Asthma

brief explanation to bronchial asthma

1. A Presentation on Bronchial Asthma Presented by : Pritam Pandey Intern , Department Of Pediatrics Chitwan Medical College Teaching Hospital

2. Asthma The Chronic inflammatory condition of airways Resulting in episode of dynamic airways obstruction caused by airways hyperresponsiveness to provocative triggers characteried by paroxysmal dyspnoea , wheeze and cough.

3. Asthma triggers Indoor allergens ( Animal danders , dust mites molds ) Seasonal aero allergen ( pollens , seasonal molds ) Air pollutants (Environmental tobacco smoke dust , ozone , mycotoxin ) Strong noxious odor Occupational exposure ( fomaldehyde , cedar, cold dry air , exercise , crying )

4. Co morbid conditions ( Rhinitis , sinusitis , Gerd ) Drugs ( aspirin , b blockers , tartrazine )

5. Etiopathogenesis Type 1 hypersensitivity reaction :

6. Etiopathogenesis ( contd ) IL 13 : stimulate mucus production IL4 :stimulate and promote IgE production IL5 : activate eosinophils

7. Etiopathogenesis ( contd ) IgE binds with the Fc receptor of mast cell Degranualation of mast cell ( histamine , ECF , NCF) Immediate ( 5 – 30 min) response vasoconstriction vascular leakage and smooth muscle spasm Late phase reaction(2 -8 hours ) : activation of eosinophills , neutrophills and t cell and thus amplication of the inflammation

8. Etiopathogenesis ( contd ) Aiways remodeling (hypertrophy smooth muscles , mucus gland, Increased vascularity and deposition of subepithelial collagen

9. Epidemiology In USA, Prevalence of Asthma in 2015 , 9.1 % female Vs 6.1 %male 8.4 % children and 7.6 % adults Source :https://www.cdc.gov/asthma/asthmadata.htm

10. 100 and 150 million people around the globe -- roughly the equivalent of the population of the Russian Federation -- suffer from asthma . World-wide, deaths over 180,000 annually In Australia , one child in six under the age of 16 is affected Source :http://www.who.int/mediacentre/factsheets/fs206/en/

11. Risk Factor Parental asthma A llergy ( atopic dermatitis , allergic rhinitis , food allergy ) Severe Lower respiratory tract infection ( Pneumonia , Bronchiolitis requiring hospitalization ) Male gender Low birth weight Environment tobacco smoke exposure

12. Clinical features Intermittent dry cough Expiratory wheeze Symptom worst at night Symptoms triggered on exertion, cold, dry air , laughing Tachypnea Audible wheeze worsening on crying

13. Pulsus parodoxus (drop in systolic BP by10 mm Hg during inspiration) Decreased breathe sound in some lung field ( right lower posterior lobe common) crackles and rhonchi Child appears normal in between the episode

14. Acute asthma : Hyperinflammation Tachypnea (air Hunger) Use of assesory muscles Indrawing of chest ,flaring of alae Prolonged expiration cyanosis

15. Absence of previously present wheeze in a cyanosed child is a sigh of omen

16. Differential Diagnosis Upper respiratory tract infection Allergic rhinitis Chronic rhinitis Sinusitis Tonsillar hypertrophy Nasal foreign body

17. Middle respiratory tract infection Laryngotracheobronchomalacia Larygotracheobronchitis Laryngeal web Vocal cord paralysis Foreign body aspiration

18. Lower respiratory tract infection Viral bronchiolitis GERD Tuberculosis Pneumonia Bronchiolitis obliterans CCF

19. Ruling out Differential Diagnosis

20. Asthma vs bronchiolitis recurrent wheezing in a child >2 years old personal and/or family history of atopy or a family history of asthma . Bronchiolitis : < 2 years of age and the leading cause of hospital admission under 6 months of age Environmental or allergic precipitants are often present in older children.

21. Asthma vs Vocal cord dysfunction Intermittent day time wheeze Stridor Improvement with bronchodilator in asthma Flexible rhinolaryngoscopy : Parodoxica l vocal cord movement with anatomically normal vocal cords

22. Asthma vs foreign body aspiration Unilateral wheeze after an episode of choking and coughing No previous h/o respiratory episode Localized area of reduced air entry in patient with chronic respiratory illness is suggestive

23. Asthma vs Laryngotracheobronchitis Caused by parainfuenza virus I and II Croupy cough (barking seal like) Fever Inspiratory stridor Steeple sigh in radiograph

24. Asthma vs Laryngeomalacia Inspiratry stridor Stridor increasing on crying and subside on placing the patient prone

25. Investigation Pulmonary function test FEV1:FVC <0.8 BRONCODILATOR RESPONSE :improvement in FEV1 more than or equal to 12 % Exercise challenge :worsening of FEV1 of more than or equal to 15 % Daily PEFR/FEV1 : diurnal variation of > or equal to 20 %

26. Chest Xray Hyperinflatted lung Peribronchial thickening Hyperlucent lung field ( bonchiolitis obliterans ) Complication of asthma ( atelectasis , pneumothorax , pneumomediastinum )

27. Classification of Asthma Severity

28. Day Time Symptoms Night Time Symptoms Short acting B agonist use Predictibility ( FEV1) Therapy Intermittent <2/ week -4 years : 0 ≥5 years : <2/month <2/week >80% step 1 Mild Persistent >2/week but not daily -4 years :1-2/month ≥5 : 2- 3 /month >2/week but not more than 1 per day >80 % Step 2 Moderately persistent daily -4 years :3-4/month ≥5 :>1/week but not nightly daily 60-80% Step 3 Severely persisent Through out the day -4 years :>1/week ≥5 : often 7 / week Several times in a day <60% STEP 4

29. Stepwise approach of managing Asthma in Children

30. Step 1 : SABA as needed for the symptoms

31. step 2 0-4years : low dose ICS / chromolyn / montelukast 5 -11 years :low dose ICS alternate : Chromolyn /LTRA/ Theophylline ≥12 years : low dose ICS Alternative : LTRA or theophylline

32. Step 3 0-4years : medium dose ICS 5 -11 years :medium dose ICS Low dose ICS ±LABA/LTRA or theophylline ≥12 years : medium dose ICS Low dose ICS+LABA

33. Step 4 0-4years : medium dose ICS +LABA/LTRA 5 -11 years : medium dose ICS +LABA/LTRA or theophylline ≥12 years : medium dose ICS+LABA

34. STEP 5 0-4years : High dose ICS + LABA/LTRA or theophylline 5 -11 years :high dose ICS +LABA/LTRA or theophylline ≥12 years : high dose ICS+LABA add omalizumab in allergic cases

35. Step 6 0-4years : High dose ICS + LABA/LTRA or theophylline + 0ral cortiosteroid 5 -11 years :high dose ICS +LABA/LTRA or theophylline + oral corticosteroid ≥12 years : high dose ICS+LABA +oral corticosteroid add omalizumab in allergic cases

36. 0-4 years ( budesonide / fluticasone )0.5 -1->1 nebulization

37. Selection of appropriate inhalation device A rough guide < 4 years of age :MDI with spacer with face mask 4-12 years :MDI with spacer >12 years :MDI

38. Use of MDI Remove cap and shape well in vertical direction Breathe out gently Put the mouth piece in mouth and start inspiration slowly pressing the canister and continue to inhale deeply Hold breathe for 10 sec or more Wait for few second before repeating the inhalation again

39. Assessing Asthma control and Adjusting therapy in children

40. Well controlled components symptoms ≤2 days / week but not more than once on each day Night awakening 0-11 years : ≤1 /month ≥12 years : ≤2/month Short acting B agonist use ≤2days/week Exacerbation requiring systemic corticosteroid 0-1/year Lung function FEV1 >80 % FEV1/FVC >0.8

41. Not well tolerate components symptoms >2 days / week or multiple times on ≤2days/week Night awakening 0-4 years : >1 /month 5-11 year : >2 /month ≥12 years : 1-3/week Short acting B agonist use >2days/week Exacerbation requiring systemic corticosteroid 2-3/year Lung function FEV1 : 60-80% FEV1/FVC : 0.75 -0.8

42. Very poorly controlled controlled components symptoms through out the day Night awakening 0-4 years : >1 /week 5-11 year : ≥2/week ≥12 years : ≥4 /week Short acting B agonist use several times per day Exacerbation requiring systemic corticosteroid 3+ /year Lung function FEV1 <60% FEV1/FVC <0.75

43. Step up and step down approach

44. Well controlled: maintain current step ,follow up 1 to 6 month Step down treatment if controlled for at least 3 months

45. Not Well controlled Step up (1step) and reevaluate in 2-4 weeks If no improvement consider in 2-4 weeks alternative diagnosis or adjusting therapy For side effect , consider alternative option

46. Very poorly controlled Consider a short course of oral steroid Step up 1-2 steps and re evaluate in 2 weeks If no improvement consider in 2-4 weeks alternative diagnosis or adjusting therapy For side effect , consider alternative option

47. Risk Assesment for corticosteroid Adverse effect

48. Low risk low or medium dose

49. Medium risk high dose <4 cases oral steroid burst treatment/year)

50. High risk Chronic corticosteroid use >7.5mg daily or equivalent for more than a month >7 cases oral corticosteroid burst treatment/year

51. Steroid adverse effect Osteoporosis (ALP, calcium phosphoros,DEXA scan) Peptic ulcer Growth reduction ( standiometry ) Avascular necrosis of head of femur Cataract ( opthalmic evaluation )

52. Steroid adverse effect Oral ulcer, candidiasis Cushingoid feature Flaring of TB Immunosuppression Adrenal insufficiency

53. theophylline Narrow therapeutic index (10-20mg/dl) Overdose : seizure, hypokalemia,cardiac arrhythmia Ciprofloxacin , macrolides,oral anti fungal agent,increases the plasma conc

54. SABA Salbutamol albuterol Tebutaline LABA Salmeterol form0terol Hypokalemia Arrhythmia ( tachycardia , fibrillation)

55. Leucotriene receptor antagonist Zafirlukast (use in > 5yrs)and montelucast (use in >1 yrs) Omalizumab (>12 years) subcutenous , anaphyaxis can some time occur

56. Status asthmaticus

57. Medical emergency A severity of exacerbation of asthma that doesn’t improve with standard therapy

58. Management of status asthmaticus At home Immediate treatment with rescue medication (inhaled SABA , up to 3 treatment with I hour, a short couse of corticosteroid can be given for days not to exceed 60mg/day ) Consult physician if bronchodilators are required frequently in 24-48 hours

59. At emergency department Oxygen supplementation inhaled B agonist ( albuterol 0.15mg/kg) every 20 min for 1 hour Systemic corticosterid oral/IV (hydrocortisone 5mg/kg) Discharged if PEF 70 % of predicteded and saturation of >92 %maintained at room air for 4 hours

60. At Hospital

61. At Hospital

62. Injectable theophylline followed by continous infusion Mgso4 50mg/kg dissolved in dextose If no improvement prepare for mechanical ventilation

63. C/C Acute exacerbation Pneumothorax Peumomediastinim Atelectasis Secondary infection Respiratory failure Steroid toxicity

64. Brain storming ?

65. A 3 years Male child presented to the pediatrics OPD with a chief complain of sudden onset of shortness of breathe while playing in garden .The child gives a history of frequent running nose. He was admitted twice for bronchilitis in the past What social history would you ask ?

66. Day Time Symptoms Night Time Symptoms Short acting B agonist use Predictibility ( FEV1) Therapy Intermittent <2/ week -4 years : 0 ≥5 years : <2/month <2/week >80% step 1 Mild Persistent >2/week but not daily -4 years :1-2/month ≥5 : 2- 3 /month >2/week but not more than 1 per day >80 % Step 2 Moderately persistent daily -4 years :3-4/month ≥5 :>1/week but not nightly daily 60-80% Step 3 Severely persisent Through out the day -4 years :>1/week ≥5 : often 7 / week Several times in a day <60% STEP 4

67. A 3 years male child with asthma presents to you with the history of night symptom of 1 times in month and a day symptom of 2 times in a week ? Where do you classify it in asthma severity ? What treatment will you give ?

68. A 6 years male child with asthma presents to you with the history of night symptom of 1 times in month and a day symptom of 2 times in a week ? Where do you classify it in asthma severity ? What treatment will you give ?

69. http://www.eaaci.org/attachments/878_PRACTALL%20Consensus%20Report%20PP.pdf http://www.asthma.ca/adults/control/pdf/Asthma_in_infants_and_young_children_tip_sheet.pdf http://journals.plos.org/plosone/article/file?id=10.1371/journal.pone.0136841&type=printable