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DR. A.Mirshokraei NIOC Hospital Pediatrics Ward

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1 DR. A.Mirshokraei NIOC Hospital Pediatrics Ward
Asthma in Children DR. A.Mirshokraei NIOC Hospital Pediatrics Ward

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3 Anyway exacerbations occur
Definition : - Chronic inflammatory condition of the lung airways resulting in episodic airflow obstruction - AHR to provocative exposures Asthma management Reducing airway inflammation by: Minimizing pro inflammatory environmental exposure, using daily controller anti inflammatory medication, controlling co morbid conditions that worsen asthma, less inflammation better asthma control and fewer exacerbations Anyway exacerbations occur BUT Even the uncommon child with sever asthma can be managed to live normally DEFINITION

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5 RECURRENT WHEEZING EPISODES WITH COMMON RESPIRATORY VIRUSES(RSV,RHINOVIRUS,INFLUENZA,PARAINFLUENZA,A DENOVIRUS,HUMAN METAPNUMOVIRUS) HOST FEATURES AFFECTING IMMUNOLOGIC HOST DEFENSE,INFLAMMATION/PREVIOUS VIRAL INFECTIONS MAINIFESTED AS PNUMONIA OR BRONCHIOLITIS REQUIRING HOSPITALIZATION UNDERLIE THE RECURRENT WHEEZING IN EARLY CHILDHOOD OTHER AIRWAY EXPOSURES SUCH AS INDOOR AND HOME ALLERGENS,COLD AIR,STRONG ODORS,TOBACCO SMOKE,ALL INCREASE AHR ALLERGEN ELLIMINATION SOMETIMES LEEDS TO CURE

6 EPIDEMIOLOGY Common etiology of emergency visits and school day missing in childhood ,occasionally hospitalization and rare deaths specially in poverty ,urban living ,ethnic minorities Increasing asthma prevalence worldwide(50% per decade) Good correlation of asthma prevalence with allergic rhino sinusitis and atopic eczema and other allergies More prevalence in high level urban modern families than suburban villagers More than 80%of asthmatics reported getting the disease before 6 year

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8 CLINICS RECURRENT COUGHING/WHEEZING PATTERNS IN CHILDHOOD BASED ON NATURAL HISTORY

9 TRANSIENT EARLY WHEEZING
Common in early preschool years Recurrent coughing/wheezing primary triggered by common respiratory viral INF Tend to resolve during preschool yrs without increasing risk of asthma later in life Problems due to reduced airflow at birth suggestive of relative narrow airways improved by school yrs

10 Persistent Atopy Associated Asthma
Begins in early preschool yrs Associated with atopy (eg atopic dermatitis in infancy, allergic rhinitis, food allergy) Biologic factors e.g.: early inhalant sensitization, increase serum IGE, increase blood eosinophills, High risk of persistence into later childhood and adulthood lung function abnormality Those with onset<3 yrs reduced air flow by school yrs Those with later onset of symptoms or allergen sensitizations unlikely persistence lung function abnormality later

11 Non-Atopic Wheezing Wheezing ,coughing beginning in early life often with RSV INF resolves later in childhood without increasing risk of persistence asthma Associated with bronchial hyper responsiveness near birth

12 Asthma with declining lung function
Children with asthma with progressive increase in air flow limitation Associated with hyper inflation in childhood Male gender

13 Occupational type asthma in children
Late onset asthma in females associated with obesity and early onset puberty Onset between 8_13 yrs Associated with early onset puberty and obesity Specific for females Occupational type asthma in children Children with asthma and occupational type exposure known to trigger asthma in adults in occupational settings

14 Types of Asthma common clinical presentations of intermittent recurrent wheezing and/or coughing
Recurrent wheezing in early childhood Chronic asthma associated with allergy Females 11 yrs with early onset puberty and obesity

15 Pathogenesis Airflow obstruction resulting from
Broncho constriction of bronchiolar smooth muscle mass Cellular inflammatory infiltrates and exudates mostly Eosinophills(also N , M ,L ,mast cells ,basophiles)fill and obstruct airways and damage epithelium and induce desquamation into airway lumen mediated by T helper cells and other immune cells that produce pro allergic pro inflammatory cytokines(IL4,IL6,IL13) Breach in normal immune regulatory process

16 Air obstruction RESULT Airway inflammation AHR
Edema basement membrane thickness sub epithelial collagen deposition Smooth muscle and mucus gland hypertrophy and mucus hyper secretion Air obstruction

17 Clinical manifestations and diagnosis
Most common intermittent dry cough and expiratory wheezing Shortness of breath and chest tightness in older children and adults Intermittent non focal chest pain in younger children Worsening of respiratory symptoms at night Worsening of day time symptoms by activity

18 Continue….. Subtle symptoms such as self limitation of activities ,general fatigue ,difficulty in keeping up with peers Relief with aerosolized bronchodilators Lack of improvement with bronchodilators and steroid is inconsistent with Asthma and should consider Asthma masquerading conditions!!!! Hyper ventilation, intercostal retractions ,nasal flaring ,respiratory accessory muscle use Its common not to hear the expiratory wheezing when Air flow is so limited before treatment

19 Asthma Triggers Common viral infections of the respiratory tract
Aero allergens in sensitized asthmatics ,animal dander ,dust mite ,molds ,indoor allergens ,cockroaches Seasonal aero allergens ,pollens(trees ,grasses ,weeds ,) Environmental tobacco smoke Air pollutants ,ozone ,so2,wood or coal smoke ,endotoxin ,mycotoxin ,dust Strong or noxious odors or fumes ,perfume ,hair spray ,cleaning agents Occupational exposure Cold air ,dry air Exercise Crying ,laughter ,hyperventilation Co morbid conditions Rhinitis ,Sinusitis ,GER

20 Clinics History: Triggering symptoms by laughter ,cold air ,airway irritants Exposures that induce airway irritation such as viral URTI Mycoplasma ,Chlamydia Inhaled allergens All lead to AHR

21 Presence Of Risk Factors:
History of other allergies ,allergic Rhinitis, allergic Conjunctivitis ,atopic Dermatitis ,food allergies Parental Asthma Symptoms apart from cold

22 Continue….. No or minimal signs in routine visits
Dry or persistent cough Normal chest findings unless wheezing when asking to breath deeper Quick relief (10 MIN) after SABA use Expiratory wheezing ,prolonged expiratory phase ,decreased sounds in RT lower pos lobe due to regional hypoventilation owing to airway obstruction Rales , ronchi ,crackles due to hyper secretion Segmental crackles and poor breath sounds atelectasis?

23 Continue…. Labored respiration ,respiratory distress increased prolongation of expiration and wheezing in E and I Poor air entry Inter costal retractions ,nasal flaring ,supra and infra sternal retractions And again in most sever forms expiratory wheezing does not appear until some broncho dilation

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25 DD GERD Rhino sinusitis co morbid conditions with asthma
Recurrent aspiration in early life(tracheo broncho malacia ,TEF , foreign body ,CF ,BPD VCD in older children and adolescents

26 Table page 785

27 Pulmonary Function Testing
LAB FINDINGS Pulmonary Function Testing

28 Continue…. Forced expiratory airflow measures helpful in Diagnosis , assessing efficacy of therapy and monitoring Asthma in children specially in poor children who do not have PHE unless obstruction is sever

29 Page 785 table 138-6

30 Valueablity of spirometric findings in children>6 yrs
3 efforts the highest is the peak Reduced FEV FEV1/FVC <0.80 means significant obstruction Improvement in FEV1 following beta 2 agonist > = 12% or 200 ml is consistent with Asthma Peak flow meter

31 CXR Often normal aside from subtle and nonspecific findings of hyperinflation Peribronchial thickening Helping in diagnosis of Asthma differentials Diagnosis of complications of Asthma exacerbations

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33 Other tests such as allergy skin prick testing

34 Treatment

35 Asthma Treatment & Management has 4 components :
Assessment and monitoring of disease activity Provision to educate pt and family Identification and management of precipitating factors and co morbid conditions Appropriate selection of medication  Attainment of optimal Asthma control

36 Component 1 Asthma severity :intermittent
Persistent: mild ,mod ,severe Only once during patient initial evaluation in pt who is not using a daily controller agent Asthma control degree to which symptoms , on going functional impairments , risk of adverse events minimized and goals of therapy are met

37 Continue…. Well controlled Not well controlled Very poor controlled
NIH guidelines for both severity and control for 3 age groups 0-4 yrs 5-11 yrs =>12 yrs

38 Important even in the absence of frequent symptoms infants and children whom have risk factors for asthma and 4 or more episodes of wheezing over the past yr which lasted more than 1 day or 2 or more exacerbations in the last 6 months requiring syst corticosteroids should be considered in the persistent group and hence receive long term controller therapy

39 Important Tips.. Regular clinical visits every 2-6 weeks
Assessment of : Pt symptoms frequency night and day Need for short acting inhaled b2 agonists for quick relief Ability to engage in normal activities Air flow measures for>=5 yrs

40 Continue.. Component 2 : pt education
Component 3 : control of factors contributing to asthma severity Environmental exposures Co morbid conditions Component 4 :principals of asthma pharmacotherapy

41 Asthma Medication SABA ICS LABA LTRA SYSTEMIC STEROIDS
NONSTEROIDAL ANTIINFLAMMATORY CROMOLYN AND NEDOCROMYL OXYGEN ANTICHOLINERGIC AGENTS IPRATROPIUM BROMIDE ANTIIMMUNOGLUBOLINE E

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45 MANAGEMENT OF ASTHMA EXACERBATION(STATUS ASTHMATICUS)
RISK ASSESMENT ON ADMISSION FOCUSED HISTORY ONSET OF CURRENT EXACERBATION FREQUENCY AND severity of daytime and night time symptoms and activity limitation Frequency of rescue bronchodilator use Current medication and allergies Potential triggers History of systemic steroid courses, emergency department visists , hospitalization, intubation or life threatening episodes Clinical assesment Physical examination findings: vital signs, breathlessness, air movement, use of accessory respiratory muscles, retractions, anxiety level, alteration in mental status Pulse oximetry Lung function(defer in pts with mod to severe distress or history of labile disease)

46 Mechanism of action and dosing Cautions and adverse effects
Treatment Drugs and trade name Mechanism of action and dosing Cautions and adverse effects Oxygen(mask or nasal canula) Inhaled short acting b2 agonist Albuterol nebulized solution(5mg/ml concentrates Albuterol MDI Levabuterol Treats hypoxia Bronchodilator Neubolizer 0.15 mg/kg every 20 min for 3 doses as needed,then 0.15_0.3 mg/kg up t 10 mg every 1_4 hour as needed or up to 0.5 mg/kg/hr by continous neubolization 2_8 puf up to every 20 min for 3 doses as needed then every 1 hr as needed Monitor pulse oximetry to maintain o2 saturation>92% Cardiorespiratory monitoring During exacerbations,frequent or continuous use can cause pulmonary vasodilatation,v/q mistmatch and hypoxemia Adverse effect palpitation, tachycardia, arrhythmia, tremor, hypoxemia Neubolizer:when giving concentrate forms,dilute with saline to 3 ml total neubolized volume For MDI use space/holding chamber Systemic corticosteroids Prednisolone tb Methyl prednisolon Anticholinergics Ipratropium Atrovent Ipratropium with Albuterol Anti inflammatory 0.5_1 mg/kg every 6-8 hr for 48 hr , then 1-2 mg/kg day bid(max 60 mg/day) Short course burst for exacerbation 1-2 mg/kg/day qd or bid for 3-7 days Mucolitic/bronchodilator Neubolizer 0.5 mg q6-8 hr (tid or qid) as needed MDI 2 paf qid 1 vial by neubolizer qid If pt has been exposed chickenpox or measles, consider passive immunoglobulin prophylaxis, also risk of complications with herspes simplex and TB For daily dosing , 8 am administration minimizes adrenal suppression Children may benefit from dosage tapering if course exceed 7 days Adverse effect monitoring: frequent therapy bursts risk numerous corticosteroid adverse effects Should not be used as first line treatment added to b2 agonist therapy Neubolizer may mix Ipratropium with Albuterol

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48 QUICK RELIEF MEDICATION
SABA Anti cholinergic(ipratropium) Short term systemic gluco corticoid

49 SABA Quick relief of asthma symptoms
Relax airway smooth muscle prompt airflow↑ Repetitive or continuous SABA is the most effective means of reversing air flow obstruction SABA should not be prescribed on a regular schedule because concerns of possibility of deteriorating asthma control Frequent use of SABA is an indication of poor asthma control Preferred root is inhalation smaller dose , fewer side effects more rapid on set of action Ipratropium Bromide as an adjunct to SABA in emergency room reduces hospital admissions and improves lung function Systemic Glucocorticoids short oral course + SABA in moderate to severe asthma exacerbation

50 LABA Salmetrol Should be used in combination with inhaled
corticosteroids and not as mono therapy Exercise induces asthma in children >= 4 Yrs one inhalation 30 min prior to exercise No additional doses for PTs who are already receiving it twice daily not recommended by NIH guidelines

51 LTRA MonteLukast ( singulair) Antihistaminic
Leukotrien receptor antagonist Asthma ( not < 12 MO) and allergic rhinitis ( not < 6 MO) Morning dosing not evaluated Prophylactic and chronic treatment of asthma Exercise induced asthma in >= 15 Yrs Zafir Lukast : prophylactic and chronic treatment of asthma

52 ICA Most potent anti inflammatory agents available for the treatment of asthma Inhibiting most steps in the cascade of the inflammatory response Benefits reducing bronchial hyper responsiveness , prevention of late asthmatic response , enhanced lung function Inhaled Glucocorticoids first line controller therapy for persistent asthma or those who require step 2

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56 Prognosis 35%of preschool children experience recurrent coughing and wheezing,1/3 of them continue to have persistent asthma into later childhood and 2/3 improvement on their own through their teen yrs Asthma severity by age 7-10 yrs is predictive of asthma persistence into adulthood Children with mod to severe asthma and lower lung function are likely to have persistent asthma as adults Children with milder asthma and N/R lung function are likely to improve over time or be periodically asthmatic

57 THANK YOU FOR YOUR ATTENTION


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