Transcript childhood_asthma - King George's Medical University

• Asthma is the most common chronic disease of childhood and the
leading cause of childhood morbidity from chronic disease as
measured by school absences, emergency department visits, and
hospitalizations.
• Asthma leads to recurrent episodes of wheezing, breathlessness,
chest tightness and coughing (particularly at night or early morning).
Clinical symptoms in children 5 years and younger are variable and
non-specific.
• Widespread, variable, and often reversible airflow limitation.
Asthma Inflammation – Cells and Mediators
Mechanism – Asthma Inflammation
Source: Peter J. Barnes, MD
Asthma Inflammation
Factors Influencing the Development
and Expression of Asthma
Host factors –
•
Genetic
1. Genes predisposing to atopy
2.
Genes predisposing to airway hyper responsiveness
• Obesity
• Sex
Environmental factors –
• Allergens –
1. Indoor – Domestic mites, furred animals (dogs, cats, mice),
cockroach allergens, fungi, molds, yeasts.
2. Outdoor – Pollens, fungi, molds, yeasts.
• Infections (predominantly viral)
• Occupational sensitizers
• Tobacco smoke
1. Passive smoking
2. Active smoking
• Indoor/Outdoor air pollution
• Diet
Risk factors of Asthma in younger children
• Sensitization to allergen.
• Maternal diet during pregnancy and/ or lactation.
• Pollutants (particularly environmental tobacco smoke).
• Microbes and their products.
• Respiratory (viral) infections.
• Psychosocial factors.
Prevalence of Childhood asthma
The prevalence of childhood asthma has continued to
increase on the Indian subcontinent over the past 10 yrs
ISAAC Phase 3 Thorax 2007;62:758
Underdiagnosed/
Misdiagnosed
Fear of steroids
Acceptance of
Asthma
diagnosis/label
Heterogenous
Disease/varying
phenotypes
Heavy
nebulisation
Issues in
Pediatric Asthma
Cough or
Wheeze
Choice of right
device
Oral vs. Inhaled
Lack of
knowledge &
time vs.
more patients
Poor patient/
parent
education
Other Challenges
• Most of the children are below 5 years of age, who cannot tell
their problems
• Parents are proxy story teller, who may mislead the doctor
• PEF cannot be performed in children below 5 years of age
• Fear of addiction to inhalation therapy
• Physicians lack of knowledge and time
Clinical Features
• Recurrent Wheeze
• Recurrent Cough
• Recurrent Breathlessness
• Activity Induced Cough/Wheeze
• Nocturnal Cough/Breathlessness
• Tightness Of Chest
Asthma by Consensus, IAP 2003
Symptomatology
• Cough – 90%
• Wheezing – 74%
• Exercise induced wheeze or cough – 55%
Ind J Ped 2002;69:309-12
Typical features of Asthma
• Afebrile episodes
• Personal atopy
• Family history of atopy or asthma
• Exercise /Activity induced symptoms
• History of triggers
• Seasonal exacerbations
• Relief with bronchodilators
Asthma by Consensus, IAP 2003
When does Asthma begin?
• By 1 year – 26%
• 1-5 years – 51.4%
• > 5 years – 22.3%
77% Of Asthma Begins
In Children Less Than 5
Years
Ind J Ped 2002;69:309-12
Tools to Diagnosis
• Good History Taking (ASK)
• Careful Physical Examination (LOOK)
• Investigations (PERFORM) – above 5 years only
CHILDHOOD ASTHMA by KHUBCHANDANI R.P. et al
History taking (Ask)
• Has the child had an attack or recurrent episode of wheezing
(high-pitched whistling sounds when breathing out)?
• Does the child have a troublesome cough which is particularly
worse at night or on waking?
• Is the child awakened by coughing or difficult breathing?
• Does the child cough or wheeze after physical activity (like
games and exercise) or excessive crying?
• Does the child experience breathing problems during a
particular season?
CHILDHOOD ASTHMA by KHUBCHANDANI R.P. et al
History taking (Ask)
• Does the child cough, wheeze, or develop chest tightness
after exposure to airborne allergens or irritants e.g. smoke,
perfumes, animal fur?
• Does the child’s cold frequently ‘go to the chest’ or take more
days to resolve?
If than
the10answer
is ‘yes’ to any of the questions,
a• diagnosis
should
be considered
Does the child of
use asthma
any medication
when symptoms
occur?
How often?
• Are symptoms relieved when medication is used?
CHILDHOOD ASTHMA by KHUBCHANDANI R.P. et al
Physical Examination (Look)
• General Attitude And Well Being
• Deformity Of The Chest
• Character Of Breathing
• Thorough Auscultation Of Breath Sounds
• Signs Of Any Other Allergic Disorders On The Body
• Growth And Development Status
CHILDHOOD ASTHMA by KHUBCHANDANI R.P. et al
What all features one should look for specifically?
Dyspnea
• Expiratory wheeze
• Accessory muscle movement
• Difficulty in feeding, talking, getting to sleep
• Irritability
CHILDHOOD ASTHMA by KHUBCHANDANI R.P. et al
What all features one should look for specifically?
Cough
• Persistent/ recurrent / nocturnal/ exercise-induced
Associated conditions
• Eczema
• Allergic Rhinitis
 Weight/Height
CHILDHOOD ASTHMA by KHUBCHANDANI R.P. et al
What all investigations can be performed in
asthmatic children? (PERFORM)
Peak expiratory flow rate: It is highly suggestive of
asthma when:
• >15% increase in PEFR after inhaled short acting
β2 agonist
• >15% decrease in PEFR after exercise
• Diurnal variation > 10% in children not on
bronchodilator
OR
>20% In children on bronchodilator
1. Asthma by Consensus, IAP 2003
2. CHILDHOOD ASTHMA by KHUBCHANDANI R.P. et al
How to rule out the mimics?
The Early Wheezer (< 3Years)
WALRI (wheeze associated
lower respiratory tract infections)
or Viral Associated wheeze
Early onset asthma
• Febrile episodes
• Personal atopy absent
• Family history of asthma / atopy
absent
• Variable response to
bronchodilators
• Afebrile episodes
• Personal atopy present
• Family history of asthma /
atopy present
• Predictable good response to
bronchodilators
Asthma by Consensus, IAP 2003
Bronchiolitis in children
• Commonest cause of wheezing in children between 6
months to 3 years
• Resembles asthma
• Diagnosis essentially clinical
• Common viruses causing bronchiolitis in children:
– Respiratory syncytial virus (RSV)
Clinical manifestations of RSV disease
• Rhinorrhoea
• Pharyngitis
• Cough
• Low grade fever
• Wheezing
• Increased respiratory rate
Differential diagnosis
Age
Common
Uncommon
Less than
6 months
Bronchiolitis
Gastroesophageal
reflux
Aspiration pneumonia
Asthma
Bronchopulmonary dysplasia Foreign body aspiration
Congestive heart failure
Cystic fibrosis
6 months - Bronchiolitis
2 years
Foreign body
aspiration
Aspiration pneumonia
Congestive heart failure
Asthma
Bronchopulmonary dysplasia
Cystic fibrosis
Gastro-esophageal reflux
2 - 5 years
Cystic fibrosis
Gastro-esophageal reflux
Viral pneumonia
Asthma
Foreign body
aspiration
Rare
Aspiration pneumonia
Bronchiolitis
Congestive heart failure
Gastro-esophageal reflux
IPAG 2007
Co morbid conditions
• Allergic Rhinitis
Colds, ear infections
Sneezing in the morning
Blocked nose, snoring, mouth breathing
• Gastro esophageal reflux (GER)
Nocturnal cough followed by vomiting
• Eczema
Guidelines for confirming
Childhood Asthma diagnosis
IPAG Diagnosis
•
•
•
•
•
•
Characterize the problem
Establish chronicity
Exclude non-respiratory or other causes
Exclude infectious diseases
Consider patient’s age
Use diagnostic aids
International Primary Care Airways Group 2007
Early Childhood Asthma Diagnosis
(below 6 years)
Diagnostic Tool
Findings that Support Diagnosis
Differential
diagnosis
The diagnosis of asthma in children under age 6 is primarily
one of exclusion.
Physical
examination
If the child does not appear acutely ill and is growing, and
there is no evidence specifically indicating another cause of
symptoms, a trial of therapy is warranted.
Trial of therapy
(bronchodilators)
Improvement with treatment supports a diagnosis of
asthma.
Frequent
reassessment
Health care professionals should always be prepared to
reconsider the diagnosis if management is ineffective or if
the clinical situation changes.
IPAG 2007
Childhood Asthma Diagnosis (6-14 years)
IPAG 2007
Childhood Asthma Diagnosis (6-14 years)
IPAG 2007
NORDIC CONSENSUS
Confirm Asthma if,
If the child is having 3 attacks of airway obstruction in
last 1 yr.
If the child gets 1 attack of asthmatic symptoms after
the age of 2 yrs.
Irrespective of age in an attack in children with
allergy (eczema, food allergy etc.) or history of atopy.
If the child does not become free of symptoms when
infection has ceased or has persistent symptoms for
more than a month.
Respir Med. 2000;94(4):299-327
IAP GUIDELINES
3 Or More Episodes Of Airflow Obstruction With Several Of The
Following:
• Afebrile Episodes
• Personal Atopy Or Family H/O Atopy / Asthma
• Nocturnal Exacerbations
• Exercise/Activity Induced Symptoms
• Trigger Induced Symptoms
• Seasonal Exacerbations
• Relief With Bronchodilators ± Oral Steroid
Asthma by Consensus, The Indian Academy of Pediatrics 2003
GINA
• The following symptoms are highly suggestive of a diagnosis of
asthma:
– frequent episodes of wheeze (more than once a month)
– activity-induced cough or wheeze
– nocturnal cough in periods without viral infections
– absence of seasonal variation in wheeze
– symptoms that persist after age 3
• A simple clinical index based on:
– presence of a wheeze before the age of 3
– presence of one major risk factor (parental history of asthma
or eczema) or two of three minor risk factors (eosinophilia,
wheezing without colds, and allergic rhinitis) has been
shown to predict the presence of asthma in later childhood
Global Initiative for Asthma 2008
GINA
• A useful method for confirming the diagnosis of asthma in
children 5 years and younger is a trial of treatment with shortacting bronchodilators and inhaled glucocorticosteroids
• Children 4 to 5 years old can be taught to use a PEF meter, but
to ensure reliability parental supervision is required
• Use of spirometry and other measures recommended for older
children such as airway responsiveness and markers of airway
inflammation is difficult and several require complex
equipment making them unsuitable for routine use
GINA 2008
BTS
•
Initial assessment of children suspected of having asthma
should be based on:
– presence of key features in the history and clinical examination
– careful consideration of alternative diagnoses
•
Using a structured questionnaire may produce a more
standardised approach to the recording of presenting clinical
features and the basis for a diagnosis of asthma
British Thoracic Society 2008
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
BTS 2008
Clinical features that lower the probability of asthma
• Symptoms with colds only, with no interval symptoms
• 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 peak expiratory flow (PEF) or spirometry when symptomatic
• No response to a trial of asthma therapy
• Clinical features pointing to alternative diagnosis
BTS 2008
Asthma Phenotypes
What do you understand by
phenotypes?
• Phenotypes
“the visible properties of an organism that are
produced by the interaction of genotype and
the environment”
-Webster’s New Collegiate Dictionary
Pre-school “Asthma phenotypes”
Wheezing is common in young children but is it asthma?
Prevalence of wheeze
Atopic asthma
Non-atopic viral
induced wheeze
Transient wheeze
0
3
6
Age Years
11
Martinez Pediatrics 2002;109:362
Asthma phenotypes in childhood
Transient
• linked with smoking during pregnancy
• viral RTIs
• not associated with atopy
• remits by school age
• Impaired lung function at birth
Asthma phenotypes in childhood
Persistent
• not associated with atopy:
- associated with viral RTIs (RSV),
- may remit during school age
- LTRAs have been found to be beneficial
• associated with atopy:
- bronchial responsiveness, impaired lung function
- parental history of asthma
- most ongoing during school age
Classification of Asthma
• The goal of the treatment is to achieve and maintain control for
prolonged periods with due regard to the safety of treatment, potential for
adverse effects, and the cost of treatment required to achieve this goal.
• Assessment of asthma control should include control of the clinical
manifestations, control of the expected future risk to the patient such as
exacerbations, accelerated decline in the lung function, and side-effects
of the treatment.
• The achievement of good clinical control of asthma leads to reduced risk
of exacerbations.
Characteristic
Controlled
Partly controlled
(All of the following)
(Any present in any week)
More than
Daytime symptoms
None (2 or less / week)
Limitations of activities
None
Any
None
Any
Nocturnal symptoms /
awakening
Need for rescue /
“reliever” treatment
Lung function#
(PEF or FEV1)
*Any
Exacerbation
twice / week
3 or more features of
partly controlled asthma
More than
None (2 or less / week)
present in any week*
twice / week
< 80% predicted or
Normal
personal best (if known)
on any day
None
One or more / year
exacerbation should be prompt review of maintenance treatment to ensure that it is adequate.
#Lung
Uncontrolled
function is not a reliable test for children 5 years and younger .
1 in any week
GINA 2009
Levels of Asthma Control in Children 5 years and younger
Characteristic
Controlled (All of the following)
Partly Controlled (Any
measure present in any
week)
Uncontrolled
(Three or more of features of
partly controlled asthma in any
week)
Daytime symptoms
– wheezing, cough,
difficult breathing
None
(less than twice/week, typically
for short periods of on the order
minutes and rapidly relieved by
use of a rapid-acting
bronchodilator)
More than twice/week
(typically for short periods
on the order minutes and
rapidly relieved by use of a
rapid-acting bronchodilator)
More than twice/week
(typically last minutes of hour or
recur, but partially or fully
relieved with rapid-acting
bronchodilators)
Limitation of
activities
None
(child is fully active, plays and
runs without limitation or
symptoms)
Any
(may cough, wheeze, or have
difficulty breathing during
exercise, vigorous play or
laughing)
Any
(may cough, wheeze, or have
difficulty breathing during
exercise, vigorous play or
laughing)
Nocturnal
symptoms/
awakening
None
(no nocturnal coughing during
sleep)
Any
(typically coughs during
sleep/wakes with cough,
wheezing and/or difficult
breathing)
Any
(typically coughs during
sleep/wakes with cough,
wheezing and/or difficult
breathing)
Need for
reliever/rescue
treatment
Less than/equal to 2 days/week
> 2 days/week
> 2 days/week
• Examples of validated measures for assessing clinical control of asthma
include –
• Asthma Control Test (ACT) – www.asthmacontrol.com
• Childhood Asthma Control test (C - Act)
• Asthma Control Questionnaire (ACQ) – www.qoltech.co.uk/asthma1.htm
• Asthma Therapy Assessment Questionnaire (ATAQ) –
www.ataqinstrument.com
• Asthma Control Scoring System
Asthma Treatments
• Classified into Controllers and Relievers
• Controllers – medications to be taken on daily long term basis.
• Relievers – medications to be used on as-needed basis to
relieve symptoms quickly.
• Asthma treatment can be administered in different ways – inhaled,
oral, or by injection.
• Advantage of inhaled therapy - drugs are delivered directly into the
airways, producing higher local concentrations with significantly less
risk of systemic side effects.
• Inhaled medications for asthma are available as pressurized MDIs,
DPIs, soft mist inhalers and nebulized or ‘wet’ aerosols.
• CFC inhaler devices are being phased out due to the impact of CFCs
upon the atmospheric ozone layer, and are being replaced by HFA
devices.
• Choosing an inhaler device for children with asthma *Age group
Preferred device
Alternative device
Pressurized metered-dose inhaler
Younger than 4 years
plus dedicated spacer with face
Nebulizer with face mask
mask
Pressurized metered-dose inhaler
4-5 years
plus dedicated spacer with
Nebulizer with mouthpiece
mouthpiece
Dry powder inhaler or breath
actuated pressurized meteredOlder than 6 years
dose inhaler or pressurized
Nebulizer with mouthpiece
metered-dose inhaler with spacer
with mouthpiece
*Based
on efficacy of drug delivery, cost effectiveness, safety, ease of use, and convenience .
GINA 2009
Asthma management and prevention
• The goals for successful management of asthma are
1. Achieve and maintain control of symptoms
2. Maintain normal activity levels, including exercise
3. Maintain pulmonary function as close to normal as possible
4. Prevent asthma exacerbations
5. Avoid adverse effects from asthma medications
6. Prevent asthma mortality
Five interrelated components of therapy are required to achieve
and maintain control of asthma-
1. Develop Patient/Doctor partnership
2. Identify and reduce exposure to risk factors
3. Assess, treat, and monitor asthma
4. Manage asthma exacerbations
5. Special considerations
Develop Patient/Doctor partnership • Effective management of asthma requires the development of a
partnership between the person with asthma and the health care
team.
• Patients can learn to –
1. Avoid risk factors
2. Take medications correctly
3. Understand the difference between controller and reliever
medications
4. Monitor their status using symptoms and, if relevant, PEF
5. Recognize signs that asthma is worsening and take action
6. Seek medical help as appropriate
• Education should be integral part of all interactions between health care
professional and patients.
• Using variety of methods such as discussions, demonstrations, written
materials, group classes, video/audio tapes, dramas and patient support
groups helps reinforce educational messages.
• Health care professional and patients should prepare a written personal
asthma action plan that is medically appropriate and practical.
• Additional self-management plans can be found on –
1. www.asthma.org.uk
2. www.nhlbisupport.com/asthma/index.html
3. www.asthmaz.co.nz
Identify and reduce exposure to risk factors • Measures to prevent the development of asthma and asthma
exacerbations by avoiding or reducing exposure to risk factors
should be implemented wherever possible.
• Reducing patients exposure to some categories of risk factors
improves the control of asthma and reduces medication needs.
Assess, Treat and Monitor Asthma –
• The goal of asthma treatment can be reached in most patients
through a continuous cycle that involves – assessing, treating and
monitoring asthma.
• Each patient should be assessed to establish his/her current
treatment regimen, adherence to the current regimen, and level of
asthma control.
• Each patient is assigned to one of five treatment steps.
• At each treatment step, reliever medication should be provided for
quick relief of symptoms as needed.
• Inhaled medications are preferred because they deliver drugs
directly to the airways where they are needed, resulting in
potent therapeutic effects with fewer systemic side effects.
• Inhaled medications for asthma are available as pressurized
MDIs, breath actuated MDIs, DPIs and nebulizers.
• Spacer devices make inhalers easier to use and reduce
systemic absorption and side effects of ICS.
• Patients should be demonstrated about the use of devices.
• Monitoring is essential to maintain control and establish the lowest step and
dose of treatment to minimize cost and maximize safety.
• If asthma is not controlled, step up the treatment. Improvement is generally
seen within 1 month.
• If asthma is partly controlled, consider stepping up treatment, depending
more effective options available, safety and cost of possible treatment and
patient’s satisfaction with the level of control achieved.
• If controlled asthma is maintained for at least 3 months, step down with a
gradual, stepwise reduction in treatment. The goal is to decrease treatment
to the least medication necessary to maintain control.
Asthma management approach based on control
for children 5 years and younger
Asthma education, Environmental approach, and as needed rapid acting beta -agonists
Controlled on as needed rapid
Partly controlled on as needed
acting beta2-agonists
rapid acting beta2-agonists
Uncontrolled or only partly
controlled on low - dose inhaled
glucocorticosteroid
Controller options
Continue as needed rapid acting
Low – dose inhaled
Double Low – dose inhaled
beta2-agonists
glucocorticosteroid
glucocorticosteroid
Low – dose inhaled
Leukotriene modifier
glucocorticosteroid plus Leukotriene
modifier
To summarize…
Diagnosis
• Asthma is an inflammatory illness
• Diagnosis of asthma is clinical, and relies on history
• All asthma does not wheeze
• In children < 3 yrs, WALRI is an important differential diagnosis
• 2 out of 3 children outgrow their asthma
• A family history of asthma / atopy increases risk of asthma
To summarize…
Long term management
• Patient education is a very important part of asthma management
• Drugs control, but do not cure asthma
• Clinical grading over time, decides long term management plan
• Mild intermittent asthma does not merit controllers
• Inhaled steroids are mainstay of long term asthma management
• Treatment should be stepped up or stepped down depending upon patient
response
Thank You