Transcript Slide 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
Talk outline
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BTS / SIGN 2008 guidelines
Diagnosing asthma
Inhaled steroids
Allergy and asthma
Allergic rhinitis
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
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
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
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
CHILD with symptoms that may be due to asthma
Clinical assessment
High Probability
Intermediate Probability
Consider tests of lung
function and atopy
Trial of Treatment
Response?
Yes No
Assess compliance
and inhaler technique.
Consider further
investigation and/or
referral
Asthma diagnosis confirmed
Continue Rx and find minimum effective dose
Low Probability
Consider referral
Investigate/treat
other condition
Further
investigation
Consider
referral
Response?
No Yes
Continue Rx
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.
General advice
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Follow SIGN / BTS guidelines 2008
Correct inhaler device and technique
Compliance issues
Written asthma plans
Children age 5-12 yrs
Children age 5-12 yrs
Children age 5-12 yrs
Children age 5-12 yrs
Children age 5-12 yrs
Children age 5-12 yrs
Children Less than 5 yrs
Children Less than 5 yrs
Children Less than 5 yrs
Children Less than 5 yrs
Children Less than 5 yrs
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
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
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)
Treating allergic rhinitis cuts asthma costs
• 61% fewer hospitalisations in treated patients
Patients
2.5
hospitalised
over 1-year 2.0
period (%)
1.5
p<0.01
2.3
0.9
1.0
0.5
0.0
Patients untreated
for AR
(n=1357)
Patients treated
for AR
(n=3587)
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, ageappropriate delivery device
• Allergic rhinitis
The end, any questions