1. Respiratory Infections in Children Dr Basil Elnazir PhD, FRCPI, FRCPCH, DCH

2. Respiratory Tract infections
Upper
Pharyngitis
Tonsillitis
Otitis media
Croup
Lower
Croup
Bronchitis
Bronchiolitis
Pneumonia

3. Respiratory Viruses Influenza A virus 1933 Adenovirus 1953
Parainfluenza virus 1955
Rhinovirus
RSV
Enterovirus
Coronavirus
Human Herpes
Human Metapneumovirus 2001
SARS coronavirus 2003
Bocca Virus

4. Common Cold Infectious viral URTI Symptoms Usually last up to 7 days
Nasal discharge/stuffiness
Throat irritation > cough
Pyrexia (38o C)
Feeding & sleeping difficulties
Myalgia, lethargy & anorexia (older children)
Usually last up to 7 days
COMMON COLD
Key points
1. Correct identification of the common cold syndrome is important in ensuring
appropriate treatment
2. Antibiotic therapy is not useful
INTRODUCTION
The common cold is a highly infectious viral upper respiratory illness caused by over 100
different virus types 1
. It is important that clinicians correctly identify the common cold
syndrome in children and treat appropriately.
CLINICAL FEATURES
The minimal symptoms that define the common cold syndrome are nasal discharge, nasal
stuffiness and throat irritation resulting in a cough. A purulent nasal discharge does not
necessarily indicate bacterial infection.
Infants are more likely to have an associated fever (38
C or more) and experience feeding
and sleep difficulties. There is usually little or no fever in older children but they may
complain of myalgia, lethargy and anorexia.
The uncomplicated cold has a uniformly excellent outcome with illness duration of about
7 days. A persistent fever with worsening symptoms beyond 7 days may indicate
secondary bacterial infection. A lingering clear nasal discharge may persist for up to 2
weeks.
INVESTIGATIONS
None are required.
MANAGEMENT
Antibiotic therapy is not useful. The common cold is usually a self-limiting illness and
no specific therapy is indicated. Common cold remedies often prescribed have not been
shown to provide any significant benefit and are generally not recommended
2,3
. However,
general measures that may help include
1. fever relief
2. nasal obstruction/stuffiness relief
3. frequent fluid intake/small frequent feeds
4. avoidance of environmental tobacco smoke

5. Common Cold Investigations Management None Antibiotics (not useful)
General measures
Fever relief
Frequent fluid intake
Nasal obstruction/stuffiness relief
Avoidance of Environmental Tobacco smoke
Antibiotic therapy is not useful. The common cold is usually a self-limiting illness and
no specific therapy is indicated. Common cold remedies often prescribed have not been
shown to provide any significant benefit and are generally not recommended
2,3
. However,
general measures that may help include
1. fever relief
2. nasal obstruction/stuffiness relief
3. frequent fluid intake/small frequent feeds
4. avoidance of environmental tobacco smoke

6. Sore Throat
Pharyngitis,Tonsillitis, Acute exudative Tons. & Pharyngotonsillitis.
Uncommon under 1 yr (peak 4-7 yrs)
Viruses
GABHS
Fever
Diffuse redness of the tonsils & Pharyngeal exudates
Tender/enlarged anterior cervical Lymph nodes
Conjunctivitis, rhinitis, cough, hoarseness, coryza, anterior stomatitis, discrete ulcerative
lesions, viral exanthem and diarrhoea strongly suggest a viral aetiology Clinical features strongly suggestive of streptococcal pharyngitis
1,3,4
? fever
? diffuse redness of the tonsils and pharyngeal exudates OR
? tender, enlarged anterior cervical lymph nodes
? absence of symptoms or signs suggesting viral pharyngitis eg. rhinorrhoea,
conjunctivitis, cough.

7. Tonsillitis Investigations Mangement Throat swab Rapid antigen testing
Supportive/ Symptomatic
Antibiotics (not routine)
Severe clinical condition
GABHS is suspected (10 day Penicillin course)
Infectious mononucleosis !!
Throat swabs are neither sensitive nor specific for serologically confirmed infections. The
sensitivity of Rapid Antigen Testing (RAT) measured against throat culture is wide and
varies between 61% - 95%, although specificity may be better at 88%-100%. Both
considerably increase cost and alter few management decisions.
The Center for Disease Control and American Academy of Pediatrics recommended that
the diagnosis of GABHS pharyngitis should be based on results of appropriate laboratory
tests in conjunction with clinical and epidemiological findings
Ensure adequate oral hydration. 3.
Adequate analgesia is usually all that is required ie paracetamol.
Antibiotic therapy
Antibiotic therapy is not routinely required in all children with sore throat 1
. However,
antibiotics should not be withheld if the clinical condition is severe or GASBH is
suspected. 5
. Complications like rheumatic fever, otitis media and quinsy benefit from
early administration of appropriate antibiotic therapy 8 .
If GABSH pharyngitis is suspected, a 10 day course of penicillin is the treatment of
choice
1,2,3,5,
Infectious mononucleosis may present with severe sore throat, tonsillar exudates and
anterior cervical lymphadenopathy,. Ampicillin-based antibiotics, including co-
amoxiclavulanic acid should be avoided as first line treatment

8. Otitis Media Most common reason for GP/ER visits in children.
Causative organisms
Strept. Pneumonia (40-50%)
H. Influenza (20-30%)
Morexalla Catarrhalis (10-15%)
Amoxicillin ( macrolides if Penicillin allergy)
Streptococcus pneumoniae (40%-50%), nontypable Haemophilus influenzae (20%-30%), and Moraxella catarrhalis (10%-15%);

12. CROUP Acute Laryngotracheobronchitis

16. Croup Acute Respiratory disease of children
6 months –5 years (peak 2 years)
Viral prodrome
Runny nose, cough & congestion
then
Barking or seal- like cough, hoarseness, sore throat, stridor & respiratory distress of varying degree
Parainfluenza (74%) mostly type 1, RSV, adeno,Influenza, occassionally mycoplasma

18. Pathology

19. Diagnosis History Examine Oropharynx ( DON’T) Xray (lateral neck)
Laboratory work (generally unnecessary)
D/D
Diagnosis: based on history, age of child, and examination; response to treatment helpful diagnostically; stridor at rest or with agitation; young age; safe to look in throat, examine oropharynx; x-ray can be helpful (classically see narrowing of tracheal air column for 5-10 mm below cords, ballooning of hypopharynx with inspiration seen on lateral view of neck); laboratory work generally unnecessary (incidence of bacteremia “extremely low, well below probably 1%”) but may be useful in unclear cases, eg, “extremely toxic kids,” high fever

20. Croup: Assessment of Severity
Mild
Stridor with excitement or at rest; no RD
Moderate
Stridor at rest with I/C & S/C or Sternal recession
Severe
Stridor at rest with marked recession, decreased air entry and altered level of consciousness
Assessment of severity
1. Clinical Assessment of Croup 8
a. Mild:
Stridor with excitement or at rest, with no respiratory distress.
b. Moderate:
Stridor at rest with intercostal, subcostal or sternal recession.
c. Severe:
Stridor at rest with marked recession, decreased air entry and
altered level of consciousness

21. Management Supportive care in calm environment
Humidified O2 as blow by
Steroids
Nebulised Budesonide
Oral dexamethasone ( mg/Kg)
Racemic epinephrine
Potent vasoconstrictor effect which decrease airway oedema
rapid but short lived
Treatment: child’s condition made worse by agitation or upset; therefore, give supportive care in calm environment; humidified O2 as blow-by treatment; fluids as needed; mist therapy as blow-by treatment Treatment: child’s condition made worse by agitation or upset; therefore, give supportive care in calm environment; humidified
Racemic epinephrine: has potent vasoconstrictive effect that seems to decrease airway edema; effect rapid but short-lived
namely dexamethasone and nebulised budesonide in viral croup. There is significant
improvement in the following outcomes:
1. severity of symptoms
2. need for co-intervention with nebulised adrenaline
3. the number of patients admitted to hospital after treatment in emergency department
4. the number of patients requiring PICU care
5. number of children requiring intubation
6. duration of hospitalization .
Steroid therapy acts by both the anti-inflammatory and vasoconstrictive mechanisms.
Both oral dexamethasone and nebulised budesonide are equally effective and may

22. D/D Acute upper Airway obstruction
Croup (v.common)
Recurrent spasmodic croup
Bacterial tracheitis
Foreign body
Rare causes
Epiglottitis
Inhalation of smoke & hot air in fires
Trauma to the throat
Retropharyngeal abscess
Angioedema
Prexisting (congenital) structural abnormality

23. Clinical Features of LTB (Croup) vs Epiglottitis
Croup Epiglottitis
Onset over days over hours
Preceeding Coryza Yes No
Cough Yes No
Ability To drink Yes No
Drooling saliva No Yes
Appearance unwell Toxic, very ill
Fever < 38.5o C > 38.5o C
Stridor Harsh, rasping soft whispering
Voice, cry Hoarse Muffled/reluctant

28. Croup Indications for Hospital admission Moderate – severe croup
Toxic looking
Poor oral intake
Age < 6 months
Family circumstances
Indications for hospital admission
1. Moderate and severe viral croup.
2. Toxic looking
3. Poor oral intake
4. Age less than six months
5. Unreliable caregivers at home
6. Family that lives a long distance from the hospital and lacks reliable transport

29. Croup: Summary Clinical syndrome
Barking cough, inspiratory stridor, hoarse voice and resp. distress of varying severity
Routine neck Xray and Oropharynx exam is not indicated (dangerous!!)
Steroid therapy is effective (routine in moderate – severe.
Nebulised adrenaline may be used to provide rapid relief
Croup refers to a clinical syndrome characterized by barking cough,
inspiratory stridor, hoarse voice and respiratory distress of varying severity.
2. A routine neck radiograph is not necessary, unless the diagnosis is in doubt.
3. Steroid therapy is effective and should be routinely used in moderate - severe
viral croup.
4. Nebulised adrenaline may be used to provide rapid relief but its effect is
temporary.

30. Do Not

31. Bronchiolitis

32. RSV
Site of infection
Characteristic syncitum formation found in cell culture and infected tissues
Possible links between severe bronchiolitis and asthma are still under investigation.

33. Bronchiolitis
Viral Resp. Prodrome ( Runny nose, congestion, poor feeding)
Increased work of breathing, diffuse wheezing, acc. muscles, diffuse crackles
Generally mild and self limiting
Bronchiolitis: acute respiratory disease of young infants caused almost exclusively by RSV; characterized more by edema and airway inflammation than by bronchospasm; RSV causes inflammation and infection in respiratory epithelium, death of respiratory epithelial cells, and subsequent sloughing (sloughing causes edema, mucous plugging, atelectasis); young infant with viral respiratory prodrome (eg, runny nose, congestion, poor feeding) presents with increased work of breathing, diffuse wheezing, use of accessory muscles, diffuse crackles and rales; most common in fall to spring, with peak incidence in middle of winter; ubiquitous by 2 yr of age; generally mild and self-limited disease causing upper respiratory and mild lower respiratory tract infections in most children; produces bronchiolitis syndrome in many

34. Bronchiolitis
acute infectious disease of the lower respiratory tract that occurs primarily in young infants, most often in those aged 2-24 months.
Edema and inflammatory infiltration of the bronchial walls
Infection is spread by direct contact with respiratory secretions.

35. Bronchiolitis
Epidemics last 2-4 months beginning in November and peaking in January or February
Previous infection with the common etiologic viruses does not confer immunity.
Re infection is common.

36. Bronchiolitis: High Risk
Prematurity
Chronic Lung disease
Very young age (< 6 weeks)
Congenital heart disease
Underlying immune deficiency
1. Respiratory syncytial virus is the most common cause of bronchiolitis in
infancy.
2. Severe respiratory distress is more likely to develop in infants who have risk
factors namely prematurity, chronic lung disease, a very young age (less
than six weeks old) and congenital heart disease.
3. Supportive therapy and oxygen supplementation if necessary remain the
cornerstones of treatment.
4. A trial of nebulised bronchodilator therapy may be given but regular
assessment and vigilance during treatment is essential.
5. Chest physiotherapy, routine antibiotic and ribavarin therapy are not
recommended.

37. Signs & Symptoms Fever Increased work of breathing Wheezing Cyanosis
Grunting
Noisy breathing
Vomiting, especially post-tussive
Irritability
Poor feeding or anorexia
50% in 24 hrs , 70% (48hrs), 90% in 72 hrs. If babies survive >72 hrs then survival is the rule.

39. Management O2 & fluids Steroids (no role)
Bronchodilators (minimal effects)
Racemic epinephrine (appears effective)
Treatment: oxygen and fluids mainstay of therapy; fairly self-limited benign disease in most cases; no role for steroids; beta-agonists have minimal effect in bronchiolitis, however, racemic epinephrine (Vaponefrin) appears effective; first-line approach to wheezing infant at speaker’s institution is Vaponefrin, 0.05 mL/kg every 2 hr; clear advantage of racemic epinephrine over albuterol; some respond to albuterol, if so, send them home on it

40. Management Humidified oxygen (<94%).
Patients should be made as comfortable as possible (held in a parent's arms or sitting in the position of comfort).
Cardiorespiratory monitoring is essential
Pulse oximetery is helpful

41. Management ?I/V fluids (difficulty taking bottles) Isolation
?Nebulised therapy
?? steroids
Antibiotics :not indicated unless
Toxic/ recurrent apnoea & circulatory impairment
WBC > 15,000
Progressive infiltrative changes in CXR
+ve bacterial Cultures/ Acute clinical deterioration
Many dyspnoeic infants have dificulty taking a bottle
There is no definitive evidence to support the routine use of nebulised bronchodilators in
the treatment of viral bronchiolitis.
Data concerning the efficacy of ß2 agonist i.e. salbutamol in the treatment of viral
bronchiolitis remains inconclusive 14
. Limited studies using nebulised racemic
adrenaline, which has both a and ß2 agonist effects, appears superior to salbutamol or
placebo
15, 16.
The efficacy of anticholinergic agents i.e. ipratropium bromide in viral
bronchiolitis has been disappointing
recurrent apnoea and circulatory impairment,
? ? possibility of septicaemia
? ? acute clinical deterioration
? ? high white cell count
? ? progressive infiltrative changes on chest radiography.
VII

43. Bronchiolitis (CXR)
Hyperinflation of the Lungs with flattening of the diaphragm
Horizontal ribs
Hilar bronchial markings
Occasional Collapse

44. Morbidity & Mortality Significant morbidity is rare.
1% of cases (Hospitalisation).
Mechanical ventilation is required for 3-7% of admitted patients
Mortality rate is 1-2% of all hospitalized patients and 3-4% for patients with underlying cardiac or pulmonary disease.
The majority of deaths occur in infants younger than 6 months

45. Bronchiolitis: Summary
1-6 months (rare > 2 years)
RSV is the commonest cause
Severe RD is likely in high risk infants
Supportive therapy & O2
Trial of nebulised bronchodilator
Chest physio, routine antibiotic & ribavarin are not recommended
1. Respiratory syncytial virus is the most common cause of bronchiolitis in
infancy.
2. Severe respiratory distress is more likely to develop in infants who have risk
factors namely prematurity, chronic lung disease, a very young age (less
than six weeks old) and congenital heart disease.
3. Supportive therapy and oxygen supplementation if necessary remain the
cornerstones of treatment.
4. A trial of nebulised bronchodilator therapy may be given but regular
assessment and vigilance during treatment is essential.
5. Chest physiotherapy, routine antibiotic and ribavarin therapy are not
recommended.
Corticosteroid therapy
The role of corticosteroid therapy in acute bronchiolitis remains unresolved.
Randomised controlled trials of the use of inhaled steroids for treatment of viral
bronchiolitis demonstrated no meaningful benefit 20
. However a meta-analysis of the use
of systemic corticosteroid showed possible benefits in infants with severe bronchiolitis
resulting in a reduction in the clinical scores and length of hospital stay

46. Pneumonia; LRTI

47. Pneumonia
Acute respiratory disease accompanied by fever , tachypnoea, +/- cyanosis
Definition
Bronchopneumonia
febrile illness with cough, respiratory distress with evidence of localised or generalised patchy infiltrates on chest x-ray
Lobar pneumonia :
similar to bronchopneumonia except that the physical findings and radiographs indicate lobar consolidation
50 breaths/min in children <1 yr of age and >40 breaths/min in children >1 yr of age
A specific aetiological agent cannot be identified in 40% to 60% of cases
6,7.
Viral
pneumonia cannot be distinguished from bacterial pneumonia based on a combination of
clinical findings. The majority of lower respiratory tract infections that present for
medical attention in young children are viral in origin such as respiratory syncytial
virus, influenza, adenovirus and parainfluenza virus. One helpful indicator in predicting
aetiological agents is the age group as shown in Table 6.
Table 6: Pathogens causing pneumonia
Age
Bacterial Pathogens
Newborns
Group B streptococcus, Escherichia coli, Klebsiella species,
Enterobacteriaceae
1- 3 months
Chlamydia trachomatis
Preschool
Streptococcus pneumoniae, Haemophilus influenzae type b,
Staphylococcal aureus,
Less common: group A streptococcus, Moraxella catarrhalis,
Pseudomonas aeruginosa
School
Mycoplasma pneumoniae, Chlamydia pneumoniae

48. Pneumonia Majority are viral in origin Bacterial causes
RSV, Influenza, adenovirus & parainfluenza
Bacterial causes
Newborns
GBS, E. coli, Klebsiella sp., Enterobacteriaceae
1-3 months
Chlamydia trachomatis
Preschool
Strept. Pneumoniae, H. influenzae b, Staph. Aureus
GAS, M. catarrhalis, Pseudomonas!!
School
Mycoplasma pneumoniae, Chlamydia, Strept. Pneumoniae,
aetiological agents is the age group as shown in Table 6.
Table 6: Pathogens causing pneumonia
Age
Bacterial Pathogens
Newborns
Group B streptococcus, Escherichia coli, Klebsiella species,
Enterobacteriaceae
1- 3 months
Chlamydia trachomatis
Preschool
Streptococcus pneumoniae, Haemophilus influenzae type b,
Staphylococcal aureus,
Less common: group A streptococcus, Moraxella catarrhalis,
Pseudomonas aeruginosa
School
Mycoplasma pneumoniae, Chlamydia pneumoniae

49. Pneumonia Tachypnoea <2 months >60/min 2-12 months >50/min
12mo- 5 yrs >40/min
Table 7: Definition of Tachypnoea
Less than 2 months > 60 /min
2- 12 months > 50 /min
12 months – 5 years > 40/ min

50. Pneumonia Hospital admission
Community acquired pneumonia can be treated at home.
Criteria for admission
Children < 3 months
Fever ( > 38.5o C)
Refusal to feed / vomiting
Rapid breathing +/- cyanosis
Systemic manifestation
Failure of previous antibiotic therapy
Recurrent peumonia
Severe underlying disorders (immunodef, CLD)
1. Children aged <3 months whatever the severity of pneumonia.
2. Fever (>38.5
C), refusal to feed and vomiting
3. Rapid breathing with or without cyanosis
4. Systemic manifestation
5. Failure of previous antibiotic therapy
6. Recurrent pneumonia
7. Severe underlying disorders ( i.e. immunodeficiency, chronic lung disease ) IV

51. Pneumonia: Invest. Investigations CXR WBC & diff CRP
Blood Cx ( +ve %)
Resp. secretions C/S
BAL (P.carini in immune compromised)
Serological studies (M. pneumoniae)
Children with bacterial pneumonia cannot be reliably distinguished from those with
viral disease on the basis of any single parameter; clinical, laboratory or chest
radiograph findings.
1. Chest radiograph
Chest radiograph is indicated when clinical criteria suggests pneumonia. It will not
identify the aetiological agent. However the chest radiograph is not always necessary if
facilities are not available or the pneumonia is mild 13
2. Complete white blood cell and differential count
This test may be helpful as an increased white blood count with predominance of
polymorphonuclear cells may suggest bacterial cause. However, leucopenia can either
suggest a viral cause or severe overwhelming infection. 14
3. Blood culture
Blood culture remains the non-invasive gold standard for determining the precise
aetiology of pneumonia. However the sensitivity of this test is very low. Positive blood
cultures are found only in 10% to 30% of patients with pneumonia 15
. Even in 44% of
patients with radiographic findings consistent with pneumonia, only 2.7% were positive
for pathogenic bacteria. 16
Blood culture should be performed in severe pneumonia or
when there is poor response to the first line antibiotics.
4. Culture from respiratory secretions
It should be noted that bacteria isolates from throat swabs and upper respiratory tract
secretions are not representative of pathogens present in the lower respiratory tract.
Samples from the nasopharynx and throat have no predictive values. 6
This investigation
should not be routinely done.
5. Other tests
Bronchoalveolar lavage is usually necessary for the diagnosis of Pneumocystis carini
infections primarily in immunosuppressed children. It is only to be done when facilities
and expertise are available.
If there is significant pleural effusion diagnostic, pleural tap will be helpful.
Mycoplasma pneumoniae, Chlamydia, Legionella and Moxarella catarrhalis are
difficult organisms to culture, and thus serological studies should be performed in
children with suspected atypical pneumonia. An acute phase serum titre of more than
1:160 or paired samples taken 2-4 weeks apart showing four fold rise is a good indicator
of Mycoplasma pneumoniae infection. 17
This test should be considered for children

52. Pneumonia Management Supportive Antibiotic therapy Chest Physiotherapy
There is no evidence to suggest that chest physiotherapy should be routinely
performed in pneumonia

53. Pneumonia: Summary
Tachypnoea is the best single predictor of pneumonia in children of all ages.
Bacterial pneumonia cannot be reliably distinguished from viral pneumonia
The age of the child, local epidemiology of respiratory pathogens determine the choice of antibiotic therapy.
4. Anti-tussive remedies and chest physiotherapy should NOT be routinely prescribed for children with pneumonia
and sensitivity of these pathogens to particular microbial agents and the emergence of anti-microbial resistance

54. Pearls Lobar consolidation is a feature of pneumoccocal pneumonia.
Multiple cavities containing fluid/air in staphyloccocal pneumonia.
Common for children to start with viral pneumonia and get bacterial superinfection.
Pertussis (whooping cough)… Leucocytosis with absolute Lymphocytes

57. Diffuse bilateral interstitial perihilar infiltrates/ atypical mycoplasma

58. Round pneumonia RLL

60. Asthma

61. Asthma Chronic inflammatory pulmonary disorder, characterised by
REVERSIBLE OBSTRUCTION
of the airways .

62. Asthma Burden ISAAC Asthma Society of Ireland Ireland 4th 15% children
5-11 yrs 3.5 school days/ yr
12-18 yrs 2 school days/ yr
79% suboptimal control
UK, NZ, finland , Ireland
Don’t have asthma under control

63. Prevalence of asthma in children
estimated 1.4 million children
receiving treatment for asthma in the UK
29% of consultations for asthma in primary care are for children (aged 0–14 years)
An estimated 1.4 million children are currently receiving treatment for asthma in the UK.1
The rate of primary care consultations for asthma* is considerably higher in children (aged 0–14 years) than in adults, accounting for 29% of the total number of consultations for asthma.1
Many children experience wheezing that regularly disturbs sleep (one or more times a week), or have experienced attacks so severe that their speech is limited (to one or two words between breaths).1
The current rate of hospitalisation in pre-school children is still over three times higher than in older children and six times higher than in adults.1
* Based on the weekly consultation rate per 100,000 of the age group
Reference:
1. National Asthma Campaign Asthma Audit Asthma J 2001; 6: S1–S16.

66. The muscles surrounding the bronchial tubes contract excessively (bronchospasm), thus narrowing the airways.
The lining is red and swollen (inflamed) causing further narrowing.
Sticky mucus secretions block the airways.

67. Pathophysiology Chronic inflammation Bronchial Hyperresponsiveness
Reversible bronchospasm
Intermittent exacerbations

68. Causes of Asthma Exacerbations
VRI
Allergic exposure
Air pollution/ tobacco smoke
Bacterial infections
Stress/ Emotional factors
Excerise
Cold Air

70. Chronic Cough Recurrent RTI Asthma Allergic Rhinitis/ Sinusitis/ PND
Infections (Pertussis, RSV, Mycoplasma)
Inhaled foreign body
Suppurative lung disease (CF, PCD)
GOR TB
Cigarette smoking (Active /passive)
Habit cough / Psychogenic cough)
Recurrent or persistent

71. Recurrent Wheeze Asthma Post RSV bronchiolitis
Recurrent aspiration of feeds
CLD CF
Pulmonary/ cardiac Congenital anomalies
Maternal smoking
Cow milk allergy/intolerance ( infants)

72. ASTHMA: DIAGNOSIS A clinical diagnosis symptoms / history Signs
objective evidence

73. Asthma History Nature of symptoms Pattern of Symptoms
(severity/frequency/seasonal & diurnal variation)
Precipitating/aggravating factors
Profile of AAA (ER visit/ ICU)
Previous and current drug therapy
Response, dosage, delivery, S/E
Impact of disease on child and family
Exercise tolerance,sleep disturbance
Atopic History
School performance & attendance
Environmental history (active/passive smoking)
General medical History of child
Family History

74. ASTHMA: DIAGNOSIS SYMPTOMS: none are specific for asthma:
wheeze, SOB, cough (esp: at night, exercise)
F.H. (+)ve
SIGNS wheeze, Harrison’s sulcus, AP diameter
OBJECTIVE : reduced FEV1 ( / FVC )
: PEFR variability >20%
: exercise-induced bronchospasm
: sputum eosinophils (research)

75. Asthma diagnosis: children
Suspect asthma in any wheezing child:
ideally heard on auscultation
Δ Similar to adults - but can’t measure lung function
presence of KEY FEATURES
no alternative diagnosis
RESPONSE to Mx plan
RE-ASESSMENTS
HISTORY: ‘chesty’ with viral URTIs
: cough (esp. at night, on exercise )
: wheeze

77. What is Asthma Control? Standards for assessment of Control
Minimal symptoms day and night
Minimal need for reliever
No exacerbations
No limitation of physical activity
Normal Lung functions (FEV1and /or PEF >80%

78. Asthma : Management Avoidance of triggers
Prompt treatment of acute attacks
Prevention of Asthma attacks and symptoms

79. Severe Acute Asthma Severe AAA Potentially life –threatening features
Increased Resp rate
Too breathless to talk or feed
Accessory muscle use
Pulsus paradoxus (older children)
Potentially life –threatening features
Silent chest or feeble respiratory effort
Cyanosis
Reduced level of consciousness or fatigue
Pneumothorax / pneumomediatinum/ SC air
Physical and physiological features oAAA

80. Severe Acute Asthma: Treatment
Recognition
Close observation
Relieve Hypoxemia
O2 via face mask
Aggressive use of bronchodilators
Salbutamol 5mg/kg (2.5 mg/kg <5 yrs)
+/_ ipratropium bromide ( micro grams)
Systemic steroids
Oral prednisolone (1-2 mg/kg)
I/v Hydrocortisone (100 mg qid)
Reassessment (monitor PEFR & O2 sats `3

81. Severe Acute Asthma: Treatment 2
Aminophylline
20 mg/kg over 20 min (omit if theophylline)
Continuous infusion 1 mg/kg
CLOSE OBSERVATION & Reassessment `3

82. PROGNOSIS OF CHILDHOOD ASTHMA
‘Not all who wheeze will always do so’
FH asthma, rhinitis (esp. in mother )
- predict persistence to late childhood
not adulthood
Co-existent eczema / rhinitis
and adulthood
Markers e.g. (+)ve skin prick tests
- reflect current severity
- do not predict long-term outcome

83. PROGNOSIS OF CHILDHOOD ASTHMA
Gender
boys: early childhood asthma
: more likely to ‘outgrow’ asthma
girls : persistence to adulthood

84. PROGNOSIS OF CHILDHOOD ASTHMA
SMOKING
maternal smoking: infants wheeze
(no evidence of persistence to adulthood)
PREMATURE / LBW infants
more likely to wheeze in early childhood
(but not adulthood)

85. PROGNOSIS OF CHILDHOOD ASTHMA
SEVERITY
the more severe the asthma in childhood,
the more likely to persist into adulthood
LUNG FUNCTION
poor function in childhood predicts
persistence of asthma into adulthood

86. Asthma Drugs 1 Short acting Bronchodilator (Reliever, Blue)
b2 bronchodilator
Salbutamol (Ventolin / Salamol etc.)
Terbutaline (Bricanyl)
Anticholinergic Bronchodilator
Ipratropium Bromide (Atrovent )
Preventative/ Prophylactic Treatment
Cromoglycates (DSCG…..Intal)
Methylxanthines (Theophylline)
Leukotriene Inhibitor (Montelukast (singulair),Zafirlukast)
Oral Prednisolone

87. Asthma Drugs 2 Inhaled Corticosteroids
Budesonide (Pulmicort …Brown)
Beclomethasone (Becotide)
Fluticasone (Flixotide…..Orange)
Long acting Bronchodilator (LABA)
Salmetrol
Formetrol
Combination (ICS + LABA)
Seretide (Fluticasone + Salmetrol) (Purple)
Symbicort ( Budesonide + Formetrol) (Red)

88. Asthma Hx Pregnancy (smoking) Birth Hx (prem?), hx of RSV etc
When did symptoms start?
Have you ever heard your child wheezing
Hx of infantile eczema, allergies
Problems with swallowing/GOR
Environment (smokers/pets/wooden floors, overcrowded accommodation)
F Hx of atopy (asthma, eczema,hay fever, food allergy).
Nocturnal symptoms (cough, night time awakenings)
Exertional symptoms
GP/ER visits, Steroids
School absenteeism

91. Slide 42. Control-based Asthma Management (GINA 2006) As we move to a decrease in control from partially controlled to uncontrolled, there certainly is an increase in each or some of these symptoms specifically and an increase in exacerbations.
The key aspect of control-based asthma management is to try to link the level of control with the treatment action, increasing treatment as control is not achieved, reducing medication if control is achieved, and trying to link the therapy in a very fluid way with the dynamics of asthma in an individual patient. And, in fact, the goal is to treat each patient as an individual and not to use fixed paradigms or algorithms to try to encompass as many patients as possible. Individualization of asthma treatment will become a more and more important way in the control of asthma.

92. Severe Acute Asthma Physiological features:
SaO2 < 91 % (R/A , before treatment)
PEF < 50 % predicted or personal best
PaCO2 > 5.3 Kpa (40mmhg) if measured
Physical and physiological features oAAA

93. Summary BTS/SIGN Asthma Guideline for patients under 5 years
STEP 4
Refer to respiratory paediatrician
STEP 3
In children aged 2-5 years, consider trial of leukotriene receptor antagonist.
Patients should be regularly reviewed to ensure that the level of treatment they receive remains optimal.
STEP 2
Add inhaled corticosteroid*: μg/day or leukotriene receptor antagonist if inhaled coticosteroid cannot be used.
STEP 1
Inhaled short-acting β2-agonist as required
Adapted from BTS /SIGN Asthma Guideline
Thorax 2003; 58 (suppl I): i1 - i94
(*beclometasone or equivalent)