childhood asthma

Diagnosis of
Asthma
Cough and/or wheezing that:
episodic,
nocturnal (variability),
reversibility
with atopic family
 Inflammatory processes
Desquamation of
epithelium

Hyperplasia of Mucus plug

Mucos glands

Basement
Membrane
thickening

Oedema
Neutrophil and
Smooth muscle eosinophil infiltration
Hypertrophy and contraction
Barnes PJ
 Getting to asthmatic
inflammation
what
Normal
does it take ???
Asthma
 Inflammation in asthma
Acute
inflammation

Steroid
response

Chronic inflammation

Structural changes

Time

Barnes PJ
 Pathogenesis
Environment Genetic susceptibility

Chronic allergic inflammation

(Mast cells, T-Cells, Eosinophils)

AIRWAY WALL THICKENING

 Classification of asthma
Severity of attacks Class of disease
(Acute) (Chronic)
Mild Infrequent episodic
Moderate asthma
Severe Frequent episodic
Respiratory arrest asthma
imminent Persistent asthma
 Classification of
disease
Clinical parameter ,Infrequent episodicFrequent episodic
Persistent asthma
And lung function asthma asthma

Freq of attacks < 1x /month > 1x /month Daily

Duration of attacks < 1 week >1 week Daily

Frequent nocturnal
Between episodes No symptoms Symptoms (+) symptoms
Sleep and activity Normal May affect Affect

Physical exam Normal May affect Abnormal

Controller No need Steroid/combination Steroid/combination

Lung function PEF/FEV1 <60%
PEF/FEV1 >80% PEF/FEV1 60-80%
(No attacks) Variability 20-30%

Variability (attacks) >15% > 30% > 50%

 Evolving treatment options
ICS treatment Adding
introduced LAA to ICS therapy
Large use of 1972 Kips et al, AJRCCM 2000
Pauwels et al, NEJM 1997
short-acting
Greening et al, Lancet 1992 Single
2-agonists
inhaler therapy
1975
(Symbicort)

Fear of
1980 short-acting
2-agonists

1985
2000
1990 1995

Bronchospasm Inflammation Remodelling

 Goal of asthma management
Minimal (ideally no) chronic symptoms
Minimal (infrequent) exacerbations
No emergency visits
Minimal (ideally no) use of as needed 2-
agonist
No limitations on activities (exercise)
(Near) Normal lung function
Minimal (or no) adverse effects from medicine
 Asthma management
Allergen
avoidance

Pharmac Immuno-
o- COST therapy
therapy S

Education

GINA, 2002
 Avoidance
Avoidance of triggers : House dust
mite
Pre and during pharmacotherapy

GINA, 2002
 Family Education

Aim to:
Increase understanding
Increse skill
Increse satisfaction
Increse confidence
Increse compliance and self management
Patient-family-doctor relationships
GINA,2002
 Immunotherapy
Desensitisation
Controversial
Multifactorial triggers
Not populair
 Pharmacotherapy
Reliever:
2 agonist : inhaler,
nebulized, oral
Epinephrine : subcutan
Theophylline : oral, I.V.
Anticholinergic (ipratropium br) : inhaler
Steroid : oral, I.M.
Controller:
Steroid : inhaler
LABA : inhaler, oral
Leukotrien : oral
PNAA, 2002
 When??
Classifications Controller Reliever

Infrequent No Yes
episodic asthma
Frequent Yes Yes
episodic asthma
Persistent Yes Yes
asthma
 Medications
Bronchodilators
Antiinflammations
Anti-remodelling
Anti IgE
Immunizations: ??
 TREATING ASTHMA

with Bronchodilators alone

is like

Painting over rust !!!

 Infrequent episodic asthma
No daily medication
Treatment of exacerbations depend on
severity of attacks
-2 agonist as needed
 Frequent episodic and persistent
asthma
Controller medications: every day
Corticosteroid with or without any drugs
Combination with LABA, TSR, ALT
Gradual reduction if stable in 6-8 weeks
 Anti-inflammations
Antihistamine
Disodium Cromoglycate (DSCG)
Corticosteroids
 Longterm
management Low dose steroid

Medium dose Low dose Low dose Low dose

steroid steroid + LABA steroid + ALTR steroid +TSR

High dose Medium dose Medium dose Medium dose

steroid steroid + LABA steroid + ALTR steroid + TSR

ORAL
STEROID
 Corticosteroids
The most effective anti-inflammatory
medications
Improving lung function
Airway hiperresponsiveness:
Reducing symptoms
Frequency and severity of
exacerbations:
Improving quality of life
Epithelial Repair Following Steroid Treatment

Before After
P Howarth, 1999
 Steroid efficacy in asthma

Steroid
Benefit dose

Side-effects
Type of inhalation therapy
Metered dose inhaler (MDI)
With spacer
Without spacer
Dry powder inhaler (DPI)
Turbuhaler, cyclohaler
Nebulizer
Jet
Ultrasonic
Benefit of steroid inhalation
Low dose
Directly to respiratory tract
Fast onset
Minimal systemic side effects
 Longterm steroid

Adverse event
Hoarseness
Throat irritations
Candidiasis
Headaches
Growth??
SERANGAN ASMA
 Triggers
Inhalant
Chemical
Stress
Activity (exercise)
Drugs
Foods
Triggers
Pathophysiology of asthma
attacks
Triggers

b.constriction, oedema, secretion

Airway obstruction

ununiform pulmonary
ventilation hyperinflation

atelectasis mismatch compliance

abnormality
ventilation-perfution

surfactant alv.hypoventilation Resp.rate

acidosis

pulmonary
v.constriction PaCO2

PaO2
Pulsus Absent Maybe Often present Absenc
paradoxus <10 mmHg present 20-40 mmHg e
10-25 mmHg suggest
s
PEF after Over 80% Approx. 60- <60% predicted
initial 80% or personal
bronchodilat best or
or response lasts
%predicted <2 hrs
or %
personal
best

PaO2 (on air) Normal >60 mmHg <60 mmHg

Test not possible
usually cyanosis
and/or
necessary
PaCO2 <45 mmHg
<45 mmHg >45 mmHg
SaO2% >95% 91-95% <90%
 Asthma attacks algorithms
Emergency room
Assess severity.of attacks

Early treatment
nebulized -agonist 3x, interval 20 min
3rd nebulized + anticholinergic

Mild attacks
Severe attacks
(nebulized 1x, Moderate attacks
(nebulized 3x,
good response) (nebulized 2-3x,
observe 1-2 jam, partial response)
O2
discharge poor response)
reassessment mode-
symptoms (+) rate ODC O2
moderate attack IV line IV line
reassessment
severe,
admission
 One Day Care (ODC) Admission room
Discharge Oxygen therapy Oxygen therapy
give -agonist Oral steroid Treat dehydration and
(inhaled/oral) Nebulized / 2 hour acidosis
routine drugs Observe 8-12 hours, Steroid IV / 6-8 hours
viral infection: if stable discharge Nebulized / 1-2 hours
oral steroid Poor response in 12 hrs, Initial aminophylline IV,
Outpatient clinic in
admission then maintenance
24-48 hours Nebulized 4-6x
good response per 4-6 h
If stable in 24 hours
discharge
Poor response ICU
Notes:
In severe attack, directly use -agonist + anticholinergic
If nebulizers not available, use adrenalin SC 0.01 ml/kg/times
with maximal dose 0.3 ml/times
Oxygen therapy 2-4 l/min should be early treatment in moderate
and severe attack