ASTHMA:

MANAGEMENT AND PREVENTION

IN CHILDREN

Lecturer:
prof. Galyna Pavlyshyn
 What is Asthma?
Disease of chronic
inflammatory disorder of
the airways
Characterized by:
Airway inflammation
Airflow obstruction
Airway
hyperresponsiveness

Cookson W. Nature 1999; 402S: B5-11

http://health.allrefer.com/health/asthma-normal-versus-asthmatic-bronchiole.html
 DEFINITION OF ASTHMA
Asthma is a chronic inflammatory disorder
of the airways. The chronic inflammation is
associated with airway hyperresponsiveness;
- airways become obstructed and airflow is limited (by
bronchoconstriction, mucus plugs, increased inflammation)
when they are exposed to various risk factors.
Asthma causes
recurring episodes of wheezing
breathlessness
chest tightness
coughing
particularly at night or in the early morning.
 DEFINITION
Asthma is a disorder defined by its clinical,
physiological and pathological characteristics
The predominant feature of the clinical history is episodic shortness of
breath, particularly at night, often accompanied by cough. Wheezing defined
on auscultation of the chest is the most common physical finding.
The main physiological feature of asthma is episodic airway
obstruction characterized by expiratory airflow limitation.
The dominant pathological feature is airway inflammation, sometimes
associated with airway structural changes.
 Pathophysiology
Early Acute - these changes cause bronchial hyperresponsiveness and
obstruction. Airway obstruction increases resistance to airflow and decreases
expiratory flow. Impaired expiration causes hyperinflation distal to the
obstruction and increases the work of breathing.

Late Asthma Response occurs in cases of significant allergen exposure.

Recurrence of symptoms appears in 4-12 hours after the initial attack due to
persistent cellular activation. It can be more severe than the initial attack.

Untreated inflammation can cause long term airway damage that is irreversible
(airway remodeling).
What are the Triggering
Factors?
Domestic dust
mites
Animal with fur
Air pollution
Cockroaches
Pollen
Tobacco smoke
Occupational
irritants
 Triggering Factors

Respiratory (viral)
infections
Chemical irritants
Strong emotional
expressions
Drugs ( aspirin,
beta blockers)
 Potential Risk Factors
Host factors Environmental factors
Genetic predisposition Tobacco smoke
Atopy Air pollution
Airway hyperresponsiveness Respiratory infections
Gender Socioeconomic status
Race/Ethnicity Family size
Environmental factors Diet and drugs
Indoor allergens Obesity
Outdoor allergens
Occupational sensitizer

1Masoli M, et al. The Global Burden of Asthma:

Executive Summary of the GINA Dissemination
Committee Report. Allergy 2004; 59: 469-78.
 DIAGNOSING ASTHMA - Not Easy
CLINICAL DIAGNOSIS
Clinical diagnosis supported by the certain
historical, physical and laboratory findings
History of episodic symptoms of airflow obstruction
(breathlessness, wheezing, chest tightness and
COUGH)-response to therapy!
Episodic symptoms after an
incidental allergen exposure;
Seasonal variability of symptoms;
Positive family history of asthma
and atopic disease.
 DIAGNOSING ASTHMA
Consider asthma if any of the
following
signs or symptoms are present:
Frequent episodes of wheezing
more than once a month
Activity-induced cough or wheeze
Cough particularly at night during
periods without viral infections
Absence of seasonal variation in
wheeze
Symptoms that persist after age 3
The childs colds repeatedly go to
the chest or take more than 10
days to clear up
Symptoms improve when asthma
medication is given
 DIAGNOSING ASTHMA
Symptoms occur or worsen in the
presence of:
Animals with fur
Aerosol chemicals
Changes in temperature
Domestic dust mites
Drugs (aspirin, beta blockers)
Exercise
Pollen
Respiratory (viral) infections
Smoke
Strong emotional expression
 DIAGNOSING ASTHMA
Dyspnea, airflow limitation (wheeze),
hyperinflation are more likely to be present if
patients are examined during symptomatic
periods.
Physical signs reflecting severity: cyanosis,
drowsiness, difficulty speaking, tachycardia,
hyperinflated chest,
use of accessory muscles,
and intercostal recession.
 DIAGNOSING ASTHMA
Physical examination
- Respiratory rate;
- Work of breathing;
- Aeration
- Degree of wheezing
Suppotive data:
- Pulse oximetry (oxygen saturation);
- PEFR peak expiratory flow rate
- Chest radiograph;
Measurements of lung function
Spirometry is the preferred
method of measuring airflow
limitation and its reversibility to
establish a diagnosis of
asthma.

Forced expiratory volume

in 1 second (FEV1) - an
increase in FEV1 of 12% (or
200 ml) after administration
of a bronchodilator indicates
reversible airflow limitation
consistent with asthma.
The Peak Flow
Meter
Note Peak Flow Numbers
Diary cards to record
symptoms and PEF (in
children older than 5 years)
Keeping a peak flow diary
will help you predict and
prevent asthma attacks
Record peak flow numbers
daily, every morning before
taking control medicine(s)
Watch for trends in
symptoms
 Classification of Asthma
Mild Intermittent Asthma
- Symptoms less than once a week
- Brief exacerbations Traditionally, the
- Nocturnal symptoms not more than twice degree of symptoms,
a month airflow limitation,
- FEV1 or PEF 80% predicted and lung function
- PEF or FEV1 variability < 20%
variability have
Mild Persistent Asthma allowed asthma to
- Symptoms more than once a week but lessbe classified by
than once a day severity
- Exacerbations may affect activity and (Intermittent,
sleep
- Nocturnal symptoms more than twice a Mild Persistent,
month Moderate Persistent,
- FEV1 or PEF 80% predicted Severe Persistent)
- PEF or FEV1 variability < 20 30%
Classification of Asthma
Moderate Persistent Asthma
Symptoms daily
Exacerbations may affect activity and sleep
Nocturnal symptoms more than once a week
Daily use of inhaled SABA (short-acting 2-
agonist)
FEV1 or PEF 60-80% predicted
PEF or FEV1 variability > 30%

Severe Persistent Asthma

Symptoms daily
Frequent exacerbations
Frequent nocturnal asthma symptoms
Limitation of physical activities
FEV1 or PEF 60% predicted
PEF or FEV1 variability > 30%
 Severity of Asthma Exacerbations
Mild Moderate Severe
Talks in sentences Talks in phrases Talks in single words
Breathlessness Breathlessness with Breathlessness in rest
walking talking/feeding
Normal mental Mildly anxious Anxious
status
Mild tachypnea Moderate tachypnea Severe tachypnea
End expiratory Loud expiratory Inspiratory and
wheeze wheeze expiratory wheezing
Good aeration Fair aeration Poor aeration
Oxygen saturation Oxygen saturation Oxygen saturation
> 95 % 90-95 % < 90 %
PEFR > 70% PEFR = 40-69 % PEFR < 40%
 TREATMENT
Asthma Medications
Bronchodilators
(Sympathomimetics)
Bronchodilators
(Anticholinergics)
Inhaled Corticosteroids
Biologic Response Modifiers
(Monoclonal Antibodies)
Leukotriene Receptor
Antagonists
Mast Cell Stabilizers
Methylxanthene Derivatives
 TREATMENT
MILD ASTHMA
Frequent SABA are the
standard of care
Use of NEB or MDI-S are
each reasonable
Most will require just 1-2
treatment
Those who are SABA
unresponsive may benefit
from systemic
corticosteroids
Most will be discharged
home
Management Moderate Asthma
Albuterol NEB or MDI-S
Prednisone 2 mg/kg/d IM or NEB
Atrovent

No improvement
Marked improvement

Slight improvement
Hospitalize
Discharge home
Continue albuterol
every 30-45 min

Disposition
 Management Severe Asthma
Monitor pulse, RR, oxygen saturation

Supplemental oxygen
0.15mg/kg Albuterol by nebulization
Atrovent

Good response Poor response

Continue with approach to Terbutaline or epinephrine IM

moderate asthma Methylprednisolone 1-2 mg/kg IV
Albuterol |NEB
50-75 mg/kg IV Magnesii sulfate
 Acute severe asthmatic
episode (status asthmaticus)
Treatment goals are the following:
Correction of significant hypoxemia with supplemental
oxygen: In severe cases, alveolar hypoventilation requires
mechanically assisted ventilation.
Rapid reversal of airflow obstruction by using repeated or
continuous administration of an inhaled beta2-agonist;
Early administration of systemic corticosteroids ( oral
prednisone or intravenous methylprednisolone) is suggested
in children with asthma that fails to respond promptly and
completely to inhaled beta2-agonists.
Reduction in the likelihood of recurrence of severe airflow
obstruction by intensifying therapy: Often, a short course of
systemic corticosteroids is helpful.
 Asthma attacks require prompt
treatment
Oxygen is given at health centers or
hospitals if the patient is hypoxemic
Inhaled rapid-acting b2-agonists in
adequate doses are essential
Oral glucocorticosteroids (0.5 to 1
mg of prednisolone/kg or equivalent
during a 24-hour period) introduced
early in the course of a moderate
or severe attack help to reverse the
inflammation and speed recovery.
Methylxanthines are not
recommended if used in addition to
high doses of inhaled 2-agonists.
However, theophylline can be used
if inhaled 2-agonists are not
available.
 Controller Medications

Inhaled corticosteroids - ICS

Systemic corticosteroids - SCS
Leukotriene modifiers
Sodium cromoglycate (cromolyn sodium)
Nedocromil sodium
Methylxanthines
Long-acting inhaled 2-agonists,
Long-acting oral 2-agonists.
Classification of asthma by level of control is more
relevant and useful
Levels of Asthma Control
Characteristic Controlled (All of Partly Controlled - Any Uncontrolled
the following) measure present in any week
Exacerbations None One or more/year One in any
week
Daytime None (twice or More than twice/week
symptoms less/week)
Limitations of None Any Three or more
activities features of
partly
Nocturnal symp- None Any
controlled
toms/awakening
asthma
Need for reliever None (twice or More than twice/week present in any
/rescue treatment less/week)
Week
Lung function Normal < 80% predicted or
(PEF or FEV1) personal best (if known)
 Mild persistent asthma
Long-term control: Anti-inflammatory treatment
in the form of low-dose inhaled corticosteroids or
nonsteroidal agents (cromolyn, nedocromil) is
preferred.
Some evidence suggests that leukotriene antagonists
may be useful as first-line therapy in children.
Quick relief: Short-acting bronchodilators in the
form of inhaled beta2-agonists (SABA) should be used as
needed for symptom control. Use of short-acting inhaled
beta2-agonists on a daily basis or increasing use indicates
the need for additional long-term therapy.
 Moderate persistent asthma
Long-term control:
Daily anti-inflammatory treatment in the form of inhaled
corticosteroids (medium dose) is preferred. Otherwise, low- or
medium-dose inhaled corticosteroids combined with a long-
acting bronchodilator or leukotriene antagonist can be used,
especially for the control of nocturnal or exercise-induced
asthmatic symptoms.
Quick relief:
Short-acting bronchodilators in the form of inhaled beta2-
agonists (SABA) should be used as needed for symptom
control. The use of short-acting inhaled beta2-agonists on a
daily basis or increasing use indicates the need for additional
long-term therapy.