Transcript بسم الله الرحمن الرحيم

‫بسم هللا الرحمن الرحيم‬
Bronchial Asthma
Suggested Guidelines in
Egypt
Prof. Mohammad Rashad
Professor of Pediatrics
Benha University
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Asthma is the commonest chronic
disease in children.
Affects about quarter billion (235 million)
persons all over the world.
High prevalences were recorded in
advanced countries but, most deaths
occur in the developing countries.
(WHO: Asthma Fact Sheet N°307 May 2011)
In some areas of Egypt, asthma is the
commonest cause of hospital admission.
(GINA; 2004)
Annual costs in USA:
Direct health care: > $ 10 billion
Indirect health care: $ 8 billion
Prescription drugs:
$ 5 billion
= 23 billion $ / year
‫ مليـــــار جنيه كل سنة‬136 =
American Academy of Allergy, Asthma & Immunology; 2008
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In Egypt
We have:
Diagnostic problems.
Therapeutic problems.
What to do?
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Asthma Phenotypes
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Asthma can be classified into:
Atopic (extrinsic): symptoms are
precipitated by allergens.
Non-atopic (intrinsic): symptoms are
not precipitated by allergens.
Kumar, et al.: (2010); Robbins and Cotran Pathologic Basis of Disease
(8th ed.). Saunders. p. 688.
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Atopic
Non-atopic
Copyright © 2011 by the European Respiratory Society10
Atopic Asthma
Non-topic Asthma
Past history of
other atopy.
+ve
-ve
Family history of
any atopy.
+ve
-ve
Eosinophilia.
+ve
-ve
High serum IgE
+ve
- ve
Skin test
+ve
-ve
Provocation test
+ve
-ve
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Asthma Predictive
Index
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* Children <3 years with
* >4 wheezing episodes in the last year that
*lasted >1day with sleep disturbance And
One Major criterion: Or Two minor criteria:
Parent with asthma.
Wheezing apart
from colds.
Atopic dermatitis.
Aeosinophilia > 4%.
Sensitization to an
aeroallergen.
Food allergies.
If +ve , then 76% likelihood of asthma after 6 y’s of age
If –ve , then 97% likelihood of not developing asthma
National Heart, Lung and Blood Institute (NHLBI) 2007
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Asthma Diagnosis
Is it Asthma??
• Clinical history & examination.
• Pulmonary functions e.g. PEFR.
What phenotype??
• Clinical history.
• Laboratory tests e.g. S.IgE; Total +
specific.
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Asthma Symptoms
Cough.
Wheeze.
Difficult breathing.
Chest tightness.
Recurrent.
More at night,
awakening the
patient.
Responsive to antiasthma therapy.
Patient’s colds “go to the chest” or take
more than 10 days to clear up.
(GINA Pocket; 2010a)
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Other Symptoms:
Symptoms on exposure to aerosols,
smoke, drugs, cold air, exercise,
emotions or respiratory infection.
Atopic symptoms:
Symptoms on exposure to animals,
birds, cockroaches, dust mites, pollens,
Seasonal symptoms.
Past history of other atopy.
Family history of any atopy.
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Video 1 Symptoms
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Asthma Signs
Airflow limitation
Air trapping
• Increased chest dimensions
• Decreased chest movements
• Hyperresonance
• Prolonged expiration
• Expiratory + inspiratory rhonchi
• Ptosed liver & spleen
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Pulmonary Function
Tests
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Peak Expiratory Flow (PEF)
Compared to the patient’s previous
best, using his/her own peak flow meter.
Diurnal variation of >20% (with twicedaily readings, >10%). or
Improvement of >20% after inhalation of
a bronchodilator suggests asthma.
(GINA Pocket, 2010a)
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Spirometry
It is the preferred method to measures
the airflow limitation and its severity to
establish the diagnosis of asthma.
An increase in FEV1 of >12% after
inhalation of a bronchodilator indicates
reversible airflow limitation consistent
with asthma.
(GINA Pocket, 2010a)
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Laboratory Tests
Confirm the diagnosis &
detect the triggers.
Serum IgE: Total & Specific.
Skin test:
(GINA Pocket, 2010a)
Phagocytosis inhibition test: Specific
(Soliman & Attia , 2007)
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Diagnostic Challenges
Children <5 years:
The clinical picture & Serum IgE (total +
specific to inhalants) are very helpful.
Cough varient asthma:
Pulmonary function tests and Provocation
tests are important.
Exercise induced asthma:
Exercise test with an 8-minit running
protocol can establish a firm diagnosis.
(GINA Pocket, 2010a)
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Asthma Management
Environmental control.
Pharmacotherapy.
- During attacks (Relievers).
- Between attacks (Controllers).
Immunotherapy (Desensitization).
Follow up.
Parent education.
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2006
Level of Asthma Control
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Therapeutic Problems
In Egypt
1. Inhalation Phobia.
2. Steroid Phobia.
3. Antibiotic controversy.
4. Antipyretic controversy.
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(GINA 2010)
For newly diagnosed patients or not
on medication, treatment should
start at Step 2.
If the patient is very symptomatic,
start at Step 3.
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Asthma Management
for Children 5 Years and Younger
Asthma education, Environmental control
As needed rapid acting β2 agonists
Controlled
Partly controlled
Uncontrolled or
partly
controlled on lowdose ICS
No controller
Low-dose ICS
or
Double low-dose
ICS or
Leukotriene
modifier
Low-dose ICS plus
leukotriene modifier
(GINA Ped . 2009)
Antibiotic Controversy
90%
80.60%
80%
69.40%
70%
61.10%
Leukocytosis
High CRP
Shift to Lt.
Shift to Rt.
Prevalence
60%
50%
40%
30%
16.70%
20%
10%
10%
6.70% 6.70%
3.30%
0%
Atopic asthma
Non-atopic asthma
(Rashad et al., 2009)
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Antipyretic Phobia
Watch Video 2 (Paracetamol)
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Follow Up
Review the treatment every 3 months.
* If control is achieved, Step Down
i.e. gradually reduce the treatment.
* If daily and/or increasing use of
inhaled β2 agonists, Step Up to
more long-term control therapy.
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‫الحمد للـــه‬
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