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!!