Transcript Childhood Asthma

Prof.Dr. Muhi K. Aljanabi
MRCPCH; DCH; FICMS
Consultant Pediatric Pulmonologist
ASTHMA---OBJECTIVES
1. Understand the natural history of asthma during
childhood.
2. Be familiar with the key features of history and
examination that support a diagnosis of asthma.
3. Be familiar with the other common clinical
conditions that can mimic asthma
(gastroesophageal reflux, cystic fibrosis, viral
induced wheezing, bronchiolitis, croup).
ASTHMA---OBJECTIVES
4-Be able to manage an acute exacerbation of asthma.
5-Know the details of the drugs used to treat acute
and chronic asthma and understand their
mechanism of action.
6-Know the guidelines for the management of
asthma.
7-Be able to advise parents about how to care for a
child with asthma.
Childhood Asthma..Definition
 Asthma is a chronic inflammatory condition of the
lung airways resulting in episodic airflow
obstruction.
 This chronic inflammation heightens the
“twitchiness” of the airways—airways
hyperresponsiveness (AHR)—to provocative
exposures.
ETIOLOGY
 Genetics:
 More than 22 loci on 15 autosomal chromosomes
have been linked to asthma.
ETIOLOGY
 Environment :
 common respiratory viruses .
 Indoor and home allergen exposures in sensitized
individuals
 Environmental tobacco smoke and air pollutants
(ozone, sulfur dioxide)
 Cold dry air and strong odors
EPIDEMIOLOGY
 Worldwide, childhood asthma appears to be
increasing in prevalence, despite considerable
improvements in management.
 in 56 countries found a wide range in asthma
prevalence, from 1.6 to 36.8%.
 Approximately 80% of all asthmatics report disease
onset prior to 6 yr of age.
 only a minority will go on to have persistent asthma
in later childhood.
CLINICAL MANIFESTATIONS
 Intermittent dry coughing and/or expiratory
wheezing are the most common chronic symptoms
of asthma.
 shortness of breath
 worse at night
 Daytime symptoms, often linked with physical
activities
Risk factor
 history of other allergic conditions (allergic rhinitis,
allergic conjunctivitis, atopic dermatitis, food
allergies)
 parental asthma, and/or symptoms apart from
colds, supports the diagnosis of asthma.
LABORATORY FINDINGS
 Lung function tests can help to confirm the diagnosis
of asthma and determine disease severity.
 Chest radiographs in children with asthma often
appear to be normal, hyperinflation (flattening of
the diaphragms) and peribronchial thickening.
LABORATORY FINDINGS
 asthma masqueraders (aspiration pneumonitis,
bronchiolitis obliterans)
 asthma exacerbations (atelectasis,
pneumomediastinum, pneumothorax). CT scans
may be needed .
LABORATORY FINDINGS
 Other tests, such as allergy testing to assess
sensitization to inhalant allergens, help with the
management and prognosis of asthma.
 88% of asthmatic children had inhalant allergen
sensitization by allergy prick skin testing.
TREATMENT
 Principles of Asthma Pharmacotherapy:
 treat all “persistent” asthma with anti-inflammatory
controller medication
 Daily controller therapy is not recommended for
mild intermittent asthma.
The “three strikes” rule
 Day time asthma symptoms at least 3 times per wk,
 awakens at night at least 3 times per mo,
 experiences asthma exacerbations that requires
short courses of systemic corticosteroids at least 3
times a yr.
 then that patient should receive daily controller
therapy
TREATMENT
 (ICS) therapy is recommended as preferred therapy
for all levels of asthma severity except for the mild
intermittent category.
 Leukotriene pathway modifiers or sustained-release
theophylline (only for patients >5 yr of age) are
alternatives for mild persistent asthmatics.
TREATMENT
 Combination of a low-to-medium dose ICS with a
long-acting β-agonist or a leukotriene modifier or
theophylline is a mainstay therapy for moderate
persistent asthma in older children.
 For infants and young children, medium-dose ICS
alone it is considered a preferred treatment for
moderate persistent asthma.
TREATMENT
 Severe persistent asthmatics should receive highdose ICS, a long-acting bronchodilator, and routine
oral corticosteroids if needed.
 SABAs are the recommended quick-reliever
medications for symptoms and exercise
pretreatment for all asthma severity levels
INHALED CORTICOSTEROIDS
 Daily ICS therapy as the treatment of choice for all
patients with persistent asthma.
 ICS reduce asthma symptoms, improve lung
function, reduce “rescue” medication use and, most
important, reduce urgent care visits,
hospitalizations, and prednisone use for asthma
exacerbations by about 50%
LONG-ACTING INHALED β-AGONIST
 Although LABAs (salmeterol, formoterol) are
considered to be daily controller medications, not
intended for use as “rescue” medication for acute
asthma symptoms or exacerbations,
 nor as monotherapy for persistent asthma.
LEUKOTRIENE-MODIFYING AGENTS
 leukotriene receptor antagonists (LTRA)
 Montelukast > 1 yr.
 Zafirlukast > 5 yr
 Decrease need for rescue β-agonist use
NONSTEROIDAL ANTI-INFLAMMATORY
AGENTS
 Cromolyn and nedocromil are non-corticosteroid
anti-inflammatory agents that can inhibit allergeninduced asthmatic responses and reduce exerciseinduced bronchospasm.
THEOPHYLLINE
 Although it is considered an alternative
monotherapy controller agent for older children and
adults with mild persistent asthma,
 it is no longer considered a first-line agent for small
children in whom there is significant variability in
the absorption and metabolism of different
theophylline preparations, necessitating frequent
dose monitoring (blood levels) and adjustments.
SHORT-ACTING INHALED β-AGONISTS
 SABAs (albuterol, levalbuterol, terbutaline,
pirbuterol) are the first drugs of choice for acute
asthma symptoms (“rescue” medication) and for
preventing exercise-induced bronchospasm.
ANTICHOLINERGIC AGENTS
 ipratropium bromide are much less potent than the
β-agonists.
 Inhaled ipratropium is primarily used in the
treatment of acute severe asthma.
 When used in combination with albuterol,
ipratropium can improve lung function and reduce
the rate of hospitalization in children who present to
the emergency department with acute asthma.
Home Management of Asthma
Exacerbations
 Immediate treatment with “rescue” SABA
 Short course of oral corticosteroid therapy
 Injectable forms of epinephrine
 Portable oxygen at home.
 Call for emergency support services.
ED Management of Asthma
 Oxygen
 Inhaled β-agonist
 Systemic corticosteroids
 Inhaled ipratropium
 Intramuscular injection of epinephrine or other β-
agonist
 Close monitoring of clinical status, hydration, and
oxygenation
 Intubation and mechanical ventilation
PROGNOSIS
 Recurrent coughing and wheezing occurs in 35% of pre–
school-age children.
 ⅓ continue to have persistent asthma into later
childhood.
 ⅔ improve on their own through the preteen years.
That entire wheeze is not asthma
&
asthma does not always wheeze
Mark yes or no
Wheeze before 3 years
Atopy
Mostly persist
Smoking mother during
pregnancy
Wheeze after 3 year
Mark yes or no
drug
Salbutamol
Montelukast
epinephrine
preventer
controller