G lobal INitiative for A sthma

Objectives

 To discuss: • Overview

• Manifestations
• Risk factors

• Diagnosis
• Classification • Treatment

Objectives

 To discuss: • Overview

Overview

 300 M individuals are affected worldwide

 most common chronic disease of childhood
 leading cause of childhood morbidity from chronic disease  Typically begins in early childhood, with earlier onset in males than females  Atopy is present in the majority of children over 3 years of age with asthma

Objectives

 To discuss: Overview

• Manifestations

Manifestations

• • •

Symptoms Episodic breathlessness Wheezing


Cough
Chest tightness

Manifestations

• • •

Physical Examination

May be normal
Wheezing on auscultation


• • • •

Cyanosis
Drowsiness Difficulty speaking Tachycardia Hyperinflated chest

Use of accessory and intercostal muscles

Objectives

 To discuss: Overview

Manifestations
• Risk factors

Risk Factors
 HOST FACTORS • Genetic • Obesity • Sex  ENVIRONMENTAL FACTORS • Allergens
House dust mites Companion animal allergens Cockroaches Fungi

• • • •

Infections Occupational sensitizers Pollutants Tobacco smoking

Recommendations

 Avoid maternal smoking during pregnancy  Avoid exposing children to atmospheric pollution and particularly tobacco smoke  Avoid unnecessary use of antibiotics in young children  Provide a calm and nurturing environment

Objectives

 To discuss: Overview

Manifestations
Risk factors

• Diagnosis

Diagnosis

 Asthma diagnosis in childhood is difficult

 Respiratory symptoms (wheezing and cough) also common in children without asthma
 Not possible to routinely assess airflow limitation (spirometry)

Diagnosis

 can often be made based on symptom patterns and on a careful clinical assessment of family history and physical findings.  Typical symptom pattern: recurrent, during sleep, or with triggers such as activity, laughing or crying  The presence of atopy or allergic sensitization provides additional predictive support.

Diagnosis

No specific test for diagnosis The enhance diagnostic confidence:
• Spirometry (FEV1 /FVC ≤80%) • Peak Expiratory Flow (20% improvement afterbronchodilator or diurnal variation of ≥20%) • Tests for atopy (skin test w/ allergen)

Objectives

 To discuss: Overview

Manifestations
Risk factors

Diagnosis
• Classification

Classification

Characteristic
Daytime symptoms:
wheezing, cough, difficult breathing

Controlled

Partly contolled
(any measure present in any week)

Uncontrolled
(>3 features of partly controlled present in any week)

>Twice a week None
( < 2x/week)

>Twice a week

Limitations of activities Nocturnal symptoms or awakening Need for reliever/rescue

None

Any
(cough, wheeze or difficulty breathing,during exercise, play or laughing)

Any

None
(including no nocturnal coughing during sleep)

Any
(coughs during sleep or wakes with cough, wheezing, and/or difficult breathing)

Any

< 2 days/week

> 2 days/week

> 2 days/week

Classification

Asthma is controlled (all of the following):  No (or minimal)* daytime symptoms  No limitations of activity (Child is fully active,

plays and runs without limitations of symptoms)
coughing during sleep)

 No nocturnal symptoms (including no nocturnal

 No (or minimal) need for rescue medication
_________
* Minimal = twice or less per week

Classification

Asthma is uncontrolled:  Daytime symptoms >2 times/week (last minutes or

hours or recur)

 Any limitations of activity (May cough, wheeze or

have difficulty breathing during exercise, vigorous play, or laughing)

 Any nocturnal symptoms (typically coughs during

sleep or wakes with cough, wheezing, and/or difficult breathing)

 Need for rescue medication > 2 days/week

Objectives

 To discuss: Overview

Manifestations
Risk factors

Diagnosis
Classification • Treatment

Treatment Choosing an Inhaler Device
Age group Younger than 4 years Preferred device
Pressurized metereddose inhaler plus dedicated spacer with face mask

Alternative device
Nebulized with face mask

4-6 years

Pressurized metereddose inhaler plus dedicated spacer with mouth piece

Nebulizer with mouthpiece or face mask

Older than 6years

Dry powder inhaler or breath-actuated pressurized MDI or pressurized MDI w/ spacer and moutpiece

Nebulizer with mouthpiece or face mask

Treatment
Environmental control As needed rapid-acting β2-agonists
Controlled on as needed rapid-acting β2agonists Partly controlled on as needed rapid-acting β2agonists Uncontrolled on β2-agonists prn. or partly controlled on a low-dose inhaled glucocorticosteroid

Controller options
Continue as needed rapid-acting β2-agonists

Low-dose inhaled glucocorticosteroid
Leukotriene modifier

Double low-dose inhaled glucocorticosteroid
Low-dose inhaled glucocorticosteroid plus leukotriene modifier

Oral glucocorticosteroids should be used only for treatment of acute severe exacerbations of asthma. Green shaded boxes represent the preferred treatment options.

Treatment
Low daily doses of inhaled glucocorticosteroids* Daily dose
100 µg

Drug

Beclomethasone dipropionate

Budesonide pMDI+spacer Budesonide nebulized
Ciclesonide Fluticasone propionate

200 µg 500 µg
NS 100 µg

Mometasone furoate
Triamcinolone acetonide
*

NS
NS

Doses found to be without adverse systemic effects in clinical trials

Key Messages: Pharmacologic Therapy
 A pressurized metered dose inhaler with a valved spacer (with or without a face mask depending on the child’s age) is the preferred delivery system (Evidence A).
 A low-dose inhaled glucocorticosteroid is recommended as the preferred initial treatment to control asthma (Evidence A).  If low-dose inhaled glucocorticosteroid does not control symptoms, and the child is using optimal technique and is adherent to therapy, doubling the initial dose of glucocorticosteroid may be the best option (Evidence C).
(….continued)

Key Messages: Pharmacologic Therapy
 When doubling the initial dose of inhaled glucocorticosteroid fails to achieve and maintain asthma control, the child’s inhalation technique and compliance with the medication regimen should be carefully assessed and monitored.  Use of oral glucocorticosteroids should be restricted to the treatment of acute severe exacerbations, whether viral-induced or otherwise.  To avoid under and over-treatment continued need for asthma treatment should be regularly assessed (e.g., every three to six months).

Key Messages: Pharmacologic Therapy
Several trials have found little or no effect of intermittent treatment of wheezing episodes with:

× Oral glucocorticosteroids × Montelukast × Inhaled glucocorticosteroids

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