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Asthma in Children Asma in Kinders. P rof Sharon Kling Stellenbosch University & Tygerberg Children’s Hospital. Outcomes / Uitkomste. Clinical definition How common is asthma? How do we diagnose asthma in children? Other causes of wheezing in children

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asthma in children asma in kinders

Asthma in ChildrenAsma in Kinders

Prof Sharon Kling

Stellenbosch University &

Tygerberg Children’s Hospital

outcomes uitkomste
Outcomes / Uitkomste
  • Clinical definition
  • How common is asthma?
  • How do we diagnose asthma in children?
  • Other causes of wheezing in children
  • Management of asthma in children
  • Kliniesedefinisie
  • Hoe algemeen is asma?
  • Hoe diagnoseeronsasma in kinders?
  • Ander oorsake van fluitbors in kinders
  • Hantering van asma in kinders
children are not small adults
Children are NOT small adults!
  • Different anatomy
  • Congenital abnormalities: causes of wheezing
  • Different physiology
  • Growth
  • Drug handling
  • Anatomieverskil
  • Kongenitaleafwykings: oorsake van fluitbors
  • Fisiologieverskil
  • Groei
  • Hantering van middels
the global burden of asthma die globale las van asma
The Global Burden of AsthmaDie Globale Las van Asma
  • Very common
  • 300 million people worldwide
  • More prevalent in western lifestyles and urban areas
  • Asthma mortality is also increasing and is alarmingly high
  • Baiealgemeen
  • 300 miljoenmensewêreldwyd
  • Meer algemeenwaarwesterseleefstyl en stedelike areas
  • Asmamortaliteitvermeerder en is baiehoog
angelo s story
Angelo’s story
  • Presented to allergy clinic at age 10 years: asthma
  • Brother Julio had died 6 months previously after an acute asthma attack
  • Julio had been using up a full Ventolin® asthma pump every week – obtained from GP and pharmacy

Names changed to preserve confidentiality

angelo 2
Angelo 2
  • How would you feel if you were Angelo?
  • What problems do you identify in this short scenario?
definition definisie
Definition / definisie
  • Asthma is a lung disease with:
    • Airway obstruction that is reversible(spontan-eouslyor with treatment);
    • Airway inflammation; and
    • Increased airway responsiveness to a variety of stimuli
  • Asma is ‘n long-siekte met:
    • Lugwegobstruksiewatomkeerbaar is (spon-taan of nabehandeling);
    • Lugweginflammasie; en
    • Verhoogdelugwegresponsiwiteittot ‘n verskeidenheid van stimuli
risk factors risikofaktore
Risk factors / Risikofaktore
  • Genetic / Geneties
  • Allergen exposureAllergeenblootstelling
  • Environmental exposuresOmgewingsblootstellings
clinical definition of asthma kliniese definisie van asma
Clinical Definition of AsthmaKlinieseDefinisie van Asma
  • Recurrent wheezing with or without a cough Herhaalde fluitbors met of sonder hoes
  • That respondsto a bronchodilatorRespondeer op ‘n brongodilator
diagnosis diagnose
Diagnosis / Diagnose
  • History / Geskiedenis
  • Examination / Ondersoek
  • Special investigations / Spesialeondersoeke
    • Lung functions / longfunksies
    • Allergy tests / allergietoetse
    • Exclude other causes of wheezingSkakelanderoorsake van fluituit
history geskiedenis 1
History / Geskiedenis 1
  • Repeated episodes of wheezing or tight chest
  • Cough, espat night
  • Early morning waking
  • Wheeze or cough after physical activity
  • Symptoms relieved when bronchodilator is used
  • Herhaalde episodes fluit- of toebors
  • Hoes, veral snags
  • Word vroegoggendwakker
  • Fluit of hoes naoefening
  • Simptomeverbeternabrongodilator
history geskiedenis 2
History / Geskiedenis 2
  • Symptoms worse during certain seasons
  • Triggers that worsen asthma
    • Allergens
    • Irritants
  • Simptomeergertydenssekereseisoene
  • Snellerfaktorewatasmavererger
    • Allergene
    • Prikkelendemiddels
history geskiedenis 3
History / Geskiedenis 3
  • History of other allergic diseases
    • Allergic rhinitis
    • Eczema
    • Allergic conjunctivitis
  • Family history of asthma or allergy
  • Geskiedenis van anderallergiesetoestande
    • Allergieserinitis
    • Ekseem
    • Allergiesekonjunktivitis
  • Familiegeskiedenis van asma of allergie
examination ondersoek1
ExaminationOndersoek
  • Growth / groei
  • Allergic appearance / allergiesevoorkoms
  • Chest deformities / Borskasdeformiteite
  • Hyperinflation, wheezesHiperinflasie, fluite
  • Other allergic conditionsAnder allergiesetoestande
special investigations spesiale ondersoeke
Special InvestigationsSpesialeOndersoeke
  • Lung function testing (> 6 years)Longfunksietoetse (> 6 jaar)
  • Identify specific allergens Identifiseerspesifiekeallergene
    • Skin prick tests / Velpriktoetse
    • Radioallergosorbent tests (RAST)
  • Exclude other causes of wheezingSkakelanderoorsake van fluituit
differences children and adults verskille kinders en volwassenes
Differences: Children and AdultsVerskille: Kinders en Volwassenes
  • Mimics of asthma
  • Diagnosis in young child difficult
  • More allergy
  • Lung functions difficult in young child
  • Drug delivery systems
  • Safety of medications
  • Toestandewatasmanaboots
  • Diagnose moeilik in jong kind
  • Verhoogdeallergie
  • Longfunksiesmoeilik
  • Lewering van middels
  • Veiligheid van middels
causes of recurrent wheezing in children oorsake van herhaalde fluitbors in kinders
Causes of recurrent wheezing in childrenOorsake van herhaalde fluitbors in kinders
  • Asthma
  • Post-viral wheezing (bronchiolitis)
  • Congenital lung abnormalities
  • TB (lymph nodes obstructing airways)
  • Gastro-oesophageal reflux
  • Cystic fibrosis
  • Immune deficiency
  • Asma
  • Postvirale fluitbors (brongiolitis)
  • Kongenitale long afwykings
  • TB (limfnodeswatlugweëobstrukteer)
  • Gastroesofagealerefluks
  • Sistiesefibrose
  • Immuungebrek
wheezing in the first 6 years of life fluit in die eerste 6 jaar van lewe
Wheezing in the first 6 years of lifeFluit in die eerste 6 jaar van lewe

Post viral/ viraal

Asthma/ asma

Martinez 1995

wheezing studies in children
Wheezing studies in children
  • Many children (about half) will wheeze when young
  • Some of them will outgrow wheezing
  • Some will continue to wheeze
  • Difficult to distinguish these groups
  • Baiejongkinders (omtrent die helfde) salfluitborshê
  • Sommigesal die fluitontgroei
  • Sommigesalvoortgaan met fluitbors
  • Moeilikomteonderskei
exclude other causes of wheezing skakel ander oorsake van fluit uit
Exclude other causes of wheezingSkakelanderoorsake van fluituit
  • Chest X-ray: congenital abnormalities, TB
  • Sweat test: cystic fibrosis
  • Barium swallow, pH study: gastro-oesophagealreflux
  • Tests of immunity
  • Borskasplaat: kongenitaleafwykings, TB
  • Sweettoets: sistiesefibrose
  • Bariumsluk, pH studie: gastroesofagealerefluks
  • Immuuntoetse
management hantering
Management / Hantering
  • Education
  • Avoid allergens
  • Environmental control (cigarette smoke)
  • Avoid triggers
  • Controlasthma symptoms
  • Relieve acute attacks of asthma
  • Opvoeding
  • Vermyallergene
  • Omgewingsbeheer (sigaretrook)
  • Vermysnellers
  • Beheerasmaaanvalle
  • Verligakuteasmaaanvalle
management
Management

Environmental control

Asthma

Education

Medication

management of asthma in children
Management of Asthma in Children

Classify Severity

Institute treatment

Follow-up, assess control

Step therapy up or down

types of medications
Types of Medications
  • Long-term “controller” medicationLangtermyn “kontrolleerder” medikasie
    • Anti-inflammatory, inhaled corticosteroids, e.g. budesonide
  • Quick-relief rescue “reliever” medicationVinnigwerkende “verligter” medikasie
    • Bronchodilator, beta-2 agonists, e.g. salbutamol
step wise management 1
Short acting ß2 agonist (bronchodilator) as necessary (reliever only)Step-wise management 1
  • Step 1: mild intermittent

Modified from BTS SIGN guidelines 2005

step wise management 2
Step 2: Persistent Sx: introduce regular controller Rx

Inhaled steroids – start at dose appropriate to severity of disease (200 – 400 mcg/day, in two divided doses)

Safe ICS dose in children 400 mcg/day

Step-wise management 2

+ Short acting ß2 agonist as necessary

Modified from BTS SIGN guidelines 2005

how to use a metered dose inhaler mdi
How to Use a Metered-dose Inhaler (MDI)

Evaluate inhaler technique at each visit.

Source: “What You and Your Family Can Do About Asthma” by the Global Initiative For Asthma

Created and funded by NIH/NHLBI

slide44

Asthma control

Pharmacological management. Thorax 2003; 58 (Suppl I): i1-i92

if asthma control poor assess as asma beheer swak is evalueer
If asthma control poor, assess:As asmabeheerswak is, evalueer:
  • Is the diagnosis correct?
  • Is the child using the medication? -“adherence”
  • Technique
  • Delivery system ok?
  • Triggers and allergen avoidance?
  • Is diagnose korrek?
  • Gebruik die kind die medikasie?
  • Tegniek
  • Leweringstelsel ok?
  • Snellers en allergeenvermyding?
options for achieving asthma control behandelingsmoontlikhede
Options for achieving asthma controlBehandelingsmoontlikhede
  • Increase inhaled steroid dose
  • Add on other asthma drugs
    • Long-acting ß2 agonist or
    • Leukotriene receptor antagonist or
    • Theophylline sustained release
  • Oral corticosteroids (prednisone)
  • Vermeerderinhalasiesteroïededosering
  • Voeganderasmamiddels by
    • Langwerkendeß2 agonisof
    • Leukotrienreseptorantagonisof
    • Teofillien
  • Oralekortikosteroïede (prednisoon)
important considerations rx belangrike dinge om te oorweeg rx
Important considerations - RxBelangrikedingeomteoorweeg - Rx
  • Severity of asthma
  • Safety of drugs
  • Cost of drugs
  • Availability of drugs
  • Patient’s preference
  • Erns van asma
  • Middelveiligheid
  • Koste van middels
  • Beskikbaarheid van middels
  • Pasiënt se voorkeur
angelo
Angelo
  • Hoe soujyvoel as jy Angelo was?
  • Wat dink jy van Julio se behandeling?
  • Hoe saljy Angelo se asmahanteer?
  • Angelo se moederwil ‘n hondjievirhomkoop. Watterraadsaljyvirhaar gee?
  • How would you feel if you were Angelo?
  • What do you think of Julio’s treatment?
  • How would you manage Angelo’s asthma?
  • Angelo’s mother wants to get him a dog. How would you advise her?
differences children and adults verskille kinders en volwassenes1
Differences: Children and AdultsVerskille: Kinders en Volwassenes
  • Mimics of asthma
  • Diagnosis in young child difficult
  • More allergy
  • Lung functions difficult in young child
  • Delivery systems for Rx
  • Safety of medications
  • Toestandewatasmanaboots
  • Diagnose moeilik in jong kind
  • Verhoogdeallergie
  • Longfunksiesmoeilik
  • Lewering van middels
  • Veiligheid van middels
summary 1
Summary 1
  • Suspect asthma in any child who has recurrent wheezing +/- cough that responds to a bronchodilator
  • Diagnosis: history, examination, special investigations
  • Education of patient and care-giver
summary 2 management
Summary 2: Management
  • Classify severity of asthma
    • Intermittent
    • Persistent
  • Environmental control: Avoid:
    • Cigarette smoke
    • Allergens
summary 3 medication
Summary 3: Medication
  • Controllers: Inhaled cortico-steroids for persistent asthma
  • Relievers: short-acting ß-2 agonists
  • Appropriate delivery system
      • Metered dose inhaler + Spacer