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ASTHMA : MANAGEMENT A ND PREVENTION IN CHILDREN. Lecturer: prof. Galyna Pavlyshyn. What is Asthma?. Disease of chronic inflammatory disorder of the airways Characterized by: Airway inflammation Airflow obstruction Airway hyperresponsiveness. Cookson W. Nature 1999; 402S: B5-11.

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    2. What is Asthma? • Disease of chronic inflammatory disorder of the airways • Characterized by: • Airway inflammation • Airflow obstruction • Airway hyperresponsiveness Cookson W. Nature 1999; 402S: B5-11

    3. DEFINITION OF ASTHMA Asthma is a chronic inflammatory disorder of the airways. The chronic inflammation is associated with airwayhyperresponsiveness;- airwaysbecomeobstructed and airflow is limited (by bronchoconstriction, mucus plugs, increased inflammation) when they are exposed to various risk factors. Asthma causes recurring episodes of wheezing breathlessness chest tightness coughing particularly at night or in the early morning.

    4. DEFINITIONAsthma is a disorder defined by its clinical, physiologicaland pathological characteristics The predominant featureof the clinical history is episodic shortness of breath,particularly at night, often accompanied by cough.Wheezing defined on auscultation of the chest is themost common physical finding. The main physiological feature of asthma is episodic airwayobstruction characterized by expiratory airflow limitation. The dominant pathological feature is airway inflammation,sometimes associated with airway structural changes.

    5. Pathophysiology • Early Acute - these changes cause bronchial hyperresponsiveness and obstruction. Airway obstruction increases resistance to airflow and decreases expiratory flow. Impaired expiration causes hyperinflation distal to the obstruction and increases the work of breathing. • Late Asthma Response occurs in cases of significant allergen exposure. Recurrence of symptoms appears in 4-12 hours after the initial attack due to persistent cellular activation. It can be more severe than the initial attack. • Untreated inflammation can cause long term airway damage that is irreversible (airway remodeling).

    6. What are the Triggering Factors? • Domestic dust mites • Animal with fur • Air pollution • Cockroaches • Pollen • Tobacco smoke • Occupational irritants

    7. Triggering Factors • Respiratory (viral) infections • Chemical irritants • Strong emotional expressions • Drugs ( aspirin, beta blockers)

    8. Host factors Genetic predisposition Atopy Airway hyperresponsiveness Gender Race/Ethnicity Environmental factors Indoor allergens Outdoor allergens Occupational sensitizer Environmental factors Tobacco smoke Air pollution Respiratory infections Socioeconomic status Family size Diet and drugs Obesity Potential Risk Factors 1Masoli M, et al. The Global Burden of Asthma: Executive Summary of the GINA Dissemination Committee Report. Allergy 2004; 59: 469-78.

    9. DIAGNOSING ASTHMA - Not EasyCLINICAL DIAGNOSIS • Clinical diagnosis supported by the certain historical, physical and laboratory findings • History of episodic symptoms of airflow obstruction (breathlessness, wheezing, chest tightness and COUGH)-response to therapy! • Episodic symptoms after an incidental allergen exposure; • Seasonal variability of symptoms; • Positive family history of asthma and atopic disease.

    10. DIAGNOSINGASTHMA Consider asthma if any of the following signs or symptoms are present: • Frequent episodes of wheezing – more than once a month • Activity-induced cough or wheeze • Cough particularly at night during periods without viral infections • Absence of seasonal variation in wheeze • Symptoms that persist after age 3 • The child’s colds repeatedly “go to the chest” or take more than 10 days toclear up • Symptoms improve when asthma medication is given

    11. DIAGNOSINGASTHMA Symptoms occur or worsen in the presence of: • • Animals with fur • • Aerosol chemicals • • Changes in temperature • • Domestic dust mites • • Drugs (aspirin, beta blockers) • • Exercise • • Pollen • • Respiratory (viral) infections • • Smoke • • Strong emotional expression

    12. DIAGNOSINGASTHMA • Dyspnea, airflow limitation (wheeze), hyperinflation are more likely to be present if patients are examined during symptomatic periods. • Physical signs reflecting severity: cyanosis, drowsiness, difficulty speaking, tachycardia, hyperinflated chest, use of accessory muscles, and intercostal recession.

    13. DIAGNOSINGASTHMA • Physical examination • Respiratory rate; • Work of breathing; • Aeration • Degree of wheezing • Suppotive data: • Pulse oximetry (oxygen saturation); • PEFR – peak expiratory flow rate • Chest radiograph;

    14. Measurements of lung function • Spirometryisthepreferredmethodofmeasuringairflowlimitationanditsreversibilitytoestablish a diagnosisofasthma. • Forced expiratory volume in 1 second (FEV1) - anincreaseinFEV1of ≥ 12% (or ≥ 200 ml)afteradministrationof abronchodilatorindicatesreversibleairflowlimitationconsistentwithasthma.

    15. The Peak Flow Meter

    16. Note Peak Flow Numbers Diary cards to record symptoms and PEF (in children older than 5 years) • Keeping a peak flow diary will help you predict and prevent asthma attacks • Record peak flow numbers daily, every morning before taking control medicine(s) • Watch for trends in symptoms

    17. Classification of Asthma Traditionally, the degree of symptoms, airflow limitation, and lung functionvariability have allowed asthma to be classified by severity (Intermittent, Mild Persistent, Moderate Persistent, Severe Persistent) • Mild Intermittent Asthma • Symptoms less than once a week • Brief exacerbations • Nocturnal symptoms not more than twice a month • FEV1 or PEF ≥ 80% predicted • PEF or FEV1 variability < 20% • Mild Persistent Asthma • Symptoms more than once a week but less than once a day • Exacerbations may affect activity and sleep • Nocturnal symptoms more than twice a month • FEV1 or PEF ≥ 80% predicted • PEF or FEV1 variability < 20 – 30%

    18. Classification of Asthma • Moderate Persistent Asthma • Symptoms daily • Exacerbations may affect activity and sleep • Nocturnal symptoms more than once a week • Daily use of inhaled SABA (short-acting 2-agonist) • • FEV1 or PEF 60-80% predicted • • PEF or FEV1 variability > 30% • Severe Persistent Asthma • Symptoms daily • Frequent exacerbations • Frequent nocturnal asthma symptoms • Limitation of physical activities • • FEV1 or PEF ≤ 60% predicted • • PEF or FEV1 variability > 30%

    19. Severity of Asthma Exacerbations

    20. TREATMENTAsthma Medications • Bronchodilators (Sympathomimetics) • Bronchodilators (Anticholinergics) • Inhaled Corticosteroids • Biologic Response Modifiers (Monoclonal Antibodies) • Leukotriene Receptor Antagonists • Mast Cell Stabilizers • Methylxanthene Derivatives

    21. TREATMENTMILD ASTHMA • Frequent SABA are the standard of care • Use of NEB or MDI-S are each reasonable • Most will require just 1-2 treatment • Those who are SABA unresponsive may benefit from systemic corticosteroids • Most will be discharged home

    22. Management Moderate Asthma • Albuterol NEB or MDI-S • Prednisone 2 mg/kg/d IM or NEB • Atrovent ↓ No improvement Marked improvement Slight improvement Hospitalize Discharge home • Continue albuterol every 30-45 min Disposition

    23. Management Severe Asthma • Monitor pulse, RR, oxygen saturation ↓ Supplemental oxygen 0.15mg/kg Albuterol by nebulization Atrovent Poor response Good response Terbutaline or epinephrine IM Methylprednisolone 1-2 mg/kg IV Albuterol |NEB 50-75 mg/kg IV Magnesii sulfate Continue with approach to moderate asthma

    24. Acute severe asthmatic episode (status asthmaticus) • Treatment goals are the following: • Correction of significant hypoxemia with supplemental oxygen: In severe cases, alveolar hypoventilation requires mechanically assisted ventilation. • Rapid reversal of airflow obstruction by using repeated or continuous administration of an inhaled beta2-agonist; • Early administration of systemic corticosteroids ( oral prednisone or intravenous methylprednisolone) is suggested in children with asthma that fails to respond promptly and completely to inhaled beta2-agonists. • Reduction in the likelihood of recurrence of severe airflow obstruction by intensifying therapy: Often, a short course of systemic corticosteroids is helpful.

    25. Asthma attacks require prompt treatment • Oxygen is given at health centers or hospitals if the patient is hypoxemic • Inhaled rapid-acting b2-agonists in adequate doses are essential • Oral glucocorticosteroids (0.5 to 1 mg of prednisolone/kg or equivalentduring a 24-hour period) introduced early in the course of a moderateor severe attack help to reverse the inflammation and speed recovery. • Methylxanthines are not recommended if used in addition to high dosesof inhaled 2-agonists. However, theophylline can be used if inhaled2-agonists are not available.

    26. Controller Medications • Inhaled corticosteroids - ICS • Systemic corticosteroids - SCS • Leukotriene modifiers • Sodium cromoglycate (cromolyn sodium) • Nedocromil sodium • Methylxanthines • Long-acting inhaled 2-agonists, • Long-acting oral 2-agonists.

    27. Classification of asthmaby level of control is more relevant and useful

    28. Mild persistent asthma • Long-term control:Anti-inflammatory treatment in the form of low-dose inhaled corticosteroids or nonsteroidal agents (cromolyn, nedocromil) is preferred. • Some evidence suggests that leukotriene antagonists may be useful as first-line therapy in children. Quick relief: Short-acting bronchodilators in the form of inhaled beta2-agonists (SABA) should be used as needed for symptom control. Use of short-acting inhaled beta2-agonists on a daily basis or increasing use indicates the need for additional long-term therapy.

    29. Moderate persistent asthma • Long-term control: Daily anti-inflammatory treatment in the form of inhaled corticosteroids (medium dose) is preferred. Otherwise, low- or medium-dose inhaled corticosteroids combined with a long-acting bronchodilator or leukotriene antagonist can be used, especially for the control of nocturnal or exercise-induced asthmatic symptoms. • Quick relief: Short-acting bronchodilators in the form of inhaled beta2-agonists (SABA) should be used as needed for symptom control. The use of short-acting inhaled beta2-agonists on a daily basis or increasing use indicates the need for additional long-term therapy.