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8/24/2016
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Bashar S. Shihabuddin, MD, FAAP, FACEPPediatric Emergency Medicine
I have no conflicts of interest to disclose
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Identify the clinical features of asthma Identify other causes of wheezing/cough Develop an asthma treatment plan Be familiar with medications commonly used
for asthma Identify barriers to asthma care and how to
deal with them
Affects 17.7 million people 6.3 million children under 18
In 2010, 1.8 million people visited an ED for asthma-related care and 439,000 people were hospitalized because of asthma
Average LOS = 3.6 days Economic cost in 2007 was $56 BILLION In 2014; 187 child deaths and 3464 adult deaths were
due to asthma
http://www.cdc.gov/asthma/asthmadata.htm accessed 08/03/2016http://www.aaaai.org/about-aaaai/newsroom/asthma-statistics accessed
08/03/2016
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1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010
Percent
Year
http://www.cdc.gov/asthma/asthmadata.htm accessed 08/03/2016
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2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Perce
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Total number of persons in m
illions
http://www.cdc.gov/asthma/asthmadata.htm accessed 08/03/2016
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In 2012:◦ 292,000 adults had asthma (F>>M)◦ 123,100 children had asthma (M>F)◦ $57.9 Million in hospitalization costs
https://www.ok.gov/health/Wellness/Chronic_Disease_Service/Asthma/index.html accessed 08/03/2016
InflammationSmooth muscle
constrictionMucus
production & edema
InflammationSmooth muscle
constrictionMucus
production & edema
ObstructionAir trappingObstructionAir trapping
CoughWheezing
Chest tightnessProlonged exhalation
Shortness of breath
CoughWheezing
Chest tightnessProlonged exhalation
Shortness of breath
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Chronic disease of the airway Strict definition requires pulmonary function
testing before and after challenge with irritant or allergen
Term is often used when wheezing, cough and shortness of breath develop in response to a trigger
Link HW. ‘Pediatric Asthma in a Nutshell’, Pediatr Rev. 2014 Jul;35(7):287-98. doi: 10.1542/pir.35-7-287.
Viral respiratory tract infections Exercise Weather changes Exposure to tobacco—or other—smoke Air pollution Cold or hot air Perfumes Drugs (salicylic acid, beta-blockers)
Link HW. ‘Pediatric Asthma in a Nutshell’, Pediatr Rev. 2014 Jul;35(7):287-98. doi: 10.1542/pir.35-7-287.
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Asthma Predictive Index Pulmonary Function Test Peak Flow Meters Allergy Testing
Link HW. ‘Pediatric Asthma in a Nutshell’, Pediatr Rev. 2014 Jul;35(7):287-98. doi: 10.1542/pir.35-7-287.
Major Criteria Minor CriteriaParental asthma Allergic RhinitisEczema Wheezing apart
from colds
Blood eosinophils>4%
Children younger than 3 years of age with 3 or more episodes of wheezing
One major or 2 minor criteria have higher risk of asthma
Castro-Rodriguez JA.,’ The Asthma Predictive Index: a very useful tool for predicting asthma in young children.’ J Allergy Clin Immunol. 2010
Aug;126(2):212-6. doi: 10.1016/j.jaci.2010.06.032.
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Establish a baseline to compare daily measurements
Helpful in patients with poor perception of their asthma
Can be used to adjust treatment Not for routine use
Link HW. ‘Pediatric Asthma in a Nutshell’, Pediatr Rev. 2014 Jul;35(7):287-98. doi: 10.1542/pir.35-7-287.
Most asthmatics will have a positive immediate type allergy skin test
Results have to be interpreted with clinical findings
Link HW. ‘Pediatric Asthma in a Nutshell’, Pediatr Rev. 2014 Jul;35(7):287-98. doi: 10.1542/pir.35-7-287.
8/24/2016
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Aspiration Bronchiolitis Vocal cord dysfunction Cystic fibrosis Bronchiectasis
Common in younger children (<5 years) More common in males Sudden onset of symptoms in previously
healthy child, especially with history of ingestion or choking
Radiographs of chest AP and lateral If the thoracic inlet is not visualized then
radiographs of the neck
Green SS., ‘Ingested and Aspirated Foreign Bodies’, Pediatr Rev. 2015 Oct;36(10):430-6; quiz 437. doi: 10.1542/pir.36-10-430
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Viral lower respiratory tract infection in children less than 2 years old
Clinical signs and symptoms:◦ Rhinorrhea◦ Cough◦ Tachypnea◦ Wheezing◦ Rales◦ Grunting/nasal flaring/retractions
Seasonal component
Ralston SL, Lieberthal AS, Meissner HC et al.,’ Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis.’, Pediatrics.
2014 Nov;134(5):e1474-502. doi: 10.1542/peds.2014-2742.
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Involuntary closure of the vocal cords Typically occurs during exercise in highly
competitive teens Symptoms rarely occur spontaneously No response to asthma therapies and self-
limited in most times Often with inspiratory stridor Spirometry can differentiate this from asthma
Link HW. ‘Pediatric Asthma in a Nutshell’, Pediatr Rev. 2014 Jul;35(7):287-98. doi: 10.1542/pir.35-7-287.
Volume (L) Volume (L)
Flow
(L/s
)Expiration
Inspiration
AsthmaNormal
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Findings Possible DiagnosisCoughing and choking with food or drink
Oropharyngeal dysphagia with aspiration
Poor growth Cystic fibrosis or immunodefiencyChronic runny nose and sinus infections
Cystic fibrosis or immotile cilia syndrome
Chronic wet productive cough Bronchiectasis
Link HW. ‘Pediatric Asthma in a Nutshell’, Pediatr Rev. 2014 Jul;35(7):287-98. doi: 10.1542/pir.35-7-287.
Symptoms only with exercise Typically self-limiting but frustrating Diagnosis is by history and if a formal
diagnosis is needed spirometry with exercise Treatment is with beta-agonist premedication
15 minutes before exercising
Link HW. ‘Pediatric Asthma in a Nutshell’, Pediatr Rev. 2014 Jul;35(7):287-98. doi: 10.1542/pir.35-7-287.