1. ASTHMA: MANAGEMENT AND PREVENTION IN CHILDREN Lecturer: prof. Galyna Pavlyshyn prof. Galyna Pavlyshyn

2. What is Asthma? Disease of chronic inflammatory disorder of the airways Disease of chronic inflammatory disorder of the airways Characterized by: Characterized by: –Airway inflammation –Airflow obstruction –Airway hyperresponsiveness http://health.allrefer.com/health/asthma-normal-versus-asthmatic-bronchiole.html Cookson W. Nature 1999; 402S: B5-11

3. A sthma 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 OF ASTHMA

4. 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.

5. Pathophysiology Early Acute - t 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 Recurrence of symptoms appears in 4-12 hours 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).

6. What are the Triggering Factors? Domestic dust Domestic dust mites mites Animal with fur Animal with fur Air pollution Air pollution Cockroaches Cockroaches Pollen Pollen Tobacco smoke Tobacco smoke Occupational irritants Occupational irritants

7. Triggering Factors Respiratory (viral) infections Respiratory (viral) infections Chemical irritants Chemical irritants Strong emotional expressions Strong emotional expressions Drugs ( aspirin, beta blockers) Drugs ( aspirin, beta blockers)

8. Potential Risk Factors Host factors Host factors –Genetic predisposition –Atopy –Airway hyperresponsiveness –Gender –Race/Ethnicity Environmental factors Environmental factors –Indoor allergens –Outdoor allergens –Occupational sensitizer Environmental factors Environmental factors –Tobacco smoke –Air pollution –Respiratory infections –Socioeconomic status –Family size –Diet and drugs –Obesity 1 Masoli M, et al. The Global Burden of Asthma: Executive Summary of the GINA Dissemination Committee Report. Allergy 2004; 59: 469-78.

9. DIAGNOSING ASTHMA - Not Easy CLINICAL DIAGNOSIS Clinical diagnosis supported by the certain historical, physical and laboratory findings 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; easonal variability of symptoms; Seasonal variability of symptoms; Positive family history of asthma Positive family history of asthma and atopic disease. and atopic disease.

10. 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 child’s colds repeatedly “go to the chest” or take more than 10 days to clear up Symptoms improve when asthma medication is given

11. 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

12. Dyspnea, airflow limitation (wheeze), hyperinflation are more likely to be present if patients are examined during symptomatic periods. 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, Physical signs reflecting severity: cyanosis, drowsiness, difficulty speaking, tachycardia, hyperinflated chest, hyperinflated chest, use of accessory muscles, use of accessory muscles, and intercostal recession. and intercostal recession. DIAGNOSING ASTHMA

13. Physical examination Physical examination - Respiratory rate; - Work of breathing; - Aeration - Degree of wheezing Suppotive data: Suppotive data: - Pulse oximetry (oxygen saturation); - PEFR – peak expiratory flow rate - Chest radiograph; DIAGNOSING ASTHMA

14. 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) - 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.

15. The Peak Flow Meter

16. Note Peak Flow Numbers Keeping a peak flow diary will help you predict and prevent asthma attacksKeeping a peak flow diary will help you predict and prevent asthma attacks Record peak flow numbers daily, every morning before taking control medicine(s)Record peak flow numbers daily, every morning before taking control medicine(s) Watch for trends in symptomsWatch for trends in symptoms Diary cards to record symptoms and PEF (in children older than 5 years )

17. Classification of Asthma Mild Intermittent Asthma Mild Intermittent Asthma - - Symptoms less than once a week - - Brief exacerbations - - Nocturnal symptoms not more than twice a month - - FEV1 or PEF ≥ 80% predicted - - PEF or FEV1 variability < 20% Mild Persistent Asthma Mild Persistent Asthma - - Symptoms more than once a week but less than once a day - - Exacerbations may affect activity and sleep - - Nocturnal symptoms more than twice a month - - FEV1 or PEF ≥ 80% predicted - - PEF or FEV1 variability < 20 – 30% Traditionally, the degree of symptoms, airflow limitation, and lung function variability have allowed asthma to be classified by severity (Intermittent, Mild Persistent, Moderate Persistent, Severe Persistent)

18. Classification of Asthma Moderate Persistent 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 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%

20. Severity of Asthma Exacerbations MildModerateSevere Talks in sentencesTalks in phrasesTalks in single words Breathlessness walking Breathlessness with talking/feeding Breathlessness in rest Normal mental status Mildly anxiousAnxious Mild tachypneaModerate tachypneaSevere tachypnea End expiratory wheeze Loud expiratory wheeze Inspiratory and expiratory wheezing Good aerationFair aerationPoor aeration Oxygen saturation > 95 % Oxygen saturation 90-95 % Oxygen saturation < 90 % PEFR > 70%PEFR = 40-69 %PEFR < 40%

21. TREATMENT Asthma Medications TREATMENT Asthma Medications Bronchodilators (Sympathomimetics) Bronchodilators (Sympathomimetics) Bronchodilators (Anticholinergics) Bronchodilators (Anticholinergics) Inhaled Corticosteroids Inhaled Corticosteroids Biologic Response Modifiers (Monoclonal Antibodies) Biologic Response Modifiers (Monoclonal Antibodies) Leukotriene Receptor Antagonists Leukotriene Receptor Antagonists Mast Cell Stabilizers Mast Cell Stabilizers Methylxanthene Derivatives Methylxanthene Derivatives

22. Frequent SABA are the standard of care Frequent SABA are the standard of care Use of NEB or MDI-S are each reasonable Use of NEB or MDI-S are each reasonable Most will require just 1-2 treatment Most will require just 1-2 treatment Those who are SABA unresponsive may benefit from systemic corticosteroids Those who are SABA unresponsive may benefit from systemic corticosteroids Most will be discharged home Most will be discharged home TREATMENT MILD ASTHMA

23. Management Moderate Asthma No improvement Marked improvement Hospitalize Slight improvement Albuterol NEB or MDI-S Albuterol NEB or MDI-S Prednisone 2 mg/kg/d IM or NEB Prednisone 2 mg/kg/d IM or NEB Atrovent Atrovent↓ Disposition Discharge home Continue albuterol every 30-45 min Continue albuterol every 30-45 min

24. Management Severe Asthma Monitor pulse, RR, oxygen saturation Monitor pulse, RR, oxygen saturation↓ Supplemental oxygen 0.15mg/kg Albuterol by nebulization Atrovent Good response Continue with approach to moderate asthma Poor response Terbutaline or epinephrine IM Methylprednisolone 1-2 mg/kg IV Albuterol |NEB 50-75 mg/kg IV Magnesii sulfate

25. 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. 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; 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. 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. Reduction in the likelihood of recurrence of severe airflow obstruction by intensifying therapy: Often, a short course of systemic corticosteroids is helpful.

26. 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.

27. Controller Medications Inhaled corticosteroids - ICS Inhaled corticosteroids - ICS Systemic corticosteroids - SCS Systemic corticosteroids - SCS Leukotriene modifiers Leukotriene modifiers Sodium cromoglycate (cromolyn sodium) Sodium cromoglycate (cromolyn sodium) Nedocromil sodium Nedocromil sodium Methylxanthines Methylxanthines Long-acting inhaled  2-agonists, Long-acting inhaled  2-agonists, Long-acting oral  2-agonists. Long-acting oral  2-agonists.

28. Classification of asthma by level of control is more relevant and useful Levels of Asthma Control CharacteristicControlled (All of the following) Partly Controlled - Any measure present in any week Uncontrolled ExacerbationsNoneOne or more/yearOne in any week Three or more features of partly controlled asthma present in any Week Daytime symptoms None (twice or less/week) More than twice/week Limitations of activities NoneAny Nocturnal symp- toms/awakening NoneAny Need for reliever /rescue treatment None (twice or less/week) More than twice/week Lung function (PEF or FEV1) Normal< 80% predicted or personal best (if known)

29. Mild persistent asthma Long-term control: Anti-inflammatory treatment in the form of low-dose inhaled corticosteroids or nonsteroidal agents (cromolyn, nedocromil) is preferred. 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.

30. 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. 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. 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.