Slide 1

Asthma in Children
DR. A.Mirshokraei
NIOC Hospital Pediatrics Ward

Definition :

DEFINITION

- Chronic inflammatory condition of the
lung airways resulting in episodic airflow
obstruction
- AHR to provocative exposures
Asthma management
• Reducing airway inflammation by: Minimizing
pro inflammatory environmental exposure, using
daily controller anti inflammatory medication,
controlling co morbid conditions that worsen
asthma, less inflammation better asthma
control and fewer exacerbations

Anyway exacerbations

occur

BUT
Even the uncommon
child with sever asthma can
be managed to live normally

 RECURRENT WHEEZING EPISODES WITH COMMON

RESPIRATORY
VIRUSES(RSV,RHINOVIRUS,INFLUENZA,PARAINFLUENZA,A
DENOVIRUS,HUMAN METAPNUMOVIRUS)

 HOST FEATURES AFFECTING IMMUNOLOGIC HOST

DEFENSE,INFLAMMATION/PREVIOUS VIRAL INFECTIONS
MAINIFESTED AS PNUMONIA OR BRONCHIOLITIS
REQUIRING HOSPITALIZATION UNDERLIE THE
RECURRENT WHEEZING IN EARLY CHILDHOOD

 OTHER AIRWAY EXPOSURES SUCH AS INDOOR AND HOME

ALLERGENS,COLD AIR,STRONG ODORS,TOBACCO
SMOKE,ALL INCREASE AHR

 ALLERGEN ELLIMINATION SOMETIMES LEEDS TO CURE

EPIDEMIOLOGY
 Common etiology of emergency visits and school day missing

in childhood ,occasionally hospitalization and rare deaths
specially in poverty ,urban living ,ethnic minorities

 Increasing asthma prevalence worldwide(50% per decade)
 Good correlation of asthma prevalence with allergic rhino

sinusitis and atopic eczema and other allergies

 More prevalence in high level urban modern families than

suburban villagers

 More than 80%of asthmatics reported getting the disease

before 6 year

CLINICS
RECURRENT COUGHING/WHEEZING
PATTERNS IN CHILDHOOD BASED ON
NATURAL HISTORY

TRANSIENT EARLY WHEEZING
 Common in early preschool years

 Recurrent coughing/wheezing primary

triggered by common respiratory viral INF
 Tend to resolve during preschool yrs without
increasing risk of asthma later in life
 Problems due to reduced airflow at birth
suggestive of relative narrow airways improved
by school yrs

Persistent Atopy Associated Asthma
 Begins in early preschool yrs

 Associated with atopy (eg atopic dermatitis in





infancy, allergic rhinitis, food allergy)
Biologic factors e.g.: early inhalant sensitization,
increase serum IGE, increase blood eosinophills,
High risk of persistence into later childhood and
adulthood lung function abnormality
Those with onset<3 yrs
reduced air flow by
school yrs
Those with later onset of symptoms or allergen
sensitizations unlikely persistence lung function
abnormality later

Non-Atopic Wheezing
 Wheezing ,coughing beginning in early life

often with RSV INF resolves later in childhood
without increasing risk of persistence asthma

 Associated with bronchial hyper

responsiveness near birth

Asthma with declining lung function
• Children with asthma with progressive

increase in air flow limitation

• Associated with hyper inflation in childhood
• Male gender

Late onset asthma in females associated with
obesity and early onset puberty
 Onset between 8_13 yrs

 Associated with early onset puberty and obesity
 Specific for females

Occupational type asthma in children
 Children with asthma and occupational type exposure

known to trigger asthma in adults in occupational settings

Types of Asthma
common clinical presentations of intermittent
recurrent wheezing and/or coughing
 Recurrent wheezing in early childhood

 Chronic asthma associated with allergy
 Females 11 yrs with early onset puberty and

obesity

Pathogenesis

 Airflow obstruction resulting from

Broncho constriction of bronchiolar smooth
muscle mass
II. Cellular inflammatory infiltrates and exudates
mostly Eosinophills(also N , M ,L ,mast cells
,basophiles)fill and obstruct airways and damage
epithelium and induce desquamation into airway
lumen mediated by T helper cells and other
immune cells that produce pro allergic pro
inflammatory cytokines(IL4,IL6,IL13)
III. Breach in normal immune regulatory process
I.

RESULT
 Airway inflammation

 AHR
 Edema basement membrane thickness sub

epithelial collagen deposition
 Smooth muscle and mucus gland hypertrophy
and mucus hyper secretion

Air obstruction

Clinical manifestations and diagnosis
 Most common intermittent dry cough and

expiratory wheezing

 Shortness of breath and chest tightness in older

children and adults

 Intermittent non focal chest pain in younger

children

 Worsening of respiratory symptoms at night
 Worsening of day time symptoms by activity

Continue…..
 Subtle symptoms such as self limitation of activities

,general fatigue ,difficulty in keeping up with peers

 Relief with aerosolized bronchodilators
 Lack of improvement with bronchodilators and steroid

is inconsistent with Asthma and should consider
Asthma masquerading conditions!!!!

 Hyper ventilation, intercostal retractions ,nasal flaring

,respiratory accessory muscle use

 Its common not to hear the expiratory wheezing when

Air flow is so limited before treatment

Asthma Triggers
 Common viral infections of the respiratory tract
 Aero allergens in sensitized asthmatics ,animal dander ,dust











mite ,molds ,indoor allergens ,cockroaches
Seasonal aero allergens ,pollens(trees ,grasses ,weeds ,)
Environmental tobacco smoke
Air pollutants ,ozone ,so2,wood or coal smoke ,endotoxin
,mycotoxin ,dust
Strong or noxious odors or fumes ,perfume ,hair spray
,cleaning agents
Occupational exposure
Cold air ,dry air
Exercise
Crying ,laughter ,hyperventilation
Co morbid conditions Rhinitis ,Sinusitis ,GER

Clinics
History:
Triggering symptoms by laughter
,cold air ,airway irritants
Exposures that induce airway
irritation such as viral URTI
Mycoplasma ,Chlamydia
Inhaled allergens
All lead to AHR

Presence Of Risk Factors:
 History of other allergies ,allergic Rhinitis,

allergic Conjunctivitis ,atopic Dermatitis ,food
allergies

 Parental Asthma
 Symptoms apart from cold

Continue…..
 No or minimal signs in routine visits

 Dry or persistent cough

 Normal chest findings unless wheezing when asking

to breath deeper
 Quick relief (10 MIN) after SABA use
 Expiratory wheezing ,prolonged expiratory phase
,decreased sounds in RT lower pos lobe due to
regional hypoventilation owing to airway
obstruction
 Rales , ronchi ,crackles due to hyper secretion
 Segmental crackles and poor breath sounds
atelectasis?

Continue….
 Labored respiration ,respiratory distress increased

prolongation of expiration and wheezing in E and I

 Poor air entry
 Inter costal retractions ,nasal flaring ,supra and

infra sternal retractions

 And again in most sever forms expiratory wheezing

does not appear until some broncho dilation

DD

GERD Rhino sinusitis co morbid

conditions with asthma

Recurrent aspiration in early

life(tracheo broncho malacia
,TEF , foreign body ,CF ,BPD

VCD in older children and

adolescents

LAB FINDINGS
Pulmonary Function
Testing

Continue….
 Forced expiratory airflow measures helpful

in Diagnosis , assessing efficacy of therapy
and monitoring Asthma in children specially
in poor children who do not have PHE
unless obstruction is sever

 Valueablity of spirometric findings in children>6

yrs

 3 efforts the highest is the peak
 Reduced FEV

obstruction

FEV1/FVC <0.80 means significant

 Improvement in FEV1 following beta 2 agonist > =

12% or 200 ml is consistent with Asthma

 Peak flow meter

CXR

Often normal aside from subtle and

nonspecific findings of hyperinflation

Peribronchial thickening
Helping in diagnosis of Asthma

differentials

Diagnosis of complications of Asthma

exacerbations

Other tests such as allergy skin prick
testing

Treatment
 www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm

Asthma Treatment & Management
has 4 components :
Assessment and monitoring of disease
activity
2. Provision to educate pt and family
3. Identification and management of
precipitating factors and co morbid
conditions
4. Appropriate selection of medication
1.

 Attainment of optimal Asthma control

Component 1
 Asthma severity :intermittent
 Persistent: mild ,mod ,severe
 Only once during patient initial evaluation in pt

who is not using a daily controller agent
 Asthma control degree to which symptoms ,
on going functional impairments , risk of
adverse events minimized and goals of
therapy are met

Continue….
Well controlled
2. Not well controlled
3. Very poor controlled
1.

 NIH guidelines for both severity and

control for 3 age groups

0-4 yrs
2. 5-11 yrs
3. =>12 yrs
1.

Important
even in the absence of frequent symptoms
infants and children whom have risk factors
for asthma and 4 or more episodes of
wheezing over the past yr which lasted more
than 1 day or 2 or more exacerbations in
the last 6 months requiring syst
corticosteroids should be considered in the
persistent group and hence receive long term
controller therapy

Important Tips..
 Regular clinical visits every 2-6 weeks
 Assessment of :

Pt symptoms frequency night and day
2. Need for short acting inhaled b2 agonists for
quick relief
3. Ability to engage in normal activities
4. Air flow measures for>=5 yrs
1.

Continue..
 Component 2 : pt education

 Component 3 : control of factors contributing

to asthma severity
1. Environmental exposures
2. Co morbid conditions
 Component 4 :principals of asthma
pharmacotherapy

Asthma Medication
 SABA

 ICS

 LABA
 LTRA

 SYSTEMIC STEROIDS

 NONSTEROIDAL ANTIINFLAMMATORY

CROMOLYN AND NEDOCROMYL
 OXYGEN
 ANTICHOLINERGIC AGENTS
IPRATROPIUM
BROMIDE
 ANTIIMMUNOGLUBOLINE E

MANAGEMENT OF ASTHMA EXACERBATION(STATUS ASTHMATICUS)
RISK ASSESMENT ON ADMISSION

FOCUSED HISTORY

ONSET OF CURRENT EXACERBATION
FREQUENCY AND severity of daytime and night
time symptoms and activity limitation
Frequency of rescue bronchodilator use
Current medication and allergies
Potential triggers
History of systemic steroid courses, emergency
department visists , hospitalization, intubation or life
threatening episodes

Clinical assesment

Physical examination findings: vital signs,
breathlessness, air movement, use of accessory
respiratory muscles, retractions, anxiety level,
alteration in mental status
Pulse oximetry
Lung function(defer in pts with mod to severe
distress or history of labile disease)

Treatment
Drugs and trade name

Mechanism of action and dosing

Cautions and adverse effects

Oxygen(mask or nasal canula)
Inhaled short acting b2
agonist
Albuterol nebulized
solution(5mg/ml concentrates
Albuterol MDI
Levabuterol

Treats hypoxia
Bronchodilator
Neubolizer 0.15 mg/kg every 20 min for 3
doses as needed,then 0.15_0.3 mg/kg up t 10
mg every 1_4 hour as needed or up to 0.5
mg/kg/hr by continous neubolization
2_8 puf up to every 20 min for 3 doses as
needed then every 1 hr as needed

Monitor pulse oximetry to maintain o2 saturation>92%
Cardiorespiratory monitoring
During exacerbations,frequent or continuous use can cause
pulmonary vasodilatation,v/q mistmatch and hypoxemia
Adverse effect palpitation, tachycardia, arrhythmia, tremor,
hypoxemia
Neubolizer:when giving concentrate forms,dilute with saline to 3
ml total neubolized volume
For MDI use space/holding chamber

Systemic corticosteroids
Prednisolone tb
Methyl prednisolon
Anticholinergics
Ipratropium
Atrovent
Ipratropium with Albuterol

Anti inflammatory
0.5_1 mg/kg every 6-8 hr for 48 hr , then 1-2 mg/kg
day bid(max 60 mg/day)
Short course burst for exacerbation 1-2 mg/kg/day qd
or bid for 3-7 days
Mucolitic/bronchodilator
Neubolizer 0.5 mg q6-8 hr (tid or qid) as needed
MDI 2 paf qid
1 vial by neubolizer qid



If pt has been exposed chickenpox or measles, consider passive
immunoglobulin prophylaxis, also risk of complications with
herspes simplex and TB

For daily dosing , 8 am administration minimizes adrenal
suppression

Children may benefit from dosage tapering if course exceed 7 days

Adverse effect monitoring: frequent therapy bursts risk numerous
corticosteroid adverse effects

Should not be used as first line treatment added to b2 agonist
therapy
Neubolizer may mix Ipratropium with Albuterol

QUICK RELIEF MEDICATION
SABA

Anti cholinergic(ipratropium)
Short term systemic gluco

corticoid

SABA
 Quick relief of asthma symptoms
 Relax airway smooth muscle prompt airflow↑
 Repetitive or continuous SABA is the most effective means







of reversing air flow obstruction
SABA should not be prescribed on a regular schedule
because concerns of possibility of deteriorating asthma
control
Frequent use of SABA is an indication of poor asthma control
Preferred root is inhalation smaller dose , fewer side effects
more rapid on set of action
Ipratropium Bromide as an adjunct to SABA in emergency
room reduces hospital admissions and improves lung function
Systemic Glucocorticoids short oral course + SABA in
moderate to severe asthma exacerbation

LABA
 Salmetrol

 Should be used in combination with inhaled

corticosteroids and not as mono therapy
 Exercise induces asthma in children >= 4 Yrs
one inhalation 30 min prior to exercise
 No additional doses for PTs who are already
receiving it twice daily not recommended by
NIH guidelines

LTRA

 MonteLukast ( singulair)

 Antihistaminic

 Leukotrien receptor antagonist

 Asthma ( not < 12 MO) and allergic rhinitis (





not < 6 MO)
Morning dosing not evaluated
Prophylactic and chronic treatment of asthma
Exercise induced asthma in >= 15 Yrs
Zafir Lukast : prophylactic and chronic
treatment of asthma

ICA
 Most potent anti inflammatory agents available

for the treatment of asthma
 Inhibiting most steps in the cascade of the
inflammatory response
 Benefits reducing bronchial hyper
responsiveness , prevention of late asthmatic
response , enhanced lung function
 Inhaled Glucocorticoids first line controller
therapy for persistent asthma or those who
require step 2

Prognosis
 35%of preschool children experience recurrent

coughing and wheezing,1/3 of them continue to
have persistent asthma into later childhood and
2/3 improvement on their own through their teen
yrs
 Asthma severity by age 7-10 yrs is predictive of
asthma persistence into adulthood
 Children with mod to severe asthma and lower lung
function are likely to have persistent asthma as
adults
 Children with milder asthma and N/R lung function
are likely to improve over time or be periodically
asthmatic

THANK YOU FOR YOUR
ATTENTION


Slide 2

Asthma in Children
DR. A.Mirshokraei
NIOC Hospital Pediatrics Ward

Definition :

DEFINITION

- Chronic inflammatory condition of the
lung airways resulting in episodic airflow
obstruction
- AHR to provocative exposures
Asthma management
• Reducing airway inflammation by: Minimizing
pro inflammatory environmental exposure, using
daily controller anti inflammatory medication,
controlling co morbid conditions that worsen
asthma, less inflammation better asthma
control and fewer exacerbations

Anyway exacerbations

occur

BUT
Even the uncommon
child with sever asthma can
be managed to live normally

 RECURRENT WHEEZING EPISODES WITH COMMON

RESPIRATORY
VIRUSES(RSV,RHINOVIRUS,INFLUENZA,PARAINFLUENZA,A
DENOVIRUS,HUMAN METAPNUMOVIRUS)

 HOST FEATURES AFFECTING IMMUNOLOGIC HOST

DEFENSE,INFLAMMATION/PREVIOUS VIRAL INFECTIONS
MAINIFESTED AS PNUMONIA OR BRONCHIOLITIS
REQUIRING HOSPITALIZATION UNDERLIE THE
RECURRENT WHEEZING IN EARLY CHILDHOOD

 OTHER AIRWAY EXPOSURES SUCH AS INDOOR AND HOME

ALLERGENS,COLD AIR,STRONG ODORS,TOBACCO
SMOKE,ALL INCREASE AHR

 ALLERGEN ELLIMINATION SOMETIMES LEEDS TO CURE

EPIDEMIOLOGY
 Common etiology of emergency visits and school day missing

in childhood ,occasionally hospitalization and rare deaths
specially in poverty ,urban living ,ethnic minorities

 Increasing asthma prevalence worldwide(50% per decade)
 Good correlation of asthma prevalence with allergic rhino

sinusitis and atopic eczema and other allergies

 More prevalence in high level urban modern families than

suburban villagers

 More than 80%of asthmatics reported getting the disease

before 6 year

CLINICS
RECURRENT COUGHING/WHEEZING
PATTERNS IN CHILDHOOD BASED ON
NATURAL HISTORY

TRANSIENT EARLY WHEEZING
 Common in early preschool years

 Recurrent coughing/wheezing primary

triggered by common respiratory viral INF
 Tend to resolve during preschool yrs without
increasing risk of asthma later in life
 Problems due to reduced airflow at birth
suggestive of relative narrow airways improved
by school yrs

Persistent Atopy Associated Asthma
 Begins in early preschool yrs

 Associated with atopy (eg atopic dermatitis in





infancy, allergic rhinitis, food allergy)
Biologic factors e.g.: early inhalant sensitization,
increase serum IGE, increase blood eosinophills,
High risk of persistence into later childhood and
adulthood lung function abnormality
Those with onset<3 yrs
reduced air flow by
school yrs
Those with later onset of symptoms or allergen
sensitizations unlikely persistence lung function
abnormality later

Non-Atopic Wheezing
 Wheezing ,coughing beginning in early life

often with RSV INF resolves later in childhood
without increasing risk of persistence asthma

 Associated with bronchial hyper

responsiveness near birth

Asthma with declining lung function
• Children with asthma with progressive

increase in air flow limitation

• Associated with hyper inflation in childhood
• Male gender

Late onset asthma in females associated with
obesity and early onset puberty
 Onset between 8_13 yrs

 Associated with early onset puberty and obesity
 Specific for females

Occupational type asthma in children
 Children with asthma and occupational type exposure

known to trigger asthma in adults in occupational settings

Types of Asthma
common clinical presentations of intermittent
recurrent wheezing and/or coughing
 Recurrent wheezing in early childhood

 Chronic asthma associated with allergy
 Females 11 yrs with early onset puberty and

obesity

Pathogenesis

 Airflow obstruction resulting from

Broncho constriction of bronchiolar smooth
muscle mass
II. Cellular inflammatory infiltrates and exudates
mostly Eosinophills(also N , M ,L ,mast cells
,basophiles)fill and obstruct airways and damage
epithelium and induce desquamation into airway
lumen mediated by T helper cells and other
immune cells that produce pro allergic pro
inflammatory cytokines(IL4,IL6,IL13)
III. Breach in normal immune regulatory process
I.

RESULT
 Airway inflammation

 AHR
 Edema basement membrane thickness sub

epithelial collagen deposition
 Smooth muscle and mucus gland hypertrophy
and mucus hyper secretion

Air obstruction

Clinical manifestations and diagnosis
 Most common intermittent dry cough and

expiratory wheezing

 Shortness of breath and chest tightness in older

children and adults

 Intermittent non focal chest pain in younger

children

 Worsening of respiratory symptoms at night
 Worsening of day time symptoms by activity

Continue…..
 Subtle symptoms such as self limitation of activities

,general fatigue ,difficulty in keeping up with peers

 Relief with aerosolized bronchodilators
 Lack of improvement with bronchodilators and steroid

is inconsistent with Asthma and should consider
Asthma masquerading conditions!!!!

 Hyper ventilation, intercostal retractions ,nasal flaring

,respiratory accessory muscle use

 Its common not to hear the expiratory wheezing when

Air flow is so limited before treatment

Asthma Triggers
 Common viral infections of the respiratory tract
 Aero allergens in sensitized asthmatics ,animal dander ,dust











mite ,molds ,indoor allergens ,cockroaches
Seasonal aero allergens ,pollens(trees ,grasses ,weeds ,)
Environmental tobacco smoke
Air pollutants ,ozone ,so2,wood or coal smoke ,endotoxin
,mycotoxin ,dust
Strong or noxious odors or fumes ,perfume ,hair spray
,cleaning agents
Occupational exposure
Cold air ,dry air
Exercise
Crying ,laughter ,hyperventilation
Co morbid conditions Rhinitis ,Sinusitis ,GER

Clinics
History:
Triggering symptoms by laughter
,cold air ,airway irritants
Exposures that induce airway
irritation such as viral URTI
Mycoplasma ,Chlamydia
Inhaled allergens
All lead to AHR

Presence Of Risk Factors:
 History of other allergies ,allergic Rhinitis,

allergic Conjunctivitis ,atopic Dermatitis ,food
allergies

 Parental Asthma
 Symptoms apart from cold

Continue…..
 No or minimal signs in routine visits

 Dry or persistent cough

 Normal chest findings unless wheezing when asking

to breath deeper
 Quick relief (10 MIN) after SABA use
 Expiratory wheezing ,prolonged expiratory phase
,decreased sounds in RT lower pos lobe due to
regional hypoventilation owing to airway
obstruction
 Rales , ronchi ,crackles due to hyper secretion
 Segmental crackles and poor breath sounds
atelectasis?

Continue….
 Labored respiration ,respiratory distress increased

prolongation of expiration and wheezing in E and I

 Poor air entry
 Inter costal retractions ,nasal flaring ,supra and

infra sternal retractions

 And again in most sever forms expiratory wheezing

does not appear until some broncho dilation

DD

GERD Rhino sinusitis co morbid

conditions with asthma

Recurrent aspiration in early

life(tracheo broncho malacia
,TEF , foreign body ,CF ,BPD

VCD in older children and

adolescents

LAB FINDINGS
Pulmonary Function
Testing

Continue….
 Forced expiratory airflow measures helpful

in Diagnosis , assessing efficacy of therapy
and monitoring Asthma in children specially
in poor children who do not have PHE
unless obstruction is sever

 Valueablity of spirometric findings in children>6

yrs

 3 efforts the highest is the peak
 Reduced FEV

obstruction

FEV1/FVC <0.80 means significant

 Improvement in FEV1 following beta 2 agonist > =

12% or 200 ml is consistent with Asthma

 Peak flow meter

CXR

Often normal aside from subtle and

nonspecific findings of hyperinflation

Peribronchial thickening
Helping in diagnosis of Asthma

differentials

Diagnosis of complications of Asthma

exacerbations

Other tests such as allergy skin prick
testing

Treatment
 www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm

Asthma Treatment & Management
has 4 components :
Assessment and monitoring of disease
activity
2. Provision to educate pt and family
3. Identification and management of
precipitating factors and co morbid
conditions
4. Appropriate selection of medication
1.

 Attainment of optimal Asthma control

Component 1
 Asthma severity :intermittent
 Persistent: mild ,mod ,severe
 Only once during patient initial evaluation in pt

who is not using a daily controller agent
 Asthma control degree to which symptoms ,
on going functional impairments , risk of
adverse events minimized and goals of
therapy are met

Continue….
Well controlled
2. Not well controlled
3. Very poor controlled
1.

 NIH guidelines for both severity and

control for 3 age groups

0-4 yrs
2. 5-11 yrs
3. =>12 yrs
1.

Important
even in the absence of frequent symptoms
infants and children whom have risk factors
for asthma and 4 or more episodes of
wheezing over the past yr which lasted more
than 1 day or 2 or more exacerbations in
the last 6 months requiring syst
corticosteroids should be considered in the
persistent group and hence receive long term
controller therapy

Important Tips..
 Regular clinical visits every 2-6 weeks
 Assessment of :

Pt symptoms frequency night and day
2. Need for short acting inhaled b2 agonists for
quick relief
3. Ability to engage in normal activities
4. Air flow measures for>=5 yrs
1.

Continue..
 Component 2 : pt education

 Component 3 : control of factors contributing

to asthma severity
1. Environmental exposures
2. Co morbid conditions
 Component 4 :principals of asthma
pharmacotherapy

Asthma Medication
 SABA

 ICS

 LABA
 LTRA

 SYSTEMIC STEROIDS

 NONSTEROIDAL ANTIINFLAMMATORY

CROMOLYN AND NEDOCROMYL
 OXYGEN
 ANTICHOLINERGIC AGENTS
IPRATROPIUM
BROMIDE
 ANTIIMMUNOGLUBOLINE E

MANAGEMENT OF ASTHMA EXACERBATION(STATUS ASTHMATICUS)
RISK ASSESMENT ON ADMISSION

FOCUSED HISTORY

ONSET OF CURRENT EXACERBATION
FREQUENCY AND severity of daytime and night
time symptoms and activity limitation
Frequency of rescue bronchodilator use
Current medication and allergies
Potential triggers
History of systemic steroid courses, emergency
department visists , hospitalization, intubation or life
threatening episodes

Clinical assesment

Physical examination findings: vital signs,
breathlessness, air movement, use of accessory
respiratory muscles, retractions, anxiety level,
alteration in mental status
Pulse oximetry
Lung function(defer in pts with mod to severe
distress or history of labile disease)

Treatment
Drugs and trade name

Mechanism of action and dosing

Cautions and adverse effects

Oxygen(mask or nasal canula)
Inhaled short acting b2
agonist
Albuterol nebulized
solution(5mg/ml concentrates
Albuterol MDI
Levabuterol

Treats hypoxia
Bronchodilator
Neubolizer 0.15 mg/kg every 20 min for 3
doses as needed,then 0.15_0.3 mg/kg up t 10
mg every 1_4 hour as needed or up to 0.5
mg/kg/hr by continous neubolization
2_8 puf up to every 20 min for 3 doses as
needed then every 1 hr as needed

Monitor pulse oximetry to maintain o2 saturation>92%
Cardiorespiratory monitoring
During exacerbations,frequent or continuous use can cause
pulmonary vasodilatation,v/q mistmatch and hypoxemia
Adverse effect palpitation, tachycardia, arrhythmia, tremor,
hypoxemia
Neubolizer:when giving concentrate forms,dilute with saline to 3
ml total neubolized volume
For MDI use space/holding chamber

Systemic corticosteroids
Prednisolone tb
Methyl prednisolon
Anticholinergics
Ipratropium
Atrovent
Ipratropium with Albuterol

Anti inflammatory
0.5_1 mg/kg every 6-8 hr for 48 hr , then 1-2 mg/kg
day bid(max 60 mg/day)
Short course burst for exacerbation 1-2 mg/kg/day qd
or bid for 3-7 days
Mucolitic/bronchodilator
Neubolizer 0.5 mg q6-8 hr (tid or qid) as needed
MDI 2 paf qid
1 vial by neubolizer qid



If pt has been exposed chickenpox or measles, consider passive
immunoglobulin prophylaxis, also risk of complications with
herspes simplex and TB

For daily dosing , 8 am administration minimizes adrenal
suppression

Children may benefit from dosage tapering if course exceed 7 days

Adverse effect monitoring: frequent therapy bursts risk numerous
corticosteroid adverse effects

Should not be used as first line treatment added to b2 agonist
therapy
Neubolizer may mix Ipratropium with Albuterol

QUICK RELIEF MEDICATION
SABA

Anti cholinergic(ipratropium)
Short term systemic gluco

corticoid

SABA
 Quick relief of asthma symptoms
 Relax airway smooth muscle prompt airflow↑
 Repetitive or continuous SABA is the most effective means







of reversing air flow obstruction
SABA should not be prescribed on a regular schedule
because concerns of possibility of deteriorating asthma
control
Frequent use of SABA is an indication of poor asthma control
Preferred root is inhalation smaller dose , fewer side effects
more rapid on set of action
Ipratropium Bromide as an adjunct to SABA in emergency
room reduces hospital admissions and improves lung function
Systemic Glucocorticoids short oral course + SABA in
moderate to severe asthma exacerbation

LABA
 Salmetrol

 Should be used in combination with inhaled

corticosteroids and not as mono therapy
 Exercise induces asthma in children >= 4 Yrs
one inhalation 30 min prior to exercise
 No additional doses for PTs who are already
receiving it twice daily not recommended by
NIH guidelines

LTRA

 MonteLukast ( singulair)

 Antihistaminic

 Leukotrien receptor antagonist

 Asthma ( not < 12 MO) and allergic rhinitis (





not < 6 MO)
Morning dosing not evaluated
Prophylactic and chronic treatment of asthma
Exercise induced asthma in >= 15 Yrs
Zafir Lukast : prophylactic and chronic
treatment of asthma

ICA
 Most potent anti inflammatory agents available

for the treatment of asthma
 Inhibiting most steps in the cascade of the
inflammatory response
 Benefits reducing bronchial hyper
responsiveness , prevention of late asthmatic
response , enhanced lung function
 Inhaled Glucocorticoids first line controller
therapy for persistent asthma or those who
require step 2

Prognosis
 35%of preschool children experience recurrent

coughing and wheezing,1/3 of them continue to
have persistent asthma into later childhood and
2/3 improvement on their own through their teen
yrs
 Asthma severity by age 7-10 yrs is predictive of
asthma persistence into adulthood
 Children with mod to severe asthma and lower lung
function are likely to have persistent asthma as
adults
 Children with milder asthma and N/R lung function
are likely to improve over time or be periodically
asthmatic

THANK YOU FOR YOUR
ATTENTION


Slide 3

Asthma in Children
DR. A.Mirshokraei
NIOC Hospital Pediatrics Ward

Definition :

DEFINITION

- Chronic inflammatory condition of the
lung airways resulting in episodic airflow
obstruction
- AHR to provocative exposures
Asthma management
• Reducing airway inflammation by: Minimizing
pro inflammatory environmental exposure, using
daily controller anti inflammatory medication,
controlling co morbid conditions that worsen
asthma, less inflammation better asthma
control and fewer exacerbations

Anyway exacerbations

occur

BUT
Even the uncommon
child with sever asthma can
be managed to live normally

 RECURRENT WHEEZING EPISODES WITH COMMON

RESPIRATORY
VIRUSES(RSV,RHINOVIRUS,INFLUENZA,PARAINFLUENZA,A
DENOVIRUS,HUMAN METAPNUMOVIRUS)

 HOST FEATURES AFFECTING IMMUNOLOGIC HOST

DEFENSE,INFLAMMATION/PREVIOUS VIRAL INFECTIONS
MAINIFESTED AS PNUMONIA OR BRONCHIOLITIS
REQUIRING HOSPITALIZATION UNDERLIE THE
RECURRENT WHEEZING IN EARLY CHILDHOOD

 OTHER AIRWAY EXPOSURES SUCH AS INDOOR AND HOME

ALLERGENS,COLD AIR,STRONG ODORS,TOBACCO
SMOKE,ALL INCREASE AHR

 ALLERGEN ELLIMINATION SOMETIMES LEEDS TO CURE

EPIDEMIOLOGY
 Common etiology of emergency visits and school day missing

in childhood ,occasionally hospitalization and rare deaths
specially in poverty ,urban living ,ethnic minorities

 Increasing asthma prevalence worldwide(50% per decade)
 Good correlation of asthma prevalence with allergic rhino

sinusitis and atopic eczema and other allergies

 More prevalence in high level urban modern families than

suburban villagers

 More than 80%of asthmatics reported getting the disease

before 6 year

CLINICS
RECURRENT COUGHING/WHEEZING
PATTERNS IN CHILDHOOD BASED ON
NATURAL HISTORY

TRANSIENT EARLY WHEEZING
 Common in early preschool years

 Recurrent coughing/wheezing primary

triggered by common respiratory viral INF
 Tend to resolve during preschool yrs without
increasing risk of asthma later in life
 Problems due to reduced airflow at birth
suggestive of relative narrow airways improved
by school yrs

Persistent Atopy Associated Asthma
 Begins in early preschool yrs

 Associated with atopy (eg atopic dermatitis in





infancy, allergic rhinitis, food allergy)
Biologic factors e.g.: early inhalant sensitization,
increase serum IGE, increase blood eosinophills,
High risk of persistence into later childhood and
adulthood lung function abnormality
Those with onset<3 yrs
reduced air flow by
school yrs
Those with later onset of symptoms or allergen
sensitizations unlikely persistence lung function
abnormality later

Non-Atopic Wheezing
 Wheezing ,coughing beginning in early life

often with RSV INF resolves later in childhood
without increasing risk of persistence asthma

 Associated with bronchial hyper

responsiveness near birth

Asthma with declining lung function
• Children with asthma with progressive

increase in air flow limitation

• Associated with hyper inflation in childhood
• Male gender

Late onset asthma in females associated with
obesity and early onset puberty
 Onset between 8_13 yrs

 Associated with early onset puberty and obesity
 Specific for females

Occupational type asthma in children
 Children with asthma and occupational type exposure

known to trigger asthma in adults in occupational settings

Types of Asthma
common clinical presentations of intermittent
recurrent wheezing and/or coughing
 Recurrent wheezing in early childhood

 Chronic asthma associated with allergy
 Females 11 yrs with early onset puberty and

obesity

Pathogenesis

 Airflow obstruction resulting from

Broncho constriction of bronchiolar smooth
muscle mass
II. Cellular inflammatory infiltrates and exudates
mostly Eosinophills(also N , M ,L ,mast cells
,basophiles)fill and obstruct airways and damage
epithelium and induce desquamation into airway
lumen mediated by T helper cells and other
immune cells that produce pro allergic pro
inflammatory cytokines(IL4,IL6,IL13)
III. Breach in normal immune regulatory process
I.

RESULT
 Airway inflammation

 AHR
 Edema basement membrane thickness sub

epithelial collagen deposition
 Smooth muscle and mucus gland hypertrophy
and mucus hyper secretion

Air obstruction

Clinical manifestations and diagnosis
 Most common intermittent dry cough and

expiratory wheezing

 Shortness of breath and chest tightness in older

children and adults

 Intermittent non focal chest pain in younger

children

 Worsening of respiratory symptoms at night
 Worsening of day time symptoms by activity

Continue…..
 Subtle symptoms such as self limitation of activities

,general fatigue ,difficulty in keeping up with peers

 Relief with aerosolized bronchodilators
 Lack of improvement with bronchodilators and steroid

is inconsistent with Asthma and should consider
Asthma masquerading conditions!!!!

 Hyper ventilation, intercostal retractions ,nasal flaring

,respiratory accessory muscle use

 Its common not to hear the expiratory wheezing when

Air flow is so limited before treatment

Asthma Triggers
 Common viral infections of the respiratory tract
 Aero allergens in sensitized asthmatics ,animal dander ,dust











mite ,molds ,indoor allergens ,cockroaches
Seasonal aero allergens ,pollens(trees ,grasses ,weeds ,)
Environmental tobacco smoke
Air pollutants ,ozone ,so2,wood or coal smoke ,endotoxin
,mycotoxin ,dust
Strong or noxious odors or fumes ,perfume ,hair spray
,cleaning agents
Occupational exposure
Cold air ,dry air
Exercise
Crying ,laughter ,hyperventilation
Co morbid conditions Rhinitis ,Sinusitis ,GER

Clinics
History:
Triggering symptoms by laughter
,cold air ,airway irritants
Exposures that induce airway
irritation such as viral URTI
Mycoplasma ,Chlamydia
Inhaled allergens
All lead to AHR

Presence Of Risk Factors:
 History of other allergies ,allergic Rhinitis,

allergic Conjunctivitis ,atopic Dermatitis ,food
allergies

 Parental Asthma
 Symptoms apart from cold

Continue…..
 No or minimal signs in routine visits

 Dry or persistent cough

 Normal chest findings unless wheezing when asking

to breath deeper
 Quick relief (10 MIN) after SABA use
 Expiratory wheezing ,prolonged expiratory phase
,decreased sounds in RT lower pos lobe due to
regional hypoventilation owing to airway
obstruction
 Rales , ronchi ,crackles due to hyper secretion
 Segmental crackles and poor breath sounds
atelectasis?

Continue….
 Labored respiration ,respiratory distress increased

prolongation of expiration and wheezing in E and I

 Poor air entry
 Inter costal retractions ,nasal flaring ,supra and

infra sternal retractions

 And again in most sever forms expiratory wheezing

does not appear until some broncho dilation

DD

GERD Rhino sinusitis co morbid

conditions with asthma

Recurrent aspiration in early

life(tracheo broncho malacia
,TEF , foreign body ,CF ,BPD

VCD in older children and

adolescents

LAB FINDINGS
Pulmonary Function
Testing

Continue….
 Forced expiratory airflow measures helpful

in Diagnosis , assessing efficacy of therapy
and monitoring Asthma in children specially
in poor children who do not have PHE
unless obstruction is sever

 Valueablity of spirometric findings in children>6

yrs

 3 efforts the highest is the peak
 Reduced FEV

obstruction

FEV1/FVC <0.80 means significant

 Improvement in FEV1 following beta 2 agonist > =

12% or 200 ml is consistent with Asthma

 Peak flow meter

CXR

Often normal aside from subtle and

nonspecific findings of hyperinflation

Peribronchial thickening
Helping in diagnosis of Asthma

differentials

Diagnosis of complications of Asthma

exacerbations

Other tests such as allergy skin prick
testing

Treatment
 www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm

Asthma Treatment & Management
has 4 components :
Assessment and monitoring of disease
activity
2. Provision to educate pt and family
3. Identification and management of
precipitating factors and co morbid
conditions
4. Appropriate selection of medication
1.

 Attainment of optimal Asthma control

Component 1
 Asthma severity :intermittent
 Persistent: mild ,mod ,severe
 Only once during patient initial evaluation in pt

who is not using a daily controller agent
 Asthma control degree to which symptoms ,
on going functional impairments , risk of
adverse events minimized and goals of
therapy are met

Continue….
Well controlled
2. Not well controlled
3. Very poor controlled
1.

 NIH guidelines for both severity and

control for 3 age groups

0-4 yrs
2. 5-11 yrs
3. =>12 yrs
1.

Important
even in the absence of frequent symptoms
infants and children whom have risk factors
for asthma and 4 or more episodes of
wheezing over the past yr which lasted more
than 1 day or 2 or more exacerbations in
the last 6 months requiring syst
corticosteroids should be considered in the
persistent group and hence receive long term
controller therapy

Important Tips..
 Regular clinical visits every 2-6 weeks
 Assessment of :

Pt symptoms frequency night and day
2. Need for short acting inhaled b2 agonists for
quick relief
3. Ability to engage in normal activities
4. Air flow measures for>=5 yrs
1.

Continue..
 Component 2 : pt education

 Component 3 : control of factors contributing

to asthma severity
1. Environmental exposures
2. Co morbid conditions
 Component 4 :principals of asthma
pharmacotherapy

Asthma Medication
 SABA

 ICS

 LABA
 LTRA

 SYSTEMIC STEROIDS

 NONSTEROIDAL ANTIINFLAMMATORY

CROMOLYN AND NEDOCROMYL
 OXYGEN
 ANTICHOLINERGIC AGENTS
IPRATROPIUM
BROMIDE
 ANTIIMMUNOGLUBOLINE E

MANAGEMENT OF ASTHMA EXACERBATION(STATUS ASTHMATICUS)
RISK ASSESMENT ON ADMISSION

FOCUSED HISTORY

ONSET OF CURRENT EXACERBATION
FREQUENCY AND severity of daytime and night
time symptoms and activity limitation
Frequency of rescue bronchodilator use
Current medication and allergies
Potential triggers
History of systemic steroid courses, emergency
department visists , hospitalization, intubation or life
threatening episodes

Clinical assesment

Physical examination findings: vital signs,
breathlessness, air movement, use of accessory
respiratory muscles, retractions, anxiety level,
alteration in mental status
Pulse oximetry
Lung function(defer in pts with mod to severe
distress or history of labile disease)

Treatment
Drugs and trade name

Mechanism of action and dosing

Cautions and adverse effects

Oxygen(mask or nasal canula)
Inhaled short acting b2
agonist
Albuterol nebulized
solution(5mg/ml concentrates
Albuterol MDI
Levabuterol

Treats hypoxia
Bronchodilator
Neubolizer 0.15 mg/kg every 20 min for 3
doses as needed,then 0.15_0.3 mg/kg up t 10
mg every 1_4 hour as needed or up to 0.5
mg/kg/hr by continous neubolization
2_8 puf up to every 20 min for 3 doses as
needed then every 1 hr as needed

Monitor pulse oximetry to maintain o2 saturation>92%
Cardiorespiratory monitoring
During exacerbations,frequent or continuous use can cause
pulmonary vasodilatation,v/q mistmatch and hypoxemia
Adverse effect palpitation, tachycardia, arrhythmia, tremor,
hypoxemia
Neubolizer:when giving concentrate forms,dilute with saline to 3
ml total neubolized volume
For MDI use space/holding chamber

Systemic corticosteroids
Prednisolone tb
Methyl prednisolon
Anticholinergics
Ipratropium
Atrovent
Ipratropium with Albuterol

Anti inflammatory
0.5_1 mg/kg every 6-8 hr for 48 hr , then 1-2 mg/kg
day bid(max 60 mg/day)
Short course burst for exacerbation 1-2 mg/kg/day qd
or bid for 3-7 days
Mucolitic/bronchodilator
Neubolizer 0.5 mg q6-8 hr (tid or qid) as needed
MDI 2 paf qid
1 vial by neubolizer qid



If pt has been exposed chickenpox or measles, consider passive
immunoglobulin prophylaxis, also risk of complications with
herspes simplex and TB

For daily dosing , 8 am administration minimizes adrenal
suppression

Children may benefit from dosage tapering if course exceed 7 days

Adverse effect monitoring: frequent therapy bursts risk numerous
corticosteroid adverse effects

Should not be used as first line treatment added to b2 agonist
therapy
Neubolizer may mix Ipratropium with Albuterol

QUICK RELIEF MEDICATION
SABA

Anti cholinergic(ipratropium)
Short term systemic gluco

corticoid

SABA
 Quick relief of asthma symptoms
 Relax airway smooth muscle prompt airflow↑
 Repetitive or continuous SABA is the most effective means







of reversing air flow obstruction
SABA should not be prescribed on a regular schedule
because concerns of possibility of deteriorating asthma
control
Frequent use of SABA is an indication of poor asthma control
Preferred root is inhalation smaller dose , fewer side effects
more rapid on set of action
Ipratropium Bromide as an adjunct to SABA in emergency
room reduces hospital admissions and improves lung function
Systemic Glucocorticoids short oral course + SABA in
moderate to severe asthma exacerbation

LABA
 Salmetrol

 Should be used in combination with inhaled

corticosteroids and not as mono therapy
 Exercise induces asthma in children >= 4 Yrs
one inhalation 30 min prior to exercise
 No additional doses for PTs who are already
receiving it twice daily not recommended by
NIH guidelines

LTRA

 MonteLukast ( singulair)

 Antihistaminic

 Leukotrien receptor antagonist

 Asthma ( not < 12 MO) and allergic rhinitis (





not < 6 MO)
Morning dosing not evaluated
Prophylactic and chronic treatment of asthma
Exercise induced asthma in >= 15 Yrs
Zafir Lukast : prophylactic and chronic
treatment of asthma

ICA
 Most potent anti inflammatory agents available

for the treatment of asthma
 Inhibiting most steps in the cascade of the
inflammatory response
 Benefits reducing bronchial hyper
responsiveness , prevention of late asthmatic
response , enhanced lung function
 Inhaled Glucocorticoids first line controller
therapy for persistent asthma or those who
require step 2

Prognosis
 35%of preschool children experience recurrent

coughing and wheezing,1/3 of them continue to
have persistent asthma into later childhood and
2/3 improvement on their own through their teen
yrs
 Asthma severity by age 7-10 yrs is predictive of
asthma persistence into adulthood
 Children with mod to severe asthma and lower lung
function are likely to have persistent asthma as
adults
 Children with milder asthma and N/R lung function
are likely to improve over time or be periodically
asthmatic

THANK YOU FOR YOUR
ATTENTION


Slide 4

Asthma in Children
DR. A.Mirshokraei
NIOC Hospital Pediatrics Ward

Definition :

DEFINITION

- Chronic inflammatory condition of the
lung airways resulting in episodic airflow
obstruction
- AHR to provocative exposures
Asthma management
• Reducing airway inflammation by: Minimizing
pro inflammatory environmental exposure, using
daily controller anti inflammatory medication,
controlling co morbid conditions that worsen
asthma, less inflammation better asthma
control and fewer exacerbations

Anyway exacerbations

occur

BUT
Even the uncommon
child with sever asthma can
be managed to live normally

 RECURRENT WHEEZING EPISODES WITH COMMON

RESPIRATORY
VIRUSES(RSV,RHINOVIRUS,INFLUENZA,PARAINFLUENZA,A
DENOVIRUS,HUMAN METAPNUMOVIRUS)

 HOST FEATURES AFFECTING IMMUNOLOGIC HOST

DEFENSE,INFLAMMATION/PREVIOUS VIRAL INFECTIONS
MAINIFESTED AS PNUMONIA OR BRONCHIOLITIS
REQUIRING HOSPITALIZATION UNDERLIE THE
RECURRENT WHEEZING IN EARLY CHILDHOOD

 OTHER AIRWAY EXPOSURES SUCH AS INDOOR AND HOME

ALLERGENS,COLD AIR,STRONG ODORS,TOBACCO
SMOKE,ALL INCREASE AHR

 ALLERGEN ELLIMINATION SOMETIMES LEEDS TO CURE

EPIDEMIOLOGY
 Common etiology of emergency visits and school day missing

in childhood ,occasionally hospitalization and rare deaths
specially in poverty ,urban living ,ethnic minorities

 Increasing asthma prevalence worldwide(50% per decade)
 Good correlation of asthma prevalence with allergic rhino

sinusitis and atopic eczema and other allergies

 More prevalence in high level urban modern families than

suburban villagers

 More than 80%of asthmatics reported getting the disease

before 6 year

CLINICS
RECURRENT COUGHING/WHEEZING
PATTERNS IN CHILDHOOD BASED ON
NATURAL HISTORY

TRANSIENT EARLY WHEEZING
 Common in early preschool years

 Recurrent coughing/wheezing primary

triggered by common respiratory viral INF
 Tend to resolve during preschool yrs without
increasing risk of asthma later in life
 Problems due to reduced airflow at birth
suggestive of relative narrow airways improved
by school yrs

Persistent Atopy Associated Asthma
 Begins in early preschool yrs

 Associated with atopy (eg atopic dermatitis in





infancy, allergic rhinitis, food allergy)
Biologic factors e.g.: early inhalant sensitization,
increase serum IGE, increase blood eosinophills,
High risk of persistence into later childhood and
adulthood lung function abnormality
Those with onset<3 yrs
reduced air flow by
school yrs
Those with later onset of symptoms or allergen
sensitizations unlikely persistence lung function
abnormality later

Non-Atopic Wheezing
 Wheezing ,coughing beginning in early life

often with RSV INF resolves later in childhood
without increasing risk of persistence asthma

 Associated with bronchial hyper

responsiveness near birth

Asthma with declining lung function
• Children with asthma with progressive

increase in air flow limitation

• Associated with hyper inflation in childhood
• Male gender

Late onset asthma in females associated with
obesity and early onset puberty
 Onset between 8_13 yrs

 Associated with early onset puberty and obesity
 Specific for females

Occupational type asthma in children
 Children with asthma and occupational type exposure

known to trigger asthma in adults in occupational settings

Types of Asthma
common clinical presentations of intermittent
recurrent wheezing and/or coughing
 Recurrent wheezing in early childhood

 Chronic asthma associated with allergy
 Females 11 yrs with early onset puberty and

obesity

Pathogenesis

 Airflow obstruction resulting from

Broncho constriction of bronchiolar smooth
muscle mass
II. Cellular inflammatory infiltrates and exudates
mostly Eosinophills(also N , M ,L ,mast cells
,basophiles)fill and obstruct airways and damage
epithelium and induce desquamation into airway
lumen mediated by T helper cells and other
immune cells that produce pro allergic pro
inflammatory cytokines(IL4,IL6,IL13)
III. Breach in normal immune regulatory process
I.

RESULT
 Airway inflammation

 AHR
 Edema basement membrane thickness sub

epithelial collagen deposition
 Smooth muscle and mucus gland hypertrophy
and mucus hyper secretion

Air obstruction

Clinical manifestations and diagnosis
 Most common intermittent dry cough and

expiratory wheezing

 Shortness of breath and chest tightness in older

children and adults

 Intermittent non focal chest pain in younger

children

 Worsening of respiratory symptoms at night
 Worsening of day time symptoms by activity

Continue…..
 Subtle symptoms such as self limitation of activities

,general fatigue ,difficulty in keeping up with peers

 Relief with aerosolized bronchodilators
 Lack of improvement with bronchodilators and steroid

is inconsistent with Asthma and should consider
Asthma masquerading conditions!!!!

 Hyper ventilation, intercostal retractions ,nasal flaring

,respiratory accessory muscle use

 Its common not to hear the expiratory wheezing when

Air flow is so limited before treatment

Asthma Triggers
 Common viral infections of the respiratory tract
 Aero allergens in sensitized asthmatics ,animal dander ,dust











mite ,molds ,indoor allergens ,cockroaches
Seasonal aero allergens ,pollens(trees ,grasses ,weeds ,)
Environmental tobacco smoke
Air pollutants ,ozone ,so2,wood or coal smoke ,endotoxin
,mycotoxin ,dust
Strong or noxious odors or fumes ,perfume ,hair spray
,cleaning agents
Occupational exposure
Cold air ,dry air
Exercise
Crying ,laughter ,hyperventilation
Co morbid conditions Rhinitis ,Sinusitis ,GER

Clinics
History:
Triggering symptoms by laughter
,cold air ,airway irritants
Exposures that induce airway
irritation such as viral URTI
Mycoplasma ,Chlamydia
Inhaled allergens
All lead to AHR

Presence Of Risk Factors:
 History of other allergies ,allergic Rhinitis,

allergic Conjunctivitis ,atopic Dermatitis ,food
allergies

 Parental Asthma
 Symptoms apart from cold

Continue…..
 No or minimal signs in routine visits

 Dry or persistent cough

 Normal chest findings unless wheezing when asking

to breath deeper
 Quick relief (10 MIN) after SABA use
 Expiratory wheezing ,prolonged expiratory phase
,decreased sounds in RT lower pos lobe due to
regional hypoventilation owing to airway
obstruction
 Rales , ronchi ,crackles due to hyper secretion
 Segmental crackles and poor breath sounds
atelectasis?

Continue….
 Labored respiration ,respiratory distress increased

prolongation of expiration and wheezing in E and I

 Poor air entry
 Inter costal retractions ,nasal flaring ,supra and

infra sternal retractions

 And again in most sever forms expiratory wheezing

does not appear until some broncho dilation

DD

GERD Rhino sinusitis co morbid

conditions with asthma

Recurrent aspiration in early

life(tracheo broncho malacia
,TEF , foreign body ,CF ,BPD

VCD in older children and

adolescents

LAB FINDINGS
Pulmonary Function
Testing

Continue….
 Forced expiratory airflow measures helpful

in Diagnosis , assessing efficacy of therapy
and monitoring Asthma in children specially
in poor children who do not have PHE
unless obstruction is sever

 Valueablity of spirometric findings in children>6

yrs

 3 efforts the highest is the peak
 Reduced FEV

obstruction

FEV1/FVC <0.80 means significant

 Improvement in FEV1 following beta 2 agonist > =

12% or 200 ml is consistent with Asthma

 Peak flow meter

CXR

Often normal aside from subtle and

nonspecific findings of hyperinflation

Peribronchial thickening
Helping in diagnosis of Asthma

differentials

Diagnosis of complications of Asthma

exacerbations

Other tests such as allergy skin prick
testing

Treatment
 www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm

Asthma Treatment & Management
has 4 components :
Assessment and monitoring of disease
activity
2. Provision to educate pt and family
3. Identification and management of
precipitating factors and co morbid
conditions
4. Appropriate selection of medication
1.

 Attainment of optimal Asthma control

Component 1
 Asthma severity :intermittent
 Persistent: mild ,mod ,severe
 Only once during patient initial evaluation in pt

who is not using a daily controller agent
 Asthma control degree to which symptoms ,
on going functional impairments , risk of
adverse events minimized and goals of
therapy are met

Continue….
Well controlled
2. Not well controlled
3. Very poor controlled
1.

 NIH guidelines for both severity and

control for 3 age groups

0-4 yrs
2. 5-11 yrs
3. =>12 yrs
1.

Important
even in the absence of frequent symptoms
infants and children whom have risk factors
for asthma and 4 or more episodes of
wheezing over the past yr which lasted more
than 1 day or 2 or more exacerbations in
the last 6 months requiring syst
corticosteroids should be considered in the
persistent group and hence receive long term
controller therapy

Important Tips..
 Regular clinical visits every 2-6 weeks
 Assessment of :

Pt symptoms frequency night and day
2. Need for short acting inhaled b2 agonists for
quick relief
3. Ability to engage in normal activities
4. Air flow measures for>=5 yrs
1.

Continue..
 Component 2 : pt education

 Component 3 : control of factors contributing

to asthma severity
1. Environmental exposures
2. Co morbid conditions
 Component 4 :principals of asthma
pharmacotherapy

Asthma Medication
 SABA

 ICS

 LABA
 LTRA

 SYSTEMIC STEROIDS

 NONSTEROIDAL ANTIINFLAMMATORY

CROMOLYN AND NEDOCROMYL
 OXYGEN
 ANTICHOLINERGIC AGENTS
IPRATROPIUM
BROMIDE
 ANTIIMMUNOGLUBOLINE E

MANAGEMENT OF ASTHMA EXACERBATION(STATUS ASTHMATICUS)
RISK ASSESMENT ON ADMISSION

FOCUSED HISTORY

ONSET OF CURRENT EXACERBATION
FREQUENCY AND severity of daytime and night
time symptoms and activity limitation
Frequency of rescue bronchodilator use
Current medication and allergies
Potential triggers
History of systemic steroid courses, emergency
department visists , hospitalization, intubation or life
threatening episodes

Clinical assesment

Physical examination findings: vital signs,
breathlessness, air movement, use of accessory
respiratory muscles, retractions, anxiety level,
alteration in mental status
Pulse oximetry
Lung function(defer in pts with mod to severe
distress or history of labile disease)

Treatment
Drugs and trade name

Mechanism of action and dosing

Cautions and adverse effects

Oxygen(mask or nasal canula)
Inhaled short acting b2
agonist
Albuterol nebulized
solution(5mg/ml concentrates
Albuterol MDI
Levabuterol

Treats hypoxia
Bronchodilator
Neubolizer 0.15 mg/kg every 20 min for 3
doses as needed,then 0.15_0.3 mg/kg up t 10
mg every 1_4 hour as needed or up to 0.5
mg/kg/hr by continous neubolization
2_8 puf up to every 20 min for 3 doses as
needed then every 1 hr as needed

Monitor pulse oximetry to maintain o2 saturation>92%
Cardiorespiratory monitoring
During exacerbations,frequent or continuous use can cause
pulmonary vasodilatation,v/q mistmatch and hypoxemia
Adverse effect palpitation, tachycardia, arrhythmia, tremor,
hypoxemia
Neubolizer:when giving concentrate forms,dilute with saline to 3
ml total neubolized volume
For MDI use space/holding chamber

Systemic corticosteroids
Prednisolone tb
Methyl prednisolon
Anticholinergics
Ipratropium
Atrovent
Ipratropium with Albuterol

Anti inflammatory
0.5_1 mg/kg every 6-8 hr for 48 hr , then 1-2 mg/kg
day bid(max 60 mg/day)
Short course burst for exacerbation 1-2 mg/kg/day qd
or bid for 3-7 days
Mucolitic/bronchodilator
Neubolizer 0.5 mg q6-8 hr (tid or qid) as needed
MDI 2 paf qid
1 vial by neubolizer qid



If pt has been exposed chickenpox or measles, consider passive
immunoglobulin prophylaxis, also risk of complications with
herspes simplex and TB

For daily dosing , 8 am administration minimizes adrenal
suppression

Children may benefit from dosage tapering if course exceed 7 days

Adverse effect monitoring: frequent therapy bursts risk numerous
corticosteroid adverse effects

Should not be used as first line treatment added to b2 agonist
therapy
Neubolizer may mix Ipratropium with Albuterol

QUICK RELIEF MEDICATION
SABA

Anti cholinergic(ipratropium)
Short term systemic gluco

corticoid

SABA
 Quick relief of asthma symptoms
 Relax airway smooth muscle prompt airflow↑
 Repetitive or continuous SABA is the most effective means







of reversing air flow obstruction
SABA should not be prescribed on a regular schedule
because concerns of possibility of deteriorating asthma
control
Frequent use of SABA is an indication of poor asthma control
Preferred root is inhalation smaller dose , fewer side effects
more rapid on set of action
Ipratropium Bromide as an adjunct to SABA in emergency
room reduces hospital admissions and improves lung function
Systemic Glucocorticoids short oral course + SABA in
moderate to severe asthma exacerbation

LABA
 Salmetrol

 Should be used in combination with inhaled

corticosteroids and not as mono therapy
 Exercise induces asthma in children >= 4 Yrs
one inhalation 30 min prior to exercise
 No additional doses for PTs who are already
receiving it twice daily not recommended by
NIH guidelines

LTRA

 MonteLukast ( singulair)

 Antihistaminic

 Leukotrien receptor antagonist

 Asthma ( not < 12 MO) and allergic rhinitis (





not < 6 MO)
Morning dosing not evaluated
Prophylactic and chronic treatment of asthma
Exercise induced asthma in >= 15 Yrs
Zafir Lukast : prophylactic and chronic
treatment of asthma

ICA
 Most potent anti inflammatory agents available

for the treatment of asthma
 Inhibiting most steps in the cascade of the
inflammatory response
 Benefits reducing bronchial hyper
responsiveness , prevention of late asthmatic
response , enhanced lung function
 Inhaled Glucocorticoids first line controller
therapy for persistent asthma or those who
require step 2

Prognosis
 35%of preschool children experience recurrent

coughing and wheezing,1/3 of them continue to
have persistent asthma into later childhood and
2/3 improvement on their own through their teen
yrs
 Asthma severity by age 7-10 yrs is predictive of
asthma persistence into adulthood
 Children with mod to severe asthma and lower lung
function are likely to have persistent asthma as
adults
 Children with milder asthma and N/R lung function
are likely to improve over time or be periodically
asthmatic

THANK YOU FOR YOUR
ATTENTION


Slide 5

Asthma in Children
DR. A.Mirshokraei
NIOC Hospital Pediatrics Ward

Definition :

DEFINITION

- Chronic inflammatory condition of the
lung airways resulting in episodic airflow
obstruction
- AHR to provocative exposures
Asthma management
• Reducing airway inflammation by: Minimizing
pro inflammatory environmental exposure, using
daily controller anti inflammatory medication,
controlling co morbid conditions that worsen
asthma, less inflammation better asthma
control and fewer exacerbations

Anyway exacerbations

occur

BUT
Even the uncommon
child with sever asthma can
be managed to live normally

 RECURRENT WHEEZING EPISODES WITH COMMON

RESPIRATORY
VIRUSES(RSV,RHINOVIRUS,INFLUENZA,PARAINFLUENZA,A
DENOVIRUS,HUMAN METAPNUMOVIRUS)

 HOST FEATURES AFFECTING IMMUNOLOGIC HOST

DEFENSE,INFLAMMATION/PREVIOUS VIRAL INFECTIONS
MAINIFESTED AS PNUMONIA OR BRONCHIOLITIS
REQUIRING HOSPITALIZATION UNDERLIE THE
RECURRENT WHEEZING IN EARLY CHILDHOOD

 OTHER AIRWAY EXPOSURES SUCH AS INDOOR AND HOME

ALLERGENS,COLD AIR,STRONG ODORS,TOBACCO
SMOKE,ALL INCREASE AHR

 ALLERGEN ELLIMINATION SOMETIMES LEEDS TO CURE

EPIDEMIOLOGY
 Common etiology of emergency visits and school day missing

in childhood ,occasionally hospitalization and rare deaths
specially in poverty ,urban living ,ethnic minorities

 Increasing asthma prevalence worldwide(50% per decade)
 Good correlation of asthma prevalence with allergic rhino

sinusitis and atopic eczema and other allergies

 More prevalence in high level urban modern families than

suburban villagers

 More than 80%of asthmatics reported getting the disease

before 6 year

CLINICS
RECURRENT COUGHING/WHEEZING
PATTERNS IN CHILDHOOD BASED ON
NATURAL HISTORY

TRANSIENT EARLY WHEEZING
 Common in early preschool years

 Recurrent coughing/wheezing primary

triggered by common respiratory viral INF
 Tend to resolve during preschool yrs without
increasing risk of asthma later in life
 Problems due to reduced airflow at birth
suggestive of relative narrow airways improved
by school yrs

Persistent Atopy Associated Asthma
 Begins in early preschool yrs

 Associated with atopy (eg atopic dermatitis in





infancy, allergic rhinitis, food allergy)
Biologic factors e.g.: early inhalant sensitization,
increase serum IGE, increase blood eosinophills,
High risk of persistence into later childhood and
adulthood lung function abnormality
Those with onset<3 yrs
reduced air flow by
school yrs
Those with later onset of symptoms or allergen
sensitizations unlikely persistence lung function
abnormality later

Non-Atopic Wheezing
 Wheezing ,coughing beginning in early life

often with RSV INF resolves later in childhood
without increasing risk of persistence asthma

 Associated with bronchial hyper

responsiveness near birth

Asthma with declining lung function
• Children with asthma with progressive

increase in air flow limitation

• Associated with hyper inflation in childhood
• Male gender

Late onset asthma in females associated with
obesity and early onset puberty
 Onset between 8_13 yrs

 Associated with early onset puberty and obesity
 Specific for females

Occupational type asthma in children
 Children with asthma and occupational type exposure

known to trigger asthma in adults in occupational settings

Types of Asthma
common clinical presentations of intermittent
recurrent wheezing and/or coughing
 Recurrent wheezing in early childhood

 Chronic asthma associated with allergy
 Females 11 yrs with early onset puberty and

obesity

Pathogenesis

 Airflow obstruction resulting from

Broncho constriction of bronchiolar smooth
muscle mass
II. Cellular inflammatory infiltrates and exudates
mostly Eosinophills(also N , M ,L ,mast cells
,basophiles)fill and obstruct airways and damage
epithelium and induce desquamation into airway
lumen mediated by T helper cells and other
immune cells that produce pro allergic pro
inflammatory cytokines(IL4,IL6,IL13)
III. Breach in normal immune regulatory process
I.

RESULT
 Airway inflammation

 AHR
 Edema basement membrane thickness sub

epithelial collagen deposition
 Smooth muscle and mucus gland hypertrophy
and mucus hyper secretion

Air obstruction

Clinical manifestations and diagnosis
 Most common intermittent dry cough and

expiratory wheezing

 Shortness of breath and chest tightness in older

children and adults

 Intermittent non focal chest pain in younger

children

 Worsening of respiratory symptoms at night
 Worsening of day time symptoms by activity

Continue…..
 Subtle symptoms such as self limitation of activities

,general fatigue ,difficulty in keeping up with peers

 Relief with aerosolized bronchodilators
 Lack of improvement with bronchodilators and steroid

is inconsistent with Asthma and should consider
Asthma masquerading conditions!!!!

 Hyper ventilation, intercostal retractions ,nasal flaring

,respiratory accessory muscle use

 Its common not to hear the expiratory wheezing when

Air flow is so limited before treatment

Asthma Triggers
 Common viral infections of the respiratory tract
 Aero allergens in sensitized asthmatics ,animal dander ,dust











mite ,molds ,indoor allergens ,cockroaches
Seasonal aero allergens ,pollens(trees ,grasses ,weeds ,)
Environmental tobacco smoke
Air pollutants ,ozone ,so2,wood or coal smoke ,endotoxin
,mycotoxin ,dust
Strong or noxious odors or fumes ,perfume ,hair spray
,cleaning agents
Occupational exposure
Cold air ,dry air
Exercise
Crying ,laughter ,hyperventilation
Co morbid conditions Rhinitis ,Sinusitis ,GER

Clinics
History:
Triggering symptoms by laughter
,cold air ,airway irritants
Exposures that induce airway
irritation such as viral URTI
Mycoplasma ,Chlamydia
Inhaled allergens
All lead to AHR

Presence Of Risk Factors:
 History of other allergies ,allergic Rhinitis,

allergic Conjunctivitis ,atopic Dermatitis ,food
allergies

 Parental Asthma
 Symptoms apart from cold

Continue…..
 No or minimal signs in routine visits

 Dry or persistent cough

 Normal chest findings unless wheezing when asking

to breath deeper
 Quick relief (10 MIN) after SABA use
 Expiratory wheezing ,prolonged expiratory phase
,decreased sounds in RT lower pos lobe due to
regional hypoventilation owing to airway
obstruction
 Rales , ronchi ,crackles due to hyper secretion
 Segmental crackles and poor breath sounds
atelectasis?

Continue….
 Labored respiration ,respiratory distress increased

prolongation of expiration and wheezing in E and I

 Poor air entry
 Inter costal retractions ,nasal flaring ,supra and

infra sternal retractions

 And again in most sever forms expiratory wheezing

does not appear until some broncho dilation

DD

GERD Rhino sinusitis co morbid

conditions with asthma

Recurrent aspiration in early

life(tracheo broncho malacia
,TEF , foreign body ,CF ,BPD

VCD in older children and

adolescents

LAB FINDINGS
Pulmonary Function
Testing

Continue….
 Forced expiratory airflow measures helpful

in Diagnosis , assessing efficacy of therapy
and monitoring Asthma in children specially
in poor children who do not have PHE
unless obstruction is sever

 Valueablity of spirometric findings in children>6

yrs

 3 efforts the highest is the peak
 Reduced FEV

obstruction

FEV1/FVC <0.80 means significant

 Improvement in FEV1 following beta 2 agonist > =

12% or 200 ml is consistent with Asthma

 Peak flow meter

CXR

Often normal aside from subtle and

nonspecific findings of hyperinflation

Peribronchial thickening
Helping in diagnosis of Asthma

differentials

Diagnosis of complications of Asthma

exacerbations

Other tests such as allergy skin prick
testing

Treatment
 www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm

Asthma Treatment & Management
has 4 components :
Assessment and monitoring of disease
activity
2. Provision to educate pt and family
3. Identification and management of
precipitating factors and co morbid
conditions
4. Appropriate selection of medication
1.

 Attainment of optimal Asthma control

Component 1
 Asthma severity :intermittent
 Persistent: mild ,mod ,severe
 Only once during patient initial evaluation in pt

who is not using a daily controller agent
 Asthma control degree to which symptoms ,
on going functional impairments , risk of
adverse events minimized and goals of
therapy are met

Continue….
Well controlled
2. Not well controlled
3. Very poor controlled
1.

 NIH guidelines for both severity and

control for 3 age groups

0-4 yrs
2. 5-11 yrs
3. =>12 yrs
1.

Important
even in the absence of frequent symptoms
infants and children whom have risk factors
for asthma and 4 or more episodes of
wheezing over the past yr which lasted more
than 1 day or 2 or more exacerbations in
the last 6 months requiring syst
corticosteroids should be considered in the
persistent group and hence receive long term
controller therapy

Important Tips..
 Regular clinical visits every 2-6 weeks
 Assessment of :

Pt symptoms frequency night and day
2. Need for short acting inhaled b2 agonists for
quick relief
3. Ability to engage in normal activities
4. Air flow measures for>=5 yrs
1.

Continue..
 Component 2 : pt education

 Component 3 : control of factors contributing

to asthma severity
1. Environmental exposures
2. Co morbid conditions
 Component 4 :principals of asthma
pharmacotherapy

Asthma Medication
 SABA

 ICS

 LABA
 LTRA

 SYSTEMIC STEROIDS

 NONSTEROIDAL ANTIINFLAMMATORY

CROMOLYN AND NEDOCROMYL
 OXYGEN
 ANTICHOLINERGIC AGENTS
IPRATROPIUM
BROMIDE
 ANTIIMMUNOGLUBOLINE E

MANAGEMENT OF ASTHMA EXACERBATION(STATUS ASTHMATICUS)
RISK ASSESMENT ON ADMISSION

FOCUSED HISTORY

ONSET OF CURRENT EXACERBATION
FREQUENCY AND severity of daytime and night
time symptoms and activity limitation
Frequency of rescue bronchodilator use
Current medication and allergies
Potential triggers
History of systemic steroid courses, emergency
department visists , hospitalization, intubation or life
threatening episodes

Clinical assesment

Physical examination findings: vital signs,
breathlessness, air movement, use of accessory
respiratory muscles, retractions, anxiety level,
alteration in mental status
Pulse oximetry
Lung function(defer in pts with mod to severe
distress or history of labile disease)

Treatment
Drugs and trade name

Mechanism of action and dosing

Cautions and adverse effects

Oxygen(mask or nasal canula)
Inhaled short acting b2
agonist
Albuterol nebulized
solution(5mg/ml concentrates
Albuterol MDI
Levabuterol

Treats hypoxia
Bronchodilator
Neubolizer 0.15 mg/kg every 20 min for 3
doses as needed,then 0.15_0.3 mg/kg up t 10
mg every 1_4 hour as needed or up to 0.5
mg/kg/hr by continous neubolization
2_8 puf up to every 20 min for 3 doses as
needed then every 1 hr as needed

Monitor pulse oximetry to maintain o2 saturation>92%
Cardiorespiratory monitoring
During exacerbations,frequent or continuous use can cause
pulmonary vasodilatation,v/q mistmatch and hypoxemia
Adverse effect palpitation, tachycardia, arrhythmia, tremor,
hypoxemia
Neubolizer:when giving concentrate forms,dilute with saline to 3
ml total neubolized volume
For MDI use space/holding chamber

Systemic corticosteroids
Prednisolone tb
Methyl prednisolon
Anticholinergics
Ipratropium
Atrovent
Ipratropium with Albuterol

Anti inflammatory
0.5_1 mg/kg every 6-8 hr for 48 hr , then 1-2 mg/kg
day bid(max 60 mg/day)
Short course burst for exacerbation 1-2 mg/kg/day qd
or bid for 3-7 days
Mucolitic/bronchodilator
Neubolizer 0.5 mg q6-8 hr (tid or qid) as needed
MDI 2 paf qid
1 vial by neubolizer qid



If pt has been exposed chickenpox or measles, consider passive
immunoglobulin prophylaxis, also risk of complications with
herspes simplex and TB

For daily dosing , 8 am administration minimizes adrenal
suppression

Children may benefit from dosage tapering if course exceed 7 days

Adverse effect monitoring: frequent therapy bursts risk numerous
corticosteroid adverse effects

Should not be used as first line treatment added to b2 agonist
therapy
Neubolizer may mix Ipratropium with Albuterol

QUICK RELIEF MEDICATION
SABA

Anti cholinergic(ipratropium)
Short term systemic gluco

corticoid

SABA
 Quick relief of asthma symptoms
 Relax airway smooth muscle prompt airflow↑
 Repetitive or continuous SABA is the most effective means







of reversing air flow obstruction
SABA should not be prescribed on a regular schedule
because concerns of possibility of deteriorating asthma
control
Frequent use of SABA is an indication of poor asthma control
Preferred root is inhalation smaller dose , fewer side effects
more rapid on set of action
Ipratropium Bromide as an adjunct to SABA in emergency
room reduces hospital admissions and improves lung function
Systemic Glucocorticoids short oral course + SABA in
moderate to severe asthma exacerbation

LABA
 Salmetrol

 Should be used in combination with inhaled

corticosteroids and not as mono therapy
 Exercise induces asthma in children >= 4 Yrs
one inhalation 30 min prior to exercise
 No additional doses for PTs who are already
receiving it twice daily not recommended by
NIH guidelines

LTRA

 MonteLukast ( singulair)

 Antihistaminic

 Leukotrien receptor antagonist

 Asthma ( not < 12 MO) and allergic rhinitis (





not < 6 MO)
Morning dosing not evaluated
Prophylactic and chronic treatment of asthma
Exercise induced asthma in >= 15 Yrs
Zafir Lukast : prophylactic and chronic
treatment of asthma

ICA
 Most potent anti inflammatory agents available

for the treatment of asthma
 Inhibiting most steps in the cascade of the
inflammatory response
 Benefits reducing bronchial hyper
responsiveness , prevention of late asthmatic
response , enhanced lung function
 Inhaled Glucocorticoids first line controller
therapy for persistent asthma or those who
require step 2

Prognosis
 35%of preschool children experience recurrent

coughing and wheezing,1/3 of them continue to
have persistent asthma into later childhood and
2/3 improvement on their own through their teen
yrs
 Asthma severity by age 7-10 yrs is predictive of
asthma persistence into adulthood
 Children with mod to severe asthma and lower lung
function are likely to have persistent asthma as
adults
 Children with milder asthma and N/R lung function
are likely to improve over time or be periodically
asthmatic

THANK YOU FOR YOUR
ATTENTION


Slide 6

Asthma in Children
DR. A.Mirshokraei
NIOC Hospital Pediatrics Ward

Definition :

DEFINITION

- Chronic inflammatory condition of the
lung airways resulting in episodic airflow
obstruction
- AHR to provocative exposures
Asthma management
• Reducing airway inflammation by: Minimizing
pro inflammatory environmental exposure, using
daily controller anti inflammatory medication,
controlling co morbid conditions that worsen
asthma, less inflammation better asthma
control and fewer exacerbations

Anyway exacerbations

occur

BUT
Even the uncommon
child with sever asthma can
be managed to live normally

 RECURRENT WHEEZING EPISODES WITH COMMON

RESPIRATORY
VIRUSES(RSV,RHINOVIRUS,INFLUENZA,PARAINFLUENZA,A
DENOVIRUS,HUMAN METAPNUMOVIRUS)

 HOST FEATURES AFFECTING IMMUNOLOGIC HOST

DEFENSE,INFLAMMATION/PREVIOUS VIRAL INFECTIONS
MAINIFESTED AS PNUMONIA OR BRONCHIOLITIS
REQUIRING HOSPITALIZATION UNDERLIE THE
RECURRENT WHEEZING IN EARLY CHILDHOOD

 OTHER AIRWAY EXPOSURES SUCH AS INDOOR AND HOME

ALLERGENS,COLD AIR,STRONG ODORS,TOBACCO
SMOKE,ALL INCREASE AHR

 ALLERGEN ELLIMINATION SOMETIMES LEEDS TO CURE

EPIDEMIOLOGY
 Common etiology of emergency visits and school day missing

in childhood ,occasionally hospitalization and rare deaths
specially in poverty ,urban living ,ethnic minorities

 Increasing asthma prevalence worldwide(50% per decade)
 Good correlation of asthma prevalence with allergic rhino

sinusitis and atopic eczema and other allergies

 More prevalence in high level urban modern families than

suburban villagers

 More than 80%of asthmatics reported getting the disease

before 6 year

CLINICS
RECURRENT COUGHING/WHEEZING
PATTERNS IN CHILDHOOD BASED ON
NATURAL HISTORY

TRANSIENT EARLY WHEEZING
 Common in early preschool years

 Recurrent coughing/wheezing primary

triggered by common respiratory viral INF
 Tend to resolve during preschool yrs without
increasing risk of asthma later in life
 Problems due to reduced airflow at birth
suggestive of relative narrow airways improved
by school yrs

Persistent Atopy Associated Asthma
 Begins in early preschool yrs

 Associated with atopy (eg atopic dermatitis in





infancy, allergic rhinitis, food allergy)
Biologic factors e.g.: early inhalant sensitization,
increase serum IGE, increase blood eosinophills,
High risk of persistence into later childhood and
adulthood lung function abnormality
Those with onset<3 yrs
reduced air flow by
school yrs
Those with later onset of symptoms or allergen
sensitizations unlikely persistence lung function
abnormality later

Non-Atopic Wheezing
 Wheezing ,coughing beginning in early life

often with RSV INF resolves later in childhood
without increasing risk of persistence asthma

 Associated with bronchial hyper

responsiveness near birth

Asthma with declining lung function
• Children with asthma with progressive

increase in air flow limitation

• Associated with hyper inflation in childhood
• Male gender

Late onset asthma in females associated with
obesity and early onset puberty
 Onset between 8_13 yrs

 Associated with early onset puberty and obesity
 Specific for females

Occupational type asthma in children
 Children with asthma and occupational type exposure

known to trigger asthma in adults in occupational settings

Types of Asthma
common clinical presentations of intermittent
recurrent wheezing and/or coughing
 Recurrent wheezing in early childhood

 Chronic asthma associated with allergy
 Females 11 yrs with early onset puberty and

obesity

Pathogenesis

 Airflow obstruction resulting from

Broncho constriction of bronchiolar smooth
muscle mass
II. Cellular inflammatory infiltrates and exudates
mostly Eosinophills(also N , M ,L ,mast cells
,basophiles)fill and obstruct airways and damage
epithelium and induce desquamation into airway
lumen mediated by T helper cells and other
immune cells that produce pro allergic pro
inflammatory cytokines(IL4,IL6,IL13)
III. Breach in normal immune regulatory process
I.

RESULT
 Airway inflammation

 AHR
 Edema basement membrane thickness sub

epithelial collagen deposition
 Smooth muscle and mucus gland hypertrophy
and mucus hyper secretion

Air obstruction

Clinical manifestations and diagnosis
 Most common intermittent dry cough and

expiratory wheezing

 Shortness of breath and chest tightness in older

children and adults

 Intermittent non focal chest pain in younger

children

 Worsening of respiratory symptoms at night
 Worsening of day time symptoms by activity

Continue…..
 Subtle symptoms such as self limitation of activities

,general fatigue ,difficulty in keeping up with peers

 Relief with aerosolized bronchodilators
 Lack of improvement with bronchodilators and steroid

is inconsistent with Asthma and should consider
Asthma masquerading conditions!!!!

 Hyper ventilation, intercostal retractions ,nasal flaring

,respiratory accessory muscle use

 Its common not to hear the expiratory wheezing when

Air flow is so limited before treatment

Asthma Triggers
 Common viral infections of the respiratory tract
 Aero allergens in sensitized asthmatics ,animal dander ,dust











mite ,molds ,indoor allergens ,cockroaches
Seasonal aero allergens ,pollens(trees ,grasses ,weeds ,)
Environmental tobacco smoke
Air pollutants ,ozone ,so2,wood or coal smoke ,endotoxin
,mycotoxin ,dust
Strong or noxious odors or fumes ,perfume ,hair spray
,cleaning agents
Occupational exposure
Cold air ,dry air
Exercise
Crying ,laughter ,hyperventilation
Co morbid conditions Rhinitis ,Sinusitis ,GER

Clinics
History:
Triggering symptoms by laughter
,cold air ,airway irritants
Exposures that induce airway
irritation such as viral URTI
Mycoplasma ,Chlamydia
Inhaled allergens
All lead to AHR

Presence Of Risk Factors:
 History of other allergies ,allergic Rhinitis,

allergic Conjunctivitis ,atopic Dermatitis ,food
allergies

 Parental Asthma
 Symptoms apart from cold

Continue…..
 No or minimal signs in routine visits

 Dry or persistent cough

 Normal chest findings unless wheezing when asking

to breath deeper
 Quick relief (10 MIN) after SABA use
 Expiratory wheezing ,prolonged expiratory phase
,decreased sounds in RT lower pos lobe due to
regional hypoventilation owing to airway
obstruction
 Rales , ronchi ,crackles due to hyper secretion
 Segmental crackles and poor breath sounds
atelectasis?

Continue….
 Labored respiration ,respiratory distress increased

prolongation of expiration and wheezing in E and I

 Poor air entry
 Inter costal retractions ,nasal flaring ,supra and

infra sternal retractions

 And again in most sever forms expiratory wheezing

does not appear until some broncho dilation

DD

GERD Rhino sinusitis co morbid

conditions with asthma

Recurrent aspiration in early

life(tracheo broncho malacia
,TEF , foreign body ,CF ,BPD

VCD in older children and

adolescents

LAB FINDINGS
Pulmonary Function
Testing

Continue….
 Forced expiratory airflow measures helpful

in Diagnosis , assessing efficacy of therapy
and monitoring Asthma in children specially
in poor children who do not have PHE
unless obstruction is sever

 Valueablity of spirometric findings in children>6

yrs

 3 efforts the highest is the peak
 Reduced FEV

obstruction

FEV1/FVC <0.80 means significant

 Improvement in FEV1 following beta 2 agonist > =

12% or 200 ml is consistent with Asthma

 Peak flow meter

CXR

Often normal aside from subtle and

nonspecific findings of hyperinflation

Peribronchial thickening
Helping in diagnosis of Asthma

differentials

Diagnosis of complications of Asthma

exacerbations

Other tests such as allergy skin prick
testing

Treatment
 www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm

Asthma Treatment & Management
has 4 components :
Assessment and monitoring of disease
activity
2. Provision to educate pt and family
3. Identification and management of
precipitating factors and co morbid
conditions
4. Appropriate selection of medication
1.

 Attainment of optimal Asthma control

Component 1
 Asthma severity :intermittent
 Persistent: mild ,mod ,severe
 Only once during patient initial evaluation in pt

who is not using a daily controller agent
 Asthma control degree to which symptoms ,
on going functional impairments , risk of
adverse events minimized and goals of
therapy are met

Continue….
Well controlled
2. Not well controlled
3. Very poor controlled
1.

 NIH guidelines for both severity and

control for 3 age groups

0-4 yrs
2. 5-11 yrs
3. =>12 yrs
1.

Important
even in the absence of frequent symptoms
infants and children whom have risk factors
for asthma and 4 or more episodes of
wheezing over the past yr which lasted more
than 1 day or 2 or more exacerbations in
the last 6 months requiring syst
corticosteroids should be considered in the
persistent group and hence receive long term
controller therapy

Important Tips..
 Regular clinical visits every 2-6 weeks
 Assessment of :

Pt symptoms frequency night and day
2. Need for short acting inhaled b2 agonists for
quick relief
3. Ability to engage in normal activities
4. Air flow measures for>=5 yrs
1.

Continue..
 Component 2 : pt education

 Component 3 : control of factors contributing

to asthma severity
1. Environmental exposures
2. Co morbid conditions
 Component 4 :principals of asthma
pharmacotherapy

Asthma Medication
 SABA

 ICS

 LABA
 LTRA

 SYSTEMIC STEROIDS

 NONSTEROIDAL ANTIINFLAMMATORY

CROMOLYN AND NEDOCROMYL
 OXYGEN
 ANTICHOLINERGIC AGENTS
IPRATROPIUM
BROMIDE
 ANTIIMMUNOGLUBOLINE E

MANAGEMENT OF ASTHMA EXACERBATION(STATUS ASTHMATICUS)
RISK ASSESMENT ON ADMISSION

FOCUSED HISTORY

ONSET OF CURRENT EXACERBATION
FREQUENCY AND severity of daytime and night
time symptoms and activity limitation
Frequency of rescue bronchodilator use
Current medication and allergies
Potential triggers
History of systemic steroid courses, emergency
department visists , hospitalization, intubation or life
threatening episodes

Clinical assesment

Physical examination findings: vital signs,
breathlessness, air movement, use of accessory
respiratory muscles, retractions, anxiety level,
alteration in mental status
Pulse oximetry
Lung function(defer in pts with mod to severe
distress or history of labile disease)

Treatment
Drugs and trade name

Mechanism of action and dosing

Cautions and adverse effects

Oxygen(mask or nasal canula)
Inhaled short acting b2
agonist
Albuterol nebulized
solution(5mg/ml concentrates
Albuterol MDI
Levabuterol

Treats hypoxia
Bronchodilator
Neubolizer 0.15 mg/kg every 20 min for 3
doses as needed,then 0.15_0.3 mg/kg up t 10
mg every 1_4 hour as needed or up to 0.5
mg/kg/hr by continous neubolization
2_8 puf up to every 20 min for 3 doses as
needed then every 1 hr as needed

Monitor pulse oximetry to maintain o2 saturation>92%
Cardiorespiratory monitoring
During exacerbations,frequent or continuous use can cause
pulmonary vasodilatation,v/q mistmatch and hypoxemia
Adverse effect palpitation, tachycardia, arrhythmia, tremor,
hypoxemia
Neubolizer:when giving concentrate forms,dilute with saline to 3
ml total neubolized volume
For MDI use space/holding chamber

Systemic corticosteroids
Prednisolone tb
Methyl prednisolon
Anticholinergics
Ipratropium
Atrovent
Ipratropium with Albuterol

Anti inflammatory
0.5_1 mg/kg every 6-8 hr for 48 hr , then 1-2 mg/kg
day bid(max 60 mg/day)
Short course burst for exacerbation 1-2 mg/kg/day qd
or bid for 3-7 days
Mucolitic/bronchodilator
Neubolizer 0.5 mg q6-8 hr (tid or qid) as needed
MDI 2 paf qid
1 vial by neubolizer qid



If pt has been exposed chickenpox or measles, consider passive
immunoglobulin prophylaxis, also risk of complications with
herspes simplex and TB

For daily dosing , 8 am administration minimizes adrenal
suppression

Children may benefit from dosage tapering if course exceed 7 days

Adverse effect monitoring: frequent therapy bursts risk numerous
corticosteroid adverse effects

Should not be used as first line treatment added to b2 agonist
therapy
Neubolizer may mix Ipratropium with Albuterol

QUICK RELIEF MEDICATION
SABA

Anti cholinergic(ipratropium)
Short term systemic gluco

corticoid

SABA
 Quick relief of asthma symptoms
 Relax airway smooth muscle prompt airflow↑
 Repetitive or continuous SABA is the most effective means







of reversing air flow obstruction
SABA should not be prescribed on a regular schedule
because concerns of possibility of deteriorating asthma
control
Frequent use of SABA is an indication of poor asthma control
Preferred root is inhalation smaller dose , fewer side effects
more rapid on set of action
Ipratropium Bromide as an adjunct to SABA in emergency
room reduces hospital admissions and improves lung function
Systemic Glucocorticoids short oral course + SABA in
moderate to severe asthma exacerbation

LABA
 Salmetrol

 Should be used in combination with inhaled

corticosteroids and not as mono therapy
 Exercise induces asthma in children >= 4 Yrs
one inhalation 30 min prior to exercise
 No additional doses for PTs who are already
receiving it twice daily not recommended by
NIH guidelines

LTRA

 MonteLukast ( singulair)

 Antihistaminic

 Leukotrien receptor antagonist

 Asthma ( not < 12 MO) and allergic rhinitis (





not < 6 MO)
Morning dosing not evaluated
Prophylactic and chronic treatment of asthma
Exercise induced asthma in >= 15 Yrs
Zafir Lukast : prophylactic and chronic
treatment of asthma

ICA
 Most potent anti inflammatory agents available

for the treatment of asthma
 Inhibiting most steps in the cascade of the
inflammatory response
 Benefits reducing bronchial hyper
responsiveness , prevention of late asthmatic
response , enhanced lung function
 Inhaled Glucocorticoids first line controller
therapy for persistent asthma or those who
require step 2

Prognosis
 35%of preschool children experience recurrent

coughing and wheezing,1/3 of them continue to
have persistent asthma into later childhood and
2/3 improvement on their own through their teen
yrs
 Asthma severity by age 7-10 yrs is predictive of
asthma persistence into adulthood
 Children with mod to severe asthma and lower lung
function are likely to have persistent asthma as
adults
 Children with milder asthma and N/R lung function
are likely to improve over time or be periodically
asthmatic

THANK YOU FOR YOUR
ATTENTION


Slide 7

Asthma in Children
DR. A.Mirshokraei
NIOC Hospital Pediatrics Ward

Definition :

DEFINITION

- Chronic inflammatory condition of the
lung airways resulting in episodic airflow
obstruction
- AHR to provocative exposures
Asthma management
• Reducing airway inflammation by: Minimizing
pro inflammatory environmental exposure, using
daily controller anti inflammatory medication,
controlling co morbid conditions that worsen
asthma, less inflammation better asthma
control and fewer exacerbations

Anyway exacerbations

occur

BUT
Even the uncommon
child with sever asthma can
be managed to live normally

 RECURRENT WHEEZING EPISODES WITH COMMON

RESPIRATORY
VIRUSES(RSV,RHINOVIRUS,INFLUENZA,PARAINFLUENZA,A
DENOVIRUS,HUMAN METAPNUMOVIRUS)

 HOST FEATURES AFFECTING IMMUNOLOGIC HOST

DEFENSE,INFLAMMATION/PREVIOUS VIRAL INFECTIONS
MAINIFESTED AS PNUMONIA OR BRONCHIOLITIS
REQUIRING HOSPITALIZATION UNDERLIE THE
RECURRENT WHEEZING IN EARLY CHILDHOOD

 OTHER AIRWAY EXPOSURES SUCH AS INDOOR AND HOME

ALLERGENS,COLD AIR,STRONG ODORS,TOBACCO
SMOKE,ALL INCREASE AHR

 ALLERGEN ELLIMINATION SOMETIMES LEEDS TO CURE

EPIDEMIOLOGY
 Common etiology of emergency visits and school day missing

in childhood ,occasionally hospitalization and rare deaths
specially in poverty ,urban living ,ethnic minorities

 Increasing asthma prevalence worldwide(50% per decade)
 Good correlation of asthma prevalence with allergic rhino

sinusitis and atopic eczema and other allergies

 More prevalence in high level urban modern families than

suburban villagers

 More than 80%of asthmatics reported getting the disease

before 6 year

CLINICS
RECURRENT COUGHING/WHEEZING
PATTERNS IN CHILDHOOD BASED ON
NATURAL HISTORY

TRANSIENT EARLY WHEEZING
 Common in early preschool years

 Recurrent coughing/wheezing primary

triggered by common respiratory viral INF
 Tend to resolve during preschool yrs without
increasing risk of asthma later in life
 Problems due to reduced airflow at birth
suggestive of relative narrow airways improved
by school yrs

Persistent Atopy Associated Asthma
 Begins in early preschool yrs

 Associated with atopy (eg atopic dermatitis in





infancy, allergic rhinitis, food allergy)
Biologic factors e.g.: early inhalant sensitization,
increase serum IGE, increase blood eosinophills,
High risk of persistence into later childhood and
adulthood lung function abnormality
Those with onset<3 yrs
reduced air flow by
school yrs
Those with later onset of symptoms or allergen
sensitizations unlikely persistence lung function
abnormality later

Non-Atopic Wheezing
 Wheezing ,coughing beginning in early life

often with RSV INF resolves later in childhood
without increasing risk of persistence asthma

 Associated with bronchial hyper

responsiveness near birth

Asthma with declining lung function
• Children with asthma with progressive

increase in air flow limitation

• Associated with hyper inflation in childhood
• Male gender

Late onset asthma in females associated with
obesity and early onset puberty
 Onset between 8_13 yrs

 Associated with early onset puberty and obesity
 Specific for females

Occupational type asthma in children
 Children with asthma and occupational type exposure

known to trigger asthma in adults in occupational settings

Types of Asthma
common clinical presentations of intermittent
recurrent wheezing and/or coughing
 Recurrent wheezing in early childhood

 Chronic asthma associated with allergy
 Females 11 yrs with early onset puberty and

obesity

Pathogenesis

 Airflow obstruction resulting from

Broncho constriction of bronchiolar smooth
muscle mass
II. Cellular inflammatory infiltrates and exudates
mostly Eosinophills(also N , M ,L ,mast cells
,basophiles)fill and obstruct airways and damage
epithelium and induce desquamation into airway
lumen mediated by T helper cells and other
immune cells that produce pro allergic pro
inflammatory cytokines(IL4,IL6,IL13)
III. Breach in normal immune regulatory process
I.

RESULT
 Airway inflammation

 AHR
 Edema basement membrane thickness sub

epithelial collagen deposition
 Smooth muscle and mucus gland hypertrophy
and mucus hyper secretion

Air obstruction

Clinical manifestations and diagnosis
 Most common intermittent dry cough and

expiratory wheezing

 Shortness of breath and chest tightness in older

children and adults

 Intermittent non focal chest pain in younger

children

 Worsening of respiratory symptoms at night
 Worsening of day time symptoms by activity

Continue…..
 Subtle symptoms such as self limitation of activities

,general fatigue ,difficulty in keeping up with peers

 Relief with aerosolized bronchodilators
 Lack of improvement with bronchodilators and steroid

is inconsistent with Asthma and should consider
Asthma masquerading conditions!!!!

 Hyper ventilation, intercostal retractions ,nasal flaring

,respiratory accessory muscle use

 Its common not to hear the expiratory wheezing when

Air flow is so limited before treatment

Asthma Triggers
 Common viral infections of the respiratory tract
 Aero allergens in sensitized asthmatics ,animal dander ,dust











mite ,molds ,indoor allergens ,cockroaches
Seasonal aero allergens ,pollens(trees ,grasses ,weeds ,)
Environmental tobacco smoke
Air pollutants ,ozone ,so2,wood or coal smoke ,endotoxin
,mycotoxin ,dust
Strong or noxious odors or fumes ,perfume ,hair spray
,cleaning agents
Occupational exposure
Cold air ,dry air
Exercise
Crying ,laughter ,hyperventilation
Co morbid conditions Rhinitis ,Sinusitis ,GER

Clinics
History:
Triggering symptoms by laughter
,cold air ,airway irritants
Exposures that induce airway
irritation such as viral URTI
Mycoplasma ,Chlamydia
Inhaled allergens
All lead to AHR

Presence Of Risk Factors:
 History of other allergies ,allergic Rhinitis,

allergic Conjunctivitis ,atopic Dermatitis ,food
allergies

 Parental Asthma
 Symptoms apart from cold

Continue…..
 No or minimal signs in routine visits

 Dry or persistent cough

 Normal chest findings unless wheezing when asking

to breath deeper
 Quick relief (10 MIN) after SABA use
 Expiratory wheezing ,prolonged expiratory phase
,decreased sounds in RT lower pos lobe due to
regional hypoventilation owing to airway
obstruction
 Rales , ronchi ,crackles due to hyper secretion
 Segmental crackles and poor breath sounds
atelectasis?

Continue….
 Labored respiration ,respiratory distress increased

prolongation of expiration and wheezing in E and I

 Poor air entry
 Inter costal retractions ,nasal flaring ,supra and

infra sternal retractions

 And again in most sever forms expiratory wheezing

does not appear until some broncho dilation

DD

GERD Rhino sinusitis co morbid

conditions with asthma

Recurrent aspiration in early

life(tracheo broncho malacia
,TEF , foreign body ,CF ,BPD

VCD in older children and

adolescents

LAB FINDINGS
Pulmonary Function
Testing

Continue….
 Forced expiratory airflow measures helpful

in Diagnosis , assessing efficacy of therapy
and monitoring Asthma in children specially
in poor children who do not have PHE
unless obstruction is sever

 Valueablity of spirometric findings in children>6

yrs

 3 efforts the highest is the peak
 Reduced FEV

obstruction

FEV1/FVC <0.80 means significant

 Improvement in FEV1 following beta 2 agonist > =

12% or 200 ml is consistent with Asthma

 Peak flow meter

CXR

Often normal aside from subtle and

nonspecific findings of hyperinflation

Peribronchial thickening
Helping in diagnosis of Asthma

differentials

Diagnosis of complications of Asthma

exacerbations

Other tests such as allergy skin prick
testing

Treatment
 www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm

Asthma Treatment & Management
has 4 components :
Assessment and monitoring of disease
activity
2. Provision to educate pt and family
3. Identification and management of
precipitating factors and co morbid
conditions
4. Appropriate selection of medication
1.

 Attainment of optimal Asthma control

Component 1
 Asthma severity :intermittent
 Persistent: mild ,mod ,severe
 Only once during patient initial evaluation in pt

who is not using a daily controller agent
 Asthma control degree to which symptoms ,
on going functional impairments , risk of
adverse events minimized and goals of
therapy are met

Continue….
Well controlled
2. Not well controlled
3. Very poor controlled
1.

 NIH guidelines for both severity and

control for 3 age groups

0-4 yrs
2. 5-11 yrs
3. =>12 yrs
1.

Important
even in the absence of frequent symptoms
infants and children whom have risk factors
for asthma and 4 or more episodes of
wheezing over the past yr which lasted more
than 1 day or 2 or more exacerbations in
the last 6 months requiring syst
corticosteroids should be considered in the
persistent group and hence receive long term
controller therapy

Important Tips..
 Regular clinical visits every 2-6 weeks
 Assessment of :

Pt symptoms frequency night and day
2. Need for short acting inhaled b2 agonists for
quick relief
3. Ability to engage in normal activities
4. Air flow measures for>=5 yrs
1.

Continue..
 Component 2 : pt education

 Component 3 : control of factors contributing

to asthma severity
1. Environmental exposures
2. Co morbid conditions
 Component 4 :principals of asthma
pharmacotherapy

Asthma Medication
 SABA

 ICS

 LABA
 LTRA

 SYSTEMIC STEROIDS

 NONSTEROIDAL ANTIINFLAMMATORY

CROMOLYN AND NEDOCROMYL
 OXYGEN
 ANTICHOLINERGIC AGENTS
IPRATROPIUM
BROMIDE
 ANTIIMMUNOGLUBOLINE E

MANAGEMENT OF ASTHMA EXACERBATION(STATUS ASTHMATICUS)
RISK ASSESMENT ON ADMISSION

FOCUSED HISTORY

ONSET OF CURRENT EXACERBATION
FREQUENCY AND severity of daytime and night
time symptoms and activity limitation
Frequency of rescue bronchodilator use
Current medication and allergies
Potential triggers
History of systemic steroid courses, emergency
department visists , hospitalization, intubation or life
threatening episodes

Clinical assesment

Physical examination findings: vital signs,
breathlessness, air movement, use of accessory
respiratory muscles, retractions, anxiety level,
alteration in mental status
Pulse oximetry
Lung function(defer in pts with mod to severe
distress or history of labile disease)

Treatment
Drugs and trade name

Mechanism of action and dosing

Cautions and adverse effects

Oxygen(mask or nasal canula)
Inhaled short acting b2
agonist
Albuterol nebulized
solution(5mg/ml concentrates
Albuterol MDI
Levabuterol

Treats hypoxia
Bronchodilator
Neubolizer 0.15 mg/kg every 20 min for 3
doses as needed,then 0.15_0.3 mg/kg up t 10
mg every 1_4 hour as needed or up to 0.5
mg/kg/hr by continous neubolization
2_8 puf up to every 20 min for 3 doses as
needed then every 1 hr as needed

Monitor pulse oximetry to maintain o2 saturation>92%
Cardiorespiratory monitoring
During exacerbations,frequent or continuous use can cause
pulmonary vasodilatation,v/q mistmatch and hypoxemia
Adverse effect palpitation, tachycardia, arrhythmia, tremor,
hypoxemia
Neubolizer:when giving concentrate forms,dilute with saline to 3
ml total neubolized volume
For MDI use space/holding chamber

Systemic corticosteroids
Prednisolone tb
Methyl prednisolon
Anticholinergics
Ipratropium
Atrovent
Ipratropium with Albuterol

Anti inflammatory
0.5_1 mg/kg every 6-8 hr for 48 hr , then 1-2 mg/kg
day bid(max 60 mg/day)
Short course burst for exacerbation 1-2 mg/kg/day qd
or bid for 3-7 days
Mucolitic/bronchodilator
Neubolizer 0.5 mg q6-8 hr (tid or qid) as needed
MDI 2 paf qid
1 vial by neubolizer qid



If pt has been exposed chickenpox or measles, consider passive
immunoglobulin prophylaxis, also risk of complications with
herspes simplex and TB

For daily dosing , 8 am administration minimizes adrenal
suppression

Children may benefit from dosage tapering if course exceed 7 days

Adverse effect monitoring: frequent therapy bursts risk numerous
corticosteroid adverse effects

Should not be used as first line treatment added to b2 agonist
therapy
Neubolizer may mix Ipratropium with Albuterol

QUICK RELIEF MEDICATION
SABA

Anti cholinergic(ipratropium)
Short term systemic gluco

corticoid

SABA
 Quick relief of asthma symptoms
 Relax airway smooth muscle prompt airflow↑
 Repetitive or continuous SABA is the most effective means







of reversing air flow obstruction
SABA should not be prescribed on a regular schedule
because concerns of possibility of deteriorating asthma
control
Frequent use of SABA is an indication of poor asthma control
Preferred root is inhalation smaller dose , fewer side effects
more rapid on set of action
Ipratropium Bromide as an adjunct to SABA in emergency
room reduces hospital admissions and improves lung function
Systemic Glucocorticoids short oral course + SABA in
moderate to severe asthma exacerbation

LABA
 Salmetrol

 Should be used in combination with inhaled

corticosteroids and not as mono therapy
 Exercise induces asthma in children >= 4 Yrs
one inhalation 30 min prior to exercise
 No additional doses for PTs who are already
receiving it twice daily not recommended by
NIH guidelines

LTRA

 MonteLukast ( singulair)

 Antihistaminic

 Leukotrien receptor antagonist

 Asthma ( not < 12 MO) and allergic rhinitis (





not < 6 MO)
Morning dosing not evaluated
Prophylactic and chronic treatment of asthma
Exercise induced asthma in >= 15 Yrs
Zafir Lukast : prophylactic and chronic
treatment of asthma

ICA
 Most potent anti inflammatory agents available

for the treatment of asthma
 Inhibiting most steps in the cascade of the
inflammatory response
 Benefits reducing bronchial hyper
responsiveness , prevention of late asthmatic
response , enhanced lung function
 Inhaled Glucocorticoids first line controller
therapy for persistent asthma or those who
require step 2

Prognosis
 35%of preschool children experience recurrent

coughing and wheezing,1/3 of them continue to
have persistent asthma into later childhood and
2/3 improvement on their own through their teen
yrs
 Asthma severity by age 7-10 yrs is predictive of
asthma persistence into adulthood
 Children with mod to severe asthma and lower lung
function are likely to have persistent asthma as
adults
 Children with milder asthma and N/R lung function
are likely to improve over time or be periodically
asthmatic

THANK YOU FOR YOUR
ATTENTION


Slide 8

Asthma in Children
DR. A.Mirshokraei
NIOC Hospital Pediatrics Ward

Definition :

DEFINITION

- Chronic inflammatory condition of the
lung airways resulting in episodic airflow
obstruction
- AHR to provocative exposures
Asthma management
• Reducing airway inflammation by: Minimizing
pro inflammatory environmental exposure, using
daily controller anti inflammatory medication,
controlling co morbid conditions that worsen
asthma, less inflammation better asthma
control and fewer exacerbations

Anyway exacerbations

occur

BUT
Even the uncommon
child with sever asthma can
be managed to live normally

 RECURRENT WHEEZING EPISODES WITH COMMON

RESPIRATORY
VIRUSES(RSV,RHINOVIRUS,INFLUENZA,PARAINFLUENZA,A
DENOVIRUS,HUMAN METAPNUMOVIRUS)

 HOST FEATURES AFFECTING IMMUNOLOGIC HOST

DEFENSE,INFLAMMATION/PREVIOUS VIRAL INFECTIONS
MAINIFESTED AS PNUMONIA OR BRONCHIOLITIS
REQUIRING HOSPITALIZATION UNDERLIE THE
RECURRENT WHEEZING IN EARLY CHILDHOOD

 OTHER AIRWAY EXPOSURES SUCH AS INDOOR AND HOME

ALLERGENS,COLD AIR,STRONG ODORS,TOBACCO
SMOKE,ALL INCREASE AHR

 ALLERGEN ELLIMINATION SOMETIMES LEEDS TO CURE

EPIDEMIOLOGY
 Common etiology of emergency visits and school day missing

in childhood ,occasionally hospitalization and rare deaths
specially in poverty ,urban living ,ethnic minorities

 Increasing asthma prevalence worldwide(50% per decade)
 Good correlation of asthma prevalence with allergic rhino

sinusitis and atopic eczema and other allergies

 More prevalence in high level urban modern families than

suburban villagers

 More than 80%of asthmatics reported getting the disease

before 6 year

CLINICS
RECURRENT COUGHING/WHEEZING
PATTERNS IN CHILDHOOD BASED ON
NATURAL HISTORY

TRANSIENT EARLY WHEEZING
 Common in early preschool years

 Recurrent coughing/wheezing primary

triggered by common respiratory viral INF
 Tend to resolve during preschool yrs without
increasing risk of asthma later in life
 Problems due to reduced airflow at birth
suggestive of relative narrow airways improved
by school yrs

Persistent Atopy Associated Asthma
 Begins in early preschool yrs

 Associated with atopy (eg atopic dermatitis in





infancy, allergic rhinitis, food allergy)
Biologic factors e.g.: early inhalant sensitization,
increase serum IGE, increase blood eosinophills,
High risk of persistence into later childhood and
adulthood lung function abnormality
Those with onset<3 yrs
reduced air flow by
school yrs
Those with later onset of symptoms or allergen
sensitizations unlikely persistence lung function
abnormality later

Non-Atopic Wheezing
 Wheezing ,coughing beginning in early life

often with RSV INF resolves later in childhood
without increasing risk of persistence asthma

 Associated with bronchial hyper

responsiveness near birth

Asthma with declining lung function
• Children with asthma with progressive

increase in air flow limitation

• Associated with hyper inflation in childhood
• Male gender

Late onset asthma in females associated with
obesity and early onset puberty
 Onset between 8_13 yrs

 Associated with early onset puberty and obesity
 Specific for females

Occupational type asthma in children
 Children with asthma and occupational type exposure

known to trigger asthma in adults in occupational settings

Types of Asthma
common clinical presentations of intermittent
recurrent wheezing and/or coughing
 Recurrent wheezing in early childhood

 Chronic asthma associated with allergy
 Females 11 yrs with early onset puberty and

obesity

Pathogenesis

 Airflow obstruction resulting from

Broncho constriction of bronchiolar smooth
muscle mass
II. Cellular inflammatory infiltrates and exudates
mostly Eosinophills(also N , M ,L ,mast cells
,basophiles)fill and obstruct airways and damage
epithelium and induce desquamation into airway
lumen mediated by T helper cells and other
immune cells that produce pro allergic pro
inflammatory cytokines(IL4,IL6,IL13)
III. Breach in normal immune regulatory process
I.

RESULT
 Airway inflammation

 AHR
 Edema basement membrane thickness sub

epithelial collagen deposition
 Smooth muscle and mucus gland hypertrophy
and mucus hyper secretion

Air obstruction

Clinical manifestations and diagnosis
 Most common intermittent dry cough and

expiratory wheezing

 Shortness of breath and chest tightness in older

children and adults

 Intermittent non focal chest pain in younger

children

 Worsening of respiratory symptoms at night
 Worsening of day time symptoms by activity

Continue…..
 Subtle symptoms such as self limitation of activities

,general fatigue ,difficulty in keeping up with peers

 Relief with aerosolized bronchodilators
 Lack of improvement with bronchodilators and steroid

is inconsistent with Asthma and should consider
Asthma masquerading conditions!!!!

 Hyper ventilation, intercostal retractions ,nasal flaring

,respiratory accessory muscle use

 Its common not to hear the expiratory wheezing when

Air flow is so limited before treatment

Asthma Triggers
 Common viral infections of the respiratory tract
 Aero allergens in sensitized asthmatics ,animal dander ,dust











mite ,molds ,indoor allergens ,cockroaches
Seasonal aero allergens ,pollens(trees ,grasses ,weeds ,)
Environmental tobacco smoke
Air pollutants ,ozone ,so2,wood or coal smoke ,endotoxin
,mycotoxin ,dust
Strong or noxious odors or fumes ,perfume ,hair spray
,cleaning agents
Occupational exposure
Cold air ,dry air
Exercise
Crying ,laughter ,hyperventilation
Co morbid conditions Rhinitis ,Sinusitis ,GER

Clinics
History:
Triggering symptoms by laughter
,cold air ,airway irritants
Exposures that induce airway
irritation such as viral URTI
Mycoplasma ,Chlamydia
Inhaled allergens
All lead to AHR

Presence Of Risk Factors:
 History of other allergies ,allergic Rhinitis,

allergic Conjunctivitis ,atopic Dermatitis ,food
allergies

 Parental Asthma
 Symptoms apart from cold

Continue…..
 No or minimal signs in routine visits

 Dry or persistent cough

 Normal chest findings unless wheezing when asking

to breath deeper
 Quick relief (10 MIN) after SABA use
 Expiratory wheezing ,prolonged expiratory phase
,decreased sounds in RT lower pos lobe due to
regional hypoventilation owing to airway
obstruction
 Rales , ronchi ,crackles due to hyper secretion
 Segmental crackles and poor breath sounds
atelectasis?

Continue….
 Labored respiration ,respiratory distress increased

prolongation of expiration and wheezing in E and I

 Poor air entry
 Inter costal retractions ,nasal flaring ,supra and

infra sternal retractions

 And again in most sever forms expiratory wheezing

does not appear until some broncho dilation

DD

GERD Rhino sinusitis co morbid

conditions with asthma

Recurrent aspiration in early

life(tracheo broncho malacia
,TEF , foreign body ,CF ,BPD

VCD in older children and

adolescents

LAB FINDINGS
Pulmonary Function
Testing

Continue….
 Forced expiratory airflow measures helpful

in Diagnosis , assessing efficacy of therapy
and monitoring Asthma in children specially
in poor children who do not have PHE
unless obstruction is sever

 Valueablity of spirometric findings in children>6

yrs

 3 efforts the highest is the peak
 Reduced FEV

obstruction

FEV1/FVC <0.80 means significant

 Improvement in FEV1 following beta 2 agonist > =

12% or 200 ml is consistent with Asthma

 Peak flow meter

CXR

Often normal aside from subtle and

nonspecific findings of hyperinflation

Peribronchial thickening
Helping in diagnosis of Asthma

differentials

Diagnosis of complications of Asthma

exacerbations

Other tests such as allergy skin prick
testing

Treatment
 www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm

Asthma Treatment & Management
has 4 components :
Assessment and monitoring of disease
activity
2. Provision to educate pt and family
3. Identification and management of
precipitating factors and co morbid
conditions
4. Appropriate selection of medication
1.

 Attainment of optimal Asthma control

Component 1
 Asthma severity :intermittent
 Persistent: mild ,mod ,severe
 Only once during patient initial evaluation in pt

who is not using a daily controller agent
 Asthma control degree to which symptoms ,
on going functional impairments , risk of
adverse events minimized and goals of
therapy are met

Continue….
Well controlled
2. Not well controlled
3. Very poor controlled
1.

 NIH guidelines for both severity and

control for 3 age groups

0-4 yrs
2. 5-11 yrs
3. =>12 yrs
1.

Important
even in the absence of frequent symptoms
infants and children whom have risk factors
for asthma and 4 or more episodes of
wheezing over the past yr which lasted more
than 1 day or 2 or more exacerbations in
the last 6 months requiring syst
corticosteroids should be considered in the
persistent group and hence receive long term
controller therapy

Important Tips..
 Regular clinical visits every 2-6 weeks
 Assessment of :

Pt symptoms frequency night and day
2. Need for short acting inhaled b2 agonists for
quick relief
3. Ability to engage in normal activities
4. Air flow measures for>=5 yrs
1.

Continue..
 Component 2 : pt education

 Component 3 : control of factors contributing

to asthma severity
1. Environmental exposures
2. Co morbid conditions
 Component 4 :principals of asthma
pharmacotherapy

Asthma Medication
 SABA

 ICS

 LABA
 LTRA

 SYSTEMIC STEROIDS

 NONSTEROIDAL ANTIINFLAMMATORY

CROMOLYN AND NEDOCROMYL
 OXYGEN
 ANTICHOLINERGIC AGENTS
IPRATROPIUM
BROMIDE
 ANTIIMMUNOGLUBOLINE E

MANAGEMENT OF ASTHMA EXACERBATION(STATUS ASTHMATICUS)
RISK ASSESMENT ON ADMISSION

FOCUSED HISTORY

ONSET OF CURRENT EXACERBATION
FREQUENCY AND severity of daytime and night
time symptoms and activity limitation
Frequency of rescue bronchodilator use
Current medication and allergies
Potential triggers
History of systemic steroid courses, emergency
department visists , hospitalization, intubation or life
threatening episodes

Clinical assesment

Physical examination findings: vital signs,
breathlessness, air movement, use of accessory
respiratory muscles, retractions, anxiety level,
alteration in mental status
Pulse oximetry
Lung function(defer in pts with mod to severe
distress or history of labile disease)

Treatment
Drugs and trade name

Mechanism of action and dosing

Cautions and adverse effects

Oxygen(mask or nasal canula)
Inhaled short acting b2
agonist
Albuterol nebulized
solution(5mg/ml concentrates
Albuterol MDI
Levabuterol

Treats hypoxia
Bronchodilator
Neubolizer 0.15 mg/kg every 20 min for 3
doses as needed,then 0.15_0.3 mg/kg up t 10
mg every 1_4 hour as needed or up to 0.5
mg/kg/hr by continous neubolization
2_8 puf up to every 20 min for 3 doses as
needed then every 1 hr as needed

Monitor pulse oximetry to maintain o2 saturation>92%
Cardiorespiratory monitoring
During exacerbations,frequent or continuous use can cause
pulmonary vasodilatation,v/q mistmatch and hypoxemia
Adverse effect palpitation, tachycardia, arrhythmia, tremor,
hypoxemia
Neubolizer:when giving concentrate forms,dilute with saline to 3
ml total neubolized volume
For MDI use space/holding chamber

Systemic corticosteroids
Prednisolone tb
Methyl prednisolon
Anticholinergics
Ipratropium
Atrovent
Ipratropium with Albuterol

Anti inflammatory
0.5_1 mg/kg every 6-8 hr for 48 hr , then 1-2 mg/kg
day bid(max 60 mg/day)
Short course burst for exacerbation 1-2 mg/kg/day qd
or bid for 3-7 days
Mucolitic/bronchodilator
Neubolizer 0.5 mg q6-8 hr (tid or qid) as needed
MDI 2 paf qid
1 vial by neubolizer qid



If pt has been exposed chickenpox or measles, consider passive
immunoglobulin prophylaxis, also risk of complications with
herspes simplex and TB

For daily dosing , 8 am administration minimizes adrenal
suppression

Children may benefit from dosage tapering if course exceed 7 days

Adverse effect monitoring: frequent therapy bursts risk numerous
corticosteroid adverse effects

Should not be used as first line treatment added to b2 agonist
therapy
Neubolizer may mix Ipratropium with Albuterol

QUICK RELIEF MEDICATION
SABA

Anti cholinergic(ipratropium)
Short term systemic gluco

corticoid

SABA
 Quick relief of asthma symptoms
 Relax airway smooth muscle prompt airflow↑
 Repetitive or continuous SABA is the most effective means







of reversing air flow obstruction
SABA should not be prescribed on a regular schedule
because concerns of possibility of deteriorating asthma
control
Frequent use of SABA is an indication of poor asthma control
Preferred root is inhalation smaller dose , fewer side effects
more rapid on set of action
Ipratropium Bromide as an adjunct to SABA in emergency
room reduces hospital admissions and improves lung function
Systemic Glucocorticoids short oral course + SABA in
moderate to severe asthma exacerbation

LABA
 Salmetrol

 Should be used in combination with inhaled

corticosteroids and not as mono therapy
 Exercise induces asthma in children >= 4 Yrs
one inhalation 30 min prior to exercise
 No additional doses for PTs who are already
receiving it twice daily not recommended by
NIH guidelines

LTRA

 MonteLukast ( singulair)

 Antihistaminic

 Leukotrien receptor antagonist

 Asthma ( not < 12 MO) and allergic rhinitis (





not < 6 MO)
Morning dosing not evaluated
Prophylactic and chronic treatment of asthma
Exercise induced asthma in >= 15 Yrs
Zafir Lukast : prophylactic and chronic
treatment of asthma

ICA
 Most potent anti inflammatory agents available

for the treatment of asthma
 Inhibiting most steps in the cascade of the
inflammatory response
 Benefits reducing bronchial hyper
responsiveness , prevention of late asthmatic
response , enhanced lung function
 Inhaled Glucocorticoids first line controller
therapy for persistent asthma or those who
require step 2

Prognosis
 35%of preschool children experience recurrent

coughing and wheezing,1/3 of them continue to
have persistent asthma into later childhood and
2/3 improvement on their own through their teen
yrs
 Asthma severity by age 7-10 yrs is predictive of
asthma persistence into adulthood
 Children with mod to severe asthma and lower lung
function are likely to have persistent asthma as
adults
 Children with milder asthma and N/R lung function
are likely to improve over time or be periodically
asthmatic

THANK YOU FOR YOUR
ATTENTION


Slide 9

Asthma in Children
DR. A.Mirshokraei
NIOC Hospital Pediatrics Ward

Definition :

DEFINITION

- Chronic inflammatory condition of the
lung airways resulting in episodic airflow
obstruction
- AHR to provocative exposures
Asthma management
• Reducing airway inflammation by: Minimizing
pro inflammatory environmental exposure, using
daily controller anti inflammatory medication,
controlling co morbid conditions that worsen
asthma, less inflammation better asthma
control and fewer exacerbations

Anyway exacerbations

occur

BUT
Even the uncommon
child with sever asthma can
be managed to live normally

 RECURRENT WHEEZING EPISODES WITH COMMON

RESPIRATORY
VIRUSES(RSV,RHINOVIRUS,INFLUENZA,PARAINFLUENZA,A
DENOVIRUS,HUMAN METAPNUMOVIRUS)

 HOST FEATURES AFFECTING IMMUNOLOGIC HOST

DEFENSE,INFLAMMATION/PREVIOUS VIRAL INFECTIONS
MAINIFESTED AS PNUMONIA OR BRONCHIOLITIS
REQUIRING HOSPITALIZATION UNDERLIE THE
RECURRENT WHEEZING IN EARLY CHILDHOOD

 OTHER AIRWAY EXPOSURES SUCH AS INDOOR AND HOME

ALLERGENS,COLD AIR,STRONG ODORS,TOBACCO
SMOKE,ALL INCREASE AHR

 ALLERGEN ELLIMINATION SOMETIMES LEEDS TO CURE

EPIDEMIOLOGY
 Common etiology of emergency visits and school day missing

in childhood ,occasionally hospitalization and rare deaths
specially in poverty ,urban living ,ethnic minorities

 Increasing asthma prevalence worldwide(50% per decade)
 Good correlation of asthma prevalence with allergic rhino

sinusitis and atopic eczema and other allergies

 More prevalence in high level urban modern families than

suburban villagers

 More than 80%of asthmatics reported getting the disease

before 6 year

CLINICS
RECURRENT COUGHING/WHEEZING
PATTERNS IN CHILDHOOD BASED ON
NATURAL HISTORY

TRANSIENT EARLY WHEEZING
 Common in early preschool years

 Recurrent coughing/wheezing primary

triggered by common respiratory viral INF
 Tend to resolve during preschool yrs without
increasing risk of asthma later in life
 Problems due to reduced airflow at birth
suggestive of relative narrow airways improved
by school yrs

Persistent Atopy Associated Asthma
 Begins in early preschool yrs

 Associated with atopy (eg atopic dermatitis in





infancy, allergic rhinitis, food allergy)
Biologic factors e.g.: early inhalant sensitization,
increase serum IGE, increase blood eosinophills,
High risk of persistence into later childhood and
adulthood lung function abnormality
Those with onset<3 yrs
reduced air flow by
school yrs
Those with later onset of symptoms or allergen
sensitizations unlikely persistence lung function
abnormality later

Non-Atopic Wheezing
 Wheezing ,coughing beginning in early life

often with RSV INF resolves later in childhood
without increasing risk of persistence asthma

 Associated with bronchial hyper

responsiveness near birth

Asthma with declining lung function
• Children with asthma with progressive

increase in air flow limitation

• Associated with hyper inflation in childhood
• Male gender

Late onset asthma in females associated with
obesity and early onset puberty
 Onset between 8_13 yrs

 Associated with early onset puberty and obesity
 Specific for females

Occupational type asthma in children
 Children with asthma and occupational type exposure

known to trigger asthma in adults in occupational settings

Types of Asthma
common clinical presentations of intermittent
recurrent wheezing and/or coughing
 Recurrent wheezing in early childhood

 Chronic asthma associated with allergy
 Females 11 yrs with early onset puberty and

obesity

Pathogenesis

 Airflow obstruction resulting from

Broncho constriction of bronchiolar smooth
muscle mass
II. Cellular inflammatory infiltrates and exudates
mostly Eosinophills(also N , M ,L ,mast cells
,basophiles)fill and obstruct airways and damage
epithelium and induce desquamation into airway
lumen mediated by T helper cells and other
immune cells that produce pro allergic pro
inflammatory cytokines(IL4,IL6,IL13)
III. Breach in normal immune regulatory process
I.

RESULT
 Airway inflammation

 AHR
 Edema basement membrane thickness sub

epithelial collagen deposition
 Smooth muscle and mucus gland hypertrophy
and mucus hyper secretion

Air obstruction

Clinical manifestations and diagnosis
 Most common intermittent dry cough and

expiratory wheezing

 Shortness of breath and chest tightness in older

children and adults

 Intermittent non focal chest pain in younger

children

 Worsening of respiratory symptoms at night
 Worsening of day time symptoms by activity

Continue…..
 Subtle symptoms such as self limitation of activities

,general fatigue ,difficulty in keeping up with peers

 Relief with aerosolized bronchodilators
 Lack of improvement with bronchodilators and steroid

is inconsistent with Asthma and should consider
Asthma masquerading conditions!!!!

 Hyper ventilation, intercostal retractions ,nasal flaring

,respiratory accessory muscle use

 Its common not to hear the expiratory wheezing when

Air flow is so limited before treatment

Asthma Triggers
 Common viral infections of the respiratory tract
 Aero allergens in sensitized asthmatics ,animal dander ,dust











mite ,molds ,indoor allergens ,cockroaches
Seasonal aero allergens ,pollens(trees ,grasses ,weeds ,)
Environmental tobacco smoke
Air pollutants ,ozone ,so2,wood or coal smoke ,endotoxin
,mycotoxin ,dust
Strong or noxious odors or fumes ,perfume ,hair spray
,cleaning agents
Occupational exposure
Cold air ,dry air
Exercise
Crying ,laughter ,hyperventilation
Co morbid conditions Rhinitis ,Sinusitis ,GER

Clinics
History:
Triggering symptoms by laughter
,cold air ,airway irritants
Exposures that induce airway
irritation such as viral URTI
Mycoplasma ,Chlamydia
Inhaled allergens
All lead to AHR

Presence Of Risk Factors:
 History of other allergies ,allergic Rhinitis,

allergic Conjunctivitis ,atopic Dermatitis ,food
allergies

 Parental Asthma
 Symptoms apart from cold

Continue…..
 No or minimal signs in routine visits

 Dry or persistent cough

 Normal chest findings unless wheezing when asking

to breath deeper
 Quick relief (10 MIN) after SABA use
 Expiratory wheezing ,prolonged expiratory phase
,decreased sounds in RT lower pos lobe due to
regional hypoventilation owing to airway
obstruction
 Rales , ronchi ,crackles due to hyper secretion
 Segmental crackles and poor breath sounds
atelectasis?

Continue….
 Labored respiration ,respiratory distress increased

prolongation of expiration and wheezing in E and I

 Poor air entry
 Inter costal retractions ,nasal flaring ,supra and

infra sternal retractions

 And again in most sever forms expiratory wheezing

does not appear until some broncho dilation

DD

GERD Rhino sinusitis co morbid

conditions with asthma

Recurrent aspiration in early

life(tracheo broncho malacia
,TEF , foreign body ,CF ,BPD

VCD in older children and

adolescents

LAB FINDINGS
Pulmonary Function
Testing

Continue….
 Forced expiratory airflow measures helpful

in Diagnosis , assessing efficacy of therapy
and monitoring Asthma in children specially
in poor children who do not have PHE
unless obstruction is sever

 Valueablity of spirometric findings in children>6

yrs

 3 efforts the highest is the peak
 Reduced FEV

obstruction

FEV1/FVC <0.80 means significant

 Improvement in FEV1 following beta 2 agonist > =

12% or 200 ml is consistent with Asthma

 Peak flow meter

CXR

Often normal aside from subtle and

nonspecific findings of hyperinflation

Peribronchial thickening
Helping in diagnosis of Asthma

differentials

Diagnosis of complications of Asthma

exacerbations

Other tests such as allergy skin prick
testing

Treatment
 www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm

Asthma Treatment & Management
has 4 components :
Assessment and monitoring of disease
activity
2. Provision to educate pt and family
3. Identification and management of
precipitating factors and co morbid
conditions
4. Appropriate selection of medication
1.

 Attainment of optimal Asthma control

Component 1
 Asthma severity :intermittent
 Persistent: mild ,mod ,severe
 Only once during patient initial evaluation in pt

who is not using a daily controller agent
 Asthma control degree to which symptoms ,
on going functional impairments , risk of
adverse events minimized and goals of
therapy are met

Continue….
Well controlled
2. Not well controlled
3. Very poor controlled
1.

 NIH guidelines for both severity and

control for 3 age groups

0-4 yrs
2. 5-11 yrs
3. =>12 yrs
1.

Important
even in the absence of frequent symptoms
infants and children whom have risk factors
for asthma and 4 or more episodes of
wheezing over the past yr which lasted more
than 1 day or 2 or more exacerbations in
the last 6 months requiring syst
corticosteroids should be considered in the
persistent group and hence receive long term
controller therapy

Important Tips..
 Regular clinical visits every 2-6 weeks
 Assessment of :

Pt symptoms frequency night and day
2. Need for short acting inhaled b2 agonists for
quick relief
3. Ability to engage in normal activities
4. Air flow measures for>=5 yrs
1.

Continue..
 Component 2 : pt education

 Component 3 : control of factors contributing

to asthma severity
1. Environmental exposures
2. Co morbid conditions
 Component 4 :principals of asthma
pharmacotherapy

Asthma Medication
 SABA

 ICS

 LABA
 LTRA

 SYSTEMIC STEROIDS

 NONSTEROIDAL ANTIINFLAMMATORY

CROMOLYN AND NEDOCROMYL
 OXYGEN
 ANTICHOLINERGIC AGENTS
IPRATROPIUM
BROMIDE
 ANTIIMMUNOGLUBOLINE E

MANAGEMENT OF ASTHMA EXACERBATION(STATUS ASTHMATICUS)
RISK ASSESMENT ON ADMISSION

FOCUSED HISTORY

ONSET OF CURRENT EXACERBATION
FREQUENCY AND severity of daytime and night
time symptoms and activity limitation
Frequency of rescue bronchodilator use
Current medication and allergies
Potential triggers
History of systemic steroid courses, emergency
department visists , hospitalization, intubation or life
threatening episodes

Clinical assesment

Physical examination findings: vital signs,
breathlessness, air movement, use of accessory
respiratory muscles, retractions, anxiety level,
alteration in mental status
Pulse oximetry
Lung function(defer in pts with mod to severe
distress or history of labile disease)

Treatment
Drugs and trade name

Mechanism of action and dosing

Cautions and adverse effects

Oxygen(mask or nasal canula)
Inhaled short acting b2
agonist
Albuterol nebulized
solution(5mg/ml concentrates
Albuterol MDI
Levabuterol

Treats hypoxia
Bronchodilator
Neubolizer 0.15 mg/kg every 20 min for 3
doses as needed,then 0.15_0.3 mg/kg up t 10
mg every 1_4 hour as needed or up to 0.5
mg/kg/hr by continous neubolization
2_8 puf up to every 20 min for 3 doses as
needed then every 1 hr as needed

Monitor pulse oximetry to maintain o2 saturation>92%
Cardiorespiratory monitoring
During exacerbations,frequent or continuous use can cause
pulmonary vasodilatation,v/q mistmatch and hypoxemia
Adverse effect palpitation, tachycardia, arrhythmia, tremor,
hypoxemia
Neubolizer:when giving concentrate forms,dilute with saline to 3
ml total neubolized volume
For MDI use space/holding chamber

Systemic corticosteroids
Prednisolone tb
Methyl prednisolon
Anticholinergics
Ipratropium
Atrovent
Ipratropium with Albuterol

Anti inflammatory
0.5_1 mg/kg every 6-8 hr for 48 hr , then 1-2 mg/kg
day bid(max 60 mg/day)
Short course burst for exacerbation 1-2 mg/kg/day qd
or bid for 3-7 days
Mucolitic/bronchodilator
Neubolizer 0.5 mg q6-8 hr (tid or qid) as needed
MDI 2 paf qid
1 vial by neubolizer qid



If pt has been exposed chickenpox or measles, consider passive
immunoglobulin prophylaxis, also risk of complications with
herspes simplex and TB

For daily dosing , 8 am administration minimizes adrenal
suppression

Children may benefit from dosage tapering if course exceed 7 days

Adverse effect monitoring: frequent therapy bursts risk numerous
corticosteroid adverse effects

Should not be used as first line treatment added to b2 agonist
therapy
Neubolizer may mix Ipratropium with Albuterol

QUICK RELIEF MEDICATION
SABA

Anti cholinergic(ipratropium)
Short term systemic gluco

corticoid

SABA
 Quick relief of asthma symptoms
 Relax airway smooth muscle prompt airflow↑
 Repetitive or continuous SABA is the most effective means







of reversing air flow obstruction
SABA should not be prescribed on a regular schedule
because concerns of possibility of deteriorating asthma
control
Frequent use of SABA is an indication of poor asthma control
Preferred root is inhalation smaller dose , fewer side effects
more rapid on set of action
Ipratropium Bromide as an adjunct to SABA in emergency
room reduces hospital admissions and improves lung function
Systemic Glucocorticoids short oral course + SABA in
moderate to severe asthma exacerbation

LABA
 Salmetrol

 Should be used in combination with inhaled

corticosteroids and not as mono therapy
 Exercise induces asthma in children >= 4 Yrs
one inhalation 30 min prior to exercise
 No additional doses for PTs who are already
receiving it twice daily not recommended by
NIH guidelines

LTRA

 MonteLukast ( singulair)

 Antihistaminic

 Leukotrien receptor antagonist

 Asthma ( not < 12 MO) and allergic rhinitis (





not < 6 MO)
Morning dosing not evaluated
Prophylactic and chronic treatment of asthma
Exercise induced asthma in >= 15 Yrs
Zafir Lukast : prophylactic and chronic
treatment of asthma

ICA
 Most potent anti inflammatory agents available

for the treatment of asthma
 Inhibiting most steps in the cascade of the
inflammatory response
 Benefits reducing bronchial hyper
responsiveness , prevention of late asthmatic
response , enhanced lung function
 Inhaled Glucocorticoids first line controller
therapy for persistent asthma or those who
require step 2

Prognosis
 35%of preschool children experience recurrent

coughing and wheezing,1/3 of them continue to
have persistent asthma into later childhood and
2/3 improvement on their own through their teen
yrs
 Asthma severity by age 7-10 yrs is predictive of
asthma persistence into adulthood
 Children with mod to severe asthma and lower lung
function are likely to have persistent asthma as
adults
 Children with milder asthma and N/R lung function
are likely to improve over time or be periodically
asthmatic

THANK YOU FOR YOUR
ATTENTION


Slide 10

Asthma in Children
DR. A.Mirshokraei
NIOC Hospital Pediatrics Ward

Definition :

DEFINITION

- Chronic inflammatory condition of the
lung airways resulting in episodic airflow
obstruction
- AHR to provocative exposures
Asthma management
• Reducing airway inflammation by: Minimizing
pro inflammatory environmental exposure, using
daily controller anti inflammatory medication,
controlling co morbid conditions that worsen
asthma, less inflammation better asthma
control and fewer exacerbations

Anyway exacerbations

occur

BUT
Even the uncommon
child with sever asthma can
be managed to live normally

 RECURRENT WHEEZING EPISODES WITH COMMON

RESPIRATORY
VIRUSES(RSV,RHINOVIRUS,INFLUENZA,PARAINFLUENZA,A
DENOVIRUS,HUMAN METAPNUMOVIRUS)

 HOST FEATURES AFFECTING IMMUNOLOGIC HOST

DEFENSE,INFLAMMATION/PREVIOUS VIRAL INFECTIONS
MAINIFESTED AS PNUMONIA OR BRONCHIOLITIS
REQUIRING HOSPITALIZATION UNDERLIE THE
RECURRENT WHEEZING IN EARLY CHILDHOOD

 OTHER AIRWAY EXPOSURES SUCH AS INDOOR AND HOME

ALLERGENS,COLD AIR,STRONG ODORS,TOBACCO
SMOKE,ALL INCREASE AHR

 ALLERGEN ELLIMINATION SOMETIMES LEEDS TO CURE

EPIDEMIOLOGY
 Common etiology of emergency visits and school day missing

in childhood ,occasionally hospitalization and rare deaths
specially in poverty ,urban living ,ethnic minorities

 Increasing asthma prevalence worldwide(50% per decade)
 Good correlation of asthma prevalence with allergic rhino

sinusitis and atopic eczema and other allergies

 More prevalence in high level urban modern families than

suburban villagers

 More than 80%of asthmatics reported getting the disease

before 6 year

CLINICS
RECURRENT COUGHING/WHEEZING
PATTERNS IN CHILDHOOD BASED ON
NATURAL HISTORY

TRANSIENT EARLY WHEEZING
 Common in early preschool years

 Recurrent coughing/wheezing primary

triggered by common respiratory viral INF
 Tend to resolve during preschool yrs without
increasing risk of asthma later in life
 Problems due to reduced airflow at birth
suggestive of relative narrow airways improved
by school yrs

Persistent Atopy Associated Asthma
 Begins in early preschool yrs

 Associated with atopy (eg atopic dermatitis in





infancy, allergic rhinitis, food allergy)
Biologic factors e.g.: early inhalant sensitization,
increase serum IGE, increase blood eosinophills,
High risk of persistence into later childhood and
adulthood lung function abnormality
Those with onset<3 yrs
reduced air flow by
school yrs
Those with later onset of symptoms or allergen
sensitizations unlikely persistence lung function
abnormality later

Non-Atopic Wheezing
 Wheezing ,coughing beginning in early life

often with RSV INF resolves later in childhood
without increasing risk of persistence asthma

 Associated with bronchial hyper

responsiveness near birth

Asthma with declining lung function
• Children with asthma with progressive

increase in air flow limitation

• Associated with hyper inflation in childhood
• Male gender

Late onset asthma in females associated with
obesity and early onset puberty
 Onset between 8_13 yrs

 Associated with early onset puberty and obesity
 Specific for females

Occupational type asthma in children
 Children with asthma and occupational type exposure

known to trigger asthma in adults in occupational settings

Types of Asthma
common clinical presentations of intermittent
recurrent wheezing and/or coughing
 Recurrent wheezing in early childhood

 Chronic asthma associated with allergy
 Females 11 yrs with early onset puberty and

obesity

Pathogenesis

 Airflow obstruction resulting from

Broncho constriction of bronchiolar smooth
muscle mass
II. Cellular inflammatory infiltrates and exudates
mostly Eosinophills(also N , M ,L ,mast cells
,basophiles)fill and obstruct airways and damage
epithelium and induce desquamation into airway
lumen mediated by T helper cells and other
immune cells that produce pro allergic pro
inflammatory cytokines(IL4,IL6,IL13)
III. Breach in normal immune regulatory process
I.

RESULT
 Airway inflammation

 AHR
 Edema basement membrane thickness sub

epithelial collagen deposition
 Smooth muscle and mucus gland hypertrophy
and mucus hyper secretion

Air obstruction

Clinical manifestations and diagnosis
 Most common intermittent dry cough and

expiratory wheezing

 Shortness of breath and chest tightness in older

children and adults

 Intermittent non focal chest pain in younger

children

 Worsening of respiratory symptoms at night
 Worsening of day time symptoms by activity

Continue…..
 Subtle symptoms such as self limitation of activities

,general fatigue ,difficulty in keeping up with peers

 Relief with aerosolized bronchodilators
 Lack of improvement with bronchodilators and steroid

is inconsistent with Asthma and should consider
Asthma masquerading conditions!!!!

 Hyper ventilation, intercostal retractions ,nasal flaring

,respiratory accessory muscle use

 Its common not to hear the expiratory wheezing when

Air flow is so limited before treatment

Asthma Triggers
 Common viral infections of the respiratory tract
 Aero allergens in sensitized asthmatics ,animal dander ,dust











mite ,molds ,indoor allergens ,cockroaches
Seasonal aero allergens ,pollens(trees ,grasses ,weeds ,)
Environmental tobacco smoke
Air pollutants ,ozone ,so2,wood or coal smoke ,endotoxin
,mycotoxin ,dust
Strong or noxious odors or fumes ,perfume ,hair spray
,cleaning agents
Occupational exposure
Cold air ,dry air
Exercise
Crying ,laughter ,hyperventilation
Co morbid conditions Rhinitis ,Sinusitis ,GER

Clinics
History:
Triggering symptoms by laughter
,cold air ,airway irritants
Exposures that induce airway
irritation such as viral URTI
Mycoplasma ,Chlamydia
Inhaled allergens
All lead to AHR

Presence Of Risk Factors:
 History of other allergies ,allergic Rhinitis,

allergic Conjunctivitis ,atopic Dermatitis ,food
allergies

 Parental Asthma
 Symptoms apart from cold

Continue…..
 No or minimal signs in routine visits

 Dry or persistent cough

 Normal chest findings unless wheezing when asking

to breath deeper
 Quick relief (10 MIN) after SABA use
 Expiratory wheezing ,prolonged expiratory phase
,decreased sounds in RT lower pos lobe due to
regional hypoventilation owing to airway
obstruction
 Rales , ronchi ,crackles due to hyper secretion
 Segmental crackles and poor breath sounds
atelectasis?

Continue….
 Labored respiration ,respiratory distress increased

prolongation of expiration and wheezing in E and I

 Poor air entry
 Inter costal retractions ,nasal flaring ,supra and

infra sternal retractions

 And again in most sever forms expiratory wheezing

does not appear until some broncho dilation

DD

GERD Rhino sinusitis co morbid

conditions with asthma

Recurrent aspiration in early

life(tracheo broncho malacia
,TEF , foreign body ,CF ,BPD

VCD in older children and

adolescents

LAB FINDINGS
Pulmonary Function
Testing

Continue….
 Forced expiratory airflow measures helpful

in Diagnosis , assessing efficacy of therapy
and monitoring Asthma in children specially
in poor children who do not have PHE
unless obstruction is sever

 Valueablity of spirometric findings in children>6

yrs

 3 efforts the highest is the peak
 Reduced FEV

obstruction

FEV1/FVC <0.80 means significant

 Improvement in FEV1 following beta 2 agonist > =

12% or 200 ml is consistent with Asthma

 Peak flow meter

CXR

Often normal aside from subtle and

nonspecific findings of hyperinflation

Peribronchial thickening
Helping in diagnosis of Asthma

differentials

Diagnosis of complications of Asthma

exacerbations

Other tests such as allergy skin prick
testing

Treatment
 www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm

Asthma Treatment & Management
has 4 components :
Assessment and monitoring of disease
activity
2. Provision to educate pt and family
3. Identification and management of
precipitating factors and co morbid
conditions
4. Appropriate selection of medication
1.

 Attainment of optimal Asthma control

Component 1
 Asthma severity :intermittent
 Persistent: mild ,mod ,severe
 Only once during patient initial evaluation in pt

who is not using a daily controller agent
 Asthma control degree to which symptoms ,
on going functional impairments , risk of
adverse events minimized and goals of
therapy are met

Continue….
Well controlled
2. Not well controlled
3. Very poor controlled
1.

 NIH guidelines for both severity and

control for 3 age groups

0-4 yrs
2. 5-11 yrs
3. =>12 yrs
1.

Important
even in the absence of frequent symptoms
infants and children whom have risk factors
for asthma and 4 or more episodes of
wheezing over the past yr which lasted more
than 1 day or 2 or more exacerbations in
the last 6 months requiring syst
corticosteroids should be considered in the
persistent group and hence receive long term
controller therapy

Important Tips..
 Regular clinical visits every 2-6 weeks
 Assessment of :

Pt symptoms frequency night and day
2. Need for short acting inhaled b2 agonists for
quick relief
3. Ability to engage in normal activities
4. Air flow measures for>=5 yrs
1.

Continue..
 Component 2 : pt education

 Component 3 : control of factors contributing

to asthma severity
1. Environmental exposures
2. Co morbid conditions
 Component 4 :principals of asthma
pharmacotherapy

Asthma Medication
 SABA

 ICS

 LABA
 LTRA

 SYSTEMIC STEROIDS

 NONSTEROIDAL ANTIINFLAMMATORY

CROMOLYN AND NEDOCROMYL
 OXYGEN
 ANTICHOLINERGIC AGENTS
IPRATROPIUM
BROMIDE
 ANTIIMMUNOGLUBOLINE E

MANAGEMENT OF ASTHMA EXACERBATION(STATUS ASTHMATICUS)
RISK ASSESMENT ON ADMISSION

FOCUSED HISTORY

ONSET OF CURRENT EXACERBATION
FREQUENCY AND severity of daytime and night
time symptoms and activity limitation
Frequency of rescue bronchodilator use
Current medication and allergies
Potential triggers
History of systemic steroid courses, emergency
department visists , hospitalization, intubation or life
threatening episodes

Clinical assesment

Physical examination findings: vital signs,
breathlessness, air movement, use of accessory
respiratory muscles, retractions, anxiety level,
alteration in mental status
Pulse oximetry
Lung function(defer in pts with mod to severe
distress or history of labile disease)

Treatment
Drugs and trade name

Mechanism of action and dosing

Cautions and adverse effects

Oxygen(mask or nasal canula)
Inhaled short acting b2
agonist
Albuterol nebulized
solution(5mg/ml concentrates
Albuterol MDI
Levabuterol

Treats hypoxia
Bronchodilator
Neubolizer 0.15 mg/kg every 20 min for 3
doses as needed,then 0.15_0.3 mg/kg up t 10
mg every 1_4 hour as needed or up to 0.5
mg/kg/hr by continous neubolization
2_8 puf up to every 20 min for 3 doses as
needed then every 1 hr as needed

Monitor pulse oximetry to maintain o2 saturation>92%
Cardiorespiratory monitoring
During exacerbations,frequent or continuous use can cause
pulmonary vasodilatation,v/q mistmatch and hypoxemia
Adverse effect palpitation, tachycardia, arrhythmia, tremor,
hypoxemia
Neubolizer:when giving concentrate forms,dilute with saline to 3
ml total neubolized volume
For MDI use space/holding chamber

Systemic corticosteroids
Prednisolone tb
Methyl prednisolon
Anticholinergics
Ipratropium
Atrovent
Ipratropium with Albuterol

Anti inflammatory
0.5_1 mg/kg every 6-8 hr for 48 hr , then 1-2 mg/kg
day bid(max 60 mg/day)
Short course burst for exacerbation 1-2 mg/kg/day qd
or bid for 3-7 days
Mucolitic/bronchodilator
Neubolizer 0.5 mg q6-8 hr (tid or qid) as needed
MDI 2 paf qid
1 vial by neubolizer qid



If pt has been exposed chickenpox or measles, consider passive
immunoglobulin prophylaxis, also risk of complications with
herspes simplex and TB

For daily dosing , 8 am administration minimizes adrenal
suppression

Children may benefit from dosage tapering if course exceed 7 days

Adverse effect monitoring: frequent therapy bursts risk numerous
corticosteroid adverse effects

Should not be used as first line treatment added to b2 agonist
therapy
Neubolizer may mix Ipratropium with Albuterol

QUICK RELIEF MEDICATION
SABA

Anti cholinergic(ipratropium)
Short term systemic gluco

corticoid

SABA
 Quick relief of asthma symptoms
 Relax airway smooth muscle prompt airflow↑
 Repetitive or continuous SABA is the most effective means







of reversing air flow obstruction
SABA should not be prescribed on a regular schedule
because concerns of possibility of deteriorating asthma
control
Frequent use of SABA is an indication of poor asthma control
Preferred root is inhalation smaller dose , fewer side effects
more rapid on set of action
Ipratropium Bromide as an adjunct to SABA in emergency
room reduces hospital admissions and improves lung function
Systemic Glucocorticoids short oral course + SABA in
moderate to severe asthma exacerbation

LABA
 Salmetrol

 Should be used in combination with inhaled

corticosteroids and not as mono therapy
 Exercise induces asthma in children >= 4 Yrs
one inhalation 30 min prior to exercise
 No additional doses for PTs who are already
receiving it twice daily not recommended by
NIH guidelines

LTRA

 MonteLukast ( singulair)

 Antihistaminic

 Leukotrien receptor antagonist

 Asthma ( not < 12 MO) and allergic rhinitis (





not < 6 MO)
Morning dosing not evaluated
Prophylactic and chronic treatment of asthma
Exercise induced asthma in >= 15 Yrs
Zafir Lukast : prophylactic and chronic
treatment of asthma

ICA
 Most potent anti inflammatory agents available

for the treatment of asthma
 Inhibiting most steps in the cascade of the
inflammatory response
 Benefits reducing bronchial hyper
responsiveness , prevention of late asthmatic
response , enhanced lung function
 Inhaled Glucocorticoids first line controller
therapy for persistent asthma or those who
require step 2

Prognosis
 35%of preschool children experience recurrent

coughing and wheezing,1/3 of them continue to
have persistent asthma into later childhood and
2/3 improvement on their own through their teen
yrs
 Asthma severity by age 7-10 yrs is predictive of
asthma persistence into adulthood
 Children with mod to severe asthma and lower lung
function are likely to have persistent asthma as
adults
 Children with milder asthma and N/R lung function
are likely to improve over time or be periodically
asthmatic

THANK YOU FOR YOUR
ATTENTION


Slide 11

Asthma in Children
DR. A.Mirshokraei
NIOC Hospital Pediatrics Ward

Definition :

DEFINITION

- Chronic inflammatory condition of the
lung airways resulting in episodic airflow
obstruction
- AHR to provocative exposures
Asthma management
• Reducing airway inflammation by: Minimizing
pro inflammatory environmental exposure, using
daily controller anti inflammatory medication,
controlling co morbid conditions that worsen
asthma, less inflammation better asthma
control and fewer exacerbations

Anyway exacerbations

occur

BUT
Even the uncommon
child with sever asthma can
be managed to live normally

 RECURRENT WHEEZING EPISODES WITH COMMON

RESPIRATORY
VIRUSES(RSV,RHINOVIRUS,INFLUENZA,PARAINFLUENZA,A
DENOVIRUS,HUMAN METAPNUMOVIRUS)

 HOST FEATURES AFFECTING IMMUNOLOGIC HOST

DEFENSE,INFLAMMATION/PREVIOUS VIRAL INFECTIONS
MAINIFESTED AS PNUMONIA OR BRONCHIOLITIS
REQUIRING HOSPITALIZATION UNDERLIE THE
RECURRENT WHEEZING IN EARLY CHILDHOOD

 OTHER AIRWAY EXPOSURES SUCH AS INDOOR AND HOME

ALLERGENS,COLD AIR,STRONG ODORS,TOBACCO
SMOKE,ALL INCREASE AHR

 ALLERGEN ELLIMINATION SOMETIMES LEEDS TO CURE

EPIDEMIOLOGY
 Common etiology of emergency visits and school day missing

in childhood ,occasionally hospitalization and rare deaths
specially in poverty ,urban living ,ethnic minorities

 Increasing asthma prevalence worldwide(50% per decade)
 Good correlation of asthma prevalence with allergic rhino

sinusitis and atopic eczema and other allergies

 More prevalence in high level urban modern families than

suburban villagers

 More than 80%of asthmatics reported getting the disease

before 6 year

CLINICS
RECURRENT COUGHING/WHEEZING
PATTERNS IN CHILDHOOD BASED ON
NATURAL HISTORY

TRANSIENT EARLY WHEEZING
 Common in early preschool years

 Recurrent coughing/wheezing primary

triggered by common respiratory viral INF
 Tend to resolve during preschool yrs without
increasing risk of asthma later in life
 Problems due to reduced airflow at birth
suggestive of relative narrow airways improved
by school yrs

Persistent Atopy Associated Asthma
 Begins in early preschool yrs

 Associated with atopy (eg atopic dermatitis in





infancy, allergic rhinitis, food allergy)
Biologic factors e.g.: early inhalant sensitization,
increase serum IGE, increase blood eosinophills,
High risk of persistence into later childhood and
adulthood lung function abnormality
Those with onset<3 yrs
reduced air flow by
school yrs
Those with later onset of symptoms or allergen
sensitizations unlikely persistence lung function
abnormality later

Non-Atopic Wheezing
 Wheezing ,coughing beginning in early life

often with RSV INF resolves later in childhood
without increasing risk of persistence asthma

 Associated with bronchial hyper

responsiveness near birth

Asthma with declining lung function
• Children with asthma with progressive

increase in air flow limitation

• Associated with hyper inflation in childhood
• Male gender

Late onset asthma in females associated with
obesity and early onset puberty
 Onset between 8_13 yrs

 Associated with early onset puberty and obesity
 Specific for females

Occupational type asthma in children
 Children with asthma and occupational type exposure

known to trigger asthma in adults in occupational settings

Types of Asthma
common clinical presentations of intermittent
recurrent wheezing and/or coughing
 Recurrent wheezing in early childhood

 Chronic asthma associated with allergy
 Females 11 yrs with early onset puberty and

obesity

Pathogenesis

 Airflow obstruction resulting from

Broncho constriction of bronchiolar smooth
muscle mass
II. Cellular inflammatory infiltrates and exudates
mostly Eosinophills(also N , M ,L ,mast cells
,basophiles)fill and obstruct airways and damage
epithelium and induce desquamation into airway
lumen mediated by T helper cells and other
immune cells that produce pro allergic pro
inflammatory cytokines(IL4,IL6,IL13)
III. Breach in normal immune regulatory process
I.

RESULT
 Airway inflammation

 AHR
 Edema basement membrane thickness sub

epithelial collagen deposition
 Smooth muscle and mucus gland hypertrophy
and mucus hyper secretion

Air obstruction

Clinical manifestations and diagnosis
 Most common intermittent dry cough and

expiratory wheezing

 Shortness of breath and chest tightness in older

children and adults

 Intermittent non focal chest pain in younger

children

 Worsening of respiratory symptoms at night
 Worsening of day time symptoms by activity

Continue…..
 Subtle symptoms such as self limitation of activities

,general fatigue ,difficulty in keeping up with peers

 Relief with aerosolized bronchodilators
 Lack of improvement with bronchodilators and steroid

is inconsistent with Asthma and should consider
Asthma masquerading conditions!!!!

 Hyper ventilation, intercostal retractions ,nasal flaring

,respiratory accessory muscle use

 Its common not to hear the expiratory wheezing when

Air flow is so limited before treatment

Asthma Triggers
 Common viral infections of the respiratory tract
 Aero allergens in sensitized asthmatics ,animal dander ,dust











mite ,molds ,indoor allergens ,cockroaches
Seasonal aero allergens ,pollens(trees ,grasses ,weeds ,)
Environmental tobacco smoke
Air pollutants ,ozone ,so2,wood or coal smoke ,endotoxin
,mycotoxin ,dust
Strong or noxious odors or fumes ,perfume ,hair spray
,cleaning agents
Occupational exposure
Cold air ,dry air
Exercise
Crying ,laughter ,hyperventilation
Co morbid conditions Rhinitis ,Sinusitis ,GER

Clinics
History:
Triggering symptoms by laughter
,cold air ,airway irritants
Exposures that induce airway
irritation such as viral URTI
Mycoplasma ,Chlamydia
Inhaled allergens
All lead to AHR

Presence Of Risk Factors:
 History of other allergies ,allergic Rhinitis,

allergic Conjunctivitis ,atopic Dermatitis ,food
allergies

 Parental Asthma
 Symptoms apart from cold

Continue…..
 No or minimal signs in routine visits

 Dry or persistent cough

 Normal chest findings unless wheezing when asking

to breath deeper
 Quick relief (10 MIN) after SABA use
 Expiratory wheezing ,prolonged expiratory phase
,decreased sounds in RT lower pos lobe due to
regional hypoventilation owing to airway
obstruction
 Rales , ronchi ,crackles due to hyper secretion
 Segmental crackles and poor breath sounds
atelectasis?

Continue….
 Labored respiration ,respiratory distress increased

prolongation of expiration and wheezing in E and I

 Poor air entry
 Inter costal retractions ,nasal flaring ,supra and

infra sternal retractions

 And again in most sever forms expiratory wheezing

does not appear until some broncho dilation

DD

GERD Rhino sinusitis co morbid

conditions with asthma

Recurrent aspiration in early

life(tracheo broncho malacia
,TEF , foreign body ,CF ,BPD

VCD in older children and

adolescents

LAB FINDINGS
Pulmonary Function
Testing

Continue….
 Forced expiratory airflow measures helpful

in Diagnosis , assessing efficacy of therapy
and monitoring Asthma in children specially
in poor children who do not have PHE
unless obstruction is sever

 Valueablity of spirometric findings in children>6

yrs

 3 efforts the highest is the peak
 Reduced FEV

obstruction

FEV1/FVC <0.80 means significant

 Improvement in FEV1 following beta 2 agonist > =

12% or 200 ml is consistent with Asthma

 Peak flow meter

CXR

Often normal aside from subtle and

nonspecific findings of hyperinflation

Peribronchial thickening
Helping in diagnosis of Asthma

differentials

Diagnosis of complications of Asthma

exacerbations

Other tests such as allergy skin prick
testing

Treatment
 www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm

Asthma Treatment & Management
has 4 components :
Assessment and monitoring of disease
activity
2. Provision to educate pt and family
3. Identification and management of
precipitating factors and co morbid
conditions
4. Appropriate selection of medication
1.

 Attainment of optimal Asthma control

Component 1
 Asthma severity :intermittent
 Persistent: mild ,mod ,severe
 Only once during patient initial evaluation in pt

who is not using a daily controller agent
 Asthma control degree to which symptoms ,
on going functional impairments , risk of
adverse events minimized and goals of
therapy are met

Continue….
Well controlled
2. Not well controlled
3. Very poor controlled
1.

 NIH guidelines for both severity and

control for 3 age groups

0-4 yrs
2. 5-11 yrs
3. =>12 yrs
1.

Important
even in the absence of frequent symptoms
infants and children whom have risk factors
for asthma and 4 or more episodes of
wheezing over the past yr which lasted more
than 1 day or 2 or more exacerbations in
the last 6 months requiring syst
corticosteroids should be considered in the
persistent group and hence receive long term
controller therapy

Important Tips..
 Regular clinical visits every 2-6 weeks
 Assessment of :

Pt symptoms frequency night and day
2. Need for short acting inhaled b2 agonists for
quick relief
3. Ability to engage in normal activities
4. Air flow measures for>=5 yrs
1.

Continue..
 Component 2 : pt education

 Component 3 : control of factors contributing

to asthma severity
1. Environmental exposures
2. Co morbid conditions
 Component 4 :principals of asthma
pharmacotherapy

Asthma Medication
 SABA

 ICS

 LABA
 LTRA

 SYSTEMIC STEROIDS

 NONSTEROIDAL ANTIINFLAMMATORY

CROMOLYN AND NEDOCROMYL
 OXYGEN
 ANTICHOLINERGIC AGENTS
IPRATROPIUM
BROMIDE
 ANTIIMMUNOGLUBOLINE E

MANAGEMENT OF ASTHMA EXACERBATION(STATUS ASTHMATICUS)
RISK ASSESMENT ON ADMISSION

FOCUSED HISTORY

ONSET OF CURRENT EXACERBATION
FREQUENCY AND severity of daytime and night
time symptoms and activity limitation
Frequency of rescue bronchodilator use
Current medication and allergies
Potential triggers
History of systemic steroid courses, emergency
department visists , hospitalization, intubation or life
threatening episodes

Clinical assesment

Physical examination findings: vital signs,
breathlessness, air movement, use of accessory
respiratory muscles, retractions, anxiety level,
alteration in mental status
Pulse oximetry
Lung function(defer in pts with mod to severe
distress or history of labile disease)

Treatment
Drugs and trade name

Mechanism of action and dosing

Cautions and adverse effects

Oxygen(mask or nasal canula)
Inhaled short acting b2
agonist
Albuterol nebulized
solution(5mg/ml concentrates
Albuterol MDI
Levabuterol

Treats hypoxia
Bronchodilator
Neubolizer 0.15 mg/kg every 20 min for 3
doses as needed,then 0.15_0.3 mg/kg up t 10
mg every 1_4 hour as needed or up to 0.5
mg/kg/hr by continous neubolization
2_8 puf up to every 20 min for 3 doses as
needed then every 1 hr as needed

Monitor pulse oximetry to maintain o2 saturation>92%
Cardiorespiratory monitoring
During exacerbations,frequent or continuous use can cause
pulmonary vasodilatation,v/q mistmatch and hypoxemia
Adverse effect palpitation, tachycardia, arrhythmia, tremor,
hypoxemia
Neubolizer:when giving concentrate forms,dilute with saline to 3
ml total neubolized volume
For MDI use space/holding chamber

Systemic corticosteroids
Prednisolone tb
Methyl prednisolon
Anticholinergics
Ipratropium
Atrovent
Ipratropium with Albuterol

Anti inflammatory
0.5_1 mg/kg every 6-8 hr for 48 hr , then 1-2 mg/kg
day bid(max 60 mg/day)
Short course burst for exacerbation 1-2 mg/kg/day qd
or bid for 3-7 days
Mucolitic/bronchodilator
Neubolizer 0.5 mg q6-8 hr (tid or qid) as needed
MDI 2 paf qid
1 vial by neubolizer qid



If pt has been exposed chickenpox or measles, consider passive
immunoglobulin prophylaxis, also risk of complications with
herspes simplex and TB

For daily dosing , 8 am administration minimizes adrenal
suppression

Children may benefit from dosage tapering if course exceed 7 days

Adverse effect monitoring: frequent therapy bursts risk numerous
corticosteroid adverse effects

Should not be used as first line treatment added to b2 agonist
therapy
Neubolizer may mix Ipratropium with Albuterol

QUICK RELIEF MEDICATION
SABA

Anti cholinergic(ipratropium)
Short term systemic gluco

corticoid

SABA
 Quick relief of asthma symptoms
 Relax airway smooth muscle prompt airflow↑
 Repetitive or continuous SABA is the most effective means







of reversing air flow obstruction
SABA should not be prescribed on a regular schedule
because concerns of possibility of deteriorating asthma
control
Frequent use of SABA is an indication of poor asthma control
Preferred root is inhalation smaller dose , fewer side effects
more rapid on set of action
Ipratropium Bromide as an adjunct to SABA in emergency
room reduces hospital admissions and improves lung function
Systemic Glucocorticoids short oral course + SABA in
moderate to severe asthma exacerbation

LABA
 Salmetrol

 Should be used in combination with inhaled

corticosteroids and not as mono therapy
 Exercise induces asthma in children >= 4 Yrs
one inhalation 30 min prior to exercise
 No additional doses for PTs who are already
receiving it twice daily not recommended by
NIH guidelines

LTRA

 MonteLukast ( singulair)

 Antihistaminic

 Leukotrien receptor antagonist

 Asthma ( not < 12 MO) and allergic rhinitis (





not < 6 MO)
Morning dosing not evaluated
Prophylactic and chronic treatment of asthma
Exercise induced asthma in >= 15 Yrs
Zafir Lukast : prophylactic and chronic
treatment of asthma

ICA
 Most potent anti inflammatory agents available

for the treatment of asthma
 Inhibiting most steps in the cascade of the
inflammatory response
 Benefits reducing bronchial hyper
responsiveness , prevention of late asthmatic
response , enhanced lung function
 Inhaled Glucocorticoids first line controller
therapy for persistent asthma or those who
require step 2

Prognosis
 35%of preschool children experience recurrent

coughing and wheezing,1/3 of them continue to
have persistent asthma into later childhood and
2/3 improvement on their own through their teen
yrs
 Asthma severity by age 7-10 yrs is predictive of
asthma persistence into adulthood
 Children with mod to severe asthma and lower lung
function are likely to have persistent asthma as
adults
 Children with milder asthma and N/R lung function
are likely to improve over time or be periodically
asthmatic

THANK YOU FOR YOUR
ATTENTION


Slide 12

Asthma in Children
DR. A.Mirshokraei
NIOC Hospital Pediatrics Ward

Definition :

DEFINITION

- Chronic inflammatory condition of the
lung airways resulting in episodic airflow
obstruction
- AHR to provocative exposures
Asthma management
• Reducing airway inflammation by: Minimizing
pro inflammatory environmental exposure, using
daily controller anti inflammatory medication,
controlling co morbid conditions that worsen
asthma, less inflammation better asthma
control and fewer exacerbations

Anyway exacerbations

occur

BUT
Even the uncommon
child with sever asthma can
be managed to live normally

 RECURRENT WHEEZING EPISODES WITH COMMON

RESPIRATORY
VIRUSES(RSV,RHINOVIRUS,INFLUENZA,PARAINFLUENZA,A
DENOVIRUS,HUMAN METAPNUMOVIRUS)

 HOST FEATURES AFFECTING IMMUNOLOGIC HOST

DEFENSE,INFLAMMATION/PREVIOUS VIRAL INFECTIONS
MAINIFESTED AS PNUMONIA OR BRONCHIOLITIS
REQUIRING HOSPITALIZATION UNDERLIE THE
RECURRENT WHEEZING IN EARLY CHILDHOOD

 OTHER AIRWAY EXPOSURES SUCH AS INDOOR AND HOME

ALLERGENS,COLD AIR,STRONG ODORS,TOBACCO
SMOKE,ALL INCREASE AHR

 ALLERGEN ELLIMINATION SOMETIMES LEEDS TO CURE

EPIDEMIOLOGY
 Common etiology of emergency visits and school day missing

in childhood ,occasionally hospitalization and rare deaths
specially in poverty ,urban living ,ethnic minorities

 Increasing asthma prevalence worldwide(50% per decade)
 Good correlation of asthma prevalence with allergic rhino

sinusitis and atopic eczema and other allergies

 More prevalence in high level urban modern families than

suburban villagers

 More than 80%of asthmatics reported getting the disease

before 6 year

CLINICS
RECURRENT COUGHING/WHEEZING
PATTERNS IN CHILDHOOD BASED ON
NATURAL HISTORY

TRANSIENT EARLY WHEEZING
 Common in early preschool years

 Recurrent coughing/wheezing primary

triggered by common respiratory viral INF
 Tend to resolve during preschool yrs without
increasing risk of asthma later in life
 Problems due to reduced airflow at birth
suggestive of relative narrow airways improved
by school yrs

Persistent Atopy Associated Asthma
 Begins in early preschool yrs

 Associated with atopy (eg atopic dermatitis in





infancy, allergic rhinitis, food allergy)
Biologic factors e.g.: early inhalant sensitization,
increase serum IGE, increase blood eosinophills,
High risk of persistence into later childhood and
adulthood lung function abnormality
Those with onset<3 yrs
reduced air flow by
school yrs
Those with later onset of symptoms or allergen
sensitizations unlikely persistence lung function
abnormality later

Non-Atopic Wheezing
 Wheezing ,coughing beginning in early life

often with RSV INF resolves later in childhood
without increasing risk of persistence asthma

 Associated with bronchial hyper

responsiveness near birth

Asthma with declining lung function
• Children with asthma with progressive

increase in air flow limitation

• Associated with hyper inflation in childhood
• Male gender

Late onset asthma in females associated with
obesity and early onset puberty
 Onset between 8_13 yrs

 Associated with early onset puberty and obesity
 Specific for females

Occupational type asthma in children
 Children with asthma and occupational type exposure

known to trigger asthma in adults in occupational settings

Types of Asthma
common clinical presentations of intermittent
recurrent wheezing and/or coughing
 Recurrent wheezing in early childhood

 Chronic asthma associated with allergy
 Females 11 yrs with early onset puberty and

obesity

Pathogenesis

 Airflow obstruction resulting from

Broncho constriction of bronchiolar smooth
muscle mass
II. Cellular inflammatory infiltrates and exudates
mostly Eosinophills(also N , M ,L ,mast cells
,basophiles)fill and obstruct airways and damage
epithelium and induce desquamation into airway
lumen mediated by T helper cells and other
immune cells that produce pro allergic pro
inflammatory cytokines(IL4,IL6,IL13)
III. Breach in normal immune regulatory process
I.

RESULT
 Airway inflammation

 AHR
 Edema basement membrane thickness sub

epithelial collagen deposition
 Smooth muscle and mucus gland hypertrophy
and mucus hyper secretion

Air obstruction

Clinical manifestations and diagnosis
 Most common intermittent dry cough and

expiratory wheezing

 Shortness of breath and chest tightness in older

children and adults

 Intermittent non focal chest pain in younger

children

 Worsening of respiratory symptoms at night
 Worsening of day time symptoms by activity

Continue…..
 Subtle symptoms such as self limitation of activities

,general fatigue ,difficulty in keeping up with peers

 Relief with aerosolized bronchodilators
 Lack of improvement with bronchodilators and steroid

is inconsistent with Asthma and should consider
Asthma masquerading conditions!!!!

 Hyper ventilation, intercostal retractions ,nasal flaring

,respiratory accessory muscle use

 Its common not to hear the expiratory wheezing when

Air flow is so limited before treatment

Asthma Triggers
 Common viral infections of the respiratory tract
 Aero allergens in sensitized asthmatics ,animal dander ,dust











mite ,molds ,indoor allergens ,cockroaches
Seasonal aero allergens ,pollens(trees ,grasses ,weeds ,)
Environmental tobacco smoke
Air pollutants ,ozone ,so2,wood or coal smoke ,endotoxin
,mycotoxin ,dust
Strong or noxious odors or fumes ,perfume ,hair spray
,cleaning agents
Occupational exposure
Cold air ,dry air
Exercise
Crying ,laughter ,hyperventilation
Co morbid conditions Rhinitis ,Sinusitis ,GER

Clinics
History:
Triggering symptoms by laughter
,cold air ,airway irritants
Exposures that induce airway
irritation such as viral URTI
Mycoplasma ,Chlamydia
Inhaled allergens
All lead to AHR

Presence Of Risk Factors:
 History of other allergies ,allergic Rhinitis,

allergic Conjunctivitis ,atopic Dermatitis ,food
allergies

 Parental Asthma
 Symptoms apart from cold

Continue…..
 No or minimal signs in routine visits

 Dry or persistent cough

 Normal chest findings unless wheezing when asking

to breath deeper
 Quick relief (10 MIN) after SABA use
 Expiratory wheezing ,prolonged expiratory phase
,decreased sounds in RT lower pos lobe due to
regional hypoventilation owing to airway
obstruction
 Rales , ronchi ,crackles due to hyper secretion
 Segmental crackles and poor breath sounds
atelectasis?

Continue….
 Labored respiration ,respiratory distress increased

prolongation of expiration and wheezing in E and I

 Poor air entry
 Inter costal retractions ,nasal flaring ,supra and

infra sternal retractions

 And again in most sever forms expiratory wheezing

does not appear until some broncho dilation

DD

GERD Rhino sinusitis co morbid

conditions with asthma

Recurrent aspiration in early

life(tracheo broncho malacia
,TEF , foreign body ,CF ,BPD

VCD in older children and

adolescents

LAB FINDINGS
Pulmonary Function
Testing

Continue….
 Forced expiratory airflow measures helpful

in Diagnosis , assessing efficacy of therapy
and monitoring Asthma in children specially
in poor children who do not have PHE
unless obstruction is sever

 Valueablity of spirometric findings in children>6

yrs

 3 efforts the highest is the peak
 Reduced FEV

obstruction

FEV1/FVC <0.80 means significant

 Improvement in FEV1 following beta 2 agonist > =

12% or 200 ml is consistent with Asthma

 Peak flow meter

CXR

Often normal aside from subtle and

nonspecific findings of hyperinflation

Peribronchial thickening
Helping in diagnosis of Asthma

differentials

Diagnosis of complications of Asthma

exacerbations

Other tests such as allergy skin prick
testing

Treatment
 www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm

Asthma Treatment & Management
has 4 components :
Assessment and monitoring of disease
activity
2. Provision to educate pt and family
3. Identification and management of
precipitating factors and co morbid
conditions
4. Appropriate selection of medication
1.

 Attainment of optimal Asthma control

Component 1
 Asthma severity :intermittent
 Persistent: mild ,mod ,severe
 Only once during patient initial evaluation in pt

who is not using a daily controller agent
 Asthma control degree to which symptoms ,
on going functional impairments , risk of
adverse events minimized and goals of
therapy are met

Continue….
Well controlled
2. Not well controlled
3. Very poor controlled
1.

 NIH guidelines for both severity and

control for 3 age groups

0-4 yrs
2. 5-11 yrs
3. =>12 yrs
1.

Important
even in the absence of frequent symptoms
infants and children whom have risk factors
for asthma and 4 or more episodes of
wheezing over the past yr which lasted more
than 1 day or 2 or more exacerbations in
the last 6 months requiring syst
corticosteroids should be considered in the
persistent group and hence receive long term
controller therapy

Important Tips..
 Regular clinical visits every 2-6 weeks
 Assessment of :

Pt symptoms frequency night and day
2. Need for short acting inhaled b2 agonists for
quick relief
3. Ability to engage in normal activities
4. Air flow measures for>=5 yrs
1.

Continue..
 Component 2 : pt education

 Component 3 : control of factors contributing

to asthma severity
1. Environmental exposures
2. Co morbid conditions
 Component 4 :principals of asthma
pharmacotherapy

Asthma Medication
 SABA

 ICS

 LABA
 LTRA

 SYSTEMIC STEROIDS

 NONSTEROIDAL ANTIINFLAMMATORY

CROMOLYN AND NEDOCROMYL
 OXYGEN
 ANTICHOLINERGIC AGENTS
IPRATROPIUM
BROMIDE
 ANTIIMMUNOGLUBOLINE E

MANAGEMENT OF ASTHMA EXACERBATION(STATUS ASTHMATICUS)
RISK ASSESMENT ON ADMISSION

FOCUSED HISTORY

ONSET OF CURRENT EXACERBATION
FREQUENCY AND severity of daytime and night
time symptoms and activity limitation
Frequency of rescue bronchodilator use
Current medication and allergies
Potential triggers
History of systemic steroid courses, emergency
department visists , hospitalization, intubation or life
threatening episodes

Clinical assesment

Physical examination findings: vital signs,
breathlessness, air movement, use of accessory
respiratory muscles, retractions, anxiety level,
alteration in mental status
Pulse oximetry
Lung function(defer in pts with mod to severe
distress or history of labile disease)

Treatment
Drugs and trade name

Mechanism of action and dosing

Cautions and adverse effects

Oxygen(mask or nasal canula)
Inhaled short acting b2
agonist
Albuterol nebulized
solution(5mg/ml concentrates
Albuterol MDI
Levabuterol

Treats hypoxia
Bronchodilator
Neubolizer 0.15 mg/kg every 20 min for 3
doses as needed,then 0.15_0.3 mg/kg up t 10
mg every 1_4 hour as needed or up to 0.5
mg/kg/hr by continous neubolization
2_8 puf up to every 20 min for 3 doses as
needed then every 1 hr as needed

Monitor pulse oximetry to maintain o2 saturation>92%
Cardiorespiratory monitoring
During exacerbations,frequent or continuous use can cause
pulmonary vasodilatation,v/q mistmatch and hypoxemia
Adverse effect palpitation, tachycardia, arrhythmia, tremor,
hypoxemia
Neubolizer:when giving concentrate forms,dilute with saline to 3
ml total neubolized volume
For MDI use space/holding chamber

Systemic corticosteroids
Prednisolone tb
Methyl prednisolon
Anticholinergics
Ipratropium
Atrovent
Ipratropium with Albuterol

Anti inflammatory
0.5_1 mg/kg every 6-8 hr for 48 hr , then 1-2 mg/kg
day bid(max 60 mg/day)
Short course burst for exacerbation 1-2 mg/kg/day qd
or bid for 3-7 days
Mucolitic/bronchodilator
Neubolizer 0.5 mg q6-8 hr (tid or qid) as needed
MDI 2 paf qid
1 vial by neubolizer qid



If pt has been exposed chickenpox or measles, consider passive
immunoglobulin prophylaxis, also risk of complications with
herspes simplex and TB

For daily dosing , 8 am administration minimizes adrenal
suppression

Children may benefit from dosage tapering if course exceed 7 days

Adverse effect monitoring: frequent therapy bursts risk numerous
corticosteroid adverse effects

Should not be used as first line treatment added to b2 agonist
therapy
Neubolizer may mix Ipratropium with Albuterol

QUICK RELIEF MEDICATION
SABA

Anti cholinergic(ipratropium)
Short term systemic gluco

corticoid

SABA
 Quick relief of asthma symptoms
 Relax airway smooth muscle prompt airflow↑
 Repetitive or continuous SABA is the most effective means







of reversing air flow obstruction
SABA should not be prescribed on a regular schedule
because concerns of possibility of deteriorating asthma
control
Frequent use of SABA is an indication of poor asthma control
Preferred root is inhalation smaller dose , fewer side effects
more rapid on set of action
Ipratropium Bromide as an adjunct to SABA in emergency
room reduces hospital admissions and improves lung function
Systemic Glucocorticoids short oral course + SABA in
moderate to severe asthma exacerbation

LABA
 Salmetrol

 Should be used in combination with inhaled

corticosteroids and not as mono therapy
 Exercise induces asthma in children >= 4 Yrs
one inhalation 30 min prior to exercise
 No additional doses for PTs who are already
receiving it twice daily not recommended by
NIH guidelines

LTRA

 MonteLukast ( singulair)

 Antihistaminic

 Leukotrien receptor antagonist

 Asthma ( not < 12 MO) and allergic rhinitis (





not < 6 MO)
Morning dosing not evaluated
Prophylactic and chronic treatment of asthma
Exercise induced asthma in >= 15 Yrs
Zafir Lukast : prophylactic and chronic
treatment of asthma

ICA
 Most potent anti inflammatory agents available

for the treatment of asthma
 Inhibiting most steps in the cascade of the
inflammatory response
 Benefits reducing bronchial hyper
responsiveness , prevention of late asthmatic
response , enhanced lung function
 Inhaled Glucocorticoids first line controller
therapy for persistent asthma or those who
require step 2

Prognosis
 35%of preschool children experience recurrent

coughing and wheezing,1/3 of them continue to
have persistent asthma into later childhood and
2/3 improvement on their own through their teen
yrs
 Asthma severity by age 7-10 yrs is predictive of
asthma persistence into adulthood
 Children with mod to severe asthma and lower lung
function are likely to have persistent asthma as
adults
 Children with milder asthma and N/R lung function
are likely to improve over time or be periodically
asthmatic

THANK YOU FOR YOUR
ATTENTION


Slide 13

Asthma in Children
DR. A.Mirshokraei
NIOC Hospital Pediatrics Ward

Definition :

DEFINITION

- Chronic inflammatory condition of the
lung airways resulting in episodic airflow
obstruction
- AHR to provocative exposures
Asthma management
• Reducing airway inflammation by: Minimizing
pro inflammatory environmental exposure, using
daily controller anti inflammatory medication,
controlling co morbid conditions that worsen
asthma, less inflammation better asthma
control and fewer exacerbations

Anyway exacerbations

occur

BUT
Even the uncommon
child with sever asthma can
be managed to live normally

 RECURRENT WHEEZING EPISODES WITH COMMON

RESPIRATORY
VIRUSES(RSV,RHINOVIRUS,INFLUENZA,PARAINFLUENZA,A
DENOVIRUS,HUMAN METAPNUMOVIRUS)

 HOST FEATURES AFFECTING IMMUNOLOGIC HOST

DEFENSE,INFLAMMATION/PREVIOUS VIRAL INFECTIONS
MAINIFESTED AS PNUMONIA OR BRONCHIOLITIS
REQUIRING HOSPITALIZATION UNDERLIE THE
RECURRENT WHEEZING IN EARLY CHILDHOOD

 OTHER AIRWAY EXPOSURES SUCH AS INDOOR AND HOME

ALLERGENS,COLD AIR,STRONG ODORS,TOBACCO
SMOKE,ALL INCREASE AHR

 ALLERGEN ELLIMINATION SOMETIMES LEEDS TO CURE

EPIDEMIOLOGY
 Common etiology of emergency visits and school day missing

in childhood ,occasionally hospitalization and rare deaths
specially in poverty ,urban living ,ethnic minorities

 Increasing asthma prevalence worldwide(50% per decade)
 Good correlation of asthma prevalence with allergic rhino

sinusitis and atopic eczema and other allergies

 More prevalence in high level urban modern families than

suburban villagers

 More than 80%of asthmatics reported getting the disease

before 6 year

CLINICS
RECURRENT COUGHING/WHEEZING
PATTERNS IN CHILDHOOD BASED ON
NATURAL HISTORY

TRANSIENT EARLY WHEEZING
 Common in early preschool years

 Recurrent coughing/wheezing primary

triggered by common respiratory viral INF
 Tend to resolve during preschool yrs without
increasing risk of asthma later in life
 Problems due to reduced airflow at birth
suggestive of relative narrow airways improved
by school yrs

Persistent Atopy Associated Asthma
 Begins in early preschool yrs

 Associated with atopy (eg atopic dermatitis in





infancy, allergic rhinitis, food allergy)
Biologic factors e.g.: early inhalant sensitization,
increase serum IGE, increase blood eosinophills,
High risk of persistence into later childhood and
adulthood lung function abnormality
Those with onset<3 yrs
reduced air flow by
school yrs
Those with later onset of symptoms or allergen
sensitizations unlikely persistence lung function
abnormality later

Non-Atopic Wheezing
 Wheezing ,coughing beginning in early life

often with RSV INF resolves later in childhood
without increasing risk of persistence asthma

 Associated with bronchial hyper

responsiveness near birth

Asthma with declining lung function
• Children with asthma with progressive

increase in air flow limitation

• Associated with hyper inflation in childhood
• Male gender

Late onset asthma in females associated with
obesity and early onset puberty
 Onset between 8_13 yrs

 Associated with early onset puberty and obesity
 Specific for females

Occupational type asthma in children
 Children with asthma and occupational type exposure

known to trigger asthma in adults in occupational settings

Types of Asthma
common clinical presentations of intermittent
recurrent wheezing and/or coughing
 Recurrent wheezing in early childhood

 Chronic asthma associated with allergy
 Females 11 yrs with early onset puberty and

obesity

Pathogenesis

 Airflow obstruction resulting from

Broncho constriction of bronchiolar smooth
muscle mass
II. Cellular inflammatory infiltrates and exudates
mostly Eosinophills(also N , M ,L ,mast cells
,basophiles)fill and obstruct airways and damage
epithelium and induce desquamation into airway
lumen mediated by T helper cells and other
immune cells that produce pro allergic pro
inflammatory cytokines(IL4,IL6,IL13)
III. Breach in normal immune regulatory process
I.

RESULT
 Airway inflammation

 AHR
 Edema basement membrane thickness sub

epithelial collagen deposition
 Smooth muscle and mucus gland hypertrophy
and mucus hyper secretion

Air obstruction

Clinical manifestations and diagnosis
 Most common intermittent dry cough and

expiratory wheezing

 Shortness of breath and chest tightness in older

children and adults

 Intermittent non focal chest pain in younger

children

 Worsening of respiratory symptoms at night
 Worsening of day time symptoms by activity

Continue…..
 Subtle symptoms such as self limitation of activities

,general fatigue ,difficulty in keeping up with peers

 Relief with aerosolized bronchodilators
 Lack of improvement with bronchodilators and steroid

is inconsistent with Asthma and should consider
Asthma masquerading conditions!!!!

 Hyper ventilation, intercostal retractions ,nasal flaring

,respiratory accessory muscle use

 Its common not to hear the expiratory wheezing when

Air flow is so limited before treatment

Asthma Triggers
 Common viral infections of the respiratory tract
 Aero allergens in sensitized asthmatics ,animal dander ,dust











mite ,molds ,indoor allergens ,cockroaches
Seasonal aero allergens ,pollens(trees ,grasses ,weeds ,)
Environmental tobacco smoke
Air pollutants ,ozone ,so2,wood or coal smoke ,endotoxin
,mycotoxin ,dust
Strong or noxious odors or fumes ,perfume ,hair spray
,cleaning agents
Occupational exposure
Cold air ,dry air
Exercise
Crying ,laughter ,hyperventilation
Co morbid conditions Rhinitis ,Sinusitis ,GER

Clinics
History:
Triggering symptoms by laughter
,cold air ,airway irritants
Exposures that induce airway
irritation such as viral URTI
Mycoplasma ,Chlamydia
Inhaled allergens
All lead to AHR

Presence Of Risk Factors:
 History of other allergies ,allergic Rhinitis,

allergic Conjunctivitis ,atopic Dermatitis ,food
allergies

 Parental Asthma
 Symptoms apart from cold

Continue…..
 No or minimal signs in routine visits

 Dry or persistent cough

 Normal chest findings unless wheezing when asking

to breath deeper
 Quick relief (10 MIN) after SABA use
 Expiratory wheezing ,prolonged expiratory phase
,decreased sounds in RT lower pos lobe due to
regional hypoventilation owing to airway
obstruction
 Rales , ronchi ,crackles due to hyper secretion
 Segmental crackles and poor breath sounds
atelectasis?

Continue….
 Labored respiration ,respiratory distress increased

prolongation of expiration and wheezing in E and I

 Poor air entry
 Inter costal retractions ,nasal flaring ,supra and

infra sternal retractions

 And again in most sever forms expiratory wheezing

does not appear until some broncho dilation

DD

GERD Rhino sinusitis co morbid

conditions with asthma

Recurrent aspiration in early

life(tracheo broncho malacia
,TEF , foreign body ,CF ,BPD

VCD in older children and

adolescents

LAB FINDINGS
Pulmonary Function
Testing

Continue….
 Forced expiratory airflow measures helpful

in Diagnosis , assessing efficacy of therapy
and monitoring Asthma in children specially
in poor children who do not have PHE
unless obstruction is sever

 Valueablity of spirometric findings in children>6

yrs

 3 efforts the highest is the peak
 Reduced FEV

obstruction

FEV1/FVC <0.80 means significant

 Improvement in FEV1 following beta 2 agonist > =

12% or 200 ml is consistent with Asthma

 Peak flow meter

CXR

Often normal aside from subtle and

nonspecific findings of hyperinflation

Peribronchial thickening
Helping in diagnosis of Asthma

differentials

Diagnosis of complications of Asthma

exacerbations

Other tests such as allergy skin prick
testing

Treatment
 www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm

Asthma Treatment & Management
has 4 components :
Assessment and monitoring of disease
activity
2. Provision to educate pt and family
3. Identification and management of
precipitating factors and co morbid
conditions
4. Appropriate selection of medication
1.

 Attainment of optimal Asthma control

Component 1
 Asthma severity :intermittent
 Persistent: mild ,mod ,severe
 Only once during patient initial evaluation in pt

who is not using a daily controller agent
 Asthma control degree to which symptoms ,
on going functional impairments , risk of
adverse events minimized and goals of
therapy are met

Continue….
Well controlled
2. Not well controlled
3. Very poor controlled
1.

 NIH guidelines for both severity and

control for 3 age groups

0-4 yrs
2. 5-11 yrs
3. =>12 yrs
1.

Important
even in the absence of frequent symptoms
infants and children whom have risk factors
for asthma and 4 or more episodes of
wheezing over the past yr which lasted more
than 1 day or 2 or more exacerbations in
the last 6 months requiring syst
corticosteroids should be considered in the
persistent group and hence receive long term
controller therapy

Important Tips..
 Regular clinical visits every 2-6 weeks
 Assessment of :

Pt symptoms frequency night and day
2. Need for short acting inhaled b2 agonists for
quick relief
3. Ability to engage in normal activities
4. Air flow measures for>=5 yrs
1.

Continue..
 Component 2 : pt education

 Component 3 : control of factors contributing

to asthma severity
1. Environmental exposures
2. Co morbid conditions
 Component 4 :principals of asthma
pharmacotherapy

Asthma Medication
 SABA

 ICS

 LABA
 LTRA

 SYSTEMIC STEROIDS

 NONSTEROIDAL ANTIINFLAMMATORY

CROMOLYN AND NEDOCROMYL
 OXYGEN
 ANTICHOLINERGIC AGENTS
IPRATROPIUM
BROMIDE
 ANTIIMMUNOGLUBOLINE E

MANAGEMENT OF ASTHMA EXACERBATION(STATUS ASTHMATICUS)
RISK ASSESMENT ON ADMISSION

FOCUSED HISTORY

ONSET OF CURRENT EXACERBATION
FREQUENCY AND severity of daytime and night
time symptoms and activity limitation
Frequency of rescue bronchodilator use
Current medication and allergies
Potential triggers
History of systemic steroid courses, emergency
department visists , hospitalization, intubation or life
threatening episodes

Clinical assesment

Physical examination findings: vital signs,
breathlessness, air movement, use of accessory
respiratory muscles, retractions, anxiety level,
alteration in mental status
Pulse oximetry
Lung function(defer in pts with mod to severe
distress or history of labile disease)

Treatment
Drugs and trade name

Mechanism of action and dosing

Cautions and adverse effects

Oxygen(mask or nasal canula)
Inhaled short acting b2
agonist
Albuterol nebulized
solution(5mg/ml concentrates
Albuterol MDI
Levabuterol

Treats hypoxia
Bronchodilator
Neubolizer 0.15 mg/kg every 20 min for 3
doses as needed,then 0.15_0.3 mg/kg up t 10
mg every 1_4 hour as needed or up to 0.5
mg/kg/hr by continous neubolization
2_8 puf up to every 20 min for 3 doses as
needed then every 1 hr as needed

Monitor pulse oximetry to maintain o2 saturation>92%
Cardiorespiratory monitoring
During exacerbations,frequent or continuous use can cause
pulmonary vasodilatation,v/q mistmatch and hypoxemia
Adverse effect palpitation, tachycardia, arrhythmia, tremor,
hypoxemia
Neubolizer:when giving concentrate forms,dilute with saline to 3
ml total neubolized volume
For MDI use space/holding chamber

Systemic corticosteroids
Prednisolone tb
Methyl prednisolon
Anticholinergics
Ipratropium
Atrovent
Ipratropium with Albuterol

Anti inflammatory
0.5_1 mg/kg every 6-8 hr for 48 hr , then 1-2 mg/kg
day bid(max 60 mg/day)
Short course burst for exacerbation 1-2 mg/kg/day qd
or bid for 3-7 days
Mucolitic/bronchodilator
Neubolizer 0.5 mg q6-8 hr (tid or qid) as needed
MDI 2 paf qid
1 vial by neubolizer qid



If pt has been exposed chickenpox or measles, consider passive
immunoglobulin prophylaxis, also risk of complications with
herspes simplex and TB

For daily dosing , 8 am administration minimizes adrenal
suppression

Children may benefit from dosage tapering if course exceed 7 days

Adverse effect monitoring: frequent therapy bursts risk numerous
corticosteroid adverse effects

Should not be used as first line treatment added to b2 agonist
therapy
Neubolizer may mix Ipratropium with Albuterol

QUICK RELIEF MEDICATION
SABA

Anti cholinergic(ipratropium)
Short term systemic gluco

corticoid

SABA
 Quick relief of asthma symptoms
 Relax airway smooth muscle prompt airflow↑
 Repetitive or continuous SABA is the most effective means







of reversing air flow obstruction
SABA should not be prescribed on a regular schedule
because concerns of possibility of deteriorating asthma
control
Frequent use of SABA is an indication of poor asthma control
Preferred root is inhalation smaller dose , fewer side effects
more rapid on set of action
Ipratropium Bromide as an adjunct to SABA in emergency
room reduces hospital admissions and improves lung function
Systemic Glucocorticoids short oral course + SABA in
moderate to severe asthma exacerbation

LABA
 Salmetrol

 Should be used in combination with inhaled

corticosteroids and not as mono therapy
 Exercise induces asthma in children >= 4 Yrs
one inhalation 30 min prior to exercise
 No additional doses for PTs who are already
receiving it twice daily not recommended by
NIH guidelines

LTRA

 MonteLukast ( singulair)

 Antihistaminic

 Leukotrien receptor antagonist

 Asthma ( not < 12 MO) and allergic rhinitis (





not < 6 MO)
Morning dosing not evaluated
Prophylactic and chronic treatment of asthma
Exercise induced asthma in >= 15 Yrs
Zafir Lukast : prophylactic and chronic
treatment of asthma

ICA
 Most potent anti inflammatory agents available

for the treatment of asthma
 Inhibiting most steps in the cascade of the
inflammatory response
 Benefits reducing bronchial hyper
responsiveness , prevention of late asthmatic
response , enhanced lung function
 Inhaled Glucocorticoids first line controller
therapy for persistent asthma or those who
require step 2

Prognosis
 35%of preschool children experience recurrent

coughing and wheezing,1/3 of them continue to
have persistent asthma into later childhood and
2/3 improvement on their own through their teen
yrs
 Asthma severity by age 7-10 yrs is predictive of
asthma persistence into adulthood
 Children with mod to severe asthma and lower lung
function are likely to have persistent asthma as
adults
 Children with milder asthma and N/R lung function
are likely to improve over time or be periodically
asthmatic

THANK YOU FOR YOUR
ATTENTION


Slide 14

Asthma in Children
DR. A.Mirshokraei
NIOC Hospital Pediatrics Ward

Definition :

DEFINITION

- Chronic inflammatory condition of the
lung airways resulting in episodic airflow
obstruction
- AHR to provocative exposures
Asthma management
• Reducing airway inflammation by: Minimizing
pro inflammatory environmental exposure, using
daily controller anti inflammatory medication,
controlling co morbid conditions that worsen
asthma, less inflammation better asthma
control and fewer exacerbations

Anyway exacerbations

occur

BUT
Even the uncommon
child with sever asthma can
be managed to live normally

 RECURRENT WHEEZING EPISODES WITH COMMON

RESPIRATORY
VIRUSES(RSV,RHINOVIRUS,INFLUENZA,PARAINFLUENZA,A
DENOVIRUS,HUMAN METAPNUMOVIRUS)

 HOST FEATURES AFFECTING IMMUNOLOGIC HOST

DEFENSE,INFLAMMATION/PREVIOUS VIRAL INFECTIONS
MAINIFESTED AS PNUMONIA OR BRONCHIOLITIS
REQUIRING HOSPITALIZATION UNDERLIE THE
RECURRENT WHEEZING IN EARLY CHILDHOOD

 OTHER AIRWAY EXPOSURES SUCH AS INDOOR AND HOME

ALLERGENS,COLD AIR,STRONG ODORS,TOBACCO
SMOKE,ALL INCREASE AHR

 ALLERGEN ELLIMINATION SOMETIMES LEEDS TO CURE

EPIDEMIOLOGY
 Common etiology of emergency visits and school day missing

in childhood ,occasionally hospitalization and rare deaths
specially in poverty ,urban living ,ethnic minorities

 Increasing asthma prevalence worldwide(50% per decade)
 Good correlation of asthma prevalence with allergic rhino

sinusitis and atopic eczema and other allergies

 More prevalence in high level urban modern families than

suburban villagers

 More than 80%of asthmatics reported getting the disease

before 6 year

CLINICS
RECURRENT COUGHING/WHEEZING
PATTERNS IN CHILDHOOD BASED ON
NATURAL HISTORY

TRANSIENT EARLY WHEEZING
 Common in early preschool years

 Recurrent coughing/wheezing primary

triggered by common respiratory viral INF
 Tend to resolve during preschool yrs without
increasing risk of asthma later in life
 Problems due to reduced airflow at birth
suggestive of relative narrow airways improved
by school yrs

Persistent Atopy Associated Asthma
 Begins in early preschool yrs

 Associated with atopy (eg atopic dermatitis in





infancy, allergic rhinitis, food allergy)
Biologic factors e.g.: early inhalant sensitization,
increase serum IGE, increase blood eosinophills,
High risk of persistence into later childhood and
adulthood lung function abnormality
Those with onset<3 yrs
reduced air flow by
school yrs
Those with later onset of symptoms or allergen
sensitizations unlikely persistence lung function
abnormality later

Non-Atopic Wheezing
 Wheezing ,coughing beginning in early life

often with RSV INF resolves later in childhood
without increasing risk of persistence asthma

 Associated with bronchial hyper

responsiveness near birth

Asthma with declining lung function
• Children with asthma with progressive

increase in air flow limitation

• Associated with hyper inflation in childhood
• Male gender

Late onset asthma in females associated with
obesity and early onset puberty
 Onset between 8_13 yrs

 Associated with early onset puberty and obesity
 Specific for females

Occupational type asthma in children
 Children with asthma and occupational type exposure

known to trigger asthma in adults in occupational settings

Types of Asthma
common clinical presentations of intermittent
recurrent wheezing and/or coughing
 Recurrent wheezing in early childhood

 Chronic asthma associated with allergy
 Females 11 yrs with early onset puberty and

obesity

Pathogenesis

 Airflow obstruction resulting from

Broncho constriction of bronchiolar smooth
muscle mass
II. Cellular inflammatory infiltrates and exudates
mostly Eosinophills(also N , M ,L ,mast cells
,basophiles)fill and obstruct airways and damage
epithelium and induce desquamation into airway
lumen mediated by T helper cells and other
immune cells that produce pro allergic pro
inflammatory cytokines(IL4,IL6,IL13)
III. Breach in normal immune regulatory process
I.

RESULT
 Airway inflammation

 AHR
 Edema basement membrane thickness sub

epithelial collagen deposition
 Smooth muscle and mucus gland hypertrophy
and mucus hyper secretion

Air obstruction

Clinical manifestations and diagnosis
 Most common intermittent dry cough and

expiratory wheezing

 Shortness of breath and chest tightness in older

children and adults

 Intermittent non focal chest pain in younger

children

 Worsening of respiratory symptoms at night
 Worsening of day time symptoms by activity

Continue…..
 Subtle symptoms such as self limitation of activities

,general fatigue ,difficulty in keeping up with peers

 Relief with aerosolized bronchodilators
 Lack of improvement with bronchodilators and steroid

is inconsistent with Asthma and should consider
Asthma masquerading conditions!!!!

 Hyper ventilation, intercostal retractions ,nasal flaring

,respiratory accessory muscle use

 Its common not to hear the expiratory wheezing when

Air flow is so limited before treatment

Asthma Triggers
 Common viral infections of the respiratory tract
 Aero allergens in sensitized asthmatics ,animal dander ,dust











mite ,molds ,indoor allergens ,cockroaches
Seasonal aero allergens ,pollens(trees ,grasses ,weeds ,)
Environmental tobacco smoke
Air pollutants ,ozone ,so2,wood or coal smoke ,endotoxin
,mycotoxin ,dust
Strong or noxious odors or fumes ,perfume ,hair spray
,cleaning agents
Occupational exposure
Cold air ,dry air
Exercise
Crying ,laughter ,hyperventilation
Co morbid conditions Rhinitis ,Sinusitis ,GER

Clinics
History:
Triggering symptoms by laughter
,cold air ,airway irritants
Exposures that induce airway
irritation such as viral URTI
Mycoplasma ,Chlamydia
Inhaled allergens
All lead to AHR

Presence Of Risk Factors:
 History of other allergies ,allergic Rhinitis,

allergic Conjunctivitis ,atopic Dermatitis ,food
allergies

 Parental Asthma
 Symptoms apart from cold

Continue…..
 No or minimal signs in routine visits

 Dry or persistent cough

 Normal chest findings unless wheezing when asking

to breath deeper
 Quick relief (10 MIN) after SABA use
 Expiratory wheezing ,prolonged expiratory phase
,decreased sounds in RT lower pos lobe due to
regional hypoventilation owing to airway
obstruction
 Rales , ronchi ,crackles due to hyper secretion
 Segmental crackles and poor breath sounds
atelectasis?

Continue….
 Labored respiration ,respiratory distress increased

prolongation of expiration and wheezing in E and I

 Poor air entry
 Inter costal retractions ,nasal flaring ,supra and

infra sternal retractions

 And again in most sever forms expiratory wheezing

does not appear until some broncho dilation

DD

GERD Rhino sinusitis co morbid

conditions with asthma

Recurrent aspiration in early

life(tracheo broncho malacia
,TEF , foreign body ,CF ,BPD

VCD in older children and

adolescents

LAB FINDINGS
Pulmonary Function
Testing

Continue….
 Forced expiratory airflow measures helpful

in Diagnosis , assessing efficacy of therapy
and monitoring Asthma in children specially
in poor children who do not have PHE
unless obstruction is sever

 Valueablity of spirometric findings in children>6

yrs

 3 efforts the highest is the peak
 Reduced FEV

obstruction

FEV1/FVC <0.80 means significant

 Improvement in FEV1 following beta 2 agonist > =

12% or 200 ml is consistent with Asthma

 Peak flow meter

CXR

Often normal aside from subtle and

nonspecific findings of hyperinflation

Peribronchial thickening
Helping in diagnosis of Asthma

differentials

Diagnosis of complications of Asthma

exacerbations

Other tests such as allergy skin prick
testing

Treatment
 www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm

Asthma Treatment & Management
has 4 components :
Assessment and monitoring of disease
activity
2. Provision to educate pt and family
3. Identification and management of
precipitating factors and co morbid
conditions
4. Appropriate selection of medication
1.

 Attainment of optimal Asthma control

Component 1
 Asthma severity :intermittent
 Persistent: mild ,mod ,severe
 Only once during patient initial evaluation in pt

who is not using a daily controller agent
 Asthma control degree to which symptoms ,
on going functional impairments , risk of
adverse events minimized and goals of
therapy are met

Continue….
Well controlled
2. Not well controlled
3. Very poor controlled
1.

 NIH guidelines for both severity and

control for 3 age groups

0-4 yrs
2. 5-11 yrs
3. =>12 yrs
1.

Important
even in the absence of frequent symptoms
infants and children whom have risk factors
for asthma and 4 or more episodes of
wheezing over the past yr which lasted more
than 1 day or 2 or more exacerbations in
the last 6 months requiring syst
corticosteroids should be considered in the
persistent group and hence receive long term
controller therapy

Important Tips..
 Regular clinical visits every 2-6 weeks
 Assessment of :

Pt symptoms frequency night and day
2. Need for short acting inhaled b2 agonists for
quick relief
3. Ability to engage in normal activities
4. Air flow measures for>=5 yrs
1.

Continue..
 Component 2 : pt education

 Component 3 : control of factors contributing

to asthma severity
1. Environmental exposures
2. Co morbid conditions
 Component 4 :principals of asthma
pharmacotherapy

Asthma Medication
 SABA

 ICS

 LABA
 LTRA

 SYSTEMIC STEROIDS

 NONSTEROIDAL ANTIINFLAMMATORY

CROMOLYN AND NEDOCROMYL
 OXYGEN
 ANTICHOLINERGIC AGENTS
IPRATROPIUM
BROMIDE
 ANTIIMMUNOGLUBOLINE E

MANAGEMENT OF ASTHMA EXACERBATION(STATUS ASTHMATICUS)
RISK ASSESMENT ON ADMISSION

FOCUSED HISTORY

ONSET OF CURRENT EXACERBATION
FREQUENCY AND severity of daytime and night
time symptoms and activity limitation
Frequency of rescue bronchodilator use
Current medication and allergies
Potential triggers
History of systemic steroid courses, emergency
department visists , hospitalization, intubation or life
threatening episodes

Clinical assesment

Physical examination findings: vital signs,
breathlessness, air movement, use of accessory
respiratory muscles, retractions, anxiety level,
alteration in mental status
Pulse oximetry
Lung function(defer in pts with mod to severe
distress or history of labile disease)

Treatment
Drugs and trade name

Mechanism of action and dosing

Cautions and adverse effects

Oxygen(mask or nasal canula)
Inhaled short acting b2
agonist
Albuterol nebulized
solution(5mg/ml concentrates
Albuterol MDI
Levabuterol

Treats hypoxia
Bronchodilator
Neubolizer 0.15 mg/kg every 20 min for 3
doses as needed,then 0.15_0.3 mg/kg up t 10
mg every 1_4 hour as needed or up to 0.5
mg/kg/hr by continous neubolization
2_8 puf up to every 20 min for 3 doses as
needed then every 1 hr as needed

Monitor pulse oximetry to maintain o2 saturation>92%
Cardiorespiratory monitoring
During exacerbations,frequent or continuous use can cause
pulmonary vasodilatation,v/q mistmatch and hypoxemia
Adverse effect palpitation, tachycardia, arrhythmia, tremor,
hypoxemia
Neubolizer:when giving concentrate forms,dilute with saline to 3
ml total neubolized volume
For MDI use space/holding chamber

Systemic corticosteroids
Prednisolone tb
Methyl prednisolon
Anticholinergics
Ipratropium
Atrovent
Ipratropium with Albuterol

Anti inflammatory
0.5_1 mg/kg every 6-8 hr for 48 hr , then 1-2 mg/kg
day bid(max 60 mg/day)
Short course burst for exacerbation 1-2 mg/kg/day qd
or bid for 3-7 days
Mucolitic/bronchodilator
Neubolizer 0.5 mg q6-8 hr (tid or qid) as needed
MDI 2 paf qid
1 vial by neubolizer qid



If pt has been exposed chickenpox or measles, consider passive
immunoglobulin prophylaxis, also risk of complications with
herspes simplex and TB

For daily dosing , 8 am administration minimizes adrenal
suppression

Children may benefit from dosage tapering if course exceed 7 days

Adverse effect monitoring: frequent therapy bursts risk numerous
corticosteroid adverse effects

Should not be used as first line treatment added to b2 agonist
therapy
Neubolizer may mix Ipratropium with Albuterol

QUICK RELIEF MEDICATION
SABA

Anti cholinergic(ipratropium)
Short term systemic gluco

corticoid

SABA
 Quick relief of asthma symptoms
 Relax airway smooth muscle prompt airflow↑
 Repetitive or continuous SABA is the most effective means







of reversing air flow obstruction
SABA should not be prescribed on a regular schedule
because concerns of possibility of deteriorating asthma
control
Frequent use of SABA is an indication of poor asthma control
Preferred root is inhalation smaller dose , fewer side effects
more rapid on set of action
Ipratropium Bromide as an adjunct to SABA in emergency
room reduces hospital admissions and improves lung function
Systemic Glucocorticoids short oral course + SABA in
moderate to severe asthma exacerbation

LABA
 Salmetrol

 Should be used in combination with inhaled

corticosteroids and not as mono therapy
 Exercise induces asthma in children >= 4 Yrs
one inhalation 30 min prior to exercise
 No additional doses for PTs who are already
receiving it twice daily not recommended by
NIH guidelines

LTRA

 MonteLukast ( singulair)

 Antihistaminic

 Leukotrien receptor antagonist

 Asthma ( not < 12 MO) and allergic rhinitis (





not < 6 MO)
Morning dosing not evaluated
Prophylactic and chronic treatment of asthma
Exercise induced asthma in >= 15 Yrs
Zafir Lukast : prophylactic and chronic
treatment of asthma

ICA
 Most potent anti inflammatory agents available

for the treatment of asthma
 Inhibiting most steps in the cascade of the
inflammatory response
 Benefits reducing bronchial hyper
responsiveness , prevention of late asthmatic
response , enhanced lung function
 Inhaled Glucocorticoids first line controller
therapy for persistent asthma or those who
require step 2

Prognosis
 35%of preschool children experience recurrent

coughing and wheezing,1/3 of them continue to
have persistent asthma into later childhood and
2/3 improvement on their own through their teen
yrs
 Asthma severity by age 7-10 yrs is predictive of
asthma persistence into adulthood
 Children with mod to severe asthma and lower lung
function are likely to have persistent asthma as
adults
 Children with milder asthma and N/R lung function
are likely to improve over time or be periodically
asthmatic

THANK YOU FOR YOUR
ATTENTION


Slide 15

Asthma in Children
DR. A.Mirshokraei
NIOC Hospital Pediatrics Ward

Definition :

DEFINITION

- Chronic inflammatory condition of the
lung airways resulting in episodic airflow
obstruction
- AHR to provocative exposures
Asthma management
• Reducing airway inflammation by: Minimizing
pro inflammatory environmental exposure, using
daily controller anti inflammatory medication,
controlling co morbid conditions that worsen
asthma, less inflammation better asthma
control and fewer exacerbations

Anyway exacerbations

occur

BUT
Even the uncommon
child with sever asthma can
be managed to live normally

 RECURRENT WHEEZING EPISODES WITH COMMON

RESPIRATORY
VIRUSES(RSV,RHINOVIRUS,INFLUENZA,PARAINFLUENZA,A
DENOVIRUS,HUMAN METAPNUMOVIRUS)

 HOST FEATURES AFFECTING IMMUNOLOGIC HOST

DEFENSE,INFLAMMATION/PREVIOUS VIRAL INFECTIONS
MAINIFESTED AS PNUMONIA OR BRONCHIOLITIS
REQUIRING HOSPITALIZATION UNDERLIE THE
RECURRENT WHEEZING IN EARLY CHILDHOOD

 OTHER AIRWAY EXPOSURES SUCH AS INDOOR AND HOME

ALLERGENS,COLD AIR,STRONG ODORS,TOBACCO
SMOKE,ALL INCREASE AHR

 ALLERGEN ELLIMINATION SOMETIMES LEEDS TO CURE

EPIDEMIOLOGY
 Common etiology of emergency visits and school day missing

in childhood ,occasionally hospitalization and rare deaths
specially in poverty ,urban living ,ethnic minorities

 Increasing asthma prevalence worldwide(50% per decade)
 Good correlation of asthma prevalence with allergic rhino

sinusitis and atopic eczema and other allergies

 More prevalence in high level urban modern families than

suburban villagers

 More than 80%of asthmatics reported getting the disease

before 6 year

CLINICS
RECURRENT COUGHING/WHEEZING
PATTERNS IN CHILDHOOD BASED ON
NATURAL HISTORY

TRANSIENT EARLY WHEEZING
 Common in early preschool years

 Recurrent coughing/wheezing primary

triggered by common respiratory viral INF
 Tend to resolve during preschool yrs without
increasing risk of asthma later in life
 Problems due to reduced airflow at birth
suggestive of relative narrow airways improved
by school yrs

Persistent Atopy Associated Asthma
 Begins in early preschool yrs

 Associated with atopy (eg atopic dermatitis in





infancy, allergic rhinitis, food allergy)
Biologic factors e.g.: early inhalant sensitization,
increase serum IGE, increase blood eosinophills,
High risk of persistence into later childhood and
adulthood lung function abnormality
Those with onset<3 yrs
reduced air flow by
school yrs
Those with later onset of symptoms or allergen
sensitizations unlikely persistence lung function
abnormality later

Non-Atopic Wheezing
 Wheezing ,coughing beginning in early life

often with RSV INF resolves later in childhood
without increasing risk of persistence asthma

 Associated with bronchial hyper

responsiveness near birth

Asthma with declining lung function
• Children with asthma with progressive

increase in air flow limitation

• Associated with hyper inflation in childhood
• Male gender

Late onset asthma in females associated with
obesity and early onset puberty
 Onset between 8_13 yrs

 Associated with early onset puberty and obesity
 Specific for females

Occupational type asthma in children
 Children with asthma and occupational type exposure

known to trigger asthma in adults in occupational settings

Types of Asthma
common clinical presentations of intermittent
recurrent wheezing and/or coughing
 Recurrent wheezing in early childhood

 Chronic asthma associated with allergy
 Females 11 yrs with early onset puberty and

obesity

Pathogenesis

 Airflow obstruction resulting from

Broncho constriction of bronchiolar smooth
muscle mass
II. Cellular inflammatory infiltrates and exudates
mostly Eosinophills(also N , M ,L ,mast cells
,basophiles)fill and obstruct airways and damage
epithelium and induce desquamation into airway
lumen mediated by T helper cells and other
immune cells that produce pro allergic pro
inflammatory cytokines(IL4,IL6,IL13)
III. Breach in normal immune regulatory process
I.

RESULT
 Airway inflammation

 AHR
 Edema basement membrane thickness sub

epithelial collagen deposition
 Smooth muscle and mucus gland hypertrophy
and mucus hyper secretion

Air obstruction

Clinical manifestations and diagnosis
 Most common intermittent dry cough and

expiratory wheezing

 Shortness of breath and chest tightness in older

children and adults

 Intermittent non focal chest pain in younger

children

 Worsening of respiratory symptoms at night
 Worsening of day time symptoms by activity

Continue…..
 Subtle symptoms such as self limitation of activities

,general fatigue ,difficulty in keeping up with peers

 Relief with aerosolized bronchodilators
 Lack of improvement with bronchodilators and steroid

is inconsistent with Asthma and should consider
Asthma masquerading conditions!!!!

 Hyper ventilation, intercostal retractions ,nasal flaring

,respiratory accessory muscle use

 Its common not to hear the expiratory wheezing when

Air flow is so limited before treatment

Asthma Triggers
 Common viral infections of the respiratory tract
 Aero allergens in sensitized asthmatics ,animal dander ,dust











mite ,molds ,indoor allergens ,cockroaches
Seasonal aero allergens ,pollens(trees ,grasses ,weeds ,)
Environmental tobacco smoke
Air pollutants ,ozone ,so2,wood or coal smoke ,endotoxin
,mycotoxin ,dust
Strong or noxious odors or fumes ,perfume ,hair spray
,cleaning agents
Occupational exposure
Cold air ,dry air
Exercise
Crying ,laughter ,hyperventilation
Co morbid conditions Rhinitis ,Sinusitis ,GER

Clinics
History:
Triggering symptoms by laughter
,cold air ,airway irritants
Exposures that induce airway
irritation such as viral URTI
Mycoplasma ,Chlamydia
Inhaled allergens
All lead to AHR

Presence Of Risk Factors:
 History of other allergies ,allergic Rhinitis,

allergic Conjunctivitis ,atopic Dermatitis ,food
allergies

 Parental Asthma
 Symptoms apart from cold

Continue…..
 No or minimal signs in routine visits

 Dry or persistent cough

 Normal chest findings unless wheezing when asking

to breath deeper
 Quick relief (10 MIN) after SABA use
 Expiratory wheezing ,prolonged expiratory phase
,decreased sounds in RT lower pos lobe due to
regional hypoventilation owing to airway
obstruction
 Rales , ronchi ,crackles due to hyper secretion
 Segmental crackles and poor breath sounds
atelectasis?

Continue….
 Labored respiration ,respiratory distress increased

prolongation of expiration and wheezing in E and I

 Poor air entry
 Inter costal retractions ,nasal flaring ,supra and

infra sternal retractions

 And again in most sever forms expiratory wheezing

does not appear until some broncho dilation

DD

GERD Rhino sinusitis co morbid

conditions with asthma

Recurrent aspiration in early

life(tracheo broncho malacia
,TEF , foreign body ,CF ,BPD

VCD in older children and

adolescents

LAB FINDINGS
Pulmonary Function
Testing

Continue….
 Forced expiratory airflow measures helpful

in Diagnosis , assessing efficacy of therapy
and monitoring Asthma in children specially
in poor children who do not have PHE
unless obstruction is sever

 Valueablity of spirometric findings in children>6

yrs

 3 efforts the highest is the peak
 Reduced FEV

obstruction

FEV1/FVC <0.80 means significant

 Improvement in FEV1 following beta 2 agonist > =

12% or 200 ml is consistent with Asthma

 Peak flow meter

CXR

Often normal aside from subtle and

nonspecific findings of hyperinflation

Peribronchial thickening
Helping in diagnosis of Asthma

differentials

Diagnosis of complications of Asthma

exacerbations

Other tests such as allergy skin prick
testing

Treatment
 www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm

Asthma Treatment & Management
has 4 components :
Assessment and monitoring of disease
activity
2. Provision to educate pt and family
3. Identification and management of
precipitating factors and co morbid
conditions
4. Appropriate selection of medication
1.

 Attainment of optimal Asthma control

Component 1
 Asthma severity :intermittent
 Persistent: mild ,mod ,severe
 Only once during patient initial evaluation in pt

who is not using a daily controller agent
 Asthma control degree to which symptoms ,
on going functional impairments , risk of
adverse events minimized and goals of
therapy are met

Continue….
Well controlled
2. Not well controlled
3. Very poor controlled
1.

 NIH guidelines for both severity and

control for 3 age groups

0-4 yrs
2. 5-11 yrs
3. =>12 yrs
1.

Important
even in the absence of frequent symptoms
infants and children whom have risk factors
for asthma and 4 or more episodes of
wheezing over the past yr which lasted more
than 1 day or 2 or more exacerbations in
the last 6 months requiring syst
corticosteroids should be considered in the
persistent group and hence receive long term
controller therapy

Important Tips..
 Regular clinical visits every 2-6 weeks
 Assessment of :

Pt symptoms frequency night and day
2. Need for short acting inhaled b2 agonists for
quick relief
3. Ability to engage in normal activities
4. Air flow measures for>=5 yrs
1.

Continue..
 Component 2 : pt education

 Component 3 : control of factors contributing

to asthma severity
1. Environmental exposures
2. Co morbid conditions
 Component 4 :principals of asthma
pharmacotherapy

Asthma Medication
 SABA

 ICS

 LABA
 LTRA

 SYSTEMIC STEROIDS

 NONSTEROIDAL ANTIINFLAMMATORY

CROMOLYN AND NEDOCROMYL
 OXYGEN
 ANTICHOLINERGIC AGENTS
IPRATROPIUM
BROMIDE
 ANTIIMMUNOGLUBOLINE E

MANAGEMENT OF ASTHMA EXACERBATION(STATUS ASTHMATICUS)
RISK ASSESMENT ON ADMISSION

FOCUSED HISTORY

ONSET OF CURRENT EXACERBATION
FREQUENCY AND severity of daytime and night
time symptoms and activity limitation
Frequency of rescue bronchodilator use
Current medication and allergies
Potential triggers
History of systemic steroid courses, emergency
department visists , hospitalization, intubation or life
threatening episodes

Clinical assesment

Physical examination findings: vital signs,
breathlessness, air movement, use of accessory
respiratory muscles, retractions, anxiety level,
alteration in mental status
Pulse oximetry
Lung function(defer in pts with mod to severe
distress or history of labile disease)

Treatment
Drugs and trade name

Mechanism of action and dosing

Cautions and adverse effects

Oxygen(mask or nasal canula)
Inhaled short acting b2
agonist
Albuterol nebulized
solution(5mg/ml concentrates
Albuterol MDI
Levabuterol

Treats hypoxia
Bronchodilator
Neubolizer 0.15 mg/kg every 20 min for 3
doses as needed,then 0.15_0.3 mg/kg up t 10
mg every 1_4 hour as needed or up to 0.5
mg/kg/hr by continous neubolization
2_8 puf up to every 20 min for 3 doses as
needed then every 1 hr as needed

Monitor pulse oximetry to maintain o2 saturation>92%
Cardiorespiratory monitoring
During exacerbations,frequent or continuous use can cause
pulmonary vasodilatation,v/q mistmatch and hypoxemia
Adverse effect palpitation, tachycardia, arrhythmia, tremor,
hypoxemia
Neubolizer:when giving concentrate forms,dilute with saline to 3
ml total neubolized volume
For MDI use space/holding chamber

Systemic corticosteroids
Prednisolone tb
Methyl prednisolon
Anticholinergics
Ipratropium
Atrovent
Ipratropium with Albuterol

Anti inflammatory
0.5_1 mg/kg every 6-8 hr for 48 hr , then 1-2 mg/kg
day bid(max 60 mg/day)
Short course burst for exacerbation 1-2 mg/kg/day qd
or bid for 3-7 days
Mucolitic/bronchodilator
Neubolizer 0.5 mg q6-8 hr (tid or qid) as needed
MDI 2 paf qid
1 vial by neubolizer qid



If pt has been exposed chickenpox or measles, consider passive
immunoglobulin prophylaxis, also risk of complications with
herspes simplex and TB

For daily dosing , 8 am administration minimizes adrenal
suppression

Children may benefit from dosage tapering if course exceed 7 days

Adverse effect monitoring: frequent therapy bursts risk numerous
corticosteroid adverse effects

Should not be used as first line treatment added to b2 agonist
therapy
Neubolizer may mix Ipratropium with Albuterol

QUICK RELIEF MEDICATION
SABA

Anti cholinergic(ipratropium)
Short term systemic gluco

corticoid

SABA
 Quick relief of asthma symptoms
 Relax airway smooth muscle prompt airflow↑
 Repetitive or continuous SABA is the most effective means







of reversing air flow obstruction
SABA should not be prescribed on a regular schedule
because concerns of possibility of deteriorating asthma
control
Frequent use of SABA is an indication of poor asthma control
Preferred root is inhalation smaller dose , fewer side effects
more rapid on set of action
Ipratropium Bromide as an adjunct to SABA in emergency
room reduces hospital admissions and improves lung function
Systemic Glucocorticoids short oral course + SABA in
moderate to severe asthma exacerbation

LABA
 Salmetrol

 Should be used in combination with inhaled

corticosteroids and not as mono therapy
 Exercise induces asthma in children >= 4 Yrs
one inhalation 30 min prior to exercise
 No additional doses for PTs who are already
receiving it twice daily not recommended by
NIH guidelines

LTRA

 MonteLukast ( singulair)

 Antihistaminic

 Leukotrien receptor antagonist

 Asthma ( not < 12 MO) and allergic rhinitis (





not < 6 MO)
Morning dosing not evaluated
Prophylactic and chronic treatment of asthma
Exercise induced asthma in >= 15 Yrs
Zafir Lukast : prophylactic and chronic
treatment of asthma

ICA
 Most potent anti inflammatory agents available

for the treatment of asthma
 Inhibiting most steps in the cascade of the
inflammatory response
 Benefits reducing bronchial hyper
responsiveness , prevention of late asthmatic
response , enhanced lung function
 Inhaled Glucocorticoids first line controller
therapy for persistent asthma or those who
require step 2

Prognosis
 35%of preschool children experience recurrent

coughing and wheezing,1/3 of them continue to
have persistent asthma into later childhood and
2/3 improvement on their own through their teen
yrs
 Asthma severity by age 7-10 yrs is predictive of
asthma persistence into adulthood
 Children with mod to severe asthma and lower lung
function are likely to have persistent asthma as
adults
 Children with milder asthma and N/R lung function
are likely to improve over time or be periodically
asthmatic

THANK YOU FOR YOUR
ATTENTION


Slide 16

Asthma in Children
DR. A.Mirshokraei
NIOC Hospital Pediatrics Ward

Definition :

DEFINITION

- Chronic inflammatory condition of the
lung airways resulting in episodic airflow
obstruction
- AHR to provocative exposures
Asthma management
• Reducing airway inflammation by: Minimizing
pro inflammatory environmental exposure, using
daily controller anti inflammatory medication,
controlling co morbid conditions that worsen
asthma, less inflammation better asthma
control and fewer exacerbations

Anyway exacerbations

occur

BUT
Even the uncommon
child with sever asthma can
be managed to live normally

 RECURRENT WHEEZING EPISODES WITH COMMON

RESPIRATORY
VIRUSES(RSV,RHINOVIRUS,INFLUENZA,PARAINFLUENZA,A
DENOVIRUS,HUMAN METAPNUMOVIRUS)

 HOST FEATURES AFFECTING IMMUNOLOGIC HOST

DEFENSE,INFLAMMATION/PREVIOUS VIRAL INFECTIONS
MAINIFESTED AS PNUMONIA OR BRONCHIOLITIS
REQUIRING HOSPITALIZATION UNDERLIE THE
RECURRENT WHEEZING IN EARLY CHILDHOOD

 OTHER AIRWAY EXPOSURES SUCH AS INDOOR AND HOME

ALLERGENS,COLD AIR,STRONG ODORS,TOBACCO
SMOKE,ALL INCREASE AHR

 ALLERGEN ELLIMINATION SOMETIMES LEEDS TO CURE

EPIDEMIOLOGY
 Common etiology of emergency visits and school day missing

in childhood ,occasionally hospitalization and rare deaths
specially in poverty ,urban living ,ethnic minorities

 Increasing asthma prevalence worldwide(50% per decade)
 Good correlation of asthma prevalence with allergic rhino

sinusitis and atopic eczema and other allergies

 More prevalence in high level urban modern families than

suburban villagers

 More than 80%of asthmatics reported getting the disease

before 6 year

CLINICS
RECURRENT COUGHING/WHEEZING
PATTERNS IN CHILDHOOD BASED ON
NATURAL HISTORY

TRANSIENT EARLY WHEEZING
 Common in early preschool years

 Recurrent coughing/wheezing primary

triggered by common respiratory viral INF
 Tend to resolve during preschool yrs without
increasing risk of asthma later in life
 Problems due to reduced airflow at birth
suggestive of relative narrow airways improved
by school yrs

Persistent Atopy Associated Asthma
 Begins in early preschool yrs

 Associated with atopy (eg atopic dermatitis in





infancy, allergic rhinitis, food allergy)
Biologic factors e.g.: early inhalant sensitization,
increase serum IGE, increase blood eosinophills,
High risk of persistence into later childhood and
adulthood lung function abnormality
Those with onset<3 yrs
reduced air flow by
school yrs
Those with later onset of symptoms or allergen
sensitizations unlikely persistence lung function
abnormality later

Non-Atopic Wheezing
 Wheezing ,coughing beginning in early life

often with RSV INF resolves later in childhood
without increasing risk of persistence asthma

 Associated with bronchial hyper

responsiveness near birth

Asthma with declining lung function
• Children with asthma with progressive

increase in air flow limitation

• Associated with hyper inflation in childhood
• Male gender

Late onset asthma in females associated with
obesity and early onset puberty
 Onset between 8_13 yrs

 Associated with early onset puberty and obesity
 Specific for females

Occupational type asthma in children
 Children with asthma and occupational type exposure

known to trigger asthma in adults in occupational settings

Types of Asthma
common clinical presentations of intermittent
recurrent wheezing and/or coughing
 Recurrent wheezing in early childhood

 Chronic asthma associated with allergy
 Females 11 yrs with early onset puberty and

obesity

Pathogenesis

 Airflow obstruction resulting from

Broncho constriction of bronchiolar smooth
muscle mass
II. Cellular inflammatory infiltrates and exudates
mostly Eosinophills(also N , M ,L ,mast cells
,basophiles)fill and obstruct airways and damage
epithelium and induce desquamation into airway
lumen mediated by T helper cells and other
immune cells that produce pro allergic pro
inflammatory cytokines(IL4,IL6,IL13)
III. Breach in normal immune regulatory process
I.

RESULT
 Airway inflammation

 AHR
 Edema basement membrane thickness sub

epithelial collagen deposition
 Smooth muscle and mucus gland hypertrophy
and mucus hyper secretion

Air obstruction

Clinical manifestations and diagnosis
 Most common intermittent dry cough and

expiratory wheezing

 Shortness of breath and chest tightness in older

children and adults

 Intermittent non focal chest pain in younger

children

 Worsening of respiratory symptoms at night
 Worsening of day time symptoms by activity

Continue…..
 Subtle symptoms such as self limitation of activities

,general fatigue ,difficulty in keeping up with peers

 Relief with aerosolized bronchodilators
 Lack of improvement with bronchodilators and steroid

is inconsistent with Asthma and should consider
Asthma masquerading conditions!!!!

 Hyper ventilation, intercostal retractions ,nasal flaring

,respiratory accessory muscle use

 Its common not to hear the expiratory wheezing when

Air flow is so limited before treatment

Asthma Triggers
 Common viral infections of the respiratory tract
 Aero allergens in sensitized asthmatics ,animal dander ,dust











mite ,molds ,indoor allergens ,cockroaches
Seasonal aero allergens ,pollens(trees ,grasses ,weeds ,)
Environmental tobacco smoke
Air pollutants ,ozone ,so2,wood or coal smoke ,endotoxin
,mycotoxin ,dust
Strong or noxious odors or fumes ,perfume ,hair spray
,cleaning agents
Occupational exposure
Cold air ,dry air
Exercise
Crying ,laughter ,hyperventilation
Co morbid conditions Rhinitis ,Sinusitis ,GER

Clinics
History:
Triggering symptoms by laughter
,cold air ,airway irritants
Exposures that induce airway
irritation such as viral URTI
Mycoplasma ,Chlamydia
Inhaled allergens
All lead to AHR

Presence Of Risk Factors:
 History of other allergies ,allergic Rhinitis,

allergic Conjunctivitis ,atopic Dermatitis ,food
allergies

 Parental Asthma
 Symptoms apart from cold

Continue…..
 No or minimal signs in routine visits

 Dry or persistent cough

 Normal chest findings unless wheezing when asking

to breath deeper
 Quick relief (10 MIN) after SABA use
 Expiratory wheezing ,prolonged expiratory phase
,decreased sounds in RT lower pos lobe due to
regional hypoventilation owing to airway
obstruction
 Rales , ronchi ,crackles due to hyper secretion
 Segmental crackles and poor breath sounds
atelectasis?

Continue….
 Labored respiration ,respiratory distress increased

prolongation of expiration and wheezing in E and I

 Poor air entry
 Inter costal retractions ,nasal flaring ,supra and

infra sternal retractions

 And again in most sever forms expiratory wheezing

does not appear until some broncho dilation

DD

GERD Rhino sinusitis co morbid

conditions with asthma

Recurrent aspiration in early

life(tracheo broncho malacia
,TEF , foreign body ,CF ,BPD

VCD in older children and

adolescents

LAB FINDINGS
Pulmonary Function
Testing

Continue….
 Forced expiratory airflow measures helpful

in Diagnosis , assessing efficacy of therapy
and monitoring Asthma in children specially
in poor children who do not have PHE
unless obstruction is sever

 Valueablity of spirometric findings in children>6

yrs

 3 efforts the highest is the peak
 Reduced FEV

obstruction

FEV1/FVC <0.80 means significant

 Improvement in FEV1 following beta 2 agonist > =

12% or 200 ml is consistent with Asthma

 Peak flow meter

CXR

Often normal aside from subtle and

nonspecific findings of hyperinflation

Peribronchial thickening
Helping in diagnosis of Asthma

differentials

Diagnosis of complications of Asthma

exacerbations

Other tests such as allergy skin prick
testing

Treatment
 www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm

Asthma Treatment & Management
has 4 components :
Assessment and monitoring of disease
activity
2. Provision to educate pt and family
3. Identification and management of
precipitating factors and co morbid
conditions
4. Appropriate selection of medication
1.

 Attainment of optimal Asthma control

Component 1
 Asthma severity :intermittent
 Persistent: mild ,mod ,severe
 Only once during patient initial evaluation in pt

who is not using a daily controller agent
 Asthma control degree to which symptoms ,
on going functional impairments , risk of
adverse events minimized and goals of
therapy are met

Continue….
Well controlled
2. Not well controlled
3. Very poor controlled
1.

 NIH guidelines for both severity and

control for 3 age groups

0-4 yrs
2. 5-11 yrs
3. =>12 yrs
1.

Important
even in the absence of frequent symptoms
infants and children whom have risk factors
for asthma and 4 or more episodes of
wheezing over the past yr which lasted more
than 1 day or 2 or more exacerbations in
the last 6 months requiring syst
corticosteroids should be considered in the
persistent group and hence receive long term
controller therapy

Important Tips..
 Regular clinical visits every 2-6 weeks
 Assessment of :

Pt symptoms frequency night and day
2. Need for short acting inhaled b2 agonists for
quick relief
3. Ability to engage in normal activities
4. Air flow measures for>=5 yrs
1.

Continue..
 Component 2 : pt education

 Component 3 : control of factors contributing

to asthma severity
1. Environmental exposures
2. Co morbid conditions
 Component 4 :principals of asthma
pharmacotherapy

Asthma Medication
 SABA

 ICS

 LABA
 LTRA

 SYSTEMIC STEROIDS

 NONSTEROIDAL ANTIINFLAMMATORY

CROMOLYN AND NEDOCROMYL
 OXYGEN
 ANTICHOLINERGIC AGENTS
IPRATROPIUM
BROMIDE
 ANTIIMMUNOGLUBOLINE E

MANAGEMENT OF ASTHMA EXACERBATION(STATUS ASTHMATICUS)
RISK ASSESMENT ON ADMISSION

FOCUSED HISTORY

ONSET OF CURRENT EXACERBATION
FREQUENCY AND severity of daytime and night
time symptoms and activity limitation
Frequency of rescue bronchodilator use
Current medication and allergies
Potential triggers
History of systemic steroid courses, emergency
department visists , hospitalization, intubation or life
threatening episodes

Clinical assesment

Physical examination findings: vital signs,
breathlessness, air movement, use of accessory
respiratory muscles, retractions, anxiety level,
alteration in mental status
Pulse oximetry
Lung function(defer in pts with mod to severe
distress or history of labile disease)

Treatment
Drugs and trade name

Mechanism of action and dosing

Cautions and adverse effects

Oxygen(mask or nasal canula)
Inhaled short acting b2
agonist
Albuterol nebulized
solution(5mg/ml concentrates
Albuterol MDI
Levabuterol

Treats hypoxia
Bronchodilator
Neubolizer 0.15 mg/kg every 20 min for 3
doses as needed,then 0.15_0.3 mg/kg up t 10
mg every 1_4 hour as needed or up to 0.5
mg/kg/hr by continous neubolization
2_8 puf up to every 20 min for 3 doses as
needed then every 1 hr as needed

Monitor pulse oximetry to maintain o2 saturation>92%
Cardiorespiratory monitoring
During exacerbations,frequent or continuous use can cause
pulmonary vasodilatation,v/q mistmatch and hypoxemia
Adverse effect palpitation, tachycardia, arrhythmia, tremor,
hypoxemia
Neubolizer:when giving concentrate forms,dilute with saline to 3
ml total neubolized volume
For MDI use space/holding chamber

Systemic corticosteroids
Prednisolone tb
Methyl prednisolon
Anticholinergics
Ipratropium
Atrovent
Ipratropium with Albuterol

Anti inflammatory
0.5_1 mg/kg every 6-8 hr for 48 hr , then 1-2 mg/kg
day bid(max 60 mg/day)
Short course burst for exacerbation 1-2 mg/kg/day qd
or bid for 3-7 days
Mucolitic/bronchodilator
Neubolizer 0.5 mg q6-8 hr (tid or qid) as needed
MDI 2 paf qid
1 vial by neubolizer qid



If pt has been exposed chickenpox or measles, consider passive
immunoglobulin prophylaxis, also risk of complications with
herspes simplex and TB

For daily dosing , 8 am administration minimizes adrenal
suppression

Children may benefit from dosage tapering if course exceed 7 days

Adverse effect monitoring: frequent therapy bursts risk numerous
corticosteroid adverse effects

Should not be used as first line treatment added to b2 agonist
therapy
Neubolizer may mix Ipratropium with Albuterol

QUICK RELIEF MEDICATION
SABA

Anti cholinergic(ipratropium)
Short term systemic gluco

corticoid

SABA
 Quick relief of asthma symptoms
 Relax airway smooth muscle prompt airflow↑
 Repetitive or continuous SABA is the most effective means







of reversing air flow obstruction
SABA should not be prescribed on a regular schedule
because concerns of possibility of deteriorating asthma
control
Frequent use of SABA is an indication of poor asthma control
Preferred root is inhalation smaller dose , fewer side effects
more rapid on set of action
Ipratropium Bromide as an adjunct to SABA in emergency
room reduces hospital admissions and improves lung function
Systemic Glucocorticoids short oral course + SABA in
moderate to severe asthma exacerbation

LABA
 Salmetrol

 Should be used in combination with inhaled

corticosteroids and not as mono therapy
 Exercise induces asthma in children >= 4 Yrs
one inhalation 30 min prior to exercise
 No additional doses for PTs who are already
receiving it twice daily not recommended by
NIH guidelines

LTRA

 MonteLukast ( singulair)

 Antihistaminic

 Leukotrien receptor antagonist

 Asthma ( not < 12 MO) and allergic rhinitis (





not < 6 MO)
Morning dosing not evaluated
Prophylactic and chronic treatment of asthma
Exercise induced asthma in >= 15 Yrs
Zafir Lukast : prophylactic and chronic
treatment of asthma

ICA
 Most potent anti inflammatory agents available

for the treatment of asthma
 Inhibiting most steps in the cascade of the
inflammatory response
 Benefits reducing bronchial hyper
responsiveness , prevention of late asthmatic
response , enhanced lung function
 Inhaled Glucocorticoids first line controller
therapy for persistent asthma or those who
require step 2

Prognosis
 35%of preschool children experience recurrent

coughing and wheezing,1/3 of them continue to
have persistent asthma into later childhood and
2/3 improvement on their own through their teen
yrs
 Asthma severity by age 7-10 yrs is predictive of
asthma persistence into adulthood
 Children with mod to severe asthma and lower lung
function are likely to have persistent asthma as
adults
 Children with milder asthma and N/R lung function
are likely to improve over time or be periodically
asthmatic

THANK YOU FOR YOUR
ATTENTION


Slide 17

Asthma in Children
DR. A.Mirshokraei
NIOC Hospital Pediatrics Ward

Definition :

DEFINITION

- Chronic inflammatory condition of the
lung airways resulting in episodic airflow
obstruction
- AHR to provocative exposures
Asthma management
• Reducing airway inflammation by: Minimizing
pro inflammatory environmental exposure, using
daily controller anti inflammatory medication,
controlling co morbid conditions that worsen
asthma, less inflammation better asthma
control and fewer exacerbations

Anyway exacerbations

occur

BUT
Even the uncommon
child with sever asthma can
be managed to live normally

 RECURRENT WHEEZING EPISODES WITH COMMON

RESPIRATORY
VIRUSES(RSV,RHINOVIRUS,INFLUENZA,PARAINFLUENZA,A
DENOVIRUS,HUMAN METAPNUMOVIRUS)

 HOST FEATURES AFFECTING IMMUNOLOGIC HOST

DEFENSE,INFLAMMATION/PREVIOUS VIRAL INFECTIONS
MAINIFESTED AS PNUMONIA OR BRONCHIOLITIS
REQUIRING HOSPITALIZATION UNDERLIE THE
RECURRENT WHEEZING IN EARLY CHILDHOOD

 OTHER AIRWAY EXPOSURES SUCH AS INDOOR AND HOME

ALLERGENS,COLD AIR,STRONG ODORS,TOBACCO
SMOKE,ALL INCREASE AHR

 ALLERGEN ELLIMINATION SOMETIMES LEEDS TO CURE

EPIDEMIOLOGY
 Common etiology of emergency visits and school day missing

in childhood ,occasionally hospitalization and rare deaths
specially in poverty ,urban living ,ethnic minorities

 Increasing asthma prevalence worldwide(50% per decade)
 Good correlation of asthma prevalence with allergic rhino

sinusitis and atopic eczema and other allergies

 More prevalence in high level urban modern families than

suburban villagers

 More than 80%of asthmatics reported getting the disease

before 6 year

CLINICS
RECURRENT COUGHING/WHEEZING
PATTERNS IN CHILDHOOD BASED ON
NATURAL HISTORY

TRANSIENT EARLY WHEEZING
 Common in early preschool years

 Recurrent coughing/wheezing primary

triggered by common respiratory viral INF
 Tend to resolve during preschool yrs without
increasing risk of asthma later in life
 Problems due to reduced airflow at birth
suggestive of relative narrow airways improved
by school yrs

Persistent Atopy Associated Asthma
 Begins in early preschool yrs

 Associated with atopy (eg atopic dermatitis in





infancy, allergic rhinitis, food allergy)
Biologic factors e.g.: early inhalant sensitization,
increase serum IGE, increase blood eosinophills,
High risk of persistence into later childhood and
adulthood lung function abnormality
Those with onset<3 yrs
reduced air flow by
school yrs
Those with later onset of symptoms or allergen
sensitizations unlikely persistence lung function
abnormality later

Non-Atopic Wheezing
 Wheezing ,coughing beginning in early life

often with RSV INF resolves later in childhood
without increasing risk of persistence asthma

 Associated with bronchial hyper

responsiveness near birth

Asthma with declining lung function
• Children with asthma with progressive

increase in air flow limitation

• Associated with hyper inflation in childhood
• Male gender

Late onset asthma in females associated with
obesity and early onset puberty
 Onset between 8_13 yrs

 Associated with early onset puberty and obesity
 Specific for females

Occupational type asthma in children
 Children with asthma and occupational type exposure

known to trigger asthma in adults in occupational settings

Types of Asthma
common clinical presentations of intermittent
recurrent wheezing and/or coughing
 Recurrent wheezing in early childhood

 Chronic asthma associated with allergy
 Females 11 yrs with early onset puberty and

obesity

Pathogenesis

 Airflow obstruction resulting from

Broncho constriction of bronchiolar smooth
muscle mass
II. Cellular inflammatory infiltrates and exudates
mostly Eosinophills(also N , M ,L ,mast cells
,basophiles)fill and obstruct airways and damage
epithelium and induce desquamation into airway
lumen mediated by T helper cells and other
immune cells that produce pro allergic pro
inflammatory cytokines(IL4,IL6,IL13)
III. Breach in normal immune regulatory process
I.

RESULT
 Airway inflammation

 AHR
 Edema basement membrane thickness sub

epithelial collagen deposition
 Smooth muscle and mucus gland hypertrophy
and mucus hyper secretion

Air obstruction

Clinical manifestations and diagnosis
 Most common intermittent dry cough and

expiratory wheezing

 Shortness of breath and chest tightness in older

children and adults

 Intermittent non focal chest pain in younger

children

 Worsening of respiratory symptoms at night
 Worsening of day time symptoms by activity

Continue…..
 Subtle symptoms such as self limitation of activities

,general fatigue ,difficulty in keeping up with peers

 Relief with aerosolized bronchodilators
 Lack of improvement with bronchodilators and steroid

is inconsistent with Asthma and should consider
Asthma masquerading conditions!!!!

 Hyper ventilation, intercostal retractions ,nasal flaring

,respiratory accessory muscle use

 Its common not to hear the expiratory wheezing when

Air flow is so limited before treatment

Asthma Triggers
 Common viral infections of the respiratory tract
 Aero allergens in sensitized asthmatics ,animal dander ,dust











mite ,molds ,indoor allergens ,cockroaches
Seasonal aero allergens ,pollens(trees ,grasses ,weeds ,)
Environmental tobacco smoke
Air pollutants ,ozone ,so2,wood or coal smoke ,endotoxin
,mycotoxin ,dust
Strong or noxious odors or fumes ,perfume ,hair spray
,cleaning agents
Occupational exposure
Cold air ,dry air
Exercise
Crying ,laughter ,hyperventilation
Co morbid conditions Rhinitis ,Sinusitis ,GER

Clinics
History:
Triggering symptoms by laughter
,cold air ,airway irritants
Exposures that induce airway
irritation such as viral URTI
Mycoplasma ,Chlamydia
Inhaled allergens
All lead to AHR

Presence Of Risk Factors:
 History of other allergies ,allergic Rhinitis,

allergic Conjunctivitis ,atopic Dermatitis ,food
allergies

 Parental Asthma
 Symptoms apart from cold

Continue…..
 No or minimal signs in routine visits

 Dry or persistent cough

 Normal chest findings unless wheezing when asking

to breath deeper
 Quick relief (10 MIN) after SABA use
 Expiratory wheezing ,prolonged expiratory phase
,decreased sounds in RT lower pos lobe due to
regional hypoventilation owing to airway
obstruction
 Rales , ronchi ,crackles due to hyper secretion
 Segmental crackles and poor breath sounds
atelectasis?

Continue….
 Labored respiration ,respiratory distress increased

prolongation of expiration and wheezing in E and I

 Poor air entry
 Inter costal retractions ,nasal flaring ,supra and

infra sternal retractions

 And again in most sever forms expiratory wheezing

does not appear until some broncho dilation

DD

GERD Rhino sinusitis co morbid

conditions with asthma

Recurrent aspiration in early

life(tracheo broncho malacia
,TEF , foreign body ,CF ,BPD

VCD in older children and

adolescents

LAB FINDINGS
Pulmonary Function
Testing

Continue….
 Forced expiratory airflow measures helpful

in Diagnosis , assessing efficacy of therapy
and monitoring Asthma in children specially
in poor children who do not have PHE
unless obstruction is sever

 Valueablity of spirometric findings in children>6

yrs

 3 efforts the highest is the peak
 Reduced FEV

obstruction

FEV1/FVC <0.80 means significant

 Improvement in FEV1 following beta 2 agonist > =

12% or 200 ml is consistent with Asthma

 Peak flow meter

CXR

Often normal aside from subtle and

nonspecific findings of hyperinflation

Peribronchial thickening
Helping in diagnosis of Asthma

differentials

Diagnosis of complications of Asthma

exacerbations

Other tests such as allergy skin prick
testing

Treatment
 www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm

Asthma Treatment & Management
has 4 components :
Assessment and monitoring of disease
activity
2. Provision to educate pt and family
3. Identification and management of
precipitating factors and co morbid
conditions
4. Appropriate selection of medication
1.

 Attainment of optimal Asthma control

Component 1
 Asthma severity :intermittent
 Persistent: mild ,mod ,severe
 Only once during patient initial evaluation in pt

who is not using a daily controller agent
 Asthma control degree to which symptoms ,
on going functional impairments , risk of
adverse events minimized and goals of
therapy are met

Continue….
Well controlled
2. Not well controlled
3. Very poor controlled
1.

 NIH guidelines for both severity and

control for 3 age groups

0-4 yrs
2. 5-11 yrs
3. =>12 yrs
1.

Important
even in the absence of frequent symptoms
infants and children whom have risk factors
for asthma and 4 or more episodes of
wheezing over the past yr which lasted more
than 1 day or 2 or more exacerbations in
the last 6 months requiring syst
corticosteroids should be considered in the
persistent group and hence receive long term
controller therapy

Important Tips..
 Regular clinical visits every 2-6 weeks
 Assessment of :

Pt symptoms frequency night and day
2. Need for short acting inhaled b2 agonists for
quick relief
3. Ability to engage in normal activities
4. Air flow measures for>=5 yrs
1.

Continue..
 Component 2 : pt education

 Component 3 : control of factors contributing

to asthma severity
1. Environmental exposures
2. Co morbid conditions
 Component 4 :principals of asthma
pharmacotherapy

Asthma Medication
 SABA

 ICS

 LABA
 LTRA

 SYSTEMIC STEROIDS

 NONSTEROIDAL ANTIINFLAMMATORY

CROMOLYN AND NEDOCROMYL
 OXYGEN
 ANTICHOLINERGIC AGENTS
IPRATROPIUM
BROMIDE
 ANTIIMMUNOGLUBOLINE E

MANAGEMENT OF ASTHMA EXACERBATION(STATUS ASTHMATICUS)
RISK ASSESMENT ON ADMISSION

FOCUSED HISTORY

ONSET OF CURRENT EXACERBATION
FREQUENCY AND severity of daytime and night
time symptoms and activity limitation
Frequency of rescue bronchodilator use
Current medication and allergies
Potential triggers
History of systemic steroid courses, emergency
department visists , hospitalization, intubation or life
threatening episodes

Clinical assesment

Physical examination findings: vital signs,
breathlessness, air movement, use of accessory
respiratory muscles, retractions, anxiety level,
alteration in mental status
Pulse oximetry
Lung function(defer in pts with mod to severe
distress or history of labile disease)

Treatment
Drugs and trade name

Mechanism of action and dosing

Cautions and adverse effects

Oxygen(mask or nasal canula)
Inhaled short acting b2
agonist
Albuterol nebulized
solution(5mg/ml concentrates
Albuterol MDI
Levabuterol

Treats hypoxia
Bronchodilator
Neubolizer 0.15 mg/kg every 20 min for 3
doses as needed,then 0.15_0.3 mg/kg up t 10
mg every 1_4 hour as needed or up to 0.5
mg/kg/hr by continous neubolization
2_8 puf up to every 20 min for 3 doses as
needed then every 1 hr as needed

Monitor pulse oximetry to maintain o2 saturation>92%
Cardiorespiratory monitoring
During exacerbations,frequent or continuous use can cause
pulmonary vasodilatation,v/q mistmatch and hypoxemia
Adverse effect palpitation, tachycardia, arrhythmia, tremor,
hypoxemia
Neubolizer:when giving concentrate forms,dilute with saline to 3
ml total neubolized volume
For MDI use space/holding chamber

Systemic corticosteroids
Prednisolone tb
Methyl prednisolon
Anticholinergics
Ipratropium
Atrovent
Ipratropium with Albuterol

Anti inflammatory
0.5_1 mg/kg every 6-8 hr for 48 hr , then 1-2 mg/kg
day bid(max 60 mg/day)
Short course burst for exacerbation 1-2 mg/kg/day qd
or bid for 3-7 days
Mucolitic/bronchodilator
Neubolizer 0.5 mg q6-8 hr (tid or qid) as needed
MDI 2 paf qid
1 vial by neubolizer qid



If pt has been exposed chickenpox or measles, consider passive
immunoglobulin prophylaxis, also risk of complications with
herspes simplex and TB

For daily dosing , 8 am administration minimizes adrenal
suppression

Children may benefit from dosage tapering if course exceed 7 days

Adverse effect monitoring: frequent therapy bursts risk numerous
corticosteroid adverse effects

Should not be used as first line treatment added to b2 agonist
therapy
Neubolizer may mix Ipratropium with Albuterol

QUICK RELIEF MEDICATION
SABA

Anti cholinergic(ipratropium)
Short term systemic gluco

corticoid

SABA
 Quick relief of asthma symptoms
 Relax airway smooth muscle prompt airflow↑
 Repetitive or continuous SABA is the most effective means







of reversing air flow obstruction
SABA should not be prescribed on a regular schedule
because concerns of possibility of deteriorating asthma
control
Frequent use of SABA is an indication of poor asthma control
Preferred root is inhalation smaller dose , fewer side effects
more rapid on set of action
Ipratropium Bromide as an adjunct to SABA in emergency
room reduces hospital admissions and improves lung function
Systemic Glucocorticoids short oral course + SABA in
moderate to severe asthma exacerbation

LABA
 Salmetrol

 Should be used in combination with inhaled

corticosteroids and not as mono therapy
 Exercise induces asthma in children >= 4 Yrs
one inhalation 30 min prior to exercise
 No additional doses for PTs who are already
receiving it twice daily not recommended by
NIH guidelines

LTRA

 MonteLukast ( singulair)

 Antihistaminic

 Leukotrien receptor antagonist

 Asthma ( not < 12 MO) and allergic rhinitis (





not < 6 MO)
Morning dosing not evaluated
Prophylactic and chronic treatment of asthma
Exercise induced asthma in >= 15 Yrs
Zafir Lukast : prophylactic and chronic
treatment of asthma

ICA
 Most potent anti inflammatory agents available

for the treatment of asthma
 Inhibiting most steps in the cascade of the
inflammatory response
 Benefits reducing bronchial hyper
responsiveness , prevention of late asthmatic
response , enhanced lung function
 Inhaled Glucocorticoids first line controller
therapy for persistent asthma or those who
require step 2

Prognosis
 35%of preschool children experience recurrent

coughing and wheezing,1/3 of them continue to
have persistent asthma into later childhood and
2/3 improvement on their own through their teen
yrs
 Asthma severity by age 7-10 yrs is predictive of
asthma persistence into adulthood
 Children with mod to severe asthma and lower lung
function are likely to have persistent asthma as
adults
 Children with milder asthma and N/R lung function
are likely to improve over time or be periodically
asthmatic

THANK YOU FOR YOUR
ATTENTION


Slide 18

Asthma in Children
DR. A.Mirshokraei
NIOC Hospital Pediatrics Ward

Definition :

DEFINITION

- Chronic inflammatory condition of the
lung airways resulting in episodic airflow
obstruction
- AHR to provocative exposures
Asthma management
• Reducing airway inflammation by: Minimizing
pro inflammatory environmental exposure, using
daily controller anti inflammatory medication,
controlling co morbid conditions that worsen
asthma, less inflammation better asthma
control and fewer exacerbations

Anyway exacerbations

occur

BUT
Even the uncommon
child with sever asthma can
be managed to live normally

 RECURRENT WHEEZING EPISODES WITH COMMON

RESPIRATORY
VIRUSES(RSV,RHINOVIRUS,INFLUENZA,PARAINFLUENZA,A
DENOVIRUS,HUMAN METAPNUMOVIRUS)

 HOST FEATURES AFFECTING IMMUNOLOGIC HOST

DEFENSE,INFLAMMATION/PREVIOUS VIRAL INFECTIONS
MAINIFESTED AS PNUMONIA OR BRONCHIOLITIS
REQUIRING HOSPITALIZATION UNDERLIE THE
RECURRENT WHEEZING IN EARLY CHILDHOOD

 OTHER AIRWAY EXPOSURES SUCH AS INDOOR AND HOME

ALLERGENS,COLD AIR,STRONG ODORS,TOBACCO
SMOKE,ALL INCREASE AHR

 ALLERGEN ELLIMINATION SOMETIMES LEEDS TO CURE

EPIDEMIOLOGY
 Common etiology of emergency visits and school day missing

in childhood ,occasionally hospitalization and rare deaths
specially in poverty ,urban living ,ethnic minorities

 Increasing asthma prevalence worldwide(50% per decade)
 Good correlation of asthma prevalence with allergic rhino

sinusitis and atopic eczema and other allergies

 More prevalence in high level urban modern families than

suburban villagers

 More than 80%of asthmatics reported getting the disease

before 6 year

CLINICS
RECURRENT COUGHING/WHEEZING
PATTERNS IN CHILDHOOD BASED ON
NATURAL HISTORY

TRANSIENT EARLY WHEEZING
 Common in early preschool years

 Recurrent coughing/wheezing primary

triggered by common respiratory viral INF
 Tend to resolve during preschool yrs without
increasing risk of asthma later in life
 Problems due to reduced airflow at birth
suggestive of relative narrow airways improved
by school yrs

Persistent Atopy Associated Asthma
 Begins in early preschool yrs

 Associated with atopy (eg atopic dermatitis in





infancy, allergic rhinitis, food allergy)
Biologic factors e.g.: early inhalant sensitization,
increase serum IGE, increase blood eosinophills,
High risk of persistence into later childhood and
adulthood lung function abnormality
Those with onset<3 yrs
reduced air flow by
school yrs
Those with later onset of symptoms or allergen
sensitizations unlikely persistence lung function
abnormality later

Non-Atopic Wheezing
 Wheezing ,coughing beginning in early life

often with RSV INF resolves later in childhood
without increasing risk of persistence asthma

 Associated with bronchial hyper

responsiveness near birth

Asthma with declining lung function
• Children with asthma with progressive

increase in air flow limitation

• Associated with hyper inflation in childhood
• Male gender

Late onset asthma in females associated with
obesity and early onset puberty
 Onset between 8_13 yrs

 Associated with early onset puberty and obesity
 Specific for females

Occupational type asthma in children
 Children with asthma and occupational type exposure

known to trigger asthma in adults in occupational settings

Types of Asthma
common clinical presentations of intermittent
recurrent wheezing and/or coughing
 Recurrent wheezing in early childhood

 Chronic asthma associated with allergy
 Females 11 yrs with early onset puberty and

obesity

Pathogenesis

 Airflow obstruction resulting from

Broncho constriction of bronchiolar smooth
muscle mass
II. Cellular inflammatory infiltrates and exudates
mostly Eosinophills(also N , M ,L ,mast cells
,basophiles)fill and obstruct airways and damage
epithelium and induce desquamation into airway
lumen mediated by T helper cells and other
immune cells that produce pro allergic pro
inflammatory cytokines(IL4,IL6,IL13)
III. Breach in normal immune regulatory process
I.

RESULT
 Airway inflammation

 AHR
 Edema basement membrane thickness sub

epithelial collagen deposition
 Smooth muscle and mucus gland hypertrophy
and mucus hyper secretion

Air obstruction

Clinical manifestations and diagnosis
 Most common intermittent dry cough and

expiratory wheezing

 Shortness of breath and chest tightness in older

children and adults

 Intermittent non focal chest pain in younger

children

 Worsening of respiratory symptoms at night
 Worsening of day time symptoms by activity

Continue…..
 Subtle symptoms such as self limitation of activities

,general fatigue ,difficulty in keeping up with peers

 Relief with aerosolized bronchodilators
 Lack of improvement with bronchodilators and steroid

is inconsistent with Asthma and should consider
Asthma masquerading conditions!!!!

 Hyper ventilation, intercostal retractions ,nasal flaring

,respiratory accessory muscle use

 Its common not to hear the expiratory wheezing when

Air flow is so limited before treatment

Asthma Triggers
 Common viral infections of the respiratory tract
 Aero allergens in sensitized asthmatics ,animal dander ,dust











mite ,molds ,indoor allergens ,cockroaches
Seasonal aero allergens ,pollens(trees ,grasses ,weeds ,)
Environmental tobacco smoke
Air pollutants ,ozone ,so2,wood or coal smoke ,endotoxin
,mycotoxin ,dust
Strong or noxious odors or fumes ,perfume ,hair spray
,cleaning agents
Occupational exposure
Cold air ,dry air
Exercise
Crying ,laughter ,hyperventilation
Co morbid conditions Rhinitis ,Sinusitis ,GER

Clinics
History:
Triggering symptoms by laughter
,cold air ,airway irritants
Exposures that induce airway
irritation such as viral URTI
Mycoplasma ,Chlamydia
Inhaled allergens
All lead to AHR

Presence Of Risk Factors:
 History of other allergies ,allergic Rhinitis,

allergic Conjunctivitis ,atopic Dermatitis ,food
allergies

 Parental Asthma
 Symptoms apart from cold

Continue…..
 No or minimal signs in routine visits

 Dry or persistent cough

 Normal chest findings unless wheezing when asking

to breath deeper
 Quick relief (10 MIN) after SABA use
 Expiratory wheezing ,prolonged expiratory phase
,decreased sounds in RT lower pos lobe due to
regional hypoventilation owing to airway
obstruction
 Rales , ronchi ,crackles due to hyper secretion
 Segmental crackles and poor breath sounds
atelectasis?

Continue….
 Labored respiration ,respiratory distress increased

prolongation of expiration and wheezing in E and I

 Poor air entry
 Inter costal retractions ,nasal flaring ,supra and

infra sternal retractions

 And again in most sever forms expiratory wheezing

does not appear until some broncho dilation

DD

GERD Rhino sinusitis co morbid

conditions with asthma

Recurrent aspiration in early

life(tracheo broncho malacia
,TEF , foreign body ,CF ,BPD

VCD in older children and

adolescents

LAB FINDINGS
Pulmonary Function
Testing

Continue….
 Forced expiratory airflow measures helpful

in Diagnosis , assessing efficacy of therapy
and monitoring Asthma in children specially
in poor children who do not have PHE
unless obstruction is sever

 Valueablity of spirometric findings in children>6

yrs

 3 efforts the highest is the peak
 Reduced FEV

obstruction

FEV1/FVC <0.80 means significant

 Improvement in FEV1 following beta 2 agonist > =

12% or 200 ml is consistent with Asthma

 Peak flow meter

CXR

Often normal aside from subtle and

nonspecific findings of hyperinflation

Peribronchial thickening
Helping in diagnosis of Asthma

differentials

Diagnosis of complications of Asthma

exacerbations

Other tests such as allergy skin prick
testing

Treatment
 www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm

Asthma Treatment & Management
has 4 components :
Assessment and monitoring of disease
activity
2. Provision to educate pt and family
3. Identification and management of
precipitating factors and co morbid
conditions
4. Appropriate selection of medication
1.

 Attainment of optimal Asthma control

Component 1
 Asthma severity :intermittent
 Persistent: mild ,mod ,severe
 Only once during patient initial evaluation in pt

who is not using a daily controller agent
 Asthma control degree to which symptoms ,
on going functional impairments , risk of
adverse events minimized and goals of
therapy are met

Continue….
Well controlled
2. Not well controlled
3. Very poor controlled
1.

 NIH guidelines for both severity and

control for 3 age groups

0-4 yrs
2. 5-11 yrs
3. =>12 yrs
1.

Important
even in the absence of frequent symptoms
infants and children whom have risk factors
for asthma and 4 or more episodes of
wheezing over the past yr which lasted more
than 1 day or 2 or more exacerbations in
the last 6 months requiring syst
corticosteroids should be considered in the
persistent group and hence receive long term
controller therapy

Important Tips..
 Regular clinical visits every 2-6 weeks
 Assessment of :

Pt symptoms frequency night and day
2. Need for short acting inhaled b2 agonists for
quick relief
3. Ability to engage in normal activities
4. Air flow measures for>=5 yrs
1.

Continue..
 Component 2 : pt education

 Component 3 : control of factors contributing

to asthma severity
1. Environmental exposures
2. Co morbid conditions
 Component 4 :principals of asthma
pharmacotherapy

Asthma Medication
 SABA

 ICS

 LABA
 LTRA

 SYSTEMIC STEROIDS

 NONSTEROIDAL ANTIINFLAMMATORY

CROMOLYN AND NEDOCROMYL
 OXYGEN
 ANTICHOLINERGIC AGENTS
IPRATROPIUM
BROMIDE
 ANTIIMMUNOGLUBOLINE E

MANAGEMENT OF ASTHMA EXACERBATION(STATUS ASTHMATICUS)
RISK ASSESMENT ON ADMISSION

FOCUSED HISTORY

ONSET OF CURRENT EXACERBATION
FREQUENCY AND severity of daytime and night
time symptoms and activity limitation
Frequency of rescue bronchodilator use
Current medication and allergies
Potential triggers
History of systemic steroid courses, emergency
department visists , hospitalization, intubation or life
threatening episodes

Clinical assesment

Physical examination findings: vital signs,
breathlessness, air movement, use of accessory
respiratory muscles, retractions, anxiety level,
alteration in mental status
Pulse oximetry
Lung function(defer in pts with mod to severe
distress or history of labile disease)

Treatment
Drugs and trade name

Mechanism of action and dosing

Cautions and adverse effects

Oxygen(mask or nasal canula)
Inhaled short acting b2
agonist
Albuterol nebulized
solution(5mg/ml concentrates
Albuterol MDI
Levabuterol

Treats hypoxia
Bronchodilator
Neubolizer 0.15 mg/kg every 20 min for 3
doses as needed,then 0.15_0.3 mg/kg up t 10
mg every 1_4 hour as needed or up to 0.5
mg/kg/hr by continous neubolization
2_8 puf up to every 20 min for 3 doses as
needed then every 1 hr as needed

Monitor pulse oximetry to maintain o2 saturation>92%
Cardiorespiratory monitoring
During exacerbations,frequent or continuous use can cause
pulmonary vasodilatation,v/q mistmatch and hypoxemia
Adverse effect palpitation, tachycardia, arrhythmia, tremor,
hypoxemia
Neubolizer:when giving concentrate forms,dilute with saline to 3
ml total neubolized volume
For MDI use space/holding chamber

Systemic corticosteroids
Prednisolone tb
Methyl prednisolon
Anticholinergics
Ipratropium
Atrovent
Ipratropium with Albuterol

Anti inflammatory
0.5_1 mg/kg every 6-8 hr for 48 hr , then 1-2 mg/kg
day bid(max 60 mg/day)
Short course burst for exacerbation 1-2 mg/kg/day qd
or bid for 3-7 days
Mucolitic/bronchodilator
Neubolizer 0.5 mg q6-8 hr (tid or qid) as needed
MDI 2 paf qid
1 vial by neubolizer qid



If pt has been exposed chickenpox or measles, consider passive
immunoglobulin prophylaxis, also risk of complications with
herspes simplex and TB

For daily dosing , 8 am administration minimizes adrenal
suppression

Children may benefit from dosage tapering if course exceed 7 days

Adverse effect monitoring: frequent therapy bursts risk numerous
corticosteroid adverse effects

Should not be used as first line treatment added to b2 agonist
therapy
Neubolizer may mix Ipratropium with Albuterol

QUICK RELIEF MEDICATION
SABA

Anti cholinergic(ipratropium)
Short term systemic gluco

corticoid

SABA
 Quick relief of asthma symptoms
 Relax airway smooth muscle prompt airflow↑
 Repetitive or continuous SABA is the most effective means







of reversing air flow obstruction
SABA should not be prescribed on a regular schedule
because concerns of possibility of deteriorating asthma
control
Frequent use of SABA is an indication of poor asthma control
Preferred root is inhalation smaller dose , fewer side effects
more rapid on set of action
Ipratropium Bromide as an adjunct to SABA in emergency
room reduces hospital admissions and improves lung function
Systemic Glucocorticoids short oral course + SABA in
moderate to severe asthma exacerbation

LABA
 Salmetrol

 Should be used in combination with inhaled

corticosteroids and not as mono therapy
 Exercise induces asthma in children >= 4 Yrs
one inhalation 30 min prior to exercise
 No additional doses for PTs who are already
receiving it twice daily not recommended by
NIH guidelines

LTRA

 MonteLukast ( singulair)

 Antihistaminic

 Leukotrien receptor antagonist

 Asthma ( not < 12 MO) and allergic rhinitis (





not < 6 MO)
Morning dosing not evaluated
Prophylactic and chronic treatment of asthma
Exercise induced asthma in >= 15 Yrs
Zafir Lukast : prophylactic and chronic
treatment of asthma

ICA
 Most potent anti inflammatory agents available

for the treatment of asthma
 Inhibiting most steps in the cascade of the
inflammatory response
 Benefits reducing bronchial hyper
responsiveness , prevention of late asthmatic
response , enhanced lung function
 Inhaled Glucocorticoids first line controller
therapy for persistent asthma or those who
require step 2

Prognosis
 35%of preschool children experience recurrent

coughing and wheezing,1/3 of them continue to
have persistent asthma into later childhood and
2/3 improvement on their own through their teen
yrs
 Asthma severity by age 7-10 yrs is predictive of
asthma persistence into adulthood
 Children with mod to severe asthma and lower lung
function are likely to have persistent asthma as
adults
 Children with milder asthma and N/R lung function
are likely to improve over time or be periodically
asthmatic

THANK YOU FOR YOUR
ATTENTION


Slide 19

Asthma in Children
DR. A.Mirshokraei
NIOC Hospital Pediatrics Ward

Definition :

DEFINITION

- Chronic inflammatory condition of the
lung airways resulting in episodic airflow
obstruction
- AHR to provocative exposures
Asthma management
• Reducing airway inflammation by: Minimizing
pro inflammatory environmental exposure, using
daily controller anti inflammatory medication,
controlling co morbid conditions that worsen
asthma, less inflammation better asthma
control and fewer exacerbations

Anyway exacerbations

occur

BUT
Even the uncommon
child with sever asthma can
be managed to live normally

 RECURRENT WHEEZING EPISODES WITH COMMON

RESPIRATORY
VIRUSES(RSV,RHINOVIRUS,INFLUENZA,PARAINFLUENZA,A
DENOVIRUS,HUMAN METAPNUMOVIRUS)

 HOST FEATURES AFFECTING IMMUNOLOGIC HOST

DEFENSE,INFLAMMATION/PREVIOUS VIRAL INFECTIONS
MAINIFESTED AS PNUMONIA OR BRONCHIOLITIS
REQUIRING HOSPITALIZATION UNDERLIE THE
RECURRENT WHEEZING IN EARLY CHILDHOOD

 OTHER AIRWAY EXPOSURES SUCH AS INDOOR AND HOME

ALLERGENS,COLD AIR,STRONG ODORS,TOBACCO
SMOKE,ALL INCREASE AHR

 ALLERGEN ELLIMINATION SOMETIMES LEEDS TO CURE

EPIDEMIOLOGY
 Common etiology of emergency visits and school day missing

in childhood ,occasionally hospitalization and rare deaths
specially in poverty ,urban living ,ethnic minorities

 Increasing asthma prevalence worldwide(50% per decade)
 Good correlation of asthma prevalence with allergic rhino

sinusitis and atopic eczema and other allergies

 More prevalence in high level urban modern families than

suburban villagers

 More than 80%of asthmatics reported getting the disease

before 6 year

CLINICS
RECURRENT COUGHING/WHEEZING
PATTERNS IN CHILDHOOD BASED ON
NATURAL HISTORY

TRANSIENT EARLY WHEEZING
 Common in early preschool years

 Recurrent coughing/wheezing primary

triggered by common respiratory viral INF
 Tend to resolve during preschool yrs without
increasing risk of asthma later in life
 Problems due to reduced airflow at birth
suggestive of relative narrow airways improved
by school yrs

Persistent Atopy Associated Asthma
 Begins in early preschool yrs

 Associated with atopy (eg atopic dermatitis in





infancy, allergic rhinitis, food allergy)
Biologic factors e.g.: early inhalant sensitization,
increase serum IGE, increase blood eosinophills,
High risk of persistence into later childhood and
adulthood lung function abnormality
Those with onset<3 yrs
reduced air flow by
school yrs
Those with later onset of symptoms or allergen
sensitizations unlikely persistence lung function
abnormality later

Non-Atopic Wheezing
 Wheezing ,coughing beginning in early life

often with RSV INF resolves later in childhood
without increasing risk of persistence asthma

 Associated with bronchial hyper

responsiveness near birth

Asthma with declining lung function
• Children with asthma with progressive

increase in air flow limitation

• Associated with hyper inflation in childhood
• Male gender

Late onset asthma in females associated with
obesity and early onset puberty
 Onset between 8_13 yrs

 Associated with early onset puberty and obesity
 Specific for females

Occupational type asthma in children
 Children with asthma and occupational type exposure

known to trigger asthma in adults in occupational settings

Types of Asthma
common clinical presentations of intermittent
recurrent wheezing and/or coughing
 Recurrent wheezing in early childhood

 Chronic asthma associated with allergy
 Females 11 yrs with early onset puberty and

obesity

Pathogenesis

 Airflow obstruction resulting from

Broncho constriction of bronchiolar smooth
muscle mass
II. Cellular inflammatory infiltrates and exudates
mostly Eosinophills(also N , M ,L ,mast cells
,basophiles)fill and obstruct airways and damage
epithelium and induce desquamation into airway
lumen mediated by T helper cells and other
immune cells that produce pro allergic pro
inflammatory cytokines(IL4,IL6,IL13)
III. Breach in normal immune regulatory process
I.

RESULT
 Airway inflammation

 AHR
 Edema basement membrane thickness sub

epithelial collagen deposition
 Smooth muscle and mucus gland hypertrophy
and mucus hyper secretion

Air obstruction

Clinical manifestations and diagnosis
 Most common intermittent dry cough and

expiratory wheezing

 Shortness of breath and chest tightness in older

children and adults

 Intermittent non focal chest pain in younger

children

 Worsening of respiratory symptoms at night
 Worsening of day time symptoms by activity

Continue…..
 Subtle symptoms such as self limitation of activities

,general fatigue ,difficulty in keeping up with peers

 Relief with aerosolized bronchodilators
 Lack of improvement with bronchodilators and steroid

is inconsistent with Asthma and should consider
Asthma masquerading conditions!!!!

 Hyper ventilation, intercostal retractions ,nasal flaring

,respiratory accessory muscle use

 Its common not to hear the expiratory wheezing when

Air flow is so limited before treatment

Asthma Triggers
 Common viral infections of the respiratory tract
 Aero allergens in sensitized asthmatics ,animal dander ,dust











mite ,molds ,indoor allergens ,cockroaches
Seasonal aero allergens ,pollens(trees ,grasses ,weeds ,)
Environmental tobacco smoke
Air pollutants ,ozone ,so2,wood or coal smoke ,endotoxin
,mycotoxin ,dust
Strong or noxious odors or fumes ,perfume ,hair spray
,cleaning agents
Occupational exposure
Cold air ,dry air
Exercise
Crying ,laughter ,hyperventilation
Co morbid conditions Rhinitis ,Sinusitis ,GER

Clinics
History:
Triggering symptoms by laughter
,cold air ,airway irritants
Exposures that induce airway
irritation such as viral URTI
Mycoplasma ,Chlamydia
Inhaled allergens
All lead to AHR

Presence Of Risk Factors:
 History of other allergies ,allergic Rhinitis,

allergic Conjunctivitis ,atopic Dermatitis ,food
allergies

 Parental Asthma
 Symptoms apart from cold

Continue…..
 No or minimal signs in routine visits

 Dry or persistent cough

 Normal chest findings unless wheezing when asking

to breath deeper
 Quick relief (10 MIN) after SABA use
 Expiratory wheezing ,prolonged expiratory phase
,decreased sounds in RT lower pos lobe due to
regional hypoventilation owing to airway
obstruction
 Rales , ronchi ,crackles due to hyper secretion
 Segmental crackles and poor breath sounds
atelectasis?

Continue….
 Labored respiration ,respiratory distress increased

prolongation of expiration and wheezing in E and I

 Poor air entry
 Inter costal retractions ,nasal flaring ,supra and

infra sternal retractions

 And again in most sever forms expiratory wheezing

does not appear until some broncho dilation

DD

GERD Rhino sinusitis co morbid

conditions with asthma

Recurrent aspiration in early

life(tracheo broncho malacia
,TEF , foreign body ,CF ,BPD

VCD in older children and

adolescents

LAB FINDINGS
Pulmonary Function
Testing

Continue….
 Forced expiratory airflow measures helpful

in Diagnosis , assessing efficacy of therapy
and monitoring Asthma in children specially
in poor children who do not have PHE
unless obstruction is sever

 Valueablity of spirometric findings in children>6

yrs

 3 efforts the highest is the peak
 Reduced FEV

obstruction

FEV1/FVC <0.80 means significant

 Improvement in FEV1 following beta 2 agonist > =

12% or 200 ml is consistent with Asthma

 Peak flow meter

CXR

Often normal aside from subtle and

nonspecific findings of hyperinflation

Peribronchial thickening
Helping in diagnosis of Asthma

differentials

Diagnosis of complications of Asthma

exacerbations

Other tests such as allergy skin prick
testing

Treatment
 www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm

Asthma Treatment & Management
has 4 components :
Assessment and monitoring of disease
activity
2. Provision to educate pt and family
3. Identification and management of
precipitating factors and co morbid
conditions
4. Appropriate selection of medication
1.

 Attainment of optimal Asthma control

Component 1
 Asthma severity :intermittent
 Persistent: mild ,mod ,severe
 Only once during patient initial evaluation in pt

who is not using a daily controller agent
 Asthma control degree to which symptoms ,
on going functional impairments , risk of
adverse events minimized and goals of
therapy are met

Continue….
Well controlled
2. Not well controlled
3. Very poor controlled
1.

 NIH guidelines for both severity and

control for 3 age groups

0-4 yrs
2. 5-11 yrs
3. =>12 yrs
1.

Important
even in the absence of frequent symptoms
infants and children whom have risk factors
for asthma and 4 or more episodes of
wheezing over the past yr which lasted more
than 1 day or 2 or more exacerbations in
the last 6 months requiring syst
corticosteroids should be considered in the
persistent group and hence receive long term
controller therapy

Important Tips..
 Regular clinical visits every 2-6 weeks
 Assessment of :

Pt symptoms frequency night and day
2. Need for short acting inhaled b2 agonists for
quick relief
3. Ability to engage in normal activities
4. Air flow measures for>=5 yrs
1.

Continue..
 Component 2 : pt education

 Component 3 : control of factors contributing

to asthma severity
1. Environmental exposures
2. Co morbid conditions
 Component 4 :principals of asthma
pharmacotherapy

Asthma Medication
 SABA

 ICS

 LABA
 LTRA

 SYSTEMIC STEROIDS

 NONSTEROIDAL ANTIINFLAMMATORY

CROMOLYN AND NEDOCROMYL
 OXYGEN
 ANTICHOLINERGIC AGENTS
IPRATROPIUM
BROMIDE
 ANTIIMMUNOGLUBOLINE E

MANAGEMENT OF ASTHMA EXACERBATION(STATUS ASTHMATICUS)
RISK ASSESMENT ON ADMISSION

FOCUSED HISTORY

ONSET OF CURRENT EXACERBATION
FREQUENCY AND severity of daytime and night
time symptoms and activity limitation
Frequency of rescue bronchodilator use
Current medication and allergies
Potential triggers
History of systemic steroid courses, emergency
department visists , hospitalization, intubation or life
threatening episodes

Clinical assesment

Physical examination findings: vital signs,
breathlessness, air movement, use of accessory
respiratory muscles, retractions, anxiety level,
alteration in mental status
Pulse oximetry
Lung function(defer in pts with mod to severe
distress or history of labile disease)

Treatment
Drugs and trade name

Mechanism of action and dosing

Cautions and adverse effects

Oxygen(mask or nasal canula)
Inhaled short acting b2
agonist
Albuterol nebulized
solution(5mg/ml concentrates
Albuterol MDI
Levabuterol

Treats hypoxia
Bronchodilator
Neubolizer 0.15 mg/kg every 20 min for 3
doses as needed,then 0.15_0.3 mg/kg up t 10
mg every 1_4 hour as needed or up to 0.5
mg/kg/hr by continous neubolization
2_8 puf up to every 20 min for 3 doses as
needed then every 1 hr as needed

Monitor pulse oximetry to maintain o2 saturation>92%
Cardiorespiratory monitoring
During exacerbations,frequent or continuous use can cause
pulmonary vasodilatation,v/q mistmatch and hypoxemia
Adverse effect palpitation, tachycardia, arrhythmia, tremor,
hypoxemia
Neubolizer:when giving concentrate forms,dilute with saline to 3
ml total neubolized volume
For MDI use space/holding chamber

Systemic corticosteroids
Prednisolone tb
Methyl prednisolon
Anticholinergics
Ipratropium
Atrovent
Ipratropium with Albuterol

Anti inflammatory
0.5_1 mg/kg every 6-8 hr for 48 hr , then 1-2 mg/kg
day bid(max 60 mg/day)
Short course burst for exacerbation 1-2 mg/kg/day qd
or bid for 3-7 days
Mucolitic/bronchodilator
Neubolizer 0.5 mg q6-8 hr (tid or qid) as needed
MDI 2 paf qid
1 vial by neubolizer qid



If pt has been exposed chickenpox or measles, consider passive
immunoglobulin prophylaxis, also risk of complications with
herspes simplex and TB

For daily dosing , 8 am administration minimizes adrenal
suppression

Children may benefit from dosage tapering if course exceed 7 days

Adverse effect monitoring: frequent therapy bursts risk numerous
corticosteroid adverse effects

Should not be used as first line treatment added to b2 agonist
therapy
Neubolizer may mix Ipratropium with Albuterol

QUICK RELIEF MEDICATION
SABA

Anti cholinergic(ipratropium)
Short term systemic gluco

corticoid

SABA
 Quick relief of asthma symptoms
 Relax airway smooth muscle prompt airflow↑
 Repetitive or continuous SABA is the most effective means







of reversing air flow obstruction
SABA should not be prescribed on a regular schedule
because concerns of possibility of deteriorating asthma
control
Frequent use of SABA is an indication of poor asthma control
Preferred root is inhalation smaller dose , fewer side effects
more rapid on set of action
Ipratropium Bromide as an adjunct to SABA in emergency
room reduces hospital admissions and improves lung function
Systemic Glucocorticoids short oral course + SABA in
moderate to severe asthma exacerbation

LABA
 Salmetrol

 Should be used in combination with inhaled

corticosteroids and not as mono therapy
 Exercise induces asthma in children >= 4 Yrs
one inhalation 30 min prior to exercise
 No additional doses for PTs who are already
receiving it twice daily not recommended by
NIH guidelines

LTRA

 MonteLukast ( singulair)

 Antihistaminic

 Leukotrien receptor antagonist

 Asthma ( not < 12 MO) and allergic rhinitis (





not < 6 MO)
Morning dosing not evaluated
Prophylactic and chronic treatment of asthma
Exercise induced asthma in >= 15 Yrs
Zafir Lukast : prophylactic and chronic
treatment of asthma

ICA
 Most potent anti inflammatory agents available

for the treatment of asthma
 Inhibiting most steps in the cascade of the
inflammatory response
 Benefits reducing bronchial hyper
responsiveness , prevention of late asthmatic
response , enhanced lung function
 Inhaled Glucocorticoids first line controller
therapy for persistent asthma or those who
require step 2

Prognosis
 35%of preschool children experience recurrent

coughing and wheezing,1/3 of them continue to
have persistent asthma into later childhood and
2/3 improvement on their own through their teen
yrs
 Asthma severity by age 7-10 yrs is predictive of
asthma persistence into adulthood
 Children with mod to severe asthma and lower lung
function are likely to have persistent asthma as
adults
 Children with milder asthma and N/R lung function
are likely to improve over time or be periodically
asthmatic

THANK YOU FOR YOUR
ATTENTION


Slide 20

Asthma in Children
DR. A.Mirshokraei
NIOC Hospital Pediatrics Ward

Definition :

DEFINITION

- Chronic inflammatory condition of the
lung airways resulting in episodic airflow
obstruction
- AHR to provocative exposures
Asthma management
• Reducing airway inflammation by: Minimizing
pro inflammatory environmental exposure, using
daily controller anti inflammatory medication,
controlling co morbid conditions that worsen
asthma, less inflammation better asthma
control and fewer exacerbations

Anyway exacerbations

occur

BUT
Even the uncommon
child with sever asthma can
be managed to live normally

 RECURRENT WHEEZING EPISODES WITH COMMON

RESPIRATORY
VIRUSES(RSV,RHINOVIRUS,INFLUENZA,PARAINFLUENZA,A
DENOVIRUS,HUMAN METAPNUMOVIRUS)

 HOST FEATURES AFFECTING IMMUNOLOGIC HOST

DEFENSE,INFLAMMATION/PREVIOUS VIRAL INFECTIONS
MAINIFESTED AS PNUMONIA OR BRONCHIOLITIS
REQUIRING HOSPITALIZATION UNDERLIE THE
RECURRENT WHEEZING IN EARLY CHILDHOOD

 OTHER AIRWAY EXPOSURES SUCH AS INDOOR AND HOME

ALLERGENS,COLD AIR,STRONG ODORS,TOBACCO
SMOKE,ALL INCREASE AHR

 ALLERGEN ELLIMINATION SOMETIMES LEEDS TO CURE

EPIDEMIOLOGY
 Common etiology of emergency visits and school day missing

in childhood ,occasionally hospitalization and rare deaths
specially in poverty ,urban living ,ethnic minorities

 Increasing asthma prevalence worldwide(50% per decade)
 Good correlation of asthma prevalence with allergic rhino

sinusitis and atopic eczema and other allergies

 More prevalence in high level urban modern families than

suburban villagers

 More than 80%of asthmatics reported getting the disease

before 6 year

CLINICS
RECURRENT COUGHING/WHEEZING
PATTERNS IN CHILDHOOD BASED ON
NATURAL HISTORY

TRANSIENT EARLY WHEEZING
 Common in early preschool years

 Recurrent coughing/wheezing primary

triggered by common respiratory viral INF
 Tend to resolve during preschool yrs without
increasing risk of asthma later in life
 Problems due to reduced airflow at birth
suggestive of relative narrow airways improved
by school yrs

Persistent Atopy Associated Asthma
 Begins in early preschool yrs

 Associated with atopy (eg atopic dermatitis in





infancy, allergic rhinitis, food allergy)
Biologic factors e.g.: early inhalant sensitization,
increase serum IGE, increase blood eosinophills,
High risk of persistence into later childhood and
adulthood lung function abnormality
Those with onset<3 yrs
reduced air flow by
school yrs
Those with later onset of symptoms or allergen
sensitizations unlikely persistence lung function
abnormality later

Non-Atopic Wheezing
 Wheezing ,coughing beginning in early life

often with RSV INF resolves later in childhood
without increasing risk of persistence asthma

 Associated with bronchial hyper

responsiveness near birth

Asthma with declining lung function
• Children with asthma with progressive

increase in air flow limitation

• Associated with hyper inflation in childhood
• Male gender

Late onset asthma in females associated with
obesity and early onset puberty
 Onset between 8_13 yrs

 Associated with early onset puberty and obesity
 Specific for females

Occupational type asthma in children
 Children with asthma and occupational type exposure

known to trigger asthma in adults in occupational settings

Types of Asthma
common clinical presentations of intermittent
recurrent wheezing and/or coughing
 Recurrent wheezing in early childhood

 Chronic asthma associated with allergy
 Females 11 yrs with early onset puberty and

obesity

Pathogenesis

 Airflow obstruction resulting from

Broncho constriction of bronchiolar smooth
muscle mass
II. Cellular inflammatory infiltrates and exudates
mostly Eosinophills(also N , M ,L ,mast cells
,basophiles)fill and obstruct airways and damage
epithelium and induce desquamation into airway
lumen mediated by T helper cells and other
immune cells that produce pro allergic pro
inflammatory cytokines(IL4,IL6,IL13)
III. Breach in normal immune regulatory process
I.

RESULT
 Airway inflammation

 AHR
 Edema basement membrane thickness sub

epithelial collagen deposition
 Smooth muscle and mucus gland hypertrophy
and mucus hyper secretion

Air obstruction

Clinical manifestations and diagnosis
 Most common intermittent dry cough and

expiratory wheezing

 Shortness of breath and chest tightness in older

children and adults

 Intermittent non focal chest pain in younger

children

 Worsening of respiratory symptoms at night
 Worsening of day time symptoms by activity

Continue…..
 Subtle symptoms such as self limitation of activities

,general fatigue ,difficulty in keeping up with peers

 Relief with aerosolized bronchodilators
 Lack of improvement with bronchodilators and steroid

is inconsistent with Asthma and should consider
Asthma masquerading conditions!!!!

 Hyper ventilation, intercostal retractions ,nasal flaring

,respiratory accessory muscle use

 Its common not to hear the expiratory wheezing when

Air flow is so limited before treatment

Asthma Triggers
 Common viral infections of the respiratory tract
 Aero allergens in sensitized asthmatics ,animal dander ,dust











mite ,molds ,indoor allergens ,cockroaches
Seasonal aero allergens ,pollens(trees ,grasses ,weeds ,)
Environmental tobacco smoke
Air pollutants ,ozone ,so2,wood or coal smoke ,endotoxin
,mycotoxin ,dust
Strong or noxious odors or fumes ,perfume ,hair spray
,cleaning agents
Occupational exposure
Cold air ,dry air
Exercise
Crying ,laughter ,hyperventilation
Co morbid conditions Rhinitis ,Sinusitis ,GER

Clinics
History:
Triggering symptoms by laughter
,cold air ,airway irritants
Exposures that induce airway
irritation such as viral URTI
Mycoplasma ,Chlamydia
Inhaled allergens
All lead to AHR

Presence Of Risk Factors:
 History of other allergies ,allergic Rhinitis,

allergic Conjunctivitis ,atopic Dermatitis ,food
allergies

 Parental Asthma
 Symptoms apart from cold

Continue…..
 No or minimal signs in routine visits

 Dry or persistent cough

 Normal chest findings unless wheezing when asking

to breath deeper
 Quick relief (10 MIN) after SABA use
 Expiratory wheezing ,prolonged expiratory phase
,decreased sounds in RT lower pos lobe due to
regional hypoventilation owing to airway
obstruction
 Rales , ronchi ,crackles due to hyper secretion
 Segmental crackles and poor breath sounds
atelectasis?

Continue….
 Labored respiration ,respiratory distress increased

prolongation of expiration and wheezing in E and I

 Poor air entry
 Inter costal retractions ,nasal flaring ,supra and

infra sternal retractions

 And again in most sever forms expiratory wheezing

does not appear until some broncho dilation

DD

GERD Rhino sinusitis co morbid

conditions with asthma

Recurrent aspiration in early

life(tracheo broncho malacia
,TEF , foreign body ,CF ,BPD

VCD in older children and

adolescents

LAB FINDINGS
Pulmonary Function
Testing

Continue….
 Forced expiratory airflow measures helpful

in Diagnosis , assessing efficacy of therapy
and monitoring Asthma in children specially
in poor children who do not have PHE
unless obstruction is sever

 Valueablity of spirometric findings in children>6

yrs

 3 efforts the highest is the peak
 Reduced FEV

obstruction

FEV1/FVC <0.80 means significant

 Improvement in FEV1 following beta 2 agonist > =

12% or 200 ml is consistent with Asthma

 Peak flow meter

CXR

Often normal aside from subtle and

nonspecific findings of hyperinflation

Peribronchial thickening
Helping in diagnosis of Asthma

differentials

Diagnosis of complications of Asthma

exacerbations

Other tests such as allergy skin prick
testing

Treatment
 www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm

Asthma Treatment & Management
has 4 components :
Assessment and monitoring of disease
activity
2. Provision to educate pt and family
3. Identification and management of
precipitating factors and co morbid
conditions
4. Appropriate selection of medication
1.

 Attainment of optimal Asthma control

Component 1
 Asthma severity :intermittent
 Persistent: mild ,mod ,severe
 Only once during patient initial evaluation in pt

who is not using a daily controller agent
 Asthma control degree to which symptoms ,
on going functional impairments , risk of
adverse events minimized and goals of
therapy are met

Continue….
Well controlled
2. Not well controlled
3. Very poor controlled
1.

 NIH guidelines for both severity and

control for 3 age groups

0-4 yrs
2. 5-11 yrs
3. =>12 yrs
1.

Important
even in the absence of frequent symptoms
infants and children whom have risk factors
for asthma and 4 or more episodes of
wheezing over the past yr which lasted more
than 1 day or 2 or more exacerbations in
the last 6 months requiring syst
corticosteroids should be considered in the
persistent group and hence receive long term
controller therapy

Important Tips..
 Regular clinical visits every 2-6 weeks
 Assessment of :

Pt symptoms frequency night and day
2. Need for short acting inhaled b2 agonists for
quick relief
3. Ability to engage in normal activities
4. Air flow measures for>=5 yrs
1.

Continue..
 Component 2 : pt education

 Component 3 : control of factors contributing

to asthma severity
1. Environmental exposures
2. Co morbid conditions
 Component 4 :principals of asthma
pharmacotherapy

Asthma Medication
 SABA

 ICS

 LABA
 LTRA

 SYSTEMIC STEROIDS

 NONSTEROIDAL ANTIINFLAMMATORY

CROMOLYN AND NEDOCROMYL
 OXYGEN
 ANTICHOLINERGIC AGENTS
IPRATROPIUM
BROMIDE
 ANTIIMMUNOGLUBOLINE E

MANAGEMENT OF ASTHMA EXACERBATION(STATUS ASTHMATICUS)
RISK ASSESMENT ON ADMISSION

FOCUSED HISTORY

ONSET OF CURRENT EXACERBATION
FREQUENCY AND severity of daytime and night
time symptoms and activity limitation
Frequency of rescue bronchodilator use
Current medication and allergies
Potential triggers
History of systemic steroid courses, emergency
department visists , hospitalization, intubation or life
threatening episodes

Clinical assesment

Physical examination findings: vital signs,
breathlessness, air movement, use of accessory
respiratory muscles, retractions, anxiety level,
alteration in mental status
Pulse oximetry
Lung function(defer in pts with mod to severe
distress or history of labile disease)

Treatment
Drugs and trade name

Mechanism of action and dosing

Cautions and adverse effects

Oxygen(mask or nasal canula)
Inhaled short acting b2
agonist
Albuterol nebulized
solution(5mg/ml concentrates
Albuterol MDI
Levabuterol

Treats hypoxia
Bronchodilator
Neubolizer 0.15 mg/kg every 20 min for 3
doses as needed,then 0.15_0.3 mg/kg up t 10
mg every 1_4 hour as needed or up to 0.5
mg/kg/hr by continous neubolization
2_8 puf up to every 20 min for 3 doses as
needed then every 1 hr as needed

Monitor pulse oximetry to maintain o2 saturation>92%
Cardiorespiratory monitoring
During exacerbations,frequent or continuous use can cause
pulmonary vasodilatation,v/q mistmatch and hypoxemia
Adverse effect palpitation, tachycardia, arrhythmia, tremor,
hypoxemia
Neubolizer:when giving concentrate forms,dilute with saline to 3
ml total neubolized volume
For MDI use space/holding chamber

Systemic corticosteroids
Prednisolone tb
Methyl prednisolon
Anticholinergics
Ipratropium
Atrovent
Ipratropium with Albuterol

Anti inflammatory
0.5_1 mg/kg every 6-8 hr for 48 hr , then 1-2 mg/kg
day bid(max 60 mg/day)
Short course burst for exacerbation 1-2 mg/kg/day qd
or bid for 3-7 days
Mucolitic/bronchodilator
Neubolizer 0.5 mg q6-8 hr (tid or qid) as needed
MDI 2 paf qid
1 vial by neubolizer qid



If pt has been exposed chickenpox or measles, consider passive
immunoglobulin prophylaxis, also risk of complications with
herspes simplex and TB

For daily dosing , 8 am administration minimizes adrenal
suppression

Children may benefit from dosage tapering if course exceed 7 days

Adverse effect monitoring: frequent therapy bursts risk numerous
corticosteroid adverse effects

Should not be used as first line treatment added to b2 agonist
therapy
Neubolizer may mix Ipratropium with Albuterol

QUICK RELIEF MEDICATION
SABA

Anti cholinergic(ipratropium)
Short term systemic gluco

corticoid

SABA
 Quick relief of asthma symptoms
 Relax airway smooth muscle prompt airflow↑
 Repetitive or continuous SABA is the most effective means







of reversing air flow obstruction
SABA should not be prescribed on a regular schedule
because concerns of possibility of deteriorating asthma
control
Frequent use of SABA is an indication of poor asthma control
Preferred root is inhalation smaller dose , fewer side effects
more rapid on set of action
Ipratropium Bromide as an adjunct to SABA in emergency
room reduces hospital admissions and improves lung function
Systemic Glucocorticoids short oral course + SABA in
moderate to severe asthma exacerbation

LABA
 Salmetrol

 Should be used in combination with inhaled

corticosteroids and not as mono therapy
 Exercise induces asthma in children >= 4 Yrs
one inhalation 30 min prior to exercise
 No additional doses for PTs who are already
receiving it twice daily not recommended by
NIH guidelines

LTRA

 MonteLukast ( singulair)

 Antihistaminic

 Leukotrien receptor antagonist

 Asthma ( not < 12 MO) and allergic rhinitis (





not < 6 MO)
Morning dosing not evaluated
Prophylactic and chronic treatment of asthma
Exercise induced asthma in >= 15 Yrs
Zafir Lukast : prophylactic and chronic
treatment of asthma

ICA
 Most potent anti inflammatory agents available

for the treatment of asthma
 Inhibiting most steps in the cascade of the
inflammatory response
 Benefits reducing bronchial hyper
responsiveness , prevention of late asthmatic
response , enhanced lung function
 Inhaled Glucocorticoids first line controller
therapy for persistent asthma or those who
require step 2

Prognosis
 35%of preschool children experience recurrent

coughing and wheezing,1/3 of them continue to
have persistent asthma into later childhood and
2/3 improvement on their own through their teen
yrs
 Asthma severity by age 7-10 yrs is predictive of
asthma persistence into adulthood
 Children with mod to severe asthma and lower lung
function are likely to have persistent asthma as
adults
 Children with milder asthma and N/R lung function
are likely to improve over time or be periodically
asthmatic

THANK YOU FOR YOUR
ATTENTION


Slide 21

Asthma in Children
DR. A.Mirshokraei
NIOC Hospital Pediatrics Ward

Definition :

DEFINITION

- Chronic inflammatory condition of the
lung airways resulting in episodic airflow
obstruction
- AHR to provocative exposures
Asthma management
• Reducing airway inflammation by: Minimizing
pro inflammatory environmental exposure, using
daily controller anti inflammatory medication,
controlling co morbid conditions that worsen
asthma, less inflammation better asthma
control and fewer exacerbations

Anyway exacerbations

occur

BUT
Even the uncommon
child with sever asthma can
be managed to live normally

 RECURRENT WHEEZING EPISODES WITH COMMON

RESPIRATORY
VIRUSES(RSV,RHINOVIRUS,INFLUENZA,PARAINFLUENZA,A
DENOVIRUS,HUMAN METAPNUMOVIRUS)

 HOST FEATURES AFFECTING IMMUNOLOGIC HOST

DEFENSE,INFLAMMATION/PREVIOUS VIRAL INFECTIONS
MAINIFESTED AS PNUMONIA OR BRONCHIOLITIS
REQUIRING HOSPITALIZATION UNDERLIE THE
RECURRENT WHEEZING IN EARLY CHILDHOOD

 OTHER AIRWAY EXPOSURES SUCH AS INDOOR AND HOME

ALLERGENS,COLD AIR,STRONG ODORS,TOBACCO
SMOKE,ALL INCREASE AHR

 ALLERGEN ELLIMINATION SOMETIMES LEEDS TO CURE

EPIDEMIOLOGY
 Common etiology of emergency visits and school day missing

in childhood ,occasionally hospitalization and rare deaths
specially in poverty ,urban living ,ethnic minorities

 Increasing asthma prevalence worldwide(50% per decade)
 Good correlation of asthma prevalence with allergic rhino

sinusitis and atopic eczema and other allergies

 More prevalence in high level urban modern families than

suburban villagers

 More than 80%of asthmatics reported getting the disease

before 6 year

CLINICS
RECURRENT COUGHING/WHEEZING
PATTERNS IN CHILDHOOD BASED ON
NATURAL HISTORY

TRANSIENT EARLY WHEEZING
 Common in early preschool years

 Recurrent coughing/wheezing primary

triggered by common respiratory viral INF
 Tend to resolve during preschool yrs without
increasing risk of asthma later in life
 Problems due to reduced airflow at birth
suggestive of relative narrow airways improved
by school yrs

Persistent Atopy Associated Asthma
 Begins in early preschool yrs

 Associated with atopy (eg atopic dermatitis in





infancy, allergic rhinitis, food allergy)
Biologic factors e.g.: early inhalant sensitization,
increase serum IGE, increase blood eosinophills,
High risk of persistence into later childhood and
adulthood lung function abnormality
Those with onset<3 yrs
reduced air flow by
school yrs
Those with later onset of symptoms or allergen
sensitizations unlikely persistence lung function
abnormality later

Non-Atopic Wheezing
 Wheezing ,coughing beginning in early life

often with RSV INF resolves later in childhood
without increasing risk of persistence asthma

 Associated with bronchial hyper

responsiveness near birth

Asthma with declining lung function
• Children with asthma with progressive

increase in air flow limitation

• Associated with hyper inflation in childhood
• Male gender

Late onset asthma in females associated with
obesity and early onset puberty
 Onset between 8_13 yrs

 Associated with early onset puberty and obesity
 Specific for females

Occupational type asthma in children
 Children with asthma and occupational type exposure

known to trigger asthma in adults in occupational settings

Types of Asthma
common clinical presentations of intermittent
recurrent wheezing and/or coughing
 Recurrent wheezing in early childhood

 Chronic asthma associated with allergy
 Females 11 yrs with early onset puberty and

obesity

Pathogenesis

 Airflow obstruction resulting from

Broncho constriction of bronchiolar smooth
muscle mass
II. Cellular inflammatory infiltrates and exudates
mostly Eosinophills(also N , M ,L ,mast cells
,basophiles)fill and obstruct airways and damage
epithelium and induce desquamation into airway
lumen mediated by T helper cells and other
immune cells that produce pro allergic pro
inflammatory cytokines(IL4,IL6,IL13)
III. Breach in normal immune regulatory process
I.

RESULT
 Airway inflammation

 AHR
 Edema basement membrane thickness sub

epithelial collagen deposition
 Smooth muscle and mucus gland hypertrophy
and mucus hyper secretion

Air obstruction

Clinical manifestations and diagnosis
 Most common intermittent dry cough and

expiratory wheezing

 Shortness of breath and chest tightness in older

children and adults

 Intermittent non focal chest pain in younger

children

 Worsening of respiratory symptoms at night
 Worsening of day time symptoms by activity

Continue…..
 Subtle symptoms such as self limitation of activities

,general fatigue ,difficulty in keeping up with peers

 Relief with aerosolized bronchodilators
 Lack of improvement with bronchodilators and steroid

is inconsistent with Asthma and should consider
Asthma masquerading conditions!!!!

 Hyper ventilation, intercostal retractions ,nasal flaring

,respiratory accessory muscle use

 Its common not to hear the expiratory wheezing when

Air flow is so limited before treatment

Asthma Triggers
 Common viral infections of the respiratory tract
 Aero allergens in sensitized asthmatics ,animal dander ,dust











mite ,molds ,indoor allergens ,cockroaches
Seasonal aero allergens ,pollens(trees ,grasses ,weeds ,)
Environmental tobacco smoke
Air pollutants ,ozone ,so2,wood or coal smoke ,endotoxin
,mycotoxin ,dust
Strong or noxious odors or fumes ,perfume ,hair spray
,cleaning agents
Occupational exposure
Cold air ,dry air
Exercise
Crying ,laughter ,hyperventilation
Co morbid conditions Rhinitis ,Sinusitis ,GER

Clinics
History:
Triggering symptoms by laughter
,cold air ,airway irritants
Exposures that induce airway
irritation such as viral URTI
Mycoplasma ,Chlamydia
Inhaled allergens
All lead to AHR

Presence Of Risk Factors:
 History of other allergies ,allergic Rhinitis,

allergic Conjunctivitis ,atopic Dermatitis ,food
allergies

 Parental Asthma
 Symptoms apart from cold

Continue…..
 No or minimal signs in routine visits

 Dry or persistent cough

 Normal chest findings unless wheezing when asking

to breath deeper
 Quick relief (10 MIN) after SABA use
 Expiratory wheezing ,prolonged expiratory phase
,decreased sounds in RT lower pos lobe due to
regional hypoventilation owing to airway
obstruction
 Rales , ronchi ,crackles due to hyper secretion
 Segmental crackles and poor breath sounds
atelectasis?

Continue….
 Labored respiration ,respiratory distress increased

prolongation of expiration and wheezing in E and I

 Poor air entry
 Inter costal retractions ,nasal flaring ,supra and

infra sternal retractions

 And again in most sever forms expiratory wheezing

does not appear until some broncho dilation

DD

GERD Rhino sinusitis co morbid

conditions with asthma

Recurrent aspiration in early

life(tracheo broncho malacia
,TEF , foreign body ,CF ,BPD

VCD in older children and

adolescents

LAB FINDINGS
Pulmonary Function
Testing

Continue….
 Forced expiratory airflow measures helpful

in Diagnosis , assessing efficacy of therapy
and monitoring Asthma in children specially
in poor children who do not have PHE
unless obstruction is sever

 Valueablity of spirometric findings in children>6

yrs

 3 efforts the highest is the peak
 Reduced FEV

obstruction

FEV1/FVC <0.80 means significant

 Improvement in FEV1 following beta 2 agonist > =

12% or 200 ml is consistent with Asthma

 Peak flow meter

CXR

Often normal aside from subtle and

nonspecific findings of hyperinflation

Peribronchial thickening
Helping in diagnosis of Asthma

differentials

Diagnosis of complications of Asthma

exacerbations

Other tests such as allergy skin prick
testing

Treatment
 www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm

Asthma Treatment & Management
has 4 components :
Assessment and monitoring of disease
activity
2. Provision to educate pt and family
3. Identification and management of
precipitating factors and co morbid
conditions
4. Appropriate selection of medication
1.

 Attainment of optimal Asthma control

Component 1
 Asthma severity :intermittent
 Persistent: mild ,mod ,severe
 Only once during patient initial evaluation in pt

who is not using a daily controller agent
 Asthma control degree to which symptoms ,
on going functional impairments , risk of
adverse events minimized and goals of
therapy are met

Continue….
Well controlled
2. Not well controlled
3. Very poor controlled
1.

 NIH guidelines for both severity and

control for 3 age groups

0-4 yrs
2. 5-11 yrs
3. =>12 yrs
1.

Important
even in the absence of frequent symptoms
infants and children whom have risk factors
for asthma and 4 or more episodes of
wheezing over the past yr which lasted more
than 1 day or 2 or more exacerbations in
the last 6 months requiring syst
corticosteroids should be considered in the
persistent group and hence receive long term
controller therapy

Important Tips..
 Regular clinical visits every 2-6 weeks
 Assessment of :

Pt symptoms frequency night and day
2. Need for short acting inhaled b2 agonists for
quick relief
3. Ability to engage in normal activities
4. Air flow measures for>=5 yrs
1.

Continue..
 Component 2 : pt education

 Component 3 : control of factors contributing

to asthma severity
1. Environmental exposures
2. Co morbid conditions
 Component 4 :principals of asthma
pharmacotherapy

Asthma Medication
 SABA

 ICS

 LABA
 LTRA

 SYSTEMIC STEROIDS

 NONSTEROIDAL ANTIINFLAMMATORY

CROMOLYN AND NEDOCROMYL
 OXYGEN
 ANTICHOLINERGIC AGENTS
IPRATROPIUM
BROMIDE
 ANTIIMMUNOGLUBOLINE E

MANAGEMENT OF ASTHMA EXACERBATION(STATUS ASTHMATICUS)
RISK ASSESMENT ON ADMISSION

FOCUSED HISTORY

ONSET OF CURRENT EXACERBATION
FREQUENCY AND severity of daytime and night
time symptoms and activity limitation
Frequency of rescue bronchodilator use
Current medication and allergies
Potential triggers
History of systemic steroid courses, emergency
department visists , hospitalization, intubation or life
threatening episodes

Clinical assesment

Physical examination findings: vital signs,
breathlessness, air movement, use of accessory
respiratory muscles, retractions, anxiety level,
alteration in mental status
Pulse oximetry
Lung function(defer in pts with mod to severe
distress or history of labile disease)

Treatment
Drugs and trade name

Mechanism of action and dosing

Cautions and adverse effects

Oxygen(mask or nasal canula)
Inhaled short acting b2
agonist
Albuterol nebulized
solution(5mg/ml concentrates
Albuterol MDI
Levabuterol

Treats hypoxia
Bronchodilator
Neubolizer 0.15 mg/kg every 20 min for 3
doses as needed,then 0.15_0.3 mg/kg up t 10
mg every 1_4 hour as needed or up to 0.5
mg/kg/hr by continous neubolization
2_8 puf up to every 20 min for 3 doses as
needed then every 1 hr as needed

Monitor pulse oximetry to maintain o2 saturation>92%
Cardiorespiratory monitoring
During exacerbations,frequent or continuous use can cause
pulmonary vasodilatation,v/q mistmatch and hypoxemia
Adverse effect palpitation, tachycardia, arrhythmia, tremor,
hypoxemia
Neubolizer:when giving concentrate forms,dilute with saline to 3
ml total neubolized volume
For MDI use space/holding chamber

Systemic corticosteroids
Prednisolone tb
Methyl prednisolon
Anticholinergics
Ipratropium
Atrovent
Ipratropium with Albuterol

Anti inflammatory
0.5_1 mg/kg every 6-8 hr for 48 hr , then 1-2 mg/kg
day bid(max 60 mg/day)
Short course burst for exacerbation 1-2 mg/kg/day qd
or bid for 3-7 days
Mucolitic/bronchodilator
Neubolizer 0.5 mg q6-8 hr (tid or qid) as needed
MDI 2 paf qid
1 vial by neubolizer qid



If pt has been exposed chickenpox or measles, consider passive
immunoglobulin prophylaxis, also risk of complications with
herspes simplex and TB

For daily dosing , 8 am administration minimizes adrenal
suppression

Children may benefit from dosage tapering if course exceed 7 days

Adverse effect monitoring: frequent therapy bursts risk numerous
corticosteroid adverse effects

Should not be used as first line treatment added to b2 agonist
therapy
Neubolizer may mix Ipratropium with Albuterol

QUICK RELIEF MEDICATION
SABA

Anti cholinergic(ipratropium)
Short term systemic gluco

corticoid

SABA
 Quick relief of asthma symptoms
 Relax airway smooth muscle prompt airflow↑
 Repetitive or continuous SABA is the most effective means







of reversing air flow obstruction
SABA should not be prescribed on a regular schedule
because concerns of possibility of deteriorating asthma
control
Frequent use of SABA is an indication of poor asthma control
Preferred root is inhalation smaller dose , fewer side effects
more rapid on set of action
Ipratropium Bromide as an adjunct to SABA in emergency
room reduces hospital admissions and improves lung function
Systemic Glucocorticoids short oral course + SABA in
moderate to severe asthma exacerbation

LABA
 Salmetrol

 Should be used in combination with inhaled

corticosteroids and not as mono therapy
 Exercise induces asthma in children >= 4 Yrs
one inhalation 30 min prior to exercise
 No additional doses for PTs who are already
receiving it twice daily not recommended by
NIH guidelines

LTRA

 MonteLukast ( singulair)

 Antihistaminic

 Leukotrien receptor antagonist

 Asthma ( not < 12 MO) and allergic rhinitis (





not < 6 MO)
Morning dosing not evaluated
Prophylactic and chronic treatment of asthma
Exercise induced asthma in >= 15 Yrs
Zafir Lukast : prophylactic and chronic
treatment of asthma

ICA
 Most potent anti inflammatory agents available

for the treatment of asthma
 Inhibiting most steps in the cascade of the
inflammatory response
 Benefits reducing bronchial hyper
responsiveness , prevention of late asthmatic
response , enhanced lung function
 Inhaled Glucocorticoids first line controller
therapy for persistent asthma or those who
require step 2

Prognosis
 35%of preschool children experience recurrent

coughing and wheezing,1/3 of them continue to
have persistent asthma into later childhood and
2/3 improvement on their own through their teen
yrs
 Asthma severity by age 7-10 yrs is predictive of
asthma persistence into adulthood
 Children with mod to severe asthma and lower lung
function are likely to have persistent asthma as
adults
 Children with milder asthma and N/R lung function
are likely to improve over time or be periodically
asthmatic

THANK YOU FOR YOUR
ATTENTION


Slide 22

Asthma in Children
DR. A.Mirshokraei
NIOC Hospital Pediatrics Ward

Definition :

DEFINITION

- Chronic inflammatory condition of the
lung airways resulting in episodic airflow
obstruction
- AHR to provocative exposures
Asthma management
• Reducing airway inflammation by: Minimizing
pro inflammatory environmental exposure, using
daily controller anti inflammatory medication,
controlling co morbid conditions that worsen
asthma, less inflammation better asthma
control and fewer exacerbations

Anyway exacerbations

occur

BUT
Even the uncommon
child with sever asthma can
be managed to live normally

 RECURRENT WHEEZING EPISODES WITH COMMON

RESPIRATORY
VIRUSES(RSV,RHINOVIRUS,INFLUENZA,PARAINFLUENZA,A
DENOVIRUS,HUMAN METAPNUMOVIRUS)

 HOST FEATURES AFFECTING IMMUNOLOGIC HOST

DEFENSE,INFLAMMATION/PREVIOUS VIRAL INFECTIONS
MAINIFESTED AS PNUMONIA OR BRONCHIOLITIS
REQUIRING HOSPITALIZATION UNDERLIE THE
RECURRENT WHEEZING IN EARLY CHILDHOOD

 OTHER AIRWAY EXPOSURES SUCH AS INDOOR AND HOME

ALLERGENS,COLD AIR,STRONG ODORS,TOBACCO
SMOKE,ALL INCREASE AHR

 ALLERGEN ELLIMINATION SOMETIMES LEEDS TO CURE

EPIDEMIOLOGY
 Common etiology of emergency visits and school day missing

in childhood ,occasionally hospitalization and rare deaths
specially in poverty ,urban living ,ethnic minorities

 Increasing asthma prevalence worldwide(50% per decade)
 Good correlation of asthma prevalence with allergic rhino

sinusitis and atopic eczema and other allergies

 More prevalence in high level urban modern families than

suburban villagers

 More than 80%of asthmatics reported getting the disease

before 6 year

CLINICS
RECURRENT COUGHING/WHEEZING
PATTERNS IN CHILDHOOD BASED ON
NATURAL HISTORY

TRANSIENT EARLY WHEEZING
 Common in early preschool years

 Recurrent coughing/wheezing primary

triggered by common respiratory viral INF
 Tend to resolve during preschool yrs without
increasing risk of asthma later in life
 Problems due to reduced airflow at birth
suggestive of relative narrow airways improved
by school yrs

Persistent Atopy Associated Asthma
 Begins in early preschool yrs

 Associated with atopy (eg atopic dermatitis in





infancy, allergic rhinitis, food allergy)
Biologic factors e.g.: early inhalant sensitization,
increase serum IGE, increase blood eosinophills,
High risk of persistence into later childhood and
adulthood lung function abnormality
Those with onset<3 yrs
reduced air flow by
school yrs
Those with later onset of symptoms or allergen
sensitizations unlikely persistence lung function
abnormality later

Non-Atopic Wheezing
 Wheezing ,coughing beginning in early life

often with RSV INF resolves later in childhood
without increasing risk of persistence asthma

 Associated with bronchial hyper

responsiveness near birth

Asthma with declining lung function
• Children with asthma with progressive

increase in air flow limitation

• Associated with hyper inflation in childhood
• Male gender

Late onset asthma in females associated with
obesity and early onset puberty
 Onset between 8_13 yrs

 Associated with early onset puberty and obesity
 Specific for females

Occupational type asthma in children
 Children with asthma and occupational type exposure

known to trigger asthma in adults in occupational settings

Types of Asthma
common clinical presentations of intermittent
recurrent wheezing and/or coughing
 Recurrent wheezing in early childhood

 Chronic asthma associated with allergy
 Females 11 yrs with early onset puberty and

obesity

Pathogenesis

 Airflow obstruction resulting from

Broncho constriction of bronchiolar smooth
muscle mass
II. Cellular inflammatory infiltrates and exudates
mostly Eosinophills(also N , M ,L ,mast cells
,basophiles)fill and obstruct airways and damage
epithelium and induce desquamation into airway
lumen mediated by T helper cells and other
immune cells that produce pro allergic pro
inflammatory cytokines(IL4,IL6,IL13)
III. Breach in normal immune regulatory process
I.

RESULT
 Airway inflammation

 AHR
 Edema basement membrane thickness sub

epithelial collagen deposition
 Smooth muscle and mucus gland hypertrophy
and mucus hyper secretion

Air obstruction

Clinical manifestations and diagnosis
 Most common intermittent dry cough and

expiratory wheezing

 Shortness of breath and chest tightness in older

children and adults

 Intermittent non focal chest pain in younger

children

 Worsening of respiratory symptoms at night
 Worsening of day time symptoms by activity

Continue…..
 Subtle symptoms such as self limitation of activities

,general fatigue ,difficulty in keeping up with peers

 Relief with aerosolized bronchodilators
 Lack of improvement with bronchodilators and steroid

is inconsistent with Asthma and should consider
Asthma masquerading conditions!!!!

 Hyper ventilation, intercostal retractions ,nasal flaring

,respiratory accessory muscle use

 Its common not to hear the expiratory wheezing when

Air flow is so limited before treatment

Asthma Triggers
 Common viral infections of the respiratory tract
 Aero allergens in sensitized asthmatics ,animal dander ,dust











mite ,molds ,indoor allergens ,cockroaches
Seasonal aero allergens ,pollens(trees ,grasses ,weeds ,)
Environmental tobacco smoke
Air pollutants ,ozone ,so2,wood or coal smoke ,endotoxin
,mycotoxin ,dust
Strong or noxious odors or fumes ,perfume ,hair spray
,cleaning agents
Occupational exposure
Cold air ,dry air
Exercise
Crying ,laughter ,hyperventilation
Co morbid conditions Rhinitis ,Sinusitis ,GER

Clinics
History:
Triggering symptoms by laughter
,cold air ,airway irritants
Exposures that induce airway
irritation such as viral URTI
Mycoplasma ,Chlamydia
Inhaled allergens
All lead to AHR

Presence Of Risk Factors:
 History of other allergies ,allergic Rhinitis,

allergic Conjunctivitis ,atopic Dermatitis ,food
allergies

 Parental Asthma
 Symptoms apart from cold

Continue…..
 No or minimal signs in routine visits

 Dry or persistent cough

 Normal chest findings unless wheezing when asking

to breath deeper
 Quick relief (10 MIN) after SABA use
 Expiratory wheezing ,prolonged expiratory phase
,decreased sounds in RT lower pos lobe due to
regional hypoventilation owing to airway
obstruction
 Rales , ronchi ,crackles due to hyper secretion
 Segmental crackles and poor breath sounds
atelectasis?

Continue….
 Labored respiration ,respiratory distress increased

prolongation of expiration and wheezing in E and I

 Poor air entry
 Inter costal retractions ,nasal flaring ,supra and

infra sternal retractions

 And again in most sever forms expiratory wheezing

does not appear until some broncho dilation

DD

GERD Rhino sinusitis co morbid

conditions with asthma

Recurrent aspiration in early

life(tracheo broncho malacia
,TEF , foreign body ,CF ,BPD

VCD in older children and

adolescents

LAB FINDINGS
Pulmonary Function
Testing

Continue….
 Forced expiratory airflow measures helpful

in Diagnosis , assessing efficacy of therapy
and monitoring Asthma in children specially
in poor children who do not have PHE
unless obstruction is sever

 Valueablity of spirometric findings in children>6

yrs

 3 efforts the highest is the peak
 Reduced FEV

obstruction

FEV1/FVC <0.80 means significant

 Improvement in FEV1 following beta 2 agonist > =

12% or 200 ml is consistent with Asthma

 Peak flow meter

CXR

Often normal aside from subtle and

nonspecific findings of hyperinflation

Peribronchial thickening
Helping in diagnosis of Asthma

differentials

Diagnosis of complications of Asthma

exacerbations

Other tests such as allergy skin prick
testing

Treatment
 www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm

Asthma Treatment & Management
has 4 components :
Assessment and monitoring of disease
activity
2. Provision to educate pt and family
3. Identification and management of
precipitating factors and co morbid
conditions
4. Appropriate selection of medication
1.

 Attainment of optimal Asthma control

Component 1
 Asthma severity :intermittent
 Persistent: mild ,mod ,severe
 Only once during patient initial evaluation in pt

who is not using a daily controller agent
 Asthma control degree to which symptoms ,
on going functional impairments , risk of
adverse events minimized and goals of
therapy are met

Continue….
Well controlled
2. Not well controlled
3. Very poor controlled
1.

 NIH guidelines for both severity and

control for 3 age groups

0-4 yrs
2. 5-11 yrs
3. =>12 yrs
1.

Important
even in the absence of frequent symptoms
infants and children whom have risk factors
for asthma and 4 or more episodes of
wheezing over the past yr which lasted more
than 1 day or 2 or more exacerbations in
the last 6 months requiring syst
corticosteroids should be considered in the
persistent group and hence receive long term
controller therapy

Important Tips..
 Regular clinical visits every 2-6 weeks
 Assessment of :

Pt symptoms frequency night and day
2. Need for short acting inhaled b2 agonists for
quick relief
3. Ability to engage in normal activities
4. Air flow measures for>=5 yrs
1.

Continue..
 Component 2 : pt education

 Component 3 : control of factors contributing

to asthma severity
1. Environmental exposures
2. Co morbid conditions
 Component 4 :principals of asthma
pharmacotherapy

Asthma Medication
 SABA

 ICS

 LABA
 LTRA

 SYSTEMIC STEROIDS

 NONSTEROIDAL ANTIINFLAMMATORY

CROMOLYN AND NEDOCROMYL
 OXYGEN
 ANTICHOLINERGIC AGENTS
IPRATROPIUM
BROMIDE
 ANTIIMMUNOGLUBOLINE E

MANAGEMENT OF ASTHMA EXACERBATION(STATUS ASTHMATICUS)
RISK ASSESMENT ON ADMISSION

FOCUSED HISTORY

ONSET OF CURRENT EXACERBATION
FREQUENCY AND severity of daytime and night
time symptoms and activity limitation
Frequency of rescue bronchodilator use
Current medication and allergies
Potential triggers
History of systemic steroid courses, emergency
department visists , hospitalization, intubation or life
threatening episodes

Clinical assesment

Physical examination findings: vital signs,
breathlessness, air movement, use of accessory
respiratory muscles, retractions, anxiety level,
alteration in mental status
Pulse oximetry
Lung function(defer in pts with mod to severe
distress or history of labile disease)

Treatment
Drugs and trade name

Mechanism of action and dosing

Cautions and adverse effects

Oxygen(mask or nasal canula)
Inhaled short acting b2
agonist
Albuterol nebulized
solution(5mg/ml concentrates
Albuterol MDI
Levabuterol

Treats hypoxia
Bronchodilator
Neubolizer 0.15 mg/kg every 20 min for 3
doses as needed,then 0.15_0.3 mg/kg up t 10
mg every 1_4 hour as needed or up to 0.5
mg/kg/hr by continous neubolization
2_8 puf up to every 20 min for 3 doses as
needed then every 1 hr as needed

Monitor pulse oximetry to maintain o2 saturation>92%
Cardiorespiratory monitoring
During exacerbations,frequent or continuous use can cause
pulmonary vasodilatation,v/q mistmatch and hypoxemia
Adverse effect palpitation, tachycardia, arrhythmia, tremor,
hypoxemia
Neubolizer:when giving concentrate forms,dilute with saline to 3
ml total neubolized volume
For MDI use space/holding chamber

Systemic corticosteroids
Prednisolone tb
Methyl prednisolon
Anticholinergics
Ipratropium
Atrovent
Ipratropium with Albuterol

Anti inflammatory
0.5_1 mg/kg every 6-8 hr for 48 hr , then 1-2 mg/kg
day bid(max 60 mg/day)
Short course burst for exacerbation 1-2 mg/kg/day qd
or bid for 3-7 days
Mucolitic/bronchodilator
Neubolizer 0.5 mg q6-8 hr (tid or qid) as needed
MDI 2 paf qid
1 vial by neubolizer qid



If pt has been exposed chickenpox or measles, consider passive
immunoglobulin prophylaxis, also risk of complications with
herspes simplex and TB

For daily dosing , 8 am administration minimizes adrenal
suppression

Children may benefit from dosage tapering if course exceed 7 days

Adverse effect monitoring: frequent therapy bursts risk numerous
corticosteroid adverse effects

Should not be used as first line treatment added to b2 agonist
therapy
Neubolizer may mix Ipratropium with Albuterol

QUICK RELIEF MEDICATION
SABA

Anti cholinergic(ipratropium)
Short term systemic gluco

corticoid

SABA
 Quick relief of asthma symptoms
 Relax airway smooth muscle prompt airflow↑
 Repetitive or continuous SABA is the most effective means







of reversing air flow obstruction
SABA should not be prescribed on a regular schedule
because concerns of possibility of deteriorating asthma
control
Frequent use of SABA is an indication of poor asthma control
Preferred root is inhalation smaller dose , fewer side effects
more rapid on set of action
Ipratropium Bromide as an adjunct to SABA in emergency
room reduces hospital admissions and improves lung function
Systemic Glucocorticoids short oral course + SABA in
moderate to severe asthma exacerbation

LABA
 Salmetrol

 Should be used in combination with inhaled

corticosteroids and not as mono therapy
 Exercise induces asthma in children >= 4 Yrs
one inhalation 30 min prior to exercise
 No additional doses for PTs who are already
receiving it twice daily not recommended by
NIH guidelines

LTRA

 MonteLukast ( singulair)

 Antihistaminic

 Leukotrien receptor antagonist

 Asthma ( not < 12 MO) and allergic rhinitis (





not < 6 MO)
Morning dosing not evaluated
Prophylactic and chronic treatment of asthma
Exercise induced asthma in >= 15 Yrs
Zafir Lukast : prophylactic and chronic
treatment of asthma

ICA
 Most potent anti inflammatory agents available

for the treatment of asthma
 Inhibiting most steps in the cascade of the
inflammatory response
 Benefits reducing bronchial hyper
responsiveness , prevention of late asthmatic
response , enhanced lung function
 Inhaled Glucocorticoids first line controller
therapy for persistent asthma or those who
require step 2

Prognosis
 35%of preschool children experience recurrent

coughing and wheezing,1/3 of them continue to
have persistent asthma into later childhood and
2/3 improvement on their own through their teen
yrs
 Asthma severity by age 7-10 yrs is predictive of
asthma persistence into adulthood
 Children with mod to severe asthma and lower lung
function are likely to have persistent asthma as
adults
 Children with milder asthma and N/R lung function
are likely to improve over time or be periodically
asthmatic

THANK YOU FOR YOUR
ATTENTION


Slide 23

Asthma in Children
DR. A.Mirshokraei
NIOC Hospital Pediatrics Ward

Definition :

DEFINITION

- Chronic inflammatory condition of the
lung airways resulting in episodic airflow
obstruction
- AHR to provocative exposures
Asthma management
• Reducing airway inflammation by: Minimizing
pro inflammatory environmental exposure, using
daily controller anti inflammatory medication,
controlling co morbid conditions that worsen
asthma, less inflammation better asthma
control and fewer exacerbations

Anyway exacerbations

occur

BUT
Even the uncommon
child with sever asthma can
be managed to live normally

 RECURRENT WHEEZING EPISODES WITH COMMON

RESPIRATORY
VIRUSES(RSV,RHINOVIRUS,INFLUENZA,PARAINFLUENZA,A
DENOVIRUS,HUMAN METAPNUMOVIRUS)

 HOST FEATURES AFFECTING IMMUNOLOGIC HOST

DEFENSE,INFLAMMATION/PREVIOUS VIRAL INFECTIONS
MAINIFESTED AS PNUMONIA OR BRONCHIOLITIS
REQUIRING HOSPITALIZATION UNDERLIE THE
RECURRENT WHEEZING IN EARLY CHILDHOOD

 OTHER AIRWAY EXPOSURES SUCH AS INDOOR AND HOME

ALLERGENS,COLD AIR,STRONG ODORS,TOBACCO
SMOKE,ALL INCREASE AHR

 ALLERGEN ELLIMINATION SOMETIMES LEEDS TO CURE

EPIDEMIOLOGY
 Common etiology of emergency visits and school day missing

in childhood ,occasionally hospitalization and rare deaths
specially in poverty ,urban living ,ethnic minorities

 Increasing asthma prevalence worldwide(50% per decade)
 Good correlation of asthma prevalence with allergic rhino

sinusitis and atopic eczema and other allergies

 More prevalence in high level urban modern families than

suburban villagers

 More than 80%of asthmatics reported getting the disease

before 6 year

CLINICS
RECURRENT COUGHING/WHEEZING
PATTERNS IN CHILDHOOD BASED ON
NATURAL HISTORY

TRANSIENT EARLY WHEEZING
 Common in early preschool years

 Recurrent coughing/wheezing primary

triggered by common respiratory viral INF
 Tend to resolve during preschool yrs without
increasing risk of asthma later in life
 Problems due to reduced airflow at birth
suggestive of relative narrow airways improved
by school yrs

Persistent Atopy Associated Asthma
 Begins in early preschool yrs

 Associated with atopy (eg atopic dermatitis in





infancy, allergic rhinitis, food allergy)
Biologic factors e.g.: early inhalant sensitization,
increase serum IGE, increase blood eosinophills,
High risk of persistence into later childhood and
adulthood lung function abnormality
Those with onset<3 yrs
reduced air flow by
school yrs
Those with later onset of symptoms or allergen
sensitizations unlikely persistence lung function
abnormality later

Non-Atopic Wheezing
 Wheezing ,coughing beginning in early life

often with RSV INF resolves later in childhood
without increasing risk of persistence asthma

 Associated with bronchial hyper

responsiveness near birth

Asthma with declining lung function
• Children with asthma with progressive

increase in air flow limitation

• Associated with hyper inflation in childhood
• Male gender

Late onset asthma in females associated with
obesity and early onset puberty
 Onset between 8_13 yrs

 Associated with early onset puberty and obesity
 Specific for females

Occupational type asthma in children
 Children with asthma and occupational type exposure

known to trigger asthma in adults in occupational settings

Types of Asthma
common clinical presentations of intermittent
recurrent wheezing and/or coughing
 Recurrent wheezing in early childhood

 Chronic asthma associated with allergy
 Females 11 yrs with early onset puberty and

obesity

Pathogenesis

 Airflow obstruction resulting from

Broncho constriction of bronchiolar smooth
muscle mass
II. Cellular inflammatory infiltrates and exudates
mostly Eosinophills(also N , M ,L ,mast cells
,basophiles)fill and obstruct airways and damage
epithelium and induce desquamation into airway
lumen mediated by T helper cells and other
immune cells that produce pro allergic pro
inflammatory cytokines(IL4,IL6,IL13)
III. Breach in normal immune regulatory process
I.

RESULT
 Airway inflammation

 AHR
 Edema basement membrane thickness sub

epithelial collagen deposition
 Smooth muscle and mucus gland hypertrophy
and mucus hyper secretion

Air obstruction

Clinical manifestations and diagnosis
 Most common intermittent dry cough and

expiratory wheezing

 Shortness of breath and chest tightness in older

children and adults

 Intermittent non focal chest pain in younger

children

 Worsening of respiratory symptoms at night
 Worsening of day time symptoms by activity

Continue…..
 Subtle symptoms such as self limitation of activities

,general fatigue ,difficulty in keeping up with peers

 Relief with aerosolized bronchodilators
 Lack of improvement with bronchodilators and steroid

is inconsistent with Asthma and should consider
Asthma masquerading conditions!!!!

 Hyper ventilation, intercostal retractions ,nasal flaring

,respiratory accessory muscle use

 Its common not to hear the expiratory wheezing when

Air flow is so limited before treatment

Asthma Triggers
 Common viral infections of the respiratory tract
 Aero allergens in sensitized asthmatics ,animal dander ,dust











mite ,molds ,indoor allergens ,cockroaches
Seasonal aero allergens ,pollens(trees ,grasses ,weeds ,)
Environmental tobacco smoke
Air pollutants ,ozone ,so2,wood or coal smoke ,endotoxin
,mycotoxin ,dust
Strong or noxious odors or fumes ,perfume ,hair spray
,cleaning agents
Occupational exposure
Cold air ,dry air
Exercise
Crying ,laughter ,hyperventilation
Co morbid conditions Rhinitis ,Sinusitis ,GER

Clinics
History:
Triggering symptoms by laughter
,cold air ,airway irritants
Exposures that induce airway
irritation such as viral URTI
Mycoplasma ,Chlamydia
Inhaled allergens
All lead to AHR

Presence Of Risk Factors:
 History of other allergies ,allergic Rhinitis,

allergic Conjunctivitis ,atopic Dermatitis ,food
allergies

 Parental Asthma
 Symptoms apart from cold

Continue…..
 No or minimal signs in routine visits

 Dry or persistent cough

 Normal chest findings unless wheezing when asking

to breath deeper
 Quick relief (10 MIN) after SABA use
 Expiratory wheezing ,prolonged expiratory phase
,decreased sounds in RT lower pos lobe due to
regional hypoventilation owing to airway
obstruction
 Rales , ronchi ,crackles due to hyper secretion
 Segmental crackles and poor breath sounds
atelectasis?

Continue….
 Labored respiration ,respiratory distress increased

prolongation of expiration and wheezing in E and I

 Poor air entry
 Inter costal retractions ,nasal flaring ,supra and

infra sternal retractions

 And again in most sever forms expiratory wheezing

does not appear until some broncho dilation

DD

GERD Rhino sinusitis co morbid

conditions with asthma

Recurrent aspiration in early

life(tracheo broncho malacia
,TEF , foreign body ,CF ,BPD

VCD in older children and

adolescents

LAB FINDINGS
Pulmonary Function
Testing

Continue….
 Forced expiratory airflow measures helpful

in Diagnosis , assessing efficacy of therapy
and monitoring Asthma in children specially
in poor children who do not have PHE
unless obstruction is sever

 Valueablity of spirometric findings in children>6

yrs

 3 efforts the highest is the peak
 Reduced FEV

obstruction

FEV1/FVC <0.80 means significant

 Improvement in FEV1 following beta 2 agonist > =

12% or 200 ml is consistent with Asthma

 Peak flow meter

CXR

Often normal aside from subtle and

nonspecific findings of hyperinflation

Peribronchial thickening
Helping in diagnosis of Asthma

differentials

Diagnosis of complications of Asthma

exacerbations

Other tests such as allergy skin prick
testing

Treatment
 www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm

Asthma Treatment & Management
has 4 components :
Assessment and monitoring of disease
activity
2. Provision to educate pt and family
3. Identification and management of
precipitating factors and co morbid
conditions
4. Appropriate selection of medication
1.

 Attainment of optimal Asthma control

Component 1
 Asthma severity :intermittent
 Persistent: mild ,mod ,severe
 Only once during patient initial evaluation in pt

who is not using a daily controller agent
 Asthma control degree to which symptoms ,
on going functional impairments , risk of
adverse events minimized and goals of
therapy are met

Continue….
Well controlled
2. Not well controlled
3. Very poor controlled
1.

 NIH guidelines for both severity and

control for 3 age groups

0-4 yrs
2. 5-11 yrs
3. =>12 yrs
1.

Important
even in the absence of frequent symptoms
infants and children whom have risk factors
for asthma and 4 or more episodes of
wheezing over the past yr which lasted more
than 1 day or 2 or more exacerbations in
the last 6 months requiring syst
corticosteroids should be considered in the
persistent group and hence receive long term
controller therapy

Important Tips..
 Regular clinical visits every 2-6 weeks
 Assessment of :

Pt symptoms frequency night and day
2. Need for short acting inhaled b2 agonists for
quick relief
3. Ability to engage in normal activities
4. Air flow measures for>=5 yrs
1.

Continue..
 Component 2 : pt education

 Component 3 : control of factors contributing

to asthma severity
1. Environmental exposures
2. Co morbid conditions
 Component 4 :principals of asthma
pharmacotherapy

Asthma Medication
 SABA

 ICS

 LABA
 LTRA

 SYSTEMIC STEROIDS

 NONSTEROIDAL ANTIINFLAMMATORY

CROMOLYN AND NEDOCROMYL
 OXYGEN
 ANTICHOLINERGIC AGENTS
IPRATROPIUM
BROMIDE
 ANTIIMMUNOGLUBOLINE E

MANAGEMENT OF ASTHMA EXACERBATION(STATUS ASTHMATICUS)
RISK ASSESMENT ON ADMISSION

FOCUSED HISTORY

ONSET OF CURRENT EXACERBATION
FREQUENCY AND severity of daytime and night
time symptoms and activity limitation
Frequency of rescue bronchodilator use
Current medication and allergies
Potential triggers
History of systemic steroid courses, emergency
department visists , hospitalization, intubation or life
threatening episodes

Clinical assesment

Physical examination findings: vital signs,
breathlessness, air movement, use of accessory
respiratory muscles, retractions, anxiety level,
alteration in mental status
Pulse oximetry
Lung function(defer in pts with mod to severe
distress or history of labile disease)

Treatment
Drugs and trade name

Mechanism of action and dosing

Cautions and adverse effects

Oxygen(mask or nasal canula)
Inhaled short acting b2
agonist
Albuterol nebulized
solution(5mg/ml concentrates
Albuterol MDI
Levabuterol

Treats hypoxia
Bronchodilator
Neubolizer 0.15 mg/kg every 20 min for 3
doses as needed,then 0.15_0.3 mg/kg up t 10
mg every 1_4 hour as needed or up to 0.5
mg/kg/hr by continous neubolization
2_8 puf up to every 20 min for 3 doses as
needed then every 1 hr as needed

Monitor pulse oximetry to maintain o2 saturation>92%
Cardiorespiratory monitoring
During exacerbations,frequent or continuous use can cause
pulmonary vasodilatation,v/q mistmatch and hypoxemia
Adverse effect palpitation, tachycardia, arrhythmia, tremor,
hypoxemia
Neubolizer:when giving concentrate forms,dilute with saline to 3
ml total neubolized volume
For MDI use space/holding chamber

Systemic corticosteroids
Prednisolone tb
Methyl prednisolon
Anticholinergics
Ipratropium
Atrovent
Ipratropium with Albuterol

Anti inflammatory
0.5_1 mg/kg every 6-8 hr for 48 hr , then 1-2 mg/kg
day bid(max 60 mg/day)
Short course burst for exacerbation 1-2 mg/kg/day qd
or bid for 3-7 days
Mucolitic/bronchodilator
Neubolizer 0.5 mg q6-8 hr (tid or qid) as needed
MDI 2 paf qid
1 vial by neubolizer qid



If pt has been exposed chickenpox or measles, consider passive
immunoglobulin prophylaxis, also risk of complications with
herspes simplex and TB

For daily dosing , 8 am administration minimizes adrenal
suppression

Children may benefit from dosage tapering if course exceed 7 days

Adverse effect monitoring: frequent therapy bursts risk numerous
corticosteroid adverse effects

Should not be used as first line treatment added to b2 agonist
therapy
Neubolizer may mix Ipratropium with Albuterol

QUICK RELIEF MEDICATION
SABA

Anti cholinergic(ipratropium)
Short term systemic gluco

corticoid

SABA
 Quick relief of asthma symptoms
 Relax airway smooth muscle prompt airflow↑
 Repetitive or continuous SABA is the most effective means







of reversing air flow obstruction
SABA should not be prescribed on a regular schedule
because concerns of possibility of deteriorating asthma
control
Frequent use of SABA is an indication of poor asthma control
Preferred root is inhalation smaller dose , fewer side effects
more rapid on set of action
Ipratropium Bromide as an adjunct to SABA in emergency
room reduces hospital admissions and improves lung function
Systemic Glucocorticoids short oral course + SABA in
moderate to severe asthma exacerbation

LABA
 Salmetrol

 Should be used in combination with inhaled

corticosteroids and not as mono therapy
 Exercise induces asthma in children >= 4 Yrs
one inhalation 30 min prior to exercise
 No additional doses for PTs who are already
receiving it twice daily not recommended by
NIH guidelines

LTRA

 MonteLukast ( singulair)

 Antihistaminic

 Leukotrien receptor antagonist

 Asthma ( not < 12 MO) and allergic rhinitis (





not < 6 MO)
Morning dosing not evaluated
Prophylactic and chronic treatment of asthma
Exercise induced asthma in >= 15 Yrs
Zafir Lukast : prophylactic and chronic
treatment of asthma

ICA
 Most potent anti inflammatory agents available

for the treatment of asthma
 Inhibiting most steps in the cascade of the
inflammatory response
 Benefits reducing bronchial hyper
responsiveness , prevention of late asthmatic
response , enhanced lung function
 Inhaled Glucocorticoids first line controller
therapy for persistent asthma or those who
require step 2

Prognosis
 35%of preschool children experience recurrent

coughing and wheezing,1/3 of them continue to
have persistent asthma into later childhood and
2/3 improvement on their own through their teen
yrs
 Asthma severity by age 7-10 yrs is predictive of
asthma persistence into adulthood
 Children with mod to severe asthma and lower lung
function are likely to have persistent asthma as
adults
 Children with milder asthma and N/R lung function
are likely to improve over time or be periodically
asthmatic

THANK YOU FOR YOUR
ATTENTION


Slide 24

Asthma in Children
DR. A.Mirshokraei
NIOC Hospital Pediatrics Ward

Definition :

DEFINITION

- Chronic inflammatory condition of the
lung airways resulting in episodic airflow
obstruction
- AHR to provocative exposures
Asthma management
• Reducing airway inflammation by: Minimizing
pro inflammatory environmental exposure, using
daily controller anti inflammatory medication,
controlling co morbid conditions that worsen
asthma, less inflammation better asthma
control and fewer exacerbations

Anyway exacerbations

occur

BUT
Even the uncommon
child with sever asthma can
be managed to live normally

 RECURRENT WHEEZING EPISODES WITH COMMON

RESPIRATORY
VIRUSES(RSV,RHINOVIRUS,INFLUENZA,PARAINFLUENZA,A
DENOVIRUS,HUMAN METAPNUMOVIRUS)

 HOST FEATURES AFFECTING IMMUNOLOGIC HOST

DEFENSE,INFLAMMATION/PREVIOUS VIRAL INFECTIONS
MAINIFESTED AS PNUMONIA OR BRONCHIOLITIS
REQUIRING HOSPITALIZATION UNDERLIE THE
RECURRENT WHEEZING IN EARLY CHILDHOOD

 OTHER AIRWAY EXPOSURES SUCH AS INDOOR AND HOME

ALLERGENS,COLD AIR,STRONG ODORS,TOBACCO
SMOKE,ALL INCREASE AHR

 ALLERGEN ELLIMINATION SOMETIMES LEEDS TO CURE

EPIDEMIOLOGY
 Common etiology of emergency visits and school day missing

in childhood ,occasionally hospitalization and rare deaths
specially in poverty ,urban living ,ethnic minorities

 Increasing asthma prevalence worldwide(50% per decade)
 Good correlation of asthma prevalence with allergic rhino

sinusitis and atopic eczema and other allergies

 More prevalence in high level urban modern families than

suburban villagers

 More than 80%of asthmatics reported getting the disease

before 6 year

CLINICS
RECURRENT COUGHING/WHEEZING
PATTERNS IN CHILDHOOD BASED ON
NATURAL HISTORY

TRANSIENT EARLY WHEEZING
 Common in early preschool years

 Recurrent coughing/wheezing primary

triggered by common respiratory viral INF
 Tend to resolve during preschool yrs without
increasing risk of asthma later in life
 Problems due to reduced airflow at birth
suggestive of relative narrow airways improved
by school yrs

Persistent Atopy Associated Asthma
 Begins in early preschool yrs

 Associated with atopy (eg atopic dermatitis in





infancy, allergic rhinitis, food allergy)
Biologic factors e.g.: early inhalant sensitization,
increase serum IGE, increase blood eosinophills,
High risk of persistence into later childhood and
adulthood lung function abnormality
Those with onset<3 yrs
reduced air flow by
school yrs
Those with later onset of symptoms or allergen
sensitizations unlikely persistence lung function
abnormality later

Non-Atopic Wheezing
 Wheezing ,coughing beginning in early life

often with RSV INF resolves later in childhood
without increasing risk of persistence asthma

 Associated with bronchial hyper

responsiveness near birth

Asthma with declining lung function
• Children with asthma with progressive

increase in air flow limitation

• Associated with hyper inflation in childhood
• Male gender

Late onset asthma in females associated with
obesity and early onset puberty
 Onset between 8_13 yrs

 Associated with early onset puberty and obesity
 Specific for females

Occupational type asthma in children
 Children with asthma and occupational type exposure

known to trigger asthma in adults in occupational settings

Types of Asthma
common clinical presentations of intermittent
recurrent wheezing and/or coughing
 Recurrent wheezing in early childhood

 Chronic asthma associated with allergy
 Females 11 yrs with early onset puberty and

obesity

Pathogenesis

 Airflow obstruction resulting from

Broncho constriction of bronchiolar smooth
muscle mass
II. Cellular inflammatory infiltrates and exudates
mostly Eosinophills(also N , M ,L ,mast cells
,basophiles)fill and obstruct airways and damage
epithelium and induce desquamation into airway
lumen mediated by T helper cells and other
immune cells that produce pro allergic pro
inflammatory cytokines(IL4,IL6,IL13)
III. Breach in normal immune regulatory process
I.

RESULT
 Airway inflammation

 AHR
 Edema basement membrane thickness sub

epithelial collagen deposition
 Smooth muscle and mucus gland hypertrophy
and mucus hyper secretion

Air obstruction

Clinical manifestations and diagnosis
 Most common intermittent dry cough and

expiratory wheezing

 Shortness of breath and chest tightness in older

children and adults

 Intermittent non focal chest pain in younger

children

 Worsening of respiratory symptoms at night
 Worsening of day time symptoms by activity

Continue…..
 Subtle symptoms such as self limitation of activities

,general fatigue ,difficulty in keeping up with peers

 Relief with aerosolized bronchodilators
 Lack of improvement with bronchodilators and steroid

is inconsistent with Asthma and should consider
Asthma masquerading conditions!!!!

 Hyper ventilation, intercostal retractions ,nasal flaring

,respiratory accessory muscle use

 Its common not to hear the expiratory wheezing when

Air flow is so limited before treatment

Asthma Triggers
 Common viral infections of the respiratory tract
 Aero allergens in sensitized asthmatics ,animal dander ,dust











mite ,molds ,indoor allergens ,cockroaches
Seasonal aero allergens ,pollens(trees ,grasses ,weeds ,)
Environmental tobacco smoke
Air pollutants ,ozone ,so2,wood or coal smoke ,endotoxin
,mycotoxin ,dust
Strong or noxious odors or fumes ,perfume ,hair spray
,cleaning agents
Occupational exposure
Cold air ,dry air
Exercise
Crying ,laughter ,hyperventilation
Co morbid conditions Rhinitis ,Sinusitis ,GER

Clinics
History:
Triggering symptoms by laughter
,cold air ,airway irritants
Exposures that induce airway
irritation such as viral URTI
Mycoplasma ,Chlamydia
Inhaled allergens
All lead to AHR

Presence Of Risk Factors:
 History of other allergies ,allergic Rhinitis,

allergic Conjunctivitis ,atopic Dermatitis ,food
allergies

 Parental Asthma
 Symptoms apart from cold

Continue…..
 No or minimal signs in routine visits

 Dry or persistent cough

 Normal chest findings unless wheezing when asking

to breath deeper
 Quick relief (10 MIN) after SABA use
 Expiratory wheezing ,prolonged expiratory phase
,decreased sounds in RT lower pos lobe due to
regional hypoventilation owing to airway
obstruction
 Rales , ronchi ,crackles due to hyper secretion
 Segmental crackles and poor breath sounds
atelectasis?

Continue….
 Labored respiration ,respiratory distress increased

prolongation of expiration and wheezing in E and I

 Poor air entry
 Inter costal retractions ,nasal flaring ,supra and

infra sternal retractions

 And again in most sever forms expiratory wheezing

does not appear until some broncho dilation

DD

GERD Rhino sinusitis co morbid

conditions with asthma

Recurrent aspiration in early

life(tracheo broncho malacia
,TEF , foreign body ,CF ,BPD

VCD in older children and

adolescents

LAB FINDINGS
Pulmonary Function
Testing

Continue….
 Forced expiratory airflow measures helpful

in Diagnosis , assessing efficacy of therapy
and monitoring Asthma in children specially
in poor children who do not have PHE
unless obstruction is sever

 Valueablity of spirometric findings in children>6

yrs

 3 efforts the highest is the peak
 Reduced FEV

obstruction

FEV1/FVC <0.80 means significant

 Improvement in FEV1 following beta 2 agonist > =

12% or 200 ml is consistent with Asthma

 Peak flow meter

CXR

Often normal aside from subtle and

nonspecific findings of hyperinflation

Peribronchial thickening
Helping in diagnosis of Asthma

differentials

Diagnosis of complications of Asthma

exacerbations

Other tests such as allergy skin prick
testing

Treatment
 www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm

Asthma Treatment & Management
has 4 components :
Assessment and monitoring of disease
activity
2. Provision to educate pt and family
3. Identification and management of
precipitating factors and co morbid
conditions
4. Appropriate selection of medication
1.

 Attainment of optimal Asthma control

Component 1
 Asthma severity :intermittent
 Persistent: mild ,mod ,severe
 Only once during patient initial evaluation in pt

who is not using a daily controller agent
 Asthma control degree to which symptoms ,
on going functional impairments , risk of
adverse events minimized and goals of
therapy are met

Continue….
Well controlled
2. Not well controlled
3. Very poor controlled
1.

 NIH guidelines for both severity and

control for 3 age groups

0-4 yrs
2. 5-11 yrs
3. =>12 yrs
1.

Important
even in the absence of frequent symptoms
infants and children whom have risk factors
for asthma and 4 or more episodes of
wheezing over the past yr which lasted more
than 1 day or 2 or more exacerbations in
the last 6 months requiring syst
corticosteroids should be considered in the
persistent group and hence receive long term
controller therapy

Important Tips..
 Regular clinical visits every 2-6 weeks
 Assessment of :

Pt symptoms frequency night and day
2. Need for short acting inhaled b2 agonists for
quick relief
3. Ability to engage in normal activities
4. Air flow measures for>=5 yrs
1.

Continue..
 Component 2 : pt education

 Component 3 : control of factors contributing

to asthma severity
1. Environmental exposures
2. Co morbid conditions
 Component 4 :principals of asthma
pharmacotherapy

Asthma Medication
 SABA

 ICS

 LABA
 LTRA

 SYSTEMIC STEROIDS

 NONSTEROIDAL ANTIINFLAMMATORY

CROMOLYN AND NEDOCROMYL
 OXYGEN
 ANTICHOLINERGIC AGENTS
IPRATROPIUM
BROMIDE
 ANTIIMMUNOGLUBOLINE E

MANAGEMENT OF ASTHMA EXACERBATION(STATUS ASTHMATICUS)
RISK ASSESMENT ON ADMISSION

FOCUSED HISTORY

ONSET OF CURRENT EXACERBATION
FREQUENCY AND severity of daytime and night
time symptoms and activity limitation
Frequency of rescue bronchodilator use
Current medication and allergies
Potential triggers
History of systemic steroid courses, emergency
department visists , hospitalization, intubation or life
threatening episodes

Clinical assesment

Physical examination findings: vital signs,
breathlessness, air movement, use of accessory
respiratory muscles, retractions, anxiety level,
alteration in mental status
Pulse oximetry
Lung function(defer in pts with mod to severe
distress or history of labile disease)

Treatment
Drugs and trade name

Mechanism of action and dosing

Cautions and adverse effects

Oxygen(mask or nasal canula)
Inhaled short acting b2
agonist
Albuterol nebulized
solution(5mg/ml concentrates
Albuterol MDI
Levabuterol

Treats hypoxia
Bronchodilator
Neubolizer 0.15 mg/kg every 20 min for 3
doses as needed,then 0.15_0.3 mg/kg up t 10
mg every 1_4 hour as needed or up to 0.5
mg/kg/hr by continous neubolization
2_8 puf up to every 20 min for 3 doses as
needed then every 1 hr as needed

Monitor pulse oximetry to maintain o2 saturation>92%
Cardiorespiratory monitoring
During exacerbations,frequent or continuous use can cause
pulmonary vasodilatation,v/q mistmatch and hypoxemia
Adverse effect palpitation, tachycardia, arrhythmia, tremor,
hypoxemia
Neubolizer:when giving concentrate forms,dilute with saline to 3
ml total neubolized volume
For MDI use space/holding chamber

Systemic corticosteroids
Prednisolone tb
Methyl prednisolon
Anticholinergics
Ipratropium
Atrovent
Ipratropium with Albuterol

Anti inflammatory
0.5_1 mg/kg every 6-8 hr for 48 hr , then 1-2 mg/kg
day bid(max 60 mg/day)
Short course burst for exacerbation 1-2 mg/kg/day qd
or bid for 3-7 days
Mucolitic/bronchodilator
Neubolizer 0.5 mg q6-8 hr (tid or qid) as needed
MDI 2 paf qid
1 vial by neubolizer qid



If pt has been exposed chickenpox or measles, consider passive
immunoglobulin prophylaxis, also risk of complications with
herspes simplex and TB

For daily dosing , 8 am administration minimizes adrenal
suppression

Children may benefit from dosage tapering if course exceed 7 days

Adverse effect monitoring: frequent therapy bursts risk numerous
corticosteroid adverse effects

Should not be used as first line treatment added to b2 agonist
therapy
Neubolizer may mix Ipratropium with Albuterol

QUICK RELIEF MEDICATION
SABA

Anti cholinergic(ipratropium)
Short term systemic gluco

corticoid

SABA
 Quick relief of asthma symptoms
 Relax airway smooth muscle prompt airflow↑
 Repetitive or continuous SABA is the most effective means







of reversing air flow obstruction
SABA should not be prescribed on a regular schedule
because concerns of possibility of deteriorating asthma
control
Frequent use of SABA is an indication of poor asthma control
Preferred root is inhalation smaller dose , fewer side effects
more rapid on set of action
Ipratropium Bromide as an adjunct to SABA in emergency
room reduces hospital admissions and improves lung function
Systemic Glucocorticoids short oral course + SABA in
moderate to severe asthma exacerbation

LABA
 Salmetrol

 Should be used in combination with inhaled

corticosteroids and not as mono therapy
 Exercise induces asthma in children >= 4 Yrs
one inhalation 30 min prior to exercise
 No additional doses for PTs who are already
receiving it twice daily not recommended by
NIH guidelines

LTRA

 MonteLukast ( singulair)

 Antihistaminic

 Leukotrien receptor antagonist

 Asthma ( not < 12 MO) and allergic rhinitis (





not < 6 MO)
Morning dosing not evaluated
Prophylactic and chronic treatment of asthma
Exercise induced asthma in >= 15 Yrs
Zafir Lukast : prophylactic and chronic
treatment of asthma

ICA
 Most potent anti inflammatory agents available

for the treatment of asthma
 Inhibiting most steps in the cascade of the
inflammatory response
 Benefits reducing bronchial hyper
responsiveness , prevention of late asthmatic
response , enhanced lung function
 Inhaled Glucocorticoids first line controller
therapy for persistent asthma or those who
require step 2

Prognosis
 35%of preschool children experience recurrent

coughing and wheezing,1/3 of them continue to
have persistent asthma into later childhood and
2/3 improvement on their own through their teen
yrs
 Asthma severity by age 7-10 yrs is predictive of
asthma persistence into adulthood
 Children with mod to severe asthma and lower lung
function are likely to have persistent asthma as
adults
 Children with milder asthma and N/R lung function
are likely to improve over time or be periodically
asthmatic

THANK YOU FOR YOUR
ATTENTION


Slide 25

Asthma in Children
DR. A.Mirshokraei
NIOC Hospital Pediatrics Ward

Definition :

DEFINITION

- Chronic inflammatory condition of the
lung airways resulting in episodic airflow
obstruction
- AHR to provocative exposures
Asthma management
• Reducing airway inflammation by: Minimizing
pro inflammatory environmental exposure, using
daily controller anti inflammatory medication,
controlling co morbid conditions that worsen
asthma, less inflammation better asthma
control and fewer exacerbations

Anyway exacerbations

occur

BUT
Even the uncommon
child with sever asthma can
be managed to live normally

 RECURRENT WHEEZING EPISODES WITH COMMON

RESPIRATORY
VIRUSES(RSV,RHINOVIRUS,INFLUENZA,PARAINFLUENZA,A
DENOVIRUS,HUMAN METAPNUMOVIRUS)

 HOST FEATURES AFFECTING IMMUNOLOGIC HOST

DEFENSE,INFLAMMATION/PREVIOUS VIRAL INFECTIONS
MAINIFESTED AS PNUMONIA OR BRONCHIOLITIS
REQUIRING HOSPITALIZATION UNDERLIE THE
RECURRENT WHEEZING IN EARLY CHILDHOOD

 OTHER AIRWAY EXPOSURES SUCH AS INDOOR AND HOME

ALLERGENS,COLD AIR,STRONG ODORS,TOBACCO
SMOKE,ALL INCREASE AHR

 ALLERGEN ELLIMINATION SOMETIMES LEEDS TO CURE

EPIDEMIOLOGY
 Common etiology of emergency visits and school day missing

in childhood ,occasionally hospitalization and rare deaths
specially in poverty ,urban living ,ethnic minorities

 Increasing asthma prevalence worldwide(50% per decade)
 Good correlation of asthma prevalence with allergic rhino

sinusitis and atopic eczema and other allergies

 More prevalence in high level urban modern families than

suburban villagers

 More than 80%of asthmatics reported getting the disease

before 6 year

CLINICS
RECURRENT COUGHING/WHEEZING
PATTERNS IN CHILDHOOD BASED ON
NATURAL HISTORY

TRANSIENT EARLY WHEEZING
 Common in early preschool years

 Recurrent coughing/wheezing primary

triggered by common respiratory viral INF
 Tend to resolve during preschool yrs without
increasing risk of asthma later in life
 Problems due to reduced airflow at birth
suggestive of relative narrow airways improved
by school yrs

Persistent Atopy Associated Asthma
 Begins in early preschool yrs

 Associated with atopy (eg atopic dermatitis in





infancy, allergic rhinitis, food allergy)
Biologic factors e.g.: early inhalant sensitization,
increase serum IGE, increase blood eosinophills,
High risk of persistence into later childhood and
adulthood lung function abnormality
Those with onset<3 yrs
reduced air flow by
school yrs
Those with later onset of symptoms or allergen
sensitizations unlikely persistence lung function
abnormality later

Non-Atopic Wheezing
 Wheezing ,coughing beginning in early life

often with RSV INF resolves later in childhood
without increasing risk of persistence asthma

 Associated with bronchial hyper

responsiveness near birth

Asthma with declining lung function
• Children with asthma with progressive

increase in air flow limitation

• Associated with hyper inflation in childhood
• Male gender

Late onset asthma in females associated with
obesity and early onset puberty
 Onset between 8_13 yrs

 Associated with early onset puberty and obesity
 Specific for females

Occupational type asthma in children
 Children with asthma and occupational type exposure

known to trigger asthma in adults in occupational settings

Types of Asthma
common clinical presentations of intermittent
recurrent wheezing and/or coughing
 Recurrent wheezing in early childhood

 Chronic asthma associated with allergy
 Females 11 yrs with early onset puberty and

obesity

Pathogenesis

 Airflow obstruction resulting from

Broncho constriction of bronchiolar smooth
muscle mass
II. Cellular inflammatory infiltrates and exudates
mostly Eosinophills(also N , M ,L ,mast cells
,basophiles)fill and obstruct airways and damage
epithelium and induce desquamation into airway
lumen mediated by T helper cells and other
immune cells that produce pro allergic pro
inflammatory cytokines(IL4,IL6,IL13)
III. Breach in normal immune regulatory process
I.

RESULT
 Airway inflammation

 AHR
 Edema basement membrane thickness sub

epithelial collagen deposition
 Smooth muscle and mucus gland hypertrophy
and mucus hyper secretion

Air obstruction

Clinical manifestations and diagnosis
 Most common intermittent dry cough and

expiratory wheezing

 Shortness of breath and chest tightness in older

children and adults

 Intermittent non focal chest pain in younger

children

 Worsening of respiratory symptoms at night
 Worsening of day time symptoms by activity

Continue…..
 Subtle symptoms such as self limitation of activities

,general fatigue ,difficulty in keeping up with peers

 Relief with aerosolized bronchodilators
 Lack of improvement with bronchodilators and steroid

is inconsistent with Asthma and should consider
Asthma masquerading conditions!!!!

 Hyper ventilation, intercostal retractions ,nasal flaring

,respiratory accessory muscle use

 Its common not to hear the expiratory wheezing when

Air flow is so limited before treatment

Asthma Triggers
 Common viral infections of the respiratory tract
 Aero allergens in sensitized asthmatics ,animal dander ,dust











mite ,molds ,indoor allergens ,cockroaches
Seasonal aero allergens ,pollens(trees ,grasses ,weeds ,)
Environmental tobacco smoke
Air pollutants ,ozone ,so2,wood or coal smoke ,endotoxin
,mycotoxin ,dust
Strong or noxious odors or fumes ,perfume ,hair spray
,cleaning agents
Occupational exposure
Cold air ,dry air
Exercise
Crying ,laughter ,hyperventilation
Co morbid conditions Rhinitis ,Sinusitis ,GER

Clinics
History:
Triggering symptoms by laughter
,cold air ,airway irritants
Exposures that induce airway
irritation such as viral URTI
Mycoplasma ,Chlamydia
Inhaled allergens
All lead to AHR

Presence Of Risk Factors:
 History of other allergies ,allergic Rhinitis,

allergic Conjunctivitis ,atopic Dermatitis ,food
allergies

 Parental Asthma
 Symptoms apart from cold

Continue…..
 No or minimal signs in routine visits

 Dry or persistent cough

 Normal chest findings unless wheezing when asking

to breath deeper
 Quick relief (10 MIN) after SABA use
 Expiratory wheezing ,prolonged expiratory phase
,decreased sounds in RT lower pos lobe due to
regional hypoventilation owing to airway
obstruction
 Rales , ronchi ,crackles due to hyper secretion
 Segmental crackles and poor breath sounds
atelectasis?

Continue….
 Labored respiration ,respiratory distress increased

prolongation of expiration and wheezing in E and I

 Poor air entry
 Inter costal retractions ,nasal flaring ,supra and

infra sternal retractions

 And again in most sever forms expiratory wheezing

does not appear until some broncho dilation

DD

GERD Rhino sinusitis co morbid

conditions with asthma

Recurrent aspiration in early

life(tracheo broncho malacia
,TEF , foreign body ,CF ,BPD

VCD in older children and

adolescents

LAB FINDINGS
Pulmonary Function
Testing

Continue….
 Forced expiratory airflow measures helpful

in Diagnosis , assessing efficacy of therapy
and monitoring Asthma in children specially
in poor children who do not have PHE
unless obstruction is sever

 Valueablity of spirometric findings in children>6

yrs

 3 efforts the highest is the peak
 Reduced FEV

obstruction

FEV1/FVC <0.80 means significant

 Improvement in FEV1 following beta 2 agonist > =

12% or 200 ml is consistent with Asthma

 Peak flow meter

CXR

Often normal aside from subtle and

nonspecific findings of hyperinflation

Peribronchial thickening
Helping in diagnosis of Asthma

differentials

Diagnosis of complications of Asthma

exacerbations

Other tests such as allergy skin prick
testing

Treatment
 www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm

Asthma Treatment & Management
has 4 components :
Assessment and monitoring of disease
activity
2. Provision to educate pt and family
3. Identification and management of
precipitating factors and co morbid
conditions
4. Appropriate selection of medication
1.

 Attainment of optimal Asthma control

Component 1
 Asthma severity :intermittent
 Persistent: mild ,mod ,severe
 Only once during patient initial evaluation in pt

who is not using a daily controller agent
 Asthma control degree to which symptoms ,
on going functional impairments , risk of
adverse events minimized and goals of
therapy are met

Continue….
Well controlled
2. Not well controlled
3. Very poor controlled
1.

 NIH guidelines for both severity and

control for 3 age groups

0-4 yrs
2. 5-11 yrs
3. =>12 yrs
1.

Important
even in the absence of frequent symptoms
infants and children whom have risk factors
for asthma and 4 or more episodes of
wheezing over the past yr which lasted more
than 1 day or 2 or more exacerbations in
the last 6 months requiring syst
corticosteroids should be considered in the
persistent group and hence receive long term
controller therapy

Important Tips..
 Regular clinical visits every 2-6 weeks
 Assessment of :

Pt symptoms frequency night and day
2. Need for short acting inhaled b2 agonists for
quick relief
3. Ability to engage in normal activities
4. Air flow measures for>=5 yrs
1.

Continue..
 Component 2 : pt education

 Component 3 : control of factors contributing

to asthma severity
1. Environmental exposures
2. Co morbid conditions
 Component 4 :principals of asthma
pharmacotherapy

Asthma Medication
 SABA

 ICS

 LABA
 LTRA

 SYSTEMIC STEROIDS

 NONSTEROIDAL ANTIINFLAMMATORY

CROMOLYN AND NEDOCROMYL
 OXYGEN
 ANTICHOLINERGIC AGENTS
IPRATROPIUM
BROMIDE
 ANTIIMMUNOGLUBOLINE E

MANAGEMENT OF ASTHMA EXACERBATION(STATUS ASTHMATICUS)
RISK ASSESMENT ON ADMISSION

FOCUSED HISTORY

ONSET OF CURRENT EXACERBATION
FREQUENCY AND severity of daytime and night
time symptoms and activity limitation
Frequency of rescue bronchodilator use
Current medication and allergies
Potential triggers
History of systemic steroid courses, emergency
department visists , hospitalization, intubation or life
threatening episodes

Clinical assesment

Physical examination findings: vital signs,
breathlessness, air movement, use of accessory
respiratory muscles, retractions, anxiety level,
alteration in mental status
Pulse oximetry
Lung function(defer in pts with mod to severe
distress or history of labile disease)

Treatment
Drugs and trade name

Mechanism of action and dosing

Cautions and adverse effects

Oxygen(mask or nasal canula)
Inhaled short acting b2
agonist
Albuterol nebulized
solution(5mg/ml concentrates
Albuterol MDI
Levabuterol

Treats hypoxia
Bronchodilator
Neubolizer 0.15 mg/kg every 20 min for 3
doses as needed,then 0.15_0.3 mg/kg up t 10
mg every 1_4 hour as needed or up to 0.5
mg/kg/hr by continous neubolization
2_8 puf up to every 20 min for 3 doses as
needed then every 1 hr as needed

Monitor pulse oximetry to maintain o2 saturation>92%
Cardiorespiratory monitoring
During exacerbations,frequent or continuous use can cause
pulmonary vasodilatation,v/q mistmatch and hypoxemia
Adverse effect palpitation, tachycardia, arrhythmia, tremor,
hypoxemia
Neubolizer:when giving concentrate forms,dilute with saline to 3
ml total neubolized volume
For MDI use space/holding chamber

Systemic corticosteroids
Prednisolone tb
Methyl prednisolon
Anticholinergics
Ipratropium
Atrovent
Ipratropium with Albuterol

Anti inflammatory
0.5_1 mg/kg every 6-8 hr for 48 hr , then 1-2 mg/kg
day bid(max 60 mg/day)
Short course burst for exacerbation 1-2 mg/kg/day qd
or bid for 3-7 days
Mucolitic/bronchodilator
Neubolizer 0.5 mg q6-8 hr (tid or qid) as needed
MDI 2 paf qid
1 vial by neubolizer qid



If pt has been exposed chickenpox or measles, consider passive
immunoglobulin prophylaxis, also risk of complications with
herspes simplex and TB

For daily dosing , 8 am administration minimizes adrenal
suppression

Children may benefit from dosage tapering if course exceed 7 days

Adverse effect monitoring: frequent therapy bursts risk numerous
corticosteroid adverse effects

Should not be used as first line treatment added to b2 agonist
therapy
Neubolizer may mix Ipratropium with Albuterol

QUICK RELIEF MEDICATION
SABA

Anti cholinergic(ipratropium)
Short term systemic gluco

corticoid

SABA
 Quick relief of asthma symptoms
 Relax airway smooth muscle prompt airflow↑
 Repetitive or continuous SABA is the most effective means







of reversing air flow obstruction
SABA should not be prescribed on a regular schedule
because concerns of possibility of deteriorating asthma
control
Frequent use of SABA is an indication of poor asthma control
Preferred root is inhalation smaller dose , fewer side effects
more rapid on set of action
Ipratropium Bromide as an adjunct to SABA in emergency
room reduces hospital admissions and improves lung function
Systemic Glucocorticoids short oral course + SABA in
moderate to severe asthma exacerbation

LABA
 Salmetrol

 Should be used in combination with inhaled

corticosteroids and not as mono therapy
 Exercise induces asthma in children >= 4 Yrs
one inhalation 30 min prior to exercise
 No additional doses for PTs who are already
receiving it twice daily not recommended by
NIH guidelines

LTRA

 MonteLukast ( singulair)

 Antihistaminic

 Leukotrien receptor antagonist

 Asthma ( not < 12 MO) and allergic rhinitis (





not < 6 MO)
Morning dosing not evaluated
Prophylactic and chronic treatment of asthma
Exercise induced asthma in >= 15 Yrs
Zafir Lukast : prophylactic and chronic
treatment of asthma

ICA
 Most potent anti inflammatory agents available

for the treatment of asthma
 Inhibiting most steps in the cascade of the
inflammatory response
 Benefits reducing bronchial hyper
responsiveness , prevention of late asthmatic
response , enhanced lung function
 Inhaled Glucocorticoids first line controller
therapy for persistent asthma or those who
require step 2

Prognosis
 35%of preschool children experience recurrent

coughing and wheezing,1/3 of them continue to
have persistent asthma into later childhood and
2/3 improvement on their own through their teen
yrs
 Asthma severity by age 7-10 yrs is predictive of
asthma persistence into adulthood
 Children with mod to severe asthma and lower lung
function are likely to have persistent asthma as
adults
 Children with milder asthma and N/R lung function
are likely to improve over time or be periodically
asthmatic

THANK YOU FOR YOUR
ATTENTION


Slide 26

Asthma in Children
DR. A.Mirshokraei
NIOC Hospital Pediatrics Ward

Definition :

DEFINITION

- Chronic inflammatory condition of the
lung airways resulting in episodic airflow
obstruction
- AHR to provocative exposures
Asthma management
• Reducing airway inflammation by: Minimizing
pro inflammatory environmental exposure, using
daily controller anti inflammatory medication,
controlling co morbid conditions that worsen
asthma, less inflammation better asthma
control and fewer exacerbations

Anyway exacerbations

occur

BUT
Even the uncommon
child with sever asthma can
be managed to live normally

 RECURRENT WHEEZING EPISODES WITH COMMON

RESPIRATORY
VIRUSES(RSV,RHINOVIRUS,INFLUENZA,PARAINFLUENZA,A
DENOVIRUS,HUMAN METAPNUMOVIRUS)

 HOST FEATURES AFFECTING IMMUNOLOGIC HOST

DEFENSE,INFLAMMATION/PREVIOUS VIRAL INFECTIONS
MAINIFESTED AS PNUMONIA OR BRONCHIOLITIS
REQUIRING HOSPITALIZATION UNDERLIE THE
RECURRENT WHEEZING IN EARLY CHILDHOOD

 OTHER AIRWAY EXPOSURES SUCH AS INDOOR AND HOME

ALLERGENS,COLD AIR,STRONG ODORS,TOBACCO
SMOKE,ALL INCREASE AHR

 ALLERGEN ELLIMINATION SOMETIMES LEEDS TO CURE

EPIDEMIOLOGY
 Common etiology of emergency visits and school day missing

in childhood ,occasionally hospitalization and rare deaths
specially in poverty ,urban living ,ethnic minorities

 Increasing asthma prevalence worldwide(50% per decade)
 Good correlation of asthma prevalence with allergic rhino

sinusitis and atopic eczema and other allergies

 More prevalence in high level urban modern families than

suburban villagers

 More than 80%of asthmatics reported getting the disease

before 6 year

CLINICS
RECURRENT COUGHING/WHEEZING
PATTERNS IN CHILDHOOD BASED ON
NATURAL HISTORY

TRANSIENT EARLY WHEEZING
 Common in early preschool years

 Recurrent coughing/wheezing primary

triggered by common respiratory viral INF
 Tend to resolve during preschool yrs without
increasing risk of asthma later in life
 Problems due to reduced airflow at birth
suggestive of relative narrow airways improved
by school yrs

Persistent Atopy Associated Asthma
 Begins in early preschool yrs

 Associated with atopy (eg atopic dermatitis in





infancy, allergic rhinitis, food allergy)
Biologic factors e.g.: early inhalant sensitization,
increase serum IGE, increase blood eosinophills,
High risk of persistence into later childhood and
adulthood lung function abnormality
Those with onset<3 yrs
reduced air flow by
school yrs
Those with later onset of symptoms or allergen
sensitizations unlikely persistence lung function
abnormality later

Non-Atopic Wheezing
 Wheezing ,coughing beginning in early life

often with RSV INF resolves later in childhood
without increasing risk of persistence asthma

 Associated with bronchial hyper

responsiveness near birth

Asthma with declining lung function
• Children with asthma with progressive

increase in air flow limitation

• Associated with hyper inflation in childhood
• Male gender

Late onset asthma in females associated with
obesity and early onset puberty
 Onset between 8_13 yrs

 Associated with early onset puberty and obesity
 Specific for females

Occupational type asthma in children
 Children with asthma and occupational type exposure

known to trigger asthma in adults in occupational settings

Types of Asthma
common clinical presentations of intermittent
recurrent wheezing and/or coughing
 Recurrent wheezing in early childhood

 Chronic asthma associated with allergy
 Females 11 yrs with early onset puberty and

obesity

Pathogenesis

 Airflow obstruction resulting from

Broncho constriction of bronchiolar smooth
muscle mass
II. Cellular inflammatory infiltrates and exudates
mostly Eosinophills(also N , M ,L ,mast cells
,basophiles)fill and obstruct airways and damage
epithelium and induce desquamation into airway
lumen mediated by T helper cells and other
immune cells that produce pro allergic pro
inflammatory cytokines(IL4,IL6,IL13)
III. Breach in normal immune regulatory process
I.

RESULT
 Airway inflammation

 AHR
 Edema basement membrane thickness sub

epithelial collagen deposition
 Smooth muscle and mucus gland hypertrophy
and mucus hyper secretion

Air obstruction

Clinical manifestations and diagnosis
 Most common intermittent dry cough and

expiratory wheezing

 Shortness of breath and chest tightness in older

children and adults

 Intermittent non focal chest pain in younger

children

 Worsening of respiratory symptoms at night
 Worsening of day time symptoms by activity

Continue…..
 Subtle symptoms such as self limitation of activities

,general fatigue ,difficulty in keeping up with peers

 Relief with aerosolized bronchodilators
 Lack of improvement with bronchodilators and steroid

is inconsistent with Asthma and should consider
Asthma masquerading conditions!!!!

 Hyper ventilation, intercostal retractions ,nasal flaring

,respiratory accessory muscle use

 Its common not to hear the expiratory wheezing when

Air flow is so limited before treatment

Asthma Triggers
 Common viral infections of the respiratory tract
 Aero allergens in sensitized asthmatics ,animal dander ,dust











mite ,molds ,indoor allergens ,cockroaches
Seasonal aero allergens ,pollens(trees ,grasses ,weeds ,)
Environmental tobacco smoke
Air pollutants ,ozone ,so2,wood or coal smoke ,endotoxin
,mycotoxin ,dust
Strong or noxious odors or fumes ,perfume ,hair spray
,cleaning agents
Occupational exposure
Cold air ,dry air
Exercise
Crying ,laughter ,hyperventilation
Co morbid conditions Rhinitis ,Sinusitis ,GER

Clinics
History:
Triggering symptoms by laughter
,cold air ,airway irritants
Exposures that induce airway
irritation such as viral URTI
Mycoplasma ,Chlamydia
Inhaled allergens
All lead to AHR

Presence Of Risk Factors:
 History of other allergies ,allergic Rhinitis,

allergic Conjunctivitis ,atopic Dermatitis ,food
allergies

 Parental Asthma
 Symptoms apart from cold

Continue…..
 No or minimal signs in routine visits

 Dry or persistent cough

 Normal chest findings unless wheezing when asking

to breath deeper
 Quick relief (10 MIN) after SABA use
 Expiratory wheezing ,prolonged expiratory phase
,decreased sounds in RT lower pos lobe due to
regional hypoventilation owing to airway
obstruction
 Rales , ronchi ,crackles due to hyper secretion
 Segmental crackles and poor breath sounds
atelectasis?

Continue….
 Labored respiration ,respiratory distress increased

prolongation of expiration and wheezing in E and I

 Poor air entry
 Inter costal retractions ,nasal flaring ,supra and

infra sternal retractions

 And again in most sever forms expiratory wheezing

does not appear until some broncho dilation

DD

GERD Rhino sinusitis co morbid

conditions with asthma

Recurrent aspiration in early

life(tracheo broncho malacia
,TEF , foreign body ,CF ,BPD

VCD in older children and

adolescents

LAB FINDINGS
Pulmonary Function
Testing

Continue….
 Forced expiratory airflow measures helpful

in Diagnosis , assessing efficacy of therapy
and monitoring Asthma in children specially
in poor children who do not have PHE
unless obstruction is sever

 Valueablity of spirometric findings in children>6

yrs

 3 efforts the highest is the peak
 Reduced FEV

obstruction

FEV1/FVC <0.80 means significant

 Improvement in FEV1 following beta 2 agonist > =

12% or 200 ml is consistent with Asthma

 Peak flow meter

CXR

Often normal aside from subtle and

nonspecific findings of hyperinflation

Peribronchial thickening
Helping in diagnosis of Asthma

differentials

Diagnosis of complications of Asthma

exacerbations

Other tests such as allergy skin prick
testing

Treatment
 www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm

Asthma Treatment & Management
has 4 components :
Assessment and monitoring of disease
activity
2. Provision to educate pt and family
3. Identification and management of
precipitating factors and co morbid
conditions
4. Appropriate selection of medication
1.

 Attainment of optimal Asthma control

Component 1
 Asthma severity :intermittent
 Persistent: mild ,mod ,severe
 Only once during patient initial evaluation in pt

who is not using a daily controller agent
 Asthma control degree to which symptoms ,
on going functional impairments , risk of
adverse events minimized and goals of
therapy are met

Continue….
Well controlled
2. Not well controlled
3. Very poor controlled
1.

 NIH guidelines for both severity and

control for 3 age groups

0-4 yrs
2. 5-11 yrs
3. =>12 yrs
1.

Important
even in the absence of frequent symptoms
infants and children whom have risk factors
for asthma and 4 or more episodes of
wheezing over the past yr which lasted more
than 1 day or 2 or more exacerbations in
the last 6 months requiring syst
corticosteroids should be considered in the
persistent group and hence receive long term
controller therapy

Important Tips..
 Regular clinical visits every 2-6 weeks
 Assessment of :

Pt symptoms frequency night and day
2. Need for short acting inhaled b2 agonists for
quick relief
3. Ability to engage in normal activities
4. Air flow measures for>=5 yrs
1.

Continue..
 Component 2 : pt education

 Component 3 : control of factors contributing

to asthma severity
1. Environmental exposures
2. Co morbid conditions
 Component 4 :principals of asthma
pharmacotherapy

Asthma Medication
 SABA

 ICS

 LABA
 LTRA

 SYSTEMIC STEROIDS

 NONSTEROIDAL ANTIINFLAMMATORY

CROMOLYN AND NEDOCROMYL
 OXYGEN
 ANTICHOLINERGIC AGENTS
IPRATROPIUM
BROMIDE
 ANTIIMMUNOGLUBOLINE E

MANAGEMENT OF ASTHMA EXACERBATION(STATUS ASTHMATICUS)
RISK ASSESMENT ON ADMISSION

FOCUSED HISTORY

ONSET OF CURRENT EXACERBATION
FREQUENCY AND severity of daytime and night
time symptoms and activity limitation
Frequency of rescue bronchodilator use
Current medication and allergies
Potential triggers
History of systemic steroid courses, emergency
department visists , hospitalization, intubation or life
threatening episodes

Clinical assesment

Physical examination findings: vital signs,
breathlessness, air movement, use of accessory
respiratory muscles, retractions, anxiety level,
alteration in mental status
Pulse oximetry
Lung function(defer in pts with mod to severe
distress or history of labile disease)

Treatment
Drugs and trade name

Mechanism of action and dosing

Cautions and adverse effects

Oxygen(mask or nasal canula)
Inhaled short acting b2
agonist
Albuterol nebulized
solution(5mg/ml concentrates
Albuterol MDI
Levabuterol

Treats hypoxia
Bronchodilator
Neubolizer 0.15 mg/kg every 20 min for 3
doses as needed,then 0.15_0.3 mg/kg up t 10
mg every 1_4 hour as needed or up to 0.5
mg/kg/hr by continous neubolization
2_8 puf up to every 20 min for 3 doses as
needed then every 1 hr as needed

Monitor pulse oximetry to maintain o2 saturation>92%
Cardiorespiratory monitoring
During exacerbations,frequent or continuous use can cause
pulmonary vasodilatation,v/q mistmatch and hypoxemia
Adverse effect palpitation, tachycardia, arrhythmia, tremor,
hypoxemia
Neubolizer:when giving concentrate forms,dilute with saline to 3
ml total neubolized volume
For MDI use space/holding chamber

Systemic corticosteroids
Prednisolone tb
Methyl prednisolon
Anticholinergics
Ipratropium
Atrovent
Ipratropium with Albuterol

Anti inflammatory
0.5_1 mg/kg every 6-8 hr for 48 hr , then 1-2 mg/kg
day bid(max 60 mg/day)
Short course burst for exacerbation 1-2 mg/kg/day qd
or bid for 3-7 days
Mucolitic/bronchodilator
Neubolizer 0.5 mg q6-8 hr (tid or qid) as needed
MDI 2 paf qid
1 vial by neubolizer qid



If pt has been exposed chickenpox or measles, consider passive
immunoglobulin prophylaxis, also risk of complications with
herspes simplex and TB

For daily dosing , 8 am administration minimizes adrenal
suppression

Children may benefit from dosage tapering if course exceed 7 days

Adverse effect monitoring: frequent therapy bursts risk numerous
corticosteroid adverse effects

Should not be used as first line treatment added to b2 agonist
therapy
Neubolizer may mix Ipratropium with Albuterol

QUICK RELIEF MEDICATION
SABA

Anti cholinergic(ipratropium)
Short term systemic gluco

corticoid

SABA
 Quick relief of asthma symptoms
 Relax airway smooth muscle prompt airflow↑
 Repetitive or continuous SABA is the most effective means







of reversing air flow obstruction
SABA should not be prescribed on a regular schedule
because concerns of possibility of deteriorating asthma
control
Frequent use of SABA is an indication of poor asthma control
Preferred root is inhalation smaller dose , fewer side effects
more rapid on set of action
Ipratropium Bromide as an adjunct to SABA in emergency
room reduces hospital admissions and improves lung function
Systemic Glucocorticoids short oral course + SABA in
moderate to severe asthma exacerbation

LABA
 Salmetrol

 Should be used in combination with inhaled

corticosteroids and not as mono therapy
 Exercise induces asthma in children >= 4 Yrs
one inhalation 30 min prior to exercise
 No additional doses for PTs who are already
receiving it twice daily not recommended by
NIH guidelines

LTRA

 MonteLukast ( singulair)

 Antihistaminic

 Leukotrien receptor antagonist

 Asthma ( not < 12 MO) and allergic rhinitis (





not < 6 MO)
Morning dosing not evaluated
Prophylactic and chronic treatment of asthma
Exercise induced asthma in >= 15 Yrs
Zafir Lukast : prophylactic and chronic
treatment of asthma

ICA
 Most potent anti inflammatory agents available

for the treatment of asthma
 Inhibiting most steps in the cascade of the
inflammatory response
 Benefits reducing bronchial hyper
responsiveness , prevention of late asthmatic
response , enhanced lung function
 Inhaled Glucocorticoids first line controller
therapy for persistent asthma or those who
require step 2

Prognosis
 35%of preschool children experience recurrent

coughing and wheezing,1/3 of them continue to
have persistent asthma into later childhood and
2/3 improvement on their own through their teen
yrs
 Asthma severity by age 7-10 yrs is predictive of
asthma persistence into adulthood
 Children with mod to severe asthma and lower lung
function are likely to have persistent asthma as
adults
 Children with milder asthma and N/R lung function
are likely to improve over time or be periodically
asthmatic

THANK YOU FOR YOUR
ATTENTION


Slide 27

Asthma in Children
DR. A.Mirshokraei
NIOC Hospital Pediatrics Ward

Definition :

DEFINITION

- Chronic inflammatory condition of the
lung airways resulting in episodic airflow
obstruction
- AHR to provocative exposures
Asthma management
• Reducing airway inflammation by: Minimizing
pro inflammatory environmental exposure, using
daily controller anti inflammatory medication,
controlling co morbid conditions that worsen
asthma, less inflammation better asthma
control and fewer exacerbations

Anyway exacerbations

occur

BUT
Even the uncommon
child with sever asthma can
be managed to live normally

 RECURRENT WHEEZING EPISODES WITH COMMON

RESPIRATORY
VIRUSES(RSV,RHINOVIRUS,INFLUENZA,PARAINFLUENZA,A
DENOVIRUS,HUMAN METAPNUMOVIRUS)

 HOST FEATURES AFFECTING IMMUNOLOGIC HOST

DEFENSE,INFLAMMATION/PREVIOUS VIRAL INFECTIONS
MAINIFESTED AS PNUMONIA OR BRONCHIOLITIS
REQUIRING HOSPITALIZATION UNDERLIE THE
RECURRENT WHEEZING IN EARLY CHILDHOOD

 OTHER AIRWAY EXPOSURES SUCH AS INDOOR AND HOME

ALLERGENS,COLD AIR,STRONG ODORS,TOBACCO
SMOKE,ALL INCREASE AHR

 ALLERGEN ELLIMINATION SOMETIMES LEEDS TO CURE

EPIDEMIOLOGY
 Common etiology of emergency visits and school day missing

in childhood ,occasionally hospitalization and rare deaths
specially in poverty ,urban living ,ethnic minorities

 Increasing asthma prevalence worldwide(50% per decade)
 Good correlation of asthma prevalence with allergic rhino

sinusitis and atopic eczema and other allergies

 More prevalence in high level urban modern families than

suburban villagers

 More than 80%of asthmatics reported getting the disease

before 6 year

CLINICS
RECURRENT COUGHING/WHEEZING
PATTERNS IN CHILDHOOD BASED ON
NATURAL HISTORY

TRANSIENT EARLY WHEEZING
 Common in early preschool years

 Recurrent coughing/wheezing primary

triggered by common respiratory viral INF
 Tend to resolve during preschool yrs without
increasing risk of asthma later in life
 Problems due to reduced airflow at birth
suggestive of relative narrow airways improved
by school yrs

Persistent Atopy Associated Asthma
 Begins in early preschool yrs

 Associated with atopy (eg atopic dermatitis in





infancy, allergic rhinitis, food allergy)
Biologic factors e.g.: early inhalant sensitization,
increase serum IGE, increase blood eosinophills,
High risk of persistence into later childhood and
adulthood lung function abnormality
Those with onset<3 yrs
reduced air flow by
school yrs
Those with later onset of symptoms or allergen
sensitizations unlikely persistence lung function
abnormality later

Non-Atopic Wheezing
 Wheezing ,coughing beginning in early life

often with RSV INF resolves later in childhood
without increasing risk of persistence asthma

 Associated with bronchial hyper

responsiveness near birth

Asthma with declining lung function
• Children with asthma with progressive

increase in air flow limitation

• Associated with hyper inflation in childhood
• Male gender

Late onset asthma in females associated with
obesity and early onset puberty
 Onset between 8_13 yrs

 Associated with early onset puberty and obesity
 Specific for females

Occupational type asthma in children
 Children with asthma and occupational type exposure

known to trigger asthma in adults in occupational settings

Types of Asthma
common clinical presentations of intermittent
recurrent wheezing and/or coughing
 Recurrent wheezing in early childhood

 Chronic asthma associated with allergy
 Females 11 yrs with early onset puberty and

obesity

Pathogenesis

 Airflow obstruction resulting from

Broncho constriction of bronchiolar smooth
muscle mass
II. Cellular inflammatory infiltrates and exudates
mostly Eosinophills(also N , M ,L ,mast cells
,basophiles)fill and obstruct airways and damage
epithelium and induce desquamation into airway
lumen mediated by T helper cells and other
immune cells that produce pro allergic pro
inflammatory cytokines(IL4,IL6,IL13)
III. Breach in normal immune regulatory process
I.

RESULT
 Airway inflammation

 AHR
 Edema basement membrane thickness sub

epithelial collagen deposition
 Smooth muscle and mucus gland hypertrophy
and mucus hyper secretion

Air obstruction

Clinical manifestations and diagnosis
 Most common intermittent dry cough and

expiratory wheezing

 Shortness of breath and chest tightness in older

children and adults

 Intermittent non focal chest pain in younger

children

 Worsening of respiratory symptoms at night
 Worsening of day time symptoms by activity

Continue…..
 Subtle symptoms such as self limitation of activities

,general fatigue ,difficulty in keeping up with peers

 Relief with aerosolized bronchodilators
 Lack of improvement with bronchodilators and steroid

is inconsistent with Asthma and should consider
Asthma masquerading conditions!!!!

 Hyper ventilation, intercostal retractions ,nasal flaring

,respiratory accessory muscle use

 Its common not to hear the expiratory wheezing when

Air flow is so limited before treatment

Asthma Triggers
 Common viral infections of the respiratory tract
 Aero allergens in sensitized asthmatics ,animal dander ,dust











mite ,molds ,indoor allergens ,cockroaches
Seasonal aero allergens ,pollens(trees ,grasses ,weeds ,)
Environmental tobacco smoke
Air pollutants ,ozone ,so2,wood or coal smoke ,endotoxin
,mycotoxin ,dust
Strong or noxious odors or fumes ,perfume ,hair spray
,cleaning agents
Occupational exposure
Cold air ,dry air
Exercise
Crying ,laughter ,hyperventilation
Co morbid conditions Rhinitis ,Sinusitis ,GER

Clinics
History:
Triggering symptoms by laughter
,cold air ,airway irritants
Exposures that induce airway
irritation such as viral URTI
Mycoplasma ,Chlamydia
Inhaled allergens
All lead to AHR

Presence Of Risk Factors:
 History of other allergies ,allergic Rhinitis,

allergic Conjunctivitis ,atopic Dermatitis ,food
allergies

 Parental Asthma
 Symptoms apart from cold

Continue…..
 No or minimal signs in routine visits

 Dry or persistent cough

 Normal chest findings unless wheezing when asking

to breath deeper
 Quick relief (10 MIN) after SABA use
 Expiratory wheezing ,prolonged expiratory phase
,decreased sounds in RT lower pos lobe due to
regional hypoventilation owing to airway
obstruction
 Rales , ronchi ,crackles due to hyper secretion
 Segmental crackles and poor breath sounds
atelectasis?

Continue….
 Labored respiration ,respiratory distress increased

prolongation of expiration and wheezing in E and I

 Poor air entry
 Inter costal retractions ,nasal flaring ,supra and

infra sternal retractions

 And again in most sever forms expiratory wheezing

does not appear until some broncho dilation

DD

GERD Rhino sinusitis co morbid

conditions with asthma

Recurrent aspiration in early

life(tracheo broncho malacia
,TEF , foreign body ,CF ,BPD

VCD in older children and

adolescents

LAB FINDINGS
Pulmonary Function
Testing

Continue….
 Forced expiratory airflow measures helpful

in Diagnosis , assessing efficacy of therapy
and monitoring Asthma in children specially
in poor children who do not have PHE
unless obstruction is sever

 Valueablity of spirometric findings in children>6

yrs

 3 efforts the highest is the peak
 Reduced FEV

obstruction

FEV1/FVC <0.80 means significant

 Improvement in FEV1 following beta 2 agonist > =

12% or 200 ml is consistent with Asthma

 Peak flow meter

CXR

Often normal aside from subtle and

nonspecific findings of hyperinflation

Peribronchial thickening
Helping in diagnosis of Asthma

differentials

Diagnosis of complications of Asthma

exacerbations

Other tests such as allergy skin prick
testing

Treatment
 www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm

Asthma Treatment & Management
has 4 components :
Assessment and monitoring of disease
activity
2. Provision to educate pt and family
3. Identification and management of
precipitating factors and co morbid
conditions
4. Appropriate selection of medication
1.

 Attainment of optimal Asthma control

Component 1
 Asthma severity :intermittent
 Persistent: mild ,mod ,severe
 Only once during patient initial evaluation in pt

who is not using a daily controller agent
 Asthma control degree to which symptoms ,
on going functional impairments , risk of
adverse events minimized and goals of
therapy are met

Continue….
Well controlled
2. Not well controlled
3. Very poor controlled
1.

 NIH guidelines for both severity and

control for 3 age groups

0-4 yrs
2. 5-11 yrs
3. =>12 yrs
1.

Important
even in the absence of frequent symptoms
infants and children whom have risk factors
for asthma and 4 or more episodes of
wheezing over the past yr which lasted more
than 1 day or 2 or more exacerbations in
the last 6 months requiring syst
corticosteroids should be considered in the
persistent group and hence receive long term
controller therapy

Important Tips..
 Regular clinical visits every 2-6 weeks
 Assessment of :

Pt symptoms frequency night and day
2. Need for short acting inhaled b2 agonists for
quick relief
3. Ability to engage in normal activities
4. Air flow measures for>=5 yrs
1.

Continue..
 Component 2 : pt education

 Component 3 : control of factors contributing

to asthma severity
1. Environmental exposures
2. Co morbid conditions
 Component 4 :principals of asthma
pharmacotherapy

Asthma Medication
 SABA

 ICS

 LABA
 LTRA

 SYSTEMIC STEROIDS

 NONSTEROIDAL ANTIINFLAMMATORY

CROMOLYN AND NEDOCROMYL
 OXYGEN
 ANTICHOLINERGIC AGENTS
IPRATROPIUM
BROMIDE
 ANTIIMMUNOGLUBOLINE E

MANAGEMENT OF ASTHMA EXACERBATION(STATUS ASTHMATICUS)
RISK ASSESMENT ON ADMISSION

FOCUSED HISTORY

ONSET OF CURRENT EXACERBATION
FREQUENCY AND severity of daytime and night
time symptoms and activity limitation
Frequency of rescue bronchodilator use
Current medication and allergies
Potential triggers
History of systemic steroid courses, emergency
department visists , hospitalization, intubation or life
threatening episodes

Clinical assesment

Physical examination findings: vital signs,
breathlessness, air movement, use of accessory
respiratory muscles, retractions, anxiety level,
alteration in mental status
Pulse oximetry
Lung function(defer in pts with mod to severe
distress or history of labile disease)

Treatment
Drugs and trade name

Mechanism of action and dosing

Cautions and adverse effects

Oxygen(mask or nasal canula)
Inhaled short acting b2
agonist
Albuterol nebulized
solution(5mg/ml concentrates
Albuterol MDI
Levabuterol

Treats hypoxia
Bronchodilator
Neubolizer 0.15 mg/kg every 20 min for 3
doses as needed,then 0.15_0.3 mg/kg up t 10
mg every 1_4 hour as needed or up to 0.5
mg/kg/hr by continous neubolization
2_8 puf up to every 20 min for 3 doses as
needed then every 1 hr as needed

Monitor pulse oximetry to maintain o2 saturation>92%
Cardiorespiratory monitoring
During exacerbations,frequent or continuous use can cause
pulmonary vasodilatation,v/q mistmatch and hypoxemia
Adverse effect palpitation, tachycardia, arrhythmia, tremor,
hypoxemia
Neubolizer:when giving concentrate forms,dilute with saline to 3
ml total neubolized volume
For MDI use space/holding chamber

Systemic corticosteroids
Prednisolone tb
Methyl prednisolon
Anticholinergics
Ipratropium
Atrovent
Ipratropium with Albuterol

Anti inflammatory
0.5_1 mg/kg every 6-8 hr for 48 hr , then 1-2 mg/kg
day bid(max 60 mg/day)
Short course burst for exacerbation 1-2 mg/kg/day qd
or bid for 3-7 days
Mucolitic/bronchodilator
Neubolizer 0.5 mg q6-8 hr (tid or qid) as needed
MDI 2 paf qid
1 vial by neubolizer qid



If pt has been exposed chickenpox or measles, consider passive
immunoglobulin prophylaxis, also risk of complications with
herspes simplex and TB

For daily dosing , 8 am administration minimizes adrenal
suppression

Children may benefit from dosage tapering if course exceed 7 days

Adverse effect monitoring: frequent therapy bursts risk numerous
corticosteroid adverse effects

Should not be used as first line treatment added to b2 agonist
therapy
Neubolizer may mix Ipratropium with Albuterol

QUICK RELIEF MEDICATION
SABA

Anti cholinergic(ipratropium)
Short term systemic gluco

corticoid

SABA
 Quick relief of asthma symptoms
 Relax airway smooth muscle prompt airflow↑
 Repetitive or continuous SABA is the most effective means







of reversing air flow obstruction
SABA should not be prescribed on a regular schedule
because concerns of possibility of deteriorating asthma
control
Frequent use of SABA is an indication of poor asthma control
Preferred root is inhalation smaller dose , fewer side effects
more rapid on set of action
Ipratropium Bromide as an adjunct to SABA in emergency
room reduces hospital admissions and improves lung function
Systemic Glucocorticoids short oral course + SABA in
moderate to severe asthma exacerbation

LABA
 Salmetrol

 Should be used in combination with inhaled

corticosteroids and not as mono therapy
 Exercise induces asthma in children >= 4 Yrs
one inhalation 30 min prior to exercise
 No additional doses for PTs who are already
receiving it twice daily not recommended by
NIH guidelines

LTRA

 MonteLukast ( singulair)

 Antihistaminic

 Leukotrien receptor antagonist

 Asthma ( not < 12 MO) and allergic rhinitis (





not < 6 MO)
Morning dosing not evaluated
Prophylactic and chronic treatment of asthma
Exercise induced asthma in >= 15 Yrs
Zafir Lukast : prophylactic and chronic
treatment of asthma

ICA
 Most potent anti inflammatory agents available

for the treatment of asthma
 Inhibiting most steps in the cascade of the
inflammatory response
 Benefits reducing bronchial hyper
responsiveness , prevention of late asthmatic
response , enhanced lung function
 Inhaled Glucocorticoids first line controller
therapy for persistent asthma or those who
require step 2

Prognosis
 35%of preschool children experience recurrent

coughing and wheezing,1/3 of them continue to
have persistent asthma into later childhood and
2/3 improvement on their own through their teen
yrs
 Asthma severity by age 7-10 yrs is predictive of
asthma persistence into adulthood
 Children with mod to severe asthma and lower lung
function are likely to have persistent asthma as
adults
 Children with milder asthma and N/R lung function
are likely to improve over time or be periodically
asthmatic

THANK YOU FOR YOUR
ATTENTION


Slide 28

Asthma in Children
DR. A.Mirshokraei
NIOC Hospital Pediatrics Ward

Definition :

DEFINITION

- Chronic inflammatory condition of the
lung airways resulting in episodic airflow
obstruction
- AHR to provocative exposures
Asthma management
• Reducing airway inflammation by: Minimizing
pro inflammatory environmental exposure, using
daily controller anti inflammatory medication,
controlling co morbid conditions that worsen
asthma, less inflammation better asthma
control and fewer exacerbations

Anyway exacerbations

occur

BUT
Even the uncommon
child with sever asthma can
be managed to live normally

 RECURRENT WHEEZING EPISODES WITH COMMON

RESPIRATORY
VIRUSES(RSV,RHINOVIRUS,INFLUENZA,PARAINFLUENZA,A
DENOVIRUS,HUMAN METAPNUMOVIRUS)

 HOST FEATURES AFFECTING IMMUNOLOGIC HOST

DEFENSE,INFLAMMATION/PREVIOUS VIRAL INFECTIONS
MAINIFESTED AS PNUMONIA OR BRONCHIOLITIS
REQUIRING HOSPITALIZATION UNDERLIE THE
RECURRENT WHEEZING IN EARLY CHILDHOOD

 OTHER AIRWAY EXPOSURES SUCH AS INDOOR AND HOME

ALLERGENS,COLD AIR,STRONG ODORS,TOBACCO
SMOKE,ALL INCREASE AHR

 ALLERGEN ELLIMINATION SOMETIMES LEEDS TO CURE

EPIDEMIOLOGY
 Common etiology of emergency visits and school day missing

in childhood ,occasionally hospitalization and rare deaths
specially in poverty ,urban living ,ethnic minorities

 Increasing asthma prevalence worldwide(50% per decade)
 Good correlation of asthma prevalence with allergic rhino

sinusitis and atopic eczema and other allergies

 More prevalence in high level urban modern families than

suburban villagers

 More than 80%of asthmatics reported getting the disease

before 6 year

CLINICS
RECURRENT COUGHING/WHEEZING
PATTERNS IN CHILDHOOD BASED ON
NATURAL HISTORY

TRANSIENT EARLY WHEEZING
 Common in early preschool years

 Recurrent coughing/wheezing primary

triggered by common respiratory viral INF
 Tend to resolve during preschool yrs without
increasing risk of asthma later in life
 Problems due to reduced airflow at birth
suggestive of relative narrow airways improved
by school yrs

Persistent Atopy Associated Asthma
 Begins in early preschool yrs

 Associated with atopy (eg atopic dermatitis in





infancy, allergic rhinitis, food allergy)
Biologic factors e.g.: early inhalant sensitization,
increase serum IGE, increase blood eosinophills,
High risk of persistence into later childhood and
adulthood lung function abnormality
Those with onset<3 yrs
reduced air flow by
school yrs
Those with later onset of symptoms or allergen
sensitizations unlikely persistence lung function
abnormality later

Non-Atopic Wheezing
 Wheezing ,coughing beginning in early life

often with RSV INF resolves later in childhood
without increasing risk of persistence asthma

 Associated with bronchial hyper

responsiveness near birth

Asthma with declining lung function
• Children with asthma with progressive

increase in air flow limitation

• Associated with hyper inflation in childhood
• Male gender

Late onset asthma in females associated with
obesity and early onset puberty
 Onset between 8_13 yrs

 Associated with early onset puberty and obesity
 Specific for females

Occupational type asthma in children
 Children with asthma and occupational type exposure

known to trigger asthma in adults in occupational settings

Types of Asthma
common clinical presentations of intermittent
recurrent wheezing and/or coughing
 Recurrent wheezing in early childhood

 Chronic asthma associated with allergy
 Females 11 yrs with early onset puberty and

obesity

Pathogenesis

 Airflow obstruction resulting from

Broncho constriction of bronchiolar smooth
muscle mass
II. Cellular inflammatory infiltrates and exudates
mostly Eosinophills(also N , M ,L ,mast cells
,basophiles)fill and obstruct airways and damage
epithelium and induce desquamation into airway
lumen mediated by T helper cells and other
immune cells that produce pro allergic pro
inflammatory cytokines(IL4,IL6,IL13)
III. Breach in normal immune regulatory process
I.

RESULT
 Airway inflammation

 AHR
 Edema basement membrane thickness sub

epithelial collagen deposition
 Smooth muscle and mucus gland hypertrophy
and mucus hyper secretion

Air obstruction

Clinical manifestations and diagnosis
 Most common intermittent dry cough and

expiratory wheezing

 Shortness of breath and chest tightness in older

children and adults

 Intermittent non focal chest pain in younger

children

 Worsening of respiratory symptoms at night
 Worsening of day time symptoms by activity

Continue…..
 Subtle symptoms such as self limitation of activities

,general fatigue ,difficulty in keeping up with peers

 Relief with aerosolized bronchodilators
 Lack of improvement with bronchodilators and steroid

is inconsistent with Asthma and should consider
Asthma masquerading conditions!!!!

 Hyper ventilation, intercostal retractions ,nasal flaring

,respiratory accessory muscle use

 Its common not to hear the expiratory wheezing when

Air flow is so limited before treatment

Asthma Triggers
 Common viral infections of the respiratory tract
 Aero allergens in sensitized asthmatics ,animal dander ,dust











mite ,molds ,indoor allergens ,cockroaches
Seasonal aero allergens ,pollens(trees ,grasses ,weeds ,)
Environmental tobacco smoke
Air pollutants ,ozone ,so2,wood or coal smoke ,endotoxin
,mycotoxin ,dust
Strong or noxious odors or fumes ,perfume ,hair spray
,cleaning agents
Occupational exposure
Cold air ,dry air
Exercise
Crying ,laughter ,hyperventilation
Co morbid conditions Rhinitis ,Sinusitis ,GER

Clinics
History:
Triggering symptoms by laughter
,cold air ,airway irritants
Exposures that induce airway
irritation such as viral URTI
Mycoplasma ,Chlamydia
Inhaled allergens
All lead to AHR

Presence Of Risk Factors:
 History of other allergies ,allergic Rhinitis,

allergic Conjunctivitis ,atopic Dermatitis ,food
allergies

 Parental Asthma
 Symptoms apart from cold

Continue…..
 No or minimal signs in routine visits

 Dry or persistent cough

 Normal chest findings unless wheezing when asking

to breath deeper
 Quick relief (10 MIN) after SABA use
 Expiratory wheezing ,prolonged expiratory phase
,decreased sounds in RT lower pos lobe due to
regional hypoventilation owing to airway
obstruction
 Rales , ronchi ,crackles due to hyper secretion
 Segmental crackles and poor breath sounds
atelectasis?

Continue….
 Labored respiration ,respiratory distress increased

prolongation of expiration and wheezing in E and I

 Poor air entry
 Inter costal retractions ,nasal flaring ,supra and

infra sternal retractions

 And again in most sever forms expiratory wheezing

does not appear until some broncho dilation

DD

GERD Rhino sinusitis co morbid

conditions with asthma

Recurrent aspiration in early

life(tracheo broncho malacia
,TEF , foreign body ,CF ,BPD

VCD in older children and

adolescents

LAB FINDINGS
Pulmonary Function
Testing

Continue….
 Forced expiratory airflow measures helpful

in Diagnosis , assessing efficacy of therapy
and monitoring Asthma in children specially
in poor children who do not have PHE
unless obstruction is sever

 Valueablity of spirometric findings in children>6

yrs

 3 efforts the highest is the peak
 Reduced FEV

obstruction

FEV1/FVC <0.80 means significant

 Improvement in FEV1 following beta 2 agonist > =

12% or 200 ml is consistent with Asthma

 Peak flow meter

CXR

Often normal aside from subtle and

nonspecific findings of hyperinflation

Peribronchial thickening
Helping in diagnosis of Asthma

differentials

Diagnosis of complications of Asthma

exacerbations

Other tests such as allergy skin prick
testing

Treatment
 www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm

Asthma Treatment & Management
has 4 components :
Assessment and monitoring of disease
activity
2. Provision to educate pt and family
3. Identification and management of
precipitating factors and co morbid
conditions
4. Appropriate selection of medication
1.

 Attainment of optimal Asthma control

Component 1
 Asthma severity :intermittent
 Persistent: mild ,mod ,severe
 Only once during patient initial evaluation in pt

who is not using a daily controller agent
 Asthma control degree to which symptoms ,
on going functional impairments , risk of
adverse events minimized and goals of
therapy are met

Continue….
Well controlled
2. Not well controlled
3. Very poor controlled
1.

 NIH guidelines for both severity and

control for 3 age groups

0-4 yrs
2. 5-11 yrs
3. =>12 yrs
1.

Important
even in the absence of frequent symptoms
infants and children whom have risk factors
for asthma and 4 or more episodes of
wheezing over the past yr which lasted more
than 1 day or 2 or more exacerbations in
the last 6 months requiring syst
corticosteroids should be considered in the
persistent group and hence receive long term
controller therapy

Important Tips..
 Regular clinical visits every 2-6 weeks
 Assessment of :

Pt symptoms frequency night and day
2. Need for short acting inhaled b2 agonists for
quick relief
3. Ability to engage in normal activities
4. Air flow measures for>=5 yrs
1.

Continue..
 Component 2 : pt education

 Component 3 : control of factors contributing

to asthma severity
1. Environmental exposures
2. Co morbid conditions
 Component 4 :principals of asthma
pharmacotherapy

Asthma Medication
 SABA

 ICS

 LABA
 LTRA

 SYSTEMIC STEROIDS

 NONSTEROIDAL ANTIINFLAMMATORY

CROMOLYN AND NEDOCROMYL
 OXYGEN
 ANTICHOLINERGIC AGENTS
IPRATROPIUM
BROMIDE
 ANTIIMMUNOGLUBOLINE E

MANAGEMENT OF ASTHMA EXACERBATION(STATUS ASTHMATICUS)
RISK ASSESMENT ON ADMISSION

FOCUSED HISTORY

ONSET OF CURRENT EXACERBATION
FREQUENCY AND severity of daytime and night
time symptoms and activity limitation
Frequency of rescue bronchodilator use
Current medication and allergies
Potential triggers
History of systemic steroid courses, emergency
department visists , hospitalization, intubation or life
threatening episodes

Clinical assesment

Physical examination findings: vital signs,
breathlessness, air movement, use of accessory
respiratory muscles, retractions, anxiety level,
alteration in mental status
Pulse oximetry
Lung function(defer in pts with mod to severe
distress or history of labile disease)

Treatment
Drugs and trade name

Mechanism of action and dosing

Cautions and adverse effects

Oxygen(mask or nasal canula)
Inhaled short acting b2
agonist
Albuterol nebulized
solution(5mg/ml concentrates
Albuterol MDI
Levabuterol

Treats hypoxia
Bronchodilator
Neubolizer 0.15 mg/kg every 20 min for 3
doses as needed,then 0.15_0.3 mg/kg up t 10
mg every 1_4 hour as needed or up to 0.5
mg/kg/hr by continous neubolization
2_8 puf up to every 20 min for 3 doses as
needed then every 1 hr as needed

Monitor pulse oximetry to maintain o2 saturation>92%
Cardiorespiratory monitoring
During exacerbations,frequent or continuous use can cause
pulmonary vasodilatation,v/q mistmatch and hypoxemia
Adverse effect palpitation, tachycardia, arrhythmia, tremor,
hypoxemia
Neubolizer:when giving concentrate forms,dilute with saline to 3
ml total neubolized volume
For MDI use space/holding chamber

Systemic corticosteroids
Prednisolone tb
Methyl prednisolon
Anticholinergics
Ipratropium
Atrovent
Ipratropium with Albuterol

Anti inflammatory
0.5_1 mg/kg every 6-8 hr for 48 hr , then 1-2 mg/kg
day bid(max 60 mg/day)
Short course burst for exacerbation 1-2 mg/kg/day qd
or bid for 3-7 days
Mucolitic/bronchodilator
Neubolizer 0.5 mg q6-8 hr (tid or qid) as needed
MDI 2 paf qid
1 vial by neubolizer qid



If pt has been exposed chickenpox or measles, consider passive
immunoglobulin prophylaxis, also risk of complications with
herspes simplex and TB

For daily dosing , 8 am administration minimizes adrenal
suppression

Children may benefit from dosage tapering if course exceed 7 days

Adverse effect monitoring: frequent therapy bursts risk numerous
corticosteroid adverse effects

Should not be used as first line treatment added to b2 agonist
therapy
Neubolizer may mix Ipratropium with Albuterol

QUICK RELIEF MEDICATION
SABA

Anti cholinergic(ipratropium)
Short term systemic gluco

corticoid

SABA
 Quick relief of asthma symptoms
 Relax airway smooth muscle prompt airflow↑
 Repetitive or continuous SABA is the most effective means







of reversing air flow obstruction
SABA should not be prescribed on a regular schedule
because concerns of possibility of deteriorating asthma
control
Frequent use of SABA is an indication of poor asthma control
Preferred root is inhalation smaller dose , fewer side effects
more rapid on set of action
Ipratropium Bromide as an adjunct to SABA in emergency
room reduces hospital admissions and improves lung function
Systemic Glucocorticoids short oral course + SABA in
moderate to severe asthma exacerbation

LABA
 Salmetrol

 Should be used in combination with inhaled

corticosteroids and not as mono therapy
 Exercise induces asthma in children >= 4 Yrs
one inhalation 30 min prior to exercise
 No additional doses for PTs who are already
receiving it twice daily not recommended by
NIH guidelines

LTRA

 MonteLukast ( singulair)

 Antihistaminic

 Leukotrien receptor antagonist

 Asthma ( not < 12 MO) and allergic rhinitis (





not < 6 MO)
Morning dosing not evaluated
Prophylactic and chronic treatment of asthma
Exercise induced asthma in >= 15 Yrs
Zafir Lukast : prophylactic and chronic
treatment of asthma

ICA
 Most potent anti inflammatory agents available

for the treatment of asthma
 Inhibiting most steps in the cascade of the
inflammatory response
 Benefits reducing bronchial hyper
responsiveness , prevention of late asthmatic
response , enhanced lung function
 Inhaled Glucocorticoids first line controller
therapy for persistent asthma or those who
require step 2

Prognosis
 35%of preschool children experience recurrent

coughing and wheezing,1/3 of them continue to
have persistent asthma into later childhood and
2/3 improvement on their own through their teen
yrs
 Asthma severity by age 7-10 yrs is predictive of
asthma persistence into adulthood
 Children with mod to severe asthma and lower lung
function are likely to have persistent asthma as
adults
 Children with milder asthma and N/R lung function
are likely to improve over time or be periodically
asthmatic

THANK YOU FOR YOUR
ATTENTION


Slide 29

Asthma in Children
DR. A.Mirshokraei
NIOC Hospital Pediatrics Ward

Definition :

DEFINITION

- Chronic inflammatory condition of the
lung airways resulting in episodic airflow
obstruction
- AHR to provocative exposures
Asthma management
• Reducing airway inflammation by: Minimizing
pro inflammatory environmental exposure, using
daily controller anti inflammatory medication,
controlling co morbid conditions that worsen
asthma, less inflammation better asthma
control and fewer exacerbations

Anyway exacerbations

occur

BUT
Even the uncommon
child with sever asthma can
be managed to live normally

 RECURRENT WHEEZING EPISODES WITH COMMON

RESPIRATORY
VIRUSES(RSV,RHINOVIRUS,INFLUENZA,PARAINFLUENZA,A
DENOVIRUS,HUMAN METAPNUMOVIRUS)

 HOST FEATURES AFFECTING IMMUNOLOGIC HOST

DEFENSE,INFLAMMATION/PREVIOUS VIRAL INFECTIONS
MAINIFESTED AS PNUMONIA OR BRONCHIOLITIS
REQUIRING HOSPITALIZATION UNDERLIE THE
RECURRENT WHEEZING IN EARLY CHILDHOOD

 OTHER AIRWAY EXPOSURES SUCH AS INDOOR AND HOME

ALLERGENS,COLD AIR,STRONG ODORS,TOBACCO
SMOKE,ALL INCREASE AHR

 ALLERGEN ELLIMINATION SOMETIMES LEEDS TO CURE

EPIDEMIOLOGY
 Common etiology of emergency visits and school day missing

in childhood ,occasionally hospitalization and rare deaths
specially in poverty ,urban living ,ethnic minorities

 Increasing asthma prevalence worldwide(50% per decade)
 Good correlation of asthma prevalence with allergic rhino

sinusitis and atopic eczema and other allergies

 More prevalence in high level urban modern families than

suburban villagers

 More than 80%of asthmatics reported getting the disease

before 6 year

CLINICS
RECURRENT COUGHING/WHEEZING
PATTERNS IN CHILDHOOD BASED ON
NATURAL HISTORY

TRANSIENT EARLY WHEEZING
 Common in early preschool years

 Recurrent coughing/wheezing primary

triggered by common respiratory viral INF
 Tend to resolve during preschool yrs without
increasing risk of asthma later in life
 Problems due to reduced airflow at birth
suggestive of relative narrow airways improved
by school yrs

Persistent Atopy Associated Asthma
 Begins in early preschool yrs

 Associated with atopy (eg atopic dermatitis in





infancy, allergic rhinitis, food allergy)
Biologic factors e.g.: early inhalant sensitization,
increase serum IGE, increase blood eosinophills,
High risk of persistence into later childhood and
adulthood lung function abnormality
Those with onset<3 yrs
reduced air flow by
school yrs
Those with later onset of symptoms or allergen
sensitizations unlikely persistence lung function
abnormality later

Non-Atopic Wheezing
 Wheezing ,coughing beginning in early life

often with RSV INF resolves later in childhood
without increasing risk of persistence asthma

 Associated with bronchial hyper

responsiveness near birth

Asthma with declining lung function
• Children with asthma with progressive

increase in air flow limitation

• Associated with hyper inflation in childhood
• Male gender

Late onset asthma in females associated with
obesity and early onset puberty
 Onset between 8_13 yrs

 Associated with early onset puberty and obesity
 Specific for females

Occupational type asthma in children
 Children with asthma and occupational type exposure

known to trigger asthma in adults in occupational settings

Types of Asthma
common clinical presentations of intermittent
recurrent wheezing and/or coughing
 Recurrent wheezing in early childhood

 Chronic asthma associated with allergy
 Females 11 yrs with early onset puberty and

obesity

Pathogenesis

 Airflow obstruction resulting from

Broncho constriction of bronchiolar smooth
muscle mass
II. Cellular inflammatory infiltrates and exudates
mostly Eosinophills(also N , M ,L ,mast cells
,basophiles)fill and obstruct airways and damage
epithelium and induce desquamation into airway
lumen mediated by T helper cells and other
immune cells that produce pro allergic pro
inflammatory cytokines(IL4,IL6,IL13)
III. Breach in normal immune regulatory process
I.

RESULT
 Airway inflammation

 AHR
 Edema basement membrane thickness sub

epithelial collagen deposition
 Smooth muscle and mucus gland hypertrophy
and mucus hyper secretion

Air obstruction

Clinical manifestations and diagnosis
 Most common intermittent dry cough and

expiratory wheezing

 Shortness of breath and chest tightness in older

children and adults

 Intermittent non focal chest pain in younger

children

 Worsening of respiratory symptoms at night
 Worsening of day time symptoms by activity

Continue…..
 Subtle symptoms such as self limitation of activities

,general fatigue ,difficulty in keeping up with peers

 Relief with aerosolized bronchodilators
 Lack of improvement with bronchodilators and steroid

is inconsistent with Asthma and should consider
Asthma masquerading conditions!!!!

 Hyper ventilation, intercostal retractions ,nasal flaring

,respiratory accessory muscle use

 Its common not to hear the expiratory wheezing when

Air flow is so limited before treatment

Asthma Triggers
 Common viral infections of the respiratory tract
 Aero allergens in sensitized asthmatics ,animal dander ,dust











mite ,molds ,indoor allergens ,cockroaches
Seasonal aero allergens ,pollens(trees ,grasses ,weeds ,)
Environmental tobacco smoke
Air pollutants ,ozone ,so2,wood or coal smoke ,endotoxin
,mycotoxin ,dust
Strong or noxious odors or fumes ,perfume ,hair spray
,cleaning agents
Occupational exposure
Cold air ,dry air
Exercise
Crying ,laughter ,hyperventilation
Co morbid conditions Rhinitis ,Sinusitis ,GER

Clinics
History:
Triggering symptoms by laughter
,cold air ,airway irritants
Exposures that induce airway
irritation such as viral URTI
Mycoplasma ,Chlamydia
Inhaled allergens
All lead to AHR

Presence Of Risk Factors:
 History of other allergies ,allergic Rhinitis,

allergic Conjunctivitis ,atopic Dermatitis ,food
allergies

 Parental Asthma
 Symptoms apart from cold

Continue…..
 No or minimal signs in routine visits

 Dry or persistent cough

 Normal chest findings unless wheezing when asking

to breath deeper
 Quick relief (10 MIN) after SABA use
 Expiratory wheezing ,prolonged expiratory phase
,decreased sounds in RT lower pos lobe due to
regional hypoventilation owing to airway
obstruction
 Rales , ronchi ,crackles due to hyper secretion
 Segmental crackles and poor breath sounds
atelectasis?

Continue….
 Labored respiration ,respiratory distress increased

prolongation of expiration and wheezing in E and I

 Poor air entry
 Inter costal retractions ,nasal flaring ,supra and

infra sternal retractions

 And again in most sever forms expiratory wheezing

does not appear until some broncho dilation

DD

GERD Rhino sinusitis co morbid

conditions with asthma

Recurrent aspiration in early

life(tracheo broncho malacia
,TEF , foreign body ,CF ,BPD

VCD in older children and

adolescents

LAB FINDINGS
Pulmonary Function
Testing

Continue….
 Forced expiratory airflow measures helpful

in Diagnosis , assessing efficacy of therapy
and monitoring Asthma in children specially
in poor children who do not have PHE
unless obstruction is sever

 Valueablity of spirometric findings in children>6

yrs

 3 efforts the highest is the peak
 Reduced FEV

obstruction

FEV1/FVC <0.80 means significant

 Improvement in FEV1 following beta 2 agonist > =

12% or 200 ml is consistent with Asthma

 Peak flow meter

CXR

Often normal aside from subtle and

nonspecific findings of hyperinflation

Peribronchial thickening
Helping in diagnosis of Asthma

differentials

Diagnosis of complications of Asthma

exacerbations

Other tests such as allergy skin prick
testing

Treatment
 www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm

Asthma Treatment & Management
has 4 components :
Assessment and monitoring of disease
activity
2. Provision to educate pt and family
3. Identification and management of
precipitating factors and co morbid
conditions
4. Appropriate selection of medication
1.

 Attainment of optimal Asthma control

Component 1
 Asthma severity :intermittent
 Persistent: mild ,mod ,severe
 Only once during patient initial evaluation in pt

who is not using a daily controller agent
 Asthma control degree to which symptoms ,
on going functional impairments , risk of
adverse events minimized and goals of
therapy are met

Continue….
Well controlled
2. Not well controlled
3. Very poor controlled
1.

 NIH guidelines for both severity and

control for 3 age groups

0-4 yrs
2. 5-11 yrs
3. =>12 yrs
1.

Important
even in the absence of frequent symptoms
infants and children whom have risk factors
for asthma and 4 or more episodes of
wheezing over the past yr which lasted more
than 1 day or 2 or more exacerbations in
the last 6 months requiring syst
corticosteroids should be considered in the
persistent group and hence receive long term
controller therapy

Important Tips..
 Regular clinical visits every 2-6 weeks
 Assessment of :

Pt symptoms frequency night and day
2. Need for short acting inhaled b2 agonists for
quick relief
3. Ability to engage in normal activities
4. Air flow measures for>=5 yrs
1.

Continue..
 Component 2 : pt education

 Component 3 : control of factors contributing

to asthma severity
1. Environmental exposures
2. Co morbid conditions
 Component 4 :principals of asthma
pharmacotherapy

Asthma Medication
 SABA

 ICS

 LABA
 LTRA

 SYSTEMIC STEROIDS

 NONSTEROIDAL ANTIINFLAMMATORY

CROMOLYN AND NEDOCROMYL
 OXYGEN
 ANTICHOLINERGIC AGENTS
IPRATROPIUM
BROMIDE
 ANTIIMMUNOGLUBOLINE E

MANAGEMENT OF ASTHMA EXACERBATION(STATUS ASTHMATICUS)
RISK ASSESMENT ON ADMISSION

FOCUSED HISTORY

ONSET OF CURRENT EXACERBATION
FREQUENCY AND severity of daytime and night
time symptoms and activity limitation
Frequency of rescue bronchodilator use
Current medication and allergies
Potential triggers
History of systemic steroid courses, emergency
department visists , hospitalization, intubation or life
threatening episodes

Clinical assesment

Physical examination findings: vital signs,
breathlessness, air movement, use of accessory
respiratory muscles, retractions, anxiety level,
alteration in mental status
Pulse oximetry
Lung function(defer in pts with mod to severe
distress or history of labile disease)

Treatment
Drugs and trade name

Mechanism of action and dosing

Cautions and adverse effects

Oxygen(mask or nasal canula)
Inhaled short acting b2
agonist
Albuterol nebulized
solution(5mg/ml concentrates
Albuterol MDI
Levabuterol

Treats hypoxia
Bronchodilator
Neubolizer 0.15 mg/kg every 20 min for 3
doses as needed,then 0.15_0.3 mg/kg up t 10
mg every 1_4 hour as needed or up to 0.5
mg/kg/hr by continous neubolization
2_8 puf up to every 20 min for 3 doses as
needed then every 1 hr as needed

Monitor pulse oximetry to maintain o2 saturation>92%
Cardiorespiratory monitoring
During exacerbations,frequent or continuous use can cause
pulmonary vasodilatation,v/q mistmatch and hypoxemia
Adverse effect palpitation, tachycardia, arrhythmia, tremor,
hypoxemia
Neubolizer:when giving concentrate forms,dilute with saline to 3
ml total neubolized volume
For MDI use space/holding chamber

Systemic corticosteroids
Prednisolone tb
Methyl prednisolon
Anticholinergics
Ipratropium
Atrovent
Ipratropium with Albuterol

Anti inflammatory
0.5_1 mg/kg every 6-8 hr for 48 hr , then 1-2 mg/kg
day bid(max 60 mg/day)
Short course burst for exacerbation 1-2 mg/kg/day qd
or bid for 3-7 days
Mucolitic/bronchodilator
Neubolizer 0.5 mg q6-8 hr (tid or qid) as needed
MDI 2 paf qid
1 vial by neubolizer qid



If pt has been exposed chickenpox or measles, consider passive
immunoglobulin prophylaxis, also risk of complications with
herspes simplex and TB

For daily dosing , 8 am administration minimizes adrenal
suppression

Children may benefit from dosage tapering if course exceed 7 days

Adverse effect monitoring: frequent therapy bursts risk numerous
corticosteroid adverse effects

Should not be used as first line treatment added to b2 agonist
therapy
Neubolizer may mix Ipratropium with Albuterol

QUICK RELIEF MEDICATION
SABA

Anti cholinergic(ipratropium)
Short term systemic gluco

corticoid

SABA
 Quick relief of asthma symptoms
 Relax airway smooth muscle prompt airflow↑
 Repetitive or continuous SABA is the most effective means







of reversing air flow obstruction
SABA should not be prescribed on a regular schedule
because concerns of possibility of deteriorating asthma
control
Frequent use of SABA is an indication of poor asthma control
Preferred root is inhalation smaller dose , fewer side effects
more rapid on set of action
Ipratropium Bromide as an adjunct to SABA in emergency
room reduces hospital admissions and improves lung function
Systemic Glucocorticoids short oral course + SABA in
moderate to severe asthma exacerbation

LABA
 Salmetrol

 Should be used in combination with inhaled

corticosteroids and not as mono therapy
 Exercise induces asthma in children >= 4 Yrs
one inhalation 30 min prior to exercise
 No additional doses for PTs who are already
receiving it twice daily not recommended by
NIH guidelines

LTRA

 MonteLukast ( singulair)

 Antihistaminic

 Leukotrien receptor antagonist

 Asthma ( not < 12 MO) and allergic rhinitis (





not < 6 MO)
Morning dosing not evaluated
Prophylactic and chronic treatment of asthma
Exercise induced asthma in >= 15 Yrs
Zafir Lukast : prophylactic and chronic
treatment of asthma

ICA
 Most potent anti inflammatory agents available

for the treatment of asthma
 Inhibiting most steps in the cascade of the
inflammatory response
 Benefits reducing bronchial hyper
responsiveness , prevention of late asthmatic
response , enhanced lung function
 Inhaled Glucocorticoids first line controller
therapy for persistent asthma or those who
require step 2

Prognosis
 35%of preschool children experience recurrent

coughing and wheezing,1/3 of them continue to
have persistent asthma into later childhood and
2/3 improvement on their own through their teen
yrs
 Asthma severity by age 7-10 yrs is predictive of
asthma persistence into adulthood
 Children with mod to severe asthma and lower lung
function are likely to have persistent asthma as
adults
 Children with milder asthma and N/R lung function
are likely to improve over time or be periodically
asthmatic

THANK YOU FOR YOUR
ATTENTION


Slide 30

Asthma in Children
DR. A.Mirshokraei
NIOC Hospital Pediatrics Ward

Definition :

DEFINITION

- Chronic inflammatory condition of the
lung airways resulting in episodic airflow
obstruction
- AHR to provocative exposures
Asthma management
• Reducing airway inflammation by: Minimizing
pro inflammatory environmental exposure, using
daily controller anti inflammatory medication,
controlling co morbid conditions that worsen
asthma, less inflammation better asthma
control and fewer exacerbations

Anyway exacerbations

occur

BUT
Even the uncommon
child with sever asthma can
be managed to live normally

 RECURRENT WHEEZING EPISODES WITH COMMON

RESPIRATORY
VIRUSES(RSV,RHINOVIRUS,INFLUENZA,PARAINFLUENZA,A
DENOVIRUS,HUMAN METAPNUMOVIRUS)

 HOST FEATURES AFFECTING IMMUNOLOGIC HOST

DEFENSE,INFLAMMATION/PREVIOUS VIRAL INFECTIONS
MAINIFESTED AS PNUMONIA OR BRONCHIOLITIS
REQUIRING HOSPITALIZATION UNDERLIE THE
RECURRENT WHEEZING IN EARLY CHILDHOOD

 OTHER AIRWAY EXPOSURES SUCH AS INDOOR AND HOME

ALLERGENS,COLD AIR,STRONG ODORS,TOBACCO
SMOKE,ALL INCREASE AHR

 ALLERGEN ELLIMINATION SOMETIMES LEEDS TO CURE

EPIDEMIOLOGY
 Common etiology of emergency visits and school day missing

in childhood ,occasionally hospitalization and rare deaths
specially in poverty ,urban living ,ethnic minorities

 Increasing asthma prevalence worldwide(50% per decade)
 Good correlation of asthma prevalence with allergic rhino

sinusitis and atopic eczema and other allergies

 More prevalence in high level urban modern families than

suburban villagers

 More than 80%of asthmatics reported getting the disease

before 6 year

CLINICS
RECURRENT COUGHING/WHEEZING
PATTERNS IN CHILDHOOD BASED ON
NATURAL HISTORY

TRANSIENT EARLY WHEEZING
 Common in early preschool years

 Recurrent coughing/wheezing primary

triggered by common respiratory viral INF
 Tend to resolve during preschool yrs without
increasing risk of asthma later in life
 Problems due to reduced airflow at birth
suggestive of relative narrow airways improved
by school yrs

Persistent Atopy Associated Asthma
 Begins in early preschool yrs

 Associated with atopy (eg atopic dermatitis in





infancy, allergic rhinitis, food allergy)
Biologic factors e.g.: early inhalant sensitization,
increase serum IGE, increase blood eosinophills,
High risk of persistence into later childhood and
adulthood lung function abnormality
Those with onset<3 yrs
reduced air flow by
school yrs
Those with later onset of symptoms or allergen
sensitizations unlikely persistence lung function
abnormality later

Non-Atopic Wheezing
 Wheezing ,coughing beginning in early life

often with RSV INF resolves later in childhood
without increasing risk of persistence asthma

 Associated with bronchial hyper

responsiveness near birth

Asthma with declining lung function
• Children with asthma with progressive

increase in air flow limitation

• Associated with hyper inflation in childhood
• Male gender

Late onset asthma in females associated with
obesity and early onset puberty
 Onset between 8_13 yrs

 Associated with early onset puberty and obesity
 Specific for females

Occupational type asthma in children
 Children with asthma and occupational type exposure

known to trigger asthma in adults in occupational settings

Types of Asthma
common clinical presentations of intermittent
recurrent wheezing and/or coughing
 Recurrent wheezing in early childhood

 Chronic asthma associated with allergy
 Females 11 yrs with early onset puberty and

obesity

Pathogenesis

 Airflow obstruction resulting from

Broncho constriction of bronchiolar smooth
muscle mass
II. Cellular inflammatory infiltrates and exudates
mostly Eosinophills(also N , M ,L ,mast cells
,basophiles)fill and obstruct airways and damage
epithelium and induce desquamation into airway
lumen mediated by T helper cells and other
immune cells that produce pro allergic pro
inflammatory cytokines(IL4,IL6,IL13)
III. Breach in normal immune regulatory process
I.

RESULT
 Airway inflammation

 AHR
 Edema basement membrane thickness sub

epithelial collagen deposition
 Smooth muscle and mucus gland hypertrophy
and mucus hyper secretion

Air obstruction

Clinical manifestations and diagnosis
 Most common intermittent dry cough and

expiratory wheezing

 Shortness of breath and chest tightness in older

children and adults

 Intermittent non focal chest pain in younger

children

 Worsening of respiratory symptoms at night
 Worsening of day time symptoms by activity

Continue…..
 Subtle symptoms such as self limitation of activities

,general fatigue ,difficulty in keeping up with peers

 Relief with aerosolized bronchodilators
 Lack of improvement with bronchodilators and steroid

is inconsistent with Asthma and should consider
Asthma masquerading conditions!!!!

 Hyper ventilation, intercostal retractions ,nasal flaring

,respiratory accessory muscle use

 Its common not to hear the expiratory wheezing when

Air flow is so limited before treatment

Asthma Triggers
 Common viral infections of the respiratory tract
 Aero allergens in sensitized asthmatics ,animal dander ,dust











mite ,molds ,indoor allergens ,cockroaches
Seasonal aero allergens ,pollens(trees ,grasses ,weeds ,)
Environmental tobacco smoke
Air pollutants ,ozone ,so2,wood or coal smoke ,endotoxin
,mycotoxin ,dust
Strong or noxious odors or fumes ,perfume ,hair spray
,cleaning agents
Occupational exposure
Cold air ,dry air
Exercise
Crying ,laughter ,hyperventilation
Co morbid conditions Rhinitis ,Sinusitis ,GER

Clinics
History:
Triggering symptoms by laughter
,cold air ,airway irritants
Exposures that induce airway
irritation such as viral URTI
Mycoplasma ,Chlamydia
Inhaled allergens
All lead to AHR

Presence Of Risk Factors:
 History of other allergies ,allergic Rhinitis,

allergic Conjunctivitis ,atopic Dermatitis ,food
allergies

 Parental Asthma
 Symptoms apart from cold

Continue…..
 No or minimal signs in routine visits

 Dry or persistent cough

 Normal chest findings unless wheezing when asking

to breath deeper
 Quick relief (10 MIN) after SABA use
 Expiratory wheezing ,prolonged expiratory phase
,decreased sounds in RT lower pos lobe due to
regional hypoventilation owing to airway
obstruction
 Rales , ronchi ,crackles due to hyper secretion
 Segmental crackles and poor breath sounds
atelectasis?

Continue….
 Labored respiration ,respiratory distress increased

prolongation of expiration and wheezing in E and I

 Poor air entry
 Inter costal retractions ,nasal flaring ,supra and

infra sternal retractions

 And again in most sever forms expiratory wheezing

does not appear until some broncho dilation

DD

GERD Rhino sinusitis co morbid

conditions with asthma

Recurrent aspiration in early

life(tracheo broncho malacia
,TEF , foreign body ,CF ,BPD

VCD in older children and

adolescents

LAB FINDINGS
Pulmonary Function
Testing

Continue….
 Forced expiratory airflow measures helpful

in Diagnosis , assessing efficacy of therapy
and monitoring Asthma in children specially
in poor children who do not have PHE
unless obstruction is sever

 Valueablity of spirometric findings in children>6

yrs

 3 efforts the highest is the peak
 Reduced FEV

obstruction

FEV1/FVC <0.80 means significant

 Improvement in FEV1 following beta 2 agonist > =

12% or 200 ml is consistent with Asthma

 Peak flow meter

CXR

Often normal aside from subtle and

nonspecific findings of hyperinflation

Peribronchial thickening
Helping in diagnosis of Asthma

differentials

Diagnosis of complications of Asthma

exacerbations

Other tests such as allergy skin prick
testing

Treatment
 www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm

Asthma Treatment & Management
has 4 components :
Assessment and monitoring of disease
activity
2. Provision to educate pt and family
3. Identification and management of
precipitating factors and co morbid
conditions
4. Appropriate selection of medication
1.

 Attainment of optimal Asthma control

Component 1
 Asthma severity :intermittent
 Persistent: mild ,mod ,severe
 Only once during patient initial evaluation in pt

who is not using a daily controller agent
 Asthma control degree to which symptoms ,
on going functional impairments , risk of
adverse events minimized and goals of
therapy are met

Continue….
Well controlled
2. Not well controlled
3. Very poor controlled
1.

 NIH guidelines for both severity and

control for 3 age groups

0-4 yrs
2. 5-11 yrs
3. =>12 yrs
1.

Important
even in the absence of frequent symptoms
infants and children whom have risk factors
for asthma and 4 or more episodes of
wheezing over the past yr which lasted more
than 1 day or 2 or more exacerbations in
the last 6 months requiring syst
corticosteroids should be considered in the
persistent group and hence receive long term
controller therapy

Important Tips..
 Regular clinical visits every 2-6 weeks
 Assessment of :

Pt symptoms frequency night and day
2. Need for short acting inhaled b2 agonists for
quick relief
3. Ability to engage in normal activities
4. Air flow measures for>=5 yrs
1.

Continue..
 Component 2 : pt education

 Component 3 : control of factors contributing

to asthma severity
1. Environmental exposures
2. Co morbid conditions
 Component 4 :principals of asthma
pharmacotherapy

Asthma Medication
 SABA

 ICS

 LABA
 LTRA

 SYSTEMIC STEROIDS

 NONSTEROIDAL ANTIINFLAMMATORY

CROMOLYN AND NEDOCROMYL
 OXYGEN
 ANTICHOLINERGIC AGENTS
IPRATROPIUM
BROMIDE
 ANTIIMMUNOGLUBOLINE E

MANAGEMENT OF ASTHMA EXACERBATION(STATUS ASTHMATICUS)
RISK ASSESMENT ON ADMISSION

FOCUSED HISTORY

ONSET OF CURRENT EXACERBATION
FREQUENCY AND severity of daytime and night
time symptoms and activity limitation
Frequency of rescue bronchodilator use
Current medication and allergies
Potential triggers
History of systemic steroid courses, emergency
department visists , hospitalization, intubation or life
threatening episodes

Clinical assesment

Physical examination findings: vital signs,
breathlessness, air movement, use of accessory
respiratory muscles, retractions, anxiety level,
alteration in mental status
Pulse oximetry
Lung function(defer in pts with mod to severe
distress or history of labile disease)

Treatment
Drugs and trade name

Mechanism of action and dosing

Cautions and adverse effects

Oxygen(mask or nasal canula)
Inhaled short acting b2
agonist
Albuterol nebulized
solution(5mg/ml concentrates
Albuterol MDI
Levabuterol

Treats hypoxia
Bronchodilator
Neubolizer 0.15 mg/kg every 20 min for 3
doses as needed,then 0.15_0.3 mg/kg up t 10
mg every 1_4 hour as needed or up to 0.5
mg/kg/hr by continous neubolization
2_8 puf up to every 20 min for 3 doses as
needed then every 1 hr as needed

Monitor pulse oximetry to maintain o2 saturation>92%
Cardiorespiratory monitoring
During exacerbations,frequent or continuous use can cause
pulmonary vasodilatation,v/q mistmatch and hypoxemia
Adverse effect palpitation, tachycardia, arrhythmia, tremor,
hypoxemia
Neubolizer:when giving concentrate forms,dilute with saline to 3
ml total neubolized volume
For MDI use space/holding chamber

Systemic corticosteroids
Prednisolone tb
Methyl prednisolon
Anticholinergics
Ipratropium
Atrovent
Ipratropium with Albuterol

Anti inflammatory
0.5_1 mg/kg every 6-8 hr for 48 hr , then 1-2 mg/kg
day bid(max 60 mg/day)
Short course burst for exacerbation 1-2 mg/kg/day qd
or bid for 3-7 days
Mucolitic/bronchodilator
Neubolizer 0.5 mg q6-8 hr (tid or qid) as needed
MDI 2 paf qid
1 vial by neubolizer qid



If pt has been exposed chickenpox or measles, consider passive
immunoglobulin prophylaxis, also risk of complications with
herspes simplex and TB

For daily dosing , 8 am administration minimizes adrenal
suppression

Children may benefit from dosage tapering if course exceed 7 days

Adverse effect monitoring: frequent therapy bursts risk numerous
corticosteroid adverse effects

Should not be used as first line treatment added to b2 agonist
therapy
Neubolizer may mix Ipratropium with Albuterol

QUICK RELIEF MEDICATION
SABA

Anti cholinergic(ipratropium)
Short term systemic gluco

corticoid

SABA
 Quick relief of asthma symptoms
 Relax airway smooth muscle prompt airflow↑
 Repetitive or continuous SABA is the most effective means







of reversing air flow obstruction
SABA should not be prescribed on a regular schedule
because concerns of possibility of deteriorating asthma
control
Frequent use of SABA is an indication of poor asthma control
Preferred root is inhalation smaller dose , fewer side effects
more rapid on set of action
Ipratropium Bromide as an adjunct to SABA in emergency
room reduces hospital admissions and improves lung function
Systemic Glucocorticoids short oral course + SABA in
moderate to severe asthma exacerbation

LABA
 Salmetrol

 Should be used in combination with inhaled

corticosteroids and not as mono therapy
 Exercise induces asthma in children >= 4 Yrs
one inhalation 30 min prior to exercise
 No additional doses for PTs who are already
receiving it twice daily not recommended by
NIH guidelines

LTRA

 MonteLukast ( singulair)

 Antihistaminic

 Leukotrien receptor antagonist

 Asthma ( not < 12 MO) and allergic rhinitis (





not < 6 MO)
Morning dosing not evaluated
Prophylactic and chronic treatment of asthma
Exercise induced asthma in >= 15 Yrs
Zafir Lukast : prophylactic and chronic
treatment of asthma

ICA
 Most potent anti inflammatory agents available

for the treatment of asthma
 Inhibiting most steps in the cascade of the
inflammatory response
 Benefits reducing bronchial hyper
responsiveness , prevention of late asthmatic
response , enhanced lung function
 Inhaled Glucocorticoids first line controller
therapy for persistent asthma or those who
require step 2

Prognosis
 35%of preschool children experience recurrent

coughing and wheezing,1/3 of them continue to
have persistent asthma into later childhood and
2/3 improvement on their own through their teen
yrs
 Asthma severity by age 7-10 yrs is predictive of
asthma persistence into adulthood
 Children with mod to severe asthma and lower lung
function are likely to have persistent asthma as
adults
 Children with milder asthma and N/R lung function
are likely to improve over time or be periodically
asthmatic

THANK YOU FOR YOUR
ATTENTION


Slide 31

Asthma in Children
DR. A.Mirshokraei
NIOC Hospital Pediatrics Ward

Definition :

DEFINITION

- Chronic inflammatory condition of the
lung airways resulting in episodic airflow
obstruction
- AHR to provocative exposures
Asthma management
• Reducing airway inflammation by: Minimizing
pro inflammatory environmental exposure, using
daily controller anti inflammatory medication,
controlling co morbid conditions that worsen
asthma, less inflammation better asthma
control and fewer exacerbations

Anyway exacerbations

occur

BUT
Even the uncommon
child with sever asthma can
be managed to live normally

 RECURRENT WHEEZING EPISODES WITH COMMON

RESPIRATORY
VIRUSES(RSV,RHINOVIRUS,INFLUENZA,PARAINFLUENZA,A
DENOVIRUS,HUMAN METAPNUMOVIRUS)

 HOST FEATURES AFFECTING IMMUNOLOGIC HOST

DEFENSE,INFLAMMATION/PREVIOUS VIRAL INFECTIONS
MAINIFESTED AS PNUMONIA OR BRONCHIOLITIS
REQUIRING HOSPITALIZATION UNDERLIE THE
RECURRENT WHEEZING IN EARLY CHILDHOOD

 OTHER AIRWAY EXPOSURES SUCH AS INDOOR AND HOME

ALLERGENS,COLD AIR,STRONG ODORS,TOBACCO
SMOKE,ALL INCREASE AHR

 ALLERGEN ELLIMINATION SOMETIMES LEEDS TO CURE

EPIDEMIOLOGY
 Common etiology of emergency visits and school day missing

in childhood ,occasionally hospitalization and rare deaths
specially in poverty ,urban living ,ethnic minorities

 Increasing asthma prevalence worldwide(50% per decade)
 Good correlation of asthma prevalence with allergic rhino

sinusitis and atopic eczema and other allergies

 More prevalence in high level urban modern families than

suburban villagers

 More than 80%of asthmatics reported getting the disease

before 6 year

CLINICS
RECURRENT COUGHING/WHEEZING
PATTERNS IN CHILDHOOD BASED ON
NATURAL HISTORY

TRANSIENT EARLY WHEEZING
 Common in early preschool years

 Recurrent coughing/wheezing primary

triggered by common respiratory viral INF
 Tend to resolve during preschool yrs without
increasing risk of asthma later in life
 Problems due to reduced airflow at birth
suggestive of relative narrow airways improved
by school yrs

Persistent Atopy Associated Asthma
 Begins in early preschool yrs

 Associated with atopy (eg atopic dermatitis in





infancy, allergic rhinitis, food allergy)
Biologic factors e.g.: early inhalant sensitization,
increase serum IGE, increase blood eosinophills,
High risk of persistence into later childhood and
adulthood lung function abnormality
Those with onset<3 yrs
reduced air flow by
school yrs
Those with later onset of symptoms or allergen
sensitizations unlikely persistence lung function
abnormality later

Non-Atopic Wheezing
 Wheezing ,coughing beginning in early life

often with RSV INF resolves later in childhood
without increasing risk of persistence asthma

 Associated with bronchial hyper

responsiveness near birth

Asthma with declining lung function
• Children with asthma with progressive

increase in air flow limitation

• Associated with hyper inflation in childhood
• Male gender

Late onset asthma in females associated with
obesity and early onset puberty
 Onset between 8_13 yrs

 Associated with early onset puberty and obesity
 Specific for females

Occupational type asthma in children
 Children with asthma and occupational type exposure

known to trigger asthma in adults in occupational settings

Types of Asthma
common clinical presentations of intermittent
recurrent wheezing and/or coughing
 Recurrent wheezing in early childhood

 Chronic asthma associated with allergy
 Females 11 yrs with early onset puberty and

obesity

Pathogenesis

 Airflow obstruction resulting from

Broncho constriction of bronchiolar smooth
muscle mass
II. Cellular inflammatory infiltrates and exudates
mostly Eosinophills(also N , M ,L ,mast cells
,basophiles)fill and obstruct airways and damage
epithelium and induce desquamation into airway
lumen mediated by T helper cells and other
immune cells that produce pro allergic pro
inflammatory cytokines(IL4,IL6,IL13)
III. Breach in normal immune regulatory process
I.

RESULT
 Airway inflammation

 AHR
 Edema basement membrane thickness sub

epithelial collagen deposition
 Smooth muscle and mucus gland hypertrophy
and mucus hyper secretion

Air obstruction

Clinical manifestations and diagnosis
 Most common intermittent dry cough and

expiratory wheezing

 Shortness of breath and chest tightness in older

children and adults

 Intermittent non focal chest pain in younger

children

 Worsening of respiratory symptoms at night
 Worsening of day time symptoms by activity

Continue…..
 Subtle symptoms such as self limitation of activities

,general fatigue ,difficulty in keeping up with peers

 Relief with aerosolized bronchodilators
 Lack of improvement with bronchodilators and steroid

is inconsistent with Asthma and should consider
Asthma masquerading conditions!!!!

 Hyper ventilation, intercostal retractions ,nasal flaring

,respiratory accessory muscle use

 Its common not to hear the expiratory wheezing when

Air flow is so limited before treatment

Asthma Triggers
 Common viral infections of the respiratory tract
 Aero allergens in sensitized asthmatics ,animal dander ,dust











mite ,molds ,indoor allergens ,cockroaches
Seasonal aero allergens ,pollens(trees ,grasses ,weeds ,)
Environmental tobacco smoke
Air pollutants ,ozone ,so2,wood or coal smoke ,endotoxin
,mycotoxin ,dust
Strong or noxious odors or fumes ,perfume ,hair spray
,cleaning agents
Occupational exposure
Cold air ,dry air
Exercise
Crying ,laughter ,hyperventilation
Co morbid conditions Rhinitis ,Sinusitis ,GER

Clinics
History:
Triggering symptoms by laughter
,cold air ,airway irritants
Exposures that induce airway
irritation such as viral URTI
Mycoplasma ,Chlamydia
Inhaled allergens
All lead to AHR

Presence Of Risk Factors:
 History of other allergies ,allergic Rhinitis,

allergic Conjunctivitis ,atopic Dermatitis ,food
allergies

 Parental Asthma
 Symptoms apart from cold

Continue…..
 No or minimal signs in routine visits

 Dry or persistent cough

 Normal chest findings unless wheezing when asking

to breath deeper
 Quick relief (10 MIN) after SABA use
 Expiratory wheezing ,prolonged expiratory phase
,decreased sounds in RT lower pos lobe due to
regional hypoventilation owing to airway
obstruction
 Rales , ronchi ,crackles due to hyper secretion
 Segmental crackles and poor breath sounds
atelectasis?

Continue….
 Labored respiration ,respiratory distress increased

prolongation of expiration and wheezing in E and I

 Poor air entry
 Inter costal retractions ,nasal flaring ,supra and

infra sternal retractions

 And again in most sever forms expiratory wheezing

does not appear until some broncho dilation

DD

GERD Rhino sinusitis co morbid

conditions with asthma

Recurrent aspiration in early

life(tracheo broncho malacia
,TEF , foreign body ,CF ,BPD

VCD in older children and

adolescents

LAB FINDINGS
Pulmonary Function
Testing

Continue….
 Forced expiratory airflow measures helpful

in Diagnosis , assessing efficacy of therapy
and monitoring Asthma in children specially
in poor children who do not have PHE
unless obstruction is sever

 Valueablity of spirometric findings in children>6

yrs

 3 efforts the highest is the peak
 Reduced FEV

obstruction

FEV1/FVC <0.80 means significant

 Improvement in FEV1 following beta 2 agonist > =

12% or 200 ml is consistent with Asthma

 Peak flow meter

CXR

Often normal aside from subtle and

nonspecific findings of hyperinflation

Peribronchial thickening
Helping in diagnosis of Asthma

differentials

Diagnosis of complications of Asthma

exacerbations

Other tests such as allergy skin prick
testing

Treatment
 www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm

Asthma Treatment & Management
has 4 components :
Assessment and monitoring of disease
activity
2. Provision to educate pt and family
3. Identification and management of
precipitating factors and co morbid
conditions
4. Appropriate selection of medication
1.

 Attainment of optimal Asthma control

Component 1
 Asthma severity :intermittent
 Persistent: mild ,mod ,severe
 Only once during patient initial evaluation in pt

who is not using a daily controller agent
 Asthma control degree to which symptoms ,
on going functional impairments , risk of
adverse events minimized and goals of
therapy are met

Continue….
Well controlled
2. Not well controlled
3. Very poor controlled
1.

 NIH guidelines for both severity and

control for 3 age groups

0-4 yrs
2. 5-11 yrs
3. =>12 yrs
1.

Important
even in the absence of frequent symptoms
infants and children whom have risk factors
for asthma and 4 or more episodes of
wheezing over the past yr which lasted more
than 1 day or 2 or more exacerbations in
the last 6 months requiring syst
corticosteroids should be considered in the
persistent group and hence receive long term
controller therapy

Important Tips..
 Regular clinical visits every 2-6 weeks
 Assessment of :

Pt symptoms frequency night and day
2. Need for short acting inhaled b2 agonists for
quick relief
3. Ability to engage in normal activities
4. Air flow measures for>=5 yrs
1.

Continue..
 Component 2 : pt education

 Component 3 : control of factors contributing

to asthma severity
1. Environmental exposures
2. Co morbid conditions
 Component 4 :principals of asthma
pharmacotherapy

Asthma Medication
 SABA

 ICS

 LABA
 LTRA

 SYSTEMIC STEROIDS

 NONSTEROIDAL ANTIINFLAMMATORY

CROMOLYN AND NEDOCROMYL
 OXYGEN
 ANTICHOLINERGIC AGENTS
IPRATROPIUM
BROMIDE
 ANTIIMMUNOGLUBOLINE E

MANAGEMENT OF ASTHMA EXACERBATION(STATUS ASTHMATICUS)
RISK ASSESMENT ON ADMISSION

FOCUSED HISTORY

ONSET OF CURRENT EXACERBATION
FREQUENCY AND severity of daytime and night
time symptoms and activity limitation
Frequency of rescue bronchodilator use
Current medication and allergies
Potential triggers
History of systemic steroid courses, emergency
department visists , hospitalization, intubation or life
threatening episodes

Clinical assesment

Physical examination findings: vital signs,
breathlessness, air movement, use of accessory
respiratory muscles, retractions, anxiety level,
alteration in mental status
Pulse oximetry
Lung function(defer in pts with mod to severe
distress or history of labile disease)

Treatment
Drugs and trade name

Mechanism of action and dosing

Cautions and adverse effects

Oxygen(mask or nasal canula)
Inhaled short acting b2
agonist
Albuterol nebulized
solution(5mg/ml concentrates
Albuterol MDI
Levabuterol

Treats hypoxia
Bronchodilator
Neubolizer 0.15 mg/kg every 20 min for 3
doses as needed,then 0.15_0.3 mg/kg up t 10
mg every 1_4 hour as needed or up to 0.5
mg/kg/hr by continous neubolization
2_8 puf up to every 20 min for 3 doses as
needed then every 1 hr as needed

Monitor pulse oximetry to maintain o2 saturation>92%
Cardiorespiratory monitoring
During exacerbations,frequent or continuous use can cause
pulmonary vasodilatation,v/q mistmatch and hypoxemia
Adverse effect palpitation, tachycardia, arrhythmia, tremor,
hypoxemia
Neubolizer:when giving concentrate forms,dilute with saline to 3
ml total neubolized volume
For MDI use space/holding chamber

Systemic corticosteroids
Prednisolone tb
Methyl prednisolon
Anticholinergics
Ipratropium
Atrovent
Ipratropium with Albuterol

Anti inflammatory
0.5_1 mg/kg every 6-8 hr for 48 hr , then 1-2 mg/kg
day bid(max 60 mg/day)
Short course burst for exacerbation 1-2 mg/kg/day qd
or bid for 3-7 days
Mucolitic/bronchodilator
Neubolizer 0.5 mg q6-8 hr (tid or qid) as needed
MDI 2 paf qid
1 vial by neubolizer qid



If pt has been exposed chickenpox or measles, consider passive
immunoglobulin prophylaxis, also risk of complications with
herspes simplex and TB

For daily dosing , 8 am administration minimizes adrenal
suppression

Children may benefit from dosage tapering if course exceed 7 days

Adverse effect monitoring: frequent therapy bursts risk numerous
corticosteroid adverse effects

Should not be used as first line treatment added to b2 agonist
therapy
Neubolizer may mix Ipratropium with Albuterol

QUICK RELIEF MEDICATION
SABA

Anti cholinergic(ipratropium)
Short term systemic gluco

corticoid

SABA
 Quick relief of asthma symptoms
 Relax airway smooth muscle prompt airflow↑
 Repetitive or continuous SABA is the most effective means







of reversing air flow obstruction
SABA should not be prescribed on a regular schedule
because concerns of possibility of deteriorating asthma
control
Frequent use of SABA is an indication of poor asthma control
Preferred root is inhalation smaller dose , fewer side effects
more rapid on set of action
Ipratropium Bromide as an adjunct to SABA in emergency
room reduces hospital admissions and improves lung function
Systemic Glucocorticoids short oral course + SABA in
moderate to severe asthma exacerbation

LABA
 Salmetrol

 Should be used in combination with inhaled

corticosteroids and not as mono therapy
 Exercise induces asthma in children >= 4 Yrs
one inhalation 30 min prior to exercise
 No additional doses for PTs who are already
receiving it twice daily not recommended by
NIH guidelines

LTRA

 MonteLukast ( singulair)

 Antihistaminic

 Leukotrien receptor antagonist

 Asthma ( not < 12 MO) and allergic rhinitis (





not < 6 MO)
Morning dosing not evaluated
Prophylactic and chronic treatment of asthma
Exercise induced asthma in >= 15 Yrs
Zafir Lukast : prophylactic and chronic
treatment of asthma

ICA
 Most potent anti inflammatory agents available

for the treatment of asthma
 Inhibiting most steps in the cascade of the
inflammatory response
 Benefits reducing bronchial hyper
responsiveness , prevention of late asthmatic
response , enhanced lung function
 Inhaled Glucocorticoids first line controller
therapy for persistent asthma or those who
require step 2

Prognosis
 35%of preschool children experience recurrent

coughing and wheezing,1/3 of them continue to
have persistent asthma into later childhood and
2/3 improvement on their own through their teen
yrs
 Asthma severity by age 7-10 yrs is predictive of
asthma persistence into adulthood
 Children with mod to severe asthma and lower lung
function are likely to have persistent asthma as
adults
 Children with milder asthma and N/R lung function
are likely to improve over time or be periodically
asthmatic

THANK YOU FOR YOUR
ATTENTION


Slide 32

Asthma in Children
DR. A.Mirshokraei
NIOC Hospital Pediatrics Ward

Definition :

DEFINITION

- Chronic inflammatory condition of the
lung airways resulting in episodic airflow
obstruction
- AHR to provocative exposures
Asthma management
• Reducing airway inflammation by: Minimizing
pro inflammatory environmental exposure, using
daily controller anti inflammatory medication,
controlling co morbid conditions that worsen
asthma, less inflammation better asthma
control and fewer exacerbations

Anyway exacerbations

occur

BUT
Even the uncommon
child with sever asthma can
be managed to live normally

 RECURRENT WHEEZING EPISODES WITH COMMON

RESPIRATORY
VIRUSES(RSV,RHINOVIRUS,INFLUENZA,PARAINFLUENZA,A
DENOVIRUS,HUMAN METAPNUMOVIRUS)

 HOST FEATURES AFFECTING IMMUNOLOGIC HOST

DEFENSE,INFLAMMATION/PREVIOUS VIRAL INFECTIONS
MAINIFESTED AS PNUMONIA OR BRONCHIOLITIS
REQUIRING HOSPITALIZATION UNDERLIE THE
RECURRENT WHEEZING IN EARLY CHILDHOOD

 OTHER AIRWAY EXPOSURES SUCH AS INDOOR AND HOME

ALLERGENS,COLD AIR,STRONG ODORS,TOBACCO
SMOKE,ALL INCREASE AHR

 ALLERGEN ELLIMINATION SOMETIMES LEEDS TO CURE

EPIDEMIOLOGY
 Common etiology of emergency visits and school day missing

in childhood ,occasionally hospitalization and rare deaths
specially in poverty ,urban living ,ethnic minorities

 Increasing asthma prevalence worldwide(50% per decade)
 Good correlation of asthma prevalence with allergic rhino

sinusitis and atopic eczema and other allergies

 More prevalence in high level urban modern families than

suburban villagers

 More than 80%of asthmatics reported getting the disease

before 6 year

CLINICS
RECURRENT COUGHING/WHEEZING
PATTERNS IN CHILDHOOD BASED ON
NATURAL HISTORY

TRANSIENT EARLY WHEEZING
 Common in early preschool years

 Recurrent coughing/wheezing primary

triggered by common respiratory viral INF
 Tend to resolve during preschool yrs without
increasing risk of asthma later in life
 Problems due to reduced airflow at birth
suggestive of relative narrow airways improved
by school yrs

Persistent Atopy Associated Asthma
 Begins in early preschool yrs

 Associated with atopy (eg atopic dermatitis in





infancy, allergic rhinitis, food allergy)
Biologic factors e.g.: early inhalant sensitization,
increase serum IGE, increase blood eosinophills,
High risk of persistence into later childhood and
adulthood lung function abnormality
Those with onset<3 yrs
reduced air flow by
school yrs
Those with later onset of symptoms or allergen
sensitizations unlikely persistence lung function
abnormality later

Non-Atopic Wheezing
 Wheezing ,coughing beginning in early life

often with RSV INF resolves later in childhood
without increasing risk of persistence asthma

 Associated with bronchial hyper

responsiveness near birth

Asthma with declining lung function
• Children with asthma with progressive

increase in air flow limitation

• Associated with hyper inflation in childhood
• Male gender

Late onset asthma in females associated with
obesity and early onset puberty
 Onset between 8_13 yrs

 Associated with early onset puberty and obesity
 Specific for females

Occupational type asthma in children
 Children with asthma and occupational type exposure

known to trigger asthma in adults in occupational settings

Types of Asthma
common clinical presentations of intermittent
recurrent wheezing and/or coughing
 Recurrent wheezing in early childhood

 Chronic asthma associated with allergy
 Females 11 yrs with early onset puberty and

obesity

Pathogenesis

 Airflow obstruction resulting from

Broncho constriction of bronchiolar smooth
muscle mass
II. Cellular inflammatory infiltrates and exudates
mostly Eosinophills(also N , M ,L ,mast cells
,basophiles)fill and obstruct airways and damage
epithelium and induce desquamation into airway
lumen mediated by T helper cells and other
immune cells that produce pro allergic pro
inflammatory cytokines(IL4,IL6,IL13)
III. Breach in normal immune regulatory process
I.

RESULT
 Airway inflammation

 AHR
 Edema basement membrane thickness sub

epithelial collagen deposition
 Smooth muscle and mucus gland hypertrophy
and mucus hyper secretion

Air obstruction

Clinical manifestations and diagnosis
 Most common intermittent dry cough and

expiratory wheezing

 Shortness of breath and chest tightness in older

children and adults

 Intermittent non focal chest pain in younger

children

 Worsening of respiratory symptoms at night
 Worsening of day time symptoms by activity

Continue…..
 Subtle symptoms such as self limitation of activities

,general fatigue ,difficulty in keeping up with peers

 Relief with aerosolized bronchodilators
 Lack of improvement with bronchodilators and steroid

is inconsistent with Asthma and should consider
Asthma masquerading conditions!!!!

 Hyper ventilation, intercostal retractions ,nasal flaring

,respiratory accessory muscle use

 Its common not to hear the expiratory wheezing when

Air flow is so limited before treatment

Asthma Triggers
 Common viral infections of the respiratory tract
 Aero allergens in sensitized asthmatics ,animal dander ,dust











mite ,molds ,indoor allergens ,cockroaches
Seasonal aero allergens ,pollens(trees ,grasses ,weeds ,)
Environmental tobacco smoke
Air pollutants ,ozone ,so2,wood or coal smoke ,endotoxin
,mycotoxin ,dust
Strong or noxious odors or fumes ,perfume ,hair spray
,cleaning agents
Occupational exposure
Cold air ,dry air
Exercise
Crying ,laughter ,hyperventilation
Co morbid conditions Rhinitis ,Sinusitis ,GER

Clinics
History:
Triggering symptoms by laughter
,cold air ,airway irritants
Exposures that induce airway
irritation such as viral URTI
Mycoplasma ,Chlamydia
Inhaled allergens
All lead to AHR

Presence Of Risk Factors:
 History of other allergies ,allergic Rhinitis,

allergic Conjunctivitis ,atopic Dermatitis ,food
allergies

 Parental Asthma
 Symptoms apart from cold

Continue…..
 No or minimal signs in routine visits

 Dry or persistent cough

 Normal chest findings unless wheezing when asking

to breath deeper
 Quick relief (10 MIN) after SABA use
 Expiratory wheezing ,prolonged expiratory phase
,decreased sounds in RT lower pos lobe due to
regional hypoventilation owing to airway
obstruction
 Rales , ronchi ,crackles due to hyper secretion
 Segmental crackles and poor breath sounds
atelectasis?

Continue….
 Labored respiration ,respiratory distress increased

prolongation of expiration and wheezing in E and I

 Poor air entry
 Inter costal retractions ,nasal flaring ,supra and

infra sternal retractions

 And again in most sever forms expiratory wheezing

does not appear until some broncho dilation

DD

GERD Rhino sinusitis co morbid

conditions with asthma

Recurrent aspiration in early

life(tracheo broncho malacia
,TEF , foreign body ,CF ,BPD

VCD in older children and

adolescents

LAB FINDINGS
Pulmonary Function
Testing

Continue….
 Forced expiratory airflow measures helpful

in Diagnosis , assessing efficacy of therapy
and monitoring Asthma in children specially
in poor children who do not have PHE
unless obstruction is sever

 Valueablity of spirometric findings in children>6

yrs

 3 efforts the highest is the peak
 Reduced FEV

obstruction

FEV1/FVC <0.80 means significant

 Improvement in FEV1 following beta 2 agonist > =

12% or 200 ml is consistent with Asthma

 Peak flow meter

CXR

Often normal aside from subtle and

nonspecific findings of hyperinflation

Peribronchial thickening
Helping in diagnosis of Asthma

differentials

Diagnosis of complications of Asthma

exacerbations

Other tests such as allergy skin prick
testing

Treatment
 www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm

Asthma Treatment & Management
has 4 components :
Assessment and monitoring of disease
activity
2. Provision to educate pt and family
3. Identification and management of
precipitating factors and co morbid
conditions
4. Appropriate selection of medication
1.

 Attainment of optimal Asthma control

Component 1
 Asthma severity :intermittent
 Persistent: mild ,mod ,severe
 Only once during patient initial evaluation in pt

who is not using a daily controller agent
 Asthma control degree to which symptoms ,
on going functional impairments , risk of
adverse events minimized and goals of
therapy are met

Continue….
Well controlled
2. Not well controlled
3. Very poor controlled
1.

 NIH guidelines for both severity and

control for 3 age groups

0-4 yrs
2. 5-11 yrs
3. =>12 yrs
1.

Important
even in the absence of frequent symptoms
infants and children whom have risk factors
for asthma and 4 or more episodes of
wheezing over the past yr which lasted more
than 1 day or 2 or more exacerbations in
the last 6 months requiring syst
corticosteroids should be considered in the
persistent group and hence receive long term
controller therapy

Important Tips..
 Regular clinical visits every 2-6 weeks
 Assessment of :

Pt symptoms frequency night and day
2. Need for short acting inhaled b2 agonists for
quick relief
3. Ability to engage in normal activities
4. Air flow measures for>=5 yrs
1.

Continue..
 Component 2 : pt education

 Component 3 : control of factors contributing

to asthma severity
1. Environmental exposures
2. Co morbid conditions
 Component 4 :principals of asthma
pharmacotherapy

Asthma Medication
 SABA

 ICS

 LABA
 LTRA

 SYSTEMIC STEROIDS

 NONSTEROIDAL ANTIINFLAMMATORY

CROMOLYN AND NEDOCROMYL
 OXYGEN
 ANTICHOLINERGIC AGENTS
IPRATROPIUM
BROMIDE
 ANTIIMMUNOGLUBOLINE E

MANAGEMENT OF ASTHMA EXACERBATION(STATUS ASTHMATICUS)
RISK ASSESMENT ON ADMISSION

FOCUSED HISTORY

ONSET OF CURRENT EXACERBATION
FREQUENCY AND severity of daytime and night
time symptoms and activity limitation
Frequency of rescue bronchodilator use
Current medication and allergies
Potential triggers
History of systemic steroid courses, emergency
department visists , hospitalization, intubation or life
threatening episodes

Clinical assesment

Physical examination findings: vital signs,
breathlessness, air movement, use of accessory
respiratory muscles, retractions, anxiety level,
alteration in mental status
Pulse oximetry
Lung function(defer in pts with mod to severe
distress or history of labile disease)

Treatment
Drugs and trade name

Mechanism of action and dosing

Cautions and adverse effects

Oxygen(mask or nasal canula)
Inhaled short acting b2
agonist
Albuterol nebulized
solution(5mg/ml concentrates
Albuterol MDI
Levabuterol

Treats hypoxia
Bronchodilator
Neubolizer 0.15 mg/kg every 20 min for 3
doses as needed,then 0.15_0.3 mg/kg up t 10
mg every 1_4 hour as needed or up to 0.5
mg/kg/hr by continous neubolization
2_8 puf up to every 20 min for 3 doses as
needed then every 1 hr as needed

Monitor pulse oximetry to maintain o2 saturation>92%
Cardiorespiratory monitoring
During exacerbations,frequent or continuous use can cause
pulmonary vasodilatation,v/q mistmatch and hypoxemia
Adverse effect palpitation, tachycardia, arrhythmia, tremor,
hypoxemia
Neubolizer:when giving concentrate forms,dilute with saline to 3
ml total neubolized volume
For MDI use space/holding chamber

Systemic corticosteroids
Prednisolone tb
Methyl prednisolon
Anticholinergics
Ipratropium
Atrovent
Ipratropium with Albuterol

Anti inflammatory
0.5_1 mg/kg every 6-8 hr for 48 hr , then 1-2 mg/kg
day bid(max 60 mg/day)
Short course burst for exacerbation 1-2 mg/kg/day qd
or bid for 3-7 days
Mucolitic/bronchodilator
Neubolizer 0.5 mg q6-8 hr (tid or qid) as needed
MDI 2 paf qid
1 vial by neubolizer qid



If pt has been exposed chickenpox or measles, consider passive
immunoglobulin prophylaxis, also risk of complications with
herspes simplex and TB

For daily dosing , 8 am administration minimizes adrenal
suppression

Children may benefit from dosage tapering if course exceed 7 days

Adverse effect monitoring: frequent therapy bursts risk numerous
corticosteroid adverse effects

Should not be used as first line treatment added to b2 agonist
therapy
Neubolizer may mix Ipratropium with Albuterol

QUICK RELIEF MEDICATION
SABA

Anti cholinergic(ipratropium)
Short term systemic gluco

corticoid

SABA
 Quick relief of asthma symptoms
 Relax airway smooth muscle prompt airflow↑
 Repetitive or continuous SABA is the most effective means







of reversing air flow obstruction
SABA should not be prescribed on a regular schedule
because concerns of possibility of deteriorating asthma
control
Frequent use of SABA is an indication of poor asthma control
Preferred root is inhalation smaller dose , fewer side effects
more rapid on set of action
Ipratropium Bromide as an adjunct to SABA in emergency
room reduces hospital admissions and improves lung function
Systemic Glucocorticoids short oral course + SABA in
moderate to severe asthma exacerbation

LABA
 Salmetrol

 Should be used in combination with inhaled

corticosteroids and not as mono therapy
 Exercise induces asthma in children >= 4 Yrs
one inhalation 30 min prior to exercise
 No additional doses for PTs who are already
receiving it twice daily not recommended by
NIH guidelines

LTRA

 MonteLukast ( singulair)

 Antihistaminic

 Leukotrien receptor antagonist

 Asthma ( not < 12 MO) and allergic rhinitis (





not < 6 MO)
Morning dosing not evaluated
Prophylactic and chronic treatment of asthma
Exercise induced asthma in >= 15 Yrs
Zafir Lukast : prophylactic and chronic
treatment of asthma

ICA
 Most potent anti inflammatory agents available

for the treatment of asthma
 Inhibiting most steps in the cascade of the
inflammatory response
 Benefits reducing bronchial hyper
responsiveness , prevention of late asthmatic
response , enhanced lung function
 Inhaled Glucocorticoids first line controller
therapy for persistent asthma or those who
require step 2

Prognosis
 35%of preschool children experience recurrent

coughing and wheezing,1/3 of them continue to
have persistent asthma into later childhood and
2/3 improvement on their own through their teen
yrs
 Asthma severity by age 7-10 yrs is predictive of
asthma persistence into adulthood
 Children with mod to severe asthma and lower lung
function are likely to have persistent asthma as
adults
 Children with milder asthma and N/R lung function
are likely to improve over time or be periodically
asthmatic

THANK YOU FOR YOUR
ATTENTION


Slide 33

Asthma in Children
DR. A.Mirshokraei
NIOC Hospital Pediatrics Ward

Definition :

DEFINITION

- Chronic inflammatory condition of the
lung airways resulting in episodic airflow
obstruction
- AHR to provocative exposures
Asthma management
• Reducing airway inflammation by: Minimizing
pro inflammatory environmental exposure, using
daily controller anti inflammatory medication,
controlling co morbid conditions that worsen
asthma, less inflammation better asthma
control and fewer exacerbations

Anyway exacerbations

occur

BUT
Even the uncommon
child with sever asthma can
be managed to live normally

 RECURRENT WHEEZING EPISODES WITH COMMON

RESPIRATORY
VIRUSES(RSV,RHINOVIRUS,INFLUENZA,PARAINFLUENZA,A
DENOVIRUS,HUMAN METAPNUMOVIRUS)

 HOST FEATURES AFFECTING IMMUNOLOGIC HOST

DEFENSE,INFLAMMATION/PREVIOUS VIRAL INFECTIONS
MAINIFESTED AS PNUMONIA OR BRONCHIOLITIS
REQUIRING HOSPITALIZATION UNDERLIE THE
RECURRENT WHEEZING IN EARLY CHILDHOOD

 OTHER AIRWAY EXPOSURES SUCH AS INDOOR AND HOME

ALLERGENS,COLD AIR,STRONG ODORS,TOBACCO
SMOKE,ALL INCREASE AHR

 ALLERGEN ELLIMINATION SOMETIMES LEEDS TO CURE

EPIDEMIOLOGY
 Common etiology of emergency visits and school day missing

in childhood ,occasionally hospitalization and rare deaths
specially in poverty ,urban living ,ethnic minorities

 Increasing asthma prevalence worldwide(50% per decade)
 Good correlation of asthma prevalence with allergic rhino

sinusitis and atopic eczema and other allergies

 More prevalence in high level urban modern families than

suburban villagers

 More than 80%of asthmatics reported getting the disease

before 6 year

CLINICS
RECURRENT COUGHING/WHEEZING
PATTERNS IN CHILDHOOD BASED ON
NATURAL HISTORY

TRANSIENT EARLY WHEEZING
 Common in early preschool years

 Recurrent coughing/wheezing primary

triggered by common respiratory viral INF
 Tend to resolve during preschool yrs without
increasing risk of asthma later in life
 Problems due to reduced airflow at birth
suggestive of relative narrow airways improved
by school yrs

Persistent Atopy Associated Asthma
 Begins in early preschool yrs

 Associated with atopy (eg atopic dermatitis in





infancy, allergic rhinitis, food allergy)
Biologic factors e.g.: early inhalant sensitization,
increase serum IGE, increase blood eosinophills,
High risk of persistence into later childhood and
adulthood lung function abnormality
Those with onset<3 yrs
reduced air flow by
school yrs
Those with later onset of symptoms or allergen
sensitizations unlikely persistence lung function
abnormality later

Non-Atopic Wheezing
 Wheezing ,coughing beginning in early life

often with RSV INF resolves later in childhood
without increasing risk of persistence asthma

 Associated with bronchial hyper

responsiveness near birth

Asthma with declining lung function
• Children with asthma with progressive

increase in air flow limitation

• Associated with hyper inflation in childhood
• Male gender

Late onset asthma in females associated with
obesity and early onset puberty
 Onset between 8_13 yrs

 Associated with early onset puberty and obesity
 Specific for females

Occupational type asthma in children
 Children with asthma and occupational type exposure

known to trigger asthma in adults in occupational settings

Types of Asthma
common clinical presentations of intermittent
recurrent wheezing and/or coughing
 Recurrent wheezing in early childhood

 Chronic asthma associated with allergy
 Females 11 yrs with early onset puberty and

obesity

Pathogenesis

 Airflow obstruction resulting from

Broncho constriction of bronchiolar smooth
muscle mass
II. Cellular inflammatory infiltrates and exudates
mostly Eosinophills(also N , M ,L ,mast cells
,basophiles)fill and obstruct airways and damage
epithelium and induce desquamation into airway
lumen mediated by T helper cells and other
immune cells that produce pro allergic pro
inflammatory cytokines(IL4,IL6,IL13)
III. Breach in normal immune regulatory process
I.

RESULT
 Airway inflammation

 AHR
 Edema basement membrane thickness sub

epithelial collagen deposition
 Smooth muscle and mucus gland hypertrophy
and mucus hyper secretion

Air obstruction

Clinical manifestations and diagnosis
 Most common intermittent dry cough and

expiratory wheezing

 Shortness of breath and chest tightness in older

children and adults

 Intermittent non focal chest pain in younger

children

 Worsening of respiratory symptoms at night
 Worsening of day time symptoms by activity

Continue…..
 Subtle symptoms such as self limitation of activities

,general fatigue ,difficulty in keeping up with peers

 Relief with aerosolized bronchodilators
 Lack of improvement with bronchodilators and steroid

is inconsistent with Asthma and should consider
Asthma masquerading conditions!!!!

 Hyper ventilation, intercostal retractions ,nasal flaring

,respiratory accessory muscle use

 Its common not to hear the expiratory wheezing when

Air flow is so limited before treatment

Asthma Triggers
 Common viral infections of the respiratory tract
 Aero allergens in sensitized asthmatics ,animal dander ,dust











mite ,molds ,indoor allergens ,cockroaches
Seasonal aero allergens ,pollens(trees ,grasses ,weeds ,)
Environmental tobacco smoke
Air pollutants ,ozone ,so2,wood or coal smoke ,endotoxin
,mycotoxin ,dust
Strong or noxious odors or fumes ,perfume ,hair spray
,cleaning agents
Occupational exposure
Cold air ,dry air
Exercise
Crying ,laughter ,hyperventilation
Co morbid conditions Rhinitis ,Sinusitis ,GER

Clinics
History:
Triggering symptoms by laughter
,cold air ,airway irritants
Exposures that induce airway
irritation such as viral URTI
Mycoplasma ,Chlamydia
Inhaled allergens
All lead to AHR

Presence Of Risk Factors:
 History of other allergies ,allergic Rhinitis,

allergic Conjunctivitis ,atopic Dermatitis ,food
allergies

 Parental Asthma
 Symptoms apart from cold

Continue…..
 No or minimal signs in routine visits

 Dry or persistent cough

 Normal chest findings unless wheezing when asking

to breath deeper
 Quick relief (10 MIN) after SABA use
 Expiratory wheezing ,prolonged expiratory phase
,decreased sounds in RT lower pos lobe due to
regional hypoventilation owing to airway
obstruction
 Rales , ronchi ,crackles due to hyper secretion
 Segmental crackles and poor breath sounds
atelectasis?

Continue….
 Labored respiration ,respiratory distress increased

prolongation of expiration and wheezing in E and I

 Poor air entry
 Inter costal retractions ,nasal flaring ,supra and

infra sternal retractions

 And again in most sever forms expiratory wheezing

does not appear until some broncho dilation

DD

GERD Rhino sinusitis co morbid

conditions with asthma

Recurrent aspiration in early

life(tracheo broncho malacia
,TEF , foreign body ,CF ,BPD

VCD in older children and

adolescents

LAB FINDINGS
Pulmonary Function
Testing

Continue….
 Forced expiratory airflow measures helpful

in Diagnosis , assessing efficacy of therapy
and monitoring Asthma in children specially
in poor children who do not have PHE
unless obstruction is sever

 Valueablity of spirometric findings in children>6

yrs

 3 efforts the highest is the peak
 Reduced FEV

obstruction

FEV1/FVC <0.80 means significant

 Improvement in FEV1 following beta 2 agonist > =

12% or 200 ml is consistent with Asthma

 Peak flow meter

CXR

Often normal aside from subtle and

nonspecific findings of hyperinflation

Peribronchial thickening
Helping in diagnosis of Asthma

differentials

Diagnosis of complications of Asthma

exacerbations

Other tests such as allergy skin prick
testing

Treatment
 www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm

Asthma Treatment & Management
has 4 components :
Assessment and monitoring of disease
activity
2. Provision to educate pt and family
3. Identification and management of
precipitating factors and co morbid
conditions
4. Appropriate selection of medication
1.

 Attainment of optimal Asthma control

Component 1
 Asthma severity :intermittent
 Persistent: mild ,mod ,severe
 Only once during patient initial evaluation in pt

who is not using a daily controller agent
 Asthma control degree to which symptoms ,
on going functional impairments , risk of
adverse events minimized and goals of
therapy are met

Continue….
Well controlled
2. Not well controlled
3. Very poor controlled
1.

 NIH guidelines for both severity and

control for 3 age groups

0-4 yrs
2. 5-11 yrs
3. =>12 yrs
1.

Important
even in the absence of frequent symptoms
infants and children whom have risk factors
for asthma and 4 or more episodes of
wheezing over the past yr which lasted more
than 1 day or 2 or more exacerbations in
the last 6 months requiring syst
corticosteroids should be considered in the
persistent group and hence receive long term
controller therapy

Important Tips..
 Regular clinical visits every 2-6 weeks
 Assessment of :

Pt symptoms frequency night and day
2. Need for short acting inhaled b2 agonists for
quick relief
3. Ability to engage in normal activities
4. Air flow measures for>=5 yrs
1.

Continue..
 Component 2 : pt education

 Component 3 : control of factors contributing

to asthma severity
1. Environmental exposures
2. Co morbid conditions
 Component 4 :principals of asthma
pharmacotherapy

Asthma Medication
 SABA

 ICS

 LABA
 LTRA

 SYSTEMIC STEROIDS

 NONSTEROIDAL ANTIINFLAMMATORY

CROMOLYN AND NEDOCROMYL
 OXYGEN
 ANTICHOLINERGIC AGENTS
IPRATROPIUM
BROMIDE
 ANTIIMMUNOGLUBOLINE E

MANAGEMENT OF ASTHMA EXACERBATION(STATUS ASTHMATICUS)
RISK ASSESMENT ON ADMISSION

FOCUSED HISTORY

ONSET OF CURRENT EXACERBATION
FREQUENCY AND severity of daytime and night
time symptoms and activity limitation
Frequency of rescue bronchodilator use
Current medication and allergies
Potential triggers
History of systemic steroid courses, emergency
department visists , hospitalization, intubation or life
threatening episodes

Clinical assesment

Physical examination findings: vital signs,
breathlessness, air movement, use of accessory
respiratory muscles, retractions, anxiety level,
alteration in mental status
Pulse oximetry
Lung function(defer in pts with mod to severe
distress or history of labile disease)

Treatment
Drugs and trade name

Mechanism of action and dosing

Cautions and adverse effects

Oxygen(mask or nasal canula)
Inhaled short acting b2
agonist
Albuterol nebulized
solution(5mg/ml concentrates
Albuterol MDI
Levabuterol

Treats hypoxia
Bronchodilator
Neubolizer 0.15 mg/kg every 20 min for 3
doses as needed,then 0.15_0.3 mg/kg up t 10
mg every 1_4 hour as needed or up to 0.5
mg/kg/hr by continous neubolization
2_8 puf up to every 20 min for 3 doses as
needed then every 1 hr as needed

Monitor pulse oximetry to maintain o2 saturation>92%
Cardiorespiratory monitoring
During exacerbations,frequent or continuous use can cause
pulmonary vasodilatation,v/q mistmatch and hypoxemia
Adverse effect palpitation, tachycardia, arrhythmia, tremor,
hypoxemia
Neubolizer:when giving concentrate forms,dilute with saline to 3
ml total neubolized volume
For MDI use space/holding chamber

Systemic corticosteroids
Prednisolone tb
Methyl prednisolon
Anticholinergics
Ipratropium
Atrovent
Ipratropium with Albuterol

Anti inflammatory
0.5_1 mg/kg every 6-8 hr for 48 hr , then 1-2 mg/kg
day bid(max 60 mg/day)
Short course burst for exacerbation 1-2 mg/kg/day qd
or bid for 3-7 days
Mucolitic/bronchodilator
Neubolizer 0.5 mg q6-8 hr (tid or qid) as needed
MDI 2 paf qid
1 vial by neubolizer qid



If pt has been exposed chickenpox or measles, consider passive
immunoglobulin prophylaxis, also risk of complications with
herspes simplex and TB

For daily dosing , 8 am administration minimizes adrenal
suppression

Children may benefit from dosage tapering if course exceed 7 days

Adverse effect monitoring: frequent therapy bursts risk numerous
corticosteroid adverse effects

Should not be used as first line treatment added to b2 agonist
therapy
Neubolizer may mix Ipratropium with Albuterol

QUICK RELIEF MEDICATION
SABA

Anti cholinergic(ipratropium)
Short term systemic gluco

corticoid

SABA
 Quick relief of asthma symptoms
 Relax airway smooth muscle prompt airflow↑
 Repetitive or continuous SABA is the most effective means







of reversing air flow obstruction
SABA should not be prescribed on a regular schedule
because concerns of possibility of deteriorating asthma
control
Frequent use of SABA is an indication of poor asthma control
Preferred root is inhalation smaller dose , fewer side effects
more rapid on set of action
Ipratropium Bromide as an adjunct to SABA in emergency
room reduces hospital admissions and improves lung function
Systemic Glucocorticoids short oral course + SABA in
moderate to severe asthma exacerbation

LABA
 Salmetrol

 Should be used in combination with inhaled

corticosteroids and not as mono therapy
 Exercise induces asthma in children >= 4 Yrs
one inhalation 30 min prior to exercise
 No additional doses for PTs who are already
receiving it twice daily not recommended by
NIH guidelines

LTRA

 MonteLukast ( singulair)

 Antihistaminic

 Leukotrien receptor antagonist

 Asthma ( not < 12 MO) and allergic rhinitis (





not < 6 MO)
Morning dosing not evaluated
Prophylactic and chronic treatment of asthma
Exercise induced asthma in >= 15 Yrs
Zafir Lukast : prophylactic and chronic
treatment of asthma

ICA
 Most potent anti inflammatory agents available

for the treatment of asthma
 Inhibiting most steps in the cascade of the
inflammatory response
 Benefits reducing bronchial hyper
responsiveness , prevention of late asthmatic
response , enhanced lung function
 Inhaled Glucocorticoids first line controller
therapy for persistent asthma or those who
require step 2

Prognosis
 35%of preschool children experience recurrent

coughing and wheezing,1/3 of them continue to
have persistent asthma into later childhood and
2/3 improvement on their own through their teen
yrs
 Asthma severity by age 7-10 yrs is predictive of
asthma persistence into adulthood
 Children with mod to severe asthma and lower lung
function are likely to have persistent asthma as
adults
 Children with milder asthma and N/R lung function
are likely to improve over time or be periodically
asthmatic

THANK YOU FOR YOUR
ATTENTION


Slide 34

Asthma in Children
DR. A.Mirshokraei
NIOC Hospital Pediatrics Ward

Definition :

DEFINITION

- Chronic inflammatory condition of the
lung airways resulting in episodic airflow
obstruction
- AHR to provocative exposures
Asthma management
• Reducing airway inflammation by: Minimizing
pro inflammatory environmental exposure, using
daily controller anti inflammatory medication,
controlling co morbid conditions that worsen
asthma, less inflammation better asthma
control and fewer exacerbations

Anyway exacerbations

occur

BUT
Even the uncommon
child with sever asthma can
be managed to live normally

 RECURRENT WHEEZING EPISODES WITH COMMON

RESPIRATORY
VIRUSES(RSV,RHINOVIRUS,INFLUENZA,PARAINFLUENZA,A
DENOVIRUS,HUMAN METAPNUMOVIRUS)

 HOST FEATURES AFFECTING IMMUNOLOGIC HOST

DEFENSE,INFLAMMATION/PREVIOUS VIRAL INFECTIONS
MAINIFESTED AS PNUMONIA OR BRONCHIOLITIS
REQUIRING HOSPITALIZATION UNDERLIE THE
RECURRENT WHEEZING IN EARLY CHILDHOOD

 OTHER AIRWAY EXPOSURES SUCH AS INDOOR AND HOME

ALLERGENS,COLD AIR,STRONG ODORS,TOBACCO
SMOKE,ALL INCREASE AHR

 ALLERGEN ELLIMINATION SOMETIMES LEEDS TO CURE

EPIDEMIOLOGY
 Common etiology of emergency visits and school day missing

in childhood ,occasionally hospitalization and rare deaths
specially in poverty ,urban living ,ethnic minorities

 Increasing asthma prevalence worldwide(50% per decade)
 Good correlation of asthma prevalence with allergic rhino

sinusitis and atopic eczema and other allergies

 More prevalence in high level urban modern families than

suburban villagers

 More than 80%of asthmatics reported getting the disease

before 6 year

CLINICS
RECURRENT COUGHING/WHEEZING
PATTERNS IN CHILDHOOD BASED ON
NATURAL HISTORY

TRANSIENT EARLY WHEEZING
 Common in early preschool years

 Recurrent coughing/wheezing primary

triggered by common respiratory viral INF
 Tend to resolve during preschool yrs without
increasing risk of asthma later in life
 Problems due to reduced airflow at birth
suggestive of relative narrow airways improved
by school yrs

Persistent Atopy Associated Asthma
 Begins in early preschool yrs

 Associated with atopy (eg atopic dermatitis in





infancy, allergic rhinitis, food allergy)
Biologic factors e.g.: early inhalant sensitization,
increase serum IGE, increase blood eosinophills,
High risk of persistence into later childhood and
adulthood lung function abnormality
Those with onset<3 yrs
reduced air flow by
school yrs
Those with later onset of symptoms or allergen
sensitizations unlikely persistence lung function
abnormality later

Non-Atopic Wheezing
 Wheezing ,coughing beginning in early life

often with RSV INF resolves later in childhood
without increasing risk of persistence asthma

 Associated with bronchial hyper

responsiveness near birth

Asthma with declining lung function
• Children with asthma with progressive

increase in air flow limitation

• Associated with hyper inflation in childhood
• Male gender

Late onset asthma in females associated with
obesity and early onset puberty
 Onset between 8_13 yrs

 Associated with early onset puberty and obesity
 Specific for females

Occupational type asthma in children
 Children with asthma and occupational type exposure

known to trigger asthma in adults in occupational settings

Types of Asthma
common clinical presentations of intermittent
recurrent wheezing and/or coughing
 Recurrent wheezing in early childhood

 Chronic asthma associated with allergy
 Females 11 yrs with early onset puberty and

obesity

Pathogenesis

 Airflow obstruction resulting from

Broncho constriction of bronchiolar smooth
muscle mass
II. Cellular inflammatory infiltrates and exudates
mostly Eosinophills(also N , M ,L ,mast cells
,basophiles)fill and obstruct airways and damage
epithelium and induce desquamation into airway
lumen mediated by T helper cells and other
immune cells that produce pro allergic pro
inflammatory cytokines(IL4,IL6,IL13)
III. Breach in normal immune regulatory process
I.

RESULT
 Airway inflammation

 AHR
 Edema basement membrane thickness sub

epithelial collagen deposition
 Smooth muscle and mucus gland hypertrophy
and mucus hyper secretion

Air obstruction

Clinical manifestations and diagnosis
 Most common intermittent dry cough and

expiratory wheezing

 Shortness of breath and chest tightness in older

children and adults

 Intermittent non focal chest pain in younger

children

 Worsening of respiratory symptoms at night
 Worsening of day time symptoms by activity

Continue…..
 Subtle symptoms such as self limitation of activities

,general fatigue ,difficulty in keeping up with peers

 Relief with aerosolized bronchodilators
 Lack of improvement with bronchodilators and steroid

is inconsistent with Asthma and should consider
Asthma masquerading conditions!!!!

 Hyper ventilation, intercostal retractions ,nasal flaring

,respiratory accessory muscle use

 Its common not to hear the expiratory wheezing when

Air flow is so limited before treatment

Asthma Triggers
 Common viral infections of the respiratory tract
 Aero allergens in sensitized asthmatics ,animal dander ,dust











mite ,molds ,indoor allergens ,cockroaches
Seasonal aero allergens ,pollens(trees ,grasses ,weeds ,)
Environmental tobacco smoke
Air pollutants ,ozone ,so2,wood or coal smoke ,endotoxin
,mycotoxin ,dust
Strong or noxious odors or fumes ,perfume ,hair spray
,cleaning agents
Occupational exposure
Cold air ,dry air
Exercise
Crying ,laughter ,hyperventilation
Co morbid conditions Rhinitis ,Sinusitis ,GER

Clinics
History:
Triggering symptoms by laughter
,cold air ,airway irritants
Exposures that induce airway
irritation such as viral URTI
Mycoplasma ,Chlamydia
Inhaled allergens
All lead to AHR

Presence Of Risk Factors:
 History of other allergies ,allergic Rhinitis,

allergic Conjunctivitis ,atopic Dermatitis ,food
allergies

 Parental Asthma
 Symptoms apart from cold

Continue…..
 No or minimal signs in routine visits

 Dry or persistent cough

 Normal chest findings unless wheezing when asking

to breath deeper
 Quick relief (10 MIN) after SABA use
 Expiratory wheezing ,prolonged expiratory phase
,decreased sounds in RT lower pos lobe due to
regional hypoventilation owing to airway
obstruction
 Rales , ronchi ,crackles due to hyper secretion
 Segmental crackles and poor breath sounds
atelectasis?

Continue….
 Labored respiration ,respiratory distress increased

prolongation of expiration and wheezing in E and I

 Poor air entry
 Inter costal retractions ,nasal flaring ,supra and

infra sternal retractions

 And again in most sever forms expiratory wheezing

does not appear until some broncho dilation

DD

GERD Rhino sinusitis co morbid

conditions with asthma

Recurrent aspiration in early

life(tracheo broncho malacia
,TEF , foreign body ,CF ,BPD

VCD in older children and

adolescents

LAB FINDINGS
Pulmonary Function
Testing

Continue….
 Forced expiratory airflow measures helpful

in Diagnosis , assessing efficacy of therapy
and monitoring Asthma in children specially
in poor children who do not have PHE
unless obstruction is sever

 Valueablity of spirometric findings in children>6

yrs

 3 efforts the highest is the peak
 Reduced FEV

obstruction

FEV1/FVC <0.80 means significant

 Improvement in FEV1 following beta 2 agonist > =

12% or 200 ml is consistent with Asthma

 Peak flow meter

CXR

Often normal aside from subtle and

nonspecific findings of hyperinflation

Peribronchial thickening
Helping in diagnosis of Asthma

differentials

Diagnosis of complications of Asthma

exacerbations

Other tests such as allergy skin prick
testing

Treatment
 www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm

Asthma Treatment & Management
has 4 components :
Assessment and monitoring of disease
activity
2. Provision to educate pt and family
3. Identification and management of
precipitating factors and co morbid
conditions
4. Appropriate selection of medication
1.

 Attainment of optimal Asthma control

Component 1
 Asthma severity :intermittent
 Persistent: mild ,mod ,severe
 Only once during patient initial evaluation in pt

who is not using a daily controller agent
 Asthma control degree to which symptoms ,
on going functional impairments , risk of
adverse events minimized and goals of
therapy are met

Continue….
Well controlled
2. Not well controlled
3. Very poor controlled
1.

 NIH guidelines for both severity and

control for 3 age groups

0-4 yrs
2. 5-11 yrs
3. =>12 yrs
1.

Important
even in the absence of frequent symptoms
infants and children whom have risk factors
for asthma and 4 or more episodes of
wheezing over the past yr which lasted more
than 1 day or 2 or more exacerbations in
the last 6 months requiring syst
corticosteroids should be considered in the
persistent group and hence receive long term
controller therapy

Important Tips..
 Regular clinical visits every 2-6 weeks
 Assessment of :

Pt symptoms frequency night and day
2. Need for short acting inhaled b2 agonists for
quick relief
3. Ability to engage in normal activities
4. Air flow measures for>=5 yrs
1.

Continue..
 Component 2 : pt education

 Component 3 : control of factors contributing

to asthma severity
1. Environmental exposures
2. Co morbid conditions
 Component 4 :principals of asthma
pharmacotherapy

Asthma Medication
 SABA

 ICS

 LABA
 LTRA

 SYSTEMIC STEROIDS

 NONSTEROIDAL ANTIINFLAMMATORY

CROMOLYN AND NEDOCROMYL
 OXYGEN
 ANTICHOLINERGIC AGENTS
IPRATROPIUM
BROMIDE
 ANTIIMMUNOGLUBOLINE E

MANAGEMENT OF ASTHMA EXACERBATION(STATUS ASTHMATICUS)
RISK ASSESMENT ON ADMISSION

FOCUSED HISTORY

ONSET OF CURRENT EXACERBATION
FREQUENCY AND severity of daytime and night
time symptoms and activity limitation
Frequency of rescue bronchodilator use
Current medication and allergies
Potential triggers
History of systemic steroid courses, emergency
department visists , hospitalization, intubation or life
threatening episodes

Clinical assesment

Physical examination findings: vital signs,
breathlessness, air movement, use of accessory
respiratory muscles, retractions, anxiety level,
alteration in mental status
Pulse oximetry
Lung function(defer in pts with mod to severe
distress or history of labile disease)

Treatment
Drugs and trade name

Mechanism of action and dosing

Cautions and adverse effects

Oxygen(mask or nasal canula)
Inhaled short acting b2
agonist
Albuterol nebulized
solution(5mg/ml concentrates
Albuterol MDI
Levabuterol

Treats hypoxia
Bronchodilator
Neubolizer 0.15 mg/kg every 20 min for 3
doses as needed,then 0.15_0.3 mg/kg up t 10
mg every 1_4 hour as needed or up to 0.5
mg/kg/hr by continous neubolization
2_8 puf up to every 20 min for 3 doses as
needed then every 1 hr as needed

Monitor pulse oximetry to maintain o2 saturation>92%
Cardiorespiratory monitoring
During exacerbations,frequent or continuous use can cause
pulmonary vasodilatation,v/q mistmatch and hypoxemia
Adverse effect palpitation, tachycardia, arrhythmia, tremor,
hypoxemia
Neubolizer:when giving concentrate forms,dilute with saline to 3
ml total neubolized volume
For MDI use space/holding chamber

Systemic corticosteroids
Prednisolone tb
Methyl prednisolon
Anticholinergics
Ipratropium
Atrovent
Ipratropium with Albuterol

Anti inflammatory
0.5_1 mg/kg every 6-8 hr for 48 hr , then 1-2 mg/kg
day bid(max 60 mg/day)
Short course burst for exacerbation 1-2 mg/kg/day qd
or bid for 3-7 days
Mucolitic/bronchodilator
Neubolizer 0.5 mg q6-8 hr (tid or qid) as needed
MDI 2 paf qid
1 vial by neubolizer qid



If pt has been exposed chickenpox or measles, consider passive
immunoglobulin prophylaxis, also risk of complications with
herspes simplex and TB

For daily dosing , 8 am administration minimizes adrenal
suppression

Children may benefit from dosage tapering if course exceed 7 days

Adverse effect monitoring: frequent therapy bursts risk numerous
corticosteroid adverse effects

Should not be used as first line treatment added to b2 agonist
therapy
Neubolizer may mix Ipratropium with Albuterol

QUICK RELIEF MEDICATION
SABA

Anti cholinergic(ipratropium)
Short term systemic gluco

corticoid

SABA
 Quick relief of asthma symptoms
 Relax airway smooth muscle prompt airflow↑
 Repetitive or continuous SABA is the most effective means







of reversing air flow obstruction
SABA should not be prescribed on a regular schedule
because concerns of possibility of deteriorating asthma
control
Frequent use of SABA is an indication of poor asthma control
Preferred root is inhalation smaller dose , fewer side effects
more rapid on set of action
Ipratropium Bromide as an adjunct to SABA in emergency
room reduces hospital admissions and improves lung function
Systemic Glucocorticoids short oral course + SABA in
moderate to severe asthma exacerbation

LABA
 Salmetrol

 Should be used in combination with inhaled

corticosteroids and not as mono therapy
 Exercise induces asthma in children >= 4 Yrs
one inhalation 30 min prior to exercise
 No additional doses for PTs who are already
receiving it twice daily not recommended by
NIH guidelines

LTRA

 MonteLukast ( singulair)

 Antihistaminic

 Leukotrien receptor antagonist

 Asthma ( not < 12 MO) and allergic rhinitis (





not < 6 MO)
Morning dosing not evaluated
Prophylactic and chronic treatment of asthma
Exercise induced asthma in >= 15 Yrs
Zafir Lukast : prophylactic and chronic
treatment of asthma

ICA
 Most potent anti inflammatory agents available

for the treatment of asthma
 Inhibiting most steps in the cascade of the
inflammatory response
 Benefits reducing bronchial hyper
responsiveness , prevention of late asthmatic
response , enhanced lung function
 Inhaled Glucocorticoids first line controller
therapy for persistent asthma or those who
require step 2

Prognosis
 35%of preschool children experience recurrent

coughing and wheezing,1/3 of them continue to
have persistent asthma into later childhood and
2/3 improvement on their own through their teen
yrs
 Asthma severity by age 7-10 yrs is predictive of
asthma persistence into adulthood
 Children with mod to severe asthma and lower lung
function are likely to have persistent asthma as
adults
 Children with milder asthma and N/R lung function
are likely to improve over time or be periodically
asthmatic

THANK YOU FOR YOUR
ATTENTION


Slide 35

Asthma in Children
DR. A.Mirshokraei
NIOC Hospital Pediatrics Ward

Definition :

DEFINITION

- Chronic inflammatory condition of the
lung airways resulting in episodic airflow
obstruction
- AHR to provocative exposures
Asthma management
• Reducing airway inflammation by: Minimizing
pro inflammatory environmental exposure, using
daily controller anti inflammatory medication,
controlling co morbid conditions that worsen
asthma, less inflammation better asthma
control and fewer exacerbations

Anyway exacerbations

occur

BUT
Even the uncommon
child with sever asthma can
be managed to live normally

 RECURRENT WHEEZING EPISODES WITH COMMON

RESPIRATORY
VIRUSES(RSV,RHINOVIRUS,INFLUENZA,PARAINFLUENZA,A
DENOVIRUS,HUMAN METAPNUMOVIRUS)

 HOST FEATURES AFFECTING IMMUNOLOGIC HOST

DEFENSE,INFLAMMATION/PREVIOUS VIRAL INFECTIONS
MAINIFESTED AS PNUMONIA OR BRONCHIOLITIS
REQUIRING HOSPITALIZATION UNDERLIE THE
RECURRENT WHEEZING IN EARLY CHILDHOOD

 OTHER AIRWAY EXPOSURES SUCH AS INDOOR AND HOME

ALLERGENS,COLD AIR,STRONG ODORS,TOBACCO
SMOKE,ALL INCREASE AHR

 ALLERGEN ELLIMINATION SOMETIMES LEEDS TO CURE

EPIDEMIOLOGY
 Common etiology of emergency visits and school day missing

in childhood ,occasionally hospitalization and rare deaths
specially in poverty ,urban living ,ethnic minorities

 Increasing asthma prevalence worldwide(50% per decade)
 Good correlation of asthma prevalence with allergic rhino

sinusitis and atopic eczema and other allergies

 More prevalence in high level urban modern families than

suburban villagers

 More than 80%of asthmatics reported getting the disease

before 6 year

CLINICS
RECURRENT COUGHING/WHEEZING
PATTERNS IN CHILDHOOD BASED ON
NATURAL HISTORY

TRANSIENT EARLY WHEEZING
 Common in early preschool years

 Recurrent coughing/wheezing primary

triggered by common respiratory viral INF
 Tend to resolve during preschool yrs without
increasing risk of asthma later in life
 Problems due to reduced airflow at birth
suggestive of relative narrow airways improved
by school yrs

Persistent Atopy Associated Asthma
 Begins in early preschool yrs

 Associated with atopy (eg atopic dermatitis in





infancy, allergic rhinitis, food allergy)
Biologic factors e.g.: early inhalant sensitization,
increase serum IGE, increase blood eosinophills,
High risk of persistence into later childhood and
adulthood lung function abnormality
Those with onset<3 yrs
reduced air flow by
school yrs
Those with later onset of symptoms or allergen
sensitizations unlikely persistence lung function
abnormality later

Non-Atopic Wheezing
 Wheezing ,coughing beginning in early life

often with RSV INF resolves later in childhood
without increasing risk of persistence asthma

 Associated with bronchial hyper

responsiveness near birth

Asthma with declining lung function
• Children with asthma with progressive

increase in air flow limitation

• Associated with hyper inflation in childhood
• Male gender

Late onset asthma in females associated with
obesity and early onset puberty
 Onset between 8_13 yrs

 Associated with early onset puberty and obesity
 Specific for females

Occupational type asthma in children
 Children with asthma and occupational type exposure

known to trigger asthma in adults in occupational settings

Types of Asthma
common clinical presentations of intermittent
recurrent wheezing and/or coughing
 Recurrent wheezing in early childhood

 Chronic asthma associated with allergy
 Females 11 yrs with early onset puberty and

obesity

Pathogenesis

 Airflow obstruction resulting from

Broncho constriction of bronchiolar smooth
muscle mass
II. Cellular inflammatory infiltrates and exudates
mostly Eosinophills(also N , M ,L ,mast cells
,basophiles)fill and obstruct airways and damage
epithelium and induce desquamation into airway
lumen mediated by T helper cells and other
immune cells that produce pro allergic pro
inflammatory cytokines(IL4,IL6,IL13)
III. Breach in normal immune regulatory process
I.

RESULT
 Airway inflammation

 AHR
 Edema basement membrane thickness sub

epithelial collagen deposition
 Smooth muscle and mucus gland hypertrophy
and mucus hyper secretion

Air obstruction

Clinical manifestations and diagnosis
 Most common intermittent dry cough and

expiratory wheezing

 Shortness of breath and chest tightness in older

children and adults

 Intermittent non focal chest pain in younger

children

 Worsening of respiratory symptoms at night
 Worsening of day time symptoms by activity

Continue…..
 Subtle symptoms such as self limitation of activities

,general fatigue ,difficulty in keeping up with peers

 Relief with aerosolized bronchodilators
 Lack of improvement with bronchodilators and steroid

is inconsistent with Asthma and should consider
Asthma masquerading conditions!!!!

 Hyper ventilation, intercostal retractions ,nasal flaring

,respiratory accessory muscle use

 Its common not to hear the expiratory wheezing when

Air flow is so limited before treatment

Asthma Triggers
 Common viral infections of the respiratory tract
 Aero allergens in sensitized asthmatics ,animal dander ,dust











mite ,molds ,indoor allergens ,cockroaches
Seasonal aero allergens ,pollens(trees ,grasses ,weeds ,)
Environmental tobacco smoke
Air pollutants ,ozone ,so2,wood or coal smoke ,endotoxin
,mycotoxin ,dust
Strong or noxious odors or fumes ,perfume ,hair spray
,cleaning agents
Occupational exposure
Cold air ,dry air
Exercise
Crying ,laughter ,hyperventilation
Co morbid conditions Rhinitis ,Sinusitis ,GER

Clinics
History:
Triggering symptoms by laughter
,cold air ,airway irritants
Exposures that induce airway
irritation such as viral URTI
Mycoplasma ,Chlamydia
Inhaled allergens
All lead to AHR

Presence Of Risk Factors:
 History of other allergies ,allergic Rhinitis,

allergic Conjunctivitis ,atopic Dermatitis ,food
allergies

 Parental Asthma
 Symptoms apart from cold

Continue…..
 No or minimal signs in routine visits

 Dry or persistent cough

 Normal chest findings unless wheezing when asking

to breath deeper
 Quick relief (10 MIN) after SABA use
 Expiratory wheezing ,prolonged expiratory phase
,decreased sounds in RT lower pos lobe due to
regional hypoventilation owing to airway
obstruction
 Rales , ronchi ,crackles due to hyper secretion
 Segmental crackles and poor breath sounds
atelectasis?

Continue….
 Labored respiration ,respiratory distress increased

prolongation of expiration and wheezing in E and I

 Poor air entry
 Inter costal retractions ,nasal flaring ,supra and

infra sternal retractions

 And again in most sever forms expiratory wheezing

does not appear until some broncho dilation

DD

GERD Rhino sinusitis co morbid

conditions with asthma

Recurrent aspiration in early

life(tracheo broncho malacia
,TEF , foreign body ,CF ,BPD

VCD in older children and

adolescents

LAB FINDINGS
Pulmonary Function
Testing

Continue….
 Forced expiratory airflow measures helpful

in Diagnosis , assessing efficacy of therapy
and monitoring Asthma in children specially
in poor children who do not have PHE
unless obstruction is sever

 Valueablity of spirometric findings in children>6

yrs

 3 efforts the highest is the peak
 Reduced FEV

obstruction

FEV1/FVC <0.80 means significant

 Improvement in FEV1 following beta 2 agonist > =

12% or 200 ml is consistent with Asthma

 Peak flow meter

CXR

Often normal aside from subtle and

nonspecific findings of hyperinflation

Peribronchial thickening
Helping in diagnosis of Asthma

differentials

Diagnosis of complications of Asthma

exacerbations

Other tests such as allergy skin prick
testing

Treatment
 www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm

Asthma Treatment & Management
has 4 components :
Assessment and monitoring of disease
activity
2. Provision to educate pt and family
3. Identification and management of
precipitating factors and co morbid
conditions
4. Appropriate selection of medication
1.

 Attainment of optimal Asthma control

Component 1
 Asthma severity :intermittent
 Persistent: mild ,mod ,severe
 Only once during patient initial evaluation in pt

who is not using a daily controller agent
 Asthma control degree to which symptoms ,
on going functional impairments , risk of
adverse events minimized and goals of
therapy are met

Continue….
Well controlled
2. Not well controlled
3. Very poor controlled
1.

 NIH guidelines for both severity and

control for 3 age groups

0-4 yrs
2. 5-11 yrs
3. =>12 yrs
1.

Important
even in the absence of frequent symptoms
infants and children whom have risk factors
for asthma and 4 or more episodes of
wheezing over the past yr which lasted more
than 1 day or 2 or more exacerbations in
the last 6 months requiring syst
corticosteroids should be considered in the
persistent group and hence receive long term
controller therapy

Important Tips..
 Regular clinical visits every 2-6 weeks
 Assessment of :

Pt symptoms frequency night and day
2. Need for short acting inhaled b2 agonists for
quick relief
3. Ability to engage in normal activities
4. Air flow measures for>=5 yrs
1.

Continue..
 Component 2 : pt education

 Component 3 : control of factors contributing

to asthma severity
1. Environmental exposures
2. Co morbid conditions
 Component 4 :principals of asthma
pharmacotherapy

Asthma Medication
 SABA

 ICS

 LABA
 LTRA

 SYSTEMIC STEROIDS

 NONSTEROIDAL ANTIINFLAMMATORY

CROMOLYN AND NEDOCROMYL
 OXYGEN
 ANTICHOLINERGIC AGENTS
IPRATROPIUM
BROMIDE
 ANTIIMMUNOGLUBOLINE E

MANAGEMENT OF ASTHMA EXACERBATION(STATUS ASTHMATICUS)
RISK ASSESMENT ON ADMISSION

FOCUSED HISTORY

ONSET OF CURRENT EXACERBATION
FREQUENCY AND severity of daytime and night
time symptoms and activity limitation
Frequency of rescue bronchodilator use
Current medication and allergies
Potential triggers
History of systemic steroid courses, emergency
department visists , hospitalization, intubation or life
threatening episodes

Clinical assesment

Physical examination findings: vital signs,
breathlessness, air movement, use of accessory
respiratory muscles, retractions, anxiety level,
alteration in mental status
Pulse oximetry
Lung function(defer in pts with mod to severe
distress or history of labile disease)

Treatment
Drugs and trade name

Mechanism of action and dosing

Cautions and adverse effects

Oxygen(mask or nasal canula)
Inhaled short acting b2
agonist
Albuterol nebulized
solution(5mg/ml concentrates
Albuterol MDI
Levabuterol

Treats hypoxia
Bronchodilator
Neubolizer 0.15 mg/kg every 20 min for 3
doses as needed,then 0.15_0.3 mg/kg up t 10
mg every 1_4 hour as needed or up to 0.5
mg/kg/hr by continous neubolization
2_8 puf up to every 20 min for 3 doses as
needed then every 1 hr as needed

Monitor pulse oximetry to maintain o2 saturation>92%
Cardiorespiratory monitoring
During exacerbations,frequent or continuous use can cause
pulmonary vasodilatation,v/q mistmatch and hypoxemia
Adverse effect palpitation, tachycardia, arrhythmia, tremor,
hypoxemia
Neubolizer:when giving concentrate forms,dilute with saline to 3
ml total neubolized volume
For MDI use space/holding chamber

Systemic corticosteroids
Prednisolone tb
Methyl prednisolon
Anticholinergics
Ipratropium
Atrovent
Ipratropium with Albuterol

Anti inflammatory
0.5_1 mg/kg every 6-8 hr for 48 hr , then 1-2 mg/kg
day bid(max 60 mg/day)
Short course burst for exacerbation 1-2 mg/kg/day qd
or bid for 3-7 days
Mucolitic/bronchodilator
Neubolizer 0.5 mg q6-8 hr (tid or qid) as needed
MDI 2 paf qid
1 vial by neubolizer qid



If pt has been exposed chickenpox or measles, consider passive
immunoglobulin prophylaxis, also risk of complications with
herspes simplex and TB

For daily dosing , 8 am administration minimizes adrenal
suppression

Children may benefit from dosage tapering if course exceed 7 days

Adverse effect monitoring: frequent therapy bursts risk numerous
corticosteroid adverse effects

Should not be used as first line treatment added to b2 agonist
therapy
Neubolizer may mix Ipratropium with Albuterol

QUICK RELIEF MEDICATION
SABA

Anti cholinergic(ipratropium)
Short term systemic gluco

corticoid

SABA
 Quick relief of asthma symptoms
 Relax airway smooth muscle prompt airflow↑
 Repetitive or continuous SABA is the most effective means







of reversing air flow obstruction
SABA should not be prescribed on a regular schedule
because concerns of possibility of deteriorating asthma
control
Frequent use of SABA is an indication of poor asthma control
Preferred root is inhalation smaller dose , fewer side effects
more rapid on set of action
Ipratropium Bromide as an adjunct to SABA in emergency
room reduces hospital admissions and improves lung function
Systemic Glucocorticoids short oral course + SABA in
moderate to severe asthma exacerbation

LABA
 Salmetrol

 Should be used in combination with inhaled

corticosteroids and not as mono therapy
 Exercise induces asthma in children >= 4 Yrs
one inhalation 30 min prior to exercise
 No additional doses for PTs who are already
receiving it twice daily not recommended by
NIH guidelines

LTRA

 MonteLukast ( singulair)

 Antihistaminic

 Leukotrien receptor antagonist

 Asthma ( not < 12 MO) and allergic rhinitis (





not < 6 MO)
Morning dosing not evaluated
Prophylactic and chronic treatment of asthma
Exercise induced asthma in >= 15 Yrs
Zafir Lukast : prophylactic and chronic
treatment of asthma

ICA
 Most potent anti inflammatory agents available

for the treatment of asthma
 Inhibiting most steps in the cascade of the
inflammatory response
 Benefits reducing bronchial hyper
responsiveness , prevention of late asthmatic
response , enhanced lung function
 Inhaled Glucocorticoids first line controller
therapy for persistent asthma or those who
require step 2

Prognosis
 35%of preschool children experience recurrent

coughing and wheezing,1/3 of them continue to
have persistent asthma into later childhood and
2/3 improvement on their own through their teen
yrs
 Asthma severity by age 7-10 yrs is predictive of
asthma persistence into adulthood
 Children with mod to severe asthma and lower lung
function are likely to have persistent asthma as
adults
 Children with milder asthma and N/R lung function
are likely to improve over time or be periodically
asthmatic

THANK YOU FOR YOUR
ATTENTION


Slide 36

Asthma in Children
DR. A.Mirshokraei
NIOC Hospital Pediatrics Ward

Definition :

DEFINITION

- Chronic inflammatory condition of the
lung airways resulting in episodic airflow
obstruction
- AHR to provocative exposures
Asthma management
• Reducing airway inflammation by: Minimizing
pro inflammatory environmental exposure, using
daily controller anti inflammatory medication,
controlling co morbid conditions that worsen
asthma, less inflammation better asthma
control and fewer exacerbations

Anyway exacerbations

occur

BUT
Even the uncommon
child with sever asthma can
be managed to live normally

 RECURRENT WHEEZING EPISODES WITH COMMON

RESPIRATORY
VIRUSES(RSV,RHINOVIRUS,INFLUENZA,PARAINFLUENZA,A
DENOVIRUS,HUMAN METAPNUMOVIRUS)

 HOST FEATURES AFFECTING IMMUNOLOGIC HOST

DEFENSE,INFLAMMATION/PREVIOUS VIRAL INFECTIONS
MAINIFESTED AS PNUMONIA OR BRONCHIOLITIS
REQUIRING HOSPITALIZATION UNDERLIE THE
RECURRENT WHEEZING IN EARLY CHILDHOOD

 OTHER AIRWAY EXPOSURES SUCH AS INDOOR AND HOME

ALLERGENS,COLD AIR,STRONG ODORS,TOBACCO
SMOKE,ALL INCREASE AHR

 ALLERGEN ELLIMINATION SOMETIMES LEEDS TO CURE

EPIDEMIOLOGY
 Common etiology of emergency visits and school day missing

in childhood ,occasionally hospitalization and rare deaths
specially in poverty ,urban living ,ethnic minorities

 Increasing asthma prevalence worldwide(50% per decade)
 Good correlation of asthma prevalence with allergic rhino

sinusitis and atopic eczema and other allergies

 More prevalence in high level urban modern families than

suburban villagers

 More than 80%of asthmatics reported getting the disease

before 6 year

CLINICS
RECURRENT COUGHING/WHEEZING
PATTERNS IN CHILDHOOD BASED ON
NATURAL HISTORY

TRANSIENT EARLY WHEEZING
 Common in early preschool years

 Recurrent coughing/wheezing primary

triggered by common respiratory viral INF
 Tend to resolve during preschool yrs without
increasing risk of asthma later in life
 Problems due to reduced airflow at birth
suggestive of relative narrow airways improved
by school yrs

Persistent Atopy Associated Asthma
 Begins in early preschool yrs

 Associated with atopy (eg atopic dermatitis in





infancy, allergic rhinitis, food allergy)
Biologic factors e.g.: early inhalant sensitization,
increase serum IGE, increase blood eosinophills,
High risk of persistence into later childhood and
adulthood lung function abnormality
Those with onset<3 yrs
reduced air flow by
school yrs
Those with later onset of symptoms or allergen
sensitizations unlikely persistence lung function
abnormality later

Non-Atopic Wheezing
 Wheezing ,coughing beginning in early life

often with RSV INF resolves later in childhood
without increasing risk of persistence asthma

 Associated with bronchial hyper

responsiveness near birth

Asthma with declining lung function
• Children with asthma with progressive

increase in air flow limitation

• Associated with hyper inflation in childhood
• Male gender

Late onset asthma in females associated with
obesity and early onset puberty
 Onset between 8_13 yrs

 Associated with early onset puberty and obesity
 Specific for females

Occupational type asthma in children
 Children with asthma and occupational type exposure

known to trigger asthma in adults in occupational settings

Types of Asthma
common clinical presentations of intermittent
recurrent wheezing and/or coughing
 Recurrent wheezing in early childhood

 Chronic asthma associated with allergy
 Females 11 yrs with early onset puberty and

obesity

Pathogenesis

 Airflow obstruction resulting from

Broncho constriction of bronchiolar smooth
muscle mass
II. Cellular inflammatory infiltrates and exudates
mostly Eosinophills(also N , M ,L ,mast cells
,basophiles)fill and obstruct airways and damage
epithelium and induce desquamation into airway
lumen mediated by T helper cells and other
immune cells that produce pro allergic pro
inflammatory cytokines(IL4,IL6,IL13)
III. Breach in normal immune regulatory process
I.

RESULT
 Airway inflammation

 AHR
 Edema basement membrane thickness sub

epithelial collagen deposition
 Smooth muscle and mucus gland hypertrophy
and mucus hyper secretion

Air obstruction

Clinical manifestations and diagnosis
 Most common intermittent dry cough and

expiratory wheezing

 Shortness of breath and chest tightness in older

children and adults

 Intermittent non focal chest pain in younger

children

 Worsening of respiratory symptoms at night
 Worsening of day time symptoms by activity

Continue…..
 Subtle symptoms such as self limitation of activities

,general fatigue ,difficulty in keeping up with peers

 Relief with aerosolized bronchodilators
 Lack of improvement with bronchodilators and steroid

is inconsistent with Asthma and should consider
Asthma masquerading conditions!!!!

 Hyper ventilation, intercostal retractions ,nasal flaring

,respiratory accessory muscle use

 Its common not to hear the expiratory wheezing when

Air flow is so limited before treatment

Asthma Triggers
 Common viral infections of the respiratory tract
 Aero allergens in sensitized asthmatics ,animal dander ,dust











mite ,molds ,indoor allergens ,cockroaches
Seasonal aero allergens ,pollens(trees ,grasses ,weeds ,)
Environmental tobacco smoke
Air pollutants ,ozone ,so2,wood or coal smoke ,endotoxin
,mycotoxin ,dust
Strong or noxious odors or fumes ,perfume ,hair spray
,cleaning agents
Occupational exposure
Cold air ,dry air
Exercise
Crying ,laughter ,hyperventilation
Co morbid conditions Rhinitis ,Sinusitis ,GER

Clinics
History:
Triggering symptoms by laughter
,cold air ,airway irritants
Exposures that induce airway
irritation such as viral URTI
Mycoplasma ,Chlamydia
Inhaled allergens
All lead to AHR

Presence Of Risk Factors:
 History of other allergies ,allergic Rhinitis,

allergic Conjunctivitis ,atopic Dermatitis ,food
allergies

 Parental Asthma
 Symptoms apart from cold

Continue…..
 No or minimal signs in routine visits

 Dry or persistent cough

 Normal chest findings unless wheezing when asking

to breath deeper
 Quick relief (10 MIN) after SABA use
 Expiratory wheezing ,prolonged expiratory phase
,decreased sounds in RT lower pos lobe due to
regional hypoventilation owing to airway
obstruction
 Rales , ronchi ,crackles due to hyper secretion
 Segmental crackles and poor breath sounds
atelectasis?

Continue….
 Labored respiration ,respiratory distress increased

prolongation of expiration and wheezing in E and I

 Poor air entry
 Inter costal retractions ,nasal flaring ,supra and

infra sternal retractions

 And again in most sever forms expiratory wheezing

does not appear until some broncho dilation

DD

GERD Rhino sinusitis co morbid

conditions with asthma

Recurrent aspiration in early

life(tracheo broncho malacia
,TEF , foreign body ,CF ,BPD

VCD in older children and

adolescents

LAB FINDINGS
Pulmonary Function
Testing

Continue….
 Forced expiratory airflow measures helpful

in Diagnosis , assessing efficacy of therapy
and monitoring Asthma in children specially
in poor children who do not have PHE
unless obstruction is sever

 Valueablity of spirometric findings in children>6

yrs

 3 efforts the highest is the peak
 Reduced FEV

obstruction

FEV1/FVC <0.80 means significant

 Improvement in FEV1 following beta 2 agonist > =

12% or 200 ml is consistent with Asthma

 Peak flow meter

CXR

Often normal aside from subtle and

nonspecific findings of hyperinflation

Peribronchial thickening
Helping in diagnosis of Asthma

differentials

Diagnosis of complications of Asthma

exacerbations

Other tests such as allergy skin prick
testing

Treatment
 www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm

Asthma Treatment & Management
has 4 components :
Assessment and monitoring of disease
activity
2. Provision to educate pt and family
3. Identification and management of
precipitating factors and co morbid
conditions
4. Appropriate selection of medication
1.

 Attainment of optimal Asthma control

Component 1
 Asthma severity :intermittent
 Persistent: mild ,mod ,severe
 Only once during patient initial evaluation in pt

who is not using a daily controller agent
 Asthma control degree to which symptoms ,
on going functional impairments , risk of
adverse events minimized and goals of
therapy are met

Continue….
Well controlled
2. Not well controlled
3. Very poor controlled
1.

 NIH guidelines for both severity and

control for 3 age groups

0-4 yrs
2. 5-11 yrs
3. =>12 yrs
1.

Important
even in the absence of frequent symptoms
infants and children whom have risk factors
for asthma and 4 or more episodes of
wheezing over the past yr which lasted more
than 1 day or 2 or more exacerbations in
the last 6 months requiring syst
corticosteroids should be considered in the
persistent group and hence receive long term
controller therapy

Important Tips..
 Regular clinical visits every 2-6 weeks
 Assessment of :

Pt symptoms frequency night and day
2. Need for short acting inhaled b2 agonists for
quick relief
3. Ability to engage in normal activities
4. Air flow measures for>=5 yrs
1.

Continue..
 Component 2 : pt education

 Component 3 : control of factors contributing

to asthma severity
1. Environmental exposures
2. Co morbid conditions
 Component 4 :principals of asthma
pharmacotherapy

Asthma Medication
 SABA

 ICS

 LABA
 LTRA

 SYSTEMIC STEROIDS

 NONSTEROIDAL ANTIINFLAMMATORY

CROMOLYN AND NEDOCROMYL
 OXYGEN
 ANTICHOLINERGIC AGENTS
IPRATROPIUM
BROMIDE
 ANTIIMMUNOGLUBOLINE E

MANAGEMENT OF ASTHMA EXACERBATION(STATUS ASTHMATICUS)
RISK ASSESMENT ON ADMISSION

FOCUSED HISTORY

ONSET OF CURRENT EXACERBATION
FREQUENCY AND severity of daytime and night
time symptoms and activity limitation
Frequency of rescue bronchodilator use
Current medication and allergies
Potential triggers
History of systemic steroid courses, emergency
department visists , hospitalization, intubation or life
threatening episodes

Clinical assesment

Physical examination findings: vital signs,
breathlessness, air movement, use of accessory
respiratory muscles, retractions, anxiety level,
alteration in mental status
Pulse oximetry
Lung function(defer in pts with mod to severe
distress or history of labile disease)

Treatment
Drugs and trade name

Mechanism of action and dosing

Cautions and adverse effects

Oxygen(mask or nasal canula)
Inhaled short acting b2
agonist
Albuterol nebulized
solution(5mg/ml concentrates
Albuterol MDI
Levabuterol

Treats hypoxia
Bronchodilator
Neubolizer 0.15 mg/kg every 20 min for 3
doses as needed,then 0.15_0.3 mg/kg up t 10
mg every 1_4 hour as needed or up to 0.5
mg/kg/hr by continous neubolization
2_8 puf up to every 20 min for 3 doses as
needed then every 1 hr as needed

Monitor pulse oximetry to maintain o2 saturation>92%
Cardiorespiratory monitoring
During exacerbations,frequent or continuous use can cause
pulmonary vasodilatation,v/q mistmatch and hypoxemia
Adverse effect palpitation, tachycardia, arrhythmia, tremor,
hypoxemia
Neubolizer:when giving concentrate forms,dilute with saline to 3
ml total neubolized volume
For MDI use space/holding chamber

Systemic corticosteroids
Prednisolone tb
Methyl prednisolon
Anticholinergics
Ipratropium
Atrovent
Ipratropium with Albuterol

Anti inflammatory
0.5_1 mg/kg every 6-8 hr for 48 hr , then 1-2 mg/kg
day bid(max 60 mg/day)
Short course burst for exacerbation 1-2 mg/kg/day qd
or bid for 3-7 days
Mucolitic/bronchodilator
Neubolizer 0.5 mg q6-8 hr (tid or qid) as needed
MDI 2 paf qid
1 vial by neubolizer qid



If pt has been exposed chickenpox or measles, consider passive
immunoglobulin prophylaxis, also risk of complications with
herspes simplex and TB

For daily dosing , 8 am administration minimizes adrenal
suppression

Children may benefit from dosage tapering if course exceed 7 days

Adverse effect monitoring: frequent therapy bursts risk numerous
corticosteroid adverse effects

Should not be used as first line treatment added to b2 agonist
therapy
Neubolizer may mix Ipratropium with Albuterol

QUICK RELIEF MEDICATION
SABA

Anti cholinergic(ipratropium)
Short term systemic gluco

corticoid

SABA
 Quick relief of asthma symptoms
 Relax airway smooth muscle prompt airflow↑
 Repetitive or continuous SABA is the most effective means







of reversing air flow obstruction
SABA should not be prescribed on a regular schedule
because concerns of possibility of deteriorating asthma
control
Frequent use of SABA is an indication of poor asthma control
Preferred root is inhalation smaller dose , fewer side effects
more rapid on set of action
Ipratropium Bromide as an adjunct to SABA in emergency
room reduces hospital admissions and improves lung function
Systemic Glucocorticoids short oral course + SABA in
moderate to severe asthma exacerbation

LABA
 Salmetrol

 Should be used in combination with inhaled

corticosteroids and not as mono therapy
 Exercise induces asthma in children >= 4 Yrs
one inhalation 30 min prior to exercise
 No additional doses for PTs who are already
receiving it twice daily not recommended by
NIH guidelines

LTRA

 MonteLukast ( singulair)

 Antihistaminic

 Leukotrien receptor antagonist

 Asthma ( not < 12 MO) and allergic rhinitis (





not < 6 MO)
Morning dosing not evaluated
Prophylactic and chronic treatment of asthma
Exercise induced asthma in >= 15 Yrs
Zafir Lukast : prophylactic and chronic
treatment of asthma

ICA
 Most potent anti inflammatory agents available

for the treatment of asthma
 Inhibiting most steps in the cascade of the
inflammatory response
 Benefits reducing bronchial hyper
responsiveness , prevention of late asthmatic
response , enhanced lung function
 Inhaled Glucocorticoids first line controller
therapy for persistent asthma or those who
require step 2

Prognosis
 35%of preschool children experience recurrent

coughing and wheezing,1/3 of them continue to
have persistent asthma into later childhood and
2/3 improvement on their own through their teen
yrs
 Asthma severity by age 7-10 yrs is predictive of
asthma persistence into adulthood
 Children with mod to severe asthma and lower lung
function are likely to have persistent asthma as
adults
 Children with milder asthma and N/R lung function
are likely to improve over time or be periodically
asthmatic

THANK YOU FOR YOUR
ATTENTION


Slide 37

Asthma in Children
DR. A.Mirshokraei
NIOC Hospital Pediatrics Ward

Definition :

DEFINITION

- Chronic inflammatory condition of the
lung airways resulting in episodic airflow
obstruction
- AHR to provocative exposures
Asthma management
• Reducing airway inflammation by: Minimizing
pro inflammatory environmental exposure, using
daily controller anti inflammatory medication,
controlling co morbid conditions that worsen
asthma, less inflammation better asthma
control and fewer exacerbations

Anyway exacerbations

occur

BUT
Even the uncommon
child with sever asthma can
be managed to live normally

 RECURRENT WHEEZING EPISODES WITH COMMON

RESPIRATORY
VIRUSES(RSV,RHINOVIRUS,INFLUENZA,PARAINFLUENZA,A
DENOVIRUS,HUMAN METAPNUMOVIRUS)

 HOST FEATURES AFFECTING IMMUNOLOGIC HOST

DEFENSE,INFLAMMATION/PREVIOUS VIRAL INFECTIONS
MAINIFESTED AS PNUMONIA OR BRONCHIOLITIS
REQUIRING HOSPITALIZATION UNDERLIE THE
RECURRENT WHEEZING IN EARLY CHILDHOOD

 OTHER AIRWAY EXPOSURES SUCH AS INDOOR AND HOME

ALLERGENS,COLD AIR,STRONG ODORS,TOBACCO
SMOKE,ALL INCREASE AHR

 ALLERGEN ELLIMINATION SOMETIMES LEEDS TO CURE

EPIDEMIOLOGY
 Common etiology of emergency visits and school day missing

in childhood ,occasionally hospitalization and rare deaths
specially in poverty ,urban living ,ethnic minorities

 Increasing asthma prevalence worldwide(50% per decade)
 Good correlation of asthma prevalence with allergic rhino

sinusitis and atopic eczema and other allergies

 More prevalence in high level urban modern families than

suburban villagers

 More than 80%of asthmatics reported getting the disease

before 6 year

CLINICS
RECURRENT COUGHING/WHEEZING
PATTERNS IN CHILDHOOD BASED ON
NATURAL HISTORY

TRANSIENT EARLY WHEEZING
 Common in early preschool years

 Recurrent coughing/wheezing primary

triggered by common respiratory viral INF
 Tend to resolve during preschool yrs without
increasing risk of asthma later in life
 Problems due to reduced airflow at birth
suggestive of relative narrow airways improved
by school yrs

Persistent Atopy Associated Asthma
 Begins in early preschool yrs

 Associated with atopy (eg atopic dermatitis in





infancy, allergic rhinitis, food allergy)
Biologic factors e.g.: early inhalant sensitization,
increase serum IGE, increase blood eosinophills,
High risk of persistence into later childhood and
adulthood lung function abnormality
Those with onset<3 yrs
reduced air flow by
school yrs
Those with later onset of symptoms or allergen
sensitizations unlikely persistence lung function
abnormality later

Non-Atopic Wheezing
 Wheezing ,coughing beginning in early life

often with RSV INF resolves later in childhood
without increasing risk of persistence asthma

 Associated with bronchial hyper

responsiveness near birth

Asthma with declining lung function
• Children with asthma with progressive

increase in air flow limitation

• Associated with hyper inflation in childhood
• Male gender

Late onset asthma in females associated with
obesity and early onset puberty
 Onset between 8_13 yrs

 Associated with early onset puberty and obesity
 Specific for females

Occupational type asthma in children
 Children with asthma and occupational type exposure

known to trigger asthma in adults in occupational settings

Types of Asthma
common clinical presentations of intermittent
recurrent wheezing and/or coughing
 Recurrent wheezing in early childhood

 Chronic asthma associated with allergy
 Females 11 yrs with early onset puberty and

obesity

Pathogenesis

 Airflow obstruction resulting from

Broncho constriction of bronchiolar smooth
muscle mass
II. Cellular inflammatory infiltrates and exudates
mostly Eosinophills(also N , M ,L ,mast cells
,basophiles)fill and obstruct airways and damage
epithelium and induce desquamation into airway
lumen mediated by T helper cells and other
immune cells that produce pro allergic pro
inflammatory cytokines(IL4,IL6,IL13)
III. Breach in normal immune regulatory process
I.

RESULT
 Airway inflammation

 AHR
 Edema basement membrane thickness sub

epithelial collagen deposition
 Smooth muscle and mucus gland hypertrophy
and mucus hyper secretion

Air obstruction

Clinical manifestations and diagnosis
 Most common intermittent dry cough and

expiratory wheezing

 Shortness of breath and chest tightness in older

children and adults

 Intermittent non focal chest pain in younger

children

 Worsening of respiratory symptoms at night
 Worsening of day time symptoms by activity

Continue…..
 Subtle symptoms such as self limitation of activities

,general fatigue ,difficulty in keeping up with peers

 Relief with aerosolized bronchodilators
 Lack of improvement with bronchodilators and steroid

is inconsistent with Asthma and should consider
Asthma masquerading conditions!!!!

 Hyper ventilation, intercostal retractions ,nasal flaring

,respiratory accessory muscle use

 Its common not to hear the expiratory wheezing when

Air flow is so limited before treatment

Asthma Triggers
 Common viral infections of the respiratory tract
 Aero allergens in sensitized asthmatics ,animal dander ,dust











mite ,molds ,indoor allergens ,cockroaches
Seasonal aero allergens ,pollens(trees ,grasses ,weeds ,)
Environmental tobacco smoke
Air pollutants ,ozone ,so2,wood or coal smoke ,endotoxin
,mycotoxin ,dust
Strong or noxious odors or fumes ,perfume ,hair spray
,cleaning agents
Occupational exposure
Cold air ,dry air
Exercise
Crying ,laughter ,hyperventilation
Co morbid conditions Rhinitis ,Sinusitis ,GER

Clinics
History:
Triggering symptoms by laughter
,cold air ,airway irritants
Exposures that induce airway
irritation such as viral URTI
Mycoplasma ,Chlamydia
Inhaled allergens
All lead to AHR

Presence Of Risk Factors:
 History of other allergies ,allergic Rhinitis,

allergic Conjunctivitis ,atopic Dermatitis ,food
allergies

 Parental Asthma
 Symptoms apart from cold

Continue…..
 No or minimal signs in routine visits

 Dry or persistent cough

 Normal chest findings unless wheezing when asking

to breath deeper
 Quick relief (10 MIN) after SABA use
 Expiratory wheezing ,prolonged expiratory phase
,decreased sounds in RT lower pos lobe due to
regional hypoventilation owing to airway
obstruction
 Rales , ronchi ,crackles due to hyper secretion
 Segmental crackles and poor breath sounds
atelectasis?

Continue….
 Labored respiration ,respiratory distress increased

prolongation of expiration and wheezing in E and I

 Poor air entry
 Inter costal retractions ,nasal flaring ,supra and

infra sternal retractions

 And again in most sever forms expiratory wheezing

does not appear until some broncho dilation

DD

GERD Rhino sinusitis co morbid

conditions with asthma

Recurrent aspiration in early

life(tracheo broncho malacia
,TEF , foreign body ,CF ,BPD

VCD in older children and

adolescents

LAB FINDINGS
Pulmonary Function
Testing

Continue….
 Forced expiratory airflow measures helpful

in Diagnosis , assessing efficacy of therapy
and monitoring Asthma in children specially
in poor children who do not have PHE
unless obstruction is sever

 Valueablity of spirometric findings in children>6

yrs

 3 efforts the highest is the peak
 Reduced FEV

obstruction

FEV1/FVC <0.80 means significant

 Improvement in FEV1 following beta 2 agonist > =

12% or 200 ml is consistent with Asthma

 Peak flow meter

CXR

Often normal aside from subtle and

nonspecific findings of hyperinflation

Peribronchial thickening
Helping in diagnosis of Asthma

differentials

Diagnosis of complications of Asthma

exacerbations

Other tests such as allergy skin prick
testing

Treatment
 www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm

Asthma Treatment & Management
has 4 components :
Assessment and monitoring of disease
activity
2. Provision to educate pt and family
3. Identification and management of
precipitating factors and co morbid
conditions
4. Appropriate selection of medication
1.

 Attainment of optimal Asthma control

Component 1
 Asthma severity :intermittent
 Persistent: mild ,mod ,severe
 Only once during patient initial evaluation in pt

who is not using a daily controller agent
 Asthma control degree to which symptoms ,
on going functional impairments , risk of
adverse events minimized and goals of
therapy are met

Continue….
Well controlled
2. Not well controlled
3. Very poor controlled
1.

 NIH guidelines for both severity and

control for 3 age groups

0-4 yrs
2. 5-11 yrs
3. =>12 yrs
1.

Important
even in the absence of frequent symptoms
infants and children whom have risk factors
for asthma and 4 or more episodes of
wheezing over the past yr which lasted more
than 1 day or 2 or more exacerbations in
the last 6 months requiring syst
corticosteroids should be considered in the
persistent group and hence receive long term
controller therapy

Important Tips..
 Regular clinical visits every 2-6 weeks
 Assessment of :

Pt symptoms frequency night and day
2. Need for short acting inhaled b2 agonists for
quick relief
3. Ability to engage in normal activities
4. Air flow measures for>=5 yrs
1.

Continue..
 Component 2 : pt education

 Component 3 : control of factors contributing

to asthma severity
1. Environmental exposures
2. Co morbid conditions
 Component 4 :principals of asthma
pharmacotherapy

Asthma Medication
 SABA

 ICS

 LABA
 LTRA

 SYSTEMIC STEROIDS

 NONSTEROIDAL ANTIINFLAMMATORY

CROMOLYN AND NEDOCROMYL
 OXYGEN
 ANTICHOLINERGIC AGENTS
IPRATROPIUM
BROMIDE
 ANTIIMMUNOGLUBOLINE E

MANAGEMENT OF ASTHMA EXACERBATION(STATUS ASTHMATICUS)
RISK ASSESMENT ON ADMISSION

FOCUSED HISTORY

ONSET OF CURRENT EXACERBATION
FREQUENCY AND severity of daytime and night
time symptoms and activity limitation
Frequency of rescue bronchodilator use
Current medication and allergies
Potential triggers
History of systemic steroid courses, emergency
department visists , hospitalization, intubation or life
threatening episodes

Clinical assesment

Physical examination findings: vital signs,
breathlessness, air movement, use of accessory
respiratory muscles, retractions, anxiety level,
alteration in mental status
Pulse oximetry
Lung function(defer in pts with mod to severe
distress or history of labile disease)

Treatment
Drugs and trade name

Mechanism of action and dosing

Cautions and adverse effects

Oxygen(mask or nasal canula)
Inhaled short acting b2
agonist
Albuterol nebulized
solution(5mg/ml concentrates
Albuterol MDI
Levabuterol

Treats hypoxia
Bronchodilator
Neubolizer 0.15 mg/kg every 20 min for 3
doses as needed,then 0.15_0.3 mg/kg up t 10
mg every 1_4 hour as needed or up to 0.5
mg/kg/hr by continous neubolization
2_8 puf up to every 20 min for 3 doses as
needed then every 1 hr as needed

Monitor pulse oximetry to maintain o2 saturation>92%
Cardiorespiratory monitoring
During exacerbations,frequent or continuous use can cause
pulmonary vasodilatation,v/q mistmatch and hypoxemia
Adverse effect palpitation, tachycardia, arrhythmia, tremor,
hypoxemia
Neubolizer:when giving concentrate forms,dilute with saline to 3
ml total neubolized volume
For MDI use space/holding chamber

Systemic corticosteroids
Prednisolone tb
Methyl prednisolon
Anticholinergics
Ipratropium
Atrovent
Ipratropium with Albuterol

Anti inflammatory
0.5_1 mg/kg every 6-8 hr for 48 hr , then 1-2 mg/kg
day bid(max 60 mg/day)
Short course burst for exacerbation 1-2 mg/kg/day qd
or bid for 3-7 days
Mucolitic/bronchodilator
Neubolizer 0.5 mg q6-8 hr (tid or qid) as needed
MDI 2 paf qid
1 vial by neubolizer qid



If pt has been exposed chickenpox or measles, consider passive
immunoglobulin prophylaxis, also risk of complications with
herspes simplex and TB

For daily dosing , 8 am administration minimizes adrenal
suppression

Children may benefit from dosage tapering if course exceed 7 days

Adverse effect monitoring: frequent therapy bursts risk numerous
corticosteroid adverse effects

Should not be used as first line treatment added to b2 agonist
therapy
Neubolizer may mix Ipratropium with Albuterol

QUICK RELIEF MEDICATION
SABA

Anti cholinergic(ipratropium)
Short term systemic gluco

corticoid

SABA
 Quick relief of asthma symptoms
 Relax airway smooth muscle prompt airflow↑
 Repetitive or continuous SABA is the most effective means







of reversing air flow obstruction
SABA should not be prescribed on a regular schedule
because concerns of possibility of deteriorating asthma
control
Frequent use of SABA is an indication of poor asthma control
Preferred root is inhalation smaller dose , fewer side effects
more rapid on set of action
Ipratropium Bromide as an adjunct to SABA in emergency
room reduces hospital admissions and improves lung function
Systemic Glucocorticoids short oral course + SABA in
moderate to severe asthma exacerbation

LABA
 Salmetrol

 Should be used in combination with inhaled

corticosteroids and not as mono therapy
 Exercise induces asthma in children >= 4 Yrs
one inhalation 30 min prior to exercise
 No additional doses for PTs who are already
receiving it twice daily not recommended by
NIH guidelines

LTRA

 MonteLukast ( singulair)

 Antihistaminic

 Leukotrien receptor antagonist

 Asthma ( not < 12 MO) and allergic rhinitis (





not < 6 MO)
Morning dosing not evaluated
Prophylactic and chronic treatment of asthma
Exercise induced asthma in >= 15 Yrs
Zafir Lukast : prophylactic and chronic
treatment of asthma

ICA
 Most potent anti inflammatory agents available

for the treatment of asthma
 Inhibiting most steps in the cascade of the
inflammatory response
 Benefits reducing bronchial hyper
responsiveness , prevention of late asthmatic
response , enhanced lung function
 Inhaled Glucocorticoids first line controller
therapy for persistent asthma or those who
require step 2

Prognosis
 35%of preschool children experience recurrent

coughing and wheezing,1/3 of them continue to
have persistent asthma into later childhood and
2/3 improvement on their own through their teen
yrs
 Asthma severity by age 7-10 yrs is predictive of
asthma persistence into adulthood
 Children with mod to severe asthma and lower lung
function are likely to have persistent asthma as
adults
 Children with milder asthma and N/R lung function
are likely to improve over time or be periodically
asthmatic

THANK YOU FOR YOUR
ATTENTION


Slide 38

Asthma in Children
DR. A.Mirshokraei
NIOC Hospital Pediatrics Ward

Definition :

DEFINITION

- Chronic inflammatory condition of the
lung airways resulting in episodic airflow
obstruction
- AHR to provocative exposures
Asthma management
• Reducing airway inflammation by: Minimizing
pro inflammatory environmental exposure, using
daily controller anti inflammatory medication,
controlling co morbid conditions that worsen
asthma, less inflammation better asthma
control and fewer exacerbations

Anyway exacerbations

occur

BUT
Even the uncommon
child with sever asthma can
be managed to live normally

 RECURRENT WHEEZING EPISODES WITH COMMON

RESPIRATORY
VIRUSES(RSV,RHINOVIRUS,INFLUENZA,PARAINFLUENZA,A
DENOVIRUS,HUMAN METAPNUMOVIRUS)

 HOST FEATURES AFFECTING IMMUNOLOGIC HOST

DEFENSE,INFLAMMATION/PREVIOUS VIRAL INFECTIONS
MAINIFESTED AS PNUMONIA OR BRONCHIOLITIS
REQUIRING HOSPITALIZATION UNDERLIE THE
RECURRENT WHEEZING IN EARLY CHILDHOOD

 OTHER AIRWAY EXPOSURES SUCH AS INDOOR AND HOME

ALLERGENS,COLD AIR,STRONG ODORS,TOBACCO
SMOKE,ALL INCREASE AHR

 ALLERGEN ELLIMINATION SOMETIMES LEEDS TO CURE

EPIDEMIOLOGY
 Common etiology of emergency visits and school day missing

in childhood ,occasionally hospitalization and rare deaths
specially in poverty ,urban living ,ethnic minorities

 Increasing asthma prevalence worldwide(50% per decade)
 Good correlation of asthma prevalence with allergic rhino

sinusitis and atopic eczema and other allergies

 More prevalence in high level urban modern families than

suburban villagers

 More than 80%of asthmatics reported getting the disease

before 6 year

CLINICS
RECURRENT COUGHING/WHEEZING
PATTERNS IN CHILDHOOD BASED ON
NATURAL HISTORY

TRANSIENT EARLY WHEEZING
 Common in early preschool years

 Recurrent coughing/wheezing primary

triggered by common respiratory viral INF
 Tend to resolve during preschool yrs without
increasing risk of asthma later in life
 Problems due to reduced airflow at birth
suggestive of relative narrow airways improved
by school yrs

Persistent Atopy Associated Asthma
 Begins in early preschool yrs

 Associated with atopy (eg atopic dermatitis in





infancy, allergic rhinitis, food allergy)
Biologic factors e.g.: early inhalant sensitization,
increase serum IGE, increase blood eosinophills,
High risk of persistence into later childhood and
adulthood lung function abnormality
Those with onset<3 yrs
reduced air flow by
school yrs
Those with later onset of symptoms or allergen
sensitizations unlikely persistence lung function
abnormality later

Non-Atopic Wheezing
 Wheezing ,coughing beginning in early life

often with RSV INF resolves later in childhood
without increasing risk of persistence asthma

 Associated with bronchial hyper

responsiveness near birth

Asthma with declining lung function
• Children with asthma with progressive

increase in air flow limitation

• Associated with hyper inflation in childhood
• Male gender

Late onset asthma in females associated with
obesity and early onset puberty
 Onset between 8_13 yrs

 Associated with early onset puberty and obesity
 Specific for females

Occupational type asthma in children
 Children with asthma and occupational type exposure

known to trigger asthma in adults in occupational settings

Types of Asthma
common clinical presentations of intermittent
recurrent wheezing and/or coughing
 Recurrent wheezing in early childhood

 Chronic asthma associated with allergy
 Females 11 yrs with early onset puberty and

obesity

Pathogenesis

 Airflow obstruction resulting from

Broncho constriction of bronchiolar smooth
muscle mass
II. Cellular inflammatory infiltrates and exudates
mostly Eosinophills(also N , M ,L ,mast cells
,basophiles)fill and obstruct airways and damage
epithelium and induce desquamation into airway
lumen mediated by T helper cells and other
immune cells that produce pro allergic pro
inflammatory cytokines(IL4,IL6,IL13)
III. Breach in normal immune regulatory process
I.

RESULT
 Airway inflammation

 AHR
 Edema basement membrane thickness sub

epithelial collagen deposition
 Smooth muscle and mucus gland hypertrophy
and mucus hyper secretion

Air obstruction

Clinical manifestations and diagnosis
 Most common intermittent dry cough and

expiratory wheezing

 Shortness of breath and chest tightness in older

children and adults

 Intermittent non focal chest pain in younger

children

 Worsening of respiratory symptoms at night
 Worsening of day time symptoms by activity

Continue…..
 Subtle symptoms such as self limitation of activities

,general fatigue ,difficulty in keeping up with peers

 Relief with aerosolized bronchodilators
 Lack of improvement with bronchodilators and steroid

is inconsistent with Asthma and should consider
Asthma masquerading conditions!!!!

 Hyper ventilation, intercostal retractions ,nasal flaring

,respiratory accessory muscle use

 Its common not to hear the expiratory wheezing when

Air flow is so limited before treatment

Asthma Triggers
 Common viral infections of the respiratory tract
 Aero allergens in sensitized asthmatics ,animal dander ,dust











mite ,molds ,indoor allergens ,cockroaches
Seasonal aero allergens ,pollens(trees ,grasses ,weeds ,)
Environmental tobacco smoke
Air pollutants ,ozone ,so2,wood or coal smoke ,endotoxin
,mycotoxin ,dust
Strong or noxious odors or fumes ,perfume ,hair spray
,cleaning agents
Occupational exposure
Cold air ,dry air
Exercise
Crying ,laughter ,hyperventilation
Co morbid conditions Rhinitis ,Sinusitis ,GER

Clinics
History:
Triggering symptoms by laughter
,cold air ,airway irritants
Exposures that induce airway
irritation such as viral URTI
Mycoplasma ,Chlamydia
Inhaled allergens
All lead to AHR

Presence Of Risk Factors:
 History of other allergies ,allergic Rhinitis,

allergic Conjunctivitis ,atopic Dermatitis ,food
allergies

 Parental Asthma
 Symptoms apart from cold

Continue…..
 No or minimal signs in routine visits

 Dry or persistent cough

 Normal chest findings unless wheezing when asking

to breath deeper
 Quick relief (10 MIN) after SABA use
 Expiratory wheezing ,prolonged expiratory phase
,decreased sounds in RT lower pos lobe due to
regional hypoventilation owing to airway
obstruction
 Rales , ronchi ,crackles due to hyper secretion
 Segmental crackles and poor breath sounds
atelectasis?

Continue….
 Labored respiration ,respiratory distress increased

prolongation of expiration and wheezing in E and I

 Poor air entry
 Inter costal retractions ,nasal flaring ,supra and

infra sternal retractions

 And again in most sever forms expiratory wheezing

does not appear until some broncho dilation

DD

GERD Rhino sinusitis co morbid

conditions with asthma

Recurrent aspiration in early

life(tracheo broncho malacia
,TEF , foreign body ,CF ,BPD

VCD in older children and

adolescents

LAB FINDINGS
Pulmonary Function
Testing

Continue….
 Forced expiratory airflow measures helpful

in Diagnosis , assessing efficacy of therapy
and monitoring Asthma in children specially
in poor children who do not have PHE
unless obstruction is sever

 Valueablity of spirometric findings in children>6

yrs

 3 efforts the highest is the peak
 Reduced FEV

obstruction

FEV1/FVC <0.80 means significant

 Improvement in FEV1 following beta 2 agonist > =

12% or 200 ml is consistent with Asthma

 Peak flow meter

CXR

Often normal aside from subtle and

nonspecific findings of hyperinflation

Peribronchial thickening
Helping in diagnosis of Asthma

differentials

Diagnosis of complications of Asthma

exacerbations

Other tests such as allergy skin prick
testing

Treatment
 www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm

Asthma Treatment & Management
has 4 components :
Assessment and monitoring of disease
activity
2. Provision to educate pt and family
3. Identification and management of
precipitating factors and co morbid
conditions
4. Appropriate selection of medication
1.

 Attainment of optimal Asthma control

Component 1
 Asthma severity :intermittent
 Persistent: mild ,mod ,severe
 Only once during patient initial evaluation in pt

who is not using a daily controller agent
 Asthma control degree to which symptoms ,
on going functional impairments , risk of
adverse events minimized and goals of
therapy are met

Continue….
Well controlled
2. Not well controlled
3. Very poor controlled
1.

 NIH guidelines for both severity and

control for 3 age groups

0-4 yrs
2. 5-11 yrs
3. =>12 yrs
1.

Important
even in the absence of frequent symptoms
infants and children whom have risk factors
for asthma and 4 or more episodes of
wheezing over the past yr which lasted more
than 1 day or 2 or more exacerbations in
the last 6 months requiring syst
corticosteroids should be considered in the
persistent group and hence receive long term
controller therapy

Important Tips..
 Regular clinical visits every 2-6 weeks
 Assessment of :

Pt symptoms frequency night and day
2. Need for short acting inhaled b2 agonists for
quick relief
3. Ability to engage in normal activities
4. Air flow measures for>=5 yrs
1.

Continue..
 Component 2 : pt education

 Component 3 : control of factors contributing

to asthma severity
1. Environmental exposures
2. Co morbid conditions
 Component 4 :principals of asthma
pharmacotherapy

Asthma Medication
 SABA

 ICS

 LABA
 LTRA

 SYSTEMIC STEROIDS

 NONSTEROIDAL ANTIINFLAMMATORY

CROMOLYN AND NEDOCROMYL
 OXYGEN
 ANTICHOLINERGIC AGENTS
IPRATROPIUM
BROMIDE
 ANTIIMMUNOGLUBOLINE E

MANAGEMENT OF ASTHMA EXACERBATION(STATUS ASTHMATICUS)
RISK ASSESMENT ON ADMISSION

FOCUSED HISTORY

ONSET OF CURRENT EXACERBATION
FREQUENCY AND severity of daytime and night
time symptoms and activity limitation
Frequency of rescue bronchodilator use
Current medication and allergies
Potential triggers
History of systemic steroid courses, emergency
department visists , hospitalization, intubation or life
threatening episodes

Clinical assesment

Physical examination findings: vital signs,
breathlessness, air movement, use of accessory
respiratory muscles, retractions, anxiety level,
alteration in mental status
Pulse oximetry
Lung function(defer in pts with mod to severe
distress or history of labile disease)

Treatment
Drugs and trade name

Mechanism of action and dosing

Cautions and adverse effects

Oxygen(mask or nasal canula)
Inhaled short acting b2
agonist
Albuterol nebulized
solution(5mg/ml concentrates
Albuterol MDI
Levabuterol

Treats hypoxia
Bronchodilator
Neubolizer 0.15 mg/kg every 20 min for 3
doses as needed,then 0.15_0.3 mg/kg up t 10
mg every 1_4 hour as needed or up to 0.5
mg/kg/hr by continous neubolization
2_8 puf up to every 20 min for 3 doses as
needed then every 1 hr as needed

Monitor pulse oximetry to maintain o2 saturation>92%
Cardiorespiratory monitoring
During exacerbations,frequent or continuous use can cause
pulmonary vasodilatation,v/q mistmatch and hypoxemia
Adverse effect palpitation, tachycardia, arrhythmia, tremor,
hypoxemia
Neubolizer:when giving concentrate forms,dilute with saline to 3
ml total neubolized volume
For MDI use space/holding chamber

Systemic corticosteroids
Prednisolone tb
Methyl prednisolon
Anticholinergics
Ipratropium
Atrovent
Ipratropium with Albuterol

Anti inflammatory
0.5_1 mg/kg every 6-8 hr for 48 hr , then 1-2 mg/kg
day bid(max 60 mg/day)
Short course burst for exacerbation 1-2 mg/kg/day qd
or bid for 3-7 days
Mucolitic/bronchodilator
Neubolizer 0.5 mg q6-8 hr (tid or qid) as needed
MDI 2 paf qid
1 vial by neubolizer qid



If pt has been exposed chickenpox or measles, consider passive
immunoglobulin prophylaxis, also risk of complications with
herspes simplex and TB

For daily dosing , 8 am administration minimizes adrenal
suppression

Children may benefit from dosage tapering if course exceed 7 days

Adverse effect monitoring: frequent therapy bursts risk numerous
corticosteroid adverse effects

Should not be used as first line treatment added to b2 agonist
therapy
Neubolizer may mix Ipratropium with Albuterol

QUICK RELIEF MEDICATION
SABA

Anti cholinergic(ipratropium)
Short term systemic gluco

corticoid

SABA
 Quick relief of asthma symptoms
 Relax airway smooth muscle prompt airflow↑
 Repetitive or continuous SABA is the most effective means







of reversing air flow obstruction
SABA should not be prescribed on a regular schedule
because concerns of possibility of deteriorating asthma
control
Frequent use of SABA is an indication of poor asthma control
Preferred root is inhalation smaller dose , fewer side effects
more rapid on set of action
Ipratropium Bromide as an adjunct to SABA in emergency
room reduces hospital admissions and improves lung function
Systemic Glucocorticoids short oral course + SABA in
moderate to severe asthma exacerbation

LABA
 Salmetrol

 Should be used in combination with inhaled

corticosteroids and not as mono therapy
 Exercise induces asthma in children >= 4 Yrs
one inhalation 30 min prior to exercise
 No additional doses for PTs who are already
receiving it twice daily not recommended by
NIH guidelines

LTRA

 MonteLukast ( singulair)

 Antihistaminic

 Leukotrien receptor antagonist

 Asthma ( not < 12 MO) and allergic rhinitis (





not < 6 MO)
Morning dosing not evaluated
Prophylactic and chronic treatment of asthma
Exercise induced asthma in >= 15 Yrs
Zafir Lukast : prophylactic and chronic
treatment of asthma

ICA
 Most potent anti inflammatory agents available

for the treatment of asthma
 Inhibiting most steps in the cascade of the
inflammatory response
 Benefits reducing bronchial hyper
responsiveness , prevention of late asthmatic
response , enhanced lung function
 Inhaled Glucocorticoids first line controller
therapy for persistent asthma or those who
require step 2

Prognosis
 35%of preschool children experience recurrent

coughing and wheezing,1/3 of them continue to
have persistent asthma into later childhood and
2/3 improvement on their own through their teen
yrs
 Asthma severity by age 7-10 yrs is predictive of
asthma persistence into adulthood
 Children with mod to severe asthma and lower lung
function are likely to have persistent asthma as
adults
 Children with milder asthma and N/R lung function
are likely to improve over time or be periodically
asthmatic

THANK YOU FOR YOUR
ATTENTION


Slide 39

Asthma in Children
DR. A.Mirshokraei
NIOC Hospital Pediatrics Ward

Definition :

DEFINITION

- Chronic inflammatory condition of the
lung airways resulting in episodic airflow
obstruction
- AHR to provocative exposures
Asthma management
• Reducing airway inflammation by: Minimizing
pro inflammatory environmental exposure, using
daily controller anti inflammatory medication,
controlling co morbid conditions that worsen
asthma, less inflammation better asthma
control and fewer exacerbations

Anyway exacerbations

occur

BUT
Even the uncommon
child with sever asthma can
be managed to live normally

 RECURRENT WHEEZING EPISODES WITH COMMON

RESPIRATORY
VIRUSES(RSV,RHINOVIRUS,INFLUENZA,PARAINFLUENZA,A
DENOVIRUS,HUMAN METAPNUMOVIRUS)

 HOST FEATURES AFFECTING IMMUNOLOGIC HOST

DEFENSE,INFLAMMATION/PREVIOUS VIRAL INFECTIONS
MAINIFESTED AS PNUMONIA OR BRONCHIOLITIS
REQUIRING HOSPITALIZATION UNDERLIE THE
RECURRENT WHEEZING IN EARLY CHILDHOOD

 OTHER AIRWAY EXPOSURES SUCH AS INDOOR AND HOME

ALLERGENS,COLD AIR,STRONG ODORS,TOBACCO
SMOKE,ALL INCREASE AHR

 ALLERGEN ELLIMINATION SOMETIMES LEEDS TO CURE

EPIDEMIOLOGY
 Common etiology of emergency visits and school day missing

in childhood ,occasionally hospitalization and rare deaths
specially in poverty ,urban living ,ethnic minorities

 Increasing asthma prevalence worldwide(50% per decade)
 Good correlation of asthma prevalence with allergic rhino

sinusitis and atopic eczema and other allergies

 More prevalence in high level urban modern families than

suburban villagers

 More than 80%of asthmatics reported getting the disease

before 6 year

CLINICS
RECURRENT COUGHING/WHEEZING
PATTERNS IN CHILDHOOD BASED ON
NATURAL HISTORY

TRANSIENT EARLY WHEEZING
 Common in early preschool years

 Recurrent coughing/wheezing primary

triggered by common respiratory viral INF
 Tend to resolve during preschool yrs without
increasing risk of asthma later in life
 Problems due to reduced airflow at birth
suggestive of relative narrow airways improved
by school yrs

Persistent Atopy Associated Asthma
 Begins in early preschool yrs

 Associated with atopy (eg atopic dermatitis in





infancy, allergic rhinitis, food allergy)
Biologic factors e.g.: early inhalant sensitization,
increase serum IGE, increase blood eosinophills,
High risk of persistence into later childhood and
adulthood lung function abnormality
Those with onset<3 yrs
reduced air flow by
school yrs
Those with later onset of symptoms or allergen
sensitizations unlikely persistence lung function
abnormality later

Non-Atopic Wheezing
 Wheezing ,coughing beginning in early life

often with RSV INF resolves later in childhood
without increasing risk of persistence asthma

 Associated with bronchial hyper

responsiveness near birth

Asthma with declining lung function
• Children with asthma with progressive

increase in air flow limitation

• Associated with hyper inflation in childhood
• Male gender

Late onset asthma in females associated with
obesity and early onset puberty
 Onset between 8_13 yrs

 Associated with early onset puberty and obesity
 Specific for females

Occupational type asthma in children
 Children with asthma and occupational type exposure

known to trigger asthma in adults in occupational settings

Types of Asthma
common clinical presentations of intermittent
recurrent wheezing and/or coughing
 Recurrent wheezing in early childhood

 Chronic asthma associated with allergy
 Females 11 yrs with early onset puberty and

obesity

Pathogenesis

 Airflow obstruction resulting from

Broncho constriction of bronchiolar smooth
muscle mass
II. Cellular inflammatory infiltrates and exudates
mostly Eosinophills(also N , M ,L ,mast cells
,basophiles)fill and obstruct airways and damage
epithelium and induce desquamation into airway
lumen mediated by T helper cells and other
immune cells that produce pro allergic pro
inflammatory cytokines(IL4,IL6,IL13)
III. Breach in normal immune regulatory process
I.

RESULT
 Airway inflammation

 AHR
 Edema basement membrane thickness sub

epithelial collagen deposition
 Smooth muscle and mucus gland hypertrophy
and mucus hyper secretion

Air obstruction

Clinical manifestations and diagnosis
 Most common intermittent dry cough and

expiratory wheezing

 Shortness of breath and chest tightness in older

children and adults

 Intermittent non focal chest pain in younger

children

 Worsening of respiratory symptoms at night
 Worsening of day time symptoms by activity

Continue…..
 Subtle symptoms such as self limitation of activities

,general fatigue ,difficulty in keeping up with peers

 Relief with aerosolized bronchodilators
 Lack of improvement with bronchodilators and steroid

is inconsistent with Asthma and should consider
Asthma masquerading conditions!!!!

 Hyper ventilation, intercostal retractions ,nasal flaring

,respiratory accessory muscle use

 Its common not to hear the expiratory wheezing when

Air flow is so limited before treatment

Asthma Triggers
 Common viral infections of the respiratory tract
 Aero allergens in sensitized asthmatics ,animal dander ,dust











mite ,molds ,indoor allergens ,cockroaches
Seasonal aero allergens ,pollens(trees ,grasses ,weeds ,)
Environmental tobacco smoke
Air pollutants ,ozone ,so2,wood or coal smoke ,endotoxin
,mycotoxin ,dust
Strong or noxious odors or fumes ,perfume ,hair spray
,cleaning agents
Occupational exposure
Cold air ,dry air
Exercise
Crying ,laughter ,hyperventilation
Co morbid conditions Rhinitis ,Sinusitis ,GER

Clinics
History:
Triggering symptoms by laughter
,cold air ,airway irritants
Exposures that induce airway
irritation such as viral URTI
Mycoplasma ,Chlamydia
Inhaled allergens
All lead to AHR

Presence Of Risk Factors:
 History of other allergies ,allergic Rhinitis,

allergic Conjunctivitis ,atopic Dermatitis ,food
allergies

 Parental Asthma
 Symptoms apart from cold

Continue…..
 No or minimal signs in routine visits

 Dry or persistent cough

 Normal chest findings unless wheezing when asking

to breath deeper
 Quick relief (10 MIN) after SABA use
 Expiratory wheezing ,prolonged expiratory phase
,decreased sounds in RT lower pos lobe due to
regional hypoventilation owing to airway
obstruction
 Rales , ronchi ,crackles due to hyper secretion
 Segmental crackles and poor breath sounds
atelectasis?

Continue….
 Labored respiration ,respiratory distress increased

prolongation of expiration and wheezing in E and I

 Poor air entry
 Inter costal retractions ,nasal flaring ,supra and

infra sternal retractions

 And again in most sever forms expiratory wheezing

does not appear until some broncho dilation

DD

GERD Rhino sinusitis co morbid

conditions with asthma

Recurrent aspiration in early

life(tracheo broncho malacia
,TEF , foreign body ,CF ,BPD

VCD in older children and

adolescents

LAB FINDINGS
Pulmonary Function
Testing

Continue….
 Forced expiratory airflow measures helpful

in Diagnosis , assessing efficacy of therapy
and monitoring Asthma in children specially
in poor children who do not have PHE
unless obstruction is sever

 Valueablity of spirometric findings in children>6

yrs

 3 efforts the highest is the peak
 Reduced FEV

obstruction

FEV1/FVC <0.80 means significant

 Improvement in FEV1 following beta 2 agonist > =

12% or 200 ml is consistent with Asthma

 Peak flow meter

CXR

Often normal aside from subtle and

nonspecific findings of hyperinflation

Peribronchial thickening
Helping in diagnosis of Asthma

differentials

Diagnosis of complications of Asthma

exacerbations

Other tests such as allergy skin prick
testing

Treatment
 www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm

Asthma Treatment & Management
has 4 components :
Assessment and monitoring of disease
activity
2. Provision to educate pt and family
3. Identification and management of
precipitating factors and co morbid
conditions
4. Appropriate selection of medication
1.

 Attainment of optimal Asthma control

Component 1
 Asthma severity :intermittent
 Persistent: mild ,mod ,severe
 Only once during patient initial evaluation in pt

who is not using a daily controller agent
 Asthma control degree to which symptoms ,
on going functional impairments , risk of
adverse events minimized and goals of
therapy are met

Continue….
Well controlled
2. Not well controlled
3. Very poor controlled
1.

 NIH guidelines for both severity and

control for 3 age groups

0-4 yrs
2. 5-11 yrs
3. =>12 yrs
1.

Important
even in the absence of frequent symptoms
infants and children whom have risk factors
for asthma and 4 or more episodes of
wheezing over the past yr which lasted more
than 1 day or 2 or more exacerbations in
the last 6 months requiring syst
corticosteroids should be considered in the
persistent group and hence receive long term
controller therapy

Important Tips..
 Regular clinical visits every 2-6 weeks
 Assessment of :

Pt symptoms frequency night and day
2. Need for short acting inhaled b2 agonists for
quick relief
3. Ability to engage in normal activities
4. Air flow measures for>=5 yrs
1.

Continue..
 Component 2 : pt education

 Component 3 : control of factors contributing

to asthma severity
1. Environmental exposures
2. Co morbid conditions
 Component 4 :principals of asthma
pharmacotherapy

Asthma Medication
 SABA

 ICS

 LABA
 LTRA

 SYSTEMIC STEROIDS

 NONSTEROIDAL ANTIINFLAMMATORY

CROMOLYN AND NEDOCROMYL
 OXYGEN
 ANTICHOLINERGIC AGENTS
IPRATROPIUM
BROMIDE
 ANTIIMMUNOGLUBOLINE E

MANAGEMENT OF ASTHMA EXACERBATION(STATUS ASTHMATICUS)
RISK ASSESMENT ON ADMISSION

FOCUSED HISTORY

ONSET OF CURRENT EXACERBATION
FREQUENCY AND severity of daytime and night
time symptoms and activity limitation
Frequency of rescue bronchodilator use
Current medication and allergies
Potential triggers
History of systemic steroid courses, emergency
department visists , hospitalization, intubation or life
threatening episodes

Clinical assesment

Physical examination findings: vital signs,
breathlessness, air movement, use of accessory
respiratory muscles, retractions, anxiety level,
alteration in mental status
Pulse oximetry
Lung function(defer in pts with mod to severe
distress or history of labile disease)

Treatment
Drugs and trade name

Mechanism of action and dosing

Cautions and adverse effects

Oxygen(mask or nasal canula)
Inhaled short acting b2
agonist
Albuterol nebulized
solution(5mg/ml concentrates
Albuterol MDI
Levabuterol

Treats hypoxia
Bronchodilator
Neubolizer 0.15 mg/kg every 20 min for 3
doses as needed,then 0.15_0.3 mg/kg up t 10
mg every 1_4 hour as needed or up to 0.5
mg/kg/hr by continous neubolization
2_8 puf up to every 20 min for 3 doses as
needed then every 1 hr as needed

Monitor pulse oximetry to maintain o2 saturation>92%
Cardiorespiratory monitoring
During exacerbations,frequent or continuous use can cause
pulmonary vasodilatation,v/q mistmatch and hypoxemia
Adverse effect palpitation, tachycardia, arrhythmia, tremor,
hypoxemia
Neubolizer:when giving concentrate forms,dilute with saline to 3
ml total neubolized volume
For MDI use space/holding chamber

Systemic corticosteroids
Prednisolone tb
Methyl prednisolon
Anticholinergics
Ipratropium
Atrovent
Ipratropium with Albuterol

Anti inflammatory
0.5_1 mg/kg every 6-8 hr for 48 hr , then 1-2 mg/kg
day bid(max 60 mg/day)
Short course burst for exacerbation 1-2 mg/kg/day qd
or bid for 3-7 days
Mucolitic/bronchodilator
Neubolizer 0.5 mg q6-8 hr (tid or qid) as needed
MDI 2 paf qid
1 vial by neubolizer qid



If pt has been exposed chickenpox or measles, consider passive
immunoglobulin prophylaxis, also risk of complications with
herspes simplex and TB

For daily dosing , 8 am administration minimizes adrenal
suppression

Children may benefit from dosage tapering if course exceed 7 days

Adverse effect monitoring: frequent therapy bursts risk numerous
corticosteroid adverse effects

Should not be used as first line treatment added to b2 agonist
therapy
Neubolizer may mix Ipratropium with Albuterol

QUICK RELIEF MEDICATION
SABA

Anti cholinergic(ipratropium)
Short term systemic gluco

corticoid

SABA
 Quick relief of asthma symptoms
 Relax airway smooth muscle prompt airflow↑
 Repetitive or continuous SABA is the most effective means







of reversing air flow obstruction
SABA should not be prescribed on a regular schedule
because concerns of possibility of deteriorating asthma
control
Frequent use of SABA is an indication of poor asthma control
Preferred root is inhalation smaller dose , fewer side effects
more rapid on set of action
Ipratropium Bromide as an adjunct to SABA in emergency
room reduces hospital admissions and improves lung function
Systemic Glucocorticoids short oral course + SABA in
moderate to severe asthma exacerbation

LABA
 Salmetrol

 Should be used in combination with inhaled

corticosteroids and not as mono therapy
 Exercise induces asthma in children >= 4 Yrs
one inhalation 30 min prior to exercise
 No additional doses for PTs who are already
receiving it twice daily not recommended by
NIH guidelines

LTRA

 MonteLukast ( singulair)

 Antihistaminic

 Leukotrien receptor antagonist

 Asthma ( not < 12 MO) and allergic rhinitis (





not < 6 MO)
Morning dosing not evaluated
Prophylactic and chronic treatment of asthma
Exercise induced asthma in >= 15 Yrs
Zafir Lukast : prophylactic and chronic
treatment of asthma

ICA
 Most potent anti inflammatory agents available

for the treatment of asthma
 Inhibiting most steps in the cascade of the
inflammatory response
 Benefits reducing bronchial hyper
responsiveness , prevention of late asthmatic
response , enhanced lung function
 Inhaled Glucocorticoids first line controller
therapy for persistent asthma or those who
require step 2

Prognosis
 35%of preschool children experience recurrent

coughing and wheezing,1/3 of them continue to
have persistent asthma into later childhood and
2/3 improvement on their own through their teen
yrs
 Asthma severity by age 7-10 yrs is predictive of
asthma persistence into adulthood
 Children with mod to severe asthma and lower lung
function are likely to have persistent asthma as
adults
 Children with milder asthma and N/R lung function
are likely to improve over time or be periodically
asthmatic

THANK YOU FOR YOUR
ATTENTION


Slide 40

Asthma in Children
DR. A.Mirshokraei
NIOC Hospital Pediatrics Ward

Definition :

DEFINITION

- Chronic inflammatory condition of the
lung airways resulting in episodic airflow
obstruction
- AHR to provocative exposures
Asthma management
• Reducing airway inflammation by: Minimizing
pro inflammatory environmental exposure, using
daily controller anti inflammatory medication,
controlling co morbid conditions that worsen
asthma, less inflammation better asthma
control and fewer exacerbations

Anyway exacerbations

occur

BUT
Even the uncommon
child with sever asthma can
be managed to live normally

 RECURRENT WHEEZING EPISODES WITH COMMON

RESPIRATORY
VIRUSES(RSV,RHINOVIRUS,INFLUENZA,PARAINFLUENZA,A
DENOVIRUS,HUMAN METAPNUMOVIRUS)

 HOST FEATURES AFFECTING IMMUNOLOGIC HOST

DEFENSE,INFLAMMATION/PREVIOUS VIRAL INFECTIONS
MAINIFESTED AS PNUMONIA OR BRONCHIOLITIS
REQUIRING HOSPITALIZATION UNDERLIE THE
RECURRENT WHEEZING IN EARLY CHILDHOOD

 OTHER AIRWAY EXPOSURES SUCH AS INDOOR AND HOME

ALLERGENS,COLD AIR,STRONG ODORS,TOBACCO
SMOKE,ALL INCREASE AHR

 ALLERGEN ELLIMINATION SOMETIMES LEEDS TO CURE

EPIDEMIOLOGY
 Common etiology of emergency visits and school day missing

in childhood ,occasionally hospitalization and rare deaths
specially in poverty ,urban living ,ethnic minorities

 Increasing asthma prevalence worldwide(50% per decade)
 Good correlation of asthma prevalence with allergic rhino

sinusitis and atopic eczema and other allergies

 More prevalence in high level urban modern families than

suburban villagers

 More than 80%of asthmatics reported getting the disease

before 6 year

CLINICS
RECURRENT COUGHING/WHEEZING
PATTERNS IN CHILDHOOD BASED ON
NATURAL HISTORY

TRANSIENT EARLY WHEEZING
 Common in early preschool years

 Recurrent coughing/wheezing primary

triggered by common respiratory viral INF
 Tend to resolve during preschool yrs without
increasing risk of asthma later in life
 Problems due to reduced airflow at birth
suggestive of relative narrow airways improved
by school yrs

Persistent Atopy Associated Asthma
 Begins in early preschool yrs

 Associated with atopy (eg atopic dermatitis in





infancy, allergic rhinitis, food allergy)
Biologic factors e.g.: early inhalant sensitization,
increase serum IGE, increase blood eosinophills,
High risk of persistence into later childhood and
adulthood lung function abnormality
Those with onset<3 yrs
reduced air flow by
school yrs
Those with later onset of symptoms or allergen
sensitizations unlikely persistence lung function
abnormality later

Non-Atopic Wheezing
 Wheezing ,coughing beginning in early life

often with RSV INF resolves later in childhood
without increasing risk of persistence asthma

 Associated with bronchial hyper

responsiveness near birth

Asthma with declining lung function
• Children with asthma with progressive

increase in air flow limitation

• Associated with hyper inflation in childhood
• Male gender

Late onset asthma in females associated with
obesity and early onset puberty
 Onset between 8_13 yrs

 Associated with early onset puberty and obesity
 Specific for females

Occupational type asthma in children
 Children with asthma and occupational type exposure

known to trigger asthma in adults in occupational settings

Types of Asthma
common clinical presentations of intermittent
recurrent wheezing and/or coughing
 Recurrent wheezing in early childhood

 Chronic asthma associated with allergy
 Females 11 yrs with early onset puberty and

obesity

Pathogenesis

 Airflow obstruction resulting from

Broncho constriction of bronchiolar smooth
muscle mass
II. Cellular inflammatory infiltrates and exudates
mostly Eosinophills(also N , M ,L ,mast cells
,basophiles)fill and obstruct airways and damage
epithelium and induce desquamation into airway
lumen mediated by T helper cells and other
immune cells that produce pro allergic pro
inflammatory cytokines(IL4,IL6,IL13)
III. Breach in normal immune regulatory process
I.

RESULT
 Airway inflammation

 AHR
 Edema basement membrane thickness sub

epithelial collagen deposition
 Smooth muscle and mucus gland hypertrophy
and mucus hyper secretion

Air obstruction

Clinical manifestations and diagnosis
 Most common intermittent dry cough and

expiratory wheezing

 Shortness of breath and chest tightness in older

children and adults

 Intermittent non focal chest pain in younger

children

 Worsening of respiratory symptoms at night
 Worsening of day time symptoms by activity

Continue…..
 Subtle symptoms such as self limitation of activities

,general fatigue ,difficulty in keeping up with peers

 Relief with aerosolized bronchodilators
 Lack of improvement with bronchodilators and steroid

is inconsistent with Asthma and should consider
Asthma masquerading conditions!!!!

 Hyper ventilation, intercostal retractions ,nasal flaring

,respiratory accessory muscle use

 Its common not to hear the expiratory wheezing when

Air flow is so limited before treatment

Asthma Triggers
 Common viral infections of the respiratory tract
 Aero allergens in sensitized asthmatics ,animal dander ,dust











mite ,molds ,indoor allergens ,cockroaches
Seasonal aero allergens ,pollens(trees ,grasses ,weeds ,)
Environmental tobacco smoke
Air pollutants ,ozone ,so2,wood or coal smoke ,endotoxin
,mycotoxin ,dust
Strong or noxious odors or fumes ,perfume ,hair spray
,cleaning agents
Occupational exposure
Cold air ,dry air
Exercise
Crying ,laughter ,hyperventilation
Co morbid conditions Rhinitis ,Sinusitis ,GER

Clinics
History:
Triggering symptoms by laughter
,cold air ,airway irritants
Exposures that induce airway
irritation such as viral URTI
Mycoplasma ,Chlamydia
Inhaled allergens
All lead to AHR

Presence Of Risk Factors:
 History of other allergies ,allergic Rhinitis,

allergic Conjunctivitis ,atopic Dermatitis ,food
allergies

 Parental Asthma
 Symptoms apart from cold

Continue…..
 No or minimal signs in routine visits

 Dry or persistent cough

 Normal chest findings unless wheezing when asking

to breath deeper
 Quick relief (10 MIN) after SABA use
 Expiratory wheezing ,prolonged expiratory phase
,decreased sounds in RT lower pos lobe due to
regional hypoventilation owing to airway
obstruction
 Rales , ronchi ,crackles due to hyper secretion
 Segmental crackles and poor breath sounds
atelectasis?

Continue….
 Labored respiration ,respiratory distress increased

prolongation of expiration and wheezing in E and I

 Poor air entry
 Inter costal retractions ,nasal flaring ,supra and

infra sternal retractions

 And again in most sever forms expiratory wheezing

does not appear until some broncho dilation

DD

GERD Rhino sinusitis co morbid

conditions with asthma

Recurrent aspiration in early

life(tracheo broncho malacia
,TEF , foreign body ,CF ,BPD

VCD in older children and

adolescents

LAB FINDINGS
Pulmonary Function
Testing

Continue….
 Forced expiratory airflow measures helpful

in Diagnosis , assessing efficacy of therapy
and monitoring Asthma in children specially
in poor children who do not have PHE
unless obstruction is sever

 Valueablity of spirometric findings in children>6

yrs

 3 efforts the highest is the peak
 Reduced FEV

obstruction

FEV1/FVC <0.80 means significant

 Improvement in FEV1 following beta 2 agonist > =

12% or 200 ml is consistent with Asthma

 Peak flow meter

CXR

Often normal aside from subtle and

nonspecific findings of hyperinflation

Peribronchial thickening
Helping in diagnosis of Asthma

differentials

Diagnosis of complications of Asthma

exacerbations

Other tests such as allergy skin prick
testing

Treatment
 www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm

Asthma Treatment & Management
has 4 components :
Assessment and monitoring of disease
activity
2. Provision to educate pt and family
3. Identification and management of
precipitating factors and co morbid
conditions
4. Appropriate selection of medication
1.

 Attainment of optimal Asthma control

Component 1
 Asthma severity :intermittent
 Persistent: mild ,mod ,severe
 Only once during patient initial evaluation in pt

who is not using a daily controller agent
 Asthma control degree to which symptoms ,
on going functional impairments , risk of
adverse events minimized and goals of
therapy are met

Continue….
Well controlled
2. Not well controlled
3. Very poor controlled
1.

 NIH guidelines for both severity and

control for 3 age groups

0-4 yrs
2. 5-11 yrs
3. =>12 yrs
1.

Important
even in the absence of frequent symptoms
infants and children whom have risk factors
for asthma and 4 or more episodes of
wheezing over the past yr which lasted more
than 1 day or 2 or more exacerbations in
the last 6 months requiring syst
corticosteroids should be considered in the
persistent group and hence receive long term
controller therapy

Important Tips..
 Regular clinical visits every 2-6 weeks
 Assessment of :

Pt symptoms frequency night and day
2. Need for short acting inhaled b2 agonists for
quick relief
3. Ability to engage in normal activities
4. Air flow measures for>=5 yrs
1.

Continue..
 Component 2 : pt education

 Component 3 : control of factors contributing

to asthma severity
1. Environmental exposures
2. Co morbid conditions
 Component 4 :principals of asthma
pharmacotherapy

Asthma Medication
 SABA

 ICS

 LABA
 LTRA

 SYSTEMIC STEROIDS

 NONSTEROIDAL ANTIINFLAMMATORY

CROMOLYN AND NEDOCROMYL
 OXYGEN
 ANTICHOLINERGIC AGENTS
IPRATROPIUM
BROMIDE
 ANTIIMMUNOGLUBOLINE E

MANAGEMENT OF ASTHMA EXACERBATION(STATUS ASTHMATICUS)
RISK ASSESMENT ON ADMISSION

FOCUSED HISTORY

ONSET OF CURRENT EXACERBATION
FREQUENCY AND severity of daytime and night
time symptoms and activity limitation
Frequency of rescue bronchodilator use
Current medication and allergies
Potential triggers
History of systemic steroid courses, emergency
department visists , hospitalization, intubation or life
threatening episodes

Clinical assesment

Physical examination findings: vital signs,
breathlessness, air movement, use of accessory
respiratory muscles, retractions, anxiety level,
alteration in mental status
Pulse oximetry
Lung function(defer in pts with mod to severe
distress or history of labile disease)

Treatment
Drugs and trade name

Mechanism of action and dosing

Cautions and adverse effects

Oxygen(mask or nasal canula)
Inhaled short acting b2
agonist
Albuterol nebulized
solution(5mg/ml concentrates
Albuterol MDI
Levabuterol

Treats hypoxia
Bronchodilator
Neubolizer 0.15 mg/kg every 20 min for 3
doses as needed,then 0.15_0.3 mg/kg up t 10
mg every 1_4 hour as needed or up to 0.5
mg/kg/hr by continous neubolization
2_8 puf up to every 20 min for 3 doses as
needed then every 1 hr as needed

Monitor pulse oximetry to maintain o2 saturation>92%
Cardiorespiratory monitoring
During exacerbations,frequent or continuous use can cause
pulmonary vasodilatation,v/q mistmatch and hypoxemia
Adverse effect palpitation, tachycardia, arrhythmia, tremor,
hypoxemia
Neubolizer:when giving concentrate forms,dilute with saline to 3
ml total neubolized volume
For MDI use space/holding chamber

Systemic corticosteroids
Prednisolone tb
Methyl prednisolon
Anticholinergics
Ipratropium
Atrovent
Ipratropium with Albuterol

Anti inflammatory
0.5_1 mg/kg every 6-8 hr for 48 hr , then 1-2 mg/kg
day bid(max 60 mg/day)
Short course burst for exacerbation 1-2 mg/kg/day qd
or bid for 3-7 days
Mucolitic/bronchodilator
Neubolizer 0.5 mg q6-8 hr (tid or qid) as needed
MDI 2 paf qid
1 vial by neubolizer qid



If pt has been exposed chickenpox or measles, consider passive
immunoglobulin prophylaxis, also risk of complications with
herspes simplex and TB

For daily dosing , 8 am administration minimizes adrenal
suppression

Children may benefit from dosage tapering if course exceed 7 days

Adverse effect monitoring: frequent therapy bursts risk numerous
corticosteroid adverse effects

Should not be used as first line treatment added to b2 agonist
therapy
Neubolizer may mix Ipratropium with Albuterol

QUICK RELIEF MEDICATION
SABA

Anti cholinergic(ipratropium)
Short term systemic gluco

corticoid

SABA
 Quick relief of asthma symptoms
 Relax airway smooth muscle prompt airflow↑
 Repetitive or continuous SABA is the most effective means







of reversing air flow obstruction
SABA should not be prescribed on a regular schedule
because concerns of possibility of deteriorating asthma
control
Frequent use of SABA is an indication of poor asthma control
Preferred root is inhalation smaller dose , fewer side effects
more rapid on set of action
Ipratropium Bromide as an adjunct to SABA in emergency
room reduces hospital admissions and improves lung function
Systemic Glucocorticoids short oral course + SABA in
moderate to severe asthma exacerbation

LABA
 Salmetrol

 Should be used in combination with inhaled

corticosteroids and not as mono therapy
 Exercise induces asthma in children >= 4 Yrs
one inhalation 30 min prior to exercise
 No additional doses for PTs who are already
receiving it twice daily not recommended by
NIH guidelines

LTRA

 MonteLukast ( singulair)

 Antihistaminic

 Leukotrien receptor antagonist

 Asthma ( not < 12 MO) and allergic rhinitis (





not < 6 MO)
Morning dosing not evaluated
Prophylactic and chronic treatment of asthma
Exercise induced asthma in >= 15 Yrs
Zafir Lukast : prophylactic and chronic
treatment of asthma

ICA
 Most potent anti inflammatory agents available

for the treatment of asthma
 Inhibiting most steps in the cascade of the
inflammatory response
 Benefits reducing bronchial hyper
responsiveness , prevention of late asthmatic
response , enhanced lung function
 Inhaled Glucocorticoids first line controller
therapy for persistent asthma or those who
require step 2

Prognosis
 35%of preschool children experience recurrent

coughing and wheezing,1/3 of them continue to
have persistent asthma into later childhood and
2/3 improvement on their own through their teen
yrs
 Asthma severity by age 7-10 yrs is predictive of
asthma persistence into adulthood
 Children with mod to severe asthma and lower lung
function are likely to have persistent asthma as
adults
 Children with milder asthma and N/R lung function
are likely to improve over time or be periodically
asthmatic

THANK YOU FOR YOUR
ATTENTION


Slide 41

Asthma in Children
DR. A.Mirshokraei
NIOC Hospital Pediatrics Ward

Definition :

DEFINITION

- Chronic inflammatory condition of the
lung airways resulting in episodic airflow
obstruction
- AHR to provocative exposures
Asthma management
• Reducing airway inflammation by: Minimizing
pro inflammatory environmental exposure, using
daily controller anti inflammatory medication,
controlling co morbid conditions that worsen
asthma, less inflammation better asthma
control and fewer exacerbations

Anyway exacerbations

occur

BUT
Even the uncommon
child with sever asthma can
be managed to live normally

 RECURRENT WHEEZING EPISODES WITH COMMON

RESPIRATORY
VIRUSES(RSV,RHINOVIRUS,INFLUENZA,PARAINFLUENZA,A
DENOVIRUS,HUMAN METAPNUMOVIRUS)

 HOST FEATURES AFFECTING IMMUNOLOGIC HOST

DEFENSE,INFLAMMATION/PREVIOUS VIRAL INFECTIONS
MAINIFESTED AS PNUMONIA OR BRONCHIOLITIS
REQUIRING HOSPITALIZATION UNDERLIE THE
RECURRENT WHEEZING IN EARLY CHILDHOOD

 OTHER AIRWAY EXPOSURES SUCH AS INDOOR AND HOME

ALLERGENS,COLD AIR,STRONG ODORS,TOBACCO
SMOKE,ALL INCREASE AHR

 ALLERGEN ELLIMINATION SOMETIMES LEEDS TO CURE

EPIDEMIOLOGY
 Common etiology of emergency visits and school day missing

in childhood ,occasionally hospitalization and rare deaths
specially in poverty ,urban living ,ethnic minorities

 Increasing asthma prevalence worldwide(50% per decade)
 Good correlation of asthma prevalence with allergic rhino

sinusitis and atopic eczema and other allergies

 More prevalence in high level urban modern families than

suburban villagers

 More than 80%of asthmatics reported getting the disease

before 6 year

CLINICS
RECURRENT COUGHING/WHEEZING
PATTERNS IN CHILDHOOD BASED ON
NATURAL HISTORY

TRANSIENT EARLY WHEEZING
 Common in early preschool years

 Recurrent coughing/wheezing primary

triggered by common respiratory viral INF
 Tend to resolve during preschool yrs without
increasing risk of asthma later in life
 Problems due to reduced airflow at birth
suggestive of relative narrow airways improved
by school yrs

Persistent Atopy Associated Asthma
 Begins in early preschool yrs

 Associated with atopy (eg atopic dermatitis in





infancy, allergic rhinitis, food allergy)
Biologic factors e.g.: early inhalant sensitization,
increase serum IGE, increase blood eosinophills,
High risk of persistence into later childhood and
adulthood lung function abnormality
Those with onset<3 yrs
reduced air flow by
school yrs
Those with later onset of symptoms or allergen
sensitizations unlikely persistence lung function
abnormality later

Non-Atopic Wheezing
 Wheezing ,coughing beginning in early life

often with RSV INF resolves later in childhood
without increasing risk of persistence asthma

 Associated with bronchial hyper

responsiveness near birth

Asthma with declining lung function
• Children with asthma with progressive

increase in air flow limitation

• Associated with hyper inflation in childhood
• Male gender

Late onset asthma in females associated with
obesity and early onset puberty
 Onset between 8_13 yrs

 Associated with early onset puberty and obesity
 Specific for females

Occupational type asthma in children
 Children with asthma and occupational type exposure

known to trigger asthma in adults in occupational settings

Types of Asthma
common clinical presentations of intermittent
recurrent wheezing and/or coughing
 Recurrent wheezing in early childhood

 Chronic asthma associated with allergy
 Females 11 yrs with early onset puberty and

obesity

Pathogenesis

 Airflow obstruction resulting from

Broncho constriction of bronchiolar smooth
muscle mass
II. Cellular inflammatory infiltrates and exudates
mostly Eosinophills(also N , M ,L ,mast cells
,basophiles)fill and obstruct airways and damage
epithelium and induce desquamation into airway
lumen mediated by T helper cells and other
immune cells that produce pro allergic pro
inflammatory cytokines(IL4,IL6,IL13)
III. Breach in normal immune regulatory process
I.

RESULT
 Airway inflammation

 AHR
 Edema basement membrane thickness sub

epithelial collagen deposition
 Smooth muscle and mucus gland hypertrophy
and mucus hyper secretion

Air obstruction

Clinical manifestations and diagnosis
 Most common intermittent dry cough and

expiratory wheezing

 Shortness of breath and chest tightness in older

children and adults

 Intermittent non focal chest pain in younger

children

 Worsening of respiratory symptoms at night
 Worsening of day time symptoms by activity

Continue…..
 Subtle symptoms such as self limitation of activities

,general fatigue ,difficulty in keeping up with peers

 Relief with aerosolized bronchodilators
 Lack of improvement with bronchodilators and steroid

is inconsistent with Asthma and should consider
Asthma masquerading conditions!!!!

 Hyper ventilation, intercostal retractions ,nasal flaring

,respiratory accessory muscle use

 Its common not to hear the expiratory wheezing when

Air flow is so limited before treatment

Asthma Triggers
 Common viral infections of the respiratory tract
 Aero allergens in sensitized asthmatics ,animal dander ,dust











mite ,molds ,indoor allergens ,cockroaches
Seasonal aero allergens ,pollens(trees ,grasses ,weeds ,)
Environmental tobacco smoke
Air pollutants ,ozone ,so2,wood or coal smoke ,endotoxin
,mycotoxin ,dust
Strong or noxious odors or fumes ,perfume ,hair spray
,cleaning agents
Occupational exposure
Cold air ,dry air
Exercise
Crying ,laughter ,hyperventilation
Co morbid conditions Rhinitis ,Sinusitis ,GER

Clinics
History:
Triggering symptoms by laughter
,cold air ,airway irritants
Exposures that induce airway
irritation such as viral URTI
Mycoplasma ,Chlamydia
Inhaled allergens
All lead to AHR

Presence Of Risk Factors:
 History of other allergies ,allergic Rhinitis,

allergic Conjunctivitis ,atopic Dermatitis ,food
allergies

 Parental Asthma
 Symptoms apart from cold

Continue…..
 No or minimal signs in routine visits

 Dry or persistent cough

 Normal chest findings unless wheezing when asking

to breath deeper
 Quick relief (10 MIN) after SABA use
 Expiratory wheezing ,prolonged expiratory phase
,decreased sounds in RT lower pos lobe due to
regional hypoventilation owing to airway
obstruction
 Rales , ronchi ,crackles due to hyper secretion
 Segmental crackles and poor breath sounds
atelectasis?

Continue….
 Labored respiration ,respiratory distress increased

prolongation of expiration and wheezing in E and I

 Poor air entry
 Inter costal retractions ,nasal flaring ,supra and

infra sternal retractions

 And again in most sever forms expiratory wheezing

does not appear until some broncho dilation

DD

GERD Rhino sinusitis co morbid

conditions with asthma

Recurrent aspiration in early

life(tracheo broncho malacia
,TEF , foreign body ,CF ,BPD

VCD in older children and

adolescents

LAB FINDINGS
Pulmonary Function
Testing

Continue….
 Forced expiratory airflow measures helpful

in Diagnosis , assessing efficacy of therapy
and monitoring Asthma in children specially
in poor children who do not have PHE
unless obstruction is sever

 Valueablity of spirometric findings in children>6

yrs

 3 efforts the highest is the peak
 Reduced FEV

obstruction

FEV1/FVC <0.80 means significant

 Improvement in FEV1 following beta 2 agonist > =

12% or 200 ml is consistent with Asthma

 Peak flow meter

CXR

Often normal aside from subtle and

nonspecific findings of hyperinflation

Peribronchial thickening
Helping in diagnosis of Asthma

differentials

Diagnosis of complications of Asthma

exacerbations

Other tests such as allergy skin prick
testing

Treatment
 www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm

Asthma Treatment & Management
has 4 components :
Assessment and monitoring of disease
activity
2. Provision to educate pt and family
3. Identification and management of
precipitating factors and co morbid
conditions
4. Appropriate selection of medication
1.

 Attainment of optimal Asthma control

Component 1
 Asthma severity :intermittent
 Persistent: mild ,mod ,severe
 Only once during patient initial evaluation in pt

who is not using a daily controller agent
 Asthma control degree to which symptoms ,
on going functional impairments , risk of
adverse events minimized and goals of
therapy are met

Continue….
Well controlled
2. Not well controlled
3. Very poor controlled
1.

 NIH guidelines for both severity and

control for 3 age groups

0-4 yrs
2. 5-11 yrs
3. =>12 yrs
1.

Important
even in the absence of frequent symptoms
infants and children whom have risk factors
for asthma and 4 or more episodes of
wheezing over the past yr which lasted more
than 1 day or 2 or more exacerbations in
the last 6 months requiring syst
corticosteroids should be considered in the
persistent group and hence receive long term
controller therapy

Important Tips..
 Regular clinical visits every 2-6 weeks
 Assessment of :

Pt symptoms frequency night and day
2. Need for short acting inhaled b2 agonists for
quick relief
3. Ability to engage in normal activities
4. Air flow measures for>=5 yrs
1.

Continue..
 Component 2 : pt education

 Component 3 : control of factors contributing

to asthma severity
1. Environmental exposures
2. Co morbid conditions
 Component 4 :principals of asthma
pharmacotherapy

Asthma Medication
 SABA

 ICS

 LABA
 LTRA

 SYSTEMIC STEROIDS

 NONSTEROIDAL ANTIINFLAMMATORY

CROMOLYN AND NEDOCROMYL
 OXYGEN
 ANTICHOLINERGIC AGENTS
IPRATROPIUM
BROMIDE
 ANTIIMMUNOGLUBOLINE E

MANAGEMENT OF ASTHMA EXACERBATION(STATUS ASTHMATICUS)
RISK ASSESMENT ON ADMISSION

FOCUSED HISTORY

ONSET OF CURRENT EXACERBATION
FREQUENCY AND severity of daytime and night
time symptoms and activity limitation
Frequency of rescue bronchodilator use
Current medication and allergies
Potential triggers
History of systemic steroid courses, emergency
department visists , hospitalization, intubation or life
threatening episodes

Clinical assesment

Physical examination findings: vital signs,
breathlessness, air movement, use of accessory
respiratory muscles, retractions, anxiety level,
alteration in mental status
Pulse oximetry
Lung function(defer in pts with mod to severe
distress or history of labile disease)

Treatment
Drugs and trade name

Mechanism of action and dosing

Cautions and adverse effects

Oxygen(mask or nasal canula)
Inhaled short acting b2
agonist
Albuterol nebulized
solution(5mg/ml concentrates
Albuterol MDI
Levabuterol

Treats hypoxia
Bronchodilator
Neubolizer 0.15 mg/kg every 20 min for 3
doses as needed,then 0.15_0.3 mg/kg up t 10
mg every 1_4 hour as needed or up to 0.5
mg/kg/hr by continous neubolization
2_8 puf up to every 20 min for 3 doses as
needed then every 1 hr as needed

Monitor pulse oximetry to maintain o2 saturation>92%
Cardiorespiratory monitoring
During exacerbations,frequent or continuous use can cause
pulmonary vasodilatation,v/q mistmatch and hypoxemia
Adverse effect palpitation, tachycardia, arrhythmia, tremor,
hypoxemia
Neubolizer:when giving concentrate forms,dilute with saline to 3
ml total neubolized volume
For MDI use space/holding chamber

Systemic corticosteroids
Prednisolone tb
Methyl prednisolon
Anticholinergics
Ipratropium
Atrovent
Ipratropium with Albuterol

Anti inflammatory
0.5_1 mg/kg every 6-8 hr for 48 hr , then 1-2 mg/kg
day bid(max 60 mg/day)
Short course burst for exacerbation 1-2 mg/kg/day qd
or bid for 3-7 days
Mucolitic/bronchodilator
Neubolizer 0.5 mg q6-8 hr (tid or qid) as needed
MDI 2 paf qid
1 vial by neubolizer qid



If pt has been exposed chickenpox or measles, consider passive
immunoglobulin prophylaxis, also risk of complications with
herspes simplex and TB

For daily dosing , 8 am administration minimizes adrenal
suppression

Children may benefit from dosage tapering if course exceed 7 days

Adverse effect monitoring: frequent therapy bursts risk numerous
corticosteroid adverse effects

Should not be used as first line treatment added to b2 agonist
therapy
Neubolizer may mix Ipratropium with Albuterol

QUICK RELIEF MEDICATION
SABA

Anti cholinergic(ipratropium)
Short term systemic gluco

corticoid

SABA
 Quick relief of asthma symptoms
 Relax airway smooth muscle prompt airflow↑
 Repetitive or continuous SABA is the most effective means







of reversing air flow obstruction
SABA should not be prescribed on a regular schedule
because concerns of possibility of deteriorating asthma
control
Frequent use of SABA is an indication of poor asthma control
Preferred root is inhalation smaller dose , fewer side effects
more rapid on set of action
Ipratropium Bromide as an adjunct to SABA in emergency
room reduces hospital admissions and improves lung function
Systemic Glucocorticoids short oral course + SABA in
moderate to severe asthma exacerbation

LABA
 Salmetrol

 Should be used in combination with inhaled

corticosteroids and not as mono therapy
 Exercise induces asthma in children >= 4 Yrs
one inhalation 30 min prior to exercise
 No additional doses for PTs who are already
receiving it twice daily not recommended by
NIH guidelines

LTRA

 MonteLukast ( singulair)

 Antihistaminic

 Leukotrien receptor antagonist

 Asthma ( not < 12 MO) and allergic rhinitis (





not < 6 MO)
Morning dosing not evaluated
Prophylactic and chronic treatment of asthma
Exercise induced asthma in >= 15 Yrs
Zafir Lukast : prophylactic and chronic
treatment of asthma

ICA
 Most potent anti inflammatory agents available

for the treatment of asthma
 Inhibiting most steps in the cascade of the
inflammatory response
 Benefits reducing bronchial hyper
responsiveness , prevention of late asthmatic
response , enhanced lung function
 Inhaled Glucocorticoids first line controller
therapy for persistent asthma or those who
require step 2

Prognosis
 35%of preschool children experience recurrent

coughing and wheezing,1/3 of them continue to
have persistent asthma into later childhood and
2/3 improvement on their own through their teen
yrs
 Asthma severity by age 7-10 yrs is predictive of
asthma persistence into adulthood
 Children with mod to severe asthma and lower lung
function are likely to have persistent asthma as
adults
 Children with milder asthma and N/R lung function
are likely to improve over time or be periodically
asthmatic

THANK YOU FOR YOUR
ATTENTION


Slide 42

Asthma in Children
DR. A.Mirshokraei
NIOC Hospital Pediatrics Ward

Definition :

DEFINITION

- Chronic inflammatory condition of the
lung airways resulting in episodic airflow
obstruction
- AHR to provocative exposures
Asthma management
• Reducing airway inflammation by: Minimizing
pro inflammatory environmental exposure, using
daily controller anti inflammatory medication,
controlling co morbid conditions that worsen
asthma, less inflammation better asthma
control and fewer exacerbations

Anyway exacerbations

occur

BUT
Even the uncommon
child with sever asthma can
be managed to live normally

 RECURRENT WHEEZING EPISODES WITH COMMON

RESPIRATORY
VIRUSES(RSV,RHINOVIRUS,INFLUENZA,PARAINFLUENZA,A
DENOVIRUS,HUMAN METAPNUMOVIRUS)

 HOST FEATURES AFFECTING IMMUNOLOGIC HOST

DEFENSE,INFLAMMATION/PREVIOUS VIRAL INFECTIONS
MAINIFESTED AS PNUMONIA OR BRONCHIOLITIS
REQUIRING HOSPITALIZATION UNDERLIE THE
RECURRENT WHEEZING IN EARLY CHILDHOOD

 OTHER AIRWAY EXPOSURES SUCH AS INDOOR AND HOME

ALLERGENS,COLD AIR,STRONG ODORS,TOBACCO
SMOKE,ALL INCREASE AHR

 ALLERGEN ELLIMINATION SOMETIMES LEEDS TO CURE

EPIDEMIOLOGY
 Common etiology of emergency visits and school day missing

in childhood ,occasionally hospitalization and rare deaths
specially in poverty ,urban living ,ethnic minorities

 Increasing asthma prevalence worldwide(50% per decade)
 Good correlation of asthma prevalence with allergic rhino

sinusitis and atopic eczema and other allergies

 More prevalence in high level urban modern families than

suburban villagers

 More than 80%of asthmatics reported getting the disease

before 6 year

CLINICS
RECURRENT COUGHING/WHEEZING
PATTERNS IN CHILDHOOD BASED ON
NATURAL HISTORY

TRANSIENT EARLY WHEEZING
 Common in early preschool years

 Recurrent coughing/wheezing primary

triggered by common respiratory viral INF
 Tend to resolve during preschool yrs without
increasing risk of asthma later in life
 Problems due to reduced airflow at birth
suggestive of relative narrow airways improved
by school yrs

Persistent Atopy Associated Asthma
 Begins in early preschool yrs

 Associated with atopy (eg atopic dermatitis in





infancy, allergic rhinitis, food allergy)
Biologic factors e.g.: early inhalant sensitization,
increase serum IGE, increase blood eosinophills,
High risk of persistence into later childhood and
adulthood lung function abnormality
Those with onset<3 yrs
reduced air flow by
school yrs
Those with later onset of symptoms or allergen
sensitizations unlikely persistence lung function
abnormality later

Non-Atopic Wheezing
 Wheezing ,coughing beginning in early life

often with RSV INF resolves later in childhood
without increasing risk of persistence asthma

 Associated with bronchial hyper

responsiveness near birth

Asthma with declining lung function
• Children with asthma with progressive

increase in air flow limitation

• Associated with hyper inflation in childhood
• Male gender

Late onset asthma in females associated with
obesity and early onset puberty
 Onset between 8_13 yrs

 Associated with early onset puberty and obesity
 Specific for females

Occupational type asthma in children
 Children with asthma and occupational type exposure

known to trigger asthma in adults in occupational settings

Types of Asthma
common clinical presentations of intermittent
recurrent wheezing and/or coughing
 Recurrent wheezing in early childhood

 Chronic asthma associated with allergy
 Females 11 yrs with early onset puberty and

obesity

Pathogenesis

 Airflow obstruction resulting from

Broncho constriction of bronchiolar smooth
muscle mass
II. Cellular inflammatory infiltrates and exudates
mostly Eosinophills(also N , M ,L ,mast cells
,basophiles)fill and obstruct airways and damage
epithelium and induce desquamation into airway
lumen mediated by T helper cells and other
immune cells that produce pro allergic pro
inflammatory cytokines(IL4,IL6,IL13)
III. Breach in normal immune regulatory process
I.

RESULT
 Airway inflammation

 AHR
 Edema basement membrane thickness sub

epithelial collagen deposition
 Smooth muscle and mucus gland hypertrophy
and mucus hyper secretion

Air obstruction

Clinical manifestations and diagnosis
 Most common intermittent dry cough and

expiratory wheezing

 Shortness of breath and chest tightness in older

children and adults

 Intermittent non focal chest pain in younger

children

 Worsening of respiratory symptoms at night
 Worsening of day time symptoms by activity

Continue…..
 Subtle symptoms such as self limitation of activities

,general fatigue ,difficulty in keeping up with peers

 Relief with aerosolized bronchodilators
 Lack of improvement with bronchodilators and steroid

is inconsistent with Asthma and should consider
Asthma masquerading conditions!!!!

 Hyper ventilation, intercostal retractions ,nasal flaring

,respiratory accessory muscle use

 Its common not to hear the expiratory wheezing when

Air flow is so limited before treatment

Asthma Triggers
 Common viral infections of the respiratory tract
 Aero allergens in sensitized asthmatics ,animal dander ,dust











mite ,molds ,indoor allergens ,cockroaches
Seasonal aero allergens ,pollens(trees ,grasses ,weeds ,)
Environmental tobacco smoke
Air pollutants ,ozone ,so2,wood or coal smoke ,endotoxin
,mycotoxin ,dust
Strong or noxious odors or fumes ,perfume ,hair spray
,cleaning agents
Occupational exposure
Cold air ,dry air
Exercise
Crying ,laughter ,hyperventilation
Co morbid conditions Rhinitis ,Sinusitis ,GER

Clinics
History:
Triggering symptoms by laughter
,cold air ,airway irritants
Exposures that induce airway
irritation such as viral URTI
Mycoplasma ,Chlamydia
Inhaled allergens
All lead to AHR

Presence Of Risk Factors:
 History of other allergies ,allergic Rhinitis,

allergic Conjunctivitis ,atopic Dermatitis ,food
allergies

 Parental Asthma
 Symptoms apart from cold

Continue…..
 No or minimal signs in routine visits

 Dry or persistent cough

 Normal chest findings unless wheezing when asking

to breath deeper
 Quick relief (10 MIN) after SABA use
 Expiratory wheezing ,prolonged expiratory phase
,decreased sounds in RT lower pos lobe due to
regional hypoventilation owing to airway
obstruction
 Rales , ronchi ,crackles due to hyper secretion
 Segmental crackles and poor breath sounds
atelectasis?

Continue….
 Labored respiration ,respiratory distress increased

prolongation of expiration and wheezing in E and I

 Poor air entry
 Inter costal retractions ,nasal flaring ,supra and

infra sternal retractions

 And again in most sever forms expiratory wheezing

does not appear until some broncho dilation

DD

GERD Rhino sinusitis co morbid

conditions with asthma

Recurrent aspiration in early

life(tracheo broncho malacia
,TEF , foreign body ,CF ,BPD

VCD in older children and

adolescents

LAB FINDINGS
Pulmonary Function
Testing

Continue….
 Forced expiratory airflow measures helpful

in Diagnosis , assessing efficacy of therapy
and monitoring Asthma in children specially
in poor children who do not have PHE
unless obstruction is sever

 Valueablity of spirometric findings in children>6

yrs

 3 efforts the highest is the peak
 Reduced FEV

obstruction

FEV1/FVC <0.80 means significant

 Improvement in FEV1 following beta 2 agonist > =

12% or 200 ml is consistent with Asthma

 Peak flow meter

CXR

Often normal aside from subtle and

nonspecific findings of hyperinflation

Peribronchial thickening
Helping in diagnosis of Asthma

differentials

Diagnosis of complications of Asthma

exacerbations

Other tests such as allergy skin prick
testing

Treatment
 www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm

Asthma Treatment & Management
has 4 components :
Assessment and monitoring of disease
activity
2. Provision to educate pt and family
3. Identification and management of
precipitating factors and co morbid
conditions
4. Appropriate selection of medication
1.

 Attainment of optimal Asthma control

Component 1
 Asthma severity :intermittent
 Persistent: mild ,mod ,severe
 Only once during patient initial evaluation in pt

who is not using a daily controller agent
 Asthma control degree to which symptoms ,
on going functional impairments , risk of
adverse events minimized and goals of
therapy are met

Continue….
Well controlled
2. Not well controlled
3. Very poor controlled
1.

 NIH guidelines for both severity and

control for 3 age groups

0-4 yrs
2. 5-11 yrs
3. =>12 yrs
1.

Important
even in the absence of frequent symptoms
infants and children whom have risk factors
for asthma and 4 or more episodes of
wheezing over the past yr which lasted more
than 1 day or 2 or more exacerbations in
the last 6 months requiring syst
corticosteroids should be considered in the
persistent group and hence receive long term
controller therapy

Important Tips..
 Regular clinical visits every 2-6 weeks
 Assessment of :

Pt symptoms frequency night and day
2. Need for short acting inhaled b2 agonists for
quick relief
3. Ability to engage in normal activities
4. Air flow measures for>=5 yrs
1.

Continue..
 Component 2 : pt education

 Component 3 : control of factors contributing

to asthma severity
1. Environmental exposures
2. Co morbid conditions
 Component 4 :principals of asthma
pharmacotherapy

Asthma Medication
 SABA

 ICS

 LABA
 LTRA

 SYSTEMIC STEROIDS

 NONSTEROIDAL ANTIINFLAMMATORY

CROMOLYN AND NEDOCROMYL
 OXYGEN
 ANTICHOLINERGIC AGENTS
IPRATROPIUM
BROMIDE
 ANTIIMMUNOGLUBOLINE E

MANAGEMENT OF ASTHMA EXACERBATION(STATUS ASTHMATICUS)
RISK ASSESMENT ON ADMISSION

FOCUSED HISTORY

ONSET OF CURRENT EXACERBATION
FREQUENCY AND severity of daytime and night
time symptoms and activity limitation
Frequency of rescue bronchodilator use
Current medication and allergies
Potential triggers
History of systemic steroid courses, emergency
department visists , hospitalization, intubation or life
threatening episodes

Clinical assesment

Physical examination findings: vital signs,
breathlessness, air movement, use of accessory
respiratory muscles, retractions, anxiety level,
alteration in mental status
Pulse oximetry
Lung function(defer in pts with mod to severe
distress or history of labile disease)

Treatment
Drugs and trade name

Mechanism of action and dosing

Cautions and adverse effects

Oxygen(mask or nasal canula)
Inhaled short acting b2
agonist
Albuterol nebulized
solution(5mg/ml concentrates
Albuterol MDI
Levabuterol

Treats hypoxia
Bronchodilator
Neubolizer 0.15 mg/kg every 20 min for 3
doses as needed,then 0.15_0.3 mg/kg up t 10
mg every 1_4 hour as needed or up to 0.5
mg/kg/hr by continous neubolization
2_8 puf up to every 20 min for 3 doses as
needed then every 1 hr as needed

Monitor pulse oximetry to maintain o2 saturation>92%
Cardiorespiratory monitoring
During exacerbations,frequent or continuous use can cause
pulmonary vasodilatation,v/q mistmatch and hypoxemia
Adverse effect palpitation, tachycardia, arrhythmia, tremor,
hypoxemia
Neubolizer:when giving concentrate forms,dilute with saline to 3
ml total neubolized volume
For MDI use space/holding chamber

Systemic corticosteroids
Prednisolone tb
Methyl prednisolon
Anticholinergics
Ipratropium
Atrovent
Ipratropium with Albuterol

Anti inflammatory
0.5_1 mg/kg every 6-8 hr for 48 hr , then 1-2 mg/kg
day bid(max 60 mg/day)
Short course burst for exacerbation 1-2 mg/kg/day qd
or bid for 3-7 days
Mucolitic/bronchodilator
Neubolizer 0.5 mg q6-8 hr (tid or qid) as needed
MDI 2 paf qid
1 vial by neubolizer qid



If pt has been exposed chickenpox or measles, consider passive
immunoglobulin prophylaxis, also risk of complications with
herspes simplex and TB

For daily dosing , 8 am administration minimizes adrenal
suppression

Children may benefit from dosage tapering if course exceed 7 days

Adverse effect monitoring: frequent therapy bursts risk numerous
corticosteroid adverse effects

Should not be used as first line treatment added to b2 agonist
therapy
Neubolizer may mix Ipratropium with Albuterol

QUICK RELIEF MEDICATION
SABA

Anti cholinergic(ipratropium)
Short term systemic gluco

corticoid

SABA
 Quick relief of asthma symptoms
 Relax airway smooth muscle prompt airflow↑
 Repetitive or continuous SABA is the most effective means







of reversing air flow obstruction
SABA should not be prescribed on a regular schedule
because concerns of possibility of deteriorating asthma
control
Frequent use of SABA is an indication of poor asthma control
Preferred root is inhalation smaller dose , fewer side effects
more rapid on set of action
Ipratropium Bromide as an adjunct to SABA in emergency
room reduces hospital admissions and improves lung function
Systemic Glucocorticoids short oral course + SABA in
moderate to severe asthma exacerbation

LABA
 Salmetrol

 Should be used in combination with inhaled

corticosteroids and not as mono therapy
 Exercise induces asthma in children >= 4 Yrs
one inhalation 30 min prior to exercise
 No additional doses for PTs who are already
receiving it twice daily not recommended by
NIH guidelines

LTRA

 MonteLukast ( singulair)

 Antihistaminic

 Leukotrien receptor antagonist

 Asthma ( not < 12 MO) and allergic rhinitis (





not < 6 MO)
Morning dosing not evaluated
Prophylactic and chronic treatment of asthma
Exercise induced asthma in >= 15 Yrs
Zafir Lukast : prophylactic and chronic
treatment of asthma

ICA
 Most potent anti inflammatory agents available

for the treatment of asthma
 Inhibiting most steps in the cascade of the
inflammatory response
 Benefits reducing bronchial hyper
responsiveness , prevention of late asthmatic
response , enhanced lung function
 Inhaled Glucocorticoids first line controller
therapy for persistent asthma or those who
require step 2

Prognosis
 35%of preschool children experience recurrent

coughing and wheezing,1/3 of them continue to
have persistent asthma into later childhood and
2/3 improvement on their own through their teen
yrs
 Asthma severity by age 7-10 yrs is predictive of
asthma persistence into adulthood
 Children with mod to severe asthma and lower lung
function are likely to have persistent asthma as
adults
 Children with milder asthma and N/R lung function
are likely to improve over time or be periodically
asthmatic

THANK YOU FOR YOUR
ATTENTION


Slide 43

Asthma in Children
DR. A.Mirshokraei
NIOC Hospital Pediatrics Ward

Definition :

DEFINITION

- Chronic inflammatory condition of the
lung airways resulting in episodic airflow
obstruction
- AHR to provocative exposures
Asthma management
• Reducing airway inflammation by: Minimizing
pro inflammatory environmental exposure, using
daily controller anti inflammatory medication,
controlling co morbid conditions that worsen
asthma, less inflammation better asthma
control and fewer exacerbations

Anyway exacerbations

occur

BUT
Even the uncommon
child with sever asthma can
be managed to live normally

 RECURRENT WHEEZING EPISODES WITH COMMON

RESPIRATORY
VIRUSES(RSV,RHINOVIRUS,INFLUENZA,PARAINFLUENZA,A
DENOVIRUS,HUMAN METAPNUMOVIRUS)

 HOST FEATURES AFFECTING IMMUNOLOGIC HOST

DEFENSE,INFLAMMATION/PREVIOUS VIRAL INFECTIONS
MAINIFESTED AS PNUMONIA OR BRONCHIOLITIS
REQUIRING HOSPITALIZATION UNDERLIE THE
RECURRENT WHEEZING IN EARLY CHILDHOOD

 OTHER AIRWAY EXPOSURES SUCH AS INDOOR AND HOME

ALLERGENS,COLD AIR,STRONG ODORS,TOBACCO
SMOKE,ALL INCREASE AHR

 ALLERGEN ELLIMINATION SOMETIMES LEEDS TO CURE

EPIDEMIOLOGY
 Common etiology of emergency visits and school day missing

in childhood ,occasionally hospitalization and rare deaths
specially in poverty ,urban living ,ethnic minorities

 Increasing asthma prevalence worldwide(50% per decade)
 Good correlation of asthma prevalence with allergic rhino

sinusitis and atopic eczema and other allergies

 More prevalence in high level urban modern families than

suburban villagers

 More than 80%of asthmatics reported getting the disease

before 6 year

CLINICS
RECURRENT COUGHING/WHEEZING
PATTERNS IN CHILDHOOD BASED ON
NATURAL HISTORY

TRANSIENT EARLY WHEEZING
 Common in early preschool years

 Recurrent coughing/wheezing primary

triggered by common respiratory viral INF
 Tend to resolve during preschool yrs without
increasing risk of asthma later in life
 Problems due to reduced airflow at birth
suggestive of relative narrow airways improved
by school yrs

Persistent Atopy Associated Asthma
 Begins in early preschool yrs

 Associated with atopy (eg atopic dermatitis in





infancy, allergic rhinitis, food allergy)
Biologic factors e.g.: early inhalant sensitization,
increase serum IGE, increase blood eosinophills,
High risk of persistence into later childhood and
adulthood lung function abnormality
Those with onset<3 yrs
reduced air flow by
school yrs
Those with later onset of symptoms or allergen
sensitizations unlikely persistence lung function
abnormality later

Non-Atopic Wheezing
 Wheezing ,coughing beginning in early life

often with RSV INF resolves later in childhood
without increasing risk of persistence asthma

 Associated with bronchial hyper

responsiveness near birth

Asthma with declining lung function
• Children with asthma with progressive

increase in air flow limitation

• Associated with hyper inflation in childhood
• Male gender

Late onset asthma in females associated with
obesity and early onset puberty
 Onset between 8_13 yrs

 Associated with early onset puberty and obesity
 Specific for females

Occupational type asthma in children
 Children with asthma and occupational type exposure

known to trigger asthma in adults in occupational settings

Types of Asthma
common clinical presentations of intermittent
recurrent wheezing and/or coughing
 Recurrent wheezing in early childhood

 Chronic asthma associated with allergy
 Females 11 yrs with early onset puberty and

obesity

Pathogenesis

 Airflow obstruction resulting from

Broncho constriction of bronchiolar smooth
muscle mass
II. Cellular inflammatory infiltrates and exudates
mostly Eosinophills(also N , M ,L ,mast cells
,basophiles)fill and obstruct airways and damage
epithelium and induce desquamation into airway
lumen mediated by T helper cells and other
immune cells that produce pro allergic pro
inflammatory cytokines(IL4,IL6,IL13)
III. Breach in normal immune regulatory process
I.

RESULT
 Airway inflammation

 AHR
 Edema basement membrane thickness sub

epithelial collagen deposition
 Smooth muscle and mucus gland hypertrophy
and mucus hyper secretion

Air obstruction

Clinical manifestations and diagnosis
 Most common intermittent dry cough and

expiratory wheezing

 Shortness of breath and chest tightness in older

children and adults

 Intermittent non focal chest pain in younger

children

 Worsening of respiratory symptoms at night
 Worsening of day time symptoms by activity

Continue…..
 Subtle symptoms such as self limitation of activities

,general fatigue ,difficulty in keeping up with peers

 Relief with aerosolized bronchodilators
 Lack of improvement with bronchodilators and steroid

is inconsistent with Asthma and should consider
Asthma masquerading conditions!!!!

 Hyper ventilation, intercostal retractions ,nasal flaring

,respiratory accessory muscle use

 Its common not to hear the expiratory wheezing when

Air flow is so limited before treatment

Asthma Triggers
 Common viral infections of the respiratory tract
 Aero allergens in sensitized asthmatics ,animal dander ,dust











mite ,molds ,indoor allergens ,cockroaches
Seasonal aero allergens ,pollens(trees ,grasses ,weeds ,)
Environmental tobacco smoke
Air pollutants ,ozone ,so2,wood or coal smoke ,endotoxin
,mycotoxin ,dust
Strong or noxious odors or fumes ,perfume ,hair spray
,cleaning agents
Occupational exposure
Cold air ,dry air
Exercise
Crying ,laughter ,hyperventilation
Co morbid conditions Rhinitis ,Sinusitis ,GER

Clinics
History:
Triggering symptoms by laughter
,cold air ,airway irritants
Exposures that induce airway
irritation such as viral URTI
Mycoplasma ,Chlamydia
Inhaled allergens
All lead to AHR

Presence Of Risk Factors:
 History of other allergies ,allergic Rhinitis,

allergic Conjunctivitis ,atopic Dermatitis ,food
allergies

 Parental Asthma
 Symptoms apart from cold

Continue…..
 No or minimal signs in routine visits

 Dry or persistent cough

 Normal chest findings unless wheezing when asking

to breath deeper
 Quick relief (10 MIN) after SABA use
 Expiratory wheezing ,prolonged expiratory phase
,decreased sounds in RT lower pos lobe due to
regional hypoventilation owing to airway
obstruction
 Rales , ronchi ,crackles due to hyper secretion
 Segmental crackles and poor breath sounds
atelectasis?

Continue….
 Labored respiration ,respiratory distress increased

prolongation of expiration and wheezing in E and I

 Poor air entry
 Inter costal retractions ,nasal flaring ,supra and

infra sternal retractions

 And again in most sever forms expiratory wheezing

does not appear until some broncho dilation

DD

GERD Rhino sinusitis co morbid

conditions with asthma

Recurrent aspiration in early

life(tracheo broncho malacia
,TEF , foreign body ,CF ,BPD

VCD in older children and

adolescents

LAB FINDINGS
Pulmonary Function
Testing

Continue….
 Forced expiratory airflow measures helpful

in Diagnosis , assessing efficacy of therapy
and monitoring Asthma in children specially
in poor children who do not have PHE
unless obstruction is sever

 Valueablity of spirometric findings in children>6

yrs

 3 efforts the highest is the peak
 Reduced FEV

obstruction

FEV1/FVC <0.80 means significant

 Improvement in FEV1 following beta 2 agonist > =

12% or 200 ml is consistent with Asthma

 Peak flow meter

CXR

Often normal aside from subtle and

nonspecific findings of hyperinflation

Peribronchial thickening
Helping in diagnosis of Asthma

differentials

Diagnosis of complications of Asthma

exacerbations

Other tests such as allergy skin prick
testing

Treatment
 www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm

Asthma Treatment & Management
has 4 components :
Assessment and monitoring of disease
activity
2. Provision to educate pt and family
3. Identification and management of
precipitating factors and co morbid
conditions
4. Appropriate selection of medication
1.

 Attainment of optimal Asthma control

Component 1
 Asthma severity :intermittent
 Persistent: mild ,mod ,severe
 Only once during patient initial evaluation in pt

who is not using a daily controller agent
 Asthma control degree to which symptoms ,
on going functional impairments , risk of
adverse events minimized and goals of
therapy are met

Continue….
Well controlled
2. Not well controlled
3. Very poor controlled
1.

 NIH guidelines for both severity and

control for 3 age groups

0-4 yrs
2. 5-11 yrs
3. =>12 yrs
1.

Important
even in the absence of frequent symptoms
infants and children whom have risk factors
for asthma and 4 or more episodes of
wheezing over the past yr which lasted more
than 1 day or 2 or more exacerbations in
the last 6 months requiring syst
corticosteroids should be considered in the
persistent group and hence receive long term
controller therapy

Important Tips..
 Regular clinical visits every 2-6 weeks
 Assessment of :

Pt symptoms frequency night and day
2. Need for short acting inhaled b2 agonists for
quick relief
3. Ability to engage in normal activities
4. Air flow measures for>=5 yrs
1.

Continue..
 Component 2 : pt education

 Component 3 : control of factors contributing

to asthma severity
1. Environmental exposures
2. Co morbid conditions
 Component 4 :principals of asthma
pharmacotherapy

Asthma Medication
 SABA

 ICS

 LABA
 LTRA

 SYSTEMIC STEROIDS

 NONSTEROIDAL ANTIINFLAMMATORY

CROMOLYN AND NEDOCROMYL
 OXYGEN
 ANTICHOLINERGIC AGENTS
IPRATROPIUM
BROMIDE
 ANTIIMMUNOGLUBOLINE E

MANAGEMENT OF ASTHMA EXACERBATION(STATUS ASTHMATICUS)
RISK ASSESMENT ON ADMISSION

FOCUSED HISTORY

ONSET OF CURRENT EXACERBATION
FREQUENCY AND severity of daytime and night
time symptoms and activity limitation
Frequency of rescue bronchodilator use
Current medication and allergies
Potential triggers
History of systemic steroid courses, emergency
department visists , hospitalization, intubation or life
threatening episodes

Clinical assesment

Physical examination findings: vital signs,
breathlessness, air movement, use of accessory
respiratory muscles, retractions, anxiety level,
alteration in mental status
Pulse oximetry
Lung function(defer in pts with mod to severe
distress or history of labile disease)

Treatment
Drugs and trade name

Mechanism of action and dosing

Cautions and adverse effects

Oxygen(mask or nasal canula)
Inhaled short acting b2
agonist
Albuterol nebulized
solution(5mg/ml concentrates
Albuterol MDI
Levabuterol

Treats hypoxia
Bronchodilator
Neubolizer 0.15 mg/kg every 20 min for 3
doses as needed,then 0.15_0.3 mg/kg up t 10
mg every 1_4 hour as needed or up to 0.5
mg/kg/hr by continous neubolization
2_8 puf up to every 20 min for 3 doses as
needed then every 1 hr as needed

Monitor pulse oximetry to maintain o2 saturation>92%
Cardiorespiratory monitoring
During exacerbations,frequent or continuous use can cause
pulmonary vasodilatation,v/q mistmatch and hypoxemia
Adverse effect palpitation, tachycardia, arrhythmia, tremor,
hypoxemia
Neubolizer:when giving concentrate forms,dilute with saline to 3
ml total neubolized volume
For MDI use space/holding chamber

Systemic corticosteroids
Prednisolone tb
Methyl prednisolon
Anticholinergics
Ipratropium
Atrovent
Ipratropium with Albuterol

Anti inflammatory
0.5_1 mg/kg every 6-8 hr for 48 hr , then 1-2 mg/kg
day bid(max 60 mg/day)
Short course burst for exacerbation 1-2 mg/kg/day qd
or bid for 3-7 days
Mucolitic/bronchodilator
Neubolizer 0.5 mg q6-8 hr (tid or qid) as needed
MDI 2 paf qid
1 vial by neubolizer qid



If pt has been exposed chickenpox or measles, consider passive
immunoglobulin prophylaxis, also risk of complications with
herspes simplex and TB

For daily dosing , 8 am administration minimizes adrenal
suppression

Children may benefit from dosage tapering if course exceed 7 days

Adverse effect monitoring: frequent therapy bursts risk numerous
corticosteroid adverse effects

Should not be used as first line treatment added to b2 agonist
therapy
Neubolizer may mix Ipratropium with Albuterol

QUICK RELIEF MEDICATION
SABA

Anti cholinergic(ipratropium)
Short term systemic gluco

corticoid

SABA
 Quick relief of asthma symptoms
 Relax airway smooth muscle prompt airflow↑
 Repetitive or continuous SABA is the most effective means







of reversing air flow obstruction
SABA should not be prescribed on a regular schedule
because concerns of possibility of deteriorating asthma
control
Frequent use of SABA is an indication of poor asthma control
Preferred root is inhalation smaller dose , fewer side effects
more rapid on set of action
Ipratropium Bromide as an adjunct to SABA in emergency
room reduces hospital admissions and improves lung function
Systemic Glucocorticoids short oral course + SABA in
moderate to severe asthma exacerbation

LABA
 Salmetrol

 Should be used in combination with inhaled

corticosteroids and not as mono therapy
 Exercise induces asthma in children >= 4 Yrs
one inhalation 30 min prior to exercise
 No additional doses for PTs who are already
receiving it twice daily not recommended by
NIH guidelines

LTRA

 MonteLukast ( singulair)

 Antihistaminic

 Leukotrien receptor antagonist

 Asthma ( not < 12 MO) and allergic rhinitis (





not < 6 MO)
Morning dosing not evaluated
Prophylactic and chronic treatment of asthma
Exercise induced asthma in >= 15 Yrs
Zafir Lukast : prophylactic and chronic
treatment of asthma

ICA
 Most potent anti inflammatory agents available

for the treatment of asthma
 Inhibiting most steps in the cascade of the
inflammatory response
 Benefits reducing bronchial hyper
responsiveness , prevention of late asthmatic
response , enhanced lung function
 Inhaled Glucocorticoids first line controller
therapy for persistent asthma or those who
require step 2

Prognosis
 35%of preschool children experience recurrent

coughing and wheezing,1/3 of them continue to
have persistent asthma into later childhood and
2/3 improvement on their own through their teen
yrs
 Asthma severity by age 7-10 yrs is predictive of
asthma persistence into adulthood
 Children with mod to severe asthma and lower lung
function are likely to have persistent asthma as
adults
 Children with milder asthma and N/R lung function
are likely to improve over time or be periodically
asthmatic

THANK YOU FOR YOUR
ATTENTION


Slide 44

Asthma in Children
DR. A.Mirshokraei
NIOC Hospital Pediatrics Ward

Definition :

DEFINITION

- Chronic inflammatory condition of the
lung airways resulting in episodic airflow
obstruction
- AHR to provocative exposures
Asthma management
• Reducing airway inflammation by: Minimizing
pro inflammatory environmental exposure, using
daily controller anti inflammatory medication,
controlling co morbid conditions that worsen
asthma, less inflammation better asthma
control and fewer exacerbations

Anyway exacerbations

occur

BUT
Even the uncommon
child with sever asthma can
be managed to live normally

 RECURRENT WHEEZING EPISODES WITH COMMON

RESPIRATORY
VIRUSES(RSV,RHINOVIRUS,INFLUENZA,PARAINFLUENZA,A
DENOVIRUS,HUMAN METAPNUMOVIRUS)

 HOST FEATURES AFFECTING IMMUNOLOGIC HOST

DEFENSE,INFLAMMATION/PREVIOUS VIRAL INFECTIONS
MAINIFESTED AS PNUMONIA OR BRONCHIOLITIS
REQUIRING HOSPITALIZATION UNDERLIE THE
RECURRENT WHEEZING IN EARLY CHILDHOOD

 OTHER AIRWAY EXPOSURES SUCH AS INDOOR AND HOME

ALLERGENS,COLD AIR,STRONG ODORS,TOBACCO
SMOKE,ALL INCREASE AHR

 ALLERGEN ELLIMINATION SOMETIMES LEEDS TO CURE

EPIDEMIOLOGY
 Common etiology of emergency visits and school day missing

in childhood ,occasionally hospitalization and rare deaths
specially in poverty ,urban living ,ethnic minorities

 Increasing asthma prevalence worldwide(50% per decade)
 Good correlation of asthma prevalence with allergic rhino

sinusitis and atopic eczema and other allergies

 More prevalence in high level urban modern families than

suburban villagers

 More than 80%of asthmatics reported getting the disease

before 6 year

CLINICS
RECURRENT COUGHING/WHEEZING
PATTERNS IN CHILDHOOD BASED ON
NATURAL HISTORY

TRANSIENT EARLY WHEEZING
 Common in early preschool years

 Recurrent coughing/wheezing primary

triggered by common respiratory viral INF
 Tend to resolve during preschool yrs without
increasing risk of asthma later in life
 Problems due to reduced airflow at birth
suggestive of relative narrow airways improved
by school yrs

Persistent Atopy Associated Asthma
 Begins in early preschool yrs

 Associated with atopy (eg atopic dermatitis in





infancy, allergic rhinitis, food allergy)
Biologic factors e.g.: early inhalant sensitization,
increase serum IGE, increase blood eosinophills,
High risk of persistence into later childhood and
adulthood lung function abnormality
Those with onset<3 yrs
reduced air flow by
school yrs
Those with later onset of symptoms or allergen
sensitizations unlikely persistence lung function
abnormality later

Non-Atopic Wheezing
 Wheezing ,coughing beginning in early life

often with RSV INF resolves later in childhood
without increasing risk of persistence asthma

 Associated with bronchial hyper

responsiveness near birth

Asthma with declining lung function
• Children with asthma with progressive

increase in air flow limitation

• Associated with hyper inflation in childhood
• Male gender

Late onset asthma in females associated with
obesity and early onset puberty
 Onset between 8_13 yrs

 Associated with early onset puberty and obesity
 Specific for females

Occupational type asthma in children
 Children with asthma and occupational type exposure

known to trigger asthma in adults in occupational settings

Types of Asthma
common clinical presentations of intermittent
recurrent wheezing and/or coughing
 Recurrent wheezing in early childhood

 Chronic asthma associated with allergy
 Females 11 yrs with early onset puberty and

obesity

Pathogenesis

 Airflow obstruction resulting from

Broncho constriction of bronchiolar smooth
muscle mass
II. Cellular inflammatory infiltrates and exudates
mostly Eosinophills(also N , M ,L ,mast cells
,basophiles)fill and obstruct airways and damage
epithelium and induce desquamation into airway
lumen mediated by T helper cells and other
immune cells that produce pro allergic pro
inflammatory cytokines(IL4,IL6,IL13)
III. Breach in normal immune regulatory process
I.

RESULT
 Airway inflammation

 AHR
 Edema basement membrane thickness sub

epithelial collagen deposition
 Smooth muscle and mucus gland hypertrophy
and mucus hyper secretion

Air obstruction

Clinical manifestations and diagnosis
 Most common intermittent dry cough and

expiratory wheezing

 Shortness of breath and chest tightness in older

children and adults

 Intermittent non focal chest pain in younger

children

 Worsening of respiratory symptoms at night
 Worsening of day time symptoms by activity

Continue…..
 Subtle symptoms such as self limitation of activities

,general fatigue ,difficulty in keeping up with peers

 Relief with aerosolized bronchodilators
 Lack of improvement with bronchodilators and steroid

is inconsistent with Asthma and should consider
Asthma masquerading conditions!!!!

 Hyper ventilation, intercostal retractions ,nasal flaring

,respiratory accessory muscle use

 Its common not to hear the expiratory wheezing when

Air flow is so limited before treatment

Asthma Triggers
 Common viral infections of the respiratory tract
 Aero allergens in sensitized asthmatics ,animal dander ,dust











mite ,molds ,indoor allergens ,cockroaches
Seasonal aero allergens ,pollens(trees ,grasses ,weeds ,)
Environmental tobacco smoke
Air pollutants ,ozone ,so2,wood or coal smoke ,endotoxin
,mycotoxin ,dust
Strong or noxious odors or fumes ,perfume ,hair spray
,cleaning agents
Occupational exposure
Cold air ,dry air
Exercise
Crying ,laughter ,hyperventilation
Co morbid conditions Rhinitis ,Sinusitis ,GER

Clinics
History:
Triggering symptoms by laughter
,cold air ,airway irritants
Exposures that induce airway
irritation such as viral URTI
Mycoplasma ,Chlamydia
Inhaled allergens
All lead to AHR

Presence Of Risk Factors:
 History of other allergies ,allergic Rhinitis,

allergic Conjunctivitis ,atopic Dermatitis ,food
allergies

 Parental Asthma
 Symptoms apart from cold

Continue…..
 No or minimal signs in routine visits

 Dry or persistent cough

 Normal chest findings unless wheezing when asking

to breath deeper
 Quick relief (10 MIN) after SABA use
 Expiratory wheezing ,prolonged expiratory phase
,decreased sounds in RT lower pos lobe due to
regional hypoventilation owing to airway
obstruction
 Rales , ronchi ,crackles due to hyper secretion
 Segmental crackles and poor breath sounds
atelectasis?

Continue….
 Labored respiration ,respiratory distress increased

prolongation of expiration and wheezing in E and I

 Poor air entry
 Inter costal retractions ,nasal flaring ,supra and

infra sternal retractions

 And again in most sever forms expiratory wheezing

does not appear until some broncho dilation

DD

GERD Rhino sinusitis co morbid

conditions with asthma

Recurrent aspiration in early

life(tracheo broncho malacia
,TEF , foreign body ,CF ,BPD

VCD in older children and

adolescents

LAB FINDINGS
Pulmonary Function
Testing

Continue….
 Forced expiratory airflow measures helpful

in Diagnosis , assessing efficacy of therapy
and monitoring Asthma in children specially
in poor children who do not have PHE
unless obstruction is sever

 Valueablity of spirometric findings in children>6

yrs

 3 efforts the highest is the peak
 Reduced FEV

obstruction

FEV1/FVC <0.80 means significant

 Improvement in FEV1 following beta 2 agonist > =

12% or 200 ml is consistent with Asthma

 Peak flow meter

CXR

Often normal aside from subtle and

nonspecific findings of hyperinflation

Peribronchial thickening
Helping in diagnosis of Asthma

differentials

Diagnosis of complications of Asthma

exacerbations

Other tests such as allergy skin prick
testing

Treatment
 www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm

Asthma Treatment & Management
has 4 components :
Assessment and monitoring of disease
activity
2. Provision to educate pt and family
3. Identification and management of
precipitating factors and co morbid
conditions
4. Appropriate selection of medication
1.

 Attainment of optimal Asthma control

Component 1
 Asthma severity :intermittent
 Persistent: mild ,mod ,severe
 Only once during patient initial evaluation in pt

who is not using a daily controller agent
 Asthma control degree to which symptoms ,
on going functional impairments , risk of
adverse events minimized and goals of
therapy are met

Continue….
Well controlled
2. Not well controlled
3. Very poor controlled
1.

 NIH guidelines for both severity and

control for 3 age groups

0-4 yrs
2. 5-11 yrs
3. =>12 yrs
1.

Important
even in the absence of frequent symptoms
infants and children whom have risk factors
for asthma and 4 or more episodes of
wheezing over the past yr which lasted more
than 1 day or 2 or more exacerbations in
the last 6 months requiring syst
corticosteroids should be considered in the
persistent group and hence receive long term
controller therapy

Important Tips..
 Regular clinical visits every 2-6 weeks
 Assessment of :

Pt symptoms frequency night and day
2. Need for short acting inhaled b2 agonists for
quick relief
3. Ability to engage in normal activities
4. Air flow measures for>=5 yrs
1.

Continue..
 Component 2 : pt education

 Component 3 : control of factors contributing

to asthma severity
1. Environmental exposures
2. Co morbid conditions
 Component 4 :principals of asthma
pharmacotherapy

Asthma Medication
 SABA

 ICS

 LABA
 LTRA

 SYSTEMIC STEROIDS

 NONSTEROIDAL ANTIINFLAMMATORY

CROMOLYN AND NEDOCROMYL
 OXYGEN
 ANTICHOLINERGIC AGENTS
IPRATROPIUM
BROMIDE
 ANTIIMMUNOGLUBOLINE E

MANAGEMENT OF ASTHMA EXACERBATION(STATUS ASTHMATICUS)
RISK ASSESMENT ON ADMISSION

FOCUSED HISTORY

ONSET OF CURRENT EXACERBATION
FREQUENCY AND severity of daytime and night
time symptoms and activity limitation
Frequency of rescue bronchodilator use
Current medication and allergies
Potential triggers
History of systemic steroid courses, emergency
department visists , hospitalization, intubation or life
threatening episodes

Clinical assesment

Physical examination findings: vital signs,
breathlessness, air movement, use of accessory
respiratory muscles, retractions, anxiety level,
alteration in mental status
Pulse oximetry
Lung function(defer in pts with mod to severe
distress or history of labile disease)

Treatment
Drugs and trade name

Mechanism of action and dosing

Cautions and adverse effects

Oxygen(mask or nasal canula)
Inhaled short acting b2
agonist
Albuterol nebulized
solution(5mg/ml concentrates
Albuterol MDI
Levabuterol

Treats hypoxia
Bronchodilator
Neubolizer 0.15 mg/kg every 20 min for 3
doses as needed,then 0.15_0.3 mg/kg up t 10
mg every 1_4 hour as needed or up to 0.5
mg/kg/hr by continous neubolization
2_8 puf up to every 20 min for 3 doses as
needed then every 1 hr as needed

Monitor pulse oximetry to maintain o2 saturation>92%
Cardiorespiratory monitoring
During exacerbations,frequent or continuous use can cause
pulmonary vasodilatation,v/q mistmatch and hypoxemia
Adverse effect palpitation, tachycardia, arrhythmia, tremor,
hypoxemia
Neubolizer:when giving concentrate forms,dilute with saline to 3
ml total neubolized volume
For MDI use space/holding chamber

Systemic corticosteroids
Prednisolone tb
Methyl prednisolon
Anticholinergics
Ipratropium
Atrovent
Ipratropium with Albuterol

Anti inflammatory
0.5_1 mg/kg every 6-8 hr for 48 hr , then 1-2 mg/kg
day bid(max 60 mg/day)
Short course burst for exacerbation 1-2 mg/kg/day qd
or bid for 3-7 days
Mucolitic/bronchodilator
Neubolizer 0.5 mg q6-8 hr (tid or qid) as needed
MDI 2 paf qid
1 vial by neubolizer qid



If pt has been exposed chickenpox or measles, consider passive
immunoglobulin prophylaxis, also risk of complications with
herspes simplex and TB

For daily dosing , 8 am administration minimizes adrenal
suppression

Children may benefit from dosage tapering if course exceed 7 days

Adverse effect monitoring: frequent therapy bursts risk numerous
corticosteroid adverse effects

Should not be used as first line treatment added to b2 agonist
therapy
Neubolizer may mix Ipratropium with Albuterol

QUICK RELIEF MEDICATION
SABA

Anti cholinergic(ipratropium)
Short term systemic gluco

corticoid

SABA
 Quick relief of asthma symptoms
 Relax airway smooth muscle prompt airflow↑
 Repetitive or continuous SABA is the most effective means







of reversing air flow obstruction
SABA should not be prescribed on a regular schedule
because concerns of possibility of deteriorating asthma
control
Frequent use of SABA is an indication of poor asthma control
Preferred root is inhalation smaller dose , fewer side effects
more rapid on set of action
Ipratropium Bromide as an adjunct to SABA in emergency
room reduces hospital admissions and improves lung function
Systemic Glucocorticoids short oral course + SABA in
moderate to severe asthma exacerbation

LABA
 Salmetrol

 Should be used in combination with inhaled

corticosteroids and not as mono therapy
 Exercise induces asthma in children >= 4 Yrs
one inhalation 30 min prior to exercise
 No additional doses for PTs who are already
receiving it twice daily not recommended by
NIH guidelines

LTRA

 MonteLukast ( singulair)

 Antihistaminic

 Leukotrien receptor antagonist

 Asthma ( not < 12 MO) and allergic rhinitis (





not < 6 MO)
Morning dosing not evaluated
Prophylactic and chronic treatment of asthma
Exercise induced asthma in >= 15 Yrs
Zafir Lukast : prophylactic and chronic
treatment of asthma

ICA
 Most potent anti inflammatory agents available

for the treatment of asthma
 Inhibiting most steps in the cascade of the
inflammatory response
 Benefits reducing bronchial hyper
responsiveness , prevention of late asthmatic
response , enhanced lung function
 Inhaled Glucocorticoids first line controller
therapy for persistent asthma or those who
require step 2

Prognosis
 35%of preschool children experience recurrent

coughing and wheezing,1/3 of them continue to
have persistent asthma into later childhood and
2/3 improvement on their own through their teen
yrs
 Asthma severity by age 7-10 yrs is predictive of
asthma persistence into adulthood
 Children with mod to severe asthma and lower lung
function are likely to have persistent asthma as
adults
 Children with milder asthma and N/R lung function
are likely to improve over time or be periodically
asthmatic

THANK YOU FOR YOUR
ATTENTION


Slide 45

Asthma in Children
DR. A.Mirshokraei
NIOC Hospital Pediatrics Ward

Definition :

DEFINITION

- Chronic inflammatory condition of the
lung airways resulting in episodic airflow
obstruction
- AHR to provocative exposures
Asthma management
• Reducing airway inflammation by: Minimizing
pro inflammatory environmental exposure, using
daily controller anti inflammatory medication,
controlling co morbid conditions that worsen
asthma, less inflammation better asthma
control and fewer exacerbations

Anyway exacerbations

occur

BUT
Even the uncommon
child with sever asthma can
be managed to live normally

 RECURRENT WHEEZING EPISODES WITH COMMON

RESPIRATORY
VIRUSES(RSV,RHINOVIRUS,INFLUENZA,PARAINFLUENZA,A
DENOVIRUS,HUMAN METAPNUMOVIRUS)

 HOST FEATURES AFFECTING IMMUNOLOGIC HOST

DEFENSE,INFLAMMATION/PREVIOUS VIRAL INFECTIONS
MAINIFESTED AS PNUMONIA OR BRONCHIOLITIS
REQUIRING HOSPITALIZATION UNDERLIE THE
RECURRENT WHEEZING IN EARLY CHILDHOOD

 OTHER AIRWAY EXPOSURES SUCH AS INDOOR AND HOME

ALLERGENS,COLD AIR,STRONG ODORS,TOBACCO
SMOKE,ALL INCREASE AHR

 ALLERGEN ELLIMINATION SOMETIMES LEEDS TO CURE

EPIDEMIOLOGY
 Common etiology of emergency visits and school day missing

in childhood ,occasionally hospitalization and rare deaths
specially in poverty ,urban living ,ethnic minorities

 Increasing asthma prevalence worldwide(50% per decade)
 Good correlation of asthma prevalence with allergic rhino

sinusitis and atopic eczema and other allergies

 More prevalence in high level urban modern families than

suburban villagers

 More than 80%of asthmatics reported getting the disease

before 6 year

CLINICS
RECURRENT COUGHING/WHEEZING
PATTERNS IN CHILDHOOD BASED ON
NATURAL HISTORY

TRANSIENT EARLY WHEEZING
 Common in early preschool years

 Recurrent coughing/wheezing primary

triggered by common respiratory viral INF
 Tend to resolve during preschool yrs without
increasing risk of asthma later in life
 Problems due to reduced airflow at birth
suggestive of relative narrow airways improved
by school yrs

Persistent Atopy Associated Asthma
 Begins in early preschool yrs

 Associated with atopy (eg atopic dermatitis in





infancy, allergic rhinitis, food allergy)
Biologic factors e.g.: early inhalant sensitization,
increase serum IGE, increase blood eosinophills,
High risk of persistence into later childhood and
adulthood lung function abnormality
Those with onset<3 yrs
reduced air flow by
school yrs
Those with later onset of symptoms or allergen
sensitizations unlikely persistence lung function
abnormality later

Non-Atopic Wheezing
 Wheezing ,coughing beginning in early life

often with RSV INF resolves later in childhood
without increasing risk of persistence asthma

 Associated with bronchial hyper

responsiveness near birth

Asthma with declining lung function
• Children with asthma with progressive

increase in air flow limitation

• Associated with hyper inflation in childhood
• Male gender

Late onset asthma in females associated with
obesity and early onset puberty
 Onset between 8_13 yrs

 Associated with early onset puberty and obesity
 Specific for females

Occupational type asthma in children
 Children with asthma and occupational type exposure

known to trigger asthma in adults in occupational settings

Types of Asthma
common clinical presentations of intermittent
recurrent wheezing and/or coughing
 Recurrent wheezing in early childhood

 Chronic asthma associated with allergy
 Females 11 yrs with early onset puberty and

obesity

Pathogenesis

 Airflow obstruction resulting from

Broncho constriction of bronchiolar smooth
muscle mass
II. Cellular inflammatory infiltrates and exudates
mostly Eosinophills(also N , M ,L ,mast cells
,basophiles)fill and obstruct airways and damage
epithelium and induce desquamation into airway
lumen mediated by T helper cells and other
immune cells that produce pro allergic pro
inflammatory cytokines(IL4,IL6,IL13)
III. Breach in normal immune regulatory process
I.

RESULT
 Airway inflammation

 AHR
 Edema basement membrane thickness sub

epithelial collagen deposition
 Smooth muscle and mucus gland hypertrophy
and mucus hyper secretion

Air obstruction

Clinical manifestations and diagnosis
 Most common intermittent dry cough and

expiratory wheezing

 Shortness of breath and chest tightness in older

children and adults

 Intermittent non focal chest pain in younger

children

 Worsening of respiratory symptoms at night
 Worsening of day time symptoms by activity

Continue…..
 Subtle symptoms such as self limitation of activities

,general fatigue ,difficulty in keeping up with peers

 Relief with aerosolized bronchodilators
 Lack of improvement with bronchodilators and steroid

is inconsistent with Asthma and should consider
Asthma masquerading conditions!!!!

 Hyper ventilation, intercostal retractions ,nasal flaring

,respiratory accessory muscle use

 Its common not to hear the expiratory wheezing when

Air flow is so limited before treatment

Asthma Triggers
 Common viral infections of the respiratory tract
 Aero allergens in sensitized asthmatics ,animal dander ,dust











mite ,molds ,indoor allergens ,cockroaches
Seasonal aero allergens ,pollens(trees ,grasses ,weeds ,)
Environmental tobacco smoke
Air pollutants ,ozone ,so2,wood or coal smoke ,endotoxin
,mycotoxin ,dust
Strong or noxious odors or fumes ,perfume ,hair spray
,cleaning agents
Occupational exposure
Cold air ,dry air
Exercise
Crying ,laughter ,hyperventilation
Co morbid conditions Rhinitis ,Sinusitis ,GER

Clinics
History:
Triggering symptoms by laughter
,cold air ,airway irritants
Exposures that induce airway
irritation such as viral URTI
Mycoplasma ,Chlamydia
Inhaled allergens
All lead to AHR

Presence Of Risk Factors:
 History of other allergies ,allergic Rhinitis,

allergic Conjunctivitis ,atopic Dermatitis ,food
allergies

 Parental Asthma
 Symptoms apart from cold

Continue…..
 No or minimal signs in routine visits

 Dry or persistent cough

 Normal chest findings unless wheezing when asking

to breath deeper
 Quick relief (10 MIN) after SABA use
 Expiratory wheezing ,prolonged expiratory phase
,decreased sounds in RT lower pos lobe due to
regional hypoventilation owing to airway
obstruction
 Rales , ronchi ,crackles due to hyper secretion
 Segmental crackles and poor breath sounds
atelectasis?

Continue….
 Labored respiration ,respiratory distress increased

prolongation of expiration and wheezing in E and I

 Poor air entry
 Inter costal retractions ,nasal flaring ,supra and

infra sternal retractions

 And again in most sever forms expiratory wheezing

does not appear until some broncho dilation

DD

GERD Rhino sinusitis co morbid

conditions with asthma

Recurrent aspiration in early

life(tracheo broncho malacia
,TEF , foreign body ,CF ,BPD

VCD in older children and

adolescents

LAB FINDINGS
Pulmonary Function
Testing

Continue….
 Forced expiratory airflow measures helpful

in Diagnosis , assessing efficacy of therapy
and monitoring Asthma in children specially
in poor children who do not have PHE
unless obstruction is sever

 Valueablity of spirometric findings in children>6

yrs

 3 efforts the highest is the peak
 Reduced FEV

obstruction

FEV1/FVC <0.80 means significant

 Improvement in FEV1 following beta 2 agonist > =

12% or 200 ml is consistent with Asthma

 Peak flow meter

CXR

Often normal aside from subtle and

nonspecific findings of hyperinflation

Peribronchial thickening
Helping in diagnosis of Asthma

differentials

Diagnosis of complications of Asthma

exacerbations

Other tests such as allergy skin prick
testing

Treatment
 www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm

Asthma Treatment & Management
has 4 components :
Assessment and monitoring of disease
activity
2. Provision to educate pt and family
3. Identification and management of
precipitating factors and co morbid
conditions
4. Appropriate selection of medication
1.

 Attainment of optimal Asthma control

Component 1
 Asthma severity :intermittent
 Persistent: mild ,mod ,severe
 Only once during patient initial evaluation in pt

who is not using a daily controller agent
 Asthma control degree to which symptoms ,
on going functional impairments , risk of
adverse events minimized and goals of
therapy are met

Continue….
Well controlled
2. Not well controlled
3. Very poor controlled
1.

 NIH guidelines for both severity and

control for 3 age groups

0-4 yrs
2. 5-11 yrs
3. =>12 yrs
1.

Important
even in the absence of frequent symptoms
infants and children whom have risk factors
for asthma and 4 or more episodes of
wheezing over the past yr which lasted more
than 1 day or 2 or more exacerbations in
the last 6 months requiring syst
corticosteroids should be considered in the
persistent group and hence receive long term
controller therapy

Important Tips..
 Regular clinical visits every 2-6 weeks
 Assessment of :

Pt symptoms frequency night and day
2. Need for short acting inhaled b2 agonists for
quick relief
3. Ability to engage in normal activities
4. Air flow measures for>=5 yrs
1.

Continue..
 Component 2 : pt education

 Component 3 : control of factors contributing

to asthma severity
1. Environmental exposures
2. Co morbid conditions
 Component 4 :principals of asthma
pharmacotherapy

Asthma Medication
 SABA

 ICS

 LABA
 LTRA

 SYSTEMIC STEROIDS

 NONSTEROIDAL ANTIINFLAMMATORY

CROMOLYN AND NEDOCROMYL
 OXYGEN
 ANTICHOLINERGIC AGENTS
IPRATROPIUM
BROMIDE
 ANTIIMMUNOGLUBOLINE E

MANAGEMENT OF ASTHMA EXACERBATION(STATUS ASTHMATICUS)
RISK ASSESMENT ON ADMISSION

FOCUSED HISTORY

ONSET OF CURRENT EXACERBATION
FREQUENCY AND severity of daytime and night
time symptoms and activity limitation
Frequency of rescue bronchodilator use
Current medication and allergies
Potential triggers
History of systemic steroid courses, emergency
department visists , hospitalization, intubation or life
threatening episodes

Clinical assesment

Physical examination findings: vital signs,
breathlessness, air movement, use of accessory
respiratory muscles, retractions, anxiety level,
alteration in mental status
Pulse oximetry
Lung function(defer in pts with mod to severe
distress or history of labile disease)

Treatment
Drugs and trade name

Mechanism of action and dosing

Cautions and adverse effects

Oxygen(mask or nasal canula)
Inhaled short acting b2
agonist
Albuterol nebulized
solution(5mg/ml concentrates
Albuterol MDI
Levabuterol

Treats hypoxia
Bronchodilator
Neubolizer 0.15 mg/kg every 20 min for 3
doses as needed,then 0.15_0.3 mg/kg up t 10
mg every 1_4 hour as needed or up to 0.5
mg/kg/hr by continous neubolization
2_8 puf up to every 20 min for 3 doses as
needed then every 1 hr as needed

Monitor pulse oximetry to maintain o2 saturation>92%
Cardiorespiratory monitoring
During exacerbations,frequent or continuous use can cause
pulmonary vasodilatation,v/q mistmatch and hypoxemia
Adverse effect palpitation, tachycardia, arrhythmia, tremor,
hypoxemia
Neubolizer:when giving concentrate forms,dilute with saline to 3
ml total neubolized volume
For MDI use space/holding chamber

Systemic corticosteroids
Prednisolone tb
Methyl prednisolon
Anticholinergics
Ipratropium
Atrovent
Ipratropium with Albuterol

Anti inflammatory
0.5_1 mg/kg every 6-8 hr for 48 hr , then 1-2 mg/kg
day bid(max 60 mg/day)
Short course burst for exacerbation 1-2 mg/kg/day qd
or bid for 3-7 days
Mucolitic/bronchodilator
Neubolizer 0.5 mg q6-8 hr (tid or qid) as needed
MDI 2 paf qid
1 vial by neubolizer qid



If pt has been exposed chickenpox or measles, consider passive
immunoglobulin prophylaxis, also risk of complications with
herspes simplex and TB

For daily dosing , 8 am administration minimizes adrenal
suppression

Children may benefit from dosage tapering if course exceed 7 days

Adverse effect monitoring: frequent therapy bursts risk numerous
corticosteroid adverse effects

Should not be used as first line treatment added to b2 agonist
therapy
Neubolizer may mix Ipratropium with Albuterol

QUICK RELIEF MEDICATION
SABA

Anti cholinergic(ipratropium)
Short term systemic gluco

corticoid

SABA
 Quick relief of asthma symptoms
 Relax airway smooth muscle prompt airflow↑
 Repetitive or continuous SABA is the most effective means







of reversing air flow obstruction
SABA should not be prescribed on a regular schedule
because concerns of possibility of deteriorating asthma
control
Frequent use of SABA is an indication of poor asthma control
Preferred root is inhalation smaller dose , fewer side effects
more rapid on set of action
Ipratropium Bromide as an adjunct to SABA in emergency
room reduces hospital admissions and improves lung function
Systemic Glucocorticoids short oral course + SABA in
moderate to severe asthma exacerbation

LABA
 Salmetrol

 Should be used in combination with inhaled

corticosteroids and not as mono therapy
 Exercise induces asthma in children >= 4 Yrs
one inhalation 30 min prior to exercise
 No additional doses for PTs who are already
receiving it twice daily not recommended by
NIH guidelines

LTRA

 MonteLukast ( singulair)

 Antihistaminic

 Leukotrien receptor antagonist

 Asthma ( not < 12 MO) and allergic rhinitis (





not < 6 MO)
Morning dosing not evaluated
Prophylactic and chronic treatment of asthma
Exercise induced asthma in >= 15 Yrs
Zafir Lukast : prophylactic and chronic
treatment of asthma

ICA
 Most potent anti inflammatory agents available

for the treatment of asthma
 Inhibiting most steps in the cascade of the
inflammatory response
 Benefits reducing bronchial hyper
responsiveness , prevention of late asthmatic
response , enhanced lung function
 Inhaled Glucocorticoids first line controller
therapy for persistent asthma or those who
require step 2

Prognosis
 35%of preschool children experience recurrent

coughing and wheezing,1/3 of them continue to
have persistent asthma into later childhood and
2/3 improvement on their own through their teen
yrs
 Asthma severity by age 7-10 yrs is predictive of
asthma persistence into adulthood
 Children with mod to severe asthma and lower lung
function are likely to have persistent asthma as
adults
 Children with milder asthma and N/R lung function
are likely to improve over time or be periodically
asthmatic

THANK YOU FOR YOUR
ATTENTION


Slide 46

Asthma in Children
DR. A.Mirshokraei
NIOC Hospital Pediatrics Ward

Definition :

DEFINITION

- Chronic inflammatory condition of the
lung airways resulting in episodic airflow
obstruction
- AHR to provocative exposures
Asthma management
• Reducing airway inflammation by: Minimizing
pro inflammatory environmental exposure, using
daily controller anti inflammatory medication,
controlling co morbid conditions that worsen
asthma, less inflammation better asthma
control and fewer exacerbations

Anyway exacerbations

occur

BUT
Even the uncommon
child with sever asthma can
be managed to live normally

 RECURRENT WHEEZING EPISODES WITH COMMON

RESPIRATORY
VIRUSES(RSV,RHINOVIRUS,INFLUENZA,PARAINFLUENZA,A
DENOVIRUS,HUMAN METAPNUMOVIRUS)

 HOST FEATURES AFFECTING IMMUNOLOGIC HOST

DEFENSE,INFLAMMATION/PREVIOUS VIRAL INFECTIONS
MAINIFESTED AS PNUMONIA OR BRONCHIOLITIS
REQUIRING HOSPITALIZATION UNDERLIE THE
RECURRENT WHEEZING IN EARLY CHILDHOOD

 OTHER AIRWAY EXPOSURES SUCH AS INDOOR AND HOME

ALLERGENS,COLD AIR,STRONG ODORS,TOBACCO
SMOKE,ALL INCREASE AHR

 ALLERGEN ELLIMINATION SOMETIMES LEEDS TO CURE

EPIDEMIOLOGY
 Common etiology of emergency visits and school day missing

in childhood ,occasionally hospitalization and rare deaths
specially in poverty ,urban living ,ethnic minorities

 Increasing asthma prevalence worldwide(50% per decade)
 Good correlation of asthma prevalence with allergic rhino

sinusitis and atopic eczema and other allergies

 More prevalence in high level urban modern families than

suburban villagers

 More than 80%of asthmatics reported getting the disease

before 6 year

CLINICS
RECURRENT COUGHING/WHEEZING
PATTERNS IN CHILDHOOD BASED ON
NATURAL HISTORY

TRANSIENT EARLY WHEEZING
 Common in early preschool years

 Recurrent coughing/wheezing primary

triggered by common respiratory viral INF
 Tend to resolve during preschool yrs without
increasing risk of asthma later in life
 Problems due to reduced airflow at birth
suggestive of relative narrow airways improved
by school yrs

Persistent Atopy Associated Asthma
 Begins in early preschool yrs

 Associated with atopy (eg atopic dermatitis in





infancy, allergic rhinitis, food allergy)
Biologic factors e.g.: early inhalant sensitization,
increase serum IGE, increase blood eosinophills,
High risk of persistence into later childhood and
adulthood lung function abnormality
Those with onset<3 yrs
reduced air flow by
school yrs
Those with later onset of symptoms or allergen
sensitizations unlikely persistence lung function
abnormality later

Non-Atopic Wheezing
 Wheezing ,coughing beginning in early life

often with RSV INF resolves later in childhood
without increasing risk of persistence asthma

 Associated with bronchial hyper

responsiveness near birth

Asthma with declining lung function
• Children with asthma with progressive

increase in air flow limitation

• Associated with hyper inflation in childhood
• Male gender

Late onset asthma in females associated with
obesity and early onset puberty
 Onset between 8_13 yrs

 Associated with early onset puberty and obesity
 Specific for females

Occupational type asthma in children
 Children with asthma and occupational type exposure

known to trigger asthma in adults in occupational settings

Types of Asthma
common clinical presentations of intermittent
recurrent wheezing and/or coughing
 Recurrent wheezing in early childhood

 Chronic asthma associated with allergy
 Females 11 yrs with early onset puberty and

obesity

Pathogenesis

 Airflow obstruction resulting from

Broncho constriction of bronchiolar smooth
muscle mass
II. Cellular inflammatory infiltrates and exudates
mostly Eosinophills(also N , M ,L ,mast cells
,basophiles)fill and obstruct airways and damage
epithelium and induce desquamation into airway
lumen mediated by T helper cells and other
immune cells that produce pro allergic pro
inflammatory cytokines(IL4,IL6,IL13)
III. Breach in normal immune regulatory process
I.

RESULT
 Airway inflammation

 AHR
 Edema basement membrane thickness sub

epithelial collagen deposition
 Smooth muscle and mucus gland hypertrophy
and mucus hyper secretion

Air obstruction

Clinical manifestations and diagnosis
 Most common intermittent dry cough and

expiratory wheezing

 Shortness of breath and chest tightness in older

children and adults

 Intermittent non focal chest pain in younger

children

 Worsening of respiratory symptoms at night
 Worsening of day time symptoms by activity

Continue…..
 Subtle symptoms such as self limitation of activities

,general fatigue ,difficulty in keeping up with peers

 Relief with aerosolized bronchodilators
 Lack of improvement with bronchodilators and steroid

is inconsistent with Asthma and should consider
Asthma masquerading conditions!!!!

 Hyper ventilation, intercostal retractions ,nasal flaring

,respiratory accessory muscle use

 Its common not to hear the expiratory wheezing when

Air flow is so limited before treatment

Asthma Triggers
 Common viral infections of the respiratory tract
 Aero allergens in sensitized asthmatics ,animal dander ,dust











mite ,molds ,indoor allergens ,cockroaches
Seasonal aero allergens ,pollens(trees ,grasses ,weeds ,)
Environmental tobacco smoke
Air pollutants ,ozone ,so2,wood or coal smoke ,endotoxin
,mycotoxin ,dust
Strong or noxious odors or fumes ,perfume ,hair spray
,cleaning agents
Occupational exposure
Cold air ,dry air
Exercise
Crying ,laughter ,hyperventilation
Co morbid conditions Rhinitis ,Sinusitis ,GER

Clinics
History:
Triggering symptoms by laughter
,cold air ,airway irritants
Exposures that induce airway
irritation such as viral URTI
Mycoplasma ,Chlamydia
Inhaled allergens
All lead to AHR

Presence Of Risk Factors:
 History of other allergies ,allergic Rhinitis,

allergic Conjunctivitis ,atopic Dermatitis ,food
allergies

 Parental Asthma
 Symptoms apart from cold

Continue…..
 No or minimal signs in routine visits

 Dry or persistent cough

 Normal chest findings unless wheezing when asking

to breath deeper
 Quick relief (10 MIN) after SABA use
 Expiratory wheezing ,prolonged expiratory phase
,decreased sounds in RT lower pos lobe due to
regional hypoventilation owing to airway
obstruction
 Rales , ronchi ,crackles due to hyper secretion
 Segmental crackles and poor breath sounds
atelectasis?

Continue….
 Labored respiration ,respiratory distress increased

prolongation of expiration and wheezing in E and I

 Poor air entry
 Inter costal retractions ,nasal flaring ,supra and

infra sternal retractions

 And again in most sever forms expiratory wheezing

does not appear until some broncho dilation

DD

GERD Rhino sinusitis co morbid

conditions with asthma

Recurrent aspiration in early

life(tracheo broncho malacia
,TEF , foreign body ,CF ,BPD

VCD in older children and

adolescents

LAB FINDINGS
Pulmonary Function
Testing

Continue….
 Forced expiratory airflow measures helpful

in Diagnosis , assessing efficacy of therapy
and monitoring Asthma in children specially
in poor children who do not have PHE
unless obstruction is sever

 Valueablity of spirometric findings in children>6

yrs

 3 efforts the highest is the peak
 Reduced FEV

obstruction

FEV1/FVC <0.80 means significant

 Improvement in FEV1 following beta 2 agonist > =

12% or 200 ml is consistent with Asthma

 Peak flow meter

CXR

Often normal aside from subtle and

nonspecific findings of hyperinflation

Peribronchial thickening
Helping in diagnosis of Asthma

differentials

Diagnosis of complications of Asthma

exacerbations

Other tests such as allergy skin prick
testing

Treatment
 www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm

Asthma Treatment & Management
has 4 components :
Assessment and monitoring of disease
activity
2. Provision to educate pt and family
3. Identification and management of
precipitating factors and co morbid
conditions
4. Appropriate selection of medication
1.

 Attainment of optimal Asthma control

Component 1
 Asthma severity :intermittent
 Persistent: mild ,mod ,severe
 Only once during patient initial evaluation in pt

who is not using a daily controller agent
 Asthma control degree to which symptoms ,
on going functional impairments , risk of
adverse events minimized and goals of
therapy are met

Continue….
Well controlled
2. Not well controlled
3. Very poor controlled
1.

 NIH guidelines for both severity and

control for 3 age groups

0-4 yrs
2. 5-11 yrs
3. =>12 yrs
1.

Important
even in the absence of frequent symptoms
infants and children whom have risk factors
for asthma and 4 or more episodes of
wheezing over the past yr which lasted more
than 1 day or 2 or more exacerbations in
the last 6 months requiring syst
corticosteroids should be considered in the
persistent group and hence receive long term
controller therapy

Important Tips..
 Regular clinical visits every 2-6 weeks
 Assessment of :

Pt symptoms frequency night and day
2. Need for short acting inhaled b2 agonists for
quick relief
3. Ability to engage in normal activities
4. Air flow measures for>=5 yrs
1.

Continue..
 Component 2 : pt education

 Component 3 : control of factors contributing

to asthma severity
1. Environmental exposures
2. Co morbid conditions
 Component 4 :principals of asthma
pharmacotherapy

Asthma Medication
 SABA

 ICS

 LABA
 LTRA

 SYSTEMIC STEROIDS

 NONSTEROIDAL ANTIINFLAMMATORY

CROMOLYN AND NEDOCROMYL
 OXYGEN
 ANTICHOLINERGIC AGENTS
IPRATROPIUM
BROMIDE
 ANTIIMMUNOGLUBOLINE E

MANAGEMENT OF ASTHMA EXACERBATION(STATUS ASTHMATICUS)
RISK ASSESMENT ON ADMISSION

FOCUSED HISTORY

ONSET OF CURRENT EXACERBATION
FREQUENCY AND severity of daytime and night
time symptoms and activity limitation
Frequency of rescue bronchodilator use
Current medication and allergies
Potential triggers
History of systemic steroid courses, emergency
department visists , hospitalization, intubation or life
threatening episodes

Clinical assesment

Physical examination findings: vital signs,
breathlessness, air movement, use of accessory
respiratory muscles, retractions, anxiety level,
alteration in mental status
Pulse oximetry
Lung function(defer in pts with mod to severe
distress or history of labile disease)

Treatment
Drugs and trade name

Mechanism of action and dosing

Cautions and adverse effects

Oxygen(mask or nasal canula)
Inhaled short acting b2
agonist
Albuterol nebulized
solution(5mg/ml concentrates
Albuterol MDI
Levabuterol

Treats hypoxia
Bronchodilator
Neubolizer 0.15 mg/kg every 20 min for 3
doses as needed,then 0.15_0.3 mg/kg up t 10
mg every 1_4 hour as needed or up to 0.5
mg/kg/hr by continous neubolization
2_8 puf up to every 20 min for 3 doses as
needed then every 1 hr as needed

Monitor pulse oximetry to maintain o2 saturation>92%
Cardiorespiratory monitoring
During exacerbations,frequent or continuous use can cause
pulmonary vasodilatation,v/q mistmatch and hypoxemia
Adverse effect palpitation, tachycardia, arrhythmia, tremor,
hypoxemia
Neubolizer:when giving concentrate forms,dilute with saline to 3
ml total neubolized volume
For MDI use space/holding chamber

Systemic corticosteroids
Prednisolone tb
Methyl prednisolon
Anticholinergics
Ipratropium
Atrovent
Ipratropium with Albuterol

Anti inflammatory
0.5_1 mg/kg every 6-8 hr for 48 hr , then 1-2 mg/kg
day bid(max 60 mg/day)
Short course burst for exacerbation 1-2 mg/kg/day qd
or bid for 3-7 days
Mucolitic/bronchodilator
Neubolizer 0.5 mg q6-8 hr (tid or qid) as needed
MDI 2 paf qid
1 vial by neubolizer qid



If pt has been exposed chickenpox or measles, consider passive
immunoglobulin prophylaxis, also risk of complications with
herspes simplex and TB

For daily dosing , 8 am administration minimizes adrenal
suppression

Children may benefit from dosage tapering if course exceed 7 days

Adverse effect monitoring: frequent therapy bursts risk numerous
corticosteroid adverse effects

Should not be used as first line treatment added to b2 agonist
therapy
Neubolizer may mix Ipratropium with Albuterol

QUICK RELIEF MEDICATION
SABA

Anti cholinergic(ipratropium)
Short term systemic gluco

corticoid

SABA
 Quick relief of asthma symptoms
 Relax airway smooth muscle prompt airflow↑
 Repetitive or continuous SABA is the most effective means







of reversing air flow obstruction
SABA should not be prescribed on a regular schedule
because concerns of possibility of deteriorating asthma
control
Frequent use of SABA is an indication of poor asthma control
Preferred root is inhalation smaller dose , fewer side effects
more rapid on set of action
Ipratropium Bromide as an adjunct to SABA in emergency
room reduces hospital admissions and improves lung function
Systemic Glucocorticoids short oral course + SABA in
moderate to severe asthma exacerbation

LABA
 Salmetrol

 Should be used in combination with inhaled

corticosteroids and not as mono therapy
 Exercise induces asthma in children >= 4 Yrs
one inhalation 30 min prior to exercise
 No additional doses for PTs who are already
receiving it twice daily not recommended by
NIH guidelines

LTRA

 MonteLukast ( singulair)

 Antihistaminic

 Leukotrien receptor antagonist

 Asthma ( not < 12 MO) and allergic rhinitis (





not < 6 MO)
Morning dosing not evaluated
Prophylactic and chronic treatment of asthma
Exercise induced asthma in >= 15 Yrs
Zafir Lukast : prophylactic and chronic
treatment of asthma

ICA
 Most potent anti inflammatory agents available

for the treatment of asthma
 Inhibiting most steps in the cascade of the
inflammatory response
 Benefits reducing bronchial hyper
responsiveness , prevention of late asthmatic
response , enhanced lung function
 Inhaled Glucocorticoids first line controller
therapy for persistent asthma or those who
require step 2

Prognosis
 35%of preschool children experience recurrent

coughing and wheezing,1/3 of them continue to
have persistent asthma into later childhood and
2/3 improvement on their own through their teen
yrs
 Asthma severity by age 7-10 yrs is predictive of
asthma persistence into adulthood
 Children with mod to severe asthma and lower lung
function are likely to have persistent asthma as
adults
 Children with milder asthma and N/R lung function
are likely to improve over time or be periodically
asthmatic

THANK YOU FOR YOUR
ATTENTION


Slide 47

Asthma in Children
DR. A.Mirshokraei
NIOC Hospital Pediatrics Ward

Definition :

DEFINITION

- Chronic inflammatory condition of the
lung airways resulting in episodic airflow
obstruction
- AHR to provocative exposures
Asthma management
• Reducing airway inflammation by: Minimizing
pro inflammatory environmental exposure, using
daily controller anti inflammatory medication,
controlling co morbid conditions that worsen
asthma, less inflammation better asthma
control and fewer exacerbations

Anyway exacerbations

occur

BUT
Even the uncommon
child with sever asthma can
be managed to live normally

 RECURRENT WHEEZING EPISODES WITH COMMON

RESPIRATORY
VIRUSES(RSV,RHINOVIRUS,INFLUENZA,PARAINFLUENZA,A
DENOVIRUS,HUMAN METAPNUMOVIRUS)

 HOST FEATURES AFFECTING IMMUNOLOGIC HOST

DEFENSE,INFLAMMATION/PREVIOUS VIRAL INFECTIONS
MAINIFESTED AS PNUMONIA OR BRONCHIOLITIS
REQUIRING HOSPITALIZATION UNDERLIE THE
RECURRENT WHEEZING IN EARLY CHILDHOOD

 OTHER AIRWAY EXPOSURES SUCH AS INDOOR AND HOME

ALLERGENS,COLD AIR,STRONG ODORS,TOBACCO
SMOKE,ALL INCREASE AHR

 ALLERGEN ELLIMINATION SOMETIMES LEEDS TO CURE

EPIDEMIOLOGY
 Common etiology of emergency visits and school day missing

in childhood ,occasionally hospitalization and rare deaths
specially in poverty ,urban living ,ethnic minorities

 Increasing asthma prevalence worldwide(50% per decade)
 Good correlation of asthma prevalence with allergic rhino

sinusitis and atopic eczema and other allergies

 More prevalence in high level urban modern families than

suburban villagers

 More than 80%of asthmatics reported getting the disease

before 6 year

CLINICS
RECURRENT COUGHING/WHEEZING
PATTERNS IN CHILDHOOD BASED ON
NATURAL HISTORY

TRANSIENT EARLY WHEEZING
 Common in early preschool years

 Recurrent coughing/wheezing primary

triggered by common respiratory viral INF
 Tend to resolve during preschool yrs without
increasing risk of asthma later in life
 Problems due to reduced airflow at birth
suggestive of relative narrow airways improved
by school yrs

Persistent Atopy Associated Asthma
 Begins in early preschool yrs

 Associated with atopy (eg atopic dermatitis in





infancy, allergic rhinitis, food allergy)
Biologic factors e.g.: early inhalant sensitization,
increase serum IGE, increase blood eosinophills,
High risk of persistence into later childhood and
adulthood lung function abnormality
Those with onset<3 yrs
reduced air flow by
school yrs
Those with later onset of symptoms or allergen
sensitizations unlikely persistence lung function
abnormality later

Non-Atopic Wheezing
 Wheezing ,coughing beginning in early life

often with RSV INF resolves later in childhood
without increasing risk of persistence asthma

 Associated with bronchial hyper

responsiveness near birth

Asthma with declining lung function
• Children with asthma with progressive

increase in air flow limitation

• Associated with hyper inflation in childhood
• Male gender

Late onset asthma in females associated with
obesity and early onset puberty
 Onset between 8_13 yrs

 Associated with early onset puberty and obesity
 Specific for females

Occupational type asthma in children
 Children with asthma and occupational type exposure

known to trigger asthma in adults in occupational settings

Types of Asthma
common clinical presentations of intermittent
recurrent wheezing and/or coughing
 Recurrent wheezing in early childhood

 Chronic asthma associated with allergy
 Females 11 yrs with early onset puberty and

obesity

Pathogenesis

 Airflow obstruction resulting from

Broncho constriction of bronchiolar smooth
muscle mass
II. Cellular inflammatory infiltrates and exudates
mostly Eosinophills(also N , M ,L ,mast cells
,basophiles)fill and obstruct airways and damage
epithelium and induce desquamation into airway
lumen mediated by T helper cells and other
immune cells that produce pro allergic pro
inflammatory cytokines(IL4,IL6,IL13)
III. Breach in normal immune regulatory process
I.

RESULT
 Airway inflammation

 AHR
 Edema basement membrane thickness sub

epithelial collagen deposition
 Smooth muscle and mucus gland hypertrophy
and mucus hyper secretion

Air obstruction

Clinical manifestations and diagnosis
 Most common intermittent dry cough and

expiratory wheezing

 Shortness of breath and chest tightness in older

children and adults

 Intermittent non focal chest pain in younger

children

 Worsening of respiratory symptoms at night
 Worsening of day time symptoms by activity

Continue…..
 Subtle symptoms such as self limitation of activities

,general fatigue ,difficulty in keeping up with peers

 Relief with aerosolized bronchodilators
 Lack of improvement with bronchodilators and steroid

is inconsistent with Asthma and should consider
Asthma masquerading conditions!!!!

 Hyper ventilation, intercostal retractions ,nasal flaring

,respiratory accessory muscle use

 Its common not to hear the expiratory wheezing when

Air flow is so limited before treatment

Asthma Triggers
 Common viral infections of the respiratory tract
 Aero allergens in sensitized asthmatics ,animal dander ,dust











mite ,molds ,indoor allergens ,cockroaches
Seasonal aero allergens ,pollens(trees ,grasses ,weeds ,)
Environmental tobacco smoke
Air pollutants ,ozone ,so2,wood or coal smoke ,endotoxin
,mycotoxin ,dust
Strong or noxious odors or fumes ,perfume ,hair spray
,cleaning agents
Occupational exposure
Cold air ,dry air
Exercise
Crying ,laughter ,hyperventilation
Co morbid conditions Rhinitis ,Sinusitis ,GER

Clinics
History:
Triggering symptoms by laughter
,cold air ,airway irritants
Exposures that induce airway
irritation such as viral URTI
Mycoplasma ,Chlamydia
Inhaled allergens
All lead to AHR

Presence Of Risk Factors:
 History of other allergies ,allergic Rhinitis,

allergic Conjunctivitis ,atopic Dermatitis ,food
allergies

 Parental Asthma
 Symptoms apart from cold

Continue…..
 No or minimal signs in routine visits

 Dry or persistent cough

 Normal chest findings unless wheezing when asking

to breath deeper
 Quick relief (10 MIN) after SABA use
 Expiratory wheezing ,prolonged expiratory phase
,decreased sounds in RT lower pos lobe due to
regional hypoventilation owing to airway
obstruction
 Rales , ronchi ,crackles due to hyper secretion
 Segmental crackles and poor breath sounds
atelectasis?

Continue….
 Labored respiration ,respiratory distress increased

prolongation of expiration and wheezing in E and I

 Poor air entry
 Inter costal retractions ,nasal flaring ,supra and

infra sternal retractions

 And again in most sever forms expiratory wheezing

does not appear until some broncho dilation

DD

GERD Rhino sinusitis co morbid

conditions with asthma

Recurrent aspiration in early

life(tracheo broncho malacia
,TEF , foreign body ,CF ,BPD

VCD in older children and

adolescents

LAB FINDINGS
Pulmonary Function
Testing

Continue….
 Forced expiratory airflow measures helpful

in Diagnosis , assessing efficacy of therapy
and monitoring Asthma in children specially
in poor children who do not have PHE
unless obstruction is sever

 Valueablity of spirometric findings in children>6

yrs

 3 efforts the highest is the peak
 Reduced FEV

obstruction

FEV1/FVC <0.80 means significant

 Improvement in FEV1 following beta 2 agonist > =

12% or 200 ml is consistent with Asthma

 Peak flow meter

CXR

Often normal aside from subtle and

nonspecific findings of hyperinflation

Peribronchial thickening
Helping in diagnosis of Asthma

differentials

Diagnosis of complications of Asthma

exacerbations

Other tests such as allergy skin prick
testing

Treatment
 www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm

Asthma Treatment & Management
has 4 components :
Assessment and monitoring of disease
activity
2. Provision to educate pt and family
3. Identification and management of
precipitating factors and co morbid
conditions
4. Appropriate selection of medication
1.

 Attainment of optimal Asthma control

Component 1
 Asthma severity :intermittent
 Persistent: mild ,mod ,severe
 Only once during patient initial evaluation in pt

who is not using a daily controller agent
 Asthma control degree to which symptoms ,
on going functional impairments , risk of
adverse events minimized and goals of
therapy are met

Continue….
Well controlled
2. Not well controlled
3. Very poor controlled
1.

 NIH guidelines for both severity and

control for 3 age groups

0-4 yrs
2. 5-11 yrs
3. =>12 yrs
1.

Important
even in the absence of frequent symptoms
infants and children whom have risk factors
for asthma and 4 or more episodes of
wheezing over the past yr which lasted more
than 1 day or 2 or more exacerbations in
the last 6 months requiring syst
corticosteroids should be considered in the
persistent group and hence receive long term
controller therapy

Important Tips..
 Regular clinical visits every 2-6 weeks
 Assessment of :

Pt symptoms frequency night and day
2. Need for short acting inhaled b2 agonists for
quick relief
3. Ability to engage in normal activities
4. Air flow measures for>=5 yrs
1.

Continue..
 Component 2 : pt education

 Component 3 : control of factors contributing

to asthma severity
1. Environmental exposures
2. Co morbid conditions
 Component 4 :principals of asthma
pharmacotherapy

Asthma Medication
 SABA

 ICS

 LABA
 LTRA

 SYSTEMIC STEROIDS

 NONSTEROIDAL ANTIINFLAMMATORY

CROMOLYN AND NEDOCROMYL
 OXYGEN
 ANTICHOLINERGIC AGENTS
IPRATROPIUM
BROMIDE
 ANTIIMMUNOGLUBOLINE E

MANAGEMENT OF ASTHMA EXACERBATION(STATUS ASTHMATICUS)
RISK ASSESMENT ON ADMISSION

FOCUSED HISTORY

ONSET OF CURRENT EXACERBATION
FREQUENCY AND severity of daytime and night
time symptoms and activity limitation
Frequency of rescue bronchodilator use
Current medication and allergies
Potential triggers
History of systemic steroid courses, emergency
department visists , hospitalization, intubation or life
threatening episodes

Clinical assesment

Physical examination findings: vital signs,
breathlessness, air movement, use of accessory
respiratory muscles, retractions, anxiety level,
alteration in mental status
Pulse oximetry
Lung function(defer in pts with mod to severe
distress or history of labile disease)

Treatment
Drugs and trade name

Mechanism of action and dosing

Cautions and adverse effects

Oxygen(mask or nasal canula)
Inhaled short acting b2
agonist
Albuterol nebulized
solution(5mg/ml concentrates
Albuterol MDI
Levabuterol

Treats hypoxia
Bronchodilator
Neubolizer 0.15 mg/kg every 20 min for 3
doses as needed,then 0.15_0.3 mg/kg up t 10
mg every 1_4 hour as needed or up to 0.5
mg/kg/hr by continous neubolization
2_8 puf up to every 20 min for 3 doses as
needed then every 1 hr as needed

Monitor pulse oximetry to maintain o2 saturation>92%
Cardiorespiratory monitoring
During exacerbations,frequent or continuous use can cause
pulmonary vasodilatation,v/q mistmatch and hypoxemia
Adverse effect palpitation, tachycardia, arrhythmia, tremor,
hypoxemia
Neubolizer:when giving concentrate forms,dilute with saline to 3
ml total neubolized volume
For MDI use space/holding chamber

Systemic corticosteroids
Prednisolone tb
Methyl prednisolon
Anticholinergics
Ipratropium
Atrovent
Ipratropium with Albuterol

Anti inflammatory
0.5_1 mg/kg every 6-8 hr for 48 hr , then 1-2 mg/kg
day bid(max 60 mg/day)
Short course burst for exacerbation 1-2 mg/kg/day qd
or bid for 3-7 days
Mucolitic/bronchodilator
Neubolizer 0.5 mg q6-8 hr (tid or qid) as needed
MDI 2 paf qid
1 vial by neubolizer qid



If pt has been exposed chickenpox or measles, consider passive
immunoglobulin prophylaxis, also risk of complications with
herspes simplex and TB

For daily dosing , 8 am administration minimizes adrenal
suppression

Children may benefit from dosage tapering if course exceed 7 days

Adverse effect monitoring: frequent therapy bursts risk numerous
corticosteroid adverse effects

Should not be used as first line treatment added to b2 agonist
therapy
Neubolizer may mix Ipratropium with Albuterol

QUICK RELIEF MEDICATION
SABA

Anti cholinergic(ipratropium)
Short term systemic gluco

corticoid

SABA
 Quick relief of asthma symptoms
 Relax airway smooth muscle prompt airflow↑
 Repetitive or continuous SABA is the most effective means







of reversing air flow obstruction
SABA should not be prescribed on a regular schedule
because concerns of possibility of deteriorating asthma
control
Frequent use of SABA is an indication of poor asthma control
Preferred root is inhalation smaller dose , fewer side effects
more rapid on set of action
Ipratropium Bromide as an adjunct to SABA in emergency
room reduces hospital admissions and improves lung function
Systemic Glucocorticoids short oral course + SABA in
moderate to severe asthma exacerbation

LABA
 Salmetrol

 Should be used in combination with inhaled

corticosteroids and not as mono therapy
 Exercise induces asthma in children >= 4 Yrs
one inhalation 30 min prior to exercise
 No additional doses for PTs who are already
receiving it twice daily not recommended by
NIH guidelines

LTRA

 MonteLukast ( singulair)

 Antihistaminic

 Leukotrien receptor antagonist

 Asthma ( not < 12 MO) and allergic rhinitis (





not < 6 MO)
Morning dosing not evaluated
Prophylactic and chronic treatment of asthma
Exercise induced asthma in >= 15 Yrs
Zafir Lukast : prophylactic and chronic
treatment of asthma

ICA
 Most potent anti inflammatory agents available

for the treatment of asthma
 Inhibiting most steps in the cascade of the
inflammatory response
 Benefits reducing bronchial hyper
responsiveness , prevention of late asthmatic
response , enhanced lung function
 Inhaled Glucocorticoids first line controller
therapy for persistent asthma or those who
require step 2

Prognosis
 35%of preschool children experience recurrent

coughing and wheezing,1/3 of them continue to
have persistent asthma into later childhood and
2/3 improvement on their own through their teen
yrs
 Asthma severity by age 7-10 yrs is predictive of
asthma persistence into adulthood
 Children with mod to severe asthma and lower lung
function are likely to have persistent asthma as
adults
 Children with milder asthma and N/R lung function
are likely to improve over time or be periodically
asthmatic

THANK YOU FOR YOUR
ATTENTION


Slide 48

Asthma in Children
DR. A.Mirshokraei
NIOC Hospital Pediatrics Ward

Definition :

DEFINITION

- Chronic inflammatory condition of the
lung airways resulting in episodic airflow
obstruction
- AHR to provocative exposures
Asthma management
• Reducing airway inflammation by: Minimizing
pro inflammatory environmental exposure, using
daily controller anti inflammatory medication,
controlling co morbid conditions that worsen
asthma, less inflammation better asthma
control and fewer exacerbations

Anyway exacerbations

occur

BUT
Even the uncommon
child with sever asthma can
be managed to live normally

 RECURRENT WHEEZING EPISODES WITH COMMON

RESPIRATORY
VIRUSES(RSV,RHINOVIRUS,INFLUENZA,PARAINFLUENZA,A
DENOVIRUS,HUMAN METAPNUMOVIRUS)

 HOST FEATURES AFFECTING IMMUNOLOGIC HOST

DEFENSE,INFLAMMATION/PREVIOUS VIRAL INFECTIONS
MAINIFESTED AS PNUMONIA OR BRONCHIOLITIS
REQUIRING HOSPITALIZATION UNDERLIE THE
RECURRENT WHEEZING IN EARLY CHILDHOOD

 OTHER AIRWAY EXPOSURES SUCH AS INDOOR AND HOME

ALLERGENS,COLD AIR,STRONG ODORS,TOBACCO
SMOKE,ALL INCREASE AHR

 ALLERGEN ELLIMINATION SOMETIMES LEEDS TO CURE

EPIDEMIOLOGY
 Common etiology of emergency visits and school day missing

in childhood ,occasionally hospitalization and rare deaths
specially in poverty ,urban living ,ethnic minorities

 Increasing asthma prevalence worldwide(50% per decade)
 Good correlation of asthma prevalence with allergic rhino

sinusitis and atopic eczema and other allergies

 More prevalence in high level urban modern families than

suburban villagers

 More than 80%of asthmatics reported getting the disease

before 6 year

CLINICS
RECURRENT COUGHING/WHEEZING
PATTERNS IN CHILDHOOD BASED ON
NATURAL HISTORY

TRANSIENT EARLY WHEEZING
 Common in early preschool years

 Recurrent coughing/wheezing primary

triggered by common respiratory viral INF
 Tend to resolve during preschool yrs without
increasing risk of asthma later in life
 Problems due to reduced airflow at birth
suggestive of relative narrow airways improved
by school yrs

Persistent Atopy Associated Asthma
 Begins in early preschool yrs

 Associated with atopy (eg atopic dermatitis in





infancy, allergic rhinitis, food allergy)
Biologic factors e.g.: early inhalant sensitization,
increase serum IGE, increase blood eosinophills,
High risk of persistence into later childhood and
adulthood lung function abnormality
Those with onset<3 yrs
reduced air flow by
school yrs
Those with later onset of symptoms or allergen
sensitizations unlikely persistence lung function
abnormality later

Non-Atopic Wheezing
 Wheezing ,coughing beginning in early life

often with RSV INF resolves later in childhood
without increasing risk of persistence asthma

 Associated with bronchial hyper

responsiveness near birth

Asthma with declining lung function
• Children with asthma with progressive

increase in air flow limitation

• Associated with hyper inflation in childhood
• Male gender

Late onset asthma in females associated with
obesity and early onset puberty
 Onset between 8_13 yrs

 Associated with early onset puberty and obesity
 Specific for females

Occupational type asthma in children
 Children with asthma and occupational type exposure

known to trigger asthma in adults in occupational settings

Types of Asthma
common clinical presentations of intermittent
recurrent wheezing and/or coughing
 Recurrent wheezing in early childhood

 Chronic asthma associated with allergy
 Females 11 yrs with early onset puberty and

obesity

Pathogenesis

 Airflow obstruction resulting from

Broncho constriction of bronchiolar smooth
muscle mass
II. Cellular inflammatory infiltrates and exudates
mostly Eosinophills(also N , M ,L ,mast cells
,basophiles)fill and obstruct airways and damage
epithelium and induce desquamation into airway
lumen mediated by T helper cells and other
immune cells that produce pro allergic pro
inflammatory cytokines(IL4,IL6,IL13)
III. Breach in normal immune regulatory process
I.

RESULT
 Airway inflammation

 AHR
 Edema basement membrane thickness sub

epithelial collagen deposition
 Smooth muscle and mucus gland hypertrophy
and mucus hyper secretion

Air obstruction

Clinical manifestations and diagnosis
 Most common intermittent dry cough and

expiratory wheezing

 Shortness of breath and chest tightness in older

children and adults

 Intermittent non focal chest pain in younger

children

 Worsening of respiratory symptoms at night
 Worsening of day time symptoms by activity

Continue…..
 Subtle symptoms such as self limitation of activities

,general fatigue ,difficulty in keeping up with peers

 Relief with aerosolized bronchodilators
 Lack of improvement with bronchodilators and steroid

is inconsistent with Asthma and should consider
Asthma masquerading conditions!!!!

 Hyper ventilation, intercostal retractions ,nasal flaring

,respiratory accessory muscle use

 Its common not to hear the expiratory wheezing when

Air flow is so limited before treatment

Asthma Triggers
 Common viral infections of the respiratory tract
 Aero allergens in sensitized asthmatics ,animal dander ,dust











mite ,molds ,indoor allergens ,cockroaches
Seasonal aero allergens ,pollens(trees ,grasses ,weeds ,)
Environmental tobacco smoke
Air pollutants ,ozone ,so2,wood or coal smoke ,endotoxin
,mycotoxin ,dust
Strong or noxious odors or fumes ,perfume ,hair spray
,cleaning agents
Occupational exposure
Cold air ,dry air
Exercise
Crying ,laughter ,hyperventilation
Co morbid conditions Rhinitis ,Sinusitis ,GER

Clinics
History:
Triggering symptoms by laughter
,cold air ,airway irritants
Exposures that induce airway
irritation such as viral URTI
Mycoplasma ,Chlamydia
Inhaled allergens
All lead to AHR

Presence Of Risk Factors:
 History of other allergies ,allergic Rhinitis,

allergic Conjunctivitis ,atopic Dermatitis ,food
allergies

 Parental Asthma
 Symptoms apart from cold

Continue…..
 No or minimal signs in routine visits

 Dry or persistent cough

 Normal chest findings unless wheezing when asking

to breath deeper
 Quick relief (10 MIN) after SABA use
 Expiratory wheezing ,prolonged expiratory phase
,decreased sounds in RT lower pos lobe due to
regional hypoventilation owing to airway
obstruction
 Rales , ronchi ,crackles due to hyper secretion
 Segmental crackles and poor breath sounds
atelectasis?

Continue….
 Labored respiration ,respiratory distress increased

prolongation of expiration and wheezing in E and I

 Poor air entry
 Inter costal retractions ,nasal flaring ,supra and

infra sternal retractions

 And again in most sever forms expiratory wheezing

does not appear until some broncho dilation

DD

GERD Rhino sinusitis co morbid

conditions with asthma

Recurrent aspiration in early

life(tracheo broncho malacia
,TEF , foreign body ,CF ,BPD

VCD in older children and

adolescents

LAB FINDINGS
Pulmonary Function
Testing

Continue….
 Forced expiratory airflow measures helpful

in Diagnosis , assessing efficacy of therapy
and monitoring Asthma in children specially
in poor children who do not have PHE
unless obstruction is sever

 Valueablity of spirometric findings in children>6

yrs

 3 efforts the highest is the peak
 Reduced FEV

obstruction

FEV1/FVC <0.80 means significant

 Improvement in FEV1 following beta 2 agonist > =

12% or 200 ml is consistent with Asthma

 Peak flow meter

CXR

Often normal aside from subtle and

nonspecific findings of hyperinflation

Peribronchial thickening
Helping in diagnosis of Asthma

differentials

Diagnosis of complications of Asthma

exacerbations

Other tests such as allergy skin prick
testing

Treatment
 www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm

Asthma Treatment & Management
has 4 components :
Assessment and monitoring of disease
activity
2. Provision to educate pt and family
3. Identification and management of
precipitating factors and co morbid
conditions
4. Appropriate selection of medication
1.

 Attainment of optimal Asthma control

Component 1
 Asthma severity :intermittent
 Persistent: mild ,mod ,severe
 Only once during patient initial evaluation in pt

who is not using a daily controller agent
 Asthma control degree to which symptoms ,
on going functional impairments , risk of
adverse events minimized and goals of
therapy are met

Continue….
Well controlled
2. Not well controlled
3. Very poor controlled
1.

 NIH guidelines for both severity and

control for 3 age groups

0-4 yrs
2. 5-11 yrs
3. =>12 yrs
1.

Important
even in the absence of frequent symptoms
infants and children whom have risk factors
for asthma and 4 or more episodes of
wheezing over the past yr which lasted more
than 1 day or 2 or more exacerbations in
the last 6 months requiring syst
corticosteroids should be considered in the
persistent group and hence receive long term
controller therapy

Important Tips..
 Regular clinical visits every 2-6 weeks
 Assessment of :

Pt symptoms frequency night and day
2. Need for short acting inhaled b2 agonists for
quick relief
3. Ability to engage in normal activities
4. Air flow measures for>=5 yrs
1.

Continue..
 Component 2 : pt education

 Component 3 : control of factors contributing

to asthma severity
1. Environmental exposures
2. Co morbid conditions
 Component 4 :principals of asthma
pharmacotherapy

Asthma Medication
 SABA

 ICS

 LABA
 LTRA

 SYSTEMIC STEROIDS

 NONSTEROIDAL ANTIINFLAMMATORY

CROMOLYN AND NEDOCROMYL
 OXYGEN
 ANTICHOLINERGIC AGENTS
IPRATROPIUM
BROMIDE
 ANTIIMMUNOGLUBOLINE E

MANAGEMENT OF ASTHMA EXACERBATION(STATUS ASTHMATICUS)
RISK ASSESMENT ON ADMISSION

FOCUSED HISTORY

ONSET OF CURRENT EXACERBATION
FREQUENCY AND severity of daytime and night
time symptoms and activity limitation
Frequency of rescue bronchodilator use
Current medication and allergies
Potential triggers
History of systemic steroid courses, emergency
department visists , hospitalization, intubation or life
threatening episodes

Clinical assesment

Physical examination findings: vital signs,
breathlessness, air movement, use of accessory
respiratory muscles, retractions, anxiety level,
alteration in mental status
Pulse oximetry
Lung function(defer in pts with mod to severe
distress or history of labile disease)

Treatment
Drugs and trade name

Mechanism of action and dosing

Cautions and adverse effects

Oxygen(mask or nasal canula)
Inhaled short acting b2
agonist
Albuterol nebulized
solution(5mg/ml concentrates
Albuterol MDI
Levabuterol

Treats hypoxia
Bronchodilator
Neubolizer 0.15 mg/kg every 20 min for 3
doses as needed,then 0.15_0.3 mg/kg up t 10
mg every 1_4 hour as needed or up to 0.5
mg/kg/hr by continous neubolization
2_8 puf up to every 20 min for 3 doses as
needed then every 1 hr as needed

Monitor pulse oximetry to maintain o2 saturation>92%
Cardiorespiratory monitoring
During exacerbations,frequent or continuous use can cause
pulmonary vasodilatation,v/q mistmatch and hypoxemia
Adverse effect palpitation, tachycardia, arrhythmia, tremor,
hypoxemia
Neubolizer:when giving concentrate forms,dilute with saline to 3
ml total neubolized volume
For MDI use space/holding chamber

Systemic corticosteroids
Prednisolone tb
Methyl prednisolon
Anticholinergics
Ipratropium
Atrovent
Ipratropium with Albuterol

Anti inflammatory
0.5_1 mg/kg every 6-8 hr for 48 hr , then 1-2 mg/kg
day bid(max 60 mg/day)
Short course burst for exacerbation 1-2 mg/kg/day qd
or bid for 3-7 days
Mucolitic/bronchodilator
Neubolizer 0.5 mg q6-8 hr (tid or qid) as needed
MDI 2 paf qid
1 vial by neubolizer qid



If pt has been exposed chickenpox or measles, consider passive
immunoglobulin prophylaxis, also risk of complications with
herspes simplex and TB

For daily dosing , 8 am administration minimizes adrenal
suppression

Children may benefit from dosage tapering if course exceed 7 days

Adverse effect monitoring: frequent therapy bursts risk numerous
corticosteroid adverse effects

Should not be used as first line treatment added to b2 agonist
therapy
Neubolizer may mix Ipratropium with Albuterol

QUICK RELIEF MEDICATION
SABA

Anti cholinergic(ipratropium)
Short term systemic gluco

corticoid

SABA
 Quick relief of asthma symptoms
 Relax airway smooth muscle prompt airflow↑
 Repetitive or continuous SABA is the most effective means







of reversing air flow obstruction
SABA should not be prescribed on a regular schedule
because concerns of possibility of deteriorating asthma
control
Frequent use of SABA is an indication of poor asthma control
Preferred root is inhalation smaller dose , fewer side effects
more rapid on set of action
Ipratropium Bromide as an adjunct to SABA in emergency
room reduces hospital admissions and improves lung function
Systemic Glucocorticoids short oral course + SABA in
moderate to severe asthma exacerbation

LABA
 Salmetrol

 Should be used in combination with inhaled

corticosteroids and not as mono therapy
 Exercise induces asthma in children >= 4 Yrs
one inhalation 30 min prior to exercise
 No additional doses for PTs who are already
receiving it twice daily not recommended by
NIH guidelines

LTRA

 MonteLukast ( singulair)

 Antihistaminic

 Leukotrien receptor antagonist

 Asthma ( not < 12 MO) and allergic rhinitis (





not < 6 MO)
Morning dosing not evaluated
Prophylactic and chronic treatment of asthma
Exercise induced asthma in >= 15 Yrs
Zafir Lukast : prophylactic and chronic
treatment of asthma

ICA
 Most potent anti inflammatory agents available

for the treatment of asthma
 Inhibiting most steps in the cascade of the
inflammatory response
 Benefits reducing bronchial hyper
responsiveness , prevention of late asthmatic
response , enhanced lung function
 Inhaled Glucocorticoids first line controller
therapy for persistent asthma or those who
require step 2

Prognosis
 35%of preschool children experience recurrent

coughing and wheezing,1/3 of them continue to
have persistent asthma into later childhood and
2/3 improvement on their own through their teen
yrs
 Asthma severity by age 7-10 yrs is predictive of
asthma persistence into adulthood
 Children with mod to severe asthma and lower lung
function are likely to have persistent asthma as
adults
 Children with milder asthma and N/R lung function
are likely to improve over time or be periodically
asthmatic

THANK YOU FOR YOUR
ATTENTION


Slide 49

Asthma in Children
DR. A.Mirshokraei
NIOC Hospital Pediatrics Ward

Definition :

DEFINITION

- Chronic inflammatory condition of the
lung airways resulting in episodic airflow
obstruction
- AHR to provocative exposures
Asthma management
• Reducing airway inflammation by: Minimizing
pro inflammatory environmental exposure, using
daily controller anti inflammatory medication,
controlling co morbid conditions that worsen
asthma, less inflammation better asthma
control and fewer exacerbations

Anyway exacerbations

occur

BUT
Even the uncommon
child with sever asthma can
be managed to live normally

 RECURRENT WHEEZING EPISODES WITH COMMON

RESPIRATORY
VIRUSES(RSV,RHINOVIRUS,INFLUENZA,PARAINFLUENZA,A
DENOVIRUS,HUMAN METAPNUMOVIRUS)

 HOST FEATURES AFFECTING IMMUNOLOGIC HOST

DEFENSE,INFLAMMATION/PREVIOUS VIRAL INFECTIONS
MAINIFESTED AS PNUMONIA OR BRONCHIOLITIS
REQUIRING HOSPITALIZATION UNDERLIE THE
RECURRENT WHEEZING IN EARLY CHILDHOOD

 OTHER AIRWAY EXPOSURES SUCH AS INDOOR AND HOME

ALLERGENS,COLD AIR,STRONG ODORS,TOBACCO
SMOKE,ALL INCREASE AHR

 ALLERGEN ELLIMINATION SOMETIMES LEEDS TO CURE

EPIDEMIOLOGY
 Common etiology of emergency visits and school day missing

in childhood ,occasionally hospitalization and rare deaths
specially in poverty ,urban living ,ethnic minorities

 Increasing asthma prevalence worldwide(50% per decade)
 Good correlation of asthma prevalence with allergic rhino

sinusitis and atopic eczema and other allergies

 More prevalence in high level urban modern families than

suburban villagers

 More than 80%of asthmatics reported getting the disease

before 6 year

CLINICS
RECURRENT COUGHING/WHEEZING
PATTERNS IN CHILDHOOD BASED ON
NATURAL HISTORY

TRANSIENT EARLY WHEEZING
 Common in early preschool years

 Recurrent coughing/wheezing primary

triggered by common respiratory viral INF
 Tend to resolve during preschool yrs without
increasing risk of asthma later in life
 Problems due to reduced airflow at birth
suggestive of relative narrow airways improved
by school yrs

Persistent Atopy Associated Asthma
 Begins in early preschool yrs

 Associated with atopy (eg atopic dermatitis in





infancy, allergic rhinitis, food allergy)
Biologic factors e.g.: early inhalant sensitization,
increase serum IGE, increase blood eosinophills,
High risk of persistence into later childhood and
adulthood lung function abnormality
Those with onset<3 yrs
reduced air flow by
school yrs
Those with later onset of symptoms or allergen
sensitizations unlikely persistence lung function
abnormality later

Non-Atopic Wheezing
 Wheezing ,coughing beginning in early life

often with RSV INF resolves later in childhood
without increasing risk of persistence asthma

 Associated with bronchial hyper

responsiveness near birth

Asthma with declining lung function
• Children with asthma with progressive

increase in air flow limitation

• Associated with hyper inflation in childhood
• Male gender

Late onset asthma in females associated with
obesity and early onset puberty
 Onset between 8_13 yrs

 Associated with early onset puberty and obesity
 Specific for females

Occupational type asthma in children
 Children with asthma and occupational type exposure

known to trigger asthma in adults in occupational settings

Types of Asthma
common clinical presentations of intermittent
recurrent wheezing and/or coughing
 Recurrent wheezing in early childhood

 Chronic asthma associated with allergy
 Females 11 yrs with early onset puberty and

obesity

Pathogenesis

 Airflow obstruction resulting from

Broncho constriction of bronchiolar smooth
muscle mass
II. Cellular inflammatory infiltrates and exudates
mostly Eosinophills(also N , M ,L ,mast cells
,basophiles)fill and obstruct airways and damage
epithelium and induce desquamation into airway
lumen mediated by T helper cells and other
immune cells that produce pro allergic pro
inflammatory cytokines(IL4,IL6,IL13)
III. Breach in normal immune regulatory process
I.

RESULT
 Airway inflammation

 AHR
 Edema basement membrane thickness sub

epithelial collagen deposition
 Smooth muscle and mucus gland hypertrophy
and mucus hyper secretion

Air obstruction

Clinical manifestations and diagnosis
 Most common intermittent dry cough and

expiratory wheezing

 Shortness of breath and chest tightness in older

children and adults

 Intermittent non focal chest pain in younger

children

 Worsening of respiratory symptoms at night
 Worsening of day time symptoms by activity

Continue…..
 Subtle symptoms such as self limitation of activities

,general fatigue ,difficulty in keeping up with peers

 Relief with aerosolized bronchodilators
 Lack of improvement with bronchodilators and steroid

is inconsistent with Asthma and should consider
Asthma masquerading conditions!!!!

 Hyper ventilation, intercostal retractions ,nasal flaring

,respiratory accessory muscle use

 Its common not to hear the expiratory wheezing when

Air flow is so limited before treatment

Asthma Triggers
 Common viral infections of the respiratory tract
 Aero allergens in sensitized asthmatics ,animal dander ,dust











mite ,molds ,indoor allergens ,cockroaches
Seasonal aero allergens ,pollens(trees ,grasses ,weeds ,)
Environmental tobacco smoke
Air pollutants ,ozone ,so2,wood or coal smoke ,endotoxin
,mycotoxin ,dust
Strong or noxious odors or fumes ,perfume ,hair spray
,cleaning agents
Occupational exposure
Cold air ,dry air
Exercise
Crying ,laughter ,hyperventilation
Co morbid conditions Rhinitis ,Sinusitis ,GER

Clinics
History:
Triggering symptoms by laughter
,cold air ,airway irritants
Exposures that induce airway
irritation such as viral URTI
Mycoplasma ,Chlamydia
Inhaled allergens
All lead to AHR

Presence Of Risk Factors:
 History of other allergies ,allergic Rhinitis,

allergic Conjunctivitis ,atopic Dermatitis ,food
allergies

 Parental Asthma
 Symptoms apart from cold

Continue…..
 No or minimal signs in routine visits

 Dry or persistent cough

 Normal chest findings unless wheezing when asking

to breath deeper
 Quick relief (10 MIN) after SABA use
 Expiratory wheezing ,prolonged expiratory phase
,decreased sounds in RT lower pos lobe due to
regional hypoventilation owing to airway
obstruction
 Rales , ronchi ,crackles due to hyper secretion
 Segmental crackles and poor breath sounds
atelectasis?

Continue….
 Labored respiration ,respiratory distress increased

prolongation of expiration and wheezing in E and I

 Poor air entry
 Inter costal retractions ,nasal flaring ,supra and

infra sternal retractions

 And again in most sever forms expiratory wheezing

does not appear until some broncho dilation

DD

GERD Rhino sinusitis co morbid

conditions with asthma

Recurrent aspiration in early

life(tracheo broncho malacia
,TEF , foreign body ,CF ,BPD

VCD in older children and

adolescents

LAB FINDINGS
Pulmonary Function
Testing

Continue….
 Forced expiratory airflow measures helpful

in Diagnosis , assessing efficacy of therapy
and monitoring Asthma in children specially
in poor children who do not have PHE
unless obstruction is sever

 Valueablity of spirometric findings in children>6

yrs

 3 efforts the highest is the peak
 Reduced FEV

obstruction

FEV1/FVC <0.80 means significant

 Improvement in FEV1 following beta 2 agonist > =

12% or 200 ml is consistent with Asthma

 Peak flow meter

CXR

Often normal aside from subtle and

nonspecific findings of hyperinflation

Peribronchial thickening
Helping in diagnosis of Asthma

differentials

Diagnosis of complications of Asthma

exacerbations

Other tests such as allergy skin prick
testing

Treatment
 www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm

Asthma Treatment & Management
has 4 components :
Assessment and monitoring of disease
activity
2. Provision to educate pt and family
3. Identification and management of
precipitating factors and co morbid
conditions
4. Appropriate selection of medication
1.

 Attainment of optimal Asthma control

Component 1
 Asthma severity :intermittent
 Persistent: mild ,mod ,severe
 Only once during patient initial evaluation in pt

who is not using a daily controller agent
 Asthma control degree to which symptoms ,
on going functional impairments , risk of
adverse events minimized and goals of
therapy are met

Continue….
Well controlled
2. Not well controlled
3. Very poor controlled
1.

 NIH guidelines for both severity and

control for 3 age groups

0-4 yrs
2. 5-11 yrs
3. =>12 yrs
1.

Important
even in the absence of frequent symptoms
infants and children whom have risk factors
for asthma and 4 or more episodes of
wheezing over the past yr which lasted more
than 1 day or 2 or more exacerbations in
the last 6 months requiring syst
corticosteroids should be considered in the
persistent group and hence receive long term
controller therapy

Important Tips..
 Regular clinical visits every 2-6 weeks
 Assessment of :

Pt symptoms frequency night and day
2. Need for short acting inhaled b2 agonists for
quick relief
3. Ability to engage in normal activities
4. Air flow measures for>=5 yrs
1.

Continue..
 Component 2 : pt education

 Component 3 : control of factors contributing

to asthma severity
1. Environmental exposures
2. Co morbid conditions
 Component 4 :principals of asthma
pharmacotherapy

Asthma Medication
 SABA

 ICS

 LABA
 LTRA

 SYSTEMIC STEROIDS

 NONSTEROIDAL ANTIINFLAMMATORY

CROMOLYN AND NEDOCROMYL
 OXYGEN
 ANTICHOLINERGIC AGENTS
IPRATROPIUM
BROMIDE
 ANTIIMMUNOGLUBOLINE E

MANAGEMENT OF ASTHMA EXACERBATION(STATUS ASTHMATICUS)
RISK ASSESMENT ON ADMISSION

FOCUSED HISTORY

ONSET OF CURRENT EXACERBATION
FREQUENCY AND severity of daytime and night
time symptoms and activity limitation
Frequency of rescue bronchodilator use
Current medication and allergies
Potential triggers
History of systemic steroid courses, emergency
department visists , hospitalization, intubation or life
threatening episodes

Clinical assesment

Physical examination findings: vital signs,
breathlessness, air movement, use of accessory
respiratory muscles, retractions, anxiety level,
alteration in mental status
Pulse oximetry
Lung function(defer in pts with mod to severe
distress or history of labile disease)

Treatment
Drugs and trade name

Mechanism of action and dosing

Cautions and adverse effects

Oxygen(mask or nasal canula)
Inhaled short acting b2
agonist
Albuterol nebulized
solution(5mg/ml concentrates
Albuterol MDI
Levabuterol

Treats hypoxia
Bronchodilator
Neubolizer 0.15 mg/kg every 20 min for 3
doses as needed,then 0.15_0.3 mg/kg up t 10
mg every 1_4 hour as needed or up to 0.5
mg/kg/hr by continous neubolization
2_8 puf up to every 20 min for 3 doses as
needed then every 1 hr as needed

Monitor pulse oximetry to maintain o2 saturation>92%
Cardiorespiratory monitoring
During exacerbations,frequent or continuous use can cause
pulmonary vasodilatation,v/q mistmatch and hypoxemia
Adverse effect palpitation, tachycardia, arrhythmia, tremor,
hypoxemia
Neubolizer:when giving concentrate forms,dilute with saline to 3
ml total neubolized volume
For MDI use space/holding chamber

Systemic corticosteroids
Prednisolone tb
Methyl prednisolon
Anticholinergics
Ipratropium
Atrovent
Ipratropium with Albuterol

Anti inflammatory
0.5_1 mg/kg every 6-8 hr for 48 hr , then 1-2 mg/kg
day bid(max 60 mg/day)
Short course burst for exacerbation 1-2 mg/kg/day qd
or bid for 3-7 days
Mucolitic/bronchodilator
Neubolizer 0.5 mg q6-8 hr (tid or qid) as needed
MDI 2 paf qid
1 vial by neubolizer qid



If pt has been exposed chickenpox or measles, consider passive
immunoglobulin prophylaxis, also risk of complications with
herspes simplex and TB

For daily dosing , 8 am administration minimizes adrenal
suppression

Children may benefit from dosage tapering if course exceed 7 days

Adverse effect monitoring: frequent therapy bursts risk numerous
corticosteroid adverse effects

Should not be used as first line treatment added to b2 agonist
therapy
Neubolizer may mix Ipratropium with Albuterol

QUICK RELIEF MEDICATION
SABA

Anti cholinergic(ipratropium)
Short term systemic gluco

corticoid

SABA
 Quick relief of asthma symptoms
 Relax airway smooth muscle prompt airflow↑
 Repetitive or continuous SABA is the most effective means







of reversing air flow obstruction
SABA should not be prescribed on a regular schedule
because concerns of possibility of deteriorating asthma
control
Frequent use of SABA is an indication of poor asthma control
Preferred root is inhalation smaller dose , fewer side effects
more rapid on set of action
Ipratropium Bromide as an adjunct to SABA in emergency
room reduces hospital admissions and improves lung function
Systemic Glucocorticoids short oral course + SABA in
moderate to severe asthma exacerbation

LABA
 Salmetrol

 Should be used in combination with inhaled

corticosteroids and not as mono therapy
 Exercise induces asthma in children >= 4 Yrs
one inhalation 30 min prior to exercise
 No additional doses for PTs who are already
receiving it twice daily not recommended by
NIH guidelines

LTRA

 MonteLukast ( singulair)

 Antihistaminic

 Leukotrien receptor antagonist

 Asthma ( not < 12 MO) and allergic rhinitis (





not < 6 MO)
Morning dosing not evaluated
Prophylactic and chronic treatment of asthma
Exercise induced asthma in >= 15 Yrs
Zafir Lukast : prophylactic and chronic
treatment of asthma

ICA
 Most potent anti inflammatory agents available

for the treatment of asthma
 Inhibiting most steps in the cascade of the
inflammatory response
 Benefits reducing bronchial hyper
responsiveness , prevention of late asthmatic
response , enhanced lung function
 Inhaled Glucocorticoids first line controller
therapy for persistent asthma or those who
require step 2

Prognosis
 35%of preschool children experience recurrent

coughing and wheezing,1/3 of them continue to
have persistent asthma into later childhood and
2/3 improvement on their own through their teen
yrs
 Asthma severity by age 7-10 yrs is predictive of
asthma persistence into adulthood
 Children with mod to severe asthma and lower lung
function are likely to have persistent asthma as
adults
 Children with milder asthma and N/R lung function
are likely to improve over time or be periodically
asthmatic

THANK YOU FOR YOUR
ATTENTION


Slide 50

Asthma in Children
DR. A.Mirshokraei
NIOC Hospital Pediatrics Ward

Definition :

DEFINITION

- Chronic inflammatory condition of the
lung airways resulting in episodic airflow
obstruction
- AHR to provocative exposures
Asthma management
• Reducing airway inflammation by: Minimizing
pro inflammatory environmental exposure, using
daily controller anti inflammatory medication,
controlling co morbid conditions that worsen
asthma, less inflammation better asthma
control and fewer exacerbations

Anyway exacerbations

occur

BUT
Even the uncommon
child with sever asthma can
be managed to live normally

 RECURRENT WHEEZING EPISODES WITH COMMON

RESPIRATORY
VIRUSES(RSV,RHINOVIRUS,INFLUENZA,PARAINFLUENZA,A
DENOVIRUS,HUMAN METAPNUMOVIRUS)

 HOST FEATURES AFFECTING IMMUNOLOGIC HOST

DEFENSE,INFLAMMATION/PREVIOUS VIRAL INFECTIONS
MAINIFESTED AS PNUMONIA OR BRONCHIOLITIS
REQUIRING HOSPITALIZATION UNDERLIE THE
RECURRENT WHEEZING IN EARLY CHILDHOOD

 OTHER AIRWAY EXPOSURES SUCH AS INDOOR AND HOME

ALLERGENS,COLD AIR,STRONG ODORS,TOBACCO
SMOKE,ALL INCREASE AHR

 ALLERGEN ELLIMINATION SOMETIMES LEEDS TO CURE

EPIDEMIOLOGY
 Common etiology of emergency visits and school day missing

in childhood ,occasionally hospitalization and rare deaths
specially in poverty ,urban living ,ethnic minorities

 Increasing asthma prevalence worldwide(50% per decade)
 Good correlation of asthma prevalence with allergic rhino

sinusitis and atopic eczema and other allergies

 More prevalence in high level urban modern families than

suburban villagers

 More than 80%of asthmatics reported getting the disease

before 6 year

CLINICS
RECURRENT COUGHING/WHEEZING
PATTERNS IN CHILDHOOD BASED ON
NATURAL HISTORY

TRANSIENT EARLY WHEEZING
 Common in early preschool years

 Recurrent coughing/wheezing primary

triggered by common respiratory viral INF
 Tend to resolve during preschool yrs without
increasing risk of asthma later in life
 Problems due to reduced airflow at birth
suggestive of relative narrow airways improved
by school yrs

Persistent Atopy Associated Asthma
 Begins in early preschool yrs

 Associated with atopy (eg atopic dermatitis in





infancy, allergic rhinitis, food allergy)
Biologic factors e.g.: early inhalant sensitization,
increase serum IGE, increase blood eosinophills,
High risk of persistence into later childhood and
adulthood lung function abnormality
Those with onset<3 yrs
reduced air flow by
school yrs
Those with later onset of symptoms or allergen
sensitizations unlikely persistence lung function
abnormality later

Non-Atopic Wheezing
 Wheezing ,coughing beginning in early life

often with RSV INF resolves later in childhood
without increasing risk of persistence asthma

 Associated with bronchial hyper

responsiveness near birth

Asthma with declining lung function
• Children with asthma with progressive

increase in air flow limitation

• Associated with hyper inflation in childhood
• Male gender

Late onset asthma in females associated with
obesity and early onset puberty
 Onset between 8_13 yrs

 Associated with early onset puberty and obesity
 Specific for females

Occupational type asthma in children
 Children with asthma and occupational type exposure

known to trigger asthma in adults in occupational settings

Types of Asthma
common clinical presentations of intermittent
recurrent wheezing and/or coughing
 Recurrent wheezing in early childhood

 Chronic asthma associated with allergy
 Females 11 yrs with early onset puberty and

obesity

Pathogenesis

 Airflow obstruction resulting from

Broncho constriction of bronchiolar smooth
muscle mass
II. Cellular inflammatory infiltrates and exudates
mostly Eosinophills(also N , M ,L ,mast cells
,basophiles)fill and obstruct airways and damage
epithelium and induce desquamation into airway
lumen mediated by T helper cells and other
immune cells that produce pro allergic pro
inflammatory cytokines(IL4,IL6,IL13)
III. Breach in normal immune regulatory process
I.

RESULT
 Airway inflammation

 AHR
 Edema basement membrane thickness sub

epithelial collagen deposition
 Smooth muscle and mucus gland hypertrophy
and mucus hyper secretion

Air obstruction

Clinical manifestations and diagnosis
 Most common intermittent dry cough and

expiratory wheezing

 Shortness of breath and chest tightness in older

children and adults

 Intermittent non focal chest pain in younger

children

 Worsening of respiratory symptoms at night
 Worsening of day time symptoms by activity

Continue…..
 Subtle symptoms such as self limitation of activities

,general fatigue ,difficulty in keeping up with peers

 Relief with aerosolized bronchodilators
 Lack of improvement with bronchodilators and steroid

is inconsistent with Asthma and should consider
Asthma masquerading conditions!!!!

 Hyper ventilation, intercostal retractions ,nasal flaring

,respiratory accessory muscle use

 Its common not to hear the expiratory wheezing when

Air flow is so limited before treatment

Asthma Triggers
 Common viral infections of the respiratory tract
 Aero allergens in sensitized asthmatics ,animal dander ,dust











mite ,molds ,indoor allergens ,cockroaches
Seasonal aero allergens ,pollens(trees ,grasses ,weeds ,)
Environmental tobacco smoke
Air pollutants ,ozone ,so2,wood or coal smoke ,endotoxin
,mycotoxin ,dust
Strong or noxious odors or fumes ,perfume ,hair spray
,cleaning agents
Occupational exposure
Cold air ,dry air
Exercise
Crying ,laughter ,hyperventilation
Co morbid conditions Rhinitis ,Sinusitis ,GER

Clinics
History:
Triggering symptoms by laughter
,cold air ,airway irritants
Exposures that induce airway
irritation such as viral URTI
Mycoplasma ,Chlamydia
Inhaled allergens
All lead to AHR

Presence Of Risk Factors:
 History of other allergies ,allergic Rhinitis,

allergic Conjunctivitis ,atopic Dermatitis ,food
allergies

 Parental Asthma
 Symptoms apart from cold

Continue…..
 No or minimal signs in routine visits

 Dry or persistent cough

 Normal chest findings unless wheezing when asking

to breath deeper
 Quick relief (10 MIN) after SABA use
 Expiratory wheezing ,prolonged expiratory phase
,decreased sounds in RT lower pos lobe due to
regional hypoventilation owing to airway
obstruction
 Rales , ronchi ,crackles due to hyper secretion
 Segmental crackles and poor breath sounds
atelectasis?

Continue….
 Labored respiration ,respiratory distress increased

prolongation of expiration and wheezing in E and I

 Poor air entry
 Inter costal retractions ,nasal flaring ,supra and

infra sternal retractions

 And again in most sever forms expiratory wheezing

does not appear until some broncho dilation

DD

GERD Rhino sinusitis co morbid

conditions with asthma

Recurrent aspiration in early

life(tracheo broncho malacia
,TEF , foreign body ,CF ,BPD

VCD in older children and

adolescents

LAB FINDINGS
Pulmonary Function
Testing

Continue….
 Forced expiratory airflow measures helpful

in Diagnosis , assessing efficacy of therapy
and monitoring Asthma in children specially
in poor children who do not have PHE
unless obstruction is sever

 Valueablity of spirometric findings in children>6

yrs

 3 efforts the highest is the peak
 Reduced FEV

obstruction

FEV1/FVC <0.80 means significant

 Improvement in FEV1 following beta 2 agonist > =

12% or 200 ml is consistent with Asthma

 Peak flow meter

CXR

Often normal aside from subtle and

nonspecific findings of hyperinflation

Peribronchial thickening
Helping in diagnosis of Asthma

differentials

Diagnosis of complications of Asthma

exacerbations

Other tests such as allergy skin prick
testing

Treatment
 www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm

Asthma Treatment & Management
has 4 components :
Assessment and monitoring of disease
activity
2. Provision to educate pt and family
3. Identification and management of
precipitating factors and co morbid
conditions
4. Appropriate selection of medication
1.

 Attainment of optimal Asthma control

Component 1
 Asthma severity :intermittent
 Persistent: mild ,mod ,severe
 Only once during patient initial evaluation in pt

who is not using a daily controller agent
 Asthma control degree to which symptoms ,
on going functional impairments , risk of
adverse events minimized and goals of
therapy are met

Continue….
Well controlled
2. Not well controlled
3. Very poor controlled
1.

 NIH guidelines for both severity and

control for 3 age groups

0-4 yrs
2. 5-11 yrs
3. =>12 yrs
1.

Important
even in the absence of frequent symptoms
infants and children whom have risk factors
for asthma and 4 or more episodes of
wheezing over the past yr which lasted more
than 1 day or 2 or more exacerbations in
the last 6 months requiring syst
corticosteroids should be considered in the
persistent group and hence receive long term
controller therapy

Important Tips..
 Regular clinical visits every 2-6 weeks
 Assessment of :

Pt symptoms frequency night and day
2. Need for short acting inhaled b2 agonists for
quick relief
3. Ability to engage in normal activities
4. Air flow measures for>=5 yrs
1.

Continue..
 Component 2 : pt education

 Component 3 : control of factors contributing

to asthma severity
1. Environmental exposures
2. Co morbid conditions
 Component 4 :principals of asthma
pharmacotherapy

Asthma Medication
 SABA

 ICS

 LABA
 LTRA

 SYSTEMIC STEROIDS

 NONSTEROIDAL ANTIINFLAMMATORY

CROMOLYN AND NEDOCROMYL
 OXYGEN
 ANTICHOLINERGIC AGENTS
IPRATROPIUM
BROMIDE
 ANTIIMMUNOGLUBOLINE E

MANAGEMENT OF ASTHMA EXACERBATION(STATUS ASTHMATICUS)
RISK ASSESMENT ON ADMISSION

FOCUSED HISTORY

ONSET OF CURRENT EXACERBATION
FREQUENCY AND severity of daytime and night
time symptoms and activity limitation
Frequency of rescue bronchodilator use
Current medication and allergies
Potential triggers
History of systemic steroid courses, emergency
department visists , hospitalization, intubation or life
threatening episodes

Clinical assesment

Physical examination findings: vital signs,
breathlessness, air movement, use of accessory
respiratory muscles, retractions, anxiety level,
alteration in mental status
Pulse oximetry
Lung function(defer in pts with mod to severe
distress or history of labile disease)

Treatment
Drugs and trade name

Mechanism of action and dosing

Cautions and adverse effects

Oxygen(mask or nasal canula)
Inhaled short acting b2
agonist
Albuterol nebulized
solution(5mg/ml concentrates
Albuterol MDI
Levabuterol

Treats hypoxia
Bronchodilator
Neubolizer 0.15 mg/kg every 20 min for 3
doses as needed,then 0.15_0.3 mg/kg up t 10
mg every 1_4 hour as needed or up to 0.5
mg/kg/hr by continous neubolization
2_8 puf up to every 20 min for 3 doses as
needed then every 1 hr as needed

Monitor pulse oximetry to maintain o2 saturation>92%
Cardiorespiratory monitoring
During exacerbations,frequent or continuous use can cause
pulmonary vasodilatation,v/q mistmatch and hypoxemia
Adverse effect palpitation, tachycardia, arrhythmia, tremor,
hypoxemia
Neubolizer:when giving concentrate forms,dilute with saline to 3
ml total neubolized volume
For MDI use space/holding chamber

Systemic corticosteroids
Prednisolone tb
Methyl prednisolon
Anticholinergics
Ipratropium
Atrovent
Ipratropium with Albuterol

Anti inflammatory
0.5_1 mg/kg every 6-8 hr for 48 hr , then 1-2 mg/kg
day bid(max 60 mg/day)
Short course burst for exacerbation 1-2 mg/kg/day qd
or bid for 3-7 days
Mucolitic/bronchodilator
Neubolizer 0.5 mg q6-8 hr (tid or qid) as needed
MDI 2 paf qid
1 vial by neubolizer qid



If pt has been exposed chickenpox or measles, consider passive
immunoglobulin prophylaxis, also risk of complications with
herspes simplex and TB

For daily dosing , 8 am administration minimizes adrenal
suppression

Children may benefit from dosage tapering if course exceed 7 days

Adverse effect monitoring: frequent therapy bursts risk numerous
corticosteroid adverse effects

Should not be used as first line treatment added to b2 agonist
therapy
Neubolizer may mix Ipratropium with Albuterol

QUICK RELIEF MEDICATION
SABA

Anti cholinergic(ipratropium)
Short term systemic gluco

corticoid

SABA
 Quick relief of asthma symptoms
 Relax airway smooth muscle prompt airflow↑
 Repetitive or continuous SABA is the most effective means







of reversing air flow obstruction
SABA should not be prescribed on a regular schedule
because concerns of possibility of deteriorating asthma
control
Frequent use of SABA is an indication of poor asthma control
Preferred root is inhalation smaller dose , fewer side effects
more rapid on set of action
Ipratropium Bromide as an adjunct to SABA in emergency
room reduces hospital admissions and improves lung function
Systemic Glucocorticoids short oral course + SABA in
moderate to severe asthma exacerbation

LABA
 Salmetrol

 Should be used in combination with inhaled

corticosteroids and not as mono therapy
 Exercise induces asthma in children >= 4 Yrs
one inhalation 30 min prior to exercise
 No additional doses for PTs who are already
receiving it twice daily not recommended by
NIH guidelines

LTRA

 MonteLukast ( singulair)

 Antihistaminic

 Leukotrien receptor antagonist

 Asthma ( not < 12 MO) and allergic rhinitis (





not < 6 MO)
Morning dosing not evaluated
Prophylactic and chronic treatment of asthma
Exercise induced asthma in >= 15 Yrs
Zafir Lukast : prophylactic and chronic
treatment of asthma

ICA
 Most potent anti inflammatory agents available

for the treatment of asthma
 Inhibiting most steps in the cascade of the
inflammatory response
 Benefits reducing bronchial hyper
responsiveness , prevention of late asthmatic
response , enhanced lung function
 Inhaled Glucocorticoids first line controller
therapy for persistent asthma or those who
require step 2

Prognosis
 35%of preschool children experience recurrent

coughing and wheezing,1/3 of them continue to
have persistent asthma into later childhood and
2/3 improvement on their own through their teen
yrs
 Asthma severity by age 7-10 yrs is predictive of
asthma persistence into adulthood
 Children with mod to severe asthma and lower lung
function are likely to have persistent asthma as
adults
 Children with milder asthma and N/R lung function
are likely to improve over time or be periodically
asthmatic

THANK YOU FOR YOUR
ATTENTION


Slide 51

Asthma in Children
DR. A.Mirshokraei
NIOC Hospital Pediatrics Ward

Definition :

DEFINITION

- Chronic inflammatory condition of the
lung airways resulting in episodic airflow
obstruction
- AHR to provocative exposures
Asthma management
• Reducing airway inflammation by: Minimizing
pro inflammatory environmental exposure, using
daily controller anti inflammatory medication,
controlling co morbid conditions that worsen
asthma, less inflammation better asthma
control and fewer exacerbations

Anyway exacerbations

occur

BUT
Even the uncommon
child with sever asthma can
be managed to live normally

 RECURRENT WHEEZING EPISODES WITH COMMON

RESPIRATORY
VIRUSES(RSV,RHINOVIRUS,INFLUENZA,PARAINFLUENZA,A
DENOVIRUS,HUMAN METAPNUMOVIRUS)

 HOST FEATURES AFFECTING IMMUNOLOGIC HOST

DEFENSE,INFLAMMATION/PREVIOUS VIRAL INFECTIONS
MAINIFESTED AS PNUMONIA OR BRONCHIOLITIS
REQUIRING HOSPITALIZATION UNDERLIE THE
RECURRENT WHEEZING IN EARLY CHILDHOOD

 OTHER AIRWAY EXPOSURES SUCH AS INDOOR AND HOME

ALLERGENS,COLD AIR,STRONG ODORS,TOBACCO
SMOKE,ALL INCREASE AHR

 ALLERGEN ELLIMINATION SOMETIMES LEEDS TO CURE

EPIDEMIOLOGY
 Common etiology of emergency visits and school day missing

in childhood ,occasionally hospitalization and rare deaths
specially in poverty ,urban living ,ethnic minorities

 Increasing asthma prevalence worldwide(50% per decade)
 Good correlation of asthma prevalence with allergic rhino

sinusitis and atopic eczema and other allergies

 More prevalence in high level urban modern families than

suburban villagers

 More than 80%of asthmatics reported getting the disease

before 6 year

CLINICS
RECURRENT COUGHING/WHEEZING
PATTERNS IN CHILDHOOD BASED ON
NATURAL HISTORY

TRANSIENT EARLY WHEEZING
 Common in early preschool years

 Recurrent coughing/wheezing primary

triggered by common respiratory viral INF
 Tend to resolve during preschool yrs without
increasing risk of asthma later in life
 Problems due to reduced airflow at birth
suggestive of relative narrow airways improved
by school yrs

Persistent Atopy Associated Asthma
 Begins in early preschool yrs

 Associated with atopy (eg atopic dermatitis in





infancy, allergic rhinitis, food allergy)
Biologic factors e.g.: early inhalant sensitization,
increase serum IGE, increase blood eosinophills,
High risk of persistence into later childhood and
adulthood lung function abnormality
Those with onset<3 yrs
reduced air flow by
school yrs
Those with later onset of symptoms or allergen
sensitizations unlikely persistence lung function
abnormality later

Non-Atopic Wheezing
 Wheezing ,coughing beginning in early life

often with RSV INF resolves later in childhood
without increasing risk of persistence asthma

 Associated with bronchial hyper

responsiveness near birth

Asthma with declining lung function
• Children with asthma with progressive

increase in air flow limitation

• Associated with hyper inflation in childhood
• Male gender

Late onset asthma in females associated with
obesity and early onset puberty
 Onset between 8_13 yrs

 Associated with early onset puberty and obesity
 Specific for females

Occupational type asthma in children
 Children with asthma and occupational type exposure

known to trigger asthma in adults in occupational settings

Types of Asthma
common clinical presentations of intermittent
recurrent wheezing and/or coughing
 Recurrent wheezing in early childhood

 Chronic asthma associated with allergy
 Females 11 yrs with early onset puberty and

obesity

Pathogenesis

 Airflow obstruction resulting from

Broncho constriction of bronchiolar smooth
muscle mass
II. Cellular inflammatory infiltrates and exudates
mostly Eosinophills(also N , M ,L ,mast cells
,basophiles)fill and obstruct airways and damage
epithelium and induce desquamation into airway
lumen mediated by T helper cells and other
immune cells that produce pro allergic pro
inflammatory cytokines(IL4,IL6,IL13)
III. Breach in normal immune regulatory process
I.

RESULT
 Airway inflammation

 AHR
 Edema basement membrane thickness sub

epithelial collagen deposition
 Smooth muscle and mucus gland hypertrophy
and mucus hyper secretion

Air obstruction

Clinical manifestations and diagnosis
 Most common intermittent dry cough and

expiratory wheezing

 Shortness of breath and chest tightness in older

children and adults

 Intermittent non focal chest pain in younger

children

 Worsening of respiratory symptoms at night
 Worsening of day time symptoms by activity

Continue…..
 Subtle symptoms such as self limitation of activities

,general fatigue ,difficulty in keeping up with peers

 Relief with aerosolized bronchodilators
 Lack of improvement with bronchodilators and steroid

is inconsistent with Asthma and should consider
Asthma masquerading conditions!!!!

 Hyper ventilation, intercostal retractions ,nasal flaring

,respiratory accessory muscle use

 Its common not to hear the expiratory wheezing when

Air flow is so limited before treatment

Asthma Triggers
 Common viral infections of the respiratory tract
 Aero allergens in sensitized asthmatics ,animal dander ,dust











mite ,molds ,indoor allergens ,cockroaches
Seasonal aero allergens ,pollens(trees ,grasses ,weeds ,)
Environmental tobacco smoke
Air pollutants ,ozone ,so2,wood or coal smoke ,endotoxin
,mycotoxin ,dust
Strong or noxious odors or fumes ,perfume ,hair spray
,cleaning agents
Occupational exposure
Cold air ,dry air
Exercise
Crying ,laughter ,hyperventilation
Co morbid conditions Rhinitis ,Sinusitis ,GER

Clinics
History:
Triggering symptoms by laughter
,cold air ,airway irritants
Exposures that induce airway
irritation such as viral URTI
Mycoplasma ,Chlamydia
Inhaled allergens
All lead to AHR

Presence Of Risk Factors:
 History of other allergies ,allergic Rhinitis,

allergic Conjunctivitis ,atopic Dermatitis ,food
allergies

 Parental Asthma
 Symptoms apart from cold

Continue…..
 No or minimal signs in routine visits

 Dry or persistent cough

 Normal chest findings unless wheezing when asking

to breath deeper
 Quick relief (10 MIN) after SABA use
 Expiratory wheezing ,prolonged expiratory phase
,decreased sounds in RT lower pos lobe due to
regional hypoventilation owing to airway
obstruction
 Rales , ronchi ,crackles due to hyper secretion
 Segmental crackles and poor breath sounds
atelectasis?

Continue….
 Labored respiration ,respiratory distress increased

prolongation of expiration and wheezing in E and I

 Poor air entry
 Inter costal retractions ,nasal flaring ,supra and

infra sternal retractions

 And again in most sever forms expiratory wheezing

does not appear until some broncho dilation

DD

GERD Rhino sinusitis co morbid

conditions with asthma

Recurrent aspiration in early

life(tracheo broncho malacia
,TEF , foreign body ,CF ,BPD

VCD in older children and

adolescents

LAB FINDINGS
Pulmonary Function
Testing

Continue….
 Forced expiratory airflow measures helpful

in Diagnosis , assessing efficacy of therapy
and monitoring Asthma in children specially
in poor children who do not have PHE
unless obstruction is sever

 Valueablity of spirometric findings in children>6

yrs

 3 efforts the highest is the peak
 Reduced FEV

obstruction

FEV1/FVC <0.80 means significant

 Improvement in FEV1 following beta 2 agonist > =

12% or 200 ml is consistent with Asthma

 Peak flow meter

CXR

Often normal aside from subtle and

nonspecific findings of hyperinflation

Peribronchial thickening
Helping in diagnosis of Asthma

differentials

Diagnosis of complications of Asthma

exacerbations

Other tests such as allergy skin prick
testing

Treatment
 www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm

Asthma Treatment & Management
has 4 components :
Assessment and monitoring of disease
activity
2. Provision to educate pt and family
3. Identification and management of
precipitating factors and co morbid
conditions
4. Appropriate selection of medication
1.

 Attainment of optimal Asthma control

Component 1
 Asthma severity :intermittent
 Persistent: mild ,mod ,severe
 Only once during patient initial evaluation in pt

who is not using a daily controller agent
 Asthma control degree to which symptoms ,
on going functional impairments , risk of
adverse events minimized and goals of
therapy are met

Continue….
Well controlled
2. Not well controlled
3. Very poor controlled
1.

 NIH guidelines for both severity and

control for 3 age groups

0-4 yrs
2. 5-11 yrs
3. =>12 yrs
1.

Important
even in the absence of frequent symptoms
infants and children whom have risk factors
for asthma and 4 or more episodes of
wheezing over the past yr which lasted more
than 1 day or 2 or more exacerbations in
the last 6 months requiring syst
corticosteroids should be considered in the
persistent group and hence receive long term
controller therapy

Important Tips..
 Regular clinical visits every 2-6 weeks
 Assessment of :

Pt symptoms frequency night and day
2. Need for short acting inhaled b2 agonists for
quick relief
3. Ability to engage in normal activities
4. Air flow measures for>=5 yrs
1.

Continue..
 Component 2 : pt education

 Component 3 : control of factors contributing

to asthma severity
1. Environmental exposures
2. Co morbid conditions
 Component 4 :principals of asthma
pharmacotherapy

Asthma Medication
 SABA

 ICS

 LABA
 LTRA

 SYSTEMIC STEROIDS

 NONSTEROIDAL ANTIINFLAMMATORY

CROMOLYN AND NEDOCROMYL
 OXYGEN
 ANTICHOLINERGIC AGENTS
IPRATROPIUM
BROMIDE
 ANTIIMMUNOGLUBOLINE E

MANAGEMENT OF ASTHMA EXACERBATION(STATUS ASTHMATICUS)
RISK ASSESMENT ON ADMISSION

FOCUSED HISTORY

ONSET OF CURRENT EXACERBATION
FREQUENCY AND severity of daytime and night
time symptoms and activity limitation
Frequency of rescue bronchodilator use
Current medication and allergies
Potential triggers
History of systemic steroid courses, emergency
department visists , hospitalization, intubation or life
threatening episodes

Clinical assesment

Physical examination findings: vital signs,
breathlessness, air movement, use of accessory
respiratory muscles, retractions, anxiety level,
alteration in mental status
Pulse oximetry
Lung function(defer in pts with mod to severe
distress or history of labile disease)

Treatment
Drugs and trade name

Mechanism of action and dosing

Cautions and adverse effects

Oxygen(mask or nasal canula)
Inhaled short acting b2
agonist
Albuterol nebulized
solution(5mg/ml concentrates
Albuterol MDI
Levabuterol

Treats hypoxia
Bronchodilator
Neubolizer 0.15 mg/kg every 20 min for 3
doses as needed,then 0.15_0.3 mg/kg up t 10
mg every 1_4 hour as needed or up to 0.5
mg/kg/hr by continous neubolization
2_8 puf up to every 20 min for 3 doses as
needed then every 1 hr as needed

Monitor pulse oximetry to maintain o2 saturation>92%
Cardiorespiratory monitoring
During exacerbations,frequent or continuous use can cause
pulmonary vasodilatation,v/q mistmatch and hypoxemia
Adverse effect palpitation, tachycardia, arrhythmia, tremor,
hypoxemia
Neubolizer:when giving concentrate forms,dilute with saline to 3
ml total neubolized volume
For MDI use space/holding chamber

Systemic corticosteroids
Prednisolone tb
Methyl prednisolon
Anticholinergics
Ipratropium
Atrovent
Ipratropium with Albuterol

Anti inflammatory
0.5_1 mg/kg every 6-8 hr for 48 hr , then 1-2 mg/kg
day bid(max 60 mg/day)
Short course burst for exacerbation 1-2 mg/kg/day qd
or bid for 3-7 days
Mucolitic/bronchodilator
Neubolizer 0.5 mg q6-8 hr (tid or qid) as needed
MDI 2 paf qid
1 vial by neubolizer qid



If pt has been exposed chickenpox or measles, consider passive
immunoglobulin prophylaxis, also risk of complications with
herspes simplex and TB

For daily dosing , 8 am administration minimizes adrenal
suppression

Children may benefit from dosage tapering if course exceed 7 days

Adverse effect monitoring: frequent therapy bursts risk numerous
corticosteroid adverse effects

Should not be used as first line treatment added to b2 agonist
therapy
Neubolizer may mix Ipratropium with Albuterol

QUICK RELIEF MEDICATION
SABA

Anti cholinergic(ipratropium)
Short term systemic gluco

corticoid

SABA
 Quick relief of asthma symptoms
 Relax airway smooth muscle prompt airflow↑
 Repetitive or continuous SABA is the most effective means







of reversing air flow obstruction
SABA should not be prescribed on a regular schedule
because concerns of possibility of deteriorating asthma
control
Frequent use of SABA is an indication of poor asthma control
Preferred root is inhalation smaller dose , fewer side effects
more rapid on set of action
Ipratropium Bromide as an adjunct to SABA in emergency
room reduces hospital admissions and improves lung function
Systemic Glucocorticoids short oral course + SABA in
moderate to severe asthma exacerbation

LABA
 Salmetrol

 Should be used in combination with inhaled

corticosteroids and not as mono therapy
 Exercise induces asthma in children >= 4 Yrs
one inhalation 30 min prior to exercise
 No additional doses for PTs who are already
receiving it twice daily not recommended by
NIH guidelines

LTRA

 MonteLukast ( singulair)

 Antihistaminic

 Leukotrien receptor antagonist

 Asthma ( not < 12 MO) and allergic rhinitis (





not < 6 MO)
Morning dosing not evaluated
Prophylactic and chronic treatment of asthma
Exercise induced asthma in >= 15 Yrs
Zafir Lukast : prophylactic and chronic
treatment of asthma

ICA
 Most potent anti inflammatory agents available

for the treatment of asthma
 Inhibiting most steps in the cascade of the
inflammatory response
 Benefits reducing bronchial hyper
responsiveness , prevention of late asthmatic
response , enhanced lung function
 Inhaled Glucocorticoids first line controller
therapy for persistent asthma or those who
require step 2

Prognosis
 35%of preschool children experience recurrent

coughing and wheezing,1/3 of them continue to
have persistent asthma into later childhood and
2/3 improvement on their own through their teen
yrs
 Asthma severity by age 7-10 yrs is predictive of
asthma persistence into adulthood
 Children with mod to severe asthma and lower lung
function are likely to have persistent asthma as
adults
 Children with milder asthma and N/R lung function
are likely to improve over time or be periodically
asthmatic

THANK YOU FOR YOUR
ATTENTION


Slide 52

Asthma in Children
DR. A.Mirshokraei
NIOC Hospital Pediatrics Ward

Definition :

DEFINITION

- Chronic inflammatory condition of the
lung airways resulting in episodic airflow
obstruction
- AHR to provocative exposures
Asthma management
• Reducing airway inflammation by: Minimizing
pro inflammatory environmental exposure, using
daily controller anti inflammatory medication,
controlling co morbid conditions that worsen
asthma, less inflammation better asthma
control and fewer exacerbations

Anyway exacerbations

occur

BUT
Even the uncommon
child with sever asthma can
be managed to live normally

 RECURRENT WHEEZING EPISODES WITH COMMON

RESPIRATORY
VIRUSES(RSV,RHINOVIRUS,INFLUENZA,PARAINFLUENZA,A
DENOVIRUS,HUMAN METAPNUMOVIRUS)

 HOST FEATURES AFFECTING IMMUNOLOGIC HOST

DEFENSE,INFLAMMATION/PREVIOUS VIRAL INFECTIONS
MAINIFESTED AS PNUMONIA OR BRONCHIOLITIS
REQUIRING HOSPITALIZATION UNDERLIE THE
RECURRENT WHEEZING IN EARLY CHILDHOOD

 OTHER AIRWAY EXPOSURES SUCH AS INDOOR AND HOME

ALLERGENS,COLD AIR,STRONG ODORS,TOBACCO
SMOKE,ALL INCREASE AHR

 ALLERGEN ELLIMINATION SOMETIMES LEEDS TO CURE

EPIDEMIOLOGY
 Common etiology of emergency visits and school day missing

in childhood ,occasionally hospitalization and rare deaths
specially in poverty ,urban living ,ethnic minorities

 Increasing asthma prevalence worldwide(50% per decade)
 Good correlation of asthma prevalence with allergic rhino

sinusitis and atopic eczema and other allergies

 More prevalence in high level urban modern families than

suburban villagers

 More than 80%of asthmatics reported getting the disease

before 6 year

CLINICS
RECURRENT COUGHING/WHEEZING
PATTERNS IN CHILDHOOD BASED ON
NATURAL HISTORY

TRANSIENT EARLY WHEEZING
 Common in early preschool years

 Recurrent coughing/wheezing primary

triggered by common respiratory viral INF
 Tend to resolve during preschool yrs without
increasing risk of asthma later in life
 Problems due to reduced airflow at birth
suggestive of relative narrow airways improved
by school yrs

Persistent Atopy Associated Asthma
 Begins in early preschool yrs

 Associated with atopy (eg atopic dermatitis in





infancy, allergic rhinitis, food allergy)
Biologic factors e.g.: early inhalant sensitization,
increase serum IGE, increase blood eosinophills,
High risk of persistence into later childhood and
adulthood lung function abnormality
Those with onset<3 yrs
reduced air flow by
school yrs
Those with later onset of symptoms or allergen
sensitizations unlikely persistence lung function
abnormality later

Non-Atopic Wheezing
 Wheezing ,coughing beginning in early life

often with RSV INF resolves later in childhood
without increasing risk of persistence asthma

 Associated with bronchial hyper

responsiveness near birth

Asthma with declining lung function
• Children with asthma with progressive

increase in air flow limitation

• Associated with hyper inflation in childhood
• Male gender

Late onset asthma in females associated with
obesity and early onset puberty
 Onset between 8_13 yrs

 Associated with early onset puberty and obesity
 Specific for females

Occupational type asthma in children
 Children with asthma and occupational type exposure

known to trigger asthma in adults in occupational settings

Types of Asthma
common clinical presentations of intermittent
recurrent wheezing and/or coughing
 Recurrent wheezing in early childhood

 Chronic asthma associated with allergy
 Females 11 yrs with early onset puberty and

obesity

Pathogenesis

 Airflow obstruction resulting from

Broncho constriction of bronchiolar smooth
muscle mass
II. Cellular inflammatory infiltrates and exudates
mostly Eosinophills(also N , M ,L ,mast cells
,basophiles)fill and obstruct airways and damage
epithelium and induce desquamation into airway
lumen mediated by T helper cells and other
immune cells that produce pro allergic pro
inflammatory cytokines(IL4,IL6,IL13)
III. Breach in normal immune regulatory process
I.

RESULT
 Airway inflammation

 AHR
 Edema basement membrane thickness sub

epithelial collagen deposition
 Smooth muscle and mucus gland hypertrophy
and mucus hyper secretion

Air obstruction

Clinical manifestations and diagnosis
 Most common intermittent dry cough and

expiratory wheezing

 Shortness of breath and chest tightness in older

children and adults

 Intermittent non focal chest pain in younger

children

 Worsening of respiratory symptoms at night
 Worsening of day time symptoms by activity

Continue…..
 Subtle symptoms such as self limitation of activities

,general fatigue ,difficulty in keeping up with peers

 Relief with aerosolized bronchodilators
 Lack of improvement with bronchodilators and steroid

is inconsistent with Asthma and should consider
Asthma masquerading conditions!!!!

 Hyper ventilation, intercostal retractions ,nasal flaring

,respiratory accessory muscle use

 Its common not to hear the expiratory wheezing when

Air flow is so limited before treatment

Asthma Triggers
 Common viral infections of the respiratory tract
 Aero allergens in sensitized asthmatics ,animal dander ,dust











mite ,molds ,indoor allergens ,cockroaches
Seasonal aero allergens ,pollens(trees ,grasses ,weeds ,)
Environmental tobacco smoke
Air pollutants ,ozone ,so2,wood or coal smoke ,endotoxin
,mycotoxin ,dust
Strong or noxious odors or fumes ,perfume ,hair spray
,cleaning agents
Occupational exposure
Cold air ,dry air
Exercise
Crying ,laughter ,hyperventilation
Co morbid conditions Rhinitis ,Sinusitis ,GER

Clinics
History:
Triggering symptoms by laughter
,cold air ,airway irritants
Exposures that induce airway
irritation such as viral URTI
Mycoplasma ,Chlamydia
Inhaled allergens
All lead to AHR

Presence Of Risk Factors:
 History of other allergies ,allergic Rhinitis,

allergic Conjunctivitis ,atopic Dermatitis ,food
allergies

 Parental Asthma
 Symptoms apart from cold

Continue…..
 No or minimal signs in routine visits

 Dry or persistent cough

 Normal chest findings unless wheezing when asking

to breath deeper
 Quick relief (10 MIN) after SABA use
 Expiratory wheezing ,prolonged expiratory phase
,decreased sounds in RT lower pos lobe due to
regional hypoventilation owing to airway
obstruction
 Rales , ronchi ,crackles due to hyper secretion
 Segmental crackles and poor breath sounds
atelectasis?

Continue….
 Labored respiration ,respiratory distress increased

prolongation of expiration and wheezing in E and I

 Poor air entry
 Inter costal retractions ,nasal flaring ,supra and

infra sternal retractions

 And again in most sever forms expiratory wheezing

does not appear until some broncho dilation

DD

GERD Rhino sinusitis co morbid

conditions with asthma

Recurrent aspiration in early

life(tracheo broncho malacia
,TEF , foreign body ,CF ,BPD

VCD in older children and

adolescents

LAB FINDINGS
Pulmonary Function
Testing

Continue….
 Forced expiratory airflow measures helpful

in Diagnosis , assessing efficacy of therapy
and monitoring Asthma in children specially
in poor children who do not have PHE
unless obstruction is sever

 Valueablity of spirometric findings in children>6

yrs

 3 efforts the highest is the peak
 Reduced FEV

obstruction

FEV1/FVC <0.80 means significant

 Improvement in FEV1 following beta 2 agonist > =

12% or 200 ml is consistent with Asthma

 Peak flow meter

CXR

Often normal aside from subtle and

nonspecific findings of hyperinflation

Peribronchial thickening
Helping in diagnosis of Asthma

differentials

Diagnosis of complications of Asthma

exacerbations

Other tests such as allergy skin prick
testing

Treatment
 www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm

Asthma Treatment & Management
has 4 components :
Assessment and monitoring of disease
activity
2. Provision to educate pt and family
3. Identification and management of
precipitating factors and co morbid
conditions
4. Appropriate selection of medication
1.

 Attainment of optimal Asthma control

Component 1
 Asthma severity :intermittent
 Persistent: mild ,mod ,severe
 Only once during patient initial evaluation in pt

who is not using a daily controller agent
 Asthma control degree to which symptoms ,
on going functional impairments , risk of
adverse events minimized and goals of
therapy are met

Continue….
Well controlled
2. Not well controlled
3. Very poor controlled
1.

 NIH guidelines for both severity and

control for 3 age groups

0-4 yrs
2. 5-11 yrs
3. =>12 yrs
1.

Important
even in the absence of frequent symptoms
infants and children whom have risk factors
for asthma and 4 or more episodes of
wheezing over the past yr which lasted more
than 1 day or 2 or more exacerbations in
the last 6 months requiring syst
corticosteroids should be considered in the
persistent group and hence receive long term
controller therapy

Important Tips..
 Regular clinical visits every 2-6 weeks
 Assessment of :

Pt symptoms frequency night and day
2. Need for short acting inhaled b2 agonists for
quick relief
3. Ability to engage in normal activities
4. Air flow measures for>=5 yrs
1.

Continue..
 Component 2 : pt education

 Component 3 : control of factors contributing

to asthma severity
1. Environmental exposures
2. Co morbid conditions
 Component 4 :principals of asthma
pharmacotherapy

Asthma Medication
 SABA

 ICS

 LABA
 LTRA

 SYSTEMIC STEROIDS

 NONSTEROIDAL ANTIINFLAMMATORY

CROMOLYN AND NEDOCROMYL
 OXYGEN
 ANTICHOLINERGIC AGENTS
IPRATROPIUM
BROMIDE
 ANTIIMMUNOGLUBOLINE E

MANAGEMENT OF ASTHMA EXACERBATION(STATUS ASTHMATICUS)
RISK ASSESMENT ON ADMISSION

FOCUSED HISTORY

ONSET OF CURRENT EXACERBATION
FREQUENCY AND severity of daytime and night
time symptoms and activity limitation
Frequency of rescue bronchodilator use
Current medication and allergies
Potential triggers
History of systemic steroid courses, emergency
department visists , hospitalization, intubation or life
threatening episodes

Clinical assesment

Physical examination findings: vital signs,
breathlessness, air movement, use of accessory
respiratory muscles, retractions, anxiety level,
alteration in mental status
Pulse oximetry
Lung function(defer in pts with mod to severe
distress or history of labile disease)

Treatment
Drugs and trade name

Mechanism of action and dosing

Cautions and adverse effects

Oxygen(mask or nasal canula)
Inhaled short acting b2
agonist
Albuterol nebulized
solution(5mg/ml concentrates
Albuterol MDI
Levabuterol

Treats hypoxia
Bronchodilator
Neubolizer 0.15 mg/kg every 20 min for 3
doses as needed,then 0.15_0.3 mg/kg up t 10
mg every 1_4 hour as needed or up to 0.5
mg/kg/hr by continous neubolization
2_8 puf up to every 20 min for 3 doses as
needed then every 1 hr as needed

Monitor pulse oximetry to maintain o2 saturation>92%
Cardiorespiratory monitoring
During exacerbations,frequent or continuous use can cause
pulmonary vasodilatation,v/q mistmatch and hypoxemia
Adverse effect palpitation, tachycardia, arrhythmia, tremor,
hypoxemia
Neubolizer:when giving concentrate forms,dilute with saline to 3
ml total neubolized volume
For MDI use space/holding chamber

Systemic corticosteroids
Prednisolone tb
Methyl prednisolon
Anticholinergics
Ipratropium
Atrovent
Ipratropium with Albuterol

Anti inflammatory
0.5_1 mg/kg every 6-8 hr for 48 hr , then 1-2 mg/kg
day bid(max 60 mg/day)
Short course burst for exacerbation 1-2 mg/kg/day qd
or bid for 3-7 days
Mucolitic/bronchodilator
Neubolizer 0.5 mg q6-8 hr (tid or qid) as needed
MDI 2 paf qid
1 vial by neubolizer qid



If pt has been exposed chickenpox or measles, consider passive
immunoglobulin prophylaxis, also risk of complications with
herspes simplex and TB

For daily dosing , 8 am administration minimizes adrenal
suppression

Children may benefit from dosage tapering if course exceed 7 days

Adverse effect monitoring: frequent therapy bursts risk numerous
corticosteroid adverse effects

Should not be used as first line treatment added to b2 agonist
therapy
Neubolizer may mix Ipratropium with Albuterol

QUICK RELIEF MEDICATION
SABA

Anti cholinergic(ipratropium)
Short term systemic gluco

corticoid

SABA
 Quick relief of asthma symptoms
 Relax airway smooth muscle prompt airflow↑
 Repetitive or continuous SABA is the most effective means







of reversing air flow obstruction
SABA should not be prescribed on a regular schedule
because concerns of possibility of deteriorating asthma
control
Frequent use of SABA is an indication of poor asthma control
Preferred root is inhalation smaller dose , fewer side effects
more rapid on set of action
Ipratropium Bromide as an adjunct to SABA in emergency
room reduces hospital admissions and improves lung function
Systemic Glucocorticoids short oral course + SABA in
moderate to severe asthma exacerbation

LABA
 Salmetrol

 Should be used in combination with inhaled

corticosteroids and not as mono therapy
 Exercise induces asthma in children >= 4 Yrs
one inhalation 30 min prior to exercise
 No additional doses for PTs who are already
receiving it twice daily not recommended by
NIH guidelines

LTRA

 MonteLukast ( singulair)

 Antihistaminic

 Leukotrien receptor antagonist

 Asthma ( not < 12 MO) and allergic rhinitis (





not < 6 MO)
Morning dosing not evaluated
Prophylactic and chronic treatment of asthma
Exercise induced asthma in >= 15 Yrs
Zafir Lukast : prophylactic and chronic
treatment of asthma

ICA
 Most potent anti inflammatory agents available

for the treatment of asthma
 Inhibiting most steps in the cascade of the
inflammatory response
 Benefits reducing bronchial hyper
responsiveness , prevention of late asthmatic
response , enhanced lung function
 Inhaled Glucocorticoids first line controller
therapy for persistent asthma or those who
require step 2

Prognosis
 35%of preschool children experience recurrent

coughing and wheezing,1/3 of them continue to
have persistent asthma into later childhood and
2/3 improvement on their own through their teen
yrs
 Asthma severity by age 7-10 yrs is predictive of
asthma persistence into adulthood
 Children with mod to severe asthma and lower lung
function are likely to have persistent asthma as
adults
 Children with milder asthma and N/R lung function
are likely to improve over time or be periodically
asthmatic

THANK YOU FOR YOUR
ATTENTION


Slide 53

Asthma in Children
DR. A.Mirshokraei
NIOC Hospital Pediatrics Ward

Definition :

DEFINITION

- Chronic inflammatory condition of the
lung airways resulting in episodic airflow
obstruction
- AHR to provocative exposures
Asthma management
• Reducing airway inflammation by: Minimizing
pro inflammatory environmental exposure, using
daily controller anti inflammatory medication,
controlling co morbid conditions that worsen
asthma, less inflammation better asthma
control and fewer exacerbations

Anyway exacerbations

occur

BUT
Even the uncommon
child with sever asthma can
be managed to live normally

 RECURRENT WHEEZING EPISODES WITH COMMON

RESPIRATORY
VIRUSES(RSV,RHINOVIRUS,INFLUENZA,PARAINFLUENZA,A
DENOVIRUS,HUMAN METAPNUMOVIRUS)

 HOST FEATURES AFFECTING IMMUNOLOGIC HOST

DEFENSE,INFLAMMATION/PREVIOUS VIRAL INFECTIONS
MAINIFESTED AS PNUMONIA OR BRONCHIOLITIS
REQUIRING HOSPITALIZATION UNDERLIE THE
RECURRENT WHEEZING IN EARLY CHILDHOOD

 OTHER AIRWAY EXPOSURES SUCH AS INDOOR AND HOME

ALLERGENS,COLD AIR,STRONG ODORS,TOBACCO
SMOKE,ALL INCREASE AHR

 ALLERGEN ELLIMINATION SOMETIMES LEEDS TO CURE

EPIDEMIOLOGY
 Common etiology of emergency visits and school day missing

in childhood ,occasionally hospitalization and rare deaths
specially in poverty ,urban living ,ethnic minorities

 Increasing asthma prevalence worldwide(50% per decade)
 Good correlation of asthma prevalence with allergic rhino

sinusitis and atopic eczema and other allergies

 More prevalence in high level urban modern families than

suburban villagers

 More than 80%of asthmatics reported getting the disease

before 6 year

CLINICS
RECURRENT COUGHING/WHEEZING
PATTERNS IN CHILDHOOD BASED ON
NATURAL HISTORY

TRANSIENT EARLY WHEEZING
 Common in early preschool years

 Recurrent coughing/wheezing primary

triggered by common respiratory viral INF
 Tend to resolve during preschool yrs without
increasing risk of asthma later in life
 Problems due to reduced airflow at birth
suggestive of relative narrow airways improved
by school yrs

Persistent Atopy Associated Asthma
 Begins in early preschool yrs

 Associated with atopy (eg atopic dermatitis in





infancy, allergic rhinitis, food allergy)
Biologic factors e.g.: early inhalant sensitization,
increase serum IGE, increase blood eosinophills,
High risk of persistence into later childhood and
adulthood lung function abnormality
Those with onset<3 yrs
reduced air flow by
school yrs
Those with later onset of symptoms or allergen
sensitizations unlikely persistence lung function
abnormality later

Non-Atopic Wheezing
 Wheezing ,coughing beginning in early life

often with RSV INF resolves later in childhood
without increasing risk of persistence asthma

 Associated with bronchial hyper

responsiveness near birth

Asthma with declining lung function
• Children with asthma with progressive

increase in air flow limitation

• Associated with hyper inflation in childhood
• Male gender

Late onset asthma in females associated with
obesity and early onset puberty
 Onset between 8_13 yrs

 Associated with early onset puberty and obesity
 Specific for females

Occupational type asthma in children
 Children with asthma and occupational type exposure

known to trigger asthma in adults in occupational settings

Types of Asthma
common clinical presentations of intermittent
recurrent wheezing and/or coughing
 Recurrent wheezing in early childhood

 Chronic asthma associated with allergy
 Females 11 yrs with early onset puberty and

obesity

Pathogenesis

 Airflow obstruction resulting from

Broncho constriction of bronchiolar smooth
muscle mass
II. Cellular inflammatory infiltrates and exudates
mostly Eosinophills(also N , M ,L ,mast cells
,basophiles)fill and obstruct airways and damage
epithelium and induce desquamation into airway
lumen mediated by T helper cells and other
immune cells that produce pro allergic pro
inflammatory cytokines(IL4,IL6,IL13)
III. Breach in normal immune regulatory process
I.

RESULT
 Airway inflammation

 AHR
 Edema basement membrane thickness sub

epithelial collagen deposition
 Smooth muscle and mucus gland hypertrophy
and mucus hyper secretion

Air obstruction

Clinical manifestations and diagnosis
 Most common intermittent dry cough and

expiratory wheezing

 Shortness of breath and chest tightness in older

children and adults

 Intermittent non focal chest pain in younger

children

 Worsening of respiratory symptoms at night
 Worsening of day time symptoms by activity

Continue…..
 Subtle symptoms such as self limitation of activities

,general fatigue ,difficulty in keeping up with peers

 Relief with aerosolized bronchodilators
 Lack of improvement with bronchodilators and steroid

is inconsistent with Asthma and should consider
Asthma masquerading conditions!!!!

 Hyper ventilation, intercostal retractions ,nasal flaring

,respiratory accessory muscle use

 Its common not to hear the expiratory wheezing when

Air flow is so limited before treatment

Asthma Triggers
 Common viral infections of the respiratory tract
 Aero allergens in sensitized asthmatics ,animal dander ,dust











mite ,molds ,indoor allergens ,cockroaches
Seasonal aero allergens ,pollens(trees ,grasses ,weeds ,)
Environmental tobacco smoke
Air pollutants ,ozone ,so2,wood or coal smoke ,endotoxin
,mycotoxin ,dust
Strong or noxious odors or fumes ,perfume ,hair spray
,cleaning agents
Occupational exposure
Cold air ,dry air
Exercise
Crying ,laughter ,hyperventilation
Co morbid conditions Rhinitis ,Sinusitis ,GER

Clinics
History:
Triggering symptoms by laughter
,cold air ,airway irritants
Exposures that induce airway
irritation such as viral URTI
Mycoplasma ,Chlamydia
Inhaled allergens
All lead to AHR

Presence Of Risk Factors:
 History of other allergies ,allergic Rhinitis,

allergic Conjunctivitis ,atopic Dermatitis ,food
allergies

 Parental Asthma
 Symptoms apart from cold

Continue…..
 No or minimal signs in routine visits

 Dry or persistent cough

 Normal chest findings unless wheezing when asking

to breath deeper
 Quick relief (10 MIN) after SABA use
 Expiratory wheezing ,prolonged expiratory phase
,decreased sounds in RT lower pos lobe due to
regional hypoventilation owing to airway
obstruction
 Rales , ronchi ,crackles due to hyper secretion
 Segmental crackles and poor breath sounds
atelectasis?

Continue….
 Labored respiration ,respiratory distress increased

prolongation of expiration and wheezing in E and I

 Poor air entry
 Inter costal retractions ,nasal flaring ,supra and

infra sternal retractions

 And again in most sever forms expiratory wheezing

does not appear until some broncho dilation

DD

GERD Rhino sinusitis co morbid

conditions with asthma

Recurrent aspiration in early

life(tracheo broncho malacia
,TEF , foreign body ,CF ,BPD

VCD in older children and

adolescents

LAB FINDINGS
Pulmonary Function
Testing

Continue….
 Forced expiratory airflow measures helpful

in Diagnosis , assessing efficacy of therapy
and monitoring Asthma in children specially
in poor children who do not have PHE
unless obstruction is sever

 Valueablity of spirometric findings in children>6

yrs

 3 efforts the highest is the peak
 Reduced FEV

obstruction

FEV1/FVC <0.80 means significant

 Improvement in FEV1 following beta 2 agonist > =

12% or 200 ml is consistent with Asthma

 Peak flow meter

CXR

Often normal aside from subtle and

nonspecific findings of hyperinflation

Peribronchial thickening
Helping in diagnosis of Asthma

differentials

Diagnosis of complications of Asthma

exacerbations

Other tests such as allergy skin prick
testing

Treatment
 www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm

Asthma Treatment & Management
has 4 components :
Assessment and monitoring of disease
activity
2. Provision to educate pt and family
3. Identification and management of
precipitating factors and co morbid
conditions
4. Appropriate selection of medication
1.

 Attainment of optimal Asthma control

Component 1
 Asthma severity :intermittent
 Persistent: mild ,mod ,severe
 Only once during patient initial evaluation in pt

who is not using a daily controller agent
 Asthma control degree to which symptoms ,
on going functional impairments , risk of
adverse events minimized and goals of
therapy are met

Continue….
Well controlled
2. Not well controlled
3. Very poor controlled
1.

 NIH guidelines for both severity and

control for 3 age groups

0-4 yrs
2. 5-11 yrs
3. =>12 yrs
1.

Important
even in the absence of frequent symptoms
infants and children whom have risk factors
for asthma and 4 or more episodes of
wheezing over the past yr which lasted more
than 1 day or 2 or more exacerbations in
the last 6 months requiring syst
corticosteroids should be considered in the
persistent group and hence receive long term
controller therapy

Important Tips..
 Regular clinical visits every 2-6 weeks
 Assessment of :

Pt symptoms frequency night and day
2. Need for short acting inhaled b2 agonists for
quick relief
3. Ability to engage in normal activities
4. Air flow measures for>=5 yrs
1.

Continue..
 Component 2 : pt education

 Component 3 : control of factors contributing

to asthma severity
1. Environmental exposures
2. Co morbid conditions
 Component 4 :principals of asthma
pharmacotherapy

Asthma Medication
 SABA

 ICS

 LABA
 LTRA

 SYSTEMIC STEROIDS

 NONSTEROIDAL ANTIINFLAMMATORY

CROMOLYN AND NEDOCROMYL
 OXYGEN
 ANTICHOLINERGIC AGENTS
IPRATROPIUM
BROMIDE
 ANTIIMMUNOGLUBOLINE E

MANAGEMENT OF ASTHMA EXACERBATION(STATUS ASTHMATICUS)
RISK ASSESMENT ON ADMISSION

FOCUSED HISTORY

ONSET OF CURRENT EXACERBATION
FREQUENCY AND severity of daytime and night
time symptoms and activity limitation
Frequency of rescue bronchodilator use
Current medication and allergies
Potential triggers
History of systemic steroid courses, emergency
department visists , hospitalization, intubation or life
threatening episodes

Clinical assesment

Physical examination findings: vital signs,
breathlessness, air movement, use of accessory
respiratory muscles, retractions, anxiety level,
alteration in mental status
Pulse oximetry
Lung function(defer in pts with mod to severe
distress or history of labile disease)

Treatment
Drugs and trade name

Mechanism of action and dosing

Cautions and adverse effects

Oxygen(mask or nasal canula)
Inhaled short acting b2
agonist
Albuterol nebulized
solution(5mg/ml concentrates
Albuterol MDI
Levabuterol

Treats hypoxia
Bronchodilator
Neubolizer 0.15 mg/kg every 20 min for 3
doses as needed,then 0.15_0.3 mg/kg up t 10
mg every 1_4 hour as needed or up to 0.5
mg/kg/hr by continous neubolization
2_8 puf up to every 20 min for 3 doses as
needed then every 1 hr as needed

Monitor pulse oximetry to maintain o2 saturation>92%
Cardiorespiratory monitoring
During exacerbations,frequent or continuous use can cause
pulmonary vasodilatation,v/q mistmatch and hypoxemia
Adverse effect palpitation, tachycardia, arrhythmia, tremor,
hypoxemia
Neubolizer:when giving concentrate forms,dilute with saline to 3
ml total neubolized volume
For MDI use space/holding chamber

Systemic corticosteroids
Prednisolone tb
Methyl prednisolon
Anticholinergics
Ipratropium
Atrovent
Ipratropium with Albuterol

Anti inflammatory
0.5_1 mg/kg every 6-8 hr for 48 hr , then 1-2 mg/kg
day bid(max 60 mg/day)
Short course burst for exacerbation 1-2 mg/kg/day qd
or bid for 3-7 days
Mucolitic/bronchodilator
Neubolizer 0.5 mg q6-8 hr (tid or qid) as needed
MDI 2 paf qid
1 vial by neubolizer qid



If pt has been exposed chickenpox or measles, consider passive
immunoglobulin prophylaxis, also risk of complications with
herspes simplex and TB

For daily dosing , 8 am administration minimizes adrenal
suppression

Children may benefit from dosage tapering if course exceed 7 days

Adverse effect monitoring: frequent therapy bursts risk numerous
corticosteroid adverse effects

Should not be used as first line treatment added to b2 agonist
therapy
Neubolizer may mix Ipratropium with Albuterol

QUICK RELIEF MEDICATION
SABA

Anti cholinergic(ipratropium)
Short term systemic gluco

corticoid

SABA
 Quick relief of asthma symptoms
 Relax airway smooth muscle prompt airflow↑
 Repetitive or continuous SABA is the most effective means







of reversing air flow obstruction
SABA should not be prescribed on a regular schedule
because concerns of possibility of deteriorating asthma
control
Frequent use of SABA is an indication of poor asthma control
Preferred root is inhalation smaller dose , fewer side effects
more rapid on set of action
Ipratropium Bromide as an adjunct to SABA in emergency
room reduces hospital admissions and improves lung function
Systemic Glucocorticoids short oral course + SABA in
moderate to severe asthma exacerbation

LABA
 Salmetrol

 Should be used in combination with inhaled

corticosteroids and not as mono therapy
 Exercise induces asthma in children >= 4 Yrs
one inhalation 30 min prior to exercise
 No additional doses for PTs who are already
receiving it twice daily not recommended by
NIH guidelines

LTRA

 MonteLukast ( singulair)

 Antihistaminic

 Leukotrien receptor antagonist

 Asthma ( not < 12 MO) and allergic rhinitis (





not < 6 MO)
Morning dosing not evaluated
Prophylactic and chronic treatment of asthma
Exercise induced asthma in >= 15 Yrs
Zafir Lukast : prophylactic and chronic
treatment of asthma

ICA
 Most potent anti inflammatory agents available

for the treatment of asthma
 Inhibiting most steps in the cascade of the
inflammatory response
 Benefits reducing bronchial hyper
responsiveness , prevention of late asthmatic
response , enhanced lung function
 Inhaled Glucocorticoids first line controller
therapy for persistent asthma or those who
require step 2

Prognosis
 35%of preschool children experience recurrent

coughing and wheezing,1/3 of them continue to
have persistent asthma into later childhood and
2/3 improvement on their own through their teen
yrs
 Asthma severity by age 7-10 yrs is predictive of
asthma persistence into adulthood
 Children with mod to severe asthma and lower lung
function are likely to have persistent asthma as
adults
 Children with milder asthma and N/R lung function
are likely to improve over time or be periodically
asthmatic

THANK YOU FOR YOUR
ATTENTION


Slide 54

Asthma in Children
DR. A.Mirshokraei
NIOC Hospital Pediatrics Ward

Definition :

DEFINITION

- Chronic inflammatory condition of the
lung airways resulting in episodic airflow
obstruction
- AHR to provocative exposures
Asthma management
• Reducing airway inflammation by: Minimizing
pro inflammatory environmental exposure, using
daily controller anti inflammatory medication,
controlling co morbid conditions that worsen
asthma, less inflammation better asthma
control and fewer exacerbations

Anyway exacerbations

occur

BUT
Even the uncommon
child with sever asthma can
be managed to live normally

 RECURRENT WHEEZING EPISODES WITH COMMON

RESPIRATORY
VIRUSES(RSV,RHINOVIRUS,INFLUENZA,PARAINFLUENZA,A
DENOVIRUS,HUMAN METAPNUMOVIRUS)

 HOST FEATURES AFFECTING IMMUNOLOGIC HOST

DEFENSE,INFLAMMATION/PREVIOUS VIRAL INFECTIONS
MAINIFESTED AS PNUMONIA OR BRONCHIOLITIS
REQUIRING HOSPITALIZATION UNDERLIE THE
RECURRENT WHEEZING IN EARLY CHILDHOOD

 OTHER AIRWAY EXPOSURES SUCH AS INDOOR AND HOME

ALLERGENS,COLD AIR,STRONG ODORS,TOBACCO
SMOKE,ALL INCREASE AHR

 ALLERGEN ELLIMINATION SOMETIMES LEEDS TO CURE

EPIDEMIOLOGY
 Common etiology of emergency visits and school day missing

in childhood ,occasionally hospitalization and rare deaths
specially in poverty ,urban living ,ethnic minorities

 Increasing asthma prevalence worldwide(50% per decade)
 Good correlation of asthma prevalence with allergic rhino

sinusitis and atopic eczema and other allergies

 More prevalence in high level urban modern families than

suburban villagers

 More than 80%of asthmatics reported getting the disease

before 6 year

CLINICS
RECURRENT COUGHING/WHEEZING
PATTERNS IN CHILDHOOD BASED ON
NATURAL HISTORY

TRANSIENT EARLY WHEEZING
 Common in early preschool years

 Recurrent coughing/wheezing primary

triggered by common respiratory viral INF
 Tend to resolve during preschool yrs without
increasing risk of asthma later in life
 Problems due to reduced airflow at birth
suggestive of relative narrow airways improved
by school yrs

Persistent Atopy Associated Asthma
 Begins in early preschool yrs

 Associated with atopy (eg atopic dermatitis in





infancy, allergic rhinitis, food allergy)
Biologic factors e.g.: early inhalant sensitization,
increase serum IGE, increase blood eosinophills,
High risk of persistence into later childhood and
adulthood lung function abnormality
Those with onset<3 yrs
reduced air flow by
school yrs
Those with later onset of symptoms or allergen
sensitizations unlikely persistence lung function
abnormality later

Non-Atopic Wheezing
 Wheezing ,coughing beginning in early life

often with RSV INF resolves later in childhood
without increasing risk of persistence asthma

 Associated with bronchial hyper

responsiveness near birth

Asthma with declining lung function
• Children with asthma with progressive

increase in air flow limitation

• Associated with hyper inflation in childhood
• Male gender

Late onset asthma in females associated with
obesity and early onset puberty
 Onset between 8_13 yrs

 Associated with early onset puberty and obesity
 Specific for females

Occupational type asthma in children
 Children with asthma and occupational type exposure

known to trigger asthma in adults in occupational settings

Types of Asthma
common clinical presentations of intermittent
recurrent wheezing and/or coughing
 Recurrent wheezing in early childhood

 Chronic asthma associated with allergy
 Females 11 yrs with early onset puberty and

obesity

Pathogenesis

 Airflow obstruction resulting from

Broncho constriction of bronchiolar smooth
muscle mass
II. Cellular inflammatory infiltrates and exudates
mostly Eosinophills(also N , M ,L ,mast cells
,basophiles)fill and obstruct airways and damage
epithelium and induce desquamation into airway
lumen mediated by T helper cells and other
immune cells that produce pro allergic pro
inflammatory cytokines(IL4,IL6,IL13)
III. Breach in normal immune regulatory process
I.

RESULT
 Airway inflammation

 AHR
 Edema basement membrane thickness sub

epithelial collagen deposition
 Smooth muscle and mucus gland hypertrophy
and mucus hyper secretion

Air obstruction

Clinical manifestations and diagnosis
 Most common intermittent dry cough and

expiratory wheezing

 Shortness of breath and chest tightness in older

children and adults

 Intermittent non focal chest pain in younger

children

 Worsening of respiratory symptoms at night
 Worsening of day time symptoms by activity

Continue…..
 Subtle symptoms such as self limitation of activities

,general fatigue ,difficulty in keeping up with peers

 Relief with aerosolized bronchodilators
 Lack of improvement with bronchodilators and steroid

is inconsistent with Asthma and should consider
Asthma masquerading conditions!!!!

 Hyper ventilation, intercostal retractions ,nasal flaring

,respiratory accessory muscle use

 Its common not to hear the expiratory wheezing when

Air flow is so limited before treatment

Asthma Triggers
 Common viral infections of the respiratory tract
 Aero allergens in sensitized asthmatics ,animal dander ,dust











mite ,molds ,indoor allergens ,cockroaches
Seasonal aero allergens ,pollens(trees ,grasses ,weeds ,)
Environmental tobacco smoke
Air pollutants ,ozone ,so2,wood or coal smoke ,endotoxin
,mycotoxin ,dust
Strong or noxious odors or fumes ,perfume ,hair spray
,cleaning agents
Occupational exposure
Cold air ,dry air
Exercise
Crying ,laughter ,hyperventilation
Co morbid conditions Rhinitis ,Sinusitis ,GER

Clinics
History:
Triggering symptoms by laughter
,cold air ,airway irritants
Exposures that induce airway
irritation such as viral URTI
Mycoplasma ,Chlamydia
Inhaled allergens
All lead to AHR

Presence Of Risk Factors:
 History of other allergies ,allergic Rhinitis,

allergic Conjunctivitis ,atopic Dermatitis ,food
allergies

 Parental Asthma
 Symptoms apart from cold

Continue…..
 No or minimal signs in routine visits

 Dry or persistent cough

 Normal chest findings unless wheezing when asking

to breath deeper
 Quick relief (10 MIN) after SABA use
 Expiratory wheezing ,prolonged expiratory phase
,decreased sounds in RT lower pos lobe due to
regional hypoventilation owing to airway
obstruction
 Rales , ronchi ,crackles due to hyper secretion
 Segmental crackles and poor breath sounds
atelectasis?

Continue….
 Labored respiration ,respiratory distress increased

prolongation of expiration and wheezing in E and I

 Poor air entry
 Inter costal retractions ,nasal flaring ,supra and

infra sternal retractions

 And again in most sever forms expiratory wheezing

does not appear until some broncho dilation

DD

GERD Rhino sinusitis co morbid

conditions with asthma

Recurrent aspiration in early

life(tracheo broncho malacia
,TEF , foreign body ,CF ,BPD

VCD in older children and

adolescents

LAB FINDINGS
Pulmonary Function
Testing

Continue….
 Forced expiratory airflow measures helpful

in Diagnosis , assessing efficacy of therapy
and monitoring Asthma in children specially
in poor children who do not have PHE
unless obstruction is sever

 Valueablity of spirometric findings in children>6

yrs

 3 efforts the highest is the peak
 Reduced FEV

obstruction

FEV1/FVC <0.80 means significant

 Improvement in FEV1 following beta 2 agonist > =

12% or 200 ml is consistent with Asthma

 Peak flow meter

CXR

Often normal aside from subtle and

nonspecific findings of hyperinflation

Peribronchial thickening
Helping in diagnosis of Asthma

differentials

Diagnosis of complications of Asthma

exacerbations

Other tests such as allergy skin prick
testing

Treatment
 www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm

Asthma Treatment & Management
has 4 components :
Assessment and monitoring of disease
activity
2. Provision to educate pt and family
3. Identification and management of
precipitating factors and co morbid
conditions
4. Appropriate selection of medication
1.

 Attainment of optimal Asthma control

Component 1
 Asthma severity :intermittent
 Persistent: mild ,mod ,severe
 Only once during patient initial evaluation in pt

who is not using a daily controller agent
 Asthma control degree to which symptoms ,
on going functional impairments , risk of
adverse events minimized and goals of
therapy are met

Continue….
Well controlled
2. Not well controlled
3. Very poor controlled
1.

 NIH guidelines for both severity and

control for 3 age groups

0-4 yrs
2. 5-11 yrs
3. =>12 yrs
1.

Important
even in the absence of frequent symptoms
infants and children whom have risk factors
for asthma and 4 or more episodes of
wheezing over the past yr which lasted more
than 1 day or 2 or more exacerbations in
the last 6 months requiring syst
corticosteroids should be considered in the
persistent group and hence receive long term
controller therapy

Important Tips..
 Regular clinical visits every 2-6 weeks
 Assessment of :

Pt symptoms frequency night and day
2. Need for short acting inhaled b2 agonists for
quick relief
3. Ability to engage in normal activities
4. Air flow measures for>=5 yrs
1.

Continue..
 Component 2 : pt education

 Component 3 : control of factors contributing

to asthma severity
1. Environmental exposures
2. Co morbid conditions
 Component 4 :principals of asthma
pharmacotherapy

Asthma Medication
 SABA

 ICS

 LABA
 LTRA

 SYSTEMIC STEROIDS

 NONSTEROIDAL ANTIINFLAMMATORY

CROMOLYN AND NEDOCROMYL
 OXYGEN
 ANTICHOLINERGIC AGENTS
IPRATROPIUM
BROMIDE
 ANTIIMMUNOGLUBOLINE E

MANAGEMENT OF ASTHMA EXACERBATION(STATUS ASTHMATICUS)
RISK ASSESMENT ON ADMISSION

FOCUSED HISTORY

ONSET OF CURRENT EXACERBATION
FREQUENCY AND severity of daytime and night
time symptoms and activity limitation
Frequency of rescue bronchodilator use
Current medication and allergies
Potential triggers
History of systemic steroid courses, emergency
department visists , hospitalization, intubation or life
threatening episodes

Clinical assesment

Physical examination findings: vital signs,
breathlessness, air movement, use of accessory
respiratory muscles, retractions, anxiety level,
alteration in mental status
Pulse oximetry
Lung function(defer in pts with mod to severe
distress or history of labile disease)

Treatment
Drugs and trade name

Mechanism of action and dosing

Cautions and adverse effects

Oxygen(mask or nasal canula)
Inhaled short acting b2
agonist
Albuterol nebulized
solution(5mg/ml concentrates
Albuterol MDI
Levabuterol

Treats hypoxia
Bronchodilator
Neubolizer 0.15 mg/kg every 20 min for 3
doses as needed,then 0.15_0.3 mg/kg up t 10
mg every 1_4 hour as needed or up to 0.5
mg/kg/hr by continous neubolization
2_8 puf up to every 20 min for 3 doses as
needed then every 1 hr as needed

Monitor pulse oximetry to maintain o2 saturation>92%
Cardiorespiratory monitoring
During exacerbations,frequent or continuous use can cause
pulmonary vasodilatation,v/q mistmatch and hypoxemia
Adverse effect palpitation, tachycardia, arrhythmia, tremor,
hypoxemia
Neubolizer:when giving concentrate forms,dilute with saline to 3
ml total neubolized volume
For MDI use space/holding chamber

Systemic corticosteroids
Prednisolone tb
Methyl prednisolon
Anticholinergics
Ipratropium
Atrovent
Ipratropium with Albuterol

Anti inflammatory
0.5_1 mg/kg every 6-8 hr for 48 hr , then 1-2 mg/kg
day bid(max 60 mg/day)
Short course burst for exacerbation 1-2 mg/kg/day qd
or bid for 3-7 days
Mucolitic/bronchodilator
Neubolizer 0.5 mg q6-8 hr (tid or qid) as needed
MDI 2 paf qid
1 vial by neubolizer qid



If pt has been exposed chickenpox or measles, consider passive
immunoglobulin prophylaxis, also risk of complications with
herspes simplex and TB

For daily dosing , 8 am administration minimizes adrenal
suppression

Children may benefit from dosage tapering if course exceed 7 days

Adverse effect monitoring: frequent therapy bursts risk numerous
corticosteroid adverse effects

Should not be used as first line treatment added to b2 agonist
therapy
Neubolizer may mix Ipratropium with Albuterol

QUICK RELIEF MEDICATION
SABA

Anti cholinergic(ipratropium)
Short term systemic gluco

corticoid

SABA
 Quick relief of asthma symptoms
 Relax airway smooth muscle prompt airflow↑
 Repetitive or continuous SABA is the most effective means







of reversing air flow obstruction
SABA should not be prescribed on a regular schedule
because concerns of possibility of deteriorating asthma
control
Frequent use of SABA is an indication of poor asthma control
Preferred root is inhalation smaller dose , fewer side effects
more rapid on set of action
Ipratropium Bromide as an adjunct to SABA in emergency
room reduces hospital admissions and improves lung function
Systemic Glucocorticoids short oral course + SABA in
moderate to severe asthma exacerbation

LABA
 Salmetrol

 Should be used in combination with inhaled

corticosteroids and not as mono therapy
 Exercise induces asthma in children >= 4 Yrs
one inhalation 30 min prior to exercise
 No additional doses for PTs who are already
receiving it twice daily not recommended by
NIH guidelines

LTRA

 MonteLukast ( singulair)

 Antihistaminic

 Leukotrien receptor antagonist

 Asthma ( not < 12 MO) and allergic rhinitis (





not < 6 MO)
Morning dosing not evaluated
Prophylactic and chronic treatment of asthma
Exercise induced asthma in >= 15 Yrs
Zafir Lukast : prophylactic and chronic
treatment of asthma

ICA
 Most potent anti inflammatory agents available

for the treatment of asthma
 Inhibiting most steps in the cascade of the
inflammatory response
 Benefits reducing bronchial hyper
responsiveness , prevention of late asthmatic
response , enhanced lung function
 Inhaled Glucocorticoids first line controller
therapy for persistent asthma or those who
require step 2

Prognosis
 35%of preschool children experience recurrent

coughing and wheezing,1/3 of them continue to
have persistent asthma into later childhood and
2/3 improvement on their own through their teen
yrs
 Asthma severity by age 7-10 yrs is predictive of
asthma persistence into adulthood
 Children with mod to severe asthma and lower lung
function are likely to have persistent asthma as
adults
 Children with milder asthma and N/R lung function
are likely to improve over time or be periodically
asthmatic

THANK YOU FOR YOUR
ATTENTION


Slide 55

Asthma in Children
DR. A.Mirshokraei
NIOC Hospital Pediatrics Ward

Definition :

DEFINITION

- Chronic inflammatory condition of the
lung airways resulting in episodic airflow
obstruction
- AHR to provocative exposures
Asthma management
• Reducing airway inflammation by: Minimizing
pro inflammatory environmental exposure, using
daily controller anti inflammatory medication,
controlling co morbid conditions that worsen
asthma, less inflammation better asthma
control and fewer exacerbations

Anyway exacerbations

occur

BUT
Even the uncommon
child with sever asthma can
be managed to live normally

 RECURRENT WHEEZING EPISODES WITH COMMON

RESPIRATORY
VIRUSES(RSV,RHINOVIRUS,INFLUENZA,PARAINFLUENZA,A
DENOVIRUS,HUMAN METAPNUMOVIRUS)

 HOST FEATURES AFFECTING IMMUNOLOGIC HOST

DEFENSE,INFLAMMATION/PREVIOUS VIRAL INFECTIONS
MAINIFESTED AS PNUMONIA OR BRONCHIOLITIS
REQUIRING HOSPITALIZATION UNDERLIE THE
RECURRENT WHEEZING IN EARLY CHILDHOOD

 OTHER AIRWAY EXPOSURES SUCH AS INDOOR AND HOME

ALLERGENS,COLD AIR,STRONG ODORS,TOBACCO
SMOKE,ALL INCREASE AHR

 ALLERGEN ELLIMINATION SOMETIMES LEEDS TO CURE

EPIDEMIOLOGY
 Common etiology of emergency visits and school day missing

in childhood ,occasionally hospitalization and rare deaths
specially in poverty ,urban living ,ethnic minorities

 Increasing asthma prevalence worldwide(50% per decade)
 Good correlation of asthma prevalence with allergic rhino

sinusitis and atopic eczema and other allergies

 More prevalence in high level urban modern families than

suburban villagers

 More than 80%of asthmatics reported getting the disease

before 6 year

CLINICS
RECURRENT COUGHING/WHEEZING
PATTERNS IN CHILDHOOD BASED ON
NATURAL HISTORY

TRANSIENT EARLY WHEEZING
 Common in early preschool years

 Recurrent coughing/wheezing primary

triggered by common respiratory viral INF
 Tend to resolve during preschool yrs without
increasing risk of asthma later in life
 Problems due to reduced airflow at birth
suggestive of relative narrow airways improved
by school yrs

Persistent Atopy Associated Asthma
 Begins in early preschool yrs

 Associated with atopy (eg atopic dermatitis in





infancy, allergic rhinitis, food allergy)
Biologic factors e.g.: early inhalant sensitization,
increase serum IGE, increase blood eosinophills,
High risk of persistence into later childhood and
adulthood lung function abnormality
Those with onset<3 yrs
reduced air flow by
school yrs
Those with later onset of symptoms or allergen
sensitizations unlikely persistence lung function
abnormality later

Non-Atopic Wheezing
 Wheezing ,coughing beginning in early life

often with RSV INF resolves later in childhood
without increasing risk of persistence asthma

 Associated with bronchial hyper

responsiveness near birth

Asthma with declining lung function
• Children with asthma with progressive

increase in air flow limitation

• Associated with hyper inflation in childhood
• Male gender

Late onset asthma in females associated with
obesity and early onset puberty
 Onset between 8_13 yrs

 Associated with early onset puberty and obesity
 Specific for females

Occupational type asthma in children
 Children with asthma and occupational type exposure

known to trigger asthma in adults in occupational settings

Types of Asthma
common clinical presentations of intermittent
recurrent wheezing and/or coughing
 Recurrent wheezing in early childhood

 Chronic asthma associated with allergy
 Females 11 yrs with early onset puberty and

obesity

Pathogenesis

 Airflow obstruction resulting from

Broncho constriction of bronchiolar smooth
muscle mass
II. Cellular inflammatory infiltrates and exudates
mostly Eosinophills(also N , M ,L ,mast cells
,basophiles)fill and obstruct airways and damage
epithelium and induce desquamation into airway
lumen mediated by T helper cells and other
immune cells that produce pro allergic pro
inflammatory cytokines(IL4,IL6,IL13)
III. Breach in normal immune regulatory process
I.

RESULT
 Airway inflammation

 AHR
 Edema basement membrane thickness sub

epithelial collagen deposition
 Smooth muscle and mucus gland hypertrophy
and mucus hyper secretion

Air obstruction

Clinical manifestations and diagnosis
 Most common intermittent dry cough and

expiratory wheezing

 Shortness of breath and chest tightness in older

children and adults

 Intermittent non focal chest pain in younger

children

 Worsening of respiratory symptoms at night
 Worsening of day time symptoms by activity

Continue…..
 Subtle symptoms such as self limitation of activities

,general fatigue ,difficulty in keeping up with peers

 Relief with aerosolized bronchodilators
 Lack of improvement with bronchodilators and steroid

is inconsistent with Asthma and should consider
Asthma masquerading conditions!!!!

 Hyper ventilation, intercostal retractions ,nasal flaring

,respiratory accessory muscle use

 Its common not to hear the expiratory wheezing when

Air flow is so limited before treatment

Asthma Triggers
 Common viral infections of the respiratory tract
 Aero allergens in sensitized asthmatics ,animal dander ,dust











mite ,molds ,indoor allergens ,cockroaches
Seasonal aero allergens ,pollens(trees ,grasses ,weeds ,)
Environmental tobacco smoke
Air pollutants ,ozone ,so2,wood or coal smoke ,endotoxin
,mycotoxin ,dust
Strong or noxious odors or fumes ,perfume ,hair spray
,cleaning agents
Occupational exposure
Cold air ,dry air
Exercise
Crying ,laughter ,hyperventilation
Co morbid conditions Rhinitis ,Sinusitis ,GER

Clinics
History:
Triggering symptoms by laughter
,cold air ,airway irritants
Exposures that induce airway
irritation such as viral URTI
Mycoplasma ,Chlamydia
Inhaled allergens
All lead to AHR

Presence Of Risk Factors:
 History of other allergies ,allergic Rhinitis,

allergic Conjunctivitis ,atopic Dermatitis ,food
allergies

 Parental Asthma
 Symptoms apart from cold

Continue…..
 No or minimal signs in routine visits

 Dry or persistent cough

 Normal chest findings unless wheezing when asking

to breath deeper
 Quick relief (10 MIN) after SABA use
 Expiratory wheezing ,prolonged expiratory phase
,decreased sounds in RT lower pos lobe due to
regional hypoventilation owing to airway
obstruction
 Rales , ronchi ,crackles due to hyper secretion
 Segmental crackles and poor breath sounds
atelectasis?

Continue….
 Labored respiration ,respiratory distress increased

prolongation of expiration and wheezing in E and I

 Poor air entry
 Inter costal retractions ,nasal flaring ,supra and

infra sternal retractions

 And again in most sever forms expiratory wheezing

does not appear until some broncho dilation

DD

GERD Rhino sinusitis co morbid

conditions with asthma

Recurrent aspiration in early

life(tracheo broncho malacia
,TEF , foreign body ,CF ,BPD

VCD in older children and

adolescents

LAB FINDINGS
Pulmonary Function
Testing

Continue….
 Forced expiratory airflow measures helpful

in Diagnosis , assessing efficacy of therapy
and monitoring Asthma in children specially
in poor children who do not have PHE
unless obstruction is sever

 Valueablity of spirometric findings in children>6

yrs

 3 efforts the highest is the peak
 Reduced FEV

obstruction

FEV1/FVC <0.80 means significant

 Improvement in FEV1 following beta 2 agonist > =

12% or 200 ml is consistent with Asthma

 Peak flow meter

CXR

Often normal aside from subtle and

nonspecific findings of hyperinflation

Peribronchial thickening
Helping in diagnosis of Asthma

differentials

Diagnosis of complications of Asthma

exacerbations

Other tests such as allergy skin prick
testing

Treatment
 www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm

Asthma Treatment & Management
has 4 components :
Assessment and monitoring of disease
activity
2. Provision to educate pt and family
3. Identification and management of
precipitating factors and co morbid
conditions
4. Appropriate selection of medication
1.

 Attainment of optimal Asthma control

Component 1
 Asthma severity :intermittent
 Persistent: mild ,mod ,severe
 Only once during patient initial evaluation in pt

who is not using a daily controller agent
 Asthma control degree to which symptoms ,
on going functional impairments , risk of
adverse events minimized and goals of
therapy are met

Continue….
Well controlled
2. Not well controlled
3. Very poor controlled
1.

 NIH guidelines for both severity and

control for 3 age groups

0-4 yrs
2. 5-11 yrs
3. =>12 yrs
1.

Important
even in the absence of frequent symptoms
infants and children whom have risk factors
for asthma and 4 or more episodes of
wheezing over the past yr which lasted more
than 1 day or 2 or more exacerbations in
the last 6 months requiring syst
corticosteroids should be considered in the
persistent group and hence receive long term
controller therapy

Important Tips..
 Regular clinical visits every 2-6 weeks
 Assessment of :

Pt symptoms frequency night and day
2. Need for short acting inhaled b2 agonists for
quick relief
3. Ability to engage in normal activities
4. Air flow measures for>=5 yrs
1.

Continue..
 Component 2 : pt education

 Component 3 : control of factors contributing

to asthma severity
1. Environmental exposures
2. Co morbid conditions
 Component 4 :principals of asthma
pharmacotherapy

Asthma Medication
 SABA

 ICS

 LABA
 LTRA

 SYSTEMIC STEROIDS

 NONSTEROIDAL ANTIINFLAMMATORY

CROMOLYN AND NEDOCROMYL
 OXYGEN
 ANTICHOLINERGIC AGENTS
IPRATROPIUM
BROMIDE
 ANTIIMMUNOGLUBOLINE E

MANAGEMENT OF ASTHMA EXACERBATION(STATUS ASTHMATICUS)
RISK ASSESMENT ON ADMISSION

FOCUSED HISTORY

ONSET OF CURRENT EXACERBATION
FREQUENCY AND severity of daytime and night
time symptoms and activity limitation
Frequency of rescue bronchodilator use
Current medication and allergies
Potential triggers
History of systemic steroid courses, emergency
department visists , hospitalization, intubation or life
threatening episodes

Clinical assesment

Physical examination findings: vital signs,
breathlessness, air movement, use of accessory
respiratory muscles, retractions, anxiety level,
alteration in mental status
Pulse oximetry
Lung function(defer in pts with mod to severe
distress or history of labile disease)

Treatment
Drugs and trade name

Mechanism of action and dosing

Cautions and adverse effects

Oxygen(mask or nasal canula)
Inhaled short acting b2
agonist
Albuterol nebulized
solution(5mg/ml concentrates
Albuterol MDI
Levabuterol

Treats hypoxia
Bronchodilator
Neubolizer 0.15 mg/kg every 20 min for 3
doses as needed,then 0.15_0.3 mg/kg up t 10
mg every 1_4 hour as needed or up to 0.5
mg/kg/hr by continous neubolization
2_8 puf up to every 20 min for 3 doses as
needed then every 1 hr as needed

Monitor pulse oximetry to maintain o2 saturation>92%
Cardiorespiratory monitoring
During exacerbations,frequent or continuous use can cause
pulmonary vasodilatation,v/q mistmatch and hypoxemia
Adverse effect palpitation, tachycardia, arrhythmia, tremor,
hypoxemia
Neubolizer:when giving concentrate forms,dilute with saline to 3
ml total neubolized volume
For MDI use space/holding chamber

Systemic corticosteroids
Prednisolone tb
Methyl prednisolon
Anticholinergics
Ipratropium
Atrovent
Ipratropium with Albuterol

Anti inflammatory
0.5_1 mg/kg every 6-8 hr for 48 hr , then 1-2 mg/kg
day bid(max 60 mg/day)
Short course burst for exacerbation 1-2 mg/kg/day qd
or bid for 3-7 days
Mucolitic/bronchodilator
Neubolizer 0.5 mg q6-8 hr (tid or qid) as needed
MDI 2 paf qid
1 vial by neubolizer qid



If pt has been exposed chickenpox or measles, consider passive
immunoglobulin prophylaxis, also risk of complications with
herspes simplex and TB

For daily dosing , 8 am administration minimizes adrenal
suppression

Children may benefit from dosage tapering if course exceed 7 days

Adverse effect monitoring: frequent therapy bursts risk numerous
corticosteroid adverse effects

Should not be used as first line treatment added to b2 agonist
therapy
Neubolizer may mix Ipratropium with Albuterol

QUICK RELIEF MEDICATION
SABA

Anti cholinergic(ipratropium)
Short term systemic gluco

corticoid

SABA
 Quick relief of asthma symptoms
 Relax airway smooth muscle prompt airflow↑
 Repetitive or continuous SABA is the most effective means







of reversing air flow obstruction
SABA should not be prescribed on a regular schedule
because concerns of possibility of deteriorating asthma
control
Frequent use of SABA is an indication of poor asthma control
Preferred root is inhalation smaller dose , fewer side effects
more rapid on set of action
Ipratropium Bromide as an adjunct to SABA in emergency
room reduces hospital admissions and improves lung function
Systemic Glucocorticoids short oral course + SABA in
moderate to severe asthma exacerbation

LABA
 Salmetrol

 Should be used in combination with inhaled

corticosteroids and not as mono therapy
 Exercise induces asthma in children >= 4 Yrs
one inhalation 30 min prior to exercise
 No additional doses for PTs who are already
receiving it twice daily not recommended by
NIH guidelines

LTRA

 MonteLukast ( singulair)

 Antihistaminic

 Leukotrien receptor antagonist

 Asthma ( not < 12 MO) and allergic rhinitis (





not < 6 MO)
Morning dosing not evaluated
Prophylactic and chronic treatment of asthma
Exercise induced asthma in >= 15 Yrs
Zafir Lukast : prophylactic and chronic
treatment of asthma

ICA
 Most potent anti inflammatory agents available

for the treatment of asthma
 Inhibiting most steps in the cascade of the
inflammatory response
 Benefits reducing bronchial hyper
responsiveness , prevention of late asthmatic
response , enhanced lung function
 Inhaled Glucocorticoids first line controller
therapy for persistent asthma or those who
require step 2

Prognosis
 35%of preschool children experience recurrent

coughing and wheezing,1/3 of them continue to
have persistent asthma into later childhood and
2/3 improvement on their own through their teen
yrs
 Asthma severity by age 7-10 yrs is predictive of
asthma persistence into adulthood
 Children with mod to severe asthma and lower lung
function are likely to have persistent asthma as
adults
 Children with milder asthma and N/R lung function
are likely to improve over time or be periodically
asthmatic

THANK YOU FOR YOUR
ATTENTION


Slide 56

Asthma in Children
DR. A.Mirshokraei
NIOC Hospital Pediatrics Ward

Definition :

DEFINITION

- Chronic inflammatory condition of the
lung airways resulting in episodic airflow
obstruction
- AHR to provocative exposures
Asthma management
• Reducing airway inflammation by: Minimizing
pro inflammatory environmental exposure, using
daily controller anti inflammatory medication,
controlling co morbid conditions that worsen
asthma, less inflammation better asthma
control and fewer exacerbations

Anyway exacerbations

occur

BUT
Even the uncommon
child with sever asthma can
be managed to live normally

 RECURRENT WHEEZING EPISODES WITH COMMON

RESPIRATORY
VIRUSES(RSV,RHINOVIRUS,INFLUENZA,PARAINFLUENZA,A
DENOVIRUS,HUMAN METAPNUMOVIRUS)

 HOST FEATURES AFFECTING IMMUNOLOGIC HOST

DEFENSE,INFLAMMATION/PREVIOUS VIRAL INFECTIONS
MAINIFESTED AS PNUMONIA OR BRONCHIOLITIS
REQUIRING HOSPITALIZATION UNDERLIE THE
RECURRENT WHEEZING IN EARLY CHILDHOOD

 OTHER AIRWAY EXPOSURES SUCH AS INDOOR AND HOME

ALLERGENS,COLD AIR,STRONG ODORS,TOBACCO
SMOKE,ALL INCREASE AHR

 ALLERGEN ELLIMINATION SOMETIMES LEEDS TO CURE

EPIDEMIOLOGY
 Common etiology of emergency visits and school day missing

in childhood ,occasionally hospitalization and rare deaths
specially in poverty ,urban living ,ethnic minorities

 Increasing asthma prevalence worldwide(50% per decade)
 Good correlation of asthma prevalence with allergic rhino

sinusitis and atopic eczema and other allergies

 More prevalence in high level urban modern families than

suburban villagers

 More than 80%of asthmatics reported getting the disease

before 6 year

CLINICS
RECURRENT COUGHING/WHEEZING
PATTERNS IN CHILDHOOD BASED ON
NATURAL HISTORY

TRANSIENT EARLY WHEEZING
 Common in early preschool years

 Recurrent coughing/wheezing primary

triggered by common respiratory viral INF
 Tend to resolve during preschool yrs without
increasing risk of asthma later in life
 Problems due to reduced airflow at birth
suggestive of relative narrow airways improved
by school yrs

Persistent Atopy Associated Asthma
 Begins in early preschool yrs

 Associated with atopy (eg atopic dermatitis in





infancy, allergic rhinitis, food allergy)
Biologic factors e.g.: early inhalant sensitization,
increase serum IGE, increase blood eosinophills,
High risk of persistence into later childhood and
adulthood lung function abnormality
Those with onset<3 yrs
reduced air flow by
school yrs
Those with later onset of symptoms or allergen
sensitizations unlikely persistence lung function
abnormality later

Non-Atopic Wheezing
 Wheezing ,coughing beginning in early life

often with RSV INF resolves later in childhood
without increasing risk of persistence asthma

 Associated with bronchial hyper

responsiveness near birth

Asthma with declining lung function
• Children with asthma with progressive

increase in air flow limitation

• Associated with hyper inflation in childhood
• Male gender

Late onset asthma in females associated with
obesity and early onset puberty
 Onset between 8_13 yrs

 Associated with early onset puberty and obesity
 Specific for females

Occupational type asthma in children
 Children with asthma and occupational type exposure

known to trigger asthma in adults in occupational settings

Types of Asthma
common clinical presentations of intermittent
recurrent wheezing and/or coughing
 Recurrent wheezing in early childhood

 Chronic asthma associated with allergy
 Females 11 yrs with early onset puberty and

obesity

Pathogenesis

 Airflow obstruction resulting from

Broncho constriction of bronchiolar smooth
muscle mass
II. Cellular inflammatory infiltrates and exudates
mostly Eosinophills(also N , M ,L ,mast cells
,basophiles)fill and obstruct airways and damage
epithelium and induce desquamation into airway
lumen mediated by T helper cells and other
immune cells that produce pro allergic pro
inflammatory cytokines(IL4,IL6,IL13)
III. Breach in normal immune regulatory process
I.

RESULT
 Airway inflammation

 AHR
 Edema basement membrane thickness sub

epithelial collagen deposition
 Smooth muscle and mucus gland hypertrophy
and mucus hyper secretion

Air obstruction

Clinical manifestations and diagnosis
 Most common intermittent dry cough and

expiratory wheezing

 Shortness of breath and chest tightness in older

children and adults

 Intermittent non focal chest pain in younger

children

 Worsening of respiratory symptoms at night
 Worsening of day time symptoms by activity

Continue…..
 Subtle symptoms such as self limitation of activities

,general fatigue ,difficulty in keeping up with peers

 Relief with aerosolized bronchodilators
 Lack of improvement with bronchodilators and steroid

is inconsistent with Asthma and should consider
Asthma masquerading conditions!!!!

 Hyper ventilation, intercostal retractions ,nasal flaring

,respiratory accessory muscle use

 Its common not to hear the expiratory wheezing when

Air flow is so limited before treatment

Asthma Triggers
 Common viral infections of the respiratory tract
 Aero allergens in sensitized asthmatics ,animal dander ,dust











mite ,molds ,indoor allergens ,cockroaches
Seasonal aero allergens ,pollens(trees ,grasses ,weeds ,)
Environmental tobacco smoke
Air pollutants ,ozone ,so2,wood or coal smoke ,endotoxin
,mycotoxin ,dust
Strong or noxious odors or fumes ,perfume ,hair spray
,cleaning agents
Occupational exposure
Cold air ,dry air
Exercise
Crying ,laughter ,hyperventilation
Co morbid conditions Rhinitis ,Sinusitis ,GER

Clinics
History:
Triggering symptoms by laughter
,cold air ,airway irritants
Exposures that induce airway
irritation such as viral URTI
Mycoplasma ,Chlamydia
Inhaled allergens
All lead to AHR

Presence Of Risk Factors:
 History of other allergies ,allergic Rhinitis,

allergic Conjunctivitis ,atopic Dermatitis ,food
allergies

 Parental Asthma
 Symptoms apart from cold

Continue…..
 No or minimal signs in routine visits

 Dry or persistent cough

 Normal chest findings unless wheezing when asking

to breath deeper
 Quick relief (10 MIN) after SABA use
 Expiratory wheezing ,prolonged expiratory phase
,decreased sounds in RT lower pos lobe due to
regional hypoventilation owing to airway
obstruction
 Rales , ronchi ,crackles due to hyper secretion
 Segmental crackles and poor breath sounds
atelectasis?

Continue….
 Labored respiration ,respiratory distress increased

prolongation of expiration and wheezing in E and I

 Poor air entry
 Inter costal retractions ,nasal flaring ,supra and

infra sternal retractions

 And again in most sever forms expiratory wheezing

does not appear until some broncho dilation

DD

GERD Rhino sinusitis co morbid

conditions with asthma

Recurrent aspiration in early

life(tracheo broncho malacia
,TEF , foreign body ,CF ,BPD

VCD in older children and

adolescents

LAB FINDINGS
Pulmonary Function
Testing

Continue….
 Forced expiratory airflow measures helpful

in Diagnosis , assessing efficacy of therapy
and monitoring Asthma in children specially
in poor children who do not have PHE
unless obstruction is sever

 Valueablity of spirometric findings in children>6

yrs

 3 efforts the highest is the peak
 Reduced FEV

obstruction

FEV1/FVC <0.80 means significant

 Improvement in FEV1 following beta 2 agonist > =

12% or 200 ml is consistent with Asthma

 Peak flow meter

CXR

Often normal aside from subtle and

nonspecific findings of hyperinflation

Peribronchial thickening
Helping in diagnosis of Asthma

differentials

Diagnosis of complications of Asthma

exacerbations

Other tests such as allergy skin prick
testing

Treatment
 www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm

Asthma Treatment & Management
has 4 components :
Assessment and monitoring of disease
activity
2. Provision to educate pt and family
3. Identification and management of
precipitating factors and co morbid
conditions
4. Appropriate selection of medication
1.

 Attainment of optimal Asthma control

Component 1
 Asthma severity :intermittent
 Persistent: mild ,mod ,severe
 Only once during patient initial evaluation in pt

who is not using a daily controller agent
 Asthma control degree to which symptoms ,
on going functional impairments , risk of
adverse events minimized and goals of
therapy are met

Continue….
Well controlled
2. Not well controlled
3. Very poor controlled
1.

 NIH guidelines for both severity and

control for 3 age groups

0-4 yrs
2. 5-11 yrs
3. =>12 yrs
1.

Important
even in the absence of frequent symptoms
infants and children whom have risk factors
for asthma and 4 or more episodes of
wheezing over the past yr which lasted more
than 1 day or 2 or more exacerbations in
the last 6 months requiring syst
corticosteroids should be considered in the
persistent group and hence receive long term
controller therapy

Important Tips..
 Regular clinical visits every 2-6 weeks
 Assessment of :

Pt symptoms frequency night and day
2. Need for short acting inhaled b2 agonists for
quick relief
3. Ability to engage in normal activities
4. Air flow measures for>=5 yrs
1.

Continue..
 Component 2 : pt education

 Component 3 : control of factors contributing

to asthma severity
1. Environmental exposures
2. Co morbid conditions
 Component 4 :principals of asthma
pharmacotherapy

Asthma Medication
 SABA

 ICS

 LABA
 LTRA

 SYSTEMIC STEROIDS

 NONSTEROIDAL ANTIINFLAMMATORY

CROMOLYN AND NEDOCROMYL
 OXYGEN
 ANTICHOLINERGIC AGENTS
IPRATROPIUM
BROMIDE
 ANTIIMMUNOGLUBOLINE E

MANAGEMENT OF ASTHMA EXACERBATION(STATUS ASTHMATICUS)
RISK ASSESMENT ON ADMISSION

FOCUSED HISTORY

ONSET OF CURRENT EXACERBATION
FREQUENCY AND severity of daytime and night
time symptoms and activity limitation
Frequency of rescue bronchodilator use
Current medication and allergies
Potential triggers
History of systemic steroid courses, emergency
department visists , hospitalization, intubation or life
threatening episodes

Clinical assesment

Physical examination findings: vital signs,
breathlessness, air movement, use of accessory
respiratory muscles, retractions, anxiety level,
alteration in mental status
Pulse oximetry
Lung function(defer in pts with mod to severe
distress or history of labile disease)

Treatment
Drugs and trade name

Mechanism of action and dosing

Cautions and adverse effects

Oxygen(mask or nasal canula)
Inhaled short acting b2
agonist
Albuterol nebulized
solution(5mg/ml concentrates
Albuterol MDI
Levabuterol

Treats hypoxia
Bronchodilator
Neubolizer 0.15 mg/kg every 20 min for 3
doses as needed,then 0.15_0.3 mg/kg up t 10
mg every 1_4 hour as needed or up to 0.5
mg/kg/hr by continous neubolization
2_8 puf up to every 20 min for 3 doses as
needed then every 1 hr as needed

Monitor pulse oximetry to maintain o2 saturation>92%
Cardiorespiratory monitoring
During exacerbations,frequent or continuous use can cause
pulmonary vasodilatation,v/q mistmatch and hypoxemia
Adverse effect palpitation, tachycardia, arrhythmia, tremor,
hypoxemia
Neubolizer:when giving concentrate forms,dilute with saline to 3
ml total neubolized volume
For MDI use space/holding chamber

Systemic corticosteroids
Prednisolone tb
Methyl prednisolon
Anticholinergics
Ipratropium
Atrovent
Ipratropium with Albuterol

Anti inflammatory
0.5_1 mg/kg every 6-8 hr for 48 hr , then 1-2 mg/kg
day bid(max 60 mg/day)
Short course burst for exacerbation 1-2 mg/kg/day qd
or bid for 3-7 days
Mucolitic/bronchodilator
Neubolizer 0.5 mg q6-8 hr (tid or qid) as needed
MDI 2 paf qid
1 vial by neubolizer qid



If pt has been exposed chickenpox or measles, consider passive
immunoglobulin prophylaxis, also risk of complications with
herspes simplex and TB

For daily dosing , 8 am administration minimizes adrenal
suppression

Children may benefit from dosage tapering if course exceed 7 days

Adverse effect monitoring: frequent therapy bursts risk numerous
corticosteroid adverse effects

Should not be used as first line treatment added to b2 agonist
therapy
Neubolizer may mix Ipratropium with Albuterol

QUICK RELIEF MEDICATION
SABA

Anti cholinergic(ipratropium)
Short term systemic gluco

corticoid

SABA
 Quick relief of asthma symptoms
 Relax airway smooth muscle prompt airflow↑
 Repetitive or continuous SABA is the most effective means







of reversing air flow obstruction
SABA should not be prescribed on a regular schedule
because concerns of possibility of deteriorating asthma
control
Frequent use of SABA is an indication of poor asthma control
Preferred root is inhalation smaller dose , fewer side effects
more rapid on set of action
Ipratropium Bromide as an adjunct to SABA in emergency
room reduces hospital admissions and improves lung function
Systemic Glucocorticoids short oral course + SABA in
moderate to severe asthma exacerbation

LABA
 Salmetrol

 Should be used in combination with inhaled

corticosteroids and not as mono therapy
 Exercise induces asthma in children >= 4 Yrs
one inhalation 30 min prior to exercise
 No additional doses for PTs who are already
receiving it twice daily not recommended by
NIH guidelines

LTRA

 MonteLukast ( singulair)

 Antihistaminic

 Leukotrien receptor antagonist

 Asthma ( not < 12 MO) and allergic rhinitis (





not < 6 MO)
Morning dosing not evaluated
Prophylactic and chronic treatment of asthma
Exercise induced asthma in >= 15 Yrs
Zafir Lukast : prophylactic and chronic
treatment of asthma

ICA
 Most potent anti inflammatory agents available

for the treatment of asthma
 Inhibiting most steps in the cascade of the
inflammatory response
 Benefits reducing bronchial hyper
responsiveness , prevention of late asthmatic
response , enhanced lung function
 Inhaled Glucocorticoids first line controller
therapy for persistent asthma or those who
require step 2

Prognosis
 35%of preschool children experience recurrent

coughing and wheezing,1/3 of them continue to
have persistent asthma into later childhood and
2/3 improvement on their own through their teen
yrs
 Asthma severity by age 7-10 yrs is predictive of
asthma persistence into adulthood
 Children with mod to severe asthma and lower lung
function are likely to have persistent asthma as
adults
 Children with milder asthma and N/R lung function
are likely to improve over time or be periodically
asthmatic

THANK YOU FOR YOUR
ATTENTION


Slide 57

Asthma in Children
DR. A.Mirshokraei
NIOC Hospital Pediatrics Ward

Definition :

DEFINITION

- Chronic inflammatory condition of the
lung airways resulting in episodic airflow
obstruction
- AHR to provocative exposures
Asthma management
• Reducing airway inflammation by: Minimizing
pro inflammatory environmental exposure, using
daily controller anti inflammatory medication,
controlling co morbid conditions that worsen
asthma, less inflammation better asthma
control and fewer exacerbations

Anyway exacerbations

occur

BUT
Even the uncommon
child with sever asthma can
be managed to live normally

 RECURRENT WHEEZING EPISODES WITH COMMON

RESPIRATORY
VIRUSES(RSV,RHINOVIRUS,INFLUENZA,PARAINFLUENZA,A
DENOVIRUS,HUMAN METAPNUMOVIRUS)

 HOST FEATURES AFFECTING IMMUNOLOGIC HOST

DEFENSE,INFLAMMATION/PREVIOUS VIRAL INFECTIONS
MAINIFESTED AS PNUMONIA OR BRONCHIOLITIS
REQUIRING HOSPITALIZATION UNDERLIE THE
RECURRENT WHEEZING IN EARLY CHILDHOOD

 OTHER AIRWAY EXPOSURES SUCH AS INDOOR AND HOME

ALLERGENS,COLD AIR,STRONG ODORS,TOBACCO
SMOKE,ALL INCREASE AHR

 ALLERGEN ELLIMINATION SOMETIMES LEEDS TO CURE

EPIDEMIOLOGY
 Common etiology of emergency visits and school day missing

in childhood ,occasionally hospitalization and rare deaths
specially in poverty ,urban living ,ethnic minorities

 Increasing asthma prevalence worldwide(50% per decade)
 Good correlation of asthma prevalence with allergic rhino

sinusitis and atopic eczema and other allergies

 More prevalence in high level urban modern families than

suburban villagers

 More than 80%of asthmatics reported getting the disease

before 6 year

CLINICS
RECURRENT COUGHING/WHEEZING
PATTERNS IN CHILDHOOD BASED ON
NATURAL HISTORY

TRANSIENT EARLY WHEEZING
 Common in early preschool years

 Recurrent coughing/wheezing primary

triggered by common respiratory viral INF
 Tend to resolve during preschool yrs without
increasing risk of asthma later in life
 Problems due to reduced airflow at birth
suggestive of relative narrow airways improved
by school yrs

Persistent Atopy Associated Asthma
 Begins in early preschool yrs

 Associated with atopy (eg atopic dermatitis in





infancy, allergic rhinitis, food allergy)
Biologic factors e.g.: early inhalant sensitization,
increase serum IGE, increase blood eosinophills,
High risk of persistence into later childhood and
adulthood lung function abnormality
Those with onset<3 yrs
reduced air flow by
school yrs
Those with later onset of symptoms or allergen
sensitizations unlikely persistence lung function
abnormality later

Non-Atopic Wheezing
 Wheezing ,coughing beginning in early life

often with RSV INF resolves later in childhood
without increasing risk of persistence asthma

 Associated with bronchial hyper

responsiveness near birth

Asthma with declining lung function
• Children with asthma with progressive

increase in air flow limitation

• Associated with hyper inflation in childhood
• Male gender

Late onset asthma in females associated with
obesity and early onset puberty
 Onset between 8_13 yrs

 Associated with early onset puberty and obesity
 Specific for females

Occupational type asthma in children
 Children with asthma and occupational type exposure

known to trigger asthma in adults in occupational settings

Types of Asthma
common clinical presentations of intermittent
recurrent wheezing and/or coughing
 Recurrent wheezing in early childhood

 Chronic asthma associated with allergy
 Females 11 yrs with early onset puberty and

obesity

Pathogenesis

 Airflow obstruction resulting from

Broncho constriction of bronchiolar smooth
muscle mass
II. Cellular inflammatory infiltrates and exudates
mostly Eosinophills(also N , M ,L ,mast cells
,basophiles)fill and obstruct airways and damage
epithelium and induce desquamation into airway
lumen mediated by T helper cells and other
immune cells that produce pro allergic pro
inflammatory cytokines(IL4,IL6,IL13)
III. Breach in normal immune regulatory process
I.

RESULT
 Airway inflammation

 AHR
 Edema basement membrane thickness sub

epithelial collagen deposition
 Smooth muscle and mucus gland hypertrophy
and mucus hyper secretion

Air obstruction

Clinical manifestations and diagnosis
 Most common intermittent dry cough and

expiratory wheezing

 Shortness of breath and chest tightness in older

children and adults

 Intermittent non focal chest pain in younger

children

 Worsening of respiratory symptoms at night
 Worsening of day time symptoms by activity

Continue…..
 Subtle symptoms such as self limitation of activities

,general fatigue ,difficulty in keeping up with peers

 Relief with aerosolized bronchodilators
 Lack of improvement with bronchodilators and steroid

is inconsistent with Asthma and should consider
Asthma masquerading conditions!!!!

 Hyper ventilation, intercostal retractions ,nasal flaring

,respiratory accessory muscle use

 Its common not to hear the expiratory wheezing when

Air flow is so limited before treatment

Asthma Triggers
 Common viral infections of the respiratory tract
 Aero allergens in sensitized asthmatics ,animal dander ,dust











mite ,molds ,indoor allergens ,cockroaches
Seasonal aero allergens ,pollens(trees ,grasses ,weeds ,)
Environmental tobacco smoke
Air pollutants ,ozone ,so2,wood or coal smoke ,endotoxin
,mycotoxin ,dust
Strong or noxious odors or fumes ,perfume ,hair spray
,cleaning agents
Occupational exposure
Cold air ,dry air
Exercise
Crying ,laughter ,hyperventilation
Co morbid conditions Rhinitis ,Sinusitis ,GER

Clinics
History:
Triggering symptoms by laughter
,cold air ,airway irritants
Exposures that induce airway
irritation such as viral URTI
Mycoplasma ,Chlamydia
Inhaled allergens
All lead to AHR

Presence Of Risk Factors:
 History of other allergies ,allergic Rhinitis,

allergic Conjunctivitis ,atopic Dermatitis ,food
allergies

 Parental Asthma
 Symptoms apart from cold

Continue…..
 No or minimal signs in routine visits

 Dry or persistent cough

 Normal chest findings unless wheezing when asking

to breath deeper
 Quick relief (10 MIN) after SABA use
 Expiratory wheezing ,prolonged expiratory phase
,decreased sounds in RT lower pos lobe due to
regional hypoventilation owing to airway
obstruction
 Rales , ronchi ,crackles due to hyper secretion
 Segmental crackles and poor breath sounds
atelectasis?

Continue….
 Labored respiration ,respiratory distress increased

prolongation of expiration and wheezing in E and I

 Poor air entry
 Inter costal retractions ,nasal flaring ,supra and

infra sternal retractions

 And again in most sever forms expiratory wheezing

does not appear until some broncho dilation

DD

GERD Rhino sinusitis co morbid

conditions with asthma

Recurrent aspiration in early

life(tracheo broncho malacia
,TEF , foreign body ,CF ,BPD

VCD in older children and

adolescents

LAB FINDINGS
Pulmonary Function
Testing

Continue….
 Forced expiratory airflow measures helpful

in Diagnosis , assessing efficacy of therapy
and monitoring Asthma in children specially
in poor children who do not have PHE
unless obstruction is sever

 Valueablity of spirometric findings in children>6

yrs

 3 efforts the highest is the peak
 Reduced FEV

obstruction

FEV1/FVC <0.80 means significant

 Improvement in FEV1 following beta 2 agonist > =

12% or 200 ml is consistent with Asthma

 Peak flow meter

CXR

Often normal aside from subtle and

nonspecific findings of hyperinflation

Peribronchial thickening
Helping in diagnosis of Asthma

differentials

Diagnosis of complications of Asthma

exacerbations

Other tests such as allergy skin prick
testing

Treatment
 www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm

Asthma Treatment & Management
has 4 components :
Assessment and monitoring of disease
activity
2. Provision to educate pt and family
3. Identification and management of
precipitating factors and co morbid
conditions
4. Appropriate selection of medication
1.

 Attainment of optimal Asthma control

Component 1
 Asthma severity :intermittent
 Persistent: mild ,mod ,severe
 Only once during patient initial evaluation in pt

who is not using a daily controller agent
 Asthma control degree to which symptoms ,
on going functional impairments , risk of
adverse events minimized and goals of
therapy are met

Continue….
Well controlled
2. Not well controlled
3. Very poor controlled
1.

 NIH guidelines for both severity and

control for 3 age groups

0-4 yrs
2. 5-11 yrs
3. =>12 yrs
1.

Important
even in the absence of frequent symptoms
infants and children whom have risk factors
for asthma and 4 or more episodes of
wheezing over the past yr which lasted more
than 1 day or 2 or more exacerbations in
the last 6 months requiring syst
corticosteroids should be considered in the
persistent group and hence receive long term
controller therapy

Important Tips..
 Regular clinical visits every 2-6 weeks
 Assessment of :

Pt symptoms frequency night and day
2. Need for short acting inhaled b2 agonists for
quick relief
3. Ability to engage in normal activities
4. Air flow measures for>=5 yrs
1.

Continue..
 Component 2 : pt education

 Component 3 : control of factors contributing

to asthma severity
1. Environmental exposures
2. Co morbid conditions
 Component 4 :principals of asthma
pharmacotherapy

Asthma Medication
 SABA

 ICS

 LABA
 LTRA

 SYSTEMIC STEROIDS

 NONSTEROIDAL ANTIINFLAMMATORY

CROMOLYN AND NEDOCROMYL
 OXYGEN
 ANTICHOLINERGIC AGENTS
IPRATROPIUM
BROMIDE
 ANTIIMMUNOGLUBOLINE E

MANAGEMENT OF ASTHMA EXACERBATION(STATUS ASTHMATICUS)
RISK ASSESMENT ON ADMISSION

FOCUSED HISTORY

ONSET OF CURRENT EXACERBATION
FREQUENCY AND severity of daytime and night
time symptoms and activity limitation
Frequency of rescue bronchodilator use
Current medication and allergies
Potential triggers
History of systemic steroid courses, emergency
department visists , hospitalization, intubation or life
threatening episodes

Clinical assesment

Physical examination findings: vital signs,
breathlessness, air movement, use of accessory
respiratory muscles, retractions, anxiety level,
alteration in mental status
Pulse oximetry
Lung function(defer in pts with mod to severe
distress or history of labile disease)

Treatment
Drugs and trade name

Mechanism of action and dosing

Cautions and adverse effects

Oxygen(mask or nasal canula)
Inhaled short acting b2
agonist
Albuterol nebulized
solution(5mg/ml concentrates
Albuterol MDI
Levabuterol

Treats hypoxia
Bronchodilator
Neubolizer 0.15 mg/kg every 20 min for 3
doses as needed,then 0.15_0.3 mg/kg up t 10
mg every 1_4 hour as needed or up to 0.5
mg/kg/hr by continous neubolization
2_8 puf up to every 20 min for 3 doses as
needed then every 1 hr as needed

Monitor pulse oximetry to maintain o2 saturation>92%
Cardiorespiratory monitoring
During exacerbations,frequent or continuous use can cause
pulmonary vasodilatation,v/q mistmatch and hypoxemia
Adverse effect palpitation, tachycardia, arrhythmia, tremor,
hypoxemia
Neubolizer:when giving concentrate forms,dilute with saline to 3
ml total neubolized volume
For MDI use space/holding chamber

Systemic corticosteroids
Prednisolone tb
Methyl prednisolon
Anticholinergics
Ipratropium
Atrovent
Ipratropium with Albuterol

Anti inflammatory
0.5_1 mg/kg every 6-8 hr for 48 hr , then 1-2 mg/kg
day bid(max 60 mg/day)
Short course burst for exacerbation 1-2 mg/kg/day qd
or bid for 3-7 days
Mucolitic/bronchodilator
Neubolizer 0.5 mg q6-8 hr (tid or qid) as needed
MDI 2 paf qid
1 vial by neubolizer qid



If pt has been exposed chickenpox or measles, consider passive
immunoglobulin prophylaxis, also risk of complications with
herspes simplex and TB

For daily dosing , 8 am administration minimizes adrenal
suppression

Children may benefit from dosage tapering if course exceed 7 days

Adverse effect monitoring: frequent therapy bursts risk numerous
corticosteroid adverse effects

Should not be used as first line treatment added to b2 agonist
therapy
Neubolizer may mix Ipratropium with Albuterol

QUICK RELIEF MEDICATION
SABA

Anti cholinergic(ipratropium)
Short term systemic gluco

corticoid

SABA
 Quick relief of asthma symptoms
 Relax airway smooth muscle prompt airflow↑
 Repetitive or continuous SABA is the most effective means







of reversing air flow obstruction
SABA should not be prescribed on a regular schedule
because concerns of possibility of deteriorating asthma
control
Frequent use of SABA is an indication of poor asthma control
Preferred root is inhalation smaller dose , fewer side effects
more rapid on set of action
Ipratropium Bromide as an adjunct to SABA in emergency
room reduces hospital admissions and improves lung function
Systemic Glucocorticoids short oral course + SABA in
moderate to severe asthma exacerbation

LABA
 Salmetrol

 Should be used in combination with inhaled

corticosteroids and not as mono therapy
 Exercise induces asthma in children >= 4 Yrs
one inhalation 30 min prior to exercise
 No additional doses for PTs who are already
receiving it twice daily not recommended by
NIH guidelines

LTRA

 MonteLukast ( singulair)

 Antihistaminic

 Leukotrien receptor antagonist

 Asthma ( not < 12 MO) and allergic rhinitis (





not < 6 MO)
Morning dosing not evaluated
Prophylactic and chronic treatment of asthma
Exercise induced asthma in >= 15 Yrs
Zafir Lukast : prophylactic and chronic
treatment of asthma

ICA
 Most potent anti inflammatory agents available

for the treatment of asthma
 Inhibiting most steps in the cascade of the
inflammatory response
 Benefits reducing bronchial hyper
responsiveness , prevention of late asthmatic
response , enhanced lung function
 Inhaled Glucocorticoids first line controller
therapy for persistent asthma or those who
require step 2

Prognosis
 35%of preschool children experience recurrent

coughing and wheezing,1/3 of them continue to
have persistent asthma into later childhood and
2/3 improvement on their own through their teen
yrs
 Asthma severity by age 7-10 yrs is predictive of
asthma persistence into adulthood
 Children with mod to severe asthma and lower lung
function are likely to have persistent asthma as
adults
 Children with milder asthma and N/R lung function
are likely to improve over time or be periodically
asthmatic

THANK YOU FOR YOUR
ATTENTION