Childhood asthma...a common problem in children

It's the basics of asthma in children

1. CHILDHOOD
ASTHMA

2. DEFINTIONOF ASTHMA
•Asthma is chronic inflammatory condition of the lung airways resulting in an episodic
airflow obstruction.Thischronic inflammation heightens the twitchiness of the airways to
common provocative exposures.Thisis called airway hyperresponsiveness.
•Airway inflammation is associated with:
Airway hyperresponsiveness
Airflow limitation
Respiratory symptoms

3. ETIOLOGY
• Environment Biological and genetic risk
• Allergen,infection,micro AGE Immune, lung,repair
• bes,tobacco smoke,stress,
• pollutants

4. PATHOGENESIS
•A combination of environmental and genetic factors in early life shape how the immune
system develops and respond to the ubiquitiousenvironmental exposures.
•Respiratory microbes,inhaledallergens,andpollutants that can inflame the lower airways
target the disease process to the lungs.
•Aberrant immune and repair responses to airways injury underlie the persistent disease.
•Airflow obstruction in asthma is the result of numerous pathological processes.
•In the small airways,airflow is is regulated by smoothmuscle encircling the airway
lumen;bronchoconstriction of thesebronchiolarmuscular bands restricts or blocks airflow.

5. PATHOGENESIS
•A cellular inflammatory infiltrate and exudates distinguished by eosinophils,but also
including other inflammatory cell types,can fill and obstruct the airways and induce
epithelial damage and desquamation into the airway lumen.Helper T lymphocytes and
other immune cells that produce proallergic,proinflammatory cytokines like IL4,5,13 and
chemokines like eotaxins mediate this inflammatory process.
•Pathogenic immune responses and inflammation may also result from abreach innormal
immune regulatoryprocesses that dampen effector immunity and inflammation when
they are no longer needed.

6. PATHOGENESIS
•Hypersensitivity or susceptibility to a variety of provocative exposures or triggers can
lead to airway inflammation, AHR, edema,basement membrane thickening ,subepithelial
collagendeposition, smooth muscle and mucus gland hypertrophy, and mucus
hypersecretion-all processes that contribute to airflow obstruction.

7. EPIDEMIOLOGY
•It’s a common chronic disease ,causing considerable morbidity.
•In2011, more than 10 million childrenhad ever been diagnosed with asthma,with 70% of
this group reporting current asthma in USA.
•Male gender and living in poverty aredemographicrisk factors for having childhood
asthma in USA.

8. TYPES OF ASTHMA
•BASED ON DIFFERENT NATURAL COURSES:
A)Recurrent wheezing in early childhood
B)Chronic asthma.
BASED ON DISEASE SEVERITY :
A)Intermittent
B)Persistent –mild,moderate,severe.

9. TYPES OF ASTHMA
BASED ON TREATMENT RESPONSE AND MEDICATION REQUIRED:
A)Easy to control
B)Difficult to control
C)Exacerbators
D)Refractory asthma

10. CLINICAL FEATURES
•Intermittent dry coughing and expiratory wheezing are the most common chronic symptoms
of asthma.
•Shortness of breath,chestcongestionandtightness in older children and adults .Younger ones
complain of intermittent non focal chest pain.
•Respiratory symptoms can be worse at night ,associated with sleep,especiallyduring
prolonged exacerbations triggered by respiratory infections or inhalant allergens.
•Daytime symptoms, often linked with physical activities or play are reported with greatest
frequency in children.
•Other symptoms can be non specifictype like general fatigue etc.

11. DIFFERENTIAL DIAGNOSIS
•GERD
•Rhinosinusitis
•Recurrent aspiration
•Tracheobronchomalacia
•Foreign body aspiration
•Cystic fibrosis
•Broncho pulmonary dysplasia
•Vocal cord dysfunction

12. DIAGNOSIS AND MANAGEMENT
•It is based on GINA guidelines 2019.
•GINA stands for GLOBAL INITIATIVE FOR ASTHMA established to increase awareness
about asthma among health professionals,publichealth authorities and the community.
•Guidelines were advised to decrease the risk of acute asthma exacerbations and death

13. MAJOR CHANGES IN 2019
•No longer treatment with SABA alone
•Either symptom driven (mild asthma) or daily low dose ICS containing controller therapy
since,
Low dose ICS is very effective in preventing severe exacerbations and
preventing exercise induced bronchoconstriction even in mild asthma.
Early treatment with low dose ICS leads to better lung function than if
symptoms have been present for more than 2 to 4 yrs.

14. CRITERIA FOR DIAGNOSING ASTHMA
•HISTORY OF VARIABLE RESPIRATORY SYMPTOMS
-Typical symptoms are one or more of the following: wheeze,shortnessof breath,coughand
chest tightness.
-They may vary with timeand in intensity.
-Are worse at night or in early morning.
-Are triggered or exacerbated by exercise,laughter,allergens,coldair or viral infections.

15. CRITERIA FOR DIAGNOSING ASTHMA
•Document that the variation in lung function is greater than in healthy people
(to confirm the diagnosis)
-FEV1 increases by >12% of the predicted value after inhaling bronchodilator
(bronchodilator reversibility)
-Average daily diurnal PEF variability is >13% in children.
-FEV1 increases by >12% of the predicted value after 4 weeks of anti inflammatorytherapy.

16. CRITERIA FOR CONFIRMING THE DIAGNOSIS IN
PATIENTS ALREADY ON CONTROLLER TREATMENT
•Consider other investigations if the above standard criteria have not been met ;for
example;
1)If lung function is normal, repeat reversibiltytesting when the patient is symptomatic or
after withholding bronchodilator medications for 12 hrsor >24hrs if on ultra longacting
bronchodilator.
2)If the patient has frequent symptoms, consider a trial of step up in controller treatment
and repeat lung function tests after 3 months.

17. INITIATE ASTHMA TREATMENT
•ICS containing treatment should be started as soon as the diagnosis of asthma is made.
•If the initial asthma presentation is with severlyuncontrolled asthma or with an acute
exacerbation ,give a short course of oral corticosteroids and regular controller
treatment.

18. TREATMENT CONTROLLER
STEP 1 Low dose ICS with SABA
STEP 2
1st –Regular low dose ICS
2nd-Daily LTRA or low dose ICS whenever SABA is taken.
STEP 3
Medium dose ICS or
Low dose ICS-LABA
STEP 4
Medium dose ICS or
Low dose ICS-LABA + Opinion from pediatric pulmonologist
STEP 5
Refer for phenotypic assessment +_add on treatment ;
-history of exacerbations :Tiotropium mist inhaler
-severe allergic asthma:antiIGE like scOmalizumab
-severe eosinophilic asthma :anti IL5 like scMepolizumab
-anti IL 5 R :scBenralizumab
-anti IL4 R : scDupilimab

19. ASSESS SEVERITY
•It is assessed retrospectively depending on the treatment required
-Mild asthma : Can be controlled with step 1orstep 2
-Severe asthma: Requires at least step 5 of treatment

20. Assess
control
Adjust
treatment
Review
response
FOLLOW UP

21. ASSESS CONTROL
•1) Assess asthma control
-Assess the level of asthma symptom control over last 4 weeks.
-Assess the risk factor for poor asthma control.
2)Rule out comorbidities
-Like rhinosinusitis,rhinitis,GERD,obesity,OSAS,depression and anxiety.
3)Assess and reassess the treatment issues
-Inhaler technique, drug side effects, adherance and written asthma action plan.

22. ASSESS CONTROL
•1) Assess risk factors at the time of diagnosis and then periodically at least every 1 to 2
yrs.
•2) Measure FEV1: At the start of the treatment, 3 to 6 months after starting the
treatment and then periodically every 1 to 2years and more frequently in those with
higher risk of flare ups or lung function decline.

23. ASSESS THE LEVEL OF ASTHMA SYMPTOM
CONTROL OVER THE LAST 4 WEEKS
•In the past 4 wks has the patient had;
-Day time symptoms > 2 times/wk
-Any night time awakening due to asthma
-Reliever medications needed > 2 times/ wk
-Any activity limitation due to asthma

24. 3 to 4 of these Uncontrolled asthma
1 to 2 of these Partly controlled asthma
None of these Well controlled asthma
IF ANSWER TO THOSE 4 QUESTIONS IS YES ; THEN IF

25. ASSESS RISK FACTORS FOR POOR ASTHMA
OUTCOMES
•1) Having uncontrolled asthma.
•2)Additional potentially modifiable risk factors; like poor compliance to medications,
incorrect inhaler technique, associated comorbidities, exposure to smoke ,allergen, major
socio economic issues and poor lung function like low FEV1.
•3)Other independent risk factors like been intubated or admitted in ICU for asthma.

26. REVIEW RESPONSE AND ADJUST TREATMENT
•Review 1 to 3 months after starting the treatment and every 3 to 12 months thereafter.
•After an exacerbation, review visit within a week is to be scheduled.

27. TREATMENT
STEP UP
•Sustained step up for 2 to 3 months if
symptoms or exacerbations persist despite
2 to 3 months of controller therapy.
•Short term step up for 1 to 2 weeks in
case of viral infection or allergen exposure.
STEP DOWN
•Once good asthma control has been
achieved and maintained for at least 3
months.
•Reduce ICS dose by 25% to 50% every 2
to 3 months.
•Do not completely stop ICS in adults or
adolescents.

28. ASSESS THE INHALER SKILL AND ADHERANCE
•1)Choose the most appropriate inhaler device
•2)Check the inhaler technique at every opportunity.
•3)Correct the technique using the physical demonstration.
•4)Confirm the checklist for inhalers we prescribe.

29. NON PHARMACOLOGICAL STRATEGIES AND
INTERVENTION FOR ASTHMA PREVENTION
•1)Avoid exposure to smoke,dust and pollen.
•2)Avoid foods known to cause allergies.
•3)Encourage regular physical activity with advice about exercise induced
bronchoconstriction.
•4)Avoid stress.