Approach to asthma and presentation of a clinical case

A detailed approach to asthma in Children

1. Approach to asthma in children

2. objectives Differntial diagnosis Introduction to asthma + 1slide epidemiology and CRADLE not asthma + signs and symptoms also nocturnal cough Prevention (CDC slides ) Diagnostic approaches + FeNO joke Quick relief Long term treatment Modified asthma predictive index Asthma action plan

3. A sthma is the most common chronic disease of childhood in industrialized countries.

4. Pathophysiology Type 1 heypersensitivity , IgE mediated Associated with eosinophilia + eczema , allergic rhinitis Cells: mast cells , eosinophils , T lymphocytes, neutrophils chemical mediators: histamine, leukotrienes, platelet-activating factor, bradykinin chemical mediators: histamine, leukotrienes, platelet-activating factor, bradykinin

5. cough SOB Chest tightness wheeze Asthma Presentation of Asthma: Studies of asthma's natural history have shown that almost 80% of cases begin during the first 6 years of life. The symptoms of pediatric asthma in this age group are varied and not specific to asthma making the diagnosis challenging. The primary symptoms of asthma in infancy and early childhood include cough, both dry and productive (albeit young children rarely expectorate), wheeze, shortness of breath, and work of breathing . Asthma symptoms are a result of airway inflammation, bronchospasm, airway edema, and airway mucous gland hypertrophy . Interestingly, these symptoms can also present with a multitude of other pediatric diseases including respiratory tract infections and congenital airway anomalies posing a diagnostic challenge. It is well-established that asthma in this age group is frequently under-diagnosed and undertreated  Ref:  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6603154/

6. Rhinosinusitis Aspirin GERD Can aggravate asthma

7. Features that favor the diagnosis of asthma: Intermittent episodes of wheezing that usually are the result of a common trigger Seasonal variation Family history of asthma and/or atopy Good response to asthma medications

8. Doesn‘t include ASTHMAAA!

9. Laboratory and imaging studies Spirometry Peak flow measures Allergy skin testing Radioallergosorbent test (RAST) Chest radiograph Exhaled nitric oxide analysis enzyme-linked immunosorbent assay (ELISA), are generally less sensitive in defining clinically pertinent allergens, are expensive, and time consuming.

10. A ny ways to detect non-adherence to therapy?

11. Spirometry monitor response to treatment assess degree of reversibility with therapeutic intervention measure the severity of an asthma exacerbation older than 5 y. o.

12. Radiographic Studies A chest x-ray should be performed with the first episode of asthma or with recurrent episodes of undiagnosed cough or wheeze to exclude anatomic abnormalities. Repeat chest x-rays are not needed with new episodes unless there is fever (suggesting pneumonia) or localized findings on physical examination. In mild asthma, the chest radiograph is normal In more severe, signs of air trapping may be seen: hyper lucency flattening of the diaphragms increased AP diameter horizontal positioning of the ribs

13. Pulmonary Function Test: Spirometry (usually feasible in children >5 yr of age ) many of whom can have near-normal or even supra-normal airflow despite having the other hallmarks of moderate to severe disease. exhaled nitric oxide (FENO) Peak expiratory flow (PEF) monitoring

14. Lung Function Abnormalities in Asthma: Airflow limitation   Low FEV1 (relative to percentage of predicted norms)   FEV1/FVC ratio <0.80   Bronchodilator response to inhaled β- agonist )   Improvement in FEV1 ≥ 12% or ≥ 200 mL  ( Exercise challenge    Worsening in FEV1 ≥ 15% Daily peak flow or FEV 1 monitoring : day to day and/or AM-to-PM variation ≥ 20%

15. Peak Flow Meter A device used to measure how air flows from your lungs in one “fast blast.” Children with poor symptom perception Other causes of chronic coughing in addition to asthma Moderate to severe asthma History of severe asthma Assess objectively airflow as an indicator of asthma control

16. treatment environmental control pharmacologic therapy patient education

17. Triggers and risk factors

18. What is triad asthma ?

19. Reducing Exposure to House Dust Mites Use bedding encasements Wash bed linens weekly Avoid down fillings Limit stuffed animals to those that can be washed Reduce humidity level (between 30% and 50% relative humidity per EPR-3) Source: “What You and Your Family Can Do About Asthma” by the Global Initiative For Asthma Created and funded by NIH/NHLBI, 1995 Reference: CDC

20. Reducing Exposure to Environmental Tobacco Smoke Evidence suggests an association between environmental tobacco smoke exposure and exacerbations of asthma among school-aged, older children, and adults. Evidence shows an association between environmental tobacco smoke exposure and asthma development among pre-school aged children. Reference: CDC

21. Reducing Exposure to Cockroaches Remove as many water and food sources as possible to avoid cockroaches. Reference: CDC

22. Reducing Exposure to Pets People who are allergic to pets should not have them in the house. At a minimum, do not allow pets in the bedroom. Reference: CDC

23. Reducing Exposure to Mold Eliminating mold and the moist conditions that permit mold growth may help prevent asthma exacerbations. Reference: CDC

24. Other Asthma Triggers Air pollution Trees, grass, and weed pollen Reference: CDC

25. PROGNOSIS For some children, symptoms of wheezing with respiratory infections subside in the preschool years, whereas others have more persistent asthma symptoms. Prognostic indicators for children younger than 3 years of age who are at risk for persistent asthma are known as the Modified Asthma Predictive Index for children ( Table 78.5 ). Atopy is the strongest predictor for wheezing continuing into persistent asthma