Childhood asthma 2021

asthma in children

1. Childhood Asthma Classification , Epidemiology, Etiology, Pathogenesis, Clinical Features, Complications, Management Prognosis and Prevention Prof. Imran Iqbal Fellowship in Pediatric Neurology (Australia) Prof of Paediatrics (2003-2018) Prof of Pediatrics Emeritus, CHICH Prof of Pediatrics, CIMS Multan, Pakistan

2. (God speaking to Prophet Muhammad (PBUH) They ask you what they should spend . Say: whatever you spend for good must be for parents and relatives and orphans and poor and travelers; and whatever you do of good deeds, Allah knows it well Al Quran surah Al- Baqara 2 :215

3. Case scenario 1 Ten months old baby Runny nose – 5 days C ough and noisy breathing - 1 day History of two similar episodes in last two months Grandmother has bronchial asthma Examination Temperature 98 F Respiratory rate 60 / min, chest indrawing present Bilateral expiratory rhonchi What is your diagnosis ?

4. Case scenario 1 10 months old baby runny nose – 5 days cough and noisy breathing - 1 day History of one similar episode one month before Examination Temperature is 98 F. prolonged expiration Bilateral expiratory rhonchi . What is your diagnosis ? ASTHMA (Early onset) Likely to resolve in 2-4 years

5. Case scenario 2 Six years old child Cough often since start of winter season Cough usually at night and in the morning Cough and shortness of breath starts when the child runs in school Examination , Temperature 98 F. Watery discharge in nose Expiratory rhonchi audible in chest What is your diagnosis ?

6. Case scenario 2 6 years old child Cough since start of winter season. Cough usually at night and in the morning Cough and shortness of breath starts when the child runs in school Examination , Temperature 98 F. Watery discharge in nose Expiratory rhonchi audible in chest What is your diagnosis ? ASTHMA (childhood onset) May resolve at puberty

7. ASTHMA - epidemiology Commonest respiratory disease of children Can start at any age Prevalence of asthma is increasing in children Prevalence of asthma in children in Pakistan = 20 %

8. ASTHMA is a chronic inflammatory condition of lung airways resulting in episodic airway obstruction

9. Airway inflammation produces Hyper-reactivity of airways to a variety of stimuli resulting in diffuse airway obstruction which is reversible spontaneously or as a result of treatment

10. Mechanism of Development of Asthma Chronic inflammation causes Hyper-reactivity of airways

11. Pathophysiology of Airway inflammation

12. Antigens incite Inflammatory Reaction and Cytokines produce Airway inflammation

13. Etiology of Asthma

14. How is Bronchoconstriction produced in Asthma ? Air way Inflammation Bronchial hyper-responsiveness Trigger stimulus Airway narrowing

15. Precipitating stimuli (triggers of asthma) Infection Viral infections Allergens House dust Plant pollen Animal dander Wheat hay Foods Air temperature Cold air Air Pollution Dust Cigarettes Smoke Perfumes Physiological Exercise Stress

16. Asthma Triggers

17. How are the airways obstructed ? Pathology

18. A ir - Flow Obstruction in Asthma

19. PATHOLOGY of Asthma Contraction of bronchial smooth muscle Mucosal edema Viscid mucus secretion

20. PATHOLOGY of Asthma

21. Clinical Features

22. SYMPTOMS COUGH WHEEZE BREATHLESSNESS

23. Differential Diagnosis COUGH can be due to many causes All that wheezes is not asthma

24. Causes of Cough Infections – viral / bacterial / mixed Allergy – asthma Environment – smoking / pollution

25. Causes of Recurrent / Persistent Cough Asthma Chronic irritation / Air pollution Postnasal discharge Repeated Viral Infection Recurrent Bacterial infection Whooping Cough Tuberculosis

26. Chronic Cough - Rare causes Foreign body GERD Cystic fibrosis Interstitial lung disease Hypersensitivity Pneumonitis Immunodeficiency Ciliary dyskinesia Habit cough

27. Causes of Wheezing Asthma Bronchiolitis Viral infections Foreign body GERD Heart failure

28. Diagnosis

29. DIAGNOSIS Diagnosis is Clinical on History and Examination RECURRENT / INTERMITTENT symptoms Signs of BRONCHIAL obstruction There may be NO signs at the time of examination

30. ASTHMA – symptom variability

31. Suggestive clinical features of Asthma Late night or early morning cough / breathlessness Breathlessness on Exercise Symptoms precipitated by viral colds Response to bronchodilators Family history of asthma / allergy

32. SIGNS of Asthma Wheezy Cough Prolonged Expiration Audible Wheeze Rhonchi on Auscultation

33. INVESTIGATIONS Asthma is Clinical diagnosis X-ray Chest – may show hyperinflation CBC – may show eosinophilia Serum IgE level – increased in allergy PEFR (Peak Expiratory Flow Rate) – low in exacerbation Spirometry – Lung Function tests – low FEV1/FVC

34. PEFR – Peak Expiratory Flow Rate Blow forcefully in Peak Flow Meter

35. Peak Flow Chart Exercise Test

36. Spirometry

37. Spirometry in clinic L ung Volumes measurements

38. Spirometer and flow-volume report

39. FEV1 / FVC ratio

40. Complications of Asthma Bacterial bronchitis Pneumonia Respiratory failure Re-modelling of Airways Chest deformity Growth retardation

41. MANAGEMENT of ASTHMA

42. Asthma is underdiagnosed and undertreated

43. Assess the child with ASTHMA Onset of symptoms (duration) Acute exacerbations (frequency and severity of attacks) Daily symptoms (day / night – cough / wheeze / breathless) Physical Examination (Chest, Growth) PEFR (in clinic) Environment (allergens / pollution in house)

44. Asthma Management Educate the parents about the disease Avoid allergens and irritants Prevent infections Monitor daily symptoms Relieve symptoms (Quick-Reliever medication) Prevent exacerbations (Controller / Preventer medication)

45. EDUCATE THE PARENTS Asthma is a chronic disease Many children get better as they get older Regular treatment and prevention increases cure rate Asthma triggers should be avoided Treatment will need to be increased or decreased with severity of symptoms Signs of worsening of Asthma must be recognized and appropriate treatment started

46. Avoid Allergens in House Dust in house Smoke / smoking of cigarettes Carpets in house Birds (pigeons, parrots) Animals (cats) Cold air Ice-cream Cold drinks Any foods known to start symptoms

47. Monitor Daily Symptoms in a Diary

48. Record PEFR daily in a graph

49. Asthma Medications Bronchodilator Beta – stimulants – Short-acting (Salbutamol), SABA -- Long-acting (LABA) Theophylline Anti – inflammatory LTRA (Leukotriene Receptor Antagonist ) - Monteleukast Inhaled steroids (beclomethasone, budesonide) Oral steroids Bronchodilator and Anti – inflammatory, both are needed for control of Asthma Bronchodilator and Anti-inflammatory medications should be started together in all children with Asthma

50. Asthma Medications Quick-Reliever medication – for relief of symptoms (bronchodilator) Salbutamol / Short – acting Beta – stimulants (SABA) Theophylline Oral steroids Controller / Preventer medication – to Control inflammation and Prevent exacerbations Monteleukast / LTRA (Leukotriene Receptor Antagonist) Inhaled steroids (beclomethasone, budesonide ) LABA (long acting beta agonists)

51. Assess and Manage Acute Asthma

52. Asthma Exacerbations - (non-severe) Assess severity of problem Give nebulized salbutamol Oral doxophylline Monteleukast Start oral prednisolone – if no persistent relief by nebulization

53. Asthma Exacerbations - (severe) Monitor severity of illness Oxygen Frequent salbutamol nebulization IM hydrocortisone Oral Prednisolone Monteleukast Antibiotics if needed

54. Asthma Exacerbations - (life-threatening) Status Asthmaticus Admit in hospital / PICU Oxygen IV fluids Frequent salbutamol nebulization Nebulize Ipratropium bromide IV hydrocortisone IV methylprednisolone IV Aminophylline IV magnesium Sulphate Antibiotics

55. Long-term Asthma Management Classify severity of symptoms – -- intermittent, persistent (mild, moderate, severe) Give Monteleukast / Inhaled steroids / LABA as needed Step up or step down treatment as needed Treat exacerbations: salbutamol / SABA oral steroids

56. Classification of Long-term Asthma Symptoms Severity of Asthma Day Symptoms Night time symptoms TREATMENT Step 4 Severe Persistent Asthma Continuous symptoms: Limited physical activity Frequent Beta agonists Monteleukast Inhaled steroids Oral steroids Step 3 Moderate Persistent Asthma Daily symptoms: Attacks daily affect activity   More than 1 time a week LABA Monteleukast Inhaled steroids Step 2 Mild Persistent Asthma Symptoms more than once a week but less than once a day.   More than 3 times a month Monteleukast or Inhaled steroids Step 1 Mild Intermittent Asthma Symptoms less than once a week. Asymptomatic and normal between attacks   Less than 3 times a month. BRONCHODILATORS and Montelukast as needed

57. GINA 2020, Box 3-4C

58. Evaluate Asthma Control

59. Prevention of Asthma

60. Prevention of Asthma Breastfeeding Control smoking, air pollution Avoid dust, carpets, perfumes No birds, pets in house Avoid exposure to cold air Avoid Foods guided by individual experience

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