• 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.
Factors Influencing the Development and Expression of Asthma
Host factors –
Genetic
1.Genes predisposing to atopy
2. Genes predisposing to airway hyper responsiveness
3.Obesity
4.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 [email protected]
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 [email protected]
The prevalence of childhood asthma has continued to increase on the Indian subcontinent over the past 10 yrs
ISAAC Phase 3 Thorax 2007;62:758
Epidemiological trend Bronchial Asthma Global Burden of AsthmaAround 300 m. patients (currently)Expected by 2025: 100 m. additionalLoss of DALYs : About 15 m./year (around 1% of all DALYs lost) Accounts for in every 250 deaths• Considerable economic costsThe UK has one of the highest prevalences for childhood
asthma internationally, with about 15% children affected.The prevalence is 8-10 times higher in developed countries
than in developing countries.
The prevalence of 'any wheeze' over recent months (usually taken as within the last year) amongst children has risen from about 10% in the 1960s to 20-30% in the 1990s. There is some evidence of a possible flattening of this rise from the late 1990s onwards. An increasing percentage of currently wheezing children also have a diagnosis of asthma.
There is still a significant morbidity associated with the disease, particularly severe childhood asthma, despite therapeutic advances.
Prevalence is higher in lower socioeconomic groups in urban areas.
There are gender differences. Boys are affected more before puberty (3 times greater prevalence). Prevalence is equal in adolescence, but adult-onset asthma is more common in women.
The increasing prevalence of asthma is mirrored by the increasing prevalence of childhood obesity. Prospective studies suggest that obesity increases the risk of subsequent asthma, although the underlying mechanisms are unclear, but obesity also increases the clinical severity of asthma and reduces quality of life for childrenwith [email protected]
The overall burden of Asthma in India is estimated at more than 15 million .
According to the study done by A.Anuradha1, V.Lakshmi Kalpana1,S.Narsingara. et al. The type of asthma is distributed as cough-variant-asthma (50.83%), nocturnal asthma (17.5%), allergic asthma (20.83%) and occupational asthma (10.83%). Regarding family history,59.16% showed genetic predisposition irrespective of sex. Among asthmatics, 20% were having atopicdermatitis. Twenty-five percent were smokers, 20% were alcoholics and 44.16% were with diabetics.
Advancing age, usual residence in urban area and lower socio-economic status were associated with significantly higher odds of having asthma. The present study shows that asthma is an important public health issue in urban areas.
Asthma Burden in Developing countries (INDIA)1. Wide variations – High magnitude2. Increase in prevalence with rapid
industrialization and urbanization3. High levels of pollution – important role4. Role of infections, smoking and under-
nutrition5. Under diagnosis and under treatment6. Limited drug availability7. Difficulties of management at different levels
of health-care
Fear of steroids
Heavynebulisation
Choice of right device
Oral vs. Inhaled Lack of knowledge &
time vs. more patients
Poor patient/parent
education
Cough or Wheeze
Heterogenous Disease/varying
phenotypes
Acceptance of Asthma
diagnosis/label
Underdiagnosed/Misdiagnosed
Issues in Pediatric Asthma
Other ChallengesMost 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 FeaturesRecurrent Wheeze
Recurrent Cough
Recurrent Breathlessness
Activity Induced Cough/Wheeze
Nocturnal Cough/Breathlessness
Tightness Of Chest
Asthma by Consensus, IAP [email protected]
SymptomatologyCough – 90%Wheezing – 74%Exercise induced wheeze or cough – 55%
Ind J Ped 2002;69:[email protected]
Typical features of AsthmaAfebrile episodes
Personal atopy
Family history of atopy or asthma
Exercise /Activity induced symptoms
History of triggers
Seasonal exacerbations
Relief with bronchodilatorsAsthma 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:[email protected]
Tools to DiagnosisGood History Taking (ASK)
Careful Physical Examination (LOOK)
Investigations (PERFORM) – above 5 years only
CHILDHOOD ASTHMA by KHUBCHANDANI R.P. et [email protected]
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 [email protected]
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 than 10 days to resolve?
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
If the answer is ‘yes’ to any of the questions, a diagnosis of asthma should be considered
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 [email protected]
What all features one should look for specifically?DyspneaExpiratory wheezeAccessory muscle movementDifficulty in feeding, talking, getting to sleepIrritability
CHILDHOOD ASTHMA by KHUBCHANDANI R.P. et [email protected]
What all features one should look for specifically?CoughPersistent/ recurrent / nocturnal/ exercise-
induced
Associated conditionsEczemaAllergic Rhinitis
Weight/Height
CHILDHOOD ASTHMA by KHUBCHANDANI R.P. et [email protected]
How to rule out the mimics?
The Early Wheezer (< 3Years)Early onset asthma
Afebrile episodes
Personal atopy present
Family history of asthma / atopy present
Predictable good response to bronchodilators
WALRI (wheeze associatedlower respiratory tract
infections)or Viral Associated wheeze
Febrile episodesPersonal atopy absentFamily history of asthma /
atopy absentVariable response to
bronchodilators
Asthma by Consensus, IAP [email protected]
Bronchiolitis in childrenCommonest cause of wheezing in children
between 6 months to 3 years
Resembles asthma
Diagnosis essentially clinical
Common viruses causing bronchiolitis in children:Respiratory syncytial virus (RSV)
Clinical manifestations of RSV diseaseRhinorrhoea
Pharyngitis
Cough
Low grade fever
Wheezing
Increased respiratory rate
Differential diagnosisAge Common Uncommon Rare
Less than6 months
BronchiolitisGastro-esophagealreflux
Aspiration pneumoniaBronchopulmonary dysplasiaCongestive heart failureCystic fibrosis
AsthmaForeign body aspiration
6 months -2 years
BronchiolitisForeign bodyaspiration
Aspiration pneumoniaAsthmaBronchopulmonary dysplasiaCystic fibrosisGastro-esophageal reflux
Congestive heart failure
2 - 5 years
AsthmaForeign bodyaspiration
Cystic fibrosisGastro-esophageal refluxViral pneumonia
Aspiration pneumoniaBronchiolitisCongestive heart failureGastro-esophageal reflux
IPAG [email protected]
Co morbid conditionsAllergic RhinitisColds, ear infectionsSneezing in the morningBlocked nose, snoring, mouth breathing
Gastro esophageal reflux (GER)
Nocturnal cough followed by vomitingEczema
Guidelines for confirming Childhood Asthma diagnosis
IPAG DiagnosisCharacterize the problemEstablish chronicityExclude non-respiratory or other causes
Exclude infectious diseasesConsider patient’s ageUse diagnostic aids
International Primary Care Airways Group [email protected]
SPIROMETRY SPIROMETRY IS A PULMONARY
FUNCTION TEST THAT MEASURES THE VOLUME OF AIR AN INDIVIDUAL INHALES OR EXHALES AS A FUNCTION OF TIME.
Method – how to perform 1. 4 normal breaths2. Inhale as deeply as
possible3. Exhale to normal depth4. 3 normal breaths5. Exhale as much as
possible6. 3 normal breaths7. Inhale as much as
possible8. Exhale as fast and
completely as possible9. 4 normal breaths
ROLE OF SPIROMETRY IN ASTHMAHELPS TO MAKE DIAGNOSIS
ASSESS DEGREE OF AIRFLOW OBSTRUCTION
TO PREDICT WHETHER OBSTRUCTION IS REVERSIBLE
AIDS IN MANAGEMENT OF ASTHMA
TO MONITOR PROGRESSION OF DISEASE
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 β2 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 20032. CHILDHOOD ASTHMA by KHUBCHANDANI R.P. et [email protected]
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 primarilyone of exclusion.
Physical examination
If the child does not appear acutely ill and is growing, andthere is no evidence specifically indicating another cause ofsymptoms, a trial of therapy is warranted.
Trial of therapy (bronchodilators)
Improvement with treatment supports a diagnosis of asthma.
Frequent reassessment
Health care professionals should always be prepared toreconsider the diagnosis if management is ineffective or ifthe clinical situation changes.
IPAG [email protected]
Childhood Asthma Diagnosis (6-14 years)
IPAG [email protected]
Childhood Asthma Diagnosis (6-14 years)
IPAG [email protected]
NORDIC CONSENSUSConfirm 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 [email protected]
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 [email protected]
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 [email protected]
GINAA 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 [email protected]
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 [email protected]
Clinical features that increase the probability of asthmaMore 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
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 diagnosisBTS [email protected]
Asthma management and preventionThe 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 [email protected]
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 [email protected]
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.
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.
To summarize…
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
Diagnosis
To summarize…
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
Long term management
Thank [email protected]
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