asthma presentation by a physcian for educational purpose

asthma presentation by a physcian for educational purpose

1. Approach and management of pediatric asthma B etelehem Girma (MD) (Pediatrician ) 4/15/2022 1

2. Out line Introduction Assessment of asthma Step wise management of GINA (Global initiative for asthma) 4/15/2022 2

3. Asthma is a chronic, inflammatory lung disease characterized by symptoms of cough, wheezing, dyspnea, and chest tightness that occur in paroxysms and are usually related to specific triggering events. 4/15/2022 3

4. ETIOLOGY Genetic environmental exposures Respiratory viruses Indoor and home allergen Environmental tobacco smoke and air pollutants 4/15/2022 4

5. Pathogenesis of asthma The pathophysiology of asthma is complex and involves airway inflammation, intermittent airflow obstruction, and bronchial hyper responsiveness . After exposed to allergen smooth muscle start to spasm and increase mucus secretion this will narrow air way and lead to obstruction There is also increase vascular permeability and recruitment of other immune cell to the blood ,this immune cell especially eosinophil release chemical mediator which damage endothelium of the lung 4/15/2022 5

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7. Clinical feature Cough especially at night or in the morning Wheezing a whistling sound when you breathe Shortness of breath Tightness, pain, or pressure in your chest Trouble sleeping  4/15/2022 7

8. D iagnosis History and physical examination Spirometer devises used to measure lung function -Airflow limitation: -Low FEV1 - FEV1:FVC ratio <0.80 Bronchodilator response (to inhaled β- agonist): - Improvement in FEV1 ≥12% 4/15/2022 8

9. C-XRAY; hyperinflation, peribronchial thickening, and mucoid impaction with atelectasis 4/15/2022 9

10. Assessment of asthma Common clinical scenario for assessment Patient may be on long term controller treatment Patient may be not on long term controller treatment Patient my present with exacerbation 4/15/2022 10

11. Also see level of control in the last 4 week Day time symptom >2times/week Any limitation of activity Any nocturnal awakening due to asthma Need for reliever >2 times/week 4/15/2022 11

12. Controlled Partially controlled uncontrolled 4/15/2022 12

13. GINA has consider some risk factor over-use of SABA (average more than daily use), inadequate ICS use (under-treatment, poor adherence, incorrect inhaler technique ), some comorbidities (including obesity, chronic rhinosinusitis , gastroesophageal reflux , confirmed food allergy) low FEV1 high blood eosinophil count in patients with Type 2 inflammation, and major psychological or socioeconomic problems. 4/15/2022 13

14. Management 4/15/2022 14

15. Goal of asthma management The long-term goals of asthma management are risk reduction and symptom control. The aim is to reduce the burden to the patient and to reduce their risk of asthma-related death, exacerbations, airway damage, and medication side-effects 4/15/2022 15

16. Age group <5 yr 6 to 11yr 12yr+ and adult 4/15/2022 16

17. Age 6-11yr 4/15/2022 17

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21. Age <5 year 4/15/2022 21

22. Asthma treatment steps for children ≤5 years Step 1: Provide inhaled SABA for relief of wheezing episodes. Need for SABA more than twice a week on average over 1 month indicates the need for a trial of controller medication. Step 2: The preferred option is regular daily low-dose ICS plus as-needed SABA, given for at least 3month 4/15/2022 22

23. Step 3 Before considering step-up to double the ‘low’ ICS dose, check for concomitant or alternative diagnoses, check and correct inhaler technique and adherence, and ask about risk factors such as exposure to allergen or tobacco smoke. ICS-LABA is not recommended in children Step 4: Refer the child for expert advice if symptoms and/or flare-ups persist, or at any time if side-effects of treatment are observed or suspected, or if there are doubts about diagnosis .. 4/15/2022 23

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25. Initial controller treatment Before starting initial controller treatment Record evidence for diagnosis of asthma Record symptom control and risk factor Consider factor affecting choice of treatment Advise the patient and parent Schedule an appointment 4/15/2022 25

26. After starting initial controller treatment review response after 2-3 month or according to clinical urgency Adjust treatment including non pharmacology treatment Consider step down when asthma has been well controlled for 3 month 4/15/2022 26

27. Reviewing response and adjusting treatment How often should asthma be reviewed? 1-3 month after treatment started, then every 3-12 month If after exacerbation with in 1 week 4/15/2022 27

28. Stepping up asthma treatment Sustained step- up for at least 2-3 asthma poorly controlled check for adherence poor technique ,other cause Short term step up for 1-2 week viral infection or allergen Day to day adjustment For patients prescribed with ICS 4/15/2022 28

29. General principle for stepping down controller treatment Aim to find the lowest dose that controls symptom and exacerbation and minimize the risk of side effect When to consider stepping down ? When symptom has been well controlled and lung function stable for >= 3 moth No respiratory infection,pateint not travelling 4/15/2022 29

30. Prepare for step down Record the level of symptom control and consider risk factor Make sure the patient has written asthma action plan Follow up in 1-3 month Step down through available formulation Stepping down the ICS dose 25-50% at 3 month interval is feasible and safe for most pateint 4/15/2022 30

31. Non pharmacologic treatment avoidance of tobacco smoke exposure, physical activity, healthy diet and avoidance of medications that worsen asthma. 4/15/2022 31

32. Acute exacerbation In primary care set up Acute care setting 4/15/2022 32

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42. Follow up Arrange every follow up after any exacerbation, regardless of where it was managed: Review the patient’s symptom control and risk factors for further exacerbations. Prescribe/continue ICS-containing controller therapy (preferably MART with ICS- formoterol ) to reduce the risk of further exacerbations. If already taking controller therapy , continue increased doses for 2-4 weeks. Provide a written asthma action plan and, where relevant, advice about avoiding exacerbation triggers. Check inhaler technique and adherence 4/15/2022 42

43. Primary prevention of asthma in children The development and persistence of asthma are driven by gene-environment interactions. There are limited studies and recommendations for preventing asthma in children, based on high-quality evidence or consensus, include the following: Avoid exposure to environmental tobacco smoke during pregnancy and after birth. Encourage vaginal delivery where possible. 4/15/2022 43

44. A void the use of acetaminophen and broad-spectrum antibiotics during the first year of life. Identification and correction of Vitamin D insufficiency in women with asthma who are pregnant, or planning pregnancy, may reduce the risk of early life wheezing episodes, but not asthma. Allergen avoidance Breast-feeding is advised for its general health benefits 4/15/2022 44

45. REFERENCES Nelson text book of pediatric20 th edition Global initiative for asthma management and prevention, GINA ( 2021update ) 4/15/2022 45

46. Thank you 4/15/2022 46