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  1. Asthma in children Dr Gulamabbas Khakoo BMBCh, FRCPCH Consultant Paediatrician, Hillingdon Hospital Consultant in Department of Paediatric Asthma, Allergy and Immunology, St Mary’s Hospital, W2

  2. Talk outline • BTS / SIGN 2008 guidelines • Diagnosing asthma • Inhaled steroids • Allergy and asthma • Allergic rhinitis

  3. 2008 BTS / SIGN guideline on the management of asthma in children BTS=British Thoracic Society; SIGN=Scottish Intercollegiate Guidelines Network. Pharmacological management. Thorax 2008;63(Suppl IV):iv1-iv121

  4. 2008 Guidelines 2.1 DIAGNOSIS IN CHILDREN (1) Clinical features that increase the probability of asthma • More than one of the following symptoms: wheeze, cough, difficulty breathing, chest tightness, particularly if these symptoms: • are frequent and recurrent • are worse at night and in the early morning • occur in response to, or are worse after, exercise or other triggers, such as exposure to pets, cold or damp air, or with emotions or laughter • occur apart from colds • Personal history of atopic disorder • Family history of atopic disorder and/or asthma • Widespread wheeze heard on auscultation • History of improvement in symptoms or lung function in response to adequate therapy

  5. 2008 Guidelines 2.4 DIAGNOSIS IN CHILDREN (2) Clinical features that lower the probability of asthma • Isolated cough in the absence of wheeze or difficulty breathing • History of moist cough • Prominent dizziness, light-headedness, peripheral tingling • Repeatedly normal physical examination of chest when symptomatic • Normal PEF or spirometry when symptomatic • No response to a trial of asthma therapy • Clinical features pointing to alternative diagnosis

  6. 2008 Guidelines • Clinical features pointing to another diagnosis: Failure to gain weight Clubbing Fatty stools Productive sputum Other chest findings eg crackles, unequal BS Inspiratory noises Barking cough Early onset rhinorhoea GOR symptoms Absence of nocturnal symptoms

  7. Trial of Treatment Assess compliance and inhaler technique. Consider further investigation and/or referral Response? No Asthma diagnosis confirmed Continue Rx and find minimum effective dose CHILD with symptoms that may be due to asthma Clinical assessment Intermediate Probability Low Probability High Probability Consider tests of lung function and atopy Consider referral Investigate/treat other condition Response? Further investigation Consider referral Yes No Yes Continue Rx

  8. Inhaled steroids Inhaled steroids should be considered for patients with any of the following asthma-related features: • exacerbations of asthma in the last two years • using inhaled β2 agonists three times a week or more • symptomatic three times a week or more • waking one night a week.

  9. General advice • Follow SIGN / BTS guidelines 2008 • Correct inhaler device and technique • Compliance issues • Written asthma plans

  10. Children age 5-12 yrs

  11. Children age 5-12 yrs

  12. Children age 5-12 yrs

  13. Children age 5-12 yrs

  14. Children age 5-12 yrs

  15. Children age 5-12 yrs

  16. Children Less than 5 yrs

  17. Children Less than 5 yrs

  18. Children Less than 5 yrs

  19. Children Less than 5 yrs

  20. Children Less than 5 yrs

  21. Using the guidelines • Non-compliance with inhaled steroids up to 70% or more in very young and teenagers • Inhaler technique needs checking regularly • Large volume spacer is gold standard • Dry powder inhalers only in >6-8yo • Inhaled steroids and LTRAs more likely to improve symptoms in atopic children • In asthma + rhinitis, LTRAs may be more beneficial

  22. Allergies and asthma • Look for other co-morbid conditions, especially allergic rhinitis (and food allergies) • Consider skin prick testing (for aeroallergens) if: • Seasonal symptoms (pollens, molds) • Household pets (animal dander) • Perennial symptoms (house dust mite, molds) • Change in environment changes symptoms

  23. Steroids in viral induced asthma • Oral prednisolone in pre-school viral-induced asthma • No evidence of efficacy in hospitalised children (except ? multi-factor asthma or atopic children) • High-dose fluticasone in pre-school viral-induced asthma • Modest reduction in duration of symptoms and less use of relief beta agonists, but a small reduction in linear growth • NEJM 2009;360:329-53 (plus editorial)

  24. 61% fewer hospitalisations in treated patients Treating allergic rhinitis cuts asthma costs Patientshospitalised over 1-year period (%) 2.5 p<0.01 2.3 2.0 1.5 0.9 1.0 0.5 0.0 Patients untreatedfor AR (n=1357) Patients treated for AR(n=3587)

  25. Summary • Importance of clinical history especially in the very young • Look for other markers of allergy • 2008 BTS / SIGN guidelines as a framework • Refer to secondary care if inadequate response to treatment or possible alternative diagnosis • Asthma management plans, compliance, age-appropriate delivery device • Allergic rhinitis

  26. The end, any questions