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Asthma in Children: April 2014

The document discusses asthma in children, including epidemiology showing prevalence increasing worldwide, pathophysiology involving allergens and neuronal stimulation causing inflammation and remodeling of the airways, and signs and symptoms of mild, moderate and severe exacerbations. It also covers diagnosis, goals of treatment including achieving good control and preventing exacerbations, and pharmacologic treatment options including inhaled corticosteroids, long-acting beta-agonists, and leukotriene modifiers.
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0% found this document useful (0 votes)
38 views35 pages

Asthma in Children: April 2014

The document discusses asthma in children, including epidemiology showing prevalence increasing worldwide, pathophysiology involving allergens and neuronal stimulation causing inflammation and remodeling of the airways, and signs and symptoms of mild, moderate and severe exacerbations. It also covers diagnosis, goals of treatment including achieving good control and preventing exacerbations, and pharmacologic treatment options including inhaled corticosteroids, long-acting beta-agonists, and leukotriene modifiers.
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPTX, PDF, TXT or read online on Scribd
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Asthma in Children

April 2014
Dr Hodan Ahmed,
Dept of Paediatrics, AU
Epidemiology
• Worldwide: Overall 1 – 18%
– Among pre-schools 4-32%%
– The estimated current asthma prevalence in
general increased between 2001 and 2009
• (9.6 % among children ≤18 years in 2009)
• Africa: ranges 5 - <20%
Prevalence increasing 2-3 fold over past decade
Pathophysiology
• Allergen
– Sensitized mast cell degranulation 
• Histamine, leukotriene release - bronchospasm & inflammation
– TH2 stimulation – B cell - IgE release –
• Eosinophil, release of inflammatory mediators – inflammation ;
mucosal oedema + mucous secretion
• Neuronal stimulation (exercise, cold, irritants)
– bronchospasm, mucosal secretions
• Underlying hyper-reactive airway
PATHOGENESIS

Acute Chronic Airway


Inflammation Inflammation Remodelling

Symptoms Exacerbations Bronchial hyperreactivity


Broncho-constriction Cell recruitment Cellular proliferation
Oedema Epithelial damage Extra-cellular matrix
Secretions Structural changes increase
Inducers and triggers of asthma
Allergens Triggers / Irritants
-Dust -Respiratory -Emotions
-Cockroach saliva viruses -Cold air
-Cat/dog dander -Smoke (tobacco, -Weather
-Mouse urine cooking fuel) changes
-Grass pollen -Aerosolized -Exercise
chemicals -Drugs (NSAID)
-Mould
Signs of mild asthma exacerbation

• Respiratory rate may be increased


• Accessory muscles not used
• Moderate Exp wheeze
• Pulse normal for age
• Pulsus Paradoxus absent or less than 10 mm Hg
• PEF over 80 % after initial bronchodilator
• Oxygen Sats > 95 % in air
Signs of moderate asthma exacerbation

• Respiratory rate increased, agitated.


• Use of accessory muscles
• Loud Wheeze
• Pulse increased
• Pulsus Paradoxus may be present 10-25mm Hg
• PEF 60 % after Initial bronchodilator
• Oxygen Sats 91 – 95 % in air
Signs of severe asthma exacerbation

• Agitated, Respiratory rate increased


• Use of accessory muscles
• Loud wheeze
• Pulse increased
• Pulsus Paradoxus 20 – 40 mm Hg
• PEF < 60% after initial bronchodilator (of
predicted or personal best)
• Oxygen saturation <90 % in air
Diagnosing Asthma in a Child
HISTORY-HISTORY-HISTORY
Suspect asthma if a child has recurrent and/or persistent:
• Wheeze, cough, breathlessness,
• Children / parent may report…
AND are responsive to bronchodilators

Other relevant history supporting asthma


• Personal history of atopy
• Family history of atopy
Diagnostic Tests in Children
Therapeutic trial
 Response to bronchodilators (reduction of cough, wheeze)
 + response to corticosteroids

Pulmonary function testing (PFT) – only above 6 years


• Peak expiratory flow rate
• Spirometry

Other tests
 Exercise tolerance test (in exercise-induced asthma)
 Allergen skin prick test
Four Components of Asthma Care

1. Develop patient/family/doctor partnership


(work together!)
2. Identify and reduce exposure to risk factors
3. Assess current level of control, treat, and
monitor asthma
4. Manage asthma exacerbations
1. Patient/family/doctor work together..
Teach child/family to:

• Minimize trigger exposure

• Take medication correctly

• Recognise signs of worsening asthma and take action


Four Components of Asthma Care

1. Develop patient/family/doctor partnership


(work together!)
2. Identify and reduce exposure to risk factors
3. Assess current level of control, treat, and
monitor asthma
4. Manage asthma exacerbations
Classify: Levels of Asthma Control
Characteristic Controlled (all Partly controlled (Any Uncontrolled
of the following) measure present in
any week)
Daytime symptoms None (twice or More than twice/week Three or more
less/week) features of
Limitations of activities None Any partly
controlled
Nocturnal None Any asthma
symptoms/awakening present in any
Need for None (twice or More than twice/week week
reliever/rescue less/week)
treatment
Lung function Normal <80% predicted or
PEF personal best (if
known)
Assessment of future risk: High risk – Poor control despite medication, frequent
exacerbations in past 6 – 12 months; ever admission to ICU, cigarette smoke
exposure, high dose medications, rapid decline lung function
Treatment: Goals
 Achieve GOOD CONTROL of symptoms
 Maintain normal activity levels including
exercise
 Maintain pulmonary function as close to
normal as possible
 Prevent asthma exacerbations & mortality
 Avoid adverse effects from asthma
medications

Asthma in Children. Hodan 2014 15


Pharmacotherapy
Medications to Treat Asthma
Relievers: Quick Relief

• Taken to relieve symptoms

• For rapid relaxation of airway muscles


– Inhaled beta2-agonists
– Inhaled anti-cholinergics
Medications to Treat Asthma:
Long-Term Control

• Taken daily over a long period of time


• Used to reduce inflammation, relax airway muscles, and
improve symptoms and lung function
– Inhaled corticosteroids
– Long-acting beta2-agonists
– Leukotriene receptor antagonists
Inhaled Corticosteroids (ICS); Considerations
in Children
• Growth – at low-medium doses ICS
– Small reduction in growth (1 cm) only during first year, non-
progressive thereafter
– Poorly controlled asthma has a greater potential of reducing
growth than ICS use
• Bone density – no effect (low-medium dose)

Asthma in Children. Hodan 2014 19


Pharmacologic Therapy - ICS
Paediatric dosing considerations
Inhaled Low daily Medium High daily
glucocorticosteroid dose daily dose dose
Budesonide 200mcg 400mcg ≥800mcg
(MDI 100 or 200mcg/puff
DPI 80 or 160mcg)
Beclomethasone dp. 100mcg 200mcg ≥400mcg
(50 or 100mcg/puff)
Fluticasone pr. 100mcg 250mcg ≥500mcg
(MDI: 50 or 125 mcg/puff
DPI: 50,100 or 250mcg)
Ciclesonide (80 or 160 80mcg 160mcg ≥320mcg
mcg/puff)* above 6 yr

20
Long-acting beta-agonist (LABA)
• LABAs relax airway smooth muscle but NO anti-
inflammatory activity
• Add LABA to low or medium-dose ICS as step-up in
poorly controlled child
• Potential adverse effects:
– Tachycardia, tremor, insomnia
– Bottom line: Always combine ICS/LABA
Leukotriene antagonists
• Used as step-up in additional to ICS

• May have an additive benefit when used with an ICS, but benefit
less favorable compared to adding a LABA
• …but in the “real-world”, LTRA may be equally effective since
generally many like oral meds better than inhaled meds (
adherence)
• Paediatric formulations LTRA monteleukast
– 4mg sachets (sweet granules)
– 5mg chewable tab (“sweet”)
Pharmacologic Therapy – Other Controller
Medications
Controller Medication Formulation Child dose
Leucotriene receptor 4mg sachets Child – 4-5mg od
antagonists 5, 10mg tablets Adolescent 10mg od
Monteleukast

Long acting beta2 agonist


Salmeterol DPI 50µg/blister 1 inhalation bid
Formoterol DPI 12µg/blister
Combined medication
Fluticasone/ salmeterol 50,100,250/ 50µg 1 inhalation bid
50,125/ 25µg 1 puffs bid
Budesonide/formoterol 80,160/ 4.5µg 1 inhalation bid
Both have MDI, DPI

23
Administering Asthma
Medication In Children
Initiate and Monitor
• Decide if child has
– Intermittent / seasonal  β2 agonist
– Persistent or symptoms ICS daily+ β2
• Initiate treatment
• See patient 2 weeks after initial visit
– Assess adherence, inhaler/spacer technique
– Assess adverse effects
– Assess level of control
• Poor control – see more frequently (2-4wks)
• Good control – see less frequently (3mths)
Treatment Steps 1 to 5
Step 1 Step 2 Step 3 Step 4 Step 5
Asthma education Environmental control
Rapid acting ß2 As needed rapid-acting- ß2-agonist
agonist PRN
Select one Select one Add one or Add both
more
Low-dose Medium dose Medium-or- Oral
inhaled ICS high-dose ICS corticosteroid
Controlled ICS* plus LABA (lowest dose)
options Leukotriene Low-dose ICS Leukotriene Anti-IgE
modifier ** + LABA modifier treatment
Low-dose ICS Sustained
+ leukotriene release
modifier theophyline

Asthma in Children. Hodan 2014 26


Treatment Step 2
Add Low-dose ICS
Step 1 Step 2 Step 3 Step 4 Step 5
Asthma education Environmental control
Rapid acting ß2 As needed rapid-acting- ß2-agonist
agonist PRN
Select one Select one Add one or Add both
more
Low-dose Medium dose Medium-or- Oral
inhaled ICS high-dose ICS corticosteroid
Controlled ICS* plus LABA (lowest dose)
options Leukotriene Low-dose ICS Leukotriene Anti-IgE
modifier ** + LABA modifier treatment
Low-dose ICS Sustained
+ leukotriene release
modifier theophyline

Asthma in Children. Hodan 2014 27


Treatment Step 3
Increase ICS and/or add LTRA/LABA
Step 1 Step 2 Step 3 Step 4 Step 5
Asthma education Environmental control
Rapid acting ß2 As needed rapid-acting- ß2-agonist
agonist PRN
Select one Select one Add one or Add both
more
Low-dose Medium dose Medium-or- Oral
inhaled ICS high-dose ICS corticosteroid
Controlled ICS* plus LABA (lowest dose)
options Leukotriene Low-dose ICS Leukotriene Anti-IgE
modifier ** + LABA modifier treatment
Low-dose ICS Sustained
+ leukotriene release
modifier theophyline

Asthma in Children. Hodan 2014 28


Treatment Steps 4 to 5
Increase ICS and/or add LTRA/LABA: REFER
Step 1 Step 2 Step 3 Step 4 Step 5
Asthma education Environmental control
Rapid acting ß2 As needed rapid-acting- ß2-agonist
agonist PRN
Select one Select one Add one or Add both
more
Low-dose Medium dose Medium-or- Oral
inhaled ICS high-dose ICS corticosteroid
Controlled ICS* plus LABA (lowest dose)
options Leukotriene Low-dose ICS Leukotriene Anti-IgE
modifier ** + LABA modifier treatment
Low-dose ICS Sustained
+ leukotriene release
modifier theophyline

Asthma in Children. Hodan 2014 29


Guidelines on Stepping Up and Stepping Down Asthma
Therapy

CONTROL MAINTAINED

3 months
• Step up to gain control; CHECK
ADHERENCE, MDI technique! GRADUAL
STEP-UP • Consider step down if well controlled STEP-
for at least 3 mo DOWN
• Gradually step down and closely
monitor to determine the minimal
amount of medication required to
maintain control

National Heart, Lung, and Blood Institute. National Asthma Education and Prevention Program.
www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm.
Assessing and Managing an
Asthma Exacerbation
Simplified Classification of Severity of Acute
Asthma in Children 5 yr or below
Symptoms Mild exacerbation Severe Exacerbationa
Altered consciousness No Agitated, confused or drowsy

Oximetry on ≥94% <90%


presentation (Sa O2) b
Talks in c Sentences Words
Pulse rate <100bpm d >200bpm (0-3yr)
>180 bpm (4-5yr)
Central cyanosis Absent Likely to be present
Wheeze intensity Variable May be quiet

a any of these indicates a severe asthma exacerbation


b oximetry performed before treatment with oxygen or bronchodilator
c the normal developmental ability of the child taken into account
d bpm = beats per minute 32
Asthma in Children. Hodan 2014
Other Considerations: Hydration

Oral fluids preferred for most cases, during early phase


management, and for older children – adolescents.

IV fluids may be beneficial in:


• Severe illness and unable to take adequate fluid orally
• Assess hydration status and administer judiciously (80-100%
of normal requirement)

Asthma in Children. Hodan 2014 33


Other Considerations:
Not Recommended.

• Chest physiotherapy / incentive spirometry


– Can trigger/worsen broncho-constriction.
• Mucolytics and Cough syrups
– Can worsen the bronchial obstruction
• Sedatives (strictly avoid)
• Hydration with large volumes of fluids for older children (may
be necessary for young children)
• Antibiotics (unless signs of infection)
• Epinephrine/adrenaline (except for anaphylaxis and
angioedema)
Thanks!!

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