BRONCHIAL ASTHMA in children presentation & management

Bronchial asthma in children

1. BRONCHIAL ASTHMA

2. ASTHMA
Epidemiology
Pathophysiology
Diagnosis

3. CHILDHOOD ASTHMA
• Childhood bronchial asthma is characterized
by
–Airway obstruction – which is reversible
–Airway inflammation
–Airway hyper responsiveness

4. Worldwide Asthma prevalence
(adolescents outside Europe)
> 9%
6 to < 9%
3 to 6%
< 3%
ISAAC Steering Committee, Lancet 1998

5. Prevalence of Bronchial Asthma
•Worldwide variation in prevalence
•Variation within countries
•ISAAC study – prevalence up to 25%
•More than 180,000 people die of asthma
each year
•5,000 deaths in the United States

6. Asthma components
Healthy Airway Asthmatic Airway
Smooth muscle Epithelium
Alveolar septum
Smooth muscle
contraction
Epithelial shedding /
damage
Inflammation and
oedema
Mucus and plasma
exudation

7. AsthmaNormal
Asthma - an inflammatory disease

8. INDUCERS
Allergens, Chemical sensitisers,
Air pollutants, Virus infections
INFLAMMATION
TRIGGERS
Allergens,
Exercise
Cold Air, SO
2

Particulates
SYMPTOMS
Cough Wheeze
Chest tightness
Dyspnoea
Airway
Hyperresponsiveness
Airflow Limitation

9. Mucus
hypersecretion
Hyperplasia
Eosinophil
Mast cell
Allergen
Th2 cell
Vasodilatation
New vessels
Plasma leak
Oedema
Neutrophil
Mucus plug
Macrophage/
dendritic cell
Bronchoconstriction
Hypertrophy / hyperplasia
Cholinergic
reflex
Epithelial shedding
Subepithelial
fibrosis
Sensory nerve
activation
Nerve activation
Modern view of Asthma

10. Chronic inflammation
Structural changes
Acute
inflammation
Steroid
response
Time
Inflammation in Asthma
Airway
remodeling

11. Diagnosis
Bronchial asthma is an iceberg disease
Classical features
•Persistent cough, wheezing and dyspnoea are seen
in 30%
Atypical features
•Cough-variant asthma
• Nocturnal asthma
•Activity-induced asthma
•Persistent cough after an URI
•Recurrent pneumonia at different sites/same
site(middle lobe)

12. Guidelines for diagnosis
Diagnosis is mainly clinical
•Episodic symptoms of airflow obstruction,
more than 3 episodes are present
•Airway obstruction is reversible
•Alternative diagnoses are excluded

13. ALLERGENS
•animal dander
•dust mites
•pollen
•fungi
Symptoms can occur or worsen in the presence of:
OTHERS
exercise
viral infection
smoke
changes in temperature
strong emotional expression
aerosol chemicals
drugs (NSAIDs, ß-blockers)
Ask about Triggers

14. Investigations
•Routine blood counts may not help
•Peripheral smear may show eosinophilia
•X–ray chest to rule out tuberculosis
•Sputum examination for eosinophils and
Curschmanns spiral bodies – rarely needed
•Pulmonary function tests – Gold Standard
•Spirometry
•Peak Expiratory flow rate

15. Peak expiratory flow rate (PEFR)
•Simple, Cheap and convenient
•It is the fastest rate at which air can move through
the airways during a forced expiration starting with
fully inflated lungs
•PEFR correlates well with FEV
1
•Used in children above 6 years
•Useful for monitoring the patient both at home and
office

16. Peak Flow Meter

17. Uses of PEFR
•For diagnosis and monitoring of asthma.
•PEFR taken regularly can give a warning of an impending
attack of bronchospasm before it starts. One can prevent it
by stepping up the preventive therapies.
•Long term follow up: Personal-best PEFR persistently
below 20–30% would indicate worsening of control of the
disease.

18. Spirometry
•Gold standard for diagnosis
•Smaller children cannot perform adequately
FEV
1
– The amount of air forcefully expired in the first second of an FVC manoeuvre
FVC – The maximum amount of air forcefully expired after maximum inspiration.
FEV
1
/FVC ratio less than 80% indicates airflow obstruction

19. Typical Spirometric (FEV
1) Tracings
Volume
Normal Subject
Asthmatic (After Bronchodilator)
Asthmatic (Before Bronchodilator)
Time (sec)
12345
FEV
1
Note: Each FEV1 curve represents the highest of t
hree repeat measurements

20. Differential Diagnosis of wheezing
Early infancy
Birth–6 months
Infancy–Early
childhood
6 months–3 years
Late childhood
> 3 years
Aspiration syndromes
(Gastroesophageal
Reflux etc)
Bronchiolitis Asthma
BronchiolitisTransient wheezing of
childhood (TWC)
TWC
Foreign body
inhalation (Rarely)
Foreign body
inhalation, Congenital
heart disease,
Infection e.g., TB
Congenital heart
disease

21. Treatment of Bronchial Asthma

22. •Freedom from
–Acute asthma attacks
–Symptoms including nocturnal cough
–Emergency doctor/hospital visits
•Minimal need for quick relief (as needed) ß
2-agonist
•Minimal (or no) adverse effects from medicine
•Normal
–Physical activity including participation in sports
–Maintain lung function as close to normal as possible
•Growth Charts
Treatment objectives

23. •Identify and avoid triggers that make asthma
worse
•Achieve control by selecting appropriate
medication
•Treat asthma attacks promptly and effectively
•Educate patients to manage their condition
•Monitor and modify asthma care to maintain
effective long-term control
Treatment strategy

24. Classify Asthma severity
Grade/SeveritySymptoms Night
time
PEFR
Mild intermittent
Grade 1
< 3 / week < 3 /
month
>80%, < 20%
variation
Mild intermittent
Grade 2
≥ 3 /week but < once
a day
> 3-4 /
month
>80%, 20-30%
variation
Moderate
persistent Grade 3
>Daily symptoms
attacks affect activity
> once a
week
60-80%, >30%
variation
Severe persistent
Grade 4
> Continuous Limited
physical activity
Frequent< 60%, >30%
variation

25. Drugs
Relievers
• To treat
bronchospasm and
relieve acute attacks
Preventers
•For prevention of
further attacks

26. Relievers Preventers
•Selective
short-acting 
2-
agonists
Salbutamol
Terbutaline
•Non selective
-agonist
Adrenaline
•Inhaled steroids
Beclomethasone dipropionate
Budesonide
Fluticasone propionate
•Mast cell stabilisers Sodium
cromoglycate Nedocromil
Sodium

27. Relievers Preventers
•Anticholinergics
Ipratropium bromide
•Oral steroids
•Theophylline
•Long acting 
2
-agonist
Salmeterol, Formoterol
•Long-acting oral

2
-agonist Bambuterol
•Methyl Xanthines
Sustained-release theophylline
 
•Oral Prednisolone
•Leukotriene antagonists
Montelukast, Zafirlukast, Pranlukast
•Ketotifen
Not useful in older children. May have a
role in atopy, high IgE and children with
multiple allergy syndrome

28. NEW DRUGS
Omalizumab—a recombinant humanised
monoclonal anti-IgE antibody
Soft steroids– Ciclesonide etiprednol dicloacetate
(BNP-166)
Phosphodiesterase 4 inhibitor-cilomilast
Anti IL-5 therapy
Suplatast toselate

29.  Soluble cytokine receptors as thearapeutic
agents. Nuvance Nebulisation
 Single Isomer -agonists
Levalbuterol (S-albuterol)
Dose required is less than that of
R-albuterol
 Respirable antisense oligonucleotides
eg: EPI- 2010

30. Grade 1
Step 1: Intermittent asthma
Preventer
None required
Reliever
Inhaled 
2
-agonist prn (not
more than 3 times a week)
Inhaled 
2
-agonist or cromone
prior to exercise or allergen
exposure
Avoid or control triggers

31. Management of
Persistent Asthma

32. Inhaled steroids – First line treatment
•Beclomethasone Propionate (BDP)
•Budesonide (BUD)
•Fluticasone (FP)
Dose
•Low dose < 400 mcg
•Medium dose < 400–800 mcg
•High dose > 800 mcg
•Corresponding dose for FP – half dose of BDP/BUD

33. Grade 2
Step 2: Mild persistent asthma
Avoid or control triggers
Preventer
Daily low dose inhaled corticosteroid
(<400 g) OR
Inhaled sodium cromoglycate
Reliever

Inhaled 
2
-agonist prn
(but less than 3-4 times per
day)
Nedocromil or leukotriene ↑ use may indicate need for
modifier, sustained release long term control therapy
theophylline

34. Grade 3
Step 3: Moderate persistent asthma
Avoid or control triggers
Reliever

Inhaled 
2
-agonist prn
↑use may indicate need for
long term control therapy
Preventer
Daily low dose inhaled steroid +
inhaled long-acting ß
2
agonist (may
provide better control of symptoms) OR
Daily medium dose corticosteroid 400-
800 g
LTM, SR Theophylline and long acting
ß agonist
LTM:Leukotriene modifier

35. Grade 4
Step 4: Severe persistent asthma
Avoid or control triggers
Reliever

Inhaled 
2
-agonist prn
(but less than 3-4 times per
day)
↑use may indicate need for
long term control therapy
Preventer
Daily high dose inhaled corticosteroid
> 800g
Daily long-acting bronchodilator +
theophylline
Daily oral corticosteroid tablets or syrup

LTM & long acting agonists

36. Role of Leukotriene antagonists
The only drug recommended in children is Montelukast – for children > 1 year
Dose –4-5 mg once daily
Indications –Mild persistent Asthma
–Exercise induced Asthma
–Aspirin induced Asthma
-- As an add-on agent at steps 2,3,and
4 when inhaled steroids are not
enough
Disadvantage –Poor efficacy (compared to inhaled
steroids)
– Few responders (unpredictable)
– Expensive
– Headaches (in 10%)
– Weak anti–inflammatory effect

37. TREATMENT
Avoid or control triggers
STEP 1: INTERMITTENT
Avoid or control triggers
STEP 2: MILD PERSISTENT
Avoid or control triggers
STEP 3: MODERATE PERSISTENT
Avoid or control triggers
STEP 4: SEVERE PERSISTENT
PREVENTERr: daily
medications
•Inhaled low dose steroid
•Or possibly cromone
•LTM,Theophylline
RELIEVER
•Inhaled ß
2
-agonist
p.r.n.
PREVENTER: daily medications
•Inhaled low dose steroid and long-
acting bronchodilator OR
•Inhaled medium dose steroid
•LTM,Theophylline
RELIEVER
•Inhaled ß
2
-agonist
p.r.n.
RELIEVER
•Inhaled ß
2-agonist
p.r.n.
RELIEVER
•Inhaled ß
2-agonist
p.r.n.
PREVENTER: daily multiple medications
•Inhaled high dose steroid
•Long-acting bronchodilator
•Oral steroid, theophylline,LTM
PRENVENTER:None
Step up
if not controlled (after
check on inhaler
technique and
compliance)
Step down
when
controlled
•Patient education
essential at every
step
•Reduce therapy if
controlled for at
least
3 months
•Continue
monitoring

38. Management of Acute
Severe Asthma

39. Severe acute attack
•Too breathless to feed
•Respiratory rate > 50 min
•Heart rate > 140 / min
•PEFR < 50% of the best
•Poor or only transient (<2hr) response to
bronchodilator
•Worsening despite 2–3 doses of recent dose of
bronchodilator at 15 minutes interval

40. Life-Threatening Asthma is characterized
by
•Unable to talk or cry
•Cyanosis
•Feeble chest movements
•Absent breath sounds
•Fatigue or exhausted
•Agitated
•Altered sensorium
•Oxygen saturation < 91% in pulse oximeter

41. Assessment of severity of an acute
attack of bronchial asthma can be
done by a simple scoring system
called pulmonary score Index
(PSI)–(PCNA December ‘99)

42. Pulmonary score index
Score
Respiratory Rate Wheezing Accessory muscle
< 6years > 6 years Sternomastoid activity
0 < 30< 20 None No apparent activity
1 31–4521–35 .Terminal Questionable
expiration with
stethoscope
2 46–6036–50 .Entire expiration Increase apparent
with stethoscope
3 > 60> 50 .During inspiration Maximal activity
and expiration
without stethoscope
Score0–3 Mild If no wheezing due to minimal air exchange, score-3
4–6 Moderate
> 6 Severe
Those children whose score is > 6 should be admitted to a paediatric ICU

43. Management
•Oxygen
•Adequate hydration
•Nebulised 
2-agonist, Intravenous beta agonist
•Electrolyte balance (hypokalemia due to repeated
salbutamol nebulisations)
•Anticholinergic drugs
•Steroids
•S.C.inj of Epinephrine or  agonists in severe cases
•Magnesium sulphate
•IV Aminophylline
•Heliox
•Mechanical Ventilation

44. Oxygen
•Hypoxia is due to ventilation perfusion mismatch.
–agonists may increase hypoxia by attenuating
the hypoxic pulmonary vasoconstriction, hence
oxygen should always be administered along with
nebulised -agonist.
•Maintain oxygen saturation between 90–95%.

45. Nebulised 
2-Agonists
–agonists are the drug of choice in asthma.
•Patients with acute severe asthma will require and
tolerate higher doses
•Dose of salbutamol - 0.15 mg/kg, minimum 0.25
ml for < 6 months, 0.5 ml for > 6 months, 0.5 – 1
ml for older children and adults.
•Dilute in normal saline only, never distilled water.

46. Steroids
•Steroids reduce inflammation in this predominantly
inflammatory illness
•Should be used early in all patients with acute
severe asthma
•Hydrocortisone or methylprednisolone (MPS) may
be administered IV if patient is unable to take oral
steroids

47. Rescue steroids
•Dose: MPS 2mg/kg stat followed by 1mg/kg q 6 hr OR
Hydrocortisone 10mg/kg stat followed by 5mg/kg q 6 hr
•IV steroids may be stopped after 48 hours or after
improvement commences to thrice daily dosages
•Oral or IV steroids are of more therapeutic value in the
treatment of acute severe asthma
•Inhaled or nebulised steroids are generally used as
preventive therapy. However, some reports show
benefits even in acute asthma

48. Anticholinergic agents: Ipratropium
•Useful as an adjunct with salbutamol in
the treatment of acute severe asthma
•Dose: < 1year – 0.5ml , > 1year – 1ml
•Has longer duration of action and less
systemic side effects compared to
atropine
•Smaller children with spasmodic cough
respond well to Ipratropium as compared
to Salbutamol

49. Magnesium Sulphate
•Useful in severe asthmatics
•Mechanism: Calcium channel modulation
results in decreased acetylcholine and
histamine release
•Efficacy, dose and frequency have not been
clearly worked out
•To be reserved for use in severe resistant
asthma not responding to routine therapy

50. Suggested dose
•25–50mg/kg to be diluted in normal saline
and administered as an infusion over ½ hour
Side effects
•Tachycardia/bradycardia, hypotension,
muscle weakness at higher serum level

51. Intravenous 
2
Agonists
•IV terbutaline or IV salbutamol may be used if patient fails to
improve with nebulized 
2
-agonists
•Dose: Terbutaline, initial bolus of 5–10g/ kg over 10
minutes followed by 2–10g/kg/hour. Higher infusion rates
may be used with caution
•Continuous ECG monitoring. If HR 180/minute,
arrhythmias or ST changes develop, dose
•Discontinue nebulisation at higher infusion rate if signs of
toxicity develop
•Preparation of terbutaline:1 ampoule (1ml) contains 500mcg.
Dissolve 1 ampoule in 50ml of 5% dextrose so that 1 ml =
10mcg terbutaline

52. Aminophylline
•Doubtful additional bronchodilatation if optimal –  agonists
used
•Possible role in improving diaphragmatic contractility and
inflammatory modulation may confer additional benefit
•Dose: Loading dose 5–10mg/kg/hr followed by
0.5–1.0mg/kg/hr
•Avoid loading dose if patient already receiving theophylline
•Dose of terbutaline to be decreased by 50% when
concurrently infused with aminophylline

53. •Monitor levels if possible, keep between
10–20mcg/dl. Watch for drug interactions–
anticonvulsants (decrease levels), H
2 blockers,
macrolides (increase levels). Infections, especially
viral also modify theophylline levels
•Toxicity – Gl (vomiting, gastritis), cardiac
(tachycardia, arrhythmias), CNS (irritability, seizures)
Aminophylline – Contd..

54. Antibiotics
If there is fever and evidence of bacterial
infection, the addition of antibiotics will
help

55. Indications for Intubation
 Absolute
•Cardiac arrest
•Comatose child
•Severe respiratory
distress
• Silent chest, exhaustion
Relative
•Hypoxemia pO
2
<60 mm
Hg in 60% oxygen
•pCo2> 65 mm Hg & or
pCo
2
rising by > 5mm
Hg/hr
•Metabolic acidosis
(–BE > 8 – 10)

56. Algorithm For Management of
Acute Severe Asthma
1.Establish diagnosis, consider differential diagnosis particularly
if first presentation
2.Assess severity
 
Initial treatment
•Oxygen to maintain saturation > 90–95%
•Nebulized salbutamol 3 doses at 20 minute intervals, < 20 kg:
0.5 ml salbutamol with 3 ml N Saline. >20 kg: 1 ml salbutamol
with 3 ml N Saline
•Nebulized ipratropium: < 1 year – 0.5 ml, > 1 year – 1ml
•Steroids:Methylprednisolone 2mg/kg stat, followed by
1mg/kg q 6 hr or Hydrocortisone– 10 mg/kg stat followed by 5
mg/kg x 6th hourly daily O

57. Not improved
Reassess diagnosis
Inj Magnesium Sulphate
25-30 mg/kg in 10 ml N saline
over 30 mins
May be repeated after 6 hrs
Terbutaline infusion
Load with 5–10g/kg
followed by 2-10g/kg
(Increase dose every 15 minutes)
Aminophylline infusion
(Reduce terbutaline infusion
by 50%)

Mechanical ventilation

Not improved after 1
st
dose MgSO
4
Improved
Nebulised Salbutamol
hourly
Increased interval
between doses as
tolerated to Q-4H
Continue steroids,
ipratropium
Not improved
Not improved

58. Patient Education

59. The importance of patient education in
Asthma
•Once patients understand about the disease and its
treatment, control becomes easy
•Pediatricians should handle commonly asked queries by
patients
‘Physicians who give clear explanations to their patients
are likely to be seen as competent and caring’
D L Roter and JA Hall. Doctors talking with patients, patients talking
with doctors: Improving communication in medical visits, page 13,
Auburn House Publishers, USA

60. Key features of patient education
•Acceptance of diagnosis
•Control but not necessarily cure
•Understanding of pathophysiology and trigger factors
•Concept of relievers and preventers
•Advantages of inhalation therapy and its myths and
misconceptions
•Allay fears of steroids
•Asthma monitoring
All the above may not be done in one visit.
Reinforcement at regular intervals is important

61. Additional information
•Asthma and exercise or activity
•Consider informing school teachers and/or peers
especially in severe cases

62. Acceptance of Diagnosis
•Asthma is like the tip of an iceberg
•If presents with classical features, parent
acceptance easy
•If presents with atypical features (cough variant
asthma), parent acceptance difficult.
•Wheeze associated lower respiratory infections –
patients can be given a good prognosis.

63. Fear of steroids
•Patients should be reassured that steroids are
completely safe when given by the inhaled route
at therapeutic doses
•Children with asthma who have been treated for
up to 13 years have attained normal adult height
•Uncontrolled asthma may itself lead to growth
retardation

64. Allergen avoidance and
avoidance of trigger factors

65. House Dust Mite
•Remove carpets or upholstery that tend together dust.
•Use cotton sheets rather than woolen blanket.
•Sun the room.
•Dust mattresses periodically and expose them to Sunlight.
Encase mattress in air tight cover.
•Keep soft toys away from sleeping area and wash weekly
with hot water
•Vacuuming – not proven

66. Cockroaches
•General hygiene measures to limit cockroach
population.
 
•Insecticide spraying to be done while child is away.

67. Pets (Animal Dander)
•Gentle persuasion to give pet
away
•Pets not to be allowed in sleeping
area /bed room.
•Bathe pet weekly

68. Moulds or Indoor Fungal Spores:
•Attend damp walls/ leakages.
•Clear air conditioner filters monthly.

69. Out Door Allergens
•Pollen (Flower)
–Avoid flowering plants indoor
–Stay indoor during harvesting and flowering season.

70. Irritants & Chemicals
•Passive smoking, Tobacco smoke
•Fumes from kerosene stove, chulla, wood, cow dung
•Agarbattis
•Strong odors
•Mosquito repellent mats & coils
(Advice use of mosquito nets, long cloths)
•Chalk, fine dust, sprays

71. Other important factors
•Food additives – (Sulphites, benzoate,
monosodium glutamate)
•Drugs: Avoid Aspirin, NSAIDs, Propranalol

72. Adjuvant Therapy
•Yoga
•Breathing exercises
•Exercises such as swimming

73. Treatment for Associated diseases
1.
 
Allergic Rhinitis/Sinusitis
a. Intranasal steroid spray Budesonide 100 mcg
twice a day or Fluticasone 50 mcg once a day
b.Oral antihistamines
2.Gastroesophagal Reflux
Antireflux treatment. Oral Theophylline to be
avoided.

74. Thank you