BRONCHIAL ASTHMA IN CHILDREN lecture for the 6-th year students

CONTENT DEFINTIONS EPIDIEMOLOGY ETIOLOGY CLINCAL PRESENTATION: HISTORY AND OBJECTIVE EXAMS DIAGNOSIS CLASSIFICATIONS DIFFERNTIAL DIAGNOSIS TREATMENT AND MANANGEMENT

DEFINITION A chronic inflammatory disease of the airways with the following clinical features: Episodic and/or chronic symptoms of airway obstruction Bronchial hyperresponsiveness to triggers Evidence of at least partial reversibility of the airway obstruction Alternative diagnoses are excluded

Definitions Asthma exacerbation: symptoms that require a change in medication from baseline Status asthmaticus: increasingly severe asthma that is not responsive to drugs that are usually effective Review Article in Chest 2001. Status Asthmaticus in Children. A Review. Heinrich A Werner, MD

Epidemiology 10% of children in the US: 5 million children under the age of 18 Prevalence is increasing Asthma morbidity and mortality is increasing 50% have family history of asthma, rhinitis, eczematous dermatitis, or urticaria 10 % of children in the US: the most common chronic illness of childhood in the US Reference: Pediatric Asthma:Promoting Best Practices. Guide for managing asthma in child, 1999 Prevalence is increasing—especially among children less than 12: Source: NCHS, national health interview survey, 1884-1996. Diagnostic shift (use of “asthma” for conditions classified differently) cannot fully account for this development—asthma prevalence is increasing world-wide Asthma morbidity is also on increase—rates have doubled for kids aged 1-4 About 50% of children with asthma improve or become symptom free on reaching early adulthood but a very early onset of disease is associated with a less favorable prognosis

Etiology Although the cause of childhood asthma has not been determined, contemporary research implicates a combination of environmental exposures and inherent biological and genetic vulnerabilities Respiratory exposures in this causal environment include inhaled allergens, respiratory viral infections, and chemical and biological air pollutants such as environmental tobacco smoke In the predisposed host, immune responses to these common exposures can be a stimulus for prolonged, pathogenic inflammation and aberrant repair of injured airways tissues. Lung dysfunction (i.e., AHR and reduced airflow) develops.

Stepwise Approach for Managing Asthma in Children 12 Years of Age and Adults

CLINICAL PRESENTATION WHEEZING COUGH NIGHTLY COUGHS AND EXERCISE INDUCED DYSPNOEA CHEST TIGHTNESS REFUSAL OF FEEDING SITTING UPRIGHT WORD TALKING NOT IN SENTENCES AGITATION

WHEEZING Wheezing is a high pitched musical sound produced by airflow turbulence and is also seen in upper respiratory infections is very common in small children, but: Wheezing in asthma is exhalational except in sever cases. Many of these children will not develop asthma Asthma medications may benefit patients who wheeze whether or not they have asthma

COUGH Usually nonproductive and non paroxysmal Consider asthma in children with: Recurrent episodes of cough with or without wheezing Nocturnal awakening because of cough Cough that is associated with exercise/play Cough without wheeze is often not asthma

OBJECTIVE/ PHYSICAL Respiratory rate; > 30 bpm Accessory Muscles of respiration involved Suprasternal retractions Heart rate >120bpm Loud biphasic wheezing can be Pulsus Pardoxicus Oxyhemoglobin saturation in room air<91%

In Status Asthmaticus Paradoxical abdominal movements Absent wheezing Severe hypoxemia Pulsus paradoxicus

Diagnosis Pulmonary Function test: Spirometry and Plethysmography Exercise challenge target >60% of predicted maximum Fraction of exhaled nitric oxide Radiography Allergy testing Histology

Differential diagnosis Air way foreign body Allergic Rhinitis Aspiration Syndromes Bronciolitis Cystic Fibrosis Aspergilloisis Primary Ciliary Dyskinesia

Defining Asthma Severity and Control 0–4 years 5–11 years 12 years and older

Managmement summary Assement and monitoring Education of care givers and children Environmental control Pharmacologic treatment

Pharmacologic treatment Short acting broncodilators; Albuterol Long Acting Bronchodilators; Levalbuterol Theophyliine Leukotriene Modifiers;Montelukast Inhaled coticosteroids; Beclomethazone, Budezonide Inhaled cromolyn Systemic coticosteriods Monoclonal antibodies; Omalizumab Combination Inhaled Steroids/ Long Acting B2 agonists; Budesonide/ Formoterol

Test for Respiratory and Asthma Control in Kids (TRACK)

Classifying Asthma Severity and Initiating Treatment in Children 5 to 11 Years of Age

Assessing Asthma Control and Adjusting Therapy in Children 5 to 11 Years of Age

Childhood Asthma Control Test™

Classifying Asthma Severity and Initiating Treatment in Youth ≥12 Years of Age and Adults

Assessing Asthma Control in Children ≥12 Years of Age and Adults

Role of Viral Infections

Forced Expiratory Volume in 1 Second (FEV1) Percent Predicted