Pediatric Asthma

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Pediatric Asthma
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• 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.

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Asthma Inflammation Cells and Mediators
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Mechanism Asthma Inflammation
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Asthma Inflammation
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Factors Influencing the Development and
Expression of Asthma

• Host factors
• Genetic
• Genes predisposing to atopy
• Genes predisposing to airway hyper
  responsiveness
• Obesity
• Sex

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• Environmental factors
• Allergens
• Indoor Domestic mites, furred animals (dogs,
  cats, mice), cockroach allergens, fungi, molds,
  yeasts.
• Outdoor Pollens, fungi, molds, yeasts.
• Infections (predominantly viral)
• Occupational sensitizers
• Tobacco smoke
• Passive smoking
• Active smoking
• Indoor/Outdoor air pollution
• Diet

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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.

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Prevalence of Childhood asthma
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The prevalence of childhood asthma has continued
to increase on the Indian subcontinent over
the past 10 yrs ISAAC Phase
3 Thorax 200762758
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Population Age distribution
UK 60.9m
23.5
India 1,147.9m
40.9
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Other Challenges

• Most 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

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Clinical Features

• Recurrent Wheeze
• Recurrent Cough
• Recurrent Breathlessness
• Activity Induced Cough/Wheeze
• Nocturnal Cough/Breathlessness
• Tightness Of Chest

Asthma by Consensus, IAP 2003
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Symptomatology

• Cough 90
• Wheezing 74
• Exercise induced wheeze or cough 55

Ind J Ped 200269309-12
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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
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When does Asthma begin?

• By 1 year 26
• 1-5 years 51.4
• gt 5 years 22.3
• 77 Of Asthma Begins In Children Less Than 5
  Years

Ind J Ped 200269309-12
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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
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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
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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 childs 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?

If the answer is yes to any of the questions,
a diagnosis of asthma should be considered
CHILDHOOD ASTHMA by KHUBCHANDANI R.P. et al
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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 al
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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
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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
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What all investigations can be performed in
asthmatic children? (PERFORM)

• Peak expiratory flow rate It is highly
  suggestive of asthma when
• gt15 increase in PEFR after inhaled short acting
  ß2 agonist
• gt15 decrease in PEFR after exercise
• Diurnal variation gt 10 in children not on
  bronchodilator
  OR
• gt20 In children on bronchodilator

1. Asthma by Consensus, IAP 2003 2. CHILDHOOD
ASTHMA by KHUBCHANDANI R.P. et al
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How to rule out the mimics?
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The Early Wheezer (lt 3Years)

• Early onset asthma
• Afebrile episodes
• Personal atopy present
• Family history of asthma / atopy present
• Predictable good response to bronchodilators

• WALRI (wheeze associated
• lower respiratory tract infections)
• or Viral Associated wheeze
• Febrile episodes
• Personal atopy absent
• Family history of asthma / atopy absent
• Variable response to bronchodilators

Asthma by Consensus, IAP 2003
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Bronchiolitis in children

• Commonest 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)

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Clinical manifestations of RSV disease

• Rhinorrhoea
• Pharyngitis
• Cough
• Low grade fever
• Wheezing
• Increased respiratory rate

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Differential diagnosis
Age Common Uncommon Rare
Less than 6 months Bronchiolitis Gastro-esophageal reflux Aspiration pneumonia Bronchopulmonary dysplasia Congestive heart failure Cystic fibrosis Asthma Foreign body aspiration
6 months - 2 years Bronchiolitis Foreign body aspiration Aspiration pneumonia Asthma Bronchopulmonary dysplasia Cystic fibrosis Gastro-esophageal reflux Congestive heart failure
2 - 5 years Asthma Foreign body aspiration Cystic fibrosis Gastro-esophageal reflux Viral pneumonia Aspiration pneumonia Bronchiolitis Congestive heart failure Gastro-esophageal reflux
IPAG 2007
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Identifying Co-morbidities
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Co morbid conditions

• Allergic Rhinitis
• Colds, ear infections
• Sneezing in the morning
• Blocked nose, snoring, mouth breathing
• Gastro esophageal reflux (GER)
• Nocturnal cough followed by vomiting
• Eczema

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Guidelines for confirming Childhood Asthma
diagnosis
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IPAG Diagnosis

• Characterize the problem
• Establish chronicity
• Exclude non-respiratory or other causes
• Exclude infectious diseases
• Consider patients age
• Use diagnostic aids

International Primary Care Airways Group 2007
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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 primarily one of exclusion.
Physical examination If the child does not appear acutely ill and is growing, and there is no evidence specifically indicating another cause of symptoms, 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 to reconsider the diagnosis if management is ineffective or if the clinical situation changes.
IPAG 2007
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Childhood Asthma Diagnosis (6-14 years)
IPAG 2007
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Childhood Asthma Diagnosis (6-14 years)
IPAG 2007
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NORDIC CONSENSUS
Respir Med. 200094(4)299-327
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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
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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
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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
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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
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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
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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
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Asthma Phenotypes
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What do you understand by phenotypes?

• Phenotypes
• the visible properties of an organism that are
  produced by the interaction of genotype and the
  environment
• -Websters New Collegiate Dictionary

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Pre-school Asthma phenotypesWheezing is common
in young children but is it asthma?
Prevalence of wheeze
Atopic asthma
Non-atopic viral induced wheeze
Transient wheeze
0
3
6
11
Age Years
Martinez Pediatrics 2002109362
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Asthma phenotypes in childhood

• Transient
• linked with smoking during pregnancy
• viral RTIs
• not associated with atopy
• remits by school age
• Impaired lung function at birth

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Asthma phenotypes in childhood

• Persistent
• not associated with atopy
• - associated with viral RTIs (RSV),
• - may remit during school age
• - LTRAs have been found to be beneficial
• associated with atopy
• - bronchial responsiveness, impaired lung
  function
• - parental history of asthma
• - most ongoing during school age

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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.

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Characteristic Controlled (All of the following) Partly controlled(Any present in any week) Uncontrolled
Daytime symptoms None (2 or less / week) More than twice / week 3 or more features of partly controlled asthma present in any week
Limitations of activities None Any 3 or more features of partly controlled asthma present in any week
Nocturnal symptoms / awakening None Any 3 or more features of partly controlled asthma present in any week
Need for rescue / reliever treatment None (2 or less / week) More than twice / week 3 or more features of partly controlled asthma present in any week
Lung function (PEF or FEV1) Normal lt 80 predicted or personal best (if known) on any day 3 or more features of partly controlled asthma present in any week
Exacerbation None One or more / year 1 in any week One or more / year 1 in any week
Any exacerbation should be prompt review of
maintenance treatment to ensure that it is
adequate. Lung function is not a reliable test
for children 5 years and younger.
GINA 2009
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Levels of Asthma Control in Children 5 years and
younger
Characteristic Controlled (All of the following) Partly Controlled (Any measure present in any week) Uncontrolled (Three or more of features of partly controlled asthma in any week)
Daytime symptoms wheezing, cough, difficult breathing None (less than twice/week, typically for short periods of on the order minutes and rapidly relieved by use of a rapid-acting bronchodilator) More than twice/week (typically for short periods on the order minutes and rapidly relieved by use of a rapid-acting bronchodilator) More than twice/week (typically last minutes of hour or recur, but partially or fully relieved with rapid-acting bronchodilators)
Limitation of activities None (child is fully active, plays and runs without limitation or symptoms) Any (may cough, wheeze, or have difficulty breathing during exercise, vigorous play or laughing) Any (may cough, wheeze, or have difficulty breathing during exercise, vigorous play or laughing)
Nocturnal symptoms/ awakening None (no nocturnal coughing during sleep) Any (typically coughs during sleep/wakes with cough, wheezing and/or difficult breathing) Any (typically coughs during sleep/wakes with cough, wheezing and/or difficult breathing)
Need for reliever/rescue treatment Less than/equal to 2 days/week gt 2 days/week gt 2 days/week
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• Examples of validated measures for assessing
  clinical control of asthma include
• Asthma Control Test (ACT) www.asthmacontrol.com
• Childhood Asthma Control test (C - Act)
• Asthma Control Questionnaire (ACQ)
  www.qoltech.co.uk/asthma1.htm
• Asthma Therapy Assessment Questionnaire (ATAQ)
  www.ataqinstrument.com
• Asthma Control Scoring System

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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.

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• 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.

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• Choosing an inhaler device for children with
  asthma -

Age group Preferred device Alternative device
Younger than 4 years Pressurized metered-dose inhaler plus dedicated spacer with face mask Nebulizer with face mask
4-5 years Pressurized metered-dose inhaler plus dedicated spacer with mouthpiece Nebulizer with mouthpiece
Older than 6 years Dry powder inhaler or breath actuated pressurized metered-dose inhaler or pressurized metered-dose inhaler with spacer with mouthpiece Nebulizer with mouthpiece
Based on efficacy of drug delivery, cost
effectiveness, safety, ease of use, and
convenience.
GINA 2009
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Asthma management and prevention

• The goals for successful management of asthma are
  
• Achieve and maintain control of symptoms
• Maintain normal activity levels, including
  exercise
• Maintain pulmonary function as close to normal as
  possible
• Prevent asthma exacerbations
• Avoid adverse effects from asthma medications
• Prevent asthma mortality

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• Five interrelated components of therapy are
  required to achieve and maintain control of
  asthma-
• Develop Patient/Doctor partnership
• Identify and reduce exposure to risk factors
• Assess, treat, and monitor asthma
• Manage asthma exacerbations
• Special considerations

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• 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
• Avoid risk factors
• Take medications correctly

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• 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

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• 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
  
• www.asthma.org.uk
• www.nhlbisupport.com/asthma/index.html
• www.asthmaz.co.nz

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• 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.

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• 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.

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• 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.

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• 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 patients 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.

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Asthma management approach based on control
for children 5 years and younger
Asthma education, Environmental approach, and as needed rapid acting beta -agonists Asthma education, Environmental approach, and as needed rapid acting beta -agonists Asthma education, Environmental approach, and as needed rapid acting beta -agonists
Controlled on as needed rapid acting beta2-agonists Partly controlled on as needed rapid acting beta2-agonists Uncontrolled or only partly controlled on low - dose inhaled glucocorticosteroid
Controller options Controller options Controller options
Continue as needed rapid acting beta2-agonists Low dose inhaled glucocorticosteroid Double Low dose inhaled glucocorticosteroid
Leukotriene modifier Low dose inhaled glucocorticosteroid plus Leukotriene modifier
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To summarize
Diagnosis

• Asthma is an inflammatory illness
• Diagnosis of asthma is clinical, and relies on
  history
• All asthma does not wheeze
• In children lt 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

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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
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Thank You