Approach to a child with bronchial asthma

Name: Approach to a child with bronchial asthma
Uploaded: 2017-08-27T18:01:37+00:00
Duration: PTM23S25
Channel: Eustace Pope
Description: Approach to a child with bronchial asthma

Approach to a child with bronchial asthma
Ibrahim Alsaif Consultant Pediatrician Pediatric Emergency Consultant Al Yamammah Hospital 3/9/2015 ped.emergency.Dr.Alsaif

ped.emergency.Dr.Alsaif
Learning objectives By the end of this lecture , each student should be able to: Know about the pathophysiology and etiology behind childhood asthma. Identify the clinical presentation and recognize the triggering factors of bronchial asthma in children. Develop a rational approach to the differential diagnosis Classify the severity of asthma. Discuss the management strategies of bronchial asthma. Define status asthmaticus. Recognize the signs and symptoms of status asthmaticus. Outline the emergency management of status asthmaticus. 3/9/2015 ped.emergency.Dr.Alsaif

Bronchial Asthma What is the asthma? Asthma is a chronic, inflammatory lung disease characterized by: Symptoms of cough, wheezing, dyspnea, and are usually related to specific triggering factors. Reversible Airway narrowing. Increased airways responsiveness to a variety of stimuli. The prevalence in different countries …… 1 to 18 % 3/9/2015 ped.emergency.Dr.Alsaif

Pathophysiology Pathology The symptoms of asthma are due to airflow obstruction resulting from: Constriction of smooth muscle around airways Edema of airway wall Accumulation of intraluminal mucus Inflammatory cell infiltration of the submucosa Thickening of basement membrane Physiology The physiologic changes of asthma (reduction in airway luminal diameter) Airway inflammation Reversible bronchoconstriction Increased airways hyperresponsiveness to a variety of stimuli. 3/9/2015 ped.emergency.Dr.Alsaif

3/9/2015 ped.emergency.Dr.Alsaif

Bronchial Asthma Etiology and risk factors
Why the frequency of asthma in all age groups is increased? Hypotheses?? Improved hygiene resulting in less exposure to infectious pathogens. Increased indoor air pollution, irritant gases, cigarette smoke and other allergens Increased incidence of early-onset respiratory viral infections. More premature infants surviving with chronic lung disease. Increased awareness and recognition of asthma by patients and clinicians. Psychosocial factors, including stress 3/9/2015 ped.emergency.Dr.Alsaif

Bronchial Asthma Etiology and risk factors
The etiology Complex interactions between multiple environmental and genetic influences: Asthma in children: boys > girls. Family history of asthma: genetic influences More with other atopic diseases, such as atopic dermatitis and allergic rhinitis, and with Increased total serum levels of IgE. Early Exposure to bacteria and bacterial products may influence the development of allergen sensitization and asthma. Active smoking and exposure to environmental tobacco smoke (particularly maternal) Patients with an increased body mass index (BMI) Prenatal and perinatal factors (eg, maternal age, smoking, diet, and medication use) 3/9/2015 ped.emergency.Dr.Alsaif

Clinical presentation History
The history in a child with suspected asthma centers on: Presence of symptoms Typical symptom patterns Risk factors Precipitating factors or conditions (ie, atopy) Symptoms 80 % of children with asthma < 5 year of age. Most common symptoms: Coughing and wheezing Asthmatic Cough: characteristics? Nocturnal cough Seasonal cough After specific exposures (eg, cold air, exercise, laughing, or crying) Lasts more than three weeks Typically dry 3/9/2015 ped.emergency.Dr.Alsaif

History symptoms Wheeze? A high-pitched sound produced when air is forced through narrow airways. The characteristics of wheezes in asthma: Polyphonic (varied in pitch), reflecting the heterogeneous distribution of affected airways. Expiratory When airflow obstruction becomes severe, wheezing can be heard on both inspiration and expiration. If harsh expiratory monophonic wheeze, consider central airway obstruction eg, tracheomalacia. If inspiratory monophonic wheeze, consider Upper airway obstruction (eg, vocal cord dysfunction) Seasonal symptoms Symptoms that are worse in certain pollen seasons are characteristic of atopic asthma 3/9/2015 ped.emergency.Dr.Alsaif

Precipitating factors
Respiratory tract infections Viral upper respiratory infections (URIs) are the most important triggering factor for patients with asthma of all ages Chronic sinusitis Respiratory infections due to Mycoplasma or Chlamydia. Exercise (Exercise-induced bronchospasm) May be the only manifestation of asthma in children . 90 % of children with asthma Symptoms usually resolve with rest over 30 to 60 minutes. Stress : Various types of stress can trigger or exacerbate asthma 3/9/2015 ped.emergency.Dr.Alsaif

Weather Cold air, hot, humid air, rain or wind Tobacco smoke Passive cigarette smoke is the single most common external risk factor. Allergens Indoor and outdoor allergens: House dust mites, and rodents Pet exposures (cats and dogs) Pollens Molds 3/9/2015 ped.emergency.Dr.Alsaif

Inhaled Irritant exposures Nitrogen dioxide (from gas stoves) Particulates and smoke from wood fires, pellet stoves, or kerosene space heaters. Cleaning sprays Perfumes, hair sprays Paint Room deodorizers Cleaning products with strong odors. 3/9/2015 ped.emergency.Dr.Alsaif

History Additional history Personal history of other atopic diseases Family history of asthma or other atopic diseases (eg, allergic rhinitis, atopic dermatitis, and food allergy) Environmental history Past medical history Medication use, medical utilization. School attendance, and psychosocial factors. 3/9/2015 ped.emergency.Dr.Alsaif

PHYSICAL EXAMINATION Generally normal if performed when the patient does not have an acute exacerbation. Abnormal findings in the absence of an acute exacerbation may suggest: Severe disease Suboptimal control Associated atopic conditions. 3/9/2015 ped.emergency.Dr.Alsaif

PHYSICAL EXAMINATION Signs Dry cough Signs of respiratory distress An increased anterior-posterior diameter of the chest due to air trapping Decreased air entry or wheezing A prolonged expiratory phase Signs of rhinitis, conjunctivitis, and sinusitis (nasal discharge, inflamed nasal mucosa, sinus tenderness, dark circles under the eyes) 3/9/2015 ped.emergency.Dr.Alsaif

PHYSICAL EXAMINATION 3/9/2015 ped.emergency.Dr.Alsaif

PHYSICAL EXAMINATION Allergic salute : a transverse nasal crease due to frequent itching. Halitosis due to chronic rhinitis, sinusitis, and mouth breathing. Eczema/atopic dermatitis Nasal polyps. WT (Obesity) 3/9/2015 ped.emergency.Dr.Alsaif

DIAGNOSIS Diagnosis depends on: A history of intermittent or chronic symptoms typical of asthma + the finding on physical examination of characteristic musical wheezing Confirmation Spirometry Exclusion of alternative diagnoses Spirometry Demonstration of reversible airflow obstruction establishes the diagnosis of asthma and facilitates the assessment of severity. For patients five years of age and older. 3/9/2015 ped.emergency.Dr.Alsaif

DIAGNOSIS Other studies: Chest x-ray Only if no respond to initial therapy. 3/9/2015 ped.emergency.Dr.Alsaif

DIAGNOSIS Other studies: Allergy testing Bronchoprovocation testing Methacholine, cold air, or exercise Used when the clinical features are suggestive of asthma but spirometry is normal and there is no response to asthma medications. Sweat chloride test If the cystic fibrosis is suspected Barium swallow If swallowing dysfunction with aspiration is a consideration. 3/9/2015 ped.emergency.Dr.Alsaif

DIFFERENTIAL DIAGNOSIS

Assessment of severity
Initial assessment of severity 3/9/2015 ped.emergency.Dr.Alsaif

Treatment of Acute exacerbation of Asthma
Prehospital care Use Inhaled Beta2 agonist (MDI) via Spacer/ AeroChamber Metered dose inhaler 3/9/2015 ped.emergency.Dr.Alsaif

After assessment of severity: Mild to Moderate exacerbation use albuterol as MDI (Dose is 2-4 puffs) or Nebulizer every 20 min up to 4 hr. then every 1-4 hrs as needed Moderate to Sever exacerbation use albuterol + (Ipratropium ) as Nebulizer: Dose of albuterol is mg every 20 min for 3 doses with Ipratropium (250 mic for wt<20kg, 500mic for wt>20kg) If poor response in first hour…..next 3/9/2015 ped.emergency.Dr.Alsaif

If poor response in first hour start: Continuous nebulization of albuterol at 0.5 mg/kg/h IV magnisium sulfate (25-75 mg/kg, maximum 2 g over 20 minutes). Still no response start: IV terbutaline after completion of the magnisium sulfate infusion. Bolus with 10mic/kg over 10 minutes. Then 0.3 to 0.5 mic/kg/min; infusion may be increased by 0.5 mic/kg /min every 30 minutes to a maximum of 5mic/kg /min. Or aminophylline (6 mg/kg intravenous loading dose, followed by infusion of 0.5 to 1 mg/kg per hour that is titrated based upon levels). 3/9/2015 ped.emergency.Dr.Alsaif

Systemic steroids: Recommended early in the course of acute exacerbation Oral vs IV equal in efficacy Prednisone 2mg/kg orally Dexamethasone 0.6mg/kg oral, IV, IM. Methyleprednisolone IV 1-2 mg/kg Epinephrine or terbutaline as IM or SC for Children with: Poor inspiratory flow. Children who cannot cooperate with nebulized therapy (0.01 mL/kg of a 1 mg/mL solution) 3/9/2015 ped.emergency.Dr.Alsaif

Other treatment: Noninvasive positive pressure ventilation (NPPV): Delivery of positive airway pressure without placement of an artificial airway. Continuous positive airway pressure (CPAP) Or bilevel positive airway pressure (BiPAP). Mechanical ventilation 3/9/2015 ped.emergency.Dr.Alsaif

INDICATIONS FOR REFERRAL
When the diagnosis of asthma is uncertain. The asthma is difficult to control. Medication side effects are intolerable. Patient has frequent exacerbations. 3/9/2015 ped.emergency.Dr.Alsaif

Status Asthmaticus Acute, severe exacerbation of asthma that remains unresponsive to initial treatment with bronchodilators and steroids. Associated with symptoms of potential respiratory failure. 3/9/2015 ped.emergency.Dr.Alsaif

Status Asthmaticus Clinical presentation
Risk factors History of increased use of home bronchodilator treatment without improvement. History of previous intensive care unit (ICU) admissions, with or without intubation and mechanical ventilatory support Asthma exacerbation despite recent or current use of corticosteroids Frequent emergency department visits and/or hospitalization (poor control) Less than 10% improvement in peak expiratory flow rate (PEFR) from baseline despite treatment History of syncope or seizures during acute exacerbation Oxygen saturation below 92% despite supplemental oxygen 3/9/2015 ped.emergency.Dr.Alsaif

Clinical presentation
Physical Examination Tachypneic Significant wheezing. Initially, wheezing is heard only during expiration, but wheezing later occurs during expiration and inspiration. The chest is hyperexpanded, and use of accessory muscles Silent chest Pulsus paradoxious (The difference in systolic blood pressure between inspiration and expiration >15mm Hg ). An inability to speak Ventilation/perfusion mismatch results in decreased O2 sat and hypoxia. Vital signs may show tachycardia and hypertension. Change in the level of consciousness Syncope and seizures. If untreated, pending respiratory failure lead to bradycardia, hypoventilation, and cardiorespiratory arrest. 3/9/2015 ped.emergency.Dr.Alsaif

Management laboratory studies Depends on historical data and patient condition: CBC ABG Serum electrolyte levels Serum glucose levels Peak expiratory flow measurement Chest x-ray ECG Blood theophylline levels 3/9/2015 ped.emergency.Dr.Alsaif

Management stages of status asthmaticus
Blood gas progression in status asthmaticus: Stage 1 - hyperventilation (low PCO2 ) with a normal (PO2) Stage 2 - hyperventilation with hypoxemia. Stage 3 - a false-normal PCO2 which is an extremely serious sign of respiratory muscle fatigue. Stage 4 - hypoxemia and a high PCO2, which occurs with respiratory failure and needs ventilatory support. 3/9/2015 ped.emergency.Dr.Alsaif

Management PEF, FEV1, and spirometry Use peak expiratory flow (PEF) to evaluate the severity of an asthma attack. ICU admission criteria: Change in level of consciousness Use of continuous inhaled beta-agonist therapy Exhaustion Markedly decreased air entry Rising PCO2 despite treatment The PEF value or FEV1 is less than 50% of the predicted value after treatment. Presence of high-risk factors for a severe attack Failure to improve despite adequate therapy 3/9/2015 ped.emergency.Dr.Alsaif

Management Indications for intubation and mechanical ventilation: Apnea or respiratory arrest Diminishing level of consciousness Impending respiratory failure marked by significantly rising PCO2 with fatigue, decreased air movement, and altered level of consciousness Significant hypoxemia that is poorly responsive or unresponsive to supplemental oxygen therapy alone. 3/9/2015 ped.emergency.Dr.Alsaif

Thank you 3/9/2015 ped.emergency.Dr.Alsaif

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