Childhood AsthmaDr.Rajesh.K

• Definition: • a chronic inflammatory disorder of the airways

resulting in recurrent episodes of wheezing,breathlessness,chest tightness and cough,particularly at night and in the early morning and may relieved by a bronchodilator.

•The inflamation also causes increased airway hyperreactivity to a variety of stimuli like viral infections,cold air,exercise,emotions,allergens pollutants . •conditions such as aspiration, GERD, airway anomaly, foreign body, cystic fibrosis, vocal cord dysfunction, etc have been ruled out

Clinical manifestations

• cough,increased work of breathing{tachypnea,retractions or accessory muscle use},wheezing,hypoxia andhypoventilation

• No audible wheezing may indicate very poor air movement and severe broncho spasm

• Chest X-ray shows peribrochial thickening,hyperinflation,and patchy atelectasis.

•Consider diagnosis of persistent asthma if… •recurrent episodes cough with or without wheeze•Cough that is associated with exercise/play•symptoms greater than 2 days per week.•night awakenings greater than 2 times per month secondary to asthma•patients require more than 2 steroid bursts per year•FEV1 <80%•FEV1/FVC <80% (>5 years old) and <85%(8-19 years old)

• >12% increase in FEV1 post-bronchodilator on spirometry.

• Assessment:• assess RR,HR,work of breathing,02 saturation,

peak expiratory flow,alertness,color.

Childhood wheezing

• 2 phenotypes of child hood wheezing• Episodic viral wheezer: some episodes of

wheezingcough with attacks of cold and fever.• Multitrigger wheezer: repeated episodes of

cough and wheezing.worsening of symptoms when exposed to smoke,laughs,weeps.

• Both entities can occur in all age groups.

Pulmonary score indexscore Respiratory rate

<6yrs >6yrswheezing Accessory muscles

involvement(sternocliedomastoidmuscle etc)

0 <30 <20 no none

1 31-45 21-35 Terminalexpiration

Questionable ,increase

2 46-60 36-50 Thoughoutexpiration

Increase apparently

3 >60 >50 Inspirationexpiration

All muscles involved

0-3-mild4-6 –moderate>6 (6-9)--severe

Intial management

• Give o2 to keep saturation>95%• Administer inhaled B-agonists:nebulized

albuterol,0.05 to 0.15mg/kg/dose as often needed.• Ipratropiumbromide,0.25 to 0.5mg,nebulized with

albuterol acts to decrease airway secretions.• Benefit has been demonstrated only for moderate

to severe exacerbations and its effect is not titrable(give early but no benefit has been shown from repeated doses)

• Steroids:methylprednisolone,2mg/kg IV/IM bolus,then 2mg/kg/day divide every 6hr or prednisone 2mg/kg PO every 24hr require minimum of 3hrs to take effect.

• If airmovement is still poor despite maximizing above therapy.

• 1.epineprine:0.01ml/kg SC or IM(1:1000:max dose,0.5ml)every 15 min up to 3doses.

• i.bronchodilator,vasopressor and inotropic effects.• ii.short acting (15min) and should be used as

temporizing rather than definitivetherapy.

• 2.MgSo4:25-75mg/kg/dose iv or im(max2g) infused over20min every 4-6hr up to 3-4doses

• smooth muscle relaxant,relieves bronchospasm,C/I if patient is in Hypotension or Renalfailure.

• Saline bolus can be given prior to administration to avoid hypotention.

• 3.terbutaline:0.01mg/kg SC(max 0.4mg) every 15min upto 2doses.

• Systemic b2 agonist limited by cardiac intolerence.

• Monitor continuous ecg,cardiac enzymes,urine analysis,electrolytes

Treatment

Intermittent Asthma• Step 1 (all ages):• Short acting beta agonist (e.g. salbutamol)• If symptoms greater than 2 days per week

(other than exercise induced symptoms) patient is not well-controlled and the next step needs to be considered

Long term management of asthma

• Goals:• Maintenance of near normal physical activity.• Maintenance of near normalpulmonary

function.• Prevention of night time cough or wheezing

with minimal chronic symptoms.• Prevention of exacerbation of asthma.• Avoinding adverse effects of medication.

• The effective long term management of asthma involves 3 major areas.

• Identification and elimination of exacerbating factors.

• Drug therapy • Parental education.

pharmacotherapy

• For Long term management:• SABA:adrenaline,terbutaline,salbutamol• LABA:salmeterol,formoterol.• Corticosteroids:beclomethasone,budesonide,f

luticasone.

Assessing control“Well-controlled” asthma•daytime symptoms less than 2 days per week•night awakenings secondary to asthma less than 2 times per month•ability to perform activities without limitations•less than 2 steroid bursts per year•FEV1 greater than or equal to 80% predicted•FEV1/FVC 80% (>5 years old) and 85% (8-19 years old)•Consider “stepping down” regimen if patient has been well-controlled for 3 months or more consecutively and reassess every 3-6 months•Refer to specialist if control can’t be obtained in 3-6 months using step guidelines or if patient has 2 or more emergency room visits or hospitalizations in 1 year