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Asthma is the most common chronic disease of childhood and the

leading cause of childhood morbidity from chronic disease as


measured by school absences, emergency department visits, and
hospitalizations.
Asthma leads to recurrent episodes of wheezing, breathlessness,
chest tightness and coughing (particularly at night or early morning).
Clinical symptoms in children 5 years and younger are variable and
non-specific.
Widespread, variable, and often reversible airflow limitation.

Asthma Inflammation Cells and Mediators

Mechanism Asthma Inflammation

Source: Peter J. Barnes, MD

Asthma Inflammation

Factors Influencing the Development


and Expression of Asthma
Host factors

Genetic

1. Genes predisposing to atopy


2. Genes predisposing to airway hyper responsiveness
Obesity
Sex

Environmental factors
Allergens
1. Indoor Domestic mites, furred animals (dogs, cats, mice),
cockroach allergens, fungi, molds, yeasts.
2. Outdoor Pollens, fungi, molds, yeasts.
Infections (predominantly viral)
Occupational sensitizers
Tobacco smoke
1. Passive smoking
2. Active smoking
Indoor/Outdoor air pollution
Diet

Risk factors of Asthma in younger children


Sensitization to allergen.

Maternal diet during pregnancy and/ or lactation.

Pollutants (particularly environmental tobacco smoke).

Microbes and their products.

Respiratory (viral) infections.

Psychosocial factors.

Underdiagnosed/
Misdiagnosed
Fear of steroids

Acceptance of
Asthma
diagnosis/label
Heterogenous
Disease/varying
phenotypes

Heavy
nebulisation
Issues in
Pediatric Asthma

Cough or
Wheeze

Choice of right
device

Oral vs. Inhaled

Lack of
knowledge &
time vs.
more patients

Poor patient/
parent
education

Other Challenges
Most of the children are below 5 years of age, who
cannot tell their problems
Parents are proxy story teller, who may mislead
the doctor
PEF cannot be performed in children below 5 years
of age
Fear of addiction to inhalation therapy
Physicians lack of knowledge and time

Clinical Features
Recurrent Wheeze
Recurrent Cough
Recurrent Breathlessness
Activity Induced Cough/Wheeze
Nocturnal Cough/Breathlessness
Tightness Of Chest
Asthma by Consensus, IAP 2003

Symptomatology
Cough 90%
Wheezing 74%
Exercise induced wheeze or
cough 55%

Ind J Ped 2002;69:309-12

Typical features of Asthma


Afebrile episodes
Personal atopy
Family history of atopy or asthma
Exercise /Activity induced symptoms
History of triggers
Seasonal exacerbations
Relief with bronchodilators

Asthma by Consensus, IAP 2003

When does Asthma begin?


By 1 year 26%
1-5 years 51.4%
> 5 years 22.3%
77% Of Asthma
Begins In
Children Less
Than 5 Years

Ind J Ped 2002;69:309-12

Tools to Diagnosis
Good History Taking (ASK)

Careful Physical Examination (LOOK)

Investigations (PERFORM) above 5 years


only
CHILDHOOD ASTHMA by KHUBCHANDANI R.P. et al

History taking (Ask)


Has the child had an attack or recurrent episode of
wheezing (high-pitched whistling sounds when breathing
out)?
Does the child have a troublesome cough which is
particularly worse at night or on waking?
Is the child awakened by coughing or difficult breathing?
Does the child cough or wheeze after physical activity
(like games and exercise) or excessive crying?
Does the child experience breathing problems during a
particular season?
CHILDHOOD ASTHMA by KHUBCHANDANI R.P. et al

History taking (Ask)


Does the child cough, wheeze, or develop chest
tightness after exposure to airborne allergens or
irritants e.g. smoke, perfumes, animal fur?
Does the childs cold frequently go to the chest
If or
thetake
answer
is yes
to any
of the questions,
more than
10 days
to resolve?

a diagnosis
of
asthma
should
be
considered
Does the child use any medication when
symptoms occur? How often?

Are symptoms relieved when medication is used?

CHILDHOOD ASTHMA by KHUBCHANDANI R.P. et al

Physical Examination
(Look)

General Attitude And Well Being


Deformity Of The Chest
Character Of Breathing

Thorough Auscultation Of Breath Sounds


Signs Of Any Other Allergic Disorders On The
Body
Growth And Development Status

CHILDHOOD ASTHMA by KHUBCHANDANI R.P. et al

What all features one should look


for specifically?
Dyspnea
Expiratory wheeze
Accessory muscle movement
Difficulty in feeding, talking, getting
to sleep
Irritability
CHILDHOOD ASTHMA by KHUBCHANDANI R.P. et al

What all features one should look


for specifically?
Cough
Persistent/ recurrent / nocturnal/ exerciseinduced
Associated conditions
Eczema
Allergic Rhinitis
Weight/Height
CHILDHOOD ASTHMA by KHUBCHANDANI R.P. et al

What all investigations can be


performed in asthmatic children?
(PERFORM)
Peak expiratory flow rate: It is highly
suggestive of asthma when:
>15% increase in PEFR after inhaled short
acting 2 agonist
>15% decrease in PEFR after exercise
Diurnal variation > 10% in children not on
bronchodilator
OR
>20% In children on bronchodilator
1. Asthma by Consensus, IAP 2003
2. CHILDHOOD ASTHMA by KHUBCHANDANI R.P. et al

The Early Wheezer (< 3Years)


WALRI (wheeze associated
lower respiratory tract
infections)
or Viral Associated wheeze

Febrile episodes
Personal atopy absent
Family history of asthma /
atopy absent
Variable response to
bronchodilators

Early onset asthma

Afebrile episodes

Personal atopy present

Family history of
asthma / atopy present

Predictable good
response to
bronchodilators

Asthma by Consensus, IAP 2003

Differential diagnosis
Age

Common

Uncommon

Rare

Less
than
6
months

Bronchiolitis
Gastroesophageal
reflux

Aspiration pneumonia
Bronchopulmonary
dysplasia
Congestive heart
failure
Cystic fibrosis

Asthma
Foreign body
aspiration

6
months
2 years

Bronchiolitis
Foreign body
aspiration

Aspiration pneumonia
Asthma
Bronchopulmonary
dysplasia
Cystic fibrosis
Gastro-esophageal
reflux

Congestive heart
failure

2-5
years

Asthma
Foreign body

Cystic fibrosis
Gastro-esophageal

Aspiration
pneumonia

IPAG 2007

Co morbid conditions
Allergic Rhinitis
Colds, ear infections
Sneezing in the morning
Blocked nose, snoring, mouth breathing

Gastro esophageal reflux (GER)


Nocturnal cough followed by vomiting
Eczema

Early Childhood Asthma Diagnosis


(below 6 years)

Diagnostic
Tool

Findings that Support Diagnosis

Differential
diagnosis

The diagnosis of asthma in children under age 6


is primarily
one of exclusion.

Physical
examination

If the child does not appear acutely ill and is


growing, and
there is no evidence specifically indicating
another cause of
symptoms, a trial of therapy is warranted.

Trial of therapy Improvement with treatment supports a


(bronchodilators diagnosis of asthma.
)
Frequent
reassessment

Health care professionals should always be


IPAG 2007
prepared to

Childhood Asthma Diagnosis (6-14


years)

IPAG 2007

Childhood Asthma Diagnosis (614 years)

IPAG 2007

NORDIC CONSENSUS
Confirm Asthma if,
If the child is having 3 attacks of airway obstruction in
last 1 yr.

If the child gets 1 attack of asthmatic symptoms after


the age of 2 yrs.

Irrespective of age in an attack in children with


allergy (eczema, food allergy etc.) or history of atopy.
If the child does not become free of symptoms when
infection has ceased or has persistent symptoms for
more than a month.
Respir Med. 2000;94(4):299-327

IAP GUIDELINES
3 Or More Episodes Of Airflow Obstruction With
Several Of The Following:
Afebrile Episodes
Personal Atopy Or Family H/O Atopy / Asthma
Nocturnal Exacerbations
Exercise/Activity Induced Symptoms
Trigger Induced Symptoms
Seasonal Exacerbations
Relief With Bronchodilators Oral Steroid

Asthma by Consensus, The Indian Academy of Pediatrics 2003

Clinical features that increase the


probability of asthma
More than one of the following symptoms: wheeze, cough,
difficulty breathing, chest tightness, particularly if these
symptoms:
are frequent and recurrent
are worse at night and in the early morning
occur in response to, or are worse after, exercise or other
triggers, such as exposure to pets, cold or damp air, or with
emotions or laughter
occur apart from colds

Personal history of atopic disorder


Family history of atopic disorder and/or asthma
Widespread wheeze heard on auscultation
History of improvement in symptoms or lung function in
response to adequate therapy

BTS 2008

Clinical features that lower the probability of


asthma
Symptoms with colds only, with no interval symptoms
Isolated cough in the absence of wheeze or difficulty breathing
History of moist cough
Prominent dizziness, light-headedness, peripheral tingling
Repeatedly normal physical examination of chest when
symptomatic
Normal peak expiratory flow (PEF) or spirometry when
symptomatic
No response to a trial of asthma therapy
Clinical features pointing to alternative diagnosis

BTS 2008

Asthma Treatments
Classified into Controllers and Relievers

Controllers medications to be taken on daily long term basis.

Relievers medications to be used on as-needed basis to


relieve symptoms quickly.

Asthma management and prevention

The goals for successful management of asthma are

1. Achieve and maintain control of symptoms

2. Maintain normal activity levels, including exercise

3. Maintain pulmonary function as close to normal as possible

4. Prevent asthma exacerbations

5. Avoid adverse effects from asthma medications

6. Prevent asthma mortality

Assess, Treat and Monitor Asthma


The goal of asthma treatment can be reached in most patients
through a continuous cycle that involves assessing, treating and
monitoring asthma.
Each patient should be assessed to establish his/her current
treatment regimen, adherence to the current regimen, and level of
asthma control.
Each patient is assigned to one of five treatment steps.
At each treatment step, reliever medication should be provided for
quick relief of symptoms as needed.

To summarize
Diagnosis
Asthma is an inflammatory illness
Diagnosis of asthma is clinical, and relies on history
All asthma does not wheeze
In children < 3 yrs, WALRI is an important differential diagnosis
2 out of 3 children outgrow their asthma
A family history of asthma / atopy increases risk of asthma

To summarize
Long term management
Patient education is a very important part of asthma management
Drugs control, but do not cure asthma
Clinical grading over time, decides long term management plan
Mild intermittent asthma does not merit controllers
Inhaled steroids are mainstay of long term asthma management
Treatment should be stepped up or stepped down depending upon
patient response

Thank You