Asthma in Children

Diagnosis dan Management

Roni Naning
Departement of Child Health
Faculty of Medicine
Universitas Gadjah Mada
Yogyakarta
A 7-year old girl presents to an outpatient clinic
Has history of wheezing and rhinitis since infancy.
Over the past 2 years her symptoms have worsened.
Complains of coughing and short of breath daily
Claims to awaken at least once a week in the middle of
the night by these symptoms.
A case of Mareta
History of medication:
Salbutamol puffer daily and requires monthly
refills.
In the past year she has had 4 courses of
prednisone

Family history: maternal asthma

Physical examination findings:
inflamed nose, mild wheezing, otherwise
unremarkable.
What makes you think this is
ASTHMA ?
SUSPECT ASTHMA IF:
Intermittent wheezing, cough, dyspnea.
Increased rate of breathing.
Symptoms worse at night and in early
morning.
History of medication
History of maternal asthma
Associated with triggers

What is asthma?
Various definition of asthma is used across countries
The history.
REVERSIBLE AIRFLOW OBSTRUCTION
SPONTANEOUSLY OR UNDER TREATMENT
BRONCHIAL HYPERRESPONSIVENESS
CHRONIC CONDITION, RECURRENT
BRONCHOSPASM, NARROWING AIRWAY DUE
TO STIMULI
AIRWAY INFLAMMATORY LESION, CELLULAR
INFILTRATE, SUBMUCOSAL WALL OEDEMA,
FIBROSIS
1950:
1960:
1970:
1990:
PNAA Asthma Definition
Recurrent wheezing and/or cough with tends
episodic, 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 : Pedoman Nasional Asma Anak, 2004
A condition in which episodic wheezing
and/or cough occurred in a clinical setting
where asthma was likely and other, rarer
condition had been excluded
International Pediatric Asthma Consensus Group. Arch Dis Child 1992;67:240-8

International Pediatric Consensus Statement on the
Management of Childhood Asthma
Recurrent wheezing and/or persistent
coughing in a setting where asthma is likely
and other rarer condition has been excluded
Warner et al. Pediatr Pulmonol 1998;25:1-7
1989:
1992:
1998:
National Asthma Council
(Australia, 2006)
chronic inflammatory disorder of the airways
which causes recurrent episodes of wheezing,
breathlessness, chest tightness and coughing.
These episodes are reversible with
appropriate treatment

Global Initiative for Asthma (GINA) 2011
Asthma is a chronic inflammatory disorder of the airway
in which many cells and celluler elements play a role.

The chronic inflammation is associated with airway
hyperesponsioveness which leads to recurrent episodes
of wheezing, coughing, and shortness of breath.

The episodes are associated with widespread but
variable airflow obstruction that is often reversible
either spontaneously or with treatment.
Epidemiology
Asthma is a problem worlwide, around 300 million
individuals are affected
Problems in determine the burden of asthma in children
a lack of uniform definition of asthma
different methods (population, measurement) among
studies
a lack of objective measurement the use of lung
function test ?

are likely to have asthma
(United States)



On average, 3 children in a classroom of 30
are likely to have asthma
(Australia)
On average, 10 children in a classroom of 40
Pediatric asthma prevalence in Indonesia

Djajanto (Jakarta,91) 6 12 yrs 16,4%
Naning (Yogya, 1991) 6 12 yrs 4,8%
Rosmayudi (Bandung,93) 6 12 yrs 6,6%
Dahlan (Makasar, 1996) 6 12 yrs 17,4%
Arifin (Palembang, 1996) 13 15 yrs 5,7%
Rosalina I (Bandung,1997) 13 15 yrs 2,6%
Rochman (Yogya, 1998) junior HS 10,5%
Kartasasmita (Bandung,2002) 6 7 yrs 3,0%
13 14 yrs 5,2%
Rahajoe (Jakarta,2002) 13 14 yrs 6,7%

Emergency department visits for asthma per 100 people with
asthma, by age group and sex, New South Wales and Victoria, July
1999 to June 2004 (AIHW, 2005)
Hospital separations for asthma per 100,000 population, by
age group, Australia, 19932005 (AIHW, 2005)

an attempt to standardize the methodology and definition
Measured a prevalence of current wheeze
Have you (has your child) had wheezing or whistling
in the chest in the past 12 months?
International study
on Asthma & Allergies in Childhood (ISAAC)

Phase 1
(1992-1998)
Phase 3
(1999-2004)
6-7 year age group 4.1% - 32.1% 2.8% 22.2%
13-14 year age group 2.1% - 35.1% 3.4% - 31.2%
MORTALITY
Rare and preventable
Annual death rate from asthma
international (age 5-34 yo):
0.5 to 2.0/100,000 75% of these have occurred
in children aged 5-14 years (Sears, 1991)
Australia (age 5-34 yo): 0.37/100,000
US (age 0-17 yo): 0.3/100,000
Mechanisms Underlying the Definition of Asthma

Risk Factors
(for development of asthma)

INFLAMMATION
Airway
Hyperresponsiveness
Airflow Obstruction
Risk Factors/trigger
(for exacerbations)
Symptoms
www.nature.com/nri/journal/v2/n2/images/nri725-f1.gif
Immunopathophysiology of Asthma
Features of Asthma
What is your differential
diagnosis ?
Recurrent wheezing can be caused by:
Bronchiolitis
Pneumonia
Cystic Fibrosis
Cardiac disease
GERD
Foreign body aspiration
Congenital malformation of intrathoracic
airway

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
What is your work up?
Asthma diagnosis
History and patterns of symptoms
Physical examination
Measurements of lung function
Measurements of allergic status to identify
risk factors

History taking
Does the child have:
Recurrent episodes of wheezing ?
Troublesome cough at night ?
Cough, wheeze or chest tightness after exposure
to the triggers (e.g. exercise, airborne allergens or
pollutants) ?
Colds go to the chest or take more than 10 days
to clear ?
Symptoms improved by appropriate asthma
treatment ?


Physical examination
Tachypnoea
Prolonged Expiration
Accessory muscles
Wheeze
Hyperinflation
Increase AP diameter


Peak flow meter
Spirometry
Lung Function Test
Bronchodilator test in asthma:
FEV1 improves > 12% after administration of bronchodilator
How would you classify Mareta's
asthma severity ?
Patterns of asthma in children
infrequent episodic ~ 65-75%
frequent episodic ~ 20-25%
persistent ~ 5-10%
Infrequent episodic asthma
episodes 6-8 weeks or more apart
attacks generally not severe
symptoms rare in between attacks
normal examination and lung function
between attacks
> 6 weeks
Frequent episodic asthma

attacks < 6 weeks apart
attacks more troublesome
minimal or no symptoms between attacks
normal examination and lung function
between attacks
often seasonal (winter months)
< 6 weeks
Persistent asthma
symptoms between attacks
sleep disturbance > 1 night/week
exercise induced wheeze / limitation
use of beta
2
agonists > 3 times per week
abnormal lung function between attacks
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

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
Pediatric Asthma classification
What is the best way to treat
Mareta today?
Component of patient management
1. Develop patient/doctor partnership
2. Identify and reduce exposure to risk
factors
3. Assess, treat, and monitor asthm
4. Special Consideration
1.Develop patient/doctor partnership
2. Identify and reduce exposure to risk factors
Asma Triger
3. Assess, treat, and monitor asthma
Management
Non-pharmacological
Allergen avoidance
House dust mite
Pets
Passive smoke exposure

Pharmacological
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
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)
3. Assess, treat, and monitor asthma
Pharmacologic treatment of asthma in children
Infrequent
episode
Reliever as
needed
Persistent
reliever as needed
Controller :
inhaled
corticosteroid
Oral
corticosteroid

Frequent episode
Reliever as needed
Controller : inhaled
corticosteroid
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
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
budesonide
mometason e
triamsinolone



LABA:
salmeterol
formoterol
Combination: ICS + LABA
Anti-leukotrien:
montelukast
zafirlukast
Manage asthma exacerbations
Asthma exacerbation:
Episodes of rapidly progressive increase
in shortness of breath, cough, wheezing
or chest tightness or some combination of
these symptoms
Characterized by decrease of expiratory
airflow PEF or FEV1
The severity of asthma attack
Mild Moderate Severe
Respiratory
arrest imminent
Breathless Walking


Talking
Infant softer
shorter cry;
difficulty feeding
At rest
Infants stop
feeding
Can lie down Prefers sitting Hunched forward
Talks in Sentences Phrases Words
Alertness May be agitated Usually agitated Usually agitated Drowsy or
confused
Respiratory rate Increased Increased Often > 30 / min
Normal rates of breathing in awake children:
Age Normal rate
< 2 mo < 60 x / min
2 12 mo < 50 x / min
1 5 y < 40 x / min
6 8 y < 30 x / min
Mild Moderate Severe
Respiratory
arrest
imminent
Accessory
muscles and
suprasternal
retractions
Usually not Usually Usually Paradoxical
thoraco-
abdominal
movement
Wheeze Moderate, often
only end expiratory
Loud Usually loud Absence of
wheeze
Pulse / min < 100 100 - 120 > 120 Bradycardia
Guides to limits of normal pulse rate in children
Infants 2 12 mo - Normal rate < 160 x / min
Preschool 1 2 years < 150 x / min
School age 2 8 years < 110 x / min
Mild Moderate Severe
Respiratory
arrest imminent
Pulsus
paradoxus
Absent
< 10 mmHg
May be present
10- 25 mmHg
Often present
> 25 mmHg (adult)
20 40 mmHg
(child)
Absence
suggests
respiratory
muscle fatigue
PEF
after initial
bronchodilator
% predicted or
% personal best
Over 80%
Approx. 60-
80%
< 60% predicted or
personal best
(< 100 L/min adults)
or
Response lasts < 2 h
PaO2 (on air)* Normal
Test not ussually
necessary
> 60 mmHg < 60 mmHg

Possible cyanosis
And/or
PaCO2 (on air)* < 45 mmHg < 45 mmHg > 45 mmHg;
possible respiratory
failure

Mild Moderate Severe
Respiratory
arrest
imminent
SaO2 % (on
air)*
> 95 % 91 95 % < 90 %
Hypercapnia (hypoventilation) develops more readily in
young children than in adults and adolescents

The presencce of several parameters, but not necessarily all, indicates the general
classification of the exacerbation
* Note: kilopascals are also used internationally; conversion would be appropriate in this
regard
GINA, 2002 (revised)
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
Longterm management
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
Algoritma tatalaksana jangka panjang
6-8 minggu
obat, dosis/minggu
> 3x < 3x
(+)
(-)
6-8 minggu,
respons
Obat pereda: -agonis kerja cepat
(hirupan/oral) dan/atau teofilin oral
bila perlu
Asma episodik jarang

Tambahkan obat pengendali:
Dosis rendah ICS 100-200 atau kromolin hirupan*)
Asma
episodik sering

Obat pengendali dengan steroid hirupan
Dosis 200-400 mg
Obat pereda: diberi bila perlu
6-8 minggu,
respons (-) (+)
P
E
N
G
H
I
N
D
A
R
A
N
Step
up
1-3 bl
1-3 bl
1-3 bl
Naikkan dosis
steroid hirupan >800 mg
Tambahkan steroid oral
Catatan :
*) Ketotifen/cetirizin dapat ditambahkan pada pasien asma yang disertai rinitis
6-8 minggu,
respons
(-) (+)
6-8 minggu,
respons
(-)
(+)
6-6 minggu,
respons
(-)
(+)
ICS 400-600 mg
Tambahan salah satu obat :
-agonis kerja panjang
-agonis lepas terkendali
Teofilin lepas lambat
Antileukotrin
Asma persisten
P
E
N
G
H
I
N
D
A
R
A
N
Step
down
1-3 bl
1-3 bl
1-3 bl
Inhaler devices
MDI
MDI+Spacer
MDI+Spa
cer (baby
haler)
Nebulizer
Choosing inhaler devices for children with asthma
When it doesnt seem right!
( inadequate response to appropriate dose of ICS )
non-adherence / poor technique
consider risk benefit
misinterpretation of respiratory symptoms
as asthma
check the diagnosis

Level of Asthma controll
Characteristic



Day symptoms


Limitation of
activities


Nocturnal
symptom/
awakening

Need for
reliever/rescue
treatment

Lung function (PEF
or FEV1)

Exacerbations
Controll (all of the
following)


None (twice or
less/week)


None


None



None (twice or
less/week)


Normal


None
Partly controll (any
measure present in
any week)

More than
twice/week


Any


Any



More than
twice/week

< 80% predict or
personal best (if
known)

One or more/year
Uncontrolled



Three or more
features or partly
controlled asthma
present in any
week













One in any week
Asthma attacks
Stable asthma
(No attack)
Infrequent
episodic
Frequent
episodic
Persistent
Reliever (+)
Controller (-)
Reliever (+)
Controller (+)
Reliever (+)
Controller (+)
Assess the severity of
attacks
Assess class of
disease
EDUCATION and AVOIDANCE
Thanks for
your attention