ASTHMA.pptx11112222333344445555557777888

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1. ASTHMA AND HYPERACTIVE AIRWAY DISEASE IN CHILDREN DR SHAZIA

2. Introduction Asthma can be defined as the heterogeneous disease characterised by chronic airway inflammation. Inflammation and constriction of the airways as a result of infection, environmental allergens, and irritants are characteristics of asthma. It is a complex, multifactorial, and immune-mediated process that presents with various clinical phenotypes.

3. Epidemiology The global prevalence, morbidity and mortality related to childhood asthma among children has increased significantly over the last 40 years. Although asthma is recognized as the most common chronic disease in children, issues of underdiagnoses and under treatment persist

4. The World Health Organization estimated that approximately 300 million people currently have asthma worldwide, and with current trends rising, it is expected to reach 400 million by 2025 ( D.Serebrisky et al, 2019 )

5. In a survey conducted in 2013-2014 by Global Asthma Network (GAN) implies that there was no national asthma strategy for both children and adults in many African countries due to absence of health promotion programmes to raise community awareness about asthma and associated risk factors ( Haahtela A.I, et al. 2017)

6. Asthma prevalence has been increasing across Africa, In 1990, about 11.7% (74 million including 34.1 million children) of the population had asthma; by 2010, this had increased to 12.8% (119 million including 49.7 million children). In South Africa, a high-middle-income sub-Saharan African country, only 31.5% of children with asthma had well controlled asthma and 17.6% had been admitted to hospital in 2009 Despite the high prevalence, there are limited data about the burden and determinants of asthma in sub-Saharan Africa. (M.B Rhode et al 2009)

7. In Uganda, a low-income sub-Saharan African country, under 5-year-old children with asthma symptoms, over 90% were diagnosed with pneumonia and treated with antibiotics, thus missing opportunities to address the true underlying issues .(N.R Tumwine , et al. 2013) Childhood asthma accounts for many lost school days and may deprive children of both academic achievement and social interaction, particularly in underserved populations 

8. Aetiology Environmental allergens ( eg , house dust mites; animal allergens, especially cat and dog; cockroach allergens; and fungi) Viral respiratory tract infections Exercise Chronic sinusitis or rhinitis Aspirin or nonsteroidal anti-inflammatory drug (NSAID) hypersensitivity, sulfite sensitivity Use of beta-adrenergic receptor blockers (including ophthalmic preparations) Obesity  [10] Environmental pollutants, tobacco smoke Emotional factors or stress

9. Aetiology… Occupational exposure Irritants ( eg , household sprays, paint fumes) Various high- and low-molecular-weight compounds ( eg , insects, plants, latex, gums, diisocyanates , anhydrides, wood dust, and fluxes; associated with occupational asthma) Perinatal factors (prematurity and increased maternal age; maternal smoking and prenatal exposure to tobacco smoke; breastfeeding has not been definitely shown to be protective)

10. PATHOGENESIS OF ASTHMA

11. Clinical presentation… History Wheezing Cough Shortness of breath Chest tightness Sputum production Talk in words Usually agitated Cough during or after exercise

12. Non pulmonary manifestation Signs of atopy or allergic rhinitis(conjunctival congestion and inflammation) Ocular shiners Transverse crease on the nose due to constant rubbing associated with allergic rhinitis Turbinates may be erythematous or boggy. Polyps may be present

13. Nocturnal symptoms A large percentage of patients with asthma experience nocturnal symptoms once or twice a month. Some patients only experience symptoms at night and have normal pulmonary function in the daytime . Children with nocturnal asthma tend to cough after midnight and during the early hours of morning.

14. Bronchoconstriction is highest between the hours of 4:00 am and 6:00 am (the highest morbidity and mortality from asthma is observed during this time). These patients may have a more significant decrease in cortisol levels or increased vagal tone at night

15. TO ESTABLISH DX OF ASTHMA CERTAIN CRITERIA SHOULD BE MET; Episodic symptoms of airflow Reversible airflow obstruction of at least 10% of predicted forced expiratory volume in one second FEV 1 Other diagnoses should be excluded

16. Clinical presentation… Physical examination ; Findings during a mild episodes Increased respiratory rate HR < 100 bpm Oxyhemoglobin saturation with room air is greater than >95%

17. Clinical presentation…. Findings during moderately severe episodes Increased respiratory rate Use accessory muscles of respiration Suprasternal retractions are present HR 100-120 bpm Loud expiratory wheezing Pulsus paradoxicus (10-20 mmHg) Oxyhemoglobin saturation with room air 91-95%

18. Clinical presentation…. Findings during severe episodes Increased respiratory rate Use accessory muscles of respiration Suprasternal retractions are present HR >120 bpm Loud biphasic expiratory& inspiratory wheezing Pulsus paradoxicus (20-40 mmHg) Oxyhemoglobin saturation with room air <91%

19. Diagnostic Work Up PFT Radiography ( CXR) ABG analysis FBP

20. DDX Tracheobronchomalacia Hyperventilation syndrome Vocal cord dysfunction Pulmonary edema Reactive airway disease Bronchiolitis Pediatric airway foreign body Pediatric allergic rhinitis Pediatric bronchiectasis Pediatric gastroesophageal reflux Primary ciliary dyskinesia

21. MANAGEMENT OF ASTHMA General principle of management of asthma involves long term goals to reduce risk and symptoms control It involves a continuous cycle which is to assess , adjust treatment and review

22. MEDICATIONS USED IN ASTHMA Inhaled corticosteroids (ICS) Medications: Beclometasone , Budesonide Ciclesonide fluticasone propionate fluticasone furoate mometasone triamcinolone Devices : pMDIs or DPIs .

23. ICS in combination with a long-acting beta2-agonist bronchodilator (ICS-LABA) Medications: Beclometasone-formoterol , B udesonide- formoterol , fluticasone furoatevilanterol , fluticasone propionate formoterol fluticasone propionate- salmeterol mometasone-formoterol mometasone-indacaterol Devices : pMDIs or DPIs

24. Leukotriene modifiers (leukotriene receptor antagonists, LTRA) Medications : tablets, e.g . montelukast , pranlukast , zafirlukast , zileuton .

25. Systemic corticosteroids Medications: include Prednisone Prednisolone Methylprednisolone H ydrocortisone tablets D examethasone Given by tablets or suspension or by IM or IV injection

26. Short-acting inhaled beta2-agonist bronchodilators (SABA) Medications: e.g . salbutamol (albuterol), terbutaline Administered by pMDIs , DPIs and, rarely, as solution for nebulization or injection

27. Medication symptoms Preferred controller Step 1; Symptoms less than a month Low dose ICS whenever SABA is taken II.Step 2; Symptoms twice a month or more but less a day Daily dose of ICS III.STEP 3; symptoms most days or waking up with asthma twice a week or more Low dose of ICS-LABA or medium dose ICS-LABA or very low ICS-LABA

28. IV. Step 4; Symptoms most days or waking with asthma once a week or more and low lung function Medium dose ICS-LABA or low dose ICS-LABA maintenance V. Step 5; Refer for phenotypic assessment, higher dose ICS-LABA

29. : Aims of treatment are ; Achieve and maintain control of symptoms,Prevent asthma exacerbations Maintain pulmonary function as close to normal as possible Avoid adverse effects from asthma medications Prevent development of irreversible airflow limitation and Prevent asthma mortality This involves ; Patient and family education about asthma,Patient and family participation in treatment, Avoidance of identified causes where possible, Use of the lowest effective doses of convenient medications to minimize short-term and long-term side-effects.

30. Status asthmaticus It is the extreme form of an asthma exacerbation that can result in hypoxemia, hypercarbia and secondary respiratory failure It is an acute exacerbation of asthma that remains unresponsive to initial treatment with bronchodilators Status asthmaticus can vary from a mild form to a severe form with bronchospasm, airway inflammation, and mucus plugging that can cause difficulty breathing, carbon dioxide retention, hypoxemia, and respiratory failure

31. Patients present a few days after the onset of a viral respiratory illness, following exposure to a potent allergen or irritant, or after exercise in a cold environment. Frequently, patients have underused or have been under prescribed anti-inflammatory therapy. Illicit drug use may play a role in poor adherence to anti-inflammatory therapy.

32. HX TAKING Presence of current illness, such as upper respiratory tract infection or pneumonia History of chronic respiratory diseases ( eg , bronchopulmonary dysplasia, chronic lung disease of infancy) Severe previous respiratory syncytial virus (RSV) disease History of atopy History of allergies Family history of asthma Presence of pets or smokers in the home Known triggering factors Home medications - Obtain a detailed list of medications being taken at home and, if possible, their timing and dosage

33. Clinical presentation… Tachypneic Wheezing Use of accessory muscles Pulsus paradoxus > 25mmHg Altered level of consciousness Seizures

34. Investigations Complete blood cell (CBC) count Arterial blood gas (ABG) analysis Serum electrolyte levels Serum glucose levels Peak expiratory flow measurement Chest radiography

35. ACCORDING TO GINA

36. ACCORDING TO GINA

37. Prognosis.. Poor prognosis if asthma develops in children younger than 3 years, unless it occurs solely in association with viral infections Individuals who have asthma during childhood have significantly lower (FEV 1 ), higher airway reactivity, and more persistent bronchospastic symptoms than those with infection-associated wheezing

38. Prognosis… Children with mild asthma who are asymptomatic between attacks are likely to improve and be symptom-free later in life Children with asthma appear to have less severe symptoms as they enter adolescence, but half of these children continue to have asthma. Asthma has a tendency to remit during puberty, with a somewhat earlier remission in girls

39. Prevention Education on the common triggers for asthma Adherence to drugs include instructions on how to use medications and devices ( eg , spacers, nebulizers, metered-dose inhalers [MDIs]) Write and discuss in detail a rescue plan for an acute episode. This plan should include instructions for identifying signs of an acute attack, using rescue medications, monitoring and contacting the asthma care team.

40. Referrences Nelson Textbook of Pediatrics 22 nd ED Ghai Essential Pediatrics 9 th ED Global initiative for Asthma 2022 Medscape UptoDate