Information about CHILDHOOD ASTHMA E-CLASS.pptx

Children asthma

1. CHILDHOOD ASTHMA

2. Asthma Definition It is defined by the history of respiratory symptoms such as wheeze, shortness of breath, chest tightness and cough that vary over time and in intensity, together with variable expiratory airflow limitation . Asthma is a heterogeneous disease, usually characterized by chronic airway inflammation. changing paradigm in understanding

3. Asthma Definition Asthma is characterized by reversible airflow limitation, an oversensitive cough reflex and mucus hypersecretion. It may have no inflammatory component or there may be different patterns of inflammation, as there may be contributions from bacterial and viral infections that vary over time .

4. CHALLENGE TO DIAGNOSE Classical features like wheezing and dyspnea are seen only in 30%. Wheeze - All asthmatic children do not wheeze; all that wheezes is not asthma Asthma being characteristically episodic, there may be no signs at the time of evaluation Cough – Recurrent / Persistent cough (often misdiagnosed)

5. WHEN TO SUSPECT 1.Frequent episodes of wheezing-> once a month 2. Activity induced cough or wheeze 3. Cough particularly in night during periods without viral infection. 4. Absence of seasonal variation in wheeze 5. Symptoms that persists after the age 3 Consider asthma if any the following signs or symptoms are present:

6. 6 .Symptoms occur or worsen in the presence of: Aeroallergens Exercise Pollens Respiratory infections (viral) Strong emotional stress Tobacco smoke WHEN TO SUSPECT Consider asthma if any the following signs or symptoms are present:

7. 7 . Childs cold repeatedly “goes to the chest” or takes more than 10 days to clear up. 8. Symptoms improve when asthma medications are given WHEN TO SUSPECT Consider asthma if any the following signs or symptoms are present:

8. WHEN TO SUSPECT Recurrent cough? Recurrent wheeze? Recurrent breathlessness? Exercise induced cough/wheeze? Nocturnal cough? Tightness of chest? If these symptoms of airway obstruction are recurrent then it is asthma.

9. WHAT TO LOOK FOR Asthma is a dynamic condition The examination may be essentially normal when in remission Generalized wheeze /prolonged expiration /Chest hyperinflation- symptomatic Evidences of skin/nasal atopy

10. How To Confirm No gold standard test to diagnose. Diagnosis is essentially clinical. Other causes of recurrent cough should be ruled out. Lung function tests are of definite but limited value .

11. The role of lung function in asthma Diagnosis Demonstrate variable expiratory airflow limitation Reconsider diagnosis if symptoms and lung function are discordant Frequent symptoms but normal FEV 1 : cardiac disease; lack of fitness? Few symptoms but low FEV 1 : poor perception; restriction of lifestyle? Risk assessment Low FEV 1 is an independent predictor of exacerbation risk. GINA 2014

12. The role of lung function in asthma Monitoring progress Measure lung function at diagnosis, 3-6 months after starting treatment (to identify personal best), and then periodically. Consider long-term PEF monitoring for patients with severe asthma or impaired perception of airflow limitation. Adjusting treatment? Utility of lung function for adjusting treatment is limited by between-visit variability of FEV 1 (15% year-to-year). GINA 2014

13. Diagnosis of asthma The diagnosis of asthma should be based on: A history of characteristic symptom patterns Evidence of variable airflow limitation, from bronchodilator reversibility testing or other tests Document evidence for the diagnosis in the patient’s notes, preferably before starting controller treatment It is often more difficult to confirm the diagnosis after treatment has been started. GINA 2014

14. RULE OUT MIMICS Younger age- Congenital anomalies, GERD, WARI Cardiovascular causes L-R shunts Foreign body aspiration CF, PCD , Immunodeficiency Tuberculosis/Bronchiectasis

15. Comorbidities of asthma It is important to assess for the comorbidities as if underdiagnosed or undertreated, comorbid conditions can influence quality of life and asthma control. Rhinitis Rhinosinusitis Nasal polyposis Obesity Obstructive sleep apnea Gastro-esophageal reflux disease Psychological stress, anxiety symptoms, depression Dysfunctional breathing Exercise induced laryngeal obstruction

16. GINA 2014, Box 1-1 © Global Initiative for Asthma NEW!

17. Summary so far….. > 3 episodes of airflow obstruction are present Airway obstruction is reversible Alternative diagnoses are excluded Co morbid conditions are identified Diagnosis of Asthma is mainly clinical

18. HOW TO TREAT Patient education Pharmacotherapy Long term management Trigger avoidance Treatment of acute attack Home management plan Follow up

19. HOW TO TREAT Parental and patient counseling (Education) 1.Conveying the diagnosis 2.Disease pathogenesis and natural course 3.Treatment and out come 4.Inhalation devices –use, myths 5.Home monitoring 6.Home treatment plan

20. HOW TO TREAT Pharmacotherapy -Relievers- b-agonists (oral/inhaled), Anticholinergics, systemic steroids -Preventers- -Inhalers- LABA/Steroids/chromone -oral -LTRAS -theophylline -steroids

21. ICS Anti inflammatory effect evident in 2-3 weeks Local side effects can be minimized by spacers/gargling Systemic side effects negligible Most children are controlled with medium doses. In prolonged high doses-monitor growth and eyes

22. LABA Not used as relievers Never use alone Used with ICS for synergistic effects/steroid steroid sparing effects Useful in nocturnal/Exercise induced symptoms Used only in children >4years Salmeterol / Formoterol-not much to choose

23. Leukotrine antagonists Weak anti inflammatory effect Add on in moderate to severe asthma Mono therapy may be considered in mild asthma but certainly inferior to ICS Exercise induced asthma Montelukast > 6 months

24. Theophylline Anti inflammatory/immuno modulator effect Used as preventer only (sustained release formulations as ad on to ICS), no role of syrup formulations Exception-Acute severe asthma Caution- side effects / drug interactions

25. Long term oral steroids Use limited to severe persistent asthma Minimal possible doses Alternate morning doses preferred Prednisolone – best option Monitor side effects-bone density, eyes, skin, immuno suppression, HPA axis

26. Inhalation treatment is not only the most natural, effective, fast and safe way to treat Asthma… It is the only way to treat it. What is the need for inhalation treatment?

27. PRINCIPLES OF INHALATION THERAPY Targeted delivery of medication to the airway tract Rapid onset of action Smaller doses Less systemic and GI adverse effects Relatively comfortable

28. Barriers to inhalation therapy Fear about steroids Do not like public labeling as asthmatic Fear of addiction Feel pumps reserved for serious or severe attacks or will fail to act Misconception that costly Prefer oral medications Physicians lack of knowledge and time

29. WHEN GIVEN BY INHALED ROUTE HOW MUCH DRUG GOES IN TO LUNGS Inhalation device delivery MDI with spacer 10-15 % MDI alone 5-10 % DPI 5-10 % Nebuliser 1-5%

30. When using MDI spacer is a must Eliminates need for hand-breath co ordination Improve drug delivery Reduce local side effects of ICS Dilute the taste of inhaled sprays Eliminates cold freon effect

31. Spacers in Childhood Asthma Spacers in acute wheezing < 2 yrs. Spacers in acute asthma management. Spacers in daily asthma management. A Spacer is the only practical “total asthma care” device.

32. HOW TO INITIATE INHALED THERAPY 1. Explain advantage of inhaled therapy 2. Dispel myths and fears 3. Select the appropriate device 4. Demonstrate how to use the selected device

33. Asthma control - two domains Assess symptom control over the last 4 weeks Assess risk factors for poor outcomes, including low lung function Treatment issues Check inhaler technique and adherence Ask about side-effects Does the patient have a written asthma action plan? What are the patient’s attitudes and goals for their asthma? Comorbidities Think of rhinosinusitis, GERD, obesity, obstructive sleep apnea, depression, anxiety These may contribute to symptoms and poor quality of life Assessment of asthma GINA 2014, Box 2-1

34. GINA assessment of asthma control GINA 2014, Box 2-2B

35. Assessment of risk factors for poor asthma outcomes Risk factors for exacerbations include: Ever intubated for asthma Uncontrolled asthma symptoms Having ≥1 exacerbation in last 12 months Low FEV 1 (measure lung function at start of treatment, at 3-6 months to assess personal best, and periodically thereafter) Incorrect inhaler technique and/or poor adherence Smoking Obesity, pregnancy, blood eosinophilia GINA 2014, Box 2-2B Risk factors for exacerbations include: Ever intubated for asthma Uncontrolled asthma symptoms Having ≥1 exacerbation in last 12 months Low FEV 1 (measure lung function at start of treatment, at 3-6 months to assess personal best, and periodically thereafter) Incorrect inhaler technique and/or poor adherence Smoking Obesity, pregnancy, blood eosinophilia Risk factors for fixed airflow limitation include: No ICS treatment, smoking, occupational exposure, mucus hypersecretion, blood eosinophilia Risk factors for exacerbations include: Ever intubated for asthma Uncontrolled asthma symptoms Having ≥1 exacerbation in last 12 months Low FEV 1 (measure lung function at start of treatment, at 3-6 months to assess personal best, and periodically thereafter) Incorrect inhaler technique and/or poor adherence Smoking Obesity, pregnancy, blood eosinophilia Risk factors for fixed airflow limitation include: No ICS treatment, smoking, occupational exposure, mucus hypersecretion, blood eosinophilia Risk factors for medication side-effects include: Frequent oral steroids, high dose/potent ICS, P450 inhibitors

36. How? Asthma severity is assessed retrospectively from the level of treatment required to control symptoms and exacerbations When? Assess asthma severity after patient has been on controller treatment for several months Severity is not static – it may change over months or years, or as different treatments become available Categories of asthma severity Mild asthma: well-controlled with Steps 1 or 2 (as-needed SABA or low dose ICS) Moderate asthma: well-controlled with Step 3 (low-dose ICS/LABA) Severe asthma: requires Step 4/5 (moderate or high dose ICS/LABA ± add-on), or remains uncontrolled despite this treatment Assessing asthma severity GINA 2014

37. Initial controller therapy in treatment naive Symptom un(control) First Choice Other options Infrequent Symptoms (not uncontrolled or partly controlled and with no risk factors) No controller medication Asthma symptoms (even if infrequent) with any risk factors for exacerbations, Asthma symptoms more than twice a month Waking due to asthma more than once a month Low dose ICS LRTA Troublesome symptoms on most days waking more than once a week or more Low dose ICS+ LABA(>12 yrs) Medium dose ICS (6-11Yrs) Low/medium dose ICS +LRTA/SR Theophylline Severely uncontrolled symptoms Medium to high dose ICS+LABA Short course of oral steroids and high dose ICS/Medium dose ICS+LABA

38. Asthma Management Approach Based on Control for Children 5 Years and Younger Asthma education, Environmental control, and As needed rapid-acting β 2 -agonists Controlled on as needed rapid-acting β 2 -agonists Partly controlled on as needed rapid-acting β 2 -agonists Uncontrolled or only partly controlled on low-dose inhaled glucocorticosteroid* Controller Options Continue as needed rapid-acting β 2 -agonists Low-dose inhaled glucocorticosteroid Double low-dose inhaled glucocorticosteroid Leukotriene modifier Low-dose inhaled glucocorticosteroid plus Leukotriene modifier

39. Step Care Approach Control inflammation & symptoms fast with higher dose ICS Step down ICS dose 25 – 50% every 3 –6 mo Maintain at lowest possible dose OD Flu / Bud enough in stable patients Can discontinue if stable for 6 – 12 mo

40. STEPING DOWN TREATMENT Step down the treatment after good control for 3 months i.e no symptoms/occasional use of SABA Follow the principle last in - first out Reduce the dose of ICS by 25% every 3 month Step down to the regimen suitable for the lower grade of severity.

41. STOPING TREATMENT Good control continues on low dose ICS for 3 months. Stop preventer regimen-remission Trigger avoidance continues Explain home management plan- for acute episodes. Follow up every 2-3 monthly for 1-2 years Counsel regarding future recurrences

42. NATURAL HISTORY Re emphasize that drugs control but do not cure As asthma in children often remits hence control can be considered as good as cure. Identify those at risk for persistence

43. NATURAL HISTORY 2 out of 3 children with asthma out grow their symptoms. Risk factors for persistence in adulthood are: 1.Female 2.Eczema 3.Severe disease 4.Onset after the age of 3 years 5.Parental h/o atopy/asthma

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