Asthma in children

clinical picture & management overview

Indonesian Pediatrics Society
Ikatan Dokter Anak Indonesia
Clinical picture
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adaptive
response
insults
Medical problem process
symptomatology
pathophysiology
pathology
pathogenesis
Insults
Medicine/Medical.
a. an injury or trauma
b. an agent that inflicts
this
to affect offensively or
damagingly
Any factor affecting the normal growth,
development, process, or function of the
cell, tissue, organ, system, or individu - DBS
Integumentary
system (skin)
Neuro-musculo-
skeletal system
Respiratory
defense mechns
Urinary
def mechn
Gastro-intestinal
defense mechns
Endocrine
system
Autonomic
Nerve system
Adaptive
responses
Immune
system
Integumentary
system (skin)
Adaptive
responses
Immune
system
Neuro-musculo-
skeletal system
Respiratory
defense mechns
Urinary
def mechn
Gastro-intestinal
defense mechns
Endocrine
system
Autonomic
nerve system
The OLD
asthma
Classic clinical asthma
Adaptive
response

Insults
Symptoms
Patho-phys
Pathology
Adult
Dyspnea &
wheezing

Bronchospasme

Smooth muscle
General perception
Asthma = dyspnea + wheezing
NO dyspnea NO asthma
NO wheezing NO asthma
Classic clinical asthma
response
Symptoms
Patho-phys
Pathology
Adaptive
Some
children
Insults
Dyspnea &
wheezing

Bronchospasme

Smooth muscle
NON-classic clinical asthma
response
Pathology
Adaptive
Symptoms
Other
children
Insults
Cough &
cough
Patho-phys
Airway
inflammation
Only cough
Asthma ???
Chronic & Acute
Asthma
Asthma: chronic
inflammation
time
Trigger
time
MPI:
minimal
persistent
inflammation

inflammation
Asthma: acute
attack

attack

MPI

Asthma
Asthma: symptom
symptom
symptom

MPI

Asthma
Trigger
light,
single

inflammation
time
Trigger
heavy,
combination
time
MPI:
minimal
persistent
inflammation

inflammation
Asthma: attack
attack

attack

MPI

Asthma
Asthma
Asthma: chronic - acute
symptom
inflammation
Two unseparated faces of asthma
1. Chronic condition (longterm)
2. Acute attack (current)
attack
Asthma
Asthma: chronic - acute
symptom
Chronic asthma: how frequent the symptom
attack appear during certain time
Acute asthma: how severe the symptom
attack that appear
attack
Pediatric Asthma classification
Chronic asthma
1. Infrequent
episodic asthma
2. Frequent
episodic asthma
3. Persistent
asthma
Acute asthma
1. Mild asthma
attack
2. Moderate asthma
attack
3. Severe asthma
attack
Independent relationship
Chronic asthma
Infrequent
asthma

Frequent
asthma

Persistent
asthma
Acute asthma
Mild
attack

Moderate
attack

Severe
attack
symptom

MPI

Asthma
attack
Asthma attack is a rapid progressive
worsening episode of symptoms
(cough, dyspnea, wheezing,
chest tightness or combination)
PNAA 2004
MPI:
minimal
persistent
inflammation

inflammation
symptom
Symptom - attack: a continuum
attack
Asthma: Chronic & Acute
The two aspects of asthma, often not clearly
stated, even in the major journal
Severe asthma
Severe chronic asthma? OR
Severe acute asthma?

Difficult asthma
Difficult chronic asthma? OR
Difficult acute asthma?
Definition
D
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adaptive
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insults
Asthma definition
symptomatology
pathophysiology
pathology
pathogenesis
GINA asthma definition
Asthma is a chronic inflammatory disorder of
the airway in which many cells & cellular
elements play a role. The chronic
inflammation is associated with airway
hyperresponsiveness that leads to recurrent
episodes of wheezing, breathlessness, chest
tightness & coughing, particularly at night or
early in the morning. These episodes are
associated with widespread, but
variable airflow obstruction within the lung
that is often reversible either spontaneously
or with treatment.
GINA , 2009
features: appear episodic and/or chronic,
Wheezing and/or cough with special
tends at night/early morning (nocturnal),
has triggers such as physical activity,
reversible either spontaneously or with
treatment, and has asthma history or other
allergy in patient/family.
PNAA asthma definition
PNAA, 2004
symptomatology
insults
symptomatology &/ attack
Pediatric asthma definition
Chronic lower airway disease - recurrent acute
episodes of symptoms
lower airway hypersecretion,
DB Setyanto, 2010
pathology
insults
Symptoms: cough, wheeze, dyspnea --- specific
features (periodicity, variability, reversibility, )
Due to pathophysiology wall edema &
smooth muscle constriction, which can lead to
variable degree of reversible obstruction
Underlying pathology: chronic inflammation &
remodelling of lower airway - many cells & cellular
elements play a role adaptive
The pathology is a result of chronic recurt cumulative
interaction between external insults (viral infection,
pollutant, allergen, etc) & internal insults (genetic
susceptibility) which producing mis-adaptive response
Immune response
Th2, IgE, IgG4, IgG1
Inducers: indoor allergens,
alternaria
Avoidance ??
Autonomic nerves
symphatic-cholinergic imbalance
Enhancers: rhinovirus,
ozone,
Avoidance, anti-inflammatory,
immuno-therapy?
Airway
remodelling


Triggers: excercise, cold air, histamine,
Inflammation
Th2, mast cells,
eosinophils


Avoidance, controller
AHR





Bronchospasm /
bronchoconstriction
Lower respiratory
obstruction (edema,
hypersecretion, spasm, )


Reliever


Clinical manifestation
cough, wheezing, dyspnea,
Genetically predisposed
population
Asthma
Diagnosis
Diagnosis difficulties
Wheeze in children, not always asthma,
the younger the child, the more DD/.
Pediatric asthma not always wheeze
Cough could be the only prominent
symptom
Young child can not perform the
spirometry maneuver
symptomatology
pathophysiology
Symptomatology of asthma
Wheeze
Dyspnea
Cough
Symptomatology of asthma
wheeze Asthma???
Asthma??? cough
Symptomatology of asthma
a main symptom of asthma
in children, many clinical
condition with wheeze
which wheeze is asthma???

A main symptoms of asthma
in children, many clinical
condition with cough
which cough is asthma???
Wheeze
only
Cough
only
Causes of wheeze in children
Recurrent viral LRI
Chronic rhino-sinusitis
Gastro esophageal
reflux

Tuberculosis
Congenital
malformations

Inhaled foreign body
Bronchopulmonary
dysplasia
Cystic fibrosis
Primary ciliary
dyskinesia

Immune deficiency
Congenital heart
disease

GINA 2009
Australia National Asthma Council 2002
Asthma & 2 main symptoms
Congenital malformations
Wheeze
Cough
asthma
ARI
TB
PCD
GER
BPD

CHD
Rh-S
ARI
pneumonia
TB
GER
Rh-S
Asthma symptoms features

Periodicity (recurrent)
Variability (nocturnal, worsen at night)
Reversibility (response to asthma drugs)
History of allergy (patient &/ family)
Trigger factors (inhalan, ingestan, others)
Periodicity - variability: a continuum
attack

symptom

MPI

Asthma
MPI:
minimal
persistent
inflammation

inflammation
years
Periodicity - variability: a continuum
attack

symptom

MPI
24 hrs
08AM
Asthma
08PM
MPI:
minimal
persistent
inflammation

inflammation
Clinical
parameter
Infrequent
episodic
Frequent
episodic
Persistent
frequency < 1x /month > 1x /month frequent
symptom
duration
< 1 week 1 week almost all the time
between attack no symptom few symptoms
day & night symptoms
sleep & activity not disturbed disturbed very disturbed
Phys exam when
no attack
normal few signs never in normal
condition
controller not needed need, non steroid need, steroid
lung function test PEF/FEV1 >80% PEF/FEV1 60-80% PEF/FEV1 <60%
Variability 20-30%
Variability
(during attack)
>15% < 30% < 50%
Chronic asthma parameters
Diagnosis in 5 yrs - younger

The diagnosis of asthma in early childhood
is challenging
Based on clinical judgment and an
assessment of symptoms & signs
Three categories of wheezing:
Transient early wheezing
Persistent early onset wheezing (non-atopic)
Late onset wheezing (asthma)
GINA 2006
W
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Asthma
Non-Atopic
Wheezers
Transient
Wheezers
Age (years)
0 3 6
11
Fig. 6. Hypothetical peak prevalence by age for the 3 different wheezing phenotypes.
The prevalence for each age interval should be the area under the curve. This does not
imply that the groups are exclusive.

Taussig LM, et al. JACI 2003; 111:661-675
Low LFT
at birth
AHR of atopic
asthma
Post
RSV
Major :
Atopic dermatitis
Parental asthma
Skin test (+) for
aeroallergens
Minor
Allergic rhinitis
Wheeze apart of cold
Eosinophils >4%
Skin test (+) for
ingestion allergen
Recurrent wheeze
Asthma if:
2 major AND/OR
1 major + 2 minor
Taussig LM, et al. JACI 2003; 111:661-675
Treatment
Steps of asthma treatment
1. Avoidance of trigger(s)
2. Avoidance of trigger(s)
3. Avoidance of trigger(s)
4. Drug(s)
a. Reliever
b. Controller
Insults
Adaptive
Asthma treatment, step 1-3
Symptoms

Patho-phys
Pathology
Avoidance
Avoidance
response
Avoidance
symptom

MPI

Asthma
attack
symptom
MPI: Trigger
minimal light,
persistent single
inflammation

inflammation
Trigger
heavy,
combination
Avoidance of trigger(s) !!!
attack
Asthma medication
To relieve asthma symptoms - attack
As needed medication
If the symptom relieve, stop
No package system

To control asthma inflammation
Long term medication, months - years
Evaluated regularly,
Dose adjusment: maintain, increase,
decrease
Reliever
drug
(pereda)
Controller

drug
(pengendali)
Patho-phys
Pathology
Adaptive
response
Insults
Asthma treatment, step 4a
Symptoms
Reliever
Reliever
Autonomic
nerve system
symptom

MPI

Asthma
attack
symptom
MPI: Trigger
minimal light,
persistent single
inflammation

inflammation
Trigger
heavy,
combination
Reliever drug
attack
Reliever drug

Inhalation: Nebulizer or MDI + spacer
Reliever inhalation drug:
2 agonist: salbutamol, terbutaline,
fenoterol, procaterol

Anti-cholinergic: ipratropium bromide
2 agonist + anti-cholinergic
Systemic steroid (oral, injection)
Inhaled steroid ???

Xanthin: aminophylline, theophylline
Ped acute asthma algorithm
Clinic / ER

Asses attack severity

1st management
nebulitation -agonis 3x, 20 min interval
3rd nebulitation + anticholinergic
Moderate attack
(nebulization 2-3x,
partial response)
give O2
asses: moderate
ODC
IV line
Mild attack
(nebulization 1x,
complete response)
persist 1-2 hr:
discharge
symptom reappear:
Moderate attack
Severe attack
(nebulization 3x,
no response)
O2 from the start
IV line
asses: Severe -
hospitalized
CXR
One Day Care (ODC)
Oxygen therapy
Oral steroid
Nebulized / 4-6 hour
Observe 8-12 hours,
if stable discharge
Poor response in 12h,
admission
Admission room
Oxygen therapy
Treat dehydration and
acidosis
Steroid IV / 6-8 hours
Nebulized / 2-4 hours
Initial aminophylline IV,
then maintenance
Nebulized 4-6x
good response per 4-6 h
If stable in 24 hours
discharge
Poor response ICU
Discharge
give -agonist
(inhaled/oral)
routine drugs
viral infection:
oral steroid
Outpatient clinic in
24-48 hours
Notes:
In severe attack, directly use -agonist + anticholinergic
If nebulizers not available, use adrenalin SC 0.01 ml/kg/times with maximal dose 0.3 ml/times
Oxygen therapy 2-4 l/min should be early treatment in moderate
and severe attack
Stepwise reliever treatment

Mono drugs, 2 agonist alone
No improvement, combination drug 2
agonist + anti-cholinergic
Clearly severe acute asthma, directly use
combination drug
Pathology
Asthma treatment, step 4b
Symptoms

Patho-phys
Controller
Adaptive
response

Controller

Insults
Controller

If symptoms / attack frequently appear,
i.e. in Frequent episodic asthma or
Persistent asthma
Mechanism: to control airway
inflammation, reduce the airway hyper-
reactivity, not easily triggered
Long term medication, continously,
months up to years
Controller drug
attack

symptom

MPI

Asthma
MPI: Trigger
minimal light,
persistent single
inflammation

inflammation
Trigger
heavy,
combination
Controller drug
Inhaled C-Steroid:




fluticasone (Flixotide, )
budesonide (Pulmicort, )
mometason e
triamsinolone



LABA:
salmeterol
formoterol
Combination: ICS + LABA
Anti-leukotrien:
montelukast
zafirlukast
Stepwise controller treatment

Mono drugs, ICS alone
No improvement, step up i.e combination
ICS + LABA
Inhaled cortico-steroid

Designed as controller
Steroid as reliever systemic
administration (oral OR injection)
ICS as reliever a very common
(mis)practice
o Based on concept: wrong!
o Evidence based medicine???
o High cost!