1. Dr. KANUPRIYA CHATURVEDI 14/29/2015

2.  Chronic disease of the airways that may cause  Wheezing  Breathlessness  Chest tightness  Nighttime or early morning coughing  Episodes are usually associated with widespread, but variable, airflow obstruction within the lung that is often reversible either spontaneously or with treatment. 24/29/2015

3.  Allergens  Infections  Exercise  Abrupt changes in the weather  Exposure to airway irritants, such as tobacco smoke 34/29/2015

4.  Recurrent asthma episodes, involving ◦ Shortness of breath ◦ Coughing ◦ Wheezing ◦ Chest pain or tightness  Range in severity from ◦ Mild intermittent ◦ Severe persistent 44/29/2015

5.  Increases risk for early death  Compromises child’s quality of life  Affects family’s quality of life  Increased costs associated with Increased utilization of health care 54/29/2015

6.  Most common cause of school absence ◦ An average of 9.7 days per year for asthma  Most prevalent cause of childhood disability (long-term reduction in ability to do normal activities)  In 1994-95, 1.4% of U.S. children experienced some disability due to asthma ◦ This is 21% of all children with asthma  SES disadvantage doubles rate of disability  Children with asthma have higher rates of social and emotional problems 64/29/2015

7.  Asthma is the most common chronic disease among children  It has increased at epidemic rates since the early 1980s  Most common cause of ED visits, hospitalization and missed school days  In past 2 decades, African American children had 2-4 times more ED visits than other races  Studies show a rise in worldwide prevalence  Seems to be more prevalent in affluent nations 74/29/2015

8.  Etiology of asthma is due to the interaction of environmental and genetic factors ◦ Atopy, the genetically inherited susceptibility to asthma, cannot account for epidemic.  Probably NOT due to outdoor air quality  Indoor air contaminants may be a factor ◦ Tighter construction trapping contaminants. ◦ Children spending more time indoors. 84/29/2015

9. 10.1% Overall 94/29/2015

10.  Low-income populations, minorities, and children living in inner cities experience more ED visits, hospitalizations, and deaths due to asthma than the general population.  The burden of asthma falls disproportionately on non-Hispanic black, American Indian/Alaskan Native and some Hispanic populations. 104/29/2015

11.  By gender ◦ Males 0 – 17 years are more likely than girls to have asthma or experience an asthma attack  By race/ethnicity ◦ Higher for Black non-Hispanic children ◦ Higher for Hispanic children 114/29/2015

12.  Current asthma prevalence is higher among ◦ children than adults ◦ boys than girls ◦ women than men  Asthma morbidity and mortality is higher among ◦ African Americans than Caucasians. 124/29/2015

13. ◦ Groups 6 - 7 Yrs 13-14 Yrs ◦ Wheeze 5.6 % 6.0% (0.8 - 14.6)(1.6 - 17.8) ◦ > 4 attacks 1.5%1.6% (0.1 - 4.7)(0.5 - 3.5) ◦ Night Cough 12.3%14.1% (3.3 - 27) (3.8 - 32.2) ◦ Ever had Asthma 3.7%4.5% (1.0 - 14.4)(1.12.4) Shah, Amdekar, Mathur, IJMS,6,2000,213-22 134/29/2015

14. 144/29/2015

15. 154/29/2015

16. 164/29/2015

17.  Parental Asthma  Allergy  Atopic dermatitis  Allergic rhinitis  Food allergy  Inhalant allergen sensitization  Food allergen sensitization 174/29/2015

18.  Severe lower respiratory tract infections  Wheezing apart from colds  Male gender  Low birth weight  Tobacco smoke exposure  Exposure to chlorinated swimming pools  Possible use of Acetaminophen 184/29/2015

19.  Common Viral infections  Aeroallergens  Animal dander  Dust mite  Cockroaches  Molds  Pollen 194/29/2015

20.  Air pollutants  Ozone Sulfur dioxide Particulate matter Dust Tobacco smoke  Strong/ noxious fumes  Cold, dry air  Exercise 204/29/2015

21.  Occupational exposures  Farm and barn exposure  Formaldehyde, paint fumes  Crying, laughter, hyperventilation  Co morbid conditions: Rhinitis, Sinusitis 214/29/2015

22. Symptoms:  Intermittent dry cough  Expiratory wheezing  Shortness of breath  Chest tightness  Chest pain  Fatigue  Difficulty keeping up with peers in physical activities 224/29/2015

23. Signs:  Expiratory wheezing  Prolonged expiratory phase  Decreased breath sounds  Crackles/ rales  Accessory muscle use  Nasal flaring  Absence of wheezing in severe cases  Pulses paradoxus 234/29/2015

24. Spirometry:  Feasible in children >6 years of age  Monitoring Asthma and efficacy of treatment  Measures FVC, FEV 1 and FEV1/FVC Ratio  Normal values for children available on the basis of height, gender and ethnicity. 244/29/2015

25. Airflow Limitation:  Low FEV1  FEV1/ FVC ratio < 0.80 Bronchodilator response to β-agonist:  Improvement in FEV1 ≥ 12% Exercise challenge:  Worsening of FEV1 ≥ 15% Daily peak flow or FEV1 AM-PM variation ≥ 20% 254/29/2015

26. 264/29/2015

27. 274/29/2015

28.  Often normal  Hyperinflation  Helpful in identifying masqueraders 284/29/2015

29. 294/29/2015

30.  Asthma severity: Directs initial level of therapy Determined at the time of diagnosis Categories: Intermittent, Persistent Determined by the most severe level of symptoms  Asthma control: Important for adjusting therapy  Regular Clinic visits every 2-6 weeks until good control established  Two or more Asthma check ups per year for maintaining Asthma control 304/29/2015

31. 314/29/2015

32. 324/29/2015

33. 334/29/2015

34. 344/29/2015

35. Managing Asthma: Asthma Management Goals  Achieve and maintain control of symptoms  Maintain normal activity levels, including exercise  Maintain pulmonary function as close to normal levels as possible  Prevent asthma exacerbations  Avoid adverse effects from asthma medications  Prevent asthma mortality 354/29/2015

36. Managing Asthma: Asthma Action Plan  Develop with a physician  Tailor to meet individual needs  Educate patients and families about all aspects of plan ◦ Recognizing symptoms ◦ Medication benefits and side effects ◦ Proper use of inhalers and Peak Expiratory Flow (PEF) meters 364/29/2015

37. Managing Asthma: Indications of a Severe Attack  Breathless at rest  Hunched forward  Speaks in words rather than complete sentences  Agitated  Peak flow rate less than 60% of normal 374/29/2015

38. Managing Asthma: Things People with Asthma Can Do  Have an individual management plan containing ◦ Your medications (controller and quick-relief) ◦ Your asthma triggers ◦ What to do when you are having an asthma attack  Educate yourself and others about ◦ Asthma Action Plans ◦ Environmental interventions  Seek help from asthma resources  Join an asthma support group 384/29/2015

39. Asthma action plan for management of exacerbation  Regular follow up visits  Monitor lung functions annually  Improve adherence to treatment 394/29/2015

40.  Eliminate/ reduce environmental exposures  Tobacco smoke elimination/ reduction  Allergen exposure elimination/ reduction  Treat co morbid conditions: Rhinitis, Sinusitis, GER 404/29/2015

41.  Initiate with higher level controller therapy  Step-down, once good control is achieved  If child has had well controlled asthma for at least 3 months, consider decreasing dose or number of controller medications.  Step up for poorly controlled asthma 414/29/2015

42.  All persistent Asthmatics require daily controller medications 424/29/2015

43.  Treatment of choice for persistent Asthma  Improve lung function  Reduce use of rescue medicines  Reduce ED visits, hospitalizations  May lower the risk of death due to Asthma 434/29/2015

44.  Used mainly in treatment of exacerbations  Rarely in patients with severe disease  Common: Prednisolone, Prednisone, Methyprednisolone  When used in long term, cause adverse effects 444/29/2015

45.  Salmeterol, Formoterol  Not used as monotherapy  Major role as ad-on agents with ICS  LABA use should be stopped once optimal Asthma control is achieved 454/29/2015

46.  Leukotriene synthesis inhibitor: Zileuton (Not approved for children < 12 years)  Leukotriene Receptor Antagonists: Montelukast, Zafirlukast 464/29/2015

47.  Cromolyn, Nedocromil  Inhibit exercise induced bronchospasm  Can be used in combination of SABA for exercise induced bronchospasm 474/29/2015

48.  Can reduce Asthma symptoms and need for SABA use  Narrow therapeutic window  Not used as first line anymore  May be used in corticostroid dependent children  Can cause cardiac arrhythmias, seizures and death 484/29/2015

49.  Anti IgE monoclonal antibody  Blocks IgE mediated allergic response  Approved for children > 12 years with moderate to severe Asthma  Given sub cutaneously every 2-4 weeks 494/29/2015

50.  Short Acting Beta Agonists: Albuterol, Levalbuterol, Terbutaline, Pirbuterol  Drugs of choice for acute Asthma symptoms  Overuse may be associated with increased risk of death  Use of at least 1 MDI/ month or at least 3 MDI/ year indicates inadequate Asthma control  Anticholinergic Agents: Ipratropium bromide Used in combination with Albuterol 504/29/2015

51.  Dyspnea at rest  Peak flows < 40% of personal best  Accessory muscle use  Failure to respond to initial treatment 514/29/2015

52.  Brief assessment  Administration of SABA: Repeated doses or continuously, every 20 mins. for 1 hour  Inhaled anticholinergic in addition of SABA  Oxygen: Hypoxemia/ moderate to severe exacerbation  Systemic Corticosteroids: Instituted early for moderate to severe exacerbation and failure to respond to early treatment  Intramuscular beta agonist in severe cases. 524/29/2015