Asthma Management In Children Norzila Mohamed Zainudin

1. Asthma Management In Children Norzila Mohamed Zainudin Consultant Paediatrician & Paediatric Chest Physician Paediatric Institute Hospital Kuala Lumpur 9th May 2004

2. The International Study of Asthma and Allergies in Childhood (ISSAC) Lancet 1998; 351: 1225 - 32

3. Commonest chronic disease of increasing prevalence • of childhood asthma • Widespread reporting • Prevalence in Malaysia –ISAAC study –10-12% • A difficult disease to diagnose in early childhood • Need to differentiate between episodic wheeze and asthma • Compounded by relatively small diameter of conducting airways in first 4 years of postnatal development • Frequent respiratory tract infections • Under treated base on the AIRIAP study

4. Pathogenesis • Airway Inflammation • Epithelial damage • Subepithelial basement membrane thickening • Increased vascularization • Myofibrobalst proliferation • Hypertrophy and hyperplasia of smooth muscle

5. Airway Remodelling • Relationship between airway remodelling • and pathogenesis of asthma remains unclear • May occur early in childhood • Preceeds onset of symptoms • Growing evidence that the loss of • lung function is determined in early childhood

6. Airway remodelling • Due to chronic inflammation • Epithelium as pro-inflammatory players • Epithelium undergone remodelling in response • to repeated cycles of inflammation and damage • Epithelial fragility • Smooth muscle cells to inflammatory network • playing central role by exposing cell surface • and adhesion molecules producing cytokine • Smooth muscle may de-differentiate and interchange between • Airway myofibroblast and smooth muscle

7. Martinez • 1246 infants • Children with persistent wheezing • Loss of lung function by 6 years old • Compared to non-wheezers or early transient wheezers • Irreversible damage occurs by 9 years old

8. Diagnosis History Physical Investigations

9. History • Wheezing • Chronic cough • Nocturnal exacerbations • Shortness of breath • Chest tightness • Limitation of physical activities • Parental history of atopy • Past history of eczema/rhinitis

10. Physical • Height – weight • Chest-hyperinflation • Auscultation • Eczema at flexural areas • Nose-nasal turbinate

11. Investigation • Demonstrate the reversibility of bronchial obstruction • Administer pre/post B2 agonist • FEV-15% increase or 20 % increase in PEF Formula: Post-Pre B2 X 100 % B2

12. Intermittent Symptoms less than once a week Brief exacerbations Nocturnal symptoms more than twice a month FEV1 or PEF >80 predicted PEF or FEV1 variability <20% Mild Persistent 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% PEF or FEV1 variability 20-30% Classification of asthma severity by clinical features before treatment Global Initiative of Asthma (GINA)

13. Moderate Persistent Symptoms daily Exacerbations may affect activity and sleep Nocturnal symptoms more than once a week Daily use of inhaled short acting B2 agonist FEV1 or PEF 60-80% predicted PEF or FEV1 variability >30% Severe Persistent Symptoms daily Frequent exacerbations Frequent nocturnal asthma symptoms Limitation of physical activities FEV1 or PEF <60% PEF or FEV1 variability >30%

14. Asthma Management • Educating patients to develop partnership • Assessing and monitoring of asthma severity using • measurements of symptoms and lung function • Avoiding exposure to risk factors • Establish medication plan • Establish long term asthma management exacerbations • Establishing individual plan • Regular follow-up care GINA 2002

15. Pharmacological approach to asthma management

16. Prevent Bronchoconstriction Control Inflammation Clinical control

17. Spoilt for choices

18. Guideline recommend adding LABA to ICS GINA guidelines: recommended medications in children Level of severity Daily controller medications Other treatment options Step 1 Intermittent asthma None necessary Step 2 Mild persistent asthma Sustained-release theophylline, OR cromone, OR leukotriene modifier ICS (100–400mg BUD or equivalent) Step 3 Moderate persistent asthma ICS (<800 mg BUD or equivalent) + LABA or sustained-release theophylline or leukotriene modifier OR ICS (>800 mg BUD or equivalent) ICS (400–800 mg BUD or equivalent) Step 4 Severe persistent asthma ICS (>800 mg BUD or equivalent) + one or more of the following, if needed: LABA or sustained-release theophylline, leukotriene modifier or oral corticosteroid Rapid-acting inhaled b2-agonist should be taken as required at all steps BUD, budesonide; ICS, inhaled corticosteroid; LABA, long-acting b2-agonist GINA 2002

19. Guideline recommend adding LABA to ICS GINA guidelines: recommended medications in children Level of severity Daily controller medications Other treatment options Step 1 Intermittent asthma None necessary Step 2 Mild persistent asthma Sustained-release theophylline, OR cromone, OR leukotriene modifier ICS (100–400mg BUD or equivalent) Step 3 Moderate persistent asthma ICS (<800 mg BUD or equivalent) + LABA or sustained-release theophylline or leukotriene modifier OR ICS (>800 mg BUD or equivalent) ICS (400–800 mg BUD or equivalent) Combination therapy Step 4 Severe persistent asthma ICS (>800 mg BUD or equivalent) + one or more of the following, if needed: LABA or sustained-release theophylline, leukotriene modifier or oral corticosteroid Combination therapy Rapid-acting inhaled b2-agonist should be taken as required at all steps BUD, budesonide; ICS, inhaled corticosteroid; LABA, long-acting b2-agonist GINA 2002

20. Montelukast (7%) ORAL (45%) Ketotifen (38%) Cromones (5%) INHALED (55%) Corticosteroids (50%) n TREATMENT PREFERENCE FOR ASTHMA PROPHYLAXIS IN CHILDREN UNDER 5 YEARS Chan PWK, Norzila MZ. Med J Malaysia 2003

21. PERCEPTION OF INHALED CORTICOSTEROIDS AMONG MALAYSIAN PARENTS % parents Chan PWK. J Pediatr Child Health; 46: 522

22. Inhaler Devices Recommended for Different Ages for Home Therapy • Children aged 0-6 years • Metered dose inhaler + spacer with facemask • Children aged > 6 years • Metered dose inhaler + spacer with facemask • Dry powder inhaler • Breath actuated device (> 8 years)

23. Availability of CFC Free inhalers HFA-MDI No –ozone depleting effect Reduced global warming Smoother dose delivery Improve dose uniformity No shaking required before inhalation

24. Thank You

25. META-ANALYSIS OF LINEAR GROWTH IN CHILDREN AND INHALED CORTICOSTEROIDS Reduction in linear growth 1.51 cm/yr BDP 0.43 cm/yr FP Evidence available for less than 54 weeks of treatment Sharek PJ, Bergman DA. Pediatrics 2000; 106: e8 - 15

26. Budesonide Nedocromil Placebo CAMP STUDY:Standing-height velocity1041 children aged 5 - 12 years cm/year • Reduction of growth velocity • most evident during • 1st year of treatment • At 4 - 6 years of treatment • No difference in • growth velocity • bone age • bone density • projected final height N Eng J Med 2000;343: 1054 - 63 Years

27. LONG TERM GROWTH AND INHALED CORTICOSTEROIDS Agertoft L, Pedersen S. Effect of long term treatment with inhaled budesonide on adult height in children with asthma. N Eng J Med 2000; 343: 1064 - 9

28. Summary Diagnosis Classification of severity New asthma medications Asthma Education Steroid phobia