilator (typically for short periods of the order of minutes and rapidly relieved by use of a rapid-acting bronchodilator None (child is fully active, plays and runs without limitation or symptoms) Any (cough, wheeze or difficulty breathing,during exercise, play or laughing) Any (cough, wheeze or difficulty breathing,during exercise, play or laughing) Limitations of activities Any Any Nocturnal symptoms or awakening None (including no nocturnal coughing during sleep) (coughs during sleep or wakes with cough, wheezing, and/or difficult breathing) (coughs during sleep or wakes with cough, wheezing, and/or difficult breathing) Need for reliever/rescue > 2 days/week > 2 days/week < 2 days/week GINA, 2009

  26. Assessment of severity

  27. PedomanNasionalAsmaAnak, 2004

  28. Acute asthma algorithm Clinic/ER Asses attack severity • 1st management • nebulitation-agonis 3x, 20 min interval • 3rd nebulitation + anticholinergic • Mild attack • (nebulization 1x, • complete response) • persist 1-2 hr: • discharge • symptom reappear: • Moderate attack • Moderate attack • (nebulization 2-3x, • partial response) • give O2 • asses: Moderate – • ODC • IV line • Severe attack • (nebulization 3x, • no response) • O2 from the start • IV line • asses: Severe - hospitalized • CXR

  29. Discharge • give -agonist • (inhaled/oral) • routine drugs • viral infection: • oral steroid • Outpatient clinic in • 24-48 hours • One Day Care (ODC) • Oxygen therapy • Oral steroid • Nebulized / 2 hour • Observe 8-12 hours, • if stable discharge • Poor response in 12h, •  admission • Admission room • Oxygen therapy • Treat dehydration and • acidosis • Steroid IV / 6-8 hours • Nebulized / 1-2 hours • Initial aminophylline IV, • then maintenance • Nebulized 4-6x  • good response per 4-6 h • If stable in 24 hours  • discharge • Poor response  ICU • Notes: • In severe attack, directly use -agonist + anticholinergic • If nebulizers not available, use adrenalin SC 0.01 ml/kg/timeswith maximal dose 0.3 ml/times • Oxygen therapy 2-4 l/min should be early treatment in moderate • and severe attack PedomanNasionalAsmaAnak, 2004

  30. Non responsive • Dehydration: • inadequate intake, the longer the more • evaluate: clinically, laboratory; overcome • Acidosis:correction • Atelectasis & mucus plug: CXR mandatory; physiotherapy

  31. Non responsive • Excessive use of ß-agonist  down regulation of ß-agonist receptors  tachyphylaxis, subsensitivity Systemic steroid • reduce the edema • up regulates  more ß-agonist receptors  sensitive again to ß-agonist drugs

  32. Choosing an Inhaler Device A pressurized metered-dose inhaler (MDI) with a valved spacer (with or without a face mask, depending on the child’s age) is the preferred delivery system GINA, 2009

  33. Jet nebulizer

  34. Ultrasonic nebulizer

  35. References

  36. References

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