Childhood asthma

Presented by Dr pankaj yadav

Drpankajyadav05@gmail.com

drpankajyadav05@gmail.com

• 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

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 drpankajyadav05@gmail.com

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.drpankajyadav05@gmail.com

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 asthma.drpankajyadav05@gmail.com

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 2003drpankajyadav05@gmail.com

SymptomatologyCough – 90%Wheezing – 74%Exercise induced wheeze or cough – 55%

Ind J Ped 2002;69:309-12drpankajyadav05@gmail.com

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;69:309-12drpankajyadav05@gmail.com

Tools to DiagnosisGood History Taking (ASK)

Careful Physical Examination (LOOK)

Investigations (PERFORM) – above 5 years only

CHILDHOOD ASTHMA by KHUBCHANDANI R.P. et aldrpankajyadav05@gmail.com

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?

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

What all features one should look for specifically?DyspneaExpiratory wheezeAccessory muscle movementDifficulty in feeding, talking, getting to sleepIrritability

What all features one should look for specifically?CoughPersistent/ recurrent / nocturnal/ exercise-

induced

Associated conditionsEczemaAllergic Rhinitis

Weight/Height

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 2003drpankajyadav05@gmail.com

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

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 2007drpankajyadav05@gmail.com

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 2007drpankajyadav05@gmail.com

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 aldrpankajyadav05@gmail.com

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.

Childhood Asthma Diagnosis (6-14 years)

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 drpankajyadav05@gmail.com

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 2003drpankajyadav05@gmail.com

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 2008drpankajyadav05@gmail.com

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 2008drpankajyadav05@gmail.com

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 2008drpankajyadav05@gmail.com

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

BTS 2008drpankajyadav05@gmail.com

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 2008drpankajyadav05@gmail.com

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 mortalitydrpankajyadav05@gmail.com

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

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 drpankajyadav05@gmail.com

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 Youdrpankajyadav05@gmail.com

Childhood asthma

Health & Medicine

Transcript of Childhood asthma

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