OS 213: Pulmunology Maria Liza B. Zabala, M.D.

Pediatric Asthma Exam 1

Lecture Outline  Primary physiologic manifestation is

spontaneously variable airway obstruction which
I. Epidmemiology can be modulated by:
II. Definition  Increased obstruction caused by many
III. Review of Anatomy stimuli
IV. Pathophysiology  Alleviation of obstruction by
bronchodilators and/or anti-inflammatory
V. Risk Factors
agents
VI. Clinical Features/Diagnosis
VII. Management REVIEW OF ANATOMY

EPIDEMIOLOGY

 Asthma ranked number 1 among the non-

infections admissions in 57 of accredited
hospitals
PPS Registry of Diseases, 1994

 Prevalence of wheezing among 6-19 years in

Metro Manila schools was 27.45%
Del Mundo, textbook of Pediatrics 2002

 A large international survey study of childhood

asthma prevalence in 56 countries found a wide
range in asthma prevalence, from 1.6 to 36.8%
ISAAC Study

Source: Masoli M et al. Allergy 2004

DEFINITION

 a chronic inflammatory disorder of the airways in

which many cells play a role, including mast cells
and eosinophils
 this inflammation causes symptoms that are
usually associated with widespread but variable
airflow obstruction that is often reversible either
spontaneously or with treatment, and causes
associated increase in airway PATHOPHYSIOLOGY
hyperresponsiveness to a variety of stimuli.
 a disorder defined by its clinical, physiological is complex and involves the following components:
and pathological characteristics
 Clinically, asthma is characterized by airway 1) Airway inflammation
hyperresponsiveness presenting as widespread 2) Intermittent airflow obstruction
narrowing of the airway which results from a 3) Bronchial hyperresponsiveness
variety of stimuli like allergens, exercise, physical
factors and irritant gases

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 OS 213: Pulmunology Maria Liza B. Zabala, M.D.
Pediatric Asthma Exam 1

Asthma Inflammation: Cells and Mediators

Key Mediators of Asthma:

 Chemokines
Mechanisms Of Airway Narrowing in Asthma
 recruitment of inflammatory cells into the
airways and are mainly expressed in
airway epithelial cells  Contraction of Airway smooth muscle (ASM) is
the predominant mechanism largely reversed by
 Cysteinyl leukotrienes
bronchodilators
 potent bronchoconstrictors and
 Airway wall thickening
proinflammatory mediators mainly
derived from mast cells and eosinophils  Accumulation of airway secretions, mucus casts,
and cellular debris may partially occlude the
 only mediator whose inhibition has been
lumen
associated with an improvement in lung
function and asthma symptoms
Regulation of Airway Caliber
 Cytokines
 Cholinergic (parasympathetic) motoneurons
 orchestrate the inflammatory response
innervate the airways via the vagus nerve
in asthma and determine its severity
 Nonadrenergic Noncholinergic (NANC) Nervous
 Histamine
system
 contributes to bronchoconstriction and  NANC system neurons in the vagus nerve
to the inflammatory response
release the peptides, SUBSTANCE P and
 Nitric Oxide VASOACTIVE INTESTINAL PEPTIDE
 a potent vasodilator, produced  Appears to be the most potent relaxant
predominantly from the action of component of the nervous system involved in
inducible nitric oxide synthase in airway regulation of airway diameter
epithelial cell
Factors that Influence Asthma Development and
Asthma Inflammation: Cells and Mediators Expression

Host Factors
 Genetic
 Atopy
 Airway hyperresponsiveness
 Gender
 Obesity

Environmental Factors
 Indoor allergens
 Outdoor allergens
 Occupational sensitizers
 Tobacco smoke
 Air Pollution
 Respiratory Infections
 Diet

RISK FACTORS FOR ASTHMA

 Host factors: predispose individuals to, or protect

them from, developing asthma
 Environmental factors: influence susceptibility to
development of asthma in predisposed
individuals, precipitate asthma exacerbations,
and/or cause symptoms to persist

Who gets asthma? Anyone!!!

 Most children develop asthma before age 8 years
and over half before 3 years

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 OS 213: Pulmunology
Pediatric Asthma
 30% < 1 year
 80-90% before 4-5 years old
 Before puberty: asthma occurs 11/2-3x male >
female
 Adolescence male=female
Predisposing Factors involved in the Development of
Asthma
 Atopy
 defined as the preponderance to
produce abnormal amounts of IgE in
response to environmental allergens
 Familial association among asthma,
allergic rhinitis and atopic dermatitis
suggests a common genetic basis
-chromosomes 5, 11
 90% of asthmatic children have an
allergic component
 64-84% (+) family history of asthma
among 1st degree relatives
 30% & 3.5% of asthmatic patients
reported asthma in one parent and in
none respectively
 Gender
 Male preponderance
Triggers
 Risk factors that cause asthma exacerbation by
inducing inflammation or provoking acute
bronchoconstriction or both
Trigger Factors of Asthma in Various Age Groups
Anatomic and physiologic peculiarities that predispose to
obstructive airway disease
1. Decreased amount of smooth muscle in
peripheral airways
2. Mucosal gland hyperplasia in the major bronchi
compared to adults favors increased intraluminal
mucus production
3. Disproportionately narrow peripheral airways up
to 5 years of age
4. Decreased static elastic recoil of the young lung
predisposes to early airway closure during tidal
breathing
5. Highly compliant rib cage and mechanically
disadvantageous angle of insertion of diaphragm
to ribcage increases diaphragmatic work of
breathing
6. Decreased number of fatigue-resistant skeletal
muscles in the diaphragm
7. Deficient collateral ventilation with the pores of
Kohn and the Lambert canals deficient in number
and size
Dec 11, 2008 | Thursday
Maria Liza B. Zabala, M.D.
Exam 1
Masqueraders of asthma in children
 Upper airway noise/congestion
 Cystic fibrosis (CF)
 Gastroesophageal reflux disease (GERD)
 Bronchopulmonary dysplasia (BPD)
 Foreign body aspiration
 Immunodeficiency (ID)
 Vocal cord dysfunction
CLINICAL FEATURES
 Frequent episodes of wheeze (more than once a
month)
 Activity induced cough or wheeze
 Nocturnal coughs in periods without viral
infections
 Absence of seasonal variations in wheeze
 Symptoms that persist after the age of 3
 Wheeze before the age of 3 and one major risk
factor
 parental history of asthma or eczema or
two or three risk factors (eosinophilia,
wheezing without colds, and allergic
rhinitis) has been shown to predict the
presence of asthma in later childhood
DIAGNOSIS
 Signs and symptoms to look for include:
 Frequent coughing spells, which may occur
during play, at night, or while laughing. It is
important to know that cough may be the only
symptom present.
 Less energy during play
 Rapid breathing
 Complaint of chest tightness or chest "hurting”
 Whistling sound (wheezing) when breathing in
or out
 See-saw motions (retractions) in the chest
from labored breathing
 Shortness of breath, loss of breath
 Tightened neck and chest muscles
 Feelings of weakness or tiredness
Spirometry
 Recommended in the initial assessment of
patients suspected to have asthma
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 OS 213: Pulmunology Maria Liza B. Zabala, M.D.
Pediatric Asthma Exam 1

 Usually feasible in children from age >5 years

 Useful in assessing
 Degree of airway obstruction
 Disturbances in gas exchange
 Response of airways to inhaled
allergens/ chemicals/exercise
 Assessing response to therapeutic
agents
 Evaluating long-term course of disease
 FEV1 is the single best measure for assessing
severity of airflow obstruction
 FEV1 measurements <80% of predicted value is
evidence of airway obstruction and reversibility
with use of inhaled ß2-agonist (increase in FEV1
by 15%) makes a definitive diagnosis of asthma

Diagnosis of Asthma

 Other Tests to help establish the diagnosis of

asthma
1) Methacholine/Histamine bronchoprovocation test
2) Exercise challenge test
3) Twice daily recording of peak flow to determine
diurnal variation
4) Therapeutic trial of five days steroid and
bronchodilator course

Portable Peak Flow Meter

 measure PEFR where spirometry is not available

 less sensitive, but correlates well with FEV1
 offers an acceptable alternative to assess
response to exercise challenge and peak flow
variability
 The predicted normal PEFR for Filipino children
between 6 and 17 years of age with height of at
least 100 cm can be calculated:
 Males: (Height in cm - 100) 5 + 175
 Females: (Height in cm - 100) 5 + 170

MANAGEMENT

“Basically longterm, involving both pharmacological and

non pharmacological interventions”

Philippine Consensus Report 2002

Goals of Therapy

1. to maintain normal activity levels including

exercise;

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 OS 213: Pulmunology Maria Liza B. Zabala, M.D.
Pediatric Asthma Exam 1

2. to maintain ( near ) normal pulmonary function • Should be seen one to three months after the
test; initial visit and every 3 months thereafter
3. to prevent chronic and troublesome symptoms; • After an exacerbation, follow-up should be within
4. to prevent recurrent exacerbations; and, two weeks to one month
5. to avoid adverse effects from asthma
medications ALLERGEN IMMUNOTHERAPY IN ASTHMA
• Administration of increasing quantities of specific
Components of asthma care allergic extracts to patients with IgE-mediated
allergic rhinitis, asthma or stinging insect
1) Develop patient/doctor partnership anaphylaxis
2) Identify and reduce exposure to risk factors
• Should be considered
3) Assess, treat and monitor asthma
o avoiding allergens is not possible
4) Manage asthma exacerbations
o less than complete control of symptoms
Outcome is achieved with bronchodilators or
Successful management of asthma should lead to an inhaled steroids
improvement or normalization of the child’s daily activities, • Greatest benefit of specific immunotherapy using
respiratory symptoms, pulmonary function and personal allergen extracts has been obtained in the
and family psychosocial functioning. treatment of allergic rhinitis
• Role of specific immunotherapy in asthma is
Richel: Haaaaaay. High stress itong trans na to. Half pa lang ng limited
coverage ang nababasa ko :s at kailangan ko pa tong unahin, • Specific immunotherapy should be considered
kaya basahin niyo to! Hello octetmates! Goodluck tom. Haha. only after strict environmental avoidance and
:D pharmacologic intervention, including inhaled
glucocorticosteroids, have failed to control
asthma
• Performed only by trained physician
Objectives
MANAGING EXACERBATIONS OF ASTHMA
IDEAL MINIMAL
Minimal or no chronic symptoms Least symptoms
Exacerbations of asthma
Minimal episodes Least need for PRN β2- agonist
No ER visits Least limitation of activity
• Acute or sub-acute episodes of progressively
Minimal need for PRN β2- agonist worsening symptoms of shortness of breath,
No limitation on activities Best PEFR cough, wheeze and chest tightness or a
PEF circadian variation < 20% Least adverse effects combination of these
( Near) normal PEF Minimal or no adverse effect • Exacerbations may be mild, moderate severe or
even life threatening
Long-term Management of Asthma in Children

ASSESSMENT Key points

Asthmatic child is classified to an asthma severity
category
Category of severity will suggest the initial pharmacologic
treatment
Pharmacologic therapy is described as “step care”
 control of symptoms should be established as
soon as possible
 short course of oral corticosteroids or higher
doses of inhaled corticosteroids may be
considered for faster control
 therapy should be decreased as soon as possible
to that which is required based on the identified
asthma severity category
On follow up:
 if control is attained and sustained for at least
three months, a gradual reduction in treatment
may be possible
 if control is not achieved within 2-6 weeks
 review patient’s inhaler technique
 review compliance and environmental
control measures (such as: avoidance
of allergens or other triggers)
 diagnosis should be re-evaluated and
treatment should be advanced to the
next step
*see Appendix for long term management
Monitoring to maintain control
• Control should be monitored to maintain control
and establish lowest step and dose
• Prevention of exacerbations is the optimal goal
• Severity of future attacks cannot be predicted,
thus early recognition is imperative
Note: most cases of asthma morbidity and mortality are
due to underassessment and undertreatment
• In the event of an attack, early treatment is
advised
o Recognition of early signs of attack or
worsening asthma
o Appropriate use of relievers
o Prompt communication between patient
and physician
• Management of asthma attack may include, but
is not limited to:
o Inhaled short-acting β2 agonist for
immediate relief of airway obstruction
o Systemic corticosteroids
o Oxygen
o Other agents (e.g. ipratropium bromide,
theophylline)
Note: close monitoring of patient’s condition as well as
response to therapy is crucial
Anticholinergics
• Recent studies have shown that anticholinergics
(e.g. ipratropium bromide) offer some benefit
when used early and in combination with short-
acting β2 agonists
• In children with acute asthma, addition of
anticholinergics to inhaled β2 agonists for 3
doses given every 20 minutes appears to

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 OS 213: Pulmunology Maria Liza B. Zabala, M.D.
Pediatric Asthma Exam 1

improve lung function modestly and decrease From the Emergency Room
hospital admissions. 1) symptoms are absent or minimal
2) PEFR > 80% predicted
High risk patients 3) sustained response for at least four (4) hours
These are the patients who have the potential to go into
sudden and severe airway obstruction which may From the Hospital
lead to respiratory failure or death. 1) physical examination is normal or near normal
They should be educated to seek medical care early 2) no nocturnal awakenings
during an exacerbation. 3) PEFR > 80% predicted
• infants in moderate/severe exacerbation 4) sustained response to inhaled short-acting
• current use or recent withdrawal (< 1 week) from β2 agonist (at least 4 hours)
systemic corticosteroids
• hospitalization for moderate or severe asthma in Discharge Instructions
the past year  Identify and avoid the trigger(s) that precipitated
• prior intubation or history of impending the attack
respiratory failure from asthma  Prescribe sufficient medications to continue
• psychiatric disease or psychosocial problems treatment after discharge
• difficulty perceiving airflow obstruction or its  Review inhaler technique
severity, and  If peak flow meter is available, provide an action
• non-compliance with asthma medication plan plan
 Emphasize regular, continuous follow-up with the
IMMEDIATE CASE OF ASTHMA EXACERBATIONS physician
• Treatment should be started as soon as an
Drug Therapy
asthma attack is recognized.
• Initial treatment will include inhaled short-acting 2 TYPES
β2 and if necessary, oxygen.  RESCUE/RELIEVER
o PE should be done to determine -for acute relief of symptoms
severity of exacerbation to serve as  PROPHYLACTIC/CONTROLLER
a guide to the type of management -to prevent exacerbations
appropriate for the case.
o Brief but focused history pertinent  RELIEVER
to the attack
-bronchodilators which relax airway muscles that
Pertinent points to ask tighten in and around the airways
• Severity of symptoms
• History of prior attacks -provide quick relief of symptoms but does not
treat underlying airway inflammation
• Visits to the emergency room
• Hospitalization (including history of intubation) Reliever Medications:
due to asthma  Rapid-acting inhaled beta2-agonist
• Current medications  Systemic glucocorticosteroids
• Any of other complicating illnesses (e.g. other  Anticholinergics
pulmonary or cardiac problems)  Theophylline
 Short-acting oral beta2-agonist
Particular attention should be given to patients who
present with the following features, as they are the ones
 CONTROLLER
most prone to develop acute respiratory failure:
• Cyanosis -Consists of anti-inflammatory agents which
• absence of wheeze prevent asthma attacks by reversing the underlying
• bradycardia and bradypnea inflammatory changes
• paradoxical thoraco-abdominal movement
• drowsiness or confusion -Prevents further inflammation of airways and
• a normal or elevated pCO2 in a patient with controls chronic symptoms
severe distress
Controller Medications:
Appendix. Severity of Asthma Exacerbations  Inhaled glucocorticosteroids
 Leukotriene modifiers
Admission to Intensive Care Unit  Long-acting inhaled β2-agonists
 Systemic glucocorticosteroids
Recommended in the following situations:  Theophylline
 Cromones
1) progressive worsening of asthma symptoms despite
initial Management  Long-acting oral β2-agonists
2) presence of sensorial changes (drowsiness, confusion)  Anti-IgE
or loss of consciousness  Systemic glucocorticosteroids
3) signs of respiratory fatigue (e.g. declining respiratory
rate)
4) impending respiratory arrest (paO2 < 60 mmHg on
supplemental oxygen, pCO2 > 45 mmHg)

Patient Discharge

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 OS 213: Pulmunology Maria Liza B. Zabala, M.D.
Pediatric Asthma Exam 1

On your way to ER, continue your quick relief inhaled

bronchodilator every 20 minutes and take 1 dose of oral
steroids _________

RED ZONE: EMERGENCY!!!

- Presence of any:(Trouble walking or talking due to
shortness of breath, lips and fingernails are blue)
-Quick relief medicines have not helped
-Cannot do usual activities
-Symptoms are getting worse
-Peak flow meter: _____ (< 60 % of your personal
best)

Key Points to Inhalational Devices
1) There is little difference in the therapeutic effect
between a correctly used MDI with or without a
spacer, DPI, and a nebulizer
2) MDI spacer can increase ling deposition
3) MDI spacer can decrease oropharyngeal
deposition
4) MDI with a spacer, DPI, or nebulizers can be
used for patients who have difficulty coordinating
with MDI activation, those with optimal breathing
pattern, in children, and patients with severe
illness
Non-pharmacologic interventions include
 Environmental control
 Monitoring of the status of the disease
 Asthma education
ACTION:
- Proceed to ER
- Take immediately 1 dose of your quick relief inhaled
bronchodilator and continue your inhaled bronchodilator
every 20 minutes while in transit
- Take 1 dose oral steroids __________
*may mga blanks talaga yan ha ;)
References
 Philippine Consensus For The Management Of
Childhood Asthma Revised 2002
 Global Initiative For Asthma Revised 2006
 Nelson Textbook of Pediatircs
 Lippincott’s Pathophysiology Series Pulonary
Pathophysiology 1995 By Michael Grippi
 Textbook Of Pediatric and Health Care 4th Edition By Del
Mundo
 Kendig’s Disorders of the Respiratory Tract in Children
7th Edition

Action Plan

The asthma action plan is a written asthma management

plan that is jointly prepared by the doctor and the patient.

This written instruction to the patient should be updated Richel: Greetings ulit  Hello Phinoms!  Sarap ng potatoes no?
Hehe. Saka na ulit yung next supply. Family day ulit? :p
every visit as changes in peak flow measurements or
Tinatamad na ako bumati, hello na lang to everyone! Malunggays,
asthma severity category may occur. sana matapos na natin itong research. Pahiraaaaaaaap. :D
Happy birthday Lani, Fides, and Dr.Gana! :D Hello Raphael.
GREEN ZONE: Doing Well Thank you 
- No symptoms day and night (cough, wheeze,
chest tightness and shortness of breath)
- Can do usual activities
- Peak flow meter __________
(>80 % of your personal best or predicted)

ACTION:
- Continue with your current
medication as prescribed _________

YELLOW ZONE: Acute Attack

- Presence of at least 1 of the following: (cough,
wheeze, chest tightness or shortness of breath)
- Waking at night due to asthma
- Can do some but not all usual activities
- Peak flow meter: _____ to _____
(60 to 79% of your personal best)

ACTION:
-Take your quick-relief inhaled
brochodilator_______________
every 20 minutes up to 3 doses until relieved
- Proceed to ER for further evaluation & possible
admission if:
1. getting worse at anytime
2. if no relief after 3 doses of inhaled β2 agonist

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 OS 213: Pulmunology Maria Liza B. Zabala, M.D.
Pediatric Asthma Exam 1

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