Asthma in children

Dr Gulamabbas KhakooBMBCh, FRCPCH

Consultant Paediatrician, Hillingdon Hospital

Consultant in Department of Paediatric Asthma, Allergy and Immunology,

St Mary’s Hospital, W2

Talk outline

• BTS / SIGN 2008 guidelines

• Diagnosing asthma

• Inhaled steroids

• Allergy and asthma

• Allergic rhinitis

2008 BTS / SIGN guideline on the management of

asthma in children

BTS=British Thoracic Society; SIGN=Scottish Intercollegiate Guidelines Network.

Pharmacological management. Thorax 2008;63(Suppl IV):iv1-iv121

2008 Guidelines2.1 DIAGNOSIS IN CHILDREN (1) 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

2008 Guidelines2.4 DIAGNOSIS IN CHILDREN (2)Clinical features that lower the probability of asthma• 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 PEF or spirometry when symptomatic• No response to a trial of asthma therapy• Clinical features pointing to alternative diagnosis

2008 Guidelines

• Clinical features pointing to another diagnosis:

Failure to gain weight

Clubbing

Fatty stools

Productive sputum

Other chest findings eg crackles, unequal BS

Inspiratory noises

Barking cough

Early onset rhinorhoea

GOR symptoms

Absence of nocturnal symptoms

CHILD with symptoms that may be due to asthma

Clinical assessment

High Probability Low ProbabilityIntermediate Probability

Yes No

Continue Rx

Response?

Consider referral

Yes

Trial of Treatment

Response?

Asthma diagnosis confirmedContinue Rx and find minimum effective dose

No

Assess compliance and inhaler technique.

Consider further investigation and/or

referral

Consider tests of lung function and atopy

Investigate/treat other condition

Further investigation

Consider referral

Inhaled steroids

Inhaled steroids should be considered for patients

with any of the following asthma-related features:• exacerbations of asthma in the last two years• using inhaled β2 agonists three times a week

or more• symptomatic three times a week or more• waking one night a week.

General advice

• Follow SIGN / BTS guidelines 2008

• Correct inhaler device and technique

• Compliance issues

• Written asthma plans

Children age 5-12 yrs

Children age 5-12 yrs

Children age 5-12 yrs

Children age 5-12 yrs

Children age 5-12 yrs

Children age 5-12 yrs

Children Less than 5 yrs

Children Less than 5 yrs

Children Less than 5 yrs

Children Less than 5 yrs

Children Less than 5 yrs

Using the guidelines

• Non-compliance with inhaled steroids up to 70% or more in very young and teenagers

• Inhaler technique needs checking regularly• Large volume spacer is gold standard • Dry powder inhalers only in >6-8yo• Inhaled steroids and LTRAs more likely to

improve symptoms in atopic children• In asthma + rhinitis, LTRAs may be more

beneficial

Allergies and asthma

• Look for other co-morbid conditions, especially allergic rhinitis (and food allergies)

• Consider skin prick testing (for aeroallergens) if:– Seasonal symptoms (pollens, molds)– Household pets (animal dander)– Perennial symptoms (house dust mite, molds)– Change in environment changes symptoms

Steroids in viral induced asthma

• Oral prednisolone in pre-school viral-induced asthma– No evidence of efficacy in hospitalised children

(except ? multi-factor asthma or atopic children)

• High-dose fluticasone in pre-school viral-induced asthma– Modest reduction in duration of symptoms and less

use of relief beta agonists, but a small reduction in linear growth

• NEJM 2009;360:329-53 (plus editorial)

0.9

2.3

p<0.01

Treating allergic rhinitis cuts asthma costs

• 61% fewer hospitalisations in treated patients

Patientshospitalised over 1-year period (%)

Patients untreatedfor AR

(n=1357)

Patients treated for AR

(n=3587)

2.5

2.0

1.5

1.0

0.5

0.0

Summary• Importance of clinical history especially in the

very young• Look for other markers of allergy• 2008 BTS / SIGN guidelines as a framework• Refer to secondary care if inadequate response

to treatment or possible alternative diagnosis• Asthma management plans, compliance, age-

appropriate delivery device• Allergic rhinitis

The end, any questions