CHILDHOOD ASTHMA

1. CHILDHOOD ASTHMA Dr. KANUPRIYA CHATURVEDI

2. What is Asthma ? • Chronic disease of the airways that may cause • Wheezing • Breathlessness • Chest tightness • Nighttime or early morning coughing • Episodes are usually associated with widespread, but variable, airflow obstruction within the lung that is often reversible either spontaneously or with treatment.

3. Potential Asthma Triggers • Allergens • Infections • Exercise • Abrupt changes in the weather • Exposure to airway irritants, such as tobacco smoke

4. Asthma Exacerbations • Recurrent asthma episodes, involving • Shortness of breath • Coughing • Wheezing • Chest pain or tightness • Range in severity from • Mild intermittent • Severe persistent

5. Burden of Asthma • Increases risk for early death • Compromises child’s quality of life • Affects family’s quality of life • Increased costs associated with Increased utilization of health care

6. Asthma and Quality of Life • Most common cause of school absence • An average of 9.7 days per year for asthma • Most prevalent cause of childhood disability (long-term reduction in ability to do normal activities) • In 1994-95, 1.4% of U.S. children experienced some disability due to asthma • This is 21% of all children with asthma • SES disadvantage doubles rate of disability • Children with asthma have higher rates of social and emotional problems

7. Epidemiology of Asthma • Asthma is the most common chronic disease among children • It has increased at epidemic rates since the early 1980s • Most common cause of ED visits, hospitalization and missed school days • In past 2 decades, African American children had 2-4 times more ED visits than other races • Studies show a rise in worldwide prevalence • Seems to be more prevalent in affluent nations

8. What Accounts for this Epidemic? • Etiology of asthma is due to the interaction of environmental and genetic factors • Atopy, the genetically inherited susceptibility to asthma, cannot account for epidemic. • Probably NOT due to outdoor air quality • Indoor air contaminants may be a factor • Tighter construction trapping contaminants. • Children spending more time indoors.

9. Current Asthma Prevalence for Youth by Race/Ethnicity, Ages 5-17, 2005-2007 in USA 10.1% Overall

10. Asthma Disparities Among U.S. Children • Low-income populations, minorities, and children living in inner cities experience more ED visits, hospitalizations, and deaths due to asthma than the general population. • The burden of asthma falls disproportionately on non-Hispanic black, American Indian/Alaskan Native and some Hispanic populations.

11. Variability in Asthma Prevalence • By gender • Males 0 – 17 years are more likely than girls to have asthma or experience an asthma attack • By race/ethnicity • Higher for Black non-Hispanic children • Higher for Hispanic children

12. Population Disparities in Asthma in USA • Current asthma prevalence is higher among • children than adults • boys than girls • women than men • Asthma morbidity and mortality is higher among • African Americans than Caucasians.

13. Asthma in Children in India • Groups 6 - 7 Yrs 13-14 Yrs • Wheeze 5.6 % 6.0% (0.8 - 14.6) (1.6 - 17.8) • > 4 attacks 1.5% 1.6% (0.1 - 4.7) (0.5 - 3.5) • Night Cough 12.3% 14.1% (3.3 - 27) (3.8 - 32.2) • Ever had Asthma 3.7% 4.5% (1.0 - 14.4) (1.12.4) Shah, Amdekar, Mathur, IJMS,6,2000,213-22

14. Urban/Rural Difference in Asthma Prevalence in India

15. Prevalence of Asthma in Rural Children in India

16. Etiology and Pathogenesis

17. Early Childhood Risk Factors • Parental Asthma • Allergy • Atopic dermatitis • Allergic rhinitis • Food allergy • Inhalant allergen sensitization • Food allergen sensitization

18. Contd. • Severe lower respiratory tract infections • Wheezing apart from colds • Male gender • Low birth weight • Tobacco smoke exposure • Exposure to chlorinated swimming pools • Possible use of Acetaminophen

19. Asthma Triggers • Common Viral infections • Aeroallergens • Animal dander • Dust mite • Cockroaches • Molds • Pollen

20. Contd. • Air pollutants • Ozone Sulfur dioxide Particulate matter Dust Tobacco smoke • Strong/ noxious fumes • Cold, dry air • Exercise

21. Contd. • Occupational exposures • Farm and barn exposure • Formaldehyde, paint fumes • Crying, laughter, hyperventilation • Co morbid conditions: Rhinitis, Sinusitis

22. Clinical Manifestations Symptoms: • Intermittent dry cough • Expiratory wheezing • Shortness of breath • Chest tightness • Chest pain • Fatigue • Difficulty keeping up with peers in physical activities

23. Contd. Signs: • Expiratory wheezing • Prolonged expiratory phase • Decreased breath sounds • Crackles/ rales • Accessory muscle use • Nasal flaring • Absence of wheezing in severe cases • Pulses paradoxus

24. Lab Findings Spirometry: • Feasible in children >6 years of age • Monitoring Asthma and efficacy of treatment • Measures FVC, FEV 1 and FEV1/FVC Ratio • Normal values for children available on the basis of height, gender and ethnicity.

25. Contd. Airflow Limitation: • Low FEV1 • FEV1/ FVC ratio < 0.80 Bronchodilator response to β-agonist: • Improvement in FEV1 ≥ 12% Exercise challenge: • Worsening of FEV1 ≥ 15% Daily peak flow or FEV1 AM-PM variation ≥ 20%

28. Radiology: • Often normal • Hyperinflation • Helpful in identifying masqueraders

29. Treatment

30. Regular assessment and Monitoring • Asthma severity: Directs initial level of therapy Determined at the time of diagnosis Categories: Intermittent, Persistent Determined by the most severe level of symptoms • Asthma control: Important for adjusting therapy • Regular Clinic visits every 2-6 weeks until good control established • Two or more Asthma check ups per year for maintaining Asthma control

35. Managing Asthma: Asthma Management Goals Achieve and maintain control of symptoms Maintain normal activity levels, including exercise Maintain pulmonary function as close to normal levels as possible Prevent asthma exacerbations Avoid adverse effects from asthma medications Prevent asthma mortality

36. Managing Asthma: Asthma Action Plan Develop with a physician Tailor to meet individual needs Educate patients and families about all aspects of plan Recognizing symptoms Medication benefits and side effects Proper use of inhalers and Peak Expiratory Flow (PEF) meters

37. Managing Asthma:Indications of a Severe Attack Breathless at rest Hunched forward Speaks in words rather than complete sentences Agitated Peak flow rate less than 60% of normal

38. Managing Asthma:Things People with Asthma Can Do Have an individual management plan containing Your medications (controller and quick-relief) Your asthma triggers What to do when you are having an asthma attack Educate yourself and others about Asthma Action Plans Environmental interventions Seek help from asthma resources Join an asthma support group

39. Contd. Asthma action plan for management of exacerbation • Regular follow up visits • Monitor lung functions annually • Improve adherence to treatment

40. Control of Factors Contributing to Severity • Eliminate/ reduce environmental exposures • Tobacco smoke elimination/ reduction • Allergen exposure elimination/ reduction • Treat co morbid conditions: Rhinitis, Sinusitis, GER

41. Step-up, Step-down Approach • Initiate with higher level controller therapy • Step-down, once good control is achieved • If child has had well controlled asthma for at least 3 months, consider decreasing dose or number of controller medications. • Step up for poorly controlled asthma

42. Long Term Controller Medications • All persistent Asthmatics require daily controller medications

43. Inhaled Corticosteroids • Treatment of choice for persistent Asthma • Improve lung function • Reduce use of rescue medicines • Reduce ED visits, hospitalizations • May lower the risk of death due to Asthma

44. Systemic Corticosteroids • Used mainly in treatment of exacerbations • Rarely in patients with severe disease • Common: Prednisolone, Prednisone, Methyprednisolone • When used in long term, cause adverse effects

45. Long Acting β-Agonists • Salmeterol, Formoterol • Not used as monotherapy • Major role as ad-on agents with ICS • LABA use should be stopped once optimal Asthma control is achieved

46. Leukotriene Modifying Agents • Leukotriene synthesis inhibitor: Zileuton (Not approved for children < 12 years) • Leukotriene Receptor Antagonists: Montelukast, Zafirlukast

47. Non-steroidal Anti- inflammatory Agents • Cromolyn, Nedocromil • Inhibit exercise induced bronchospasm • Can be used in combination of SABA for exercise induced bronchospasm

48. Theophyllin • Can reduce Asthma symptoms and need for SABA use • Narrow therapeutic window • Not used as first line anymore • May be used in corticostroid dependent children • Can cause cardiac arrhythmias, seizures and death

49. Omalizumab • Anti IgE monoclonal antibody • Blocks IgE mediated allergic response • Approved for children > 12 years with moderate to severe Asthma • Given sub cutaneously every 2-4 weeks

50. Rescue Drugs • Short Acting Beta Agonists: Albuterol, Levalbuterol, Terbutaline, Pirbuterol • Drugs of choice for acute Asthma symptoms • Overuse may be associated with increased risk of death • Use of at least 1 MDI/ month or at least 3 MDI/ year indicates inadequate Asthma control • Anticholinergic Agents: Ipratropium bromide Used in combination with Albuterol