childhood asthma

Prof.Dr. Muhi K. Aljanabi MRCPCH; DCH; FICMS Consultant Pediatric Pulmonologist

ASTHMA---OBJECTIVES

ASTHMA---OBJECTIVES

Childhood Asthma..Definition
Asthma is a chronic inflammatory condition of the lung airways resulting in episodic airflow obstruction. This chronic inflammation heightens the “twitchiness” of the airways—airways hyperresponsiveness (AHR)—to provocative exposures.

ETIOLOGY

Genetics: More than 22 loci on 15 autosomal chromosomes have been linked to asthma.

ETIOLOGY

Environment : common respiratory viruses . Indoor and home allergen exposures in sensitized individuals Environmental tobacco smoke and air pollutants (ozone, sulfur dioxide) Cold dry air and strong odors

EPIDEMIOLOGY

CLINICAL MANIFESTATIONS
Intermittent dry coughing and/or expiratory wheezing are the most common chronic symptoms of asthma. shortness of breath worse at night Daytime symptoms, often linked with physical activities

Risk factor

history of other allergic conditions (allergic rhinitis, allergic conjunctivitis, atopic dermatitis, food allergies) parental asthma, and/or symptoms apart from colds, supports the diagnosis of asthma.

LABORATORY FINDINGS 

Lung function tests can help to confirm the diagnosis of asthma and determine disease severity. Chest radiographs in children with asthma often appear to be normal, hyperinflation (flattening of the diaphragms) and peribronchial thickening.

LABORATORY FINDINGS

asthma masqueraders (aspiration pneumonitis, bronchiolitis obliterans) asthma exacerbations (atelectasis, pneumomediastinum, pneumothorax). CT scans may be needed .

LABORATORY FINDINGS

Other tests, such as allergy testing to assess sensitization to inhalant allergens, help with the management and prognosis of asthma. 88% of asthmatic children had inhalant allergen sensitization by allergy prick skin testing.


Principles of Asthma Pharmacotherapy:treat all “persistent” asthma with anti-inflammatory controller medicationDaily controller therapy is not recommended for mild intermittent asthma.

The “three strikes” rule Day time asthma symptoms at least 3 times per wk, awakens at night at least 3 times per mo, experiences asthma exacerbations that requires short courses of systemic corticosteroids at least 3 times a yr. then that patient should receive daily controller therapy

TREATMENT

(ICS) therapy is recommended as preferred therapy for all levels of asthma severity except for the mild intermittent category. Leukotriene pathway modifiers or sustained-release theophylline (only for patients >5 yr of age) are alternatives for mild persistent asthmatics.

TREATMENT

Combination of a low-to-medium dose ICS with a long-acting β-agonist or a leukotriene modifier or theophylline is a mainstay therapy for moderate persistent asthma in older children. For infants and young children, medium-dose ICS alone it is considered a preferred treatment for moderate persistent asthma.

TREATMENT

Severe persistent asthmatics should receive high-dose ICS, a long-acting bronchodilator, and routine oral corticosteroids if needed. SABAs are the recommended quick-reliever medications for symptoms and exercise pretreatment for all asthma severity levels

INHALED CORTICOSTEROIDS

Daily ICS therapy as the treatment of choice for all patients with persistent asthma. ICS reduce asthma symptoms, improve lung function, reduce “rescue” medication use and, most important, reduce urgent care visits, hospitalizations, and prednisone use for asthma exacerbations by about 50%

LONG-ACTING INHALED β-AGONIST Although LABAs (salmeterol, formoterol) are considered to be daily controller medications, not intended for use as “rescue” medication for acute asthma symptoms or exacerbations, nor as monotherapy for persistent asthma.

LEUKOTRIENE-MODIFYING AGENTS

leukotriene receptor antagonists (LTRA)Montelukast > 1 yr.Zafirlukast > 5 yr Decrease need for rescue β-agonist use

NONSTEROIDAL ANTI-INFLAMMATORY AGENTS

Cromolyn and nedocromil are non-corticosteroid anti-inflammatory agents that can inhibit allergen-induced asthmatic responses and reduce exercise-induced bronchospasm.

THEOPHYLLINE

Although it is considered an alternative monotherapy controller agent for older children and adults with mild persistent asthma, it is no longer considered a first-line agent for small children in whom there is significant variability in the absorption and metabolism of different theophylline preparations, necessitating frequent dose monitoring (blood levels) and adjustments.



SHORT-ACTING INHALED β-AGONISTS SABAs (albuterol, levalbuterol, terbutaline, pirbuterol) are the first drugs of choice for acute asthma symptoms (“rescue” medication) and for preventing exercise-induced bronchospasm.

ANTICHOLINERGIC AGENTS

ipratropium bromide are much less potent than the β-agonists. Inhaled ipratropium is primarily used in the treatment of acute severe asthma. When used in combination with albuterol, ipratropium can improve lung function and reduce the rate of hospitalization in children who present to the emergency department with acute asthma.

Home Management of Asthma Exacerbations

Immediate treatment with “rescue” SABAShort course of oral corticosteroid therapyInjectable forms of epinephrine Portable oxygen at home.Call for emergency support services.

ED Management of Asthma

Oxygen Inhaled β-agonist Systemic corticosteroids Inhaled ipratropium Intramuscular injection of epinephrine or other β-agonist Close monitoring of clinical status, hydration, and oxygenation Intubation and mechanical ventilation

PROGNOSIS

Recurrent coughing and wheezing occurs in 35% of pre–school-age children.⅓ continue to have persistent asthma into later childhood.⅔ improve on their own through the preteen years.

That entire wheeze is not asthma & asthma does not always wheeze

Mark yes or no
Wheeze after 3 year
Wheeze before 3 years
Atopy
Mostly persist
Smoking mother during pregnancy

Mark yes or no

controller
preventer
drug
Salbutamol
Montelukast
epinephrine