BRONCHIAL ASTHMA IN CHILDREN

Definition

Asthma is a chronic condition involving the respiratory system in which the

airway occasionally constricts, becomes inflamed, and is lined with excessive
amounts of mucus, often in response to one or more triggers.

Epidemiology

Bronchial asthma (BA) is one from the most frequent chronic diseases in children
and its incidence continues to increase in the last years. Conformable to ISAAC
data (International Study of Asthma and Allergy in Children), BA affects 5-20% of
children on the earth globe, this index varying in different countries (in USA - 5-
10%, in Canada, UK - 25-30%, in Greece, China – 3-6%).

Risk factors for BA development in children

 Familial antecedents of BA and other allergic diseases.

 Contact with home dust containing Dermatophagoides pteronyssinus.

 Contact with fur-bearing animals (cat, dog, etc.).

 Contact with mould (species of fungi Alternaria, aspergillus, Candida,

Penicillium).

 Contact with the pollen of different plants.

 Smoke of cigarettes, after woods burning.

 Presence of cockroaches.

 Alimentary (fish, egg, cow’s milk etc.) and drug allergens

 Meteorological factors (cold air, fog).

 Physical activity

 Environmental pollution

 Presence of gastroesophageal reflux.

  Drugs and vaccines (antibiotics – penicillin, cephasolin, tetracycline etc.,
sulfonamides, NSAID, colorants, etc.)

 Viral infections

 Stress factors

Clinical classification of bronchial asthma

 Atopic (allergic) asthma

 Nonatopic (nonallergic) asthma

 Status asthmaticus

Particular forms of bronchial asthma

 BA provoked by physical effort

 Cough BA

 Aspirinic BA

Classification of BA in function of severity

Type of BA Exacerbations of BA Nocturnal PEF and PEF

 accesses variability
Intermittent < 1 time per week ≤ 2 times per >80%
Asymptomatic, normal PEF month <20%
between accesses

Mild persistent >1 time per week, but <1time > 2 times per >80%
per day. Exacerbations can month 20 – 30%
affect the activity
Moderate Daily. Exacerbations affect >1 time per 60-80%
persistent the activity week >30%

Severe Permanently. Limited Frequent <60%

persistent physical activity >30%

Clinical picture of BA

Anamnesis

Which questions must be given in the case of BA suspicion:

 Had the patient the episodes of wheezing, inclusive repeated?

 Has the patient nocturnal cough?

 Has the patient cough and wheezing after physical effort?

 Had the patient episodes of wheezing and cough after the contact with
aeroallergens and pollutants?

 Had the patient episodes of wheezing after supported respiratory infection?

 Is decreasing the degree of symptoms expression after antiasthmatic drugs

receiving?

Recommendations for valuation of personal and hereditary antecedents:

  Presence of dyspnoea, wheezing, cough and thorax oppression episodes,
with valuation of duration and conditions of improving.

 Familial antecedents of bronchial asthma.

 Risk factors

 Asthmatic symptoms are manifesting concomitantly (the thoracic oppression

is less constant) and have common:

- Variability in time (are episodic);

- Preferentially nocturnal appearance;

- Appearance due to trigger factor (physical effort, exposition to

allergens, strong laugh, etc.).

- Personal, familial and environmental factors.

Characteristics of asthmatic attacks:

 Quick appearance with expiratory dyspnoea, prolonged expiration and

wheezing, pronounced sensation of thoracic oppression, lack of air
(sensation of suffocation).

 Duration from 20 – 30 min until a few hours.

 Spontaneous disappearance or at administration of ß2-adrenomymetics with

short action.

 They appear more frequently in night.

 The attacks appear suddenly and end also suddenly with tormenting cough
with elimination of mucous, viscous, “pearl” sputum in small quantity.

Suggestive symptoms for bronchial asthma diagnosis in children:

 Frequent episodes of wheezing (more than 1 episode per month);

 Cough ± wheezing induced by physical activity;

  Nocturnal cough out of viral infection periods;

 Lack of wheezing seasonal variations.

3 categories of wheezing are described:

- Precocious transitory wheezing; is associated with presence of such risk

factors as prematurity, smoking parents, dyspnoea until 3 years;

- Persistent wheezing with precocious debut (until 3 years); recurrent episodes

of wheezing associated with acute viral infections (predominantly with
respiratory syncitial virus, in children under 2 years, and other viruses, in
older children), without atopic manifestations or familial antecedents of
atopy; the symptoms persist until the school age and can be present in 12
years children in significant proportion;

- Wheezing (asthma with tardy debut, after 3 years age); in this group asthma
evolves in childhood period and even in adults; children present signs of
atopy (most frequent – atopic dermatitis) and air pathways pathology
characteristic for asthma.

Predictive signs for childhood asthma (preschool, school age):

- Wheezing until 3 years;

- Presence of major risk factor (familial antecedents of asthma);

- Two from three minor risk factors (eosinophilia, wheezing without

cough, allergic rhinitis).

Physical examination:

Basic principles:

 The signs of respiratory system affection can be absent.

 Inspection:

- Siting position (orthopnea) with accessory respiratory muscles involvement;

- Tachypnea.
  At percussion:

- Diffuse increased sonority and down placed diaphragm.

 Auscultatively:

- Diminished vesicular murmur;

- Dry sibilant, polyphonic, disseminated crackles, predominantly at

expiration, that can be heard at distance (wheezing);

- Moist and subcrepitant crackles in more advanced bronchial hypersecretion.

Causes of bronchial asthma exacerbations:

 Insufficient bronchodilator treatment.

 Long-term defect of the basic treatment.

 Viral respiratory infections.

 Changes of weather

 Stress

 Long time exposure to triggers.

Appreciation of bronchial asthma exacerbations severity

Symptome Mild Moderate Severe Imminence of

respiratory
stopping
Dyspnoea -appears -in older - appears in
during gait; children it rest;
The child can appears at - refusal to eat;
stay in bed speaking, in - forced
small children position (sit
the crying down, inclined
becomes more forward)
short and
slow; feeding
difficulties.
 - the child
prefers to sit
down.
speaking -propositions -expressions -words
State of -can be -as a rule, -as a rule, -inhibated or
alertness agitated agitated agitated in confusion
state
Frequency of -increased -increased -sometimes>
respiration 30/min.
Participation -as a rule, -as a rule, -as a rule, Paradoxical
of accessory absent absent present thoraco-
respiratory abdominal
muscles with
movement
supraclavicular
retraction
Coarse Moderately sonorous sonorous absent
crackles expressed,
often, only at
expiration
Frequency of < 100 100 – 120 > 120 Bradycardia
cardiac
contractions
Paradoxical absent Can be present Often is Absent
pulse present
PEF in % from >80% 60 – 80% <60%
predicted after
bronchodilator
using
Pa O2 at air >60mm Hg >60mm Hg <60 mm Hg
respiration,
Pa CO2 <45mm Hg <45mm Hg >45 mm Hg
SaO2% (with >95% 91-95% <90%
air)
Normal frequency of respiration in children

Age Frequency of respiration

< 2 months <60/min

2 – 12 months <50/min

1 – 5 years <40/min

6 – 8 years <30/min

Normal frequency of cardiac contractions (FCC) in children

Suckling babies 2 – 12 months <160/min

Little age 1 – 2 years <120/min

Preschool and

School age 2 – 8 years <110/min

The diagnosis of BA in children has the following basic aspects:

●atopic background: allergic rhinitis, atopic dermatitis, alimentary allergy, atopic

manifestation in family;

●clinically: paroxysmal dyspnoea with wheezing;

●functionally: reversible bronchial obstruction;

●therapeutically: efficient response at short action bronchodilators and inhalator

corticosteroids treatment.

The algorhythm for BA diagnosis in suckling baby and little child (by Martinez,
modificated)
Major criteria:
●hospitalizations at severe form of bronchiolitis or wheezing;
●≥ 3 episodes of wheezing during respiratory infections in the last 6 months;
● presence of asthma in one of parents;
●atopic dermatitis;
●sensibilization to pneumoallergens.

Minor criteria:
●rhinorrhea in the absence of flu;
●wheesing in the absence of flu;
●eosinophilia (≥ 5%);
●alimentary allergy;
●male.

Risk for persistent wheezing/asthma:

 One from first 2 major criteria + another major criterion;
 One from first 2 major criteria + 2 minor criteria.

PARACLINICAL INVESTIGATIONS IN BRONCHIAL ASTHMA

Obligatory investigations:
 PEF-metry;
 Spirography;
 Test with bronchodilator
 Skin tests with allergens;
 Pulsoxymetry;
 Hemoleukogram;
 General analysis of sputum;
 ECG; total and specific IgE
 X-ray chest in 2 proections.
Recommended investigations:
 Bronchoscopy (at necessity);
 EchoEG;
 Oxymetry of arterial blood;
  Acido – basic equilibrium valuation;
 Provoking tests (effort, acetylcholine, metacholine);
 Pulmonary, mediastinal CT (at necessity)
 General urine analysis;
 Biochemical serologic indexes (total protein, glucose, creatinine, urea, LDH,
AST, ALT, bilirubin and its fractions);
 Ionogram.

Spirography:
 It allows to appreciate the severity and reversibility of bronchial obstruction;
 It allows to differentiate from restrictive affections.
PEF-metry:
 It allows the appreciation and monitoring of bronchial obstruction severity
and reversibility.
 The formula for calculation of PEF in% towards to predicted value in%:
PEF = minimal PEF of given day/predicted PEF x 100%.
 24 hours variability of PEF is calculating after formula:
24 hours variability = 2(evening PEF – morning PEF)/(evening PEF +
morning PEF) X 100%.
Pharmacological tests:
 The test with ß2-agonist (bronchodilator test) – spirographic or PEF-metry
values performed after 15 min from inhalation of short action ß2-agonist are
compared with the usual data before inhalation; increasing of PEF values
≥20% show the obstruction reversibility and is suggestive for BA.
Physical effort test:
 The spirography or PEF-metry is performed initially and at 5-10 min after
nonstandard physical effort (running or physical exercises), but sufficient
for increase the pulse rate (until 140 – 150/min). Decreasing of PEF ≥20% is
suggestive for asthma (effort bronchospasm).
Examination of sputum:
 Eosinophils (in proportion of 10 – 90%), octoedric crystals of phospholypase
Charcot – Layden are suggestive for atopic asthma.
 Curschmann’s spirals (agglomerations of mucus).
Hemogram shows eosinophils in some cases.
Immunoglobulins:
 Total serum IgE increased in atopic asthma.
 Specific IgE to certain allergen are increased.
X-ray chest:
 Is obligatory only in the first accesses, when the diagnosis is not clear.
 In BA access – signs of pulmonary hyperinflation (flat diaphragm with
reduced movements, hypertransparence of pulmonary areas, widening of
retrosternal space, horizontal ribs).
 It can be indicated for disease complications (pneumothorax,
pneumomediastinum, atelectasis due to mucus plugs) or associated
affections (pneumonias, pneumonitis etc.) finding.
General valuation of gas exchange is necessary in patients with signs of
respiratory insufficiency, in these having SaO2 under 90%.

Allergy cutaneous testing (skin-prik test, scarification probes) is

performed by the allergologist and aims to detect IgE-induced allergic reactions. It
is usually carried out by the method of scarification: skin scarification of 4-
5 mm with standard applying a drop of allergen in a concentration of 5000 U / ml
(1 unit =0.00001 mg protein nitrogen / 1 ml).

Appreciation the allergic reaction by skin scarification test

Test appreciation Conventional sign The visual image of allergic reaction

Negative - It is the same as the control test

Uncertain +/- Local redness, without swelling

Weakly positive + Swelling papule, 2-3 mm diameter and peri-papular

redness

Positive ++ Swelling papule with a diameter >3mm<5mm and peri-

papular redness

Intense positive +++ Swelling papule with 5-10 mm diameter and peri-papular
redness

Excessively ++++ Swelling papule with more than 10 mm diameter, peri-

positive papular redness and pseudopodies

The appreciation of the reaction is done after 20 min. It must be carried

out in lack of acute manifestations of the atopic dermatitis. Administration of the
antihistaminic drugs, antidepressants,
neuroleptics decreases cutaneous receptor sensitivity and therefore may be
a false positive results. For these reasons named remedies need to be excluded for
a period of 3-7 days before the examination.

DIFFERENTIAL DIAGNOSIS

In children less than 5 years, it is performed with another affections occuring with
wheesing:

 Viral bronchiolitis;

 Cystic fibrosis;

 Foreign body aspiration;

 Upper respiratory pathways obstruction;

 Bronchopulmonal displasia;

 Intrathoracic respiratory pathways malformations;

 Congenital cardiac diseases;

 Kartagener’s syndrome;

 Immune deficiencies;

 Chronic sinusitis;

 Gastroesophageal reflux;

 Tbc;
  Mediastinal adenopathies;

 Tumors.

In children older 5 years age, it is performed with the same affections as in big
child or adults:

 Cardiovascular pathology;

 Upper respiratory pathways obstruction, foreign bodies;

 Cystic fibrosis;

 Syndrome of hyperventilation, panic, vocal chords dysfunction;

 Pulmonary interstitial pathology;

 Gastroesophageal reflux;

 Rhinosinusal pathology.

Hospitalization criteria:

Hospitalization criteria for patients with BA:

 Severe access;

 Inefficacity of broncholytic therapy during 1 – 2 hours;

 Duration of exacerbation more than 1 – 2 weeks;

 Impossibility to accord medical care at home;

 Unsatisfactory living conditions;

 Presence of increased risk factors for death due to BA.

Criteria for hospitalization in intensive care departaments for patients with BA:

 Mental deterioration;

 Paradoxic pulse >15-20 mm Hg;

  Severe pulmonary hyperinflation;

 Severe hypercapnia > 80 mm Hg;

 Cyanosis resistant to oxygenotherapy;

 Unstable hemodynamics.

THE TREATMENT OF BRONCHIAL ASTHMA IN CHILDREN

General principles of drug treatment in bronchial asthma:

●The inhalatory therapy is the most recommended in all children, the used devices
for drug inhalation must be individualised for every case in function of its
peculiarities and characteristics of used inhaler. In general lines, administration
using metered-dose-inhaler (MDI) with spacer versus nebulizing therapy is more
preferable, due to some advantages of MDI (reduced risk of adverse effects, more
decreased cost etc.). Administration through nebulizers presents a lot of
disadvantages: not precise dose, increased cost, necessity of special apparatus.

●Drugs administered through inhalation are preferable due to their increased

therapeutic index: high concentrations of medicaments are relieved directly in
respiratory pathways, with strong therapeutic effects and reduced number of
systemic adverse effects.

●Devices for medication administered through inhalation: pressure inhalers with

measured dose (MDI), dry powder inhalers, turbohalers, diskhalers, nebulizers.

●Spacers (or retention camera) make easier the use of inhalers, reduce systemic
absorption and secondary effects of inhaled glucocorticoids.

●Two types of medication help in asthma control: controlers, or drugs that prevent
the symptoms and accesses, and relievers, or drugs, used for access treatment and
having rapid effect.

●The choice of medication depends from the control level of BA at moment and
from curent medication.

●If curent medication does not ensure the adequate control of BA, the indication
of superior advanced step of treatment is necessary.
●If BA is controled 3 months, the decreasing of supporting volume for control
maintaining minimal necessary dose establishing (passing to inferior step) is
possible.

●The therapy with adequate doses of short acting inhalatory ß2-agonists is

recommended in accesses (if inhalers are not available, the bronchodilators can be
administered per os or i/v.

●In hospitals in the case of hypoxemic patient the oxygen is given.

●The treatment not recommended in accesses: sedatives, mucolytics,

physiotherapy, hydration with big volume of liquids.

●Antibiotics not treat the accesses, but are indicated in the case of concomitant
pneumonias or other bacterial infections.

The clue moments in the treatment of BA by steps:

●Each step includes variants of therapy serving as alternative in the choice of BA

control treatment, although are not similar to efficacy.

●The efficacy of treatment increases from I step to V step and depends from
accessibility and certainity of drug.

●The steps 2-5 include combinations of urgent medications, at necessity,of

systemic control treatment.

●In majority of patients with persistent BA, which anteriorly didn’t administered
control treatment, is necessary to iniciate the treatment from the 2-nd step.

●If at primary examination we determine the absence of BA control, the treatment

begins from the 3-rd step.

●The patients must use relievers (short action bronchodilators) at each step.

●The systemic use of urgent medication is a sign of uncontrolled BA, which

indicates the necessity of control therapy volume increasing.

●Reducing or absence of necessity in relievers represent the goal of treatment and,

also, a criterion of efficacity.
The I step of BA treatment:

It is indicated to patients:

- Which didn’t receive anteriorly control medication and which manifest

episodic symptoms of BA (cough, coarse crackles, dyspnoea ≤ 2 times per
week, very rare with nocturnal symptoms);

- In period between accesses the disease manifestations and nocturnal

disturbance are absent or pulmonary function is normal.

 Urgent medication:

- short action inhaled ß2-agonists are recommended;

- the inhalatory anticholinergics (ipratropium bromide, oxitropium bromide),

peroral short action ß2-agonists (salbutamol), short action theophyllin can be
the alternative medicaments.

Control medication is not necessary.

The II step of BA treatment:

 It is indicated to the patients with symptoms of persistent asthma, which

anteriorly didn’t administered control medication.

 Urgent medication:

- Recommended – inhalatory corticosteroids (ICS) in small doses;

- Alternative – antileukotrienes are indicated to the following patients:

-who doesn’t accept to use ICS;
-with hard supported ICS adverse reactions;
- with concomitant allergic rhinitis.
 The initiation of therapy is not recommended with:
- Theophyllin retard, that possesses minimal anti-inflammatory effect and
reduced efficacy in control therapy, but has multiple adverse reactions;
- Chromones (inhibitors of mast cells degranulation) having decreased
efficacy, although they are distinguished by increased inoffensiveness.
The III step of BA treatment:
 It is indicated to the patients with symptoms of disease showing the absence
of adequate control in the treatment at the steps I and II.
 Urgent medication:
Recommended - short action inhaled ß2-agonists (salbutamol, fenoterol).
 Control medication one or two drugs for disease evolution control:
- Small doses of ICS in combination with long action inhaled ß 2-agonists in
one self inhaler with still fixed doses of drugs or two different inhalers;
- Small doses of ICS in combination with leukotrienes (montelucast,
zafirlucast);
- Small doses of ICS in combination with small doses of theophyllin retard;
- Increasing of small doses of ICS until medium doses.
 Small doses of ICS, as a rule, are sufficient due to additional effect of this
combination, the dose is increasing, if over 3-4 months of treatment the BA
control was not obtained.
 The monotherapy with formoterol and salmeterol is not recommended, they
are using in combination with ICS (fluticasone, budesonid).
Note:
- The using of spacers for intensifying of drugs getting into respiratory
pathways and for decreasing of diverse oropharingean adverse reactions is
recommended for patients receiving medium and high doses of ICS;
- The patients in which the control on III step is not succeeded, need
consulting of specialist with experience in BA treatment for excluding an
alternative diagnosis or of cases of BA difficult to treat.
The IV step of BA treatment:
 It is indicated to the patients with symptoms of disease showing the
absence of control in the treatment at the 3-rd step.
 The choice of drug in the therapy at IV step depends from anterior
indications at 2-nd and 3-rd steps.
 Urgent medication:
Recommended - short action inhaled ß2-agonists
 Control medication includes two or more drugs for disease evolution
control:
 - ICS in medium and high doses in combination with long action inhaled ß 2-
agonist;
- ICS and long action inhaled ß2-agonist and, supplementarly, small doses of
retard theophyllin.
Note:
- Small and medium doses of ICS, in combination with antileukotrienes,
amplify the clinical effect smaller comparatively with combination of ICS
and long action inhaled ß2-agonist;
- Increasing of ICS dose (from medium to high) in majority of patients
ensures only nonsignificant increasing of clinical effect, and administration
of high doses is recommended only in quality of probe with duration of 1-3
months, when the control of BA at combination of ICS medium doses and
long action inhaled ß2-agonist was not obtained.
- Long-term administration of high doses of ICS is followed by increased risk
of adverse effects.
The V step of BA treatment:
 It is indicated to the patients with uncontrolled, severe BA, on the
background of IV step therapy.
 Urgent medication:
- Recommended: short action inhaled ß2-agonists.
 Control medication includes supplementary drugs for IV step medication
for disease evolution control:
- administration of CS per os can amplify the effect of treatment, but has
severe adverse effects, therefore they must be given only in severe,
uncontroled forms of BA on the background of 4-th step therapy;
- administration of anti-IgE antibodies, supplementarly to another drugs,
makes easy the control of BA, when the control of BA didn’t obtained with
controler drugs, inclusively with high doses of ICS and CS per os.
Specific immunotherapy
It is indicated only in the period when the allergic BA is controled.

THE FOLLOW-UP OF PATIENTS WITH BRONCHIAL ASTHMA

● The patients return to medical consultation at I month after first visit, ulteriorly –
in every 3 months.
● After exacerbation, the medical visits have place after 2 – 4 weeks.
● If the BA control is established, the regular maintaining visits, at 1 – 6 months,
remain essential, depending from situation.
● The number of visits at physician and determining of control level depends from
initial severity of patology at concret patient and from degree of patient’s
knowledge about the necessary measures for BA adequate control.
● The control level must be determined in certain time intervals both by physician,
and by patient.
● Patients who administered high doses of ICS or CS per os are included in the
risk group for osteoporosis and fractures (it is necessary to perform
tomodensitometry of bones and administration of biphosphates).

Continuous monitoring is essential in realization of therapeutic goals. The

schemes of treatment, the medications and level of BA control are analysed and
modified during this visits.

ADEQUATE MANAGEMENT OF BRONCHIAL ASTHMA

 Minimal or inexistent symptoms, including nocturnal symptoms.
 Minimal episods or accesses of BA.
 Absence of urgent visits at physician or hospital.
 Minimal need of urgent medications.
 Absence of physical activity and sport practise limitation.
 Pulmonary function is about normal.
 Secondary effects caused by medication are minimal or inexistent.
 Prevention of deceases caused by BA.