Asthma in Children

1. Asthma in Children DR. A.Mirshokraei NIOC Hospital Pediatrics Ward

3. DEFINITION

5. RECURRENT WHEEZING EPISODES WITH COMMON RESPIRATORY VIRUSES(RSV,RHINOVIRUS,INFLUENZA,PARAINFLUENZA,ADENOVIRUS,HUMAN METAPNUMOVIRUS) • HOST FEATURES AFFECTING IMMUNOLOGIC HOST DEFENSE,INFLAMMATION/PREVIOUS VIRAL INFECTIONS MAINIFESTED AS PNUMONIA OR BRONCHIOLITIS REQUIRING HOSPITALIZATION UNDERLIE THE RECURRENT WHEEZING IN EARLY CHILDHOOD • OTHER AIRWAY EXPOSURES SUCH AS INDOOR AND HOME ALLERGENS,COLD AIR,STRONG ODORS,TOBACCO SMOKE,ALL INCREASE AHR • ALLERGEN ELLIMINATION SOMETIMES LEEDS TO CURE

6. EPIDEMIOLOGY • Common etiology of emergency visits and school day missing in childhood ,occasionally hospitalization and rare deaths specially in poverty ,urban living ,ethnic minorities • Increasing asthma prevalence worldwide(50% per decade) • Good correlation of asthma prevalence with allergic rhino sinusitis and atopic eczema and other allergies • More prevalence in high level urban modern families than suburban villagers • More than 80%of asthmatics reported getting the disease before 6 year

8. CLINICS RECURRENT COUGHING/WHEEZING PATTERNS IN CHILDHOOD BASED ON NATURAL HISTORY

9. TRANSIENT EARLY WHEEZING • Common in early preschool years • Recurrent coughing/wheezing primary triggered by common respiratory viral INF • Tend to resolve during preschool yrs without increasing risk of asthma later in life • Problems due to reduced airflow at birth suggestive of relative narrow airways improved by school yrs

10. Persistent Atopy Associated Asthma • Begins in early preschool yrs • Associated with atopy (eg atopic dermatitis in infancy, allergic rhinitis, food allergy) • Biologic factors e.g.: early inhalant sensitization, increase serum IGE, increase blood eosinophills, • High risk of persistence into later childhood and adulthood lung function abnormality • Those with onset<3 yrs reduced air flow by school yrs • Those with later onset of symptoms or allergen sensitizations unlikely persistence lung function abnormality later

11. Non-Atopic Wheezing • Wheezing ,coughing beginning in early life often with RSV INF resolves later in childhood without increasing risk of persistence asthma • Associated with bronchial hyper responsiveness near birth

12. Asthma with declining lung function • Children with asthma with progressive increase in air flow limitation • Associated with hyper inflation in childhood • Male gender

13. Late onset asthma in females associated with obesity and early onset puberty • Onset between 8_13 yrs • Associated with early onset puberty and obesity • Specific for females Occupational type asthma in children • Children with asthma and occupational type exposure known to trigger asthma in adults in occupational settings

14. Types of Asthmacommon clinical presentations of intermittent recurrent wheezing and/or coughing • Recurrent wheezing in early childhood • Chronic asthma associated with allergy • Females 11 yrs with early onset puberty and obesity

15. Pathogenesis • Airflow obstruction resulting from • Broncho constriction of bronchiolar smooth muscle mass • Cellular inflammatory infiltrates and exudates mostly Eosinophills(also N , M ,L ,mast cells ,basophiles)fill and obstruct airways and damage epithelium and induce desquamation into airway lumen mediated by T helper cells and other immune cells that produce pro allergic pro inflammatory cytokines(IL4,IL6,IL13) • Breach in normal immune regulatory process

16. RESULT • Airway inflammation • AHR • Edema basement membrane thickness sub epithelial collagen deposition • Smooth muscle and mucus gland hypertrophy and mucus hyper secretion Air obstruction

17. Clinical manifestations and diagnosis • Most common intermittent dry cough and expiratory wheezing • Shortness of breath and chest tightness in older children and adults • Intermittent non focal chest pain in younger children • Worsening of respiratory symptoms at night • Worsening of day time symptoms by activity

18. Continue….. • Subtle symptoms such as self limitation of activities ,general fatigue ,difficulty in keeping up with peers • Relief with aerosolized bronchodilators • Lack of improvement with bronchodilators and steroid is inconsistent with Asthma and should consider Asthma masquerading conditions!!!! • Hyper ventilation, intercostal retractions ,nasal flaring ,respiratory accessory muscle use • Its common not to hear the expiratory wheezing when Air flow is so limited before treatment

19. Asthma Triggers • Common viral infections of the respiratory tract • Aero allergens in sensitized asthmatics ,animal dander ,dust mite ,molds ,indoor allergens ,cockroaches • Seasonal aero allergens ,pollens(trees ,grasses ,weeds ,) • Environmental tobacco smoke • Air pollutants ,ozone ,so2,wood or coal smoke ,endotoxin ,mycotoxin ,dust • Strong or noxious odors or fumes ,perfume ,hair spray ,cleaning agents • Occupational exposure • Cold air ,dry air • Exercise • Crying ,laughter ,hyperventilation • Co morbid conditions Rhinitis ,Sinusitis ,GER

20. Clinics History: • Triggering symptoms by laughter ,cold air ,airway irritants • Exposures that induce airway irritation such as viral URTI Mycoplasma ,Chlamydia • Inhaled allergens • All lead to AHR

21. Presence Of Risk Factors: • History of other allergies ,allergic Rhinitis, allergic Conjunctivitis ,atopic Dermatitis ,food allergies • Parental Asthma • Symptoms apart from cold

22. Continue….. • No or minimal signs in routine visits • Dry or persistent cough • Normal chest findings unless wheezing when asking to breath deeper • Quick relief (10 MIN) after SABA use • Expiratory wheezing ,prolonged expiratory phase ,decreased sounds in RT lower pos lobe due to regional hypoventilation owing to airway obstruction • Rales , ronchi ,crackles due to hyper secretion • Segmental crackles and poor breath sounds atelectasis?

23. Continue…. • Labored respiration ,respiratory distress increased prolongation of expiration and wheezing in E and I • Poor air entry • Inter costal retractions ,nasal flaring ,supra and infra sternal retractions • And again in most sever forms expiratory wheezing does not appear until some broncho dilation

25. DD • GERD Rhino sinusitis co morbid conditions with asthma • Recurrent aspiration in early life(tracheobronchomalacia ,TEF , foreign body ,CF ,BPD • VCD in older children and adolescents

27. LAB FINDINGS Pulmonary Function Testing

28. Continue…. • Forced expiratory airflow measures helpful in Diagnosis , assessing efficacy of therapy and monitoring Asthma in children specially in poor children who do not have PHE unless obstruction is sever

30. Valueablity of spirometric findings in children>6 yrs • 3 efforts the highest is the peak • Reduced FEV FEV1/FVC <0.80 means significant obstruction • Improvement in FEV1 following beta 2 agonist > = 12% or 200 ml is consistent with Asthma • Peak flow meter

31. CXR • Often normal aside from subtle and nonspecific findings of hyperinflation • Peribronchial thickening • Helping in diagnosis of Asthma differentials • Diagnosis of complications of Asthma exacerbations

33. Other tests such as allergy skin prick testing

34. Treatment • www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm

35. Asthma Treatment & Management has 4 components : • Assessment and monitoring of disease activity • Provision to educate pt and family • Identification and management of precipitating factors and co morbid conditions • Appropriate selection of medication  Attainment of optimal Asthma control

36. Component 1 • Asthma severity :intermittent • Persistent: mild ,mod ,severe • Only once during patient initial evaluation in pt who is not using a daily controller agent • Asthma control degree to which symptoms , on going functional impairments , risk of adverse events minimized and goals of therapy are met

37. Continue…. • Well controlled • Not well controlled • Very poor controlled • NIH guidelines for both severity and control for 3 age groups • 0-4 yrs • 5-11 yrs • =>12 yrs

38. Important even in the absence of frequent symptoms infants and children whom have risk factors for asthma and 4 or more episodes of wheezing over the past yr which lasted more than 1 day or 2 or more exacerbations in the last 6 months requiring syst corticosteroids should be considered in the persistent group and hence receive long term controller therapy

39. Important Tips.. • Regular clinical visits every 2-6 weeks • Assessment of : • Pt symptoms frequency night and day • Need for short acting inhaled b2 agonists for quick relief • Ability to engage in normal activities • Air flow measures for>=5 yrs

40. Continue.. • Component 2 : pt education • Component 3 : control of factors contributing to asthma severity • Environmental exposures • Co morbid conditions • Component 4 :principals of asthma pharmacotherapy

41. Asthma Medication • SABA • ICS • LABA • LTRA • SYSTEMIC STEROIDS • NONSTEROIDAL ANTIINFLAMMATORY CROMOLYN AND NEDOCROMYL • OXYGEN • ANTICHOLINERGIC AGENTS IPRATROPIUM BROMIDE • ANTIIMMUNOGLUBOLINE E

48. QUICK RELIEF MEDICATION • SABA • Anti cholinergic(ipratropium) • Short term systemic gluco corticoid

49. SABA • Quick relief of asthma symptoms • Relax airway smooth muscle prompt airflow↑ • Repetitive or continuous SABA is the most effective means of reversing air flow obstruction • SABA should not be prescribed on a regular schedule because concerns of possibility of deteriorating asthma control • Frequent use of SABA is an indication of poor asthma control • Preferred root is inhalation smaller dose , fewer side effects more rapid on set of action • Ipratropium Bromide as an adjunct to SABA in emergency room reduces hospital admissions and improves lung function • Systemic Glucocorticoids short oral course + SABA in moderate to severe asthma exacerbation

50. LABA • Salmetrol • Should be used in combination with inhaled corticosteroids and not as mono therapy • Exercise induces asthma in children >= 4 Yrs one inhalation 30 min prior to exercise • No additional doses for PTs who are already receiving it twice daily not recommended by NIH guidelines