Bronchial Asthma

• Chronic allergic inflammatory disorder of resp. tract

• Hypersensitivity of trachea & bronchi against immunologic &

non immunologic stimuli
• Leads to:

• Recurrent episodes of wheezing

• Breathlessness

• Chest tightness

• Cough (particularly at night or early morning)

 Bronchial Asthma

• Affects 5-10% children

• 50% 1-3 yr

• 80-90% children between 4-5y experience once

• Most common, widespread, variable & often

reversible airflow limitation
Risk Factors
Asthma Inflammation – Cells and Mediators
Mechanism – Asthma Inflammation

Source: Peter J. Barnes, MD

Asthma Inflammation
 Underdiagnosed/
Misdiagnosed Acceptance of
Fear of steroids Asthma
diagnosis/label

Heterogenous
Heavy
Disease/varying
nebulisation
phenotypes
Issues in
Pediatric Asthma

Choice of right Cough or

device Wheeze

Poor patient/
Oral vs. Inhaled Lack of parent
knowledge & education
time vs.
more patients
TYPES OF REACTION
TYPES OF ASTHMA
 CLINICAL MANIFESTATIONS
• Simple cough to Recurrent Wheeze
• Symptoms may develop with seasonal
change or exercise
• Acute with cold to Paroxysmal nocturnal
cough
• Early dry cough, prolonged expiration &
wheeze
• Accessory exp. Muscles→ Sweating,
Cyanosis & Fatigue
 CLINICAL MANIFESTATIONS
• Hyper-resonance
• Silent chest – a poor sign
• Severe hypoxia → severe cyanosis & Cardiac
arrhythmia
• Pulsus paradoxus – critical case
• Segmental collapse
• Barrel chest in chronic & intermittent dis.
• No clubbing in absence of complication
 DIAGNOSIS
• Recurrent wheeze
• Intermittent episodes of cough
• Cough after exercise
• Clear & mucous sputum, yellowish due to
eosinophils
• Chronic paroxysmal cough →‫استمایمخفی‬
 Lab. Exams
BLOOD:
•Eosinophilia= 250-400 cells/mm3
•Allergic, vasomotor, obs. Lung dis.
•↓ In infective Asthma or tx. With steroid
•Normal serum Ig but ↑ Ig E
 Lab. Exams
CXR:
•Bilateral & symmetric air
trap.
•Patchy atelectasis show
bronchospasm & mucous
plaques
•Pulmonary HTN
•Peribronchial &
Perivascular marking
 Lab. Exams
Indications for CXR:
•Fever
•Unilateral chest findings
•Suspected pneumothorax
•HR > 160/min
•↓ Resp. sounds
•Mechanical ventilation
Differential Dx.
Status Asthmaticus
 Hospitalization criteria
• Status asthmaticus
• History of bad episodes
• ICU hospitalization in recent 1 yr
• Multiple episodes of mod. to severe asthma in several days
despite appropriate tx.
• Tachycardia
• Fluid & oral drug intolerance
• Decreased consciousness
• Hypercapnea, Hypoxemia
• Atelectasis
 Mx. of Acute episode
• O2 by mask or nasal prong
• Sulbatamol inhalation:
• 1st safe & effective drug
• 0.5 mg/kg/dose every 20-30min.
• SE: Tachycardia, Arrhythmia, CNS stimulation,
Hypokalemia & irritability
• Adrenalin 1/1000 sol.:
• 0.01ml/kg S.C every 20 min up to 3 times
• SE: Palor, Tremor, Headace & Arrhythmia
 Mx. of Acute episode
• Turbutalin: Choice B2 antagonist
• 1/1000 sol., 0.01ml/kg/dose S.C every 20 min.
• Aminophylline:
• IV, 5mg/kg/dose over 15 mins with 25ml Dextrose
10% / 6-8hr.
• Rapid injection: Arrhythmia, Hypotension & death
• Corticosteroids:
• Hydrocortisone, 5-10mg/kg/d or inhaled steroid
 Mx. of Acute episode
• Mg Sulphate:
• 30-50mg/kg inf. over 30 mins.
• Check BP after 10, 30 min & 4hr.
• If no response after 1hr, Sulbatamol inhalation
with ipratropium, 250 mic. gr every 20 min
• Fluids
• Antibiotics
 Status asthmaticus
• ICU
• O2: 2-3lt/min to save 70-90mmHg or sat. >92%
• Hydration 1.5x. Normal Saline or Glucose
• Neubolization every 20min
• Aminophylline 5-7mg+25ml dextrose 5%/6h
• Corticosteroides: Hydrocortisone 5-10mg/kg
• Terbutaline: 0.01mg/kg S.C or IV
 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 child’s cold frequently ‘go to the chest’ or take more
If than
the10answer is ‘yes’ to any of the questions,
days to resolve?
a• diagnosis
Does the child of
use asthma should
any medication when be considered
symptoms occur?
How often?

• Are symptoms relieved when medication is used?

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/ exercise-induced

Associated conditions
• Eczema
• Allergic Rhinitis

 Weight/Height

CHILDHOOD ASTHMA by KHUBCHANDANI R.P. et al

How to rule out the mimics?
 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

 GINA
• The following symptoms are highly suggestive of a diagnosis of
asthma:
– frequent episodes of wheeze (more than once a month)
– activity-induced cough or wheeze
– nocturnal cough in periods without viral infections
– absence of seasonal variation in wheeze
– symptoms that persist after age 3

• A simple clinical index based on:

– presence of a wheeze before the age of 3
– presence of one major risk factor (parental history of asthma
or eczema) or two of three minor risk factors (eosinophilia,
wheezing without colds, and allergic rhinitis) has been
shown to predict the presence of asthma in later childhood

Global Initiative for Asthma 2008

 GINA
• A useful method for confirming the diagnosis of asthma in
children 5 years and younger is a trial of treatment with short-
acting bronchodilators and inhaled glucocorticosteroids

• Children 4 to 5 years old can be taught to use a PEF meter, but

to ensure reliability parental supervision is required

• Use of spirometry and other measures recommended for older

children such as airway responsiveness and markers of airway
inflammation is difficult and several require complex
equipment making them unsuitable for routine use

GINA 2008
 BTS

• Initial assessment of children suspected of having asthma

should be based on:
– presence of key features in the history and clinical examination
– careful consideration of alternative diagnoses

• Using a structured questionnaire may produce a more

standardised approach to the recording of presenting clinical
features and the basis for a diagnosis of asthma

British Thoracic Society 2008

 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 Phenotypes
 Classification of Asthma
• The goal of the treatment is to achieve and maintain control for
prolonged periods with due regard to the safety of treatment, potential for
adverse effects, and the cost of treatment required to achieve this goal.

• Assessment of asthma control should include control of the clinical

manifestations, control of the expected future risk to the patient such as
exacerbations, accelerated decline in the lung function, and side-effects
of the treatment.

• The achievement of good clinical control of asthma leads to reduced risk

of exacerbations.
 Controlled Partly controlled
Characteristic Uncontrolled
(All of the following) (Any present in any week)

More than
Daytime symptoms None (2 or less / week)
twice / week

Limitations of activities None Any

3 or more features of
Nocturnal symptoms /
None Any partly controlled
awakening
asthma present in any
Need for rescue / More than
None (2 or less / week) week*
“reliever” treatment twice / week

< 80% predicted or

Lung function#
Normal personal best (if known)
(PEF or FEV1)
on any day

* Exacerbation
Any exacerbation should be prompt review ofNone Onethat
maintenance treatment to ensure oritmore / year
is adequate. 1 in any week
#
Lung function is not a reliable test for children 5 years and younger . GINA 2009
 Levels of Asthma Control in Children 5 years and younger
Characteristic Controlled (All of the following)
Daytime symptoms None
– wheezing, cough, (less than twice/week, typically
difficult breathing for short periods of on the order
minutes and rapidly relieved by
use of a rapid-acting
bronchodilator)
Partly Controlled (Any
measure present in any
week)
More than twice/week
(typically for short periods
on the order minutes and
rapidly relieved by use of a
rapid-acting bronchodilator)
Uncontrolled
(Three or more of features of
partly controlled asthma in any
week)
More than twice/week
(typically last minutes of hour or
recur, but partially or fully
relieved with rapid-acting
bronchodilators)

Limitation of None Any Any

activities (child is fully active, plays and (may cough, wheeze, or (may cough, wheeze, or have
runs without limitation or have difficulty breathing difficulty breathing during
symptoms) during exercise, vigorous exercise, vigorous play or
play or laughing) laughing)

Nocturnal None Any Any

symptoms/ (no nocturnal coughing during (typically coughs during (typically coughs during
awakening sleep) sleep/wakes with cough, sleep/wakes with cough,
wheezing and/or difficult wheezing and/or difficult
breathing) breathing)

Need for Less than/equal to 2 days/week > 2 days/week > 2 days/week

reliever/rescue
treatment
 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 treatment can be administered in different ways – inhaled,
oral, or by injection.
• Advantage of inhaled therapy - drugs are delivered directly into the
airways, producing higher local concentrations with significantly less
risk of systemic side effects.
• Inhaled medications for asthma are available as pressurized MDIs,
DPIs, soft mist inhalers and nebulized or ‘wet’ aerosols.
• CFC inhaler devices are being phased out due to the impact of CFCs
upon the atmospheric ozone layer, and are being replaced by HFA
devices.
• Choosing an inhaler device for children with asthma *-

Age group Preferred device Alternative device

Pressurized metered-dose inhaler

Younger than 4 years plus dedicated spacer with face Nebulizer with face mask
mask

Pressurized metered-dose inhaler

4-5 years plus dedicated spacer with Nebulizer with mouthpiece
mouthpiece

Dry powder inhaler or breath

actuated pressurized metered-
dose inhaler or pressurized Nebulizer with mouthpiece
Older than 6 years
metered-dose inhaler with spacer
with mouthpiece

*
Based on efficacy of drug delivery, cost effectiveness, safety, ease of use, and convenience . GINA 2009
 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

Five interrelated components of therapy are required to achieve
and maintain control of asthma-

1. Develop Patient/Doctor partnership

2. Identify and reduce exposure to risk factors

3. Assess, treat, and monitor asthma

4. Manage asthma exacerbations

5. Special considerations
 Develop Patient/Doctor partnership -
• Effective management of asthma requires the development of a

partnership between the person with asthma and the health care

team.

• Patients can learn to –

1. Avoid risk factors

2. Take medications correctly

3. Understand the difference between controller and reliever

medications

4. Monitor their status using symptoms and, if relevant, PEF

5. Recognize signs that asthma is worsening and take action

6. Seek medical help as appropriate

• Education should be integral part of all interactions between health care
professional and patients.

• Using variety of methods such as discussions, demonstrations, written

materials, group classes, video/audio tapes, dramas and patient support
groups helps reinforce educational messages.

• Health care professional and patients should prepare a written personal

asthma action plan that is medically appropriate and practical.

• Additional self-management plans can be found on –

1. www.asthma.org.uk
2. www.nhlbisupport.com/asthma/index.html
3. www.asthmaz.co.nz
Identify and reduce exposure to risk factors -
• Measures to prevent the development of asthma and asthma
exacerbations by avoiding or reducing exposure to risk factors
should be implemented wherever possible.

• Reducing patients exposure to some categories of risk factors

improves the control of asthma and reduces medication needs.
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.
• Inhaled medications are preferred because they deliver drugs
directly to the airways where they are needed, resulting in
potent therapeutic effects with fewer systemic side effects.

• Inhaled medications for asthma are available as pressurized

MDIs, breath actuated MDIs, DPIs and nebulizers.

• Spacer devices make inhalers easier to use and reduce

systemic absorption and side effects of ICS.

• Patients should be demonstrated about the use of devices.

• Monitoring is essential to maintain control and establish the lowest step and
dose of treatment to minimize cost and maximize safety.

• If asthma is not controlled, step up the treatment. Improvement is generally

seen within 1 month.

• If asthma is partly controlled, consider stepping up treatment, depending

more effective options available, safety and cost of possible treatment and
patient’s satisfaction with the level of control achieved.

• If controlled asthma is maintained for at least 3 months, step down with a

gradual, stepwise reduction in treatment. The goal is to decrease treatment
to the least medication necessary to maintain control.
 Asthma management approach based on control
for children 5 years and younger

Asthma education, Environmental approach, and as needed rapid acting beta -agonists

Uncontrolled or only partly

Controlled on as needed rapid Partly controlled on as needed
controlled on low - dose inhaled
acting beta2-agonists rapid acting beta2-agonists
glucocorticosteroid

Controller options

Continue as needed rapid acting Low – dose inhaled Double Low – dose inhaled
beta2-agonists glucocorticosteroid glucocorticosteroid

Low – dose inhaled

Leukotriene modifier glucocorticosteroid plus Leukotriene
modifier
 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