Childhood asthma

Childhood Asthma

Presented by -Dr Susheel kumar saini(MD Paediatrics)

Case scenario

A 3 year old boy Rohit brought by his mother for recurrent cough for last 1 year. His cough gets worse at night which is usually associated with musical respiratory sounds and he coughs a lot after running or laughing. She also reported that he frequently had colds for which he has been nebulized on several occasions in emergency dept.

Is it Asthma? Presence of more than one of the following symptoms :

wheeze, shortness of breathe, cough, chest tightness. Symptoms often worse in night or in early morning. Symptoms very over time and in intensity. Symptoms triggered by viral infections (colds), exercise,

allergen exposure, change in weather, laughter or irritants.

Definition of Asthma

A heterogeneous chronic inflammatory disease of the airways with the following clinical features:

Episodic and/or chronic symptoms of airway obstruction such as cough, wheeze, chest tightness, breathlessness.

Bronchial hyper responsiveness to triggers.

Evidence of at least partial reversibility of the airway obstruction.

Alternative diagnoses are excluded.

Wheezing—Asthma?Wheezing with upper respiratory infections is very common in small children, but: Many of these children will not develop asthma. Asthma medications may benefit patients who wheeze

whether or not they have asthma.

All that wheezes is not asthma.

Cough—Asthma?Consider asthma in children with:Recurrent episodes of cough with or without

wheezing.Nocturnal awakening because of cough.Cough that is associated with exercise/play.Cough without wheeze is often not asthma.

Cough may be the only symptompresent in patients with asthma.

Asthma Facts Asthma is one of the most common chronic diseases

worldwide with an estimated 300 million affected ̴individuals.

A major cause of school/work absence. 80% report disease onset prior to 6 years of age. Overall prevalence in India- 3% (30 million)

3000/1lakh population.

When does Asthma begin?• By 1 year – 26%• 1-5 years – 51.4%• > 5 years – 22.3%

77% Of Asthma Begins In Children Less Than 5 Years.

EARLY CHILDHOOD RISK FACTORS FOR ASTHMA1. Parental asthma (single-20%, both-60%)

2. Allergy Atopic dermatitis (eczema) Allergic rhinitis Food allergy Inhalant allergen sensitization

3. Severe lower respiratory tract infections requiring hospitalization Pneumonia Bronchiolitis

4. Wheezing apart from colds

5. Male gender

6. Low birth weight

7. Environmental tobacco smoke exposure

8. Possible use of acetaminophen (paracetamol)

9. Reduced lung function at birth

10. Eosinophilia (>4%)

ETIOLOGY

• A combination of -

Host factors

Environmental factors

Host factors • Genetic

1. Genes predisposing to atopy

2. Genes predisposing to airway hyper responsiveness

•Obesity

•Sex

Environmental factors • Allergens –

1. Indoor – Domestic mites, furred animals (dogs, cats, mice),

cockroach allergens, fungi, molds, yeasts.

2. Outdoor – Pollens, fungi, molds, yeasts.

• Infections (predominantly viral)

• Occupational sensitizers

• Tobacco smoke – Passive / Active

• Indoor/Outdoor air pollution

• Diet

PATHOGENESIS

Airway pathology in asthma

Clinical features• Between attacks, the child may be asymptomatic

• Symptoms of an acute attack:

expiratory wheeze

Shortness of breath

sometimes cough may be the only symptom

symptoms worse at night

most patients may feel chest tightness in the morning

young children may vomit or have reduced appetite

Clinical features• Signs of an acute attack:

– Child unable speak or to walk due to breathlessness– Intercostal recession and use of accessory muscles– Exhausted– Wheeze with tachypnoea and tachycardia– Silent chest (severe presentation)

• Chronic asthmatic may have a Harrison's sulcus.

Asthma Diagnosis

• Good History Taking (ASK)

• Careful Physical Examination (LOOK)

• Investigations (PERFORM) – above 5 years only

History taking (Ask)Has the child had an attack or recurrent episode of wheezing (high-

pitched whistling sounds when breathing out)?

Does the child have a troublesome cough which is particularly worse at night or on waking?

Is the child awakened by coughing or difficult breathing?

Does the child cough or wheeze after physical activity (like games and exercise) or excessive laughing/crying?

Does the child experience breathing problems during a particular season?

Physical Examination (Look)Signs in acute exacerbation•Respiratory Distress :–Tachypnea, Working Alae nasai–Retractions–Grunting–Cyanosis, Drowziness, Coma.•Ausculation :–Decreased air entry–Prolonged expiration–Wheeze, rhonchi

Signs of chronic illness•Hyperinflated chest (Barrel-shaped chest)•Harrison’s sulci

Asthma Diagnosis (investigation)

Spirometry- Use spirometry to establish airflow

obstruction:– FEV1/FVC < 80% predicted indicate

significant airflow obstruction– FEV1 60%-80% moderate airflow

obstruction– FEV1< 60% severe airflow obstruction

Use spirometry to establish reversibility: FEV1 increases >12% and at least 200

mL after using a short-acting inhaled beta2-agonist

Exercise challenge/challenge to methacholine -Worsening in FEV1 >12% and ≥ 20% respectively.

The Peak Flow Meter(like a thermometer for asthma)

• Simple & inexpensive tool to measure airflow.• Used for diagnosis & monitoring of asthma.• PEFR monitoring should be started by measuring morning

& evening PEFRs (best of 3 attempts) for several weeks for patients to practice the technique and to determine a “personal best” and to correlate PEF values with symptoms.

• PEFR variation >13% is consistent with asthma.• Girls: 3.43 x ht – 180 lit/min• Boys: 2.98 x ht – 110 lit/min

Chest radiograph

May be normal in up to 75% of patients.

Reported features with asthma include:•pulmonary hyperinflation•bronchial wall thickening: peribronchial cuffing (non specific finding but may be present in 48% of cases with asthma) ̴•pulmonary oedema (rare): pulmonary oedema due to asthma (usually occurs with acute asthma)

http://radiopaedia.org/articles/missing?article%5Btitle%5D=pulmonary-hyperinflation

http://radiopaedia.org/articles/bronchial-wall-thickening

http://radiopaedia.org/articles/peri-bronchial-cuffing-2

http://radiopaedia.org/articles/pulmonary-oedema

http://radiopaedia.org/articles/pulmonary-oedema-due-to-asthma

How to confirm

• No gold standard test to diagnose• Diagnosis is essentially clinical• Lung function tests are occasional helpful• Other causes of recurrent cough should be

ruled out

Asthma Predictive Index

Identify high risk children :• ≥4 wheezing episodes in the past year

(at least one must be MD diagnosed)

PLUS

OR One major criterion• Parent with asthma• Atopic dermatitis• Aero-allergen

sensitivity

Two minor criteria• Food sensitivity• Peripheral

eosinophilia (≥4%) • Wheezing not

related to infection

HIGH SPECIFICITY (97%) & POSITIVE PREDICTIVE VALUE (77%) FOR PERSISTANT ASTHMA IN TO LATER CHILDHOOD.

© Global Initiative for Asthma

Patient with respiratory symptoms

Are the symptoms typical of asthma?

Detailed history/examination for asthma

History/examination supports asthma diagnosis?

Perform spirometry/PEF with reversibility test

Results support asthma diagnosis?

Empiric treatment with ICS and prn SABA

Review response

Diagnostic testing within 1-3 months

Repeat on another occasion or arrange

other tests

Confirms asthma diagnosis?

Consider trial of treatment for most likely diagnosis, or refer

for further investigations

Further history and tests for alternative diagnoses

Alternative diagnosis confirmed?

Treat for alternative diagnosisTreat for ASTHMA

Clinical urgency, and other diagnoses unlikely

YES

YES

YES NO

NO

NO

NO

YES

YES

NO

Diagnosis of asthma in children already taking controller treatment

1. Variable respiratory symptoms and variable airflow limitation – Diagnosis of

asthma is confirmed.

2. Variable respiratory symptoms but no variable airflow limitation – Repeat

bronchodilator reversibility test after withholding bronchodilator or during

symptoms. If normal consider alternate diagnosis.

(a) If FEV1 is >70% predicted : consider a bronchial provocation test. If

negative, consider stepping down controller treatment and reassess in 2-4 wks.

(b) If FEV1 is <70% predicted : consider stepping up controller treatment for 3

months, then reassess symptoms and lung functions . If no response resume

previous treatment and refer for diagnosis and investigation.

3. Few respiratory symptoms, normal lung function and no variable airflow limitation

– Repeat bronchodilator reversibility test after withholding bronchodilator or

during symptoms. If normal consider alternate diagnosis.

Consider stepping down controller treatment –

(a) If symptoms emerge and lung function falls – Asthma is confirmed.

(b) If no change in symptoms or lung function at lowest controller step – consider

stopping controller and monitor patient closely for at least 12 months.

4. Persistent shortness of breath and fixed airflow limitation – Consider stepping up

controller treatment for 3 months, then reassess symptoms and lung function. If

no response, resume previous treatment and refer patient for diagnosis and

investigation. Consider asthma – COPD overlap syndrome.

Asthma management & prevention

Updated 2015

Five components -

1. Develop Patient-Doctor Partnership

2. Identify and Reduce Exposure to Risk Factors

3. Assess, Treat and Monitor Asthma

4. Manage Asthma Exacerbations

5. Special Considerations

Asthma Management and Prevention Program

Goals of Long-term Management 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

Component 1

Develop Patient-Doctor Partnership

• Patients can learn to –

Avoid risk factors

Take medications correctly

Understand the difference between controller and reliever

medications

Monitor their status using symptoms and, if relevant, PEF

Recognize signs that asthma is worsening and take action

Seek medical help as appropriate

Key factors to facilitate communication: Friendly environment

Interactive dialogue

Encouragement and praise

Provide appropriate information

Feedback and review

Factors Involved in Non-AdherenceMedication Usage • Difficulties associated with inhalers• Complicated regimens• Fears about/actual side effects• Cost• Distance to pharmacies

Non-Medication Factors • Misunderstanding/lack of information• Fears about side-effects • Inappropriate expectations• Underestimation of severity• Attitudes toward ill health• Cultural factors• Poor communication

Component 2

Identify and Reduce Exposure to Risk Factor

Avoidance measures that improve control of asthma and reduce medication needs are:• Reduce exposure to indoor allergens• Avoid tobacco smoke• Avoid vehicle emission• Identify & avoid irritants in the workplace• Explore role of infections on asthma development, especially in children and young infants

Component 3

Assess, Treat and Monitor Asthma• The goal of asthma treatment is to achieve and to maintain clinical control• The focus of asthma control is on : Attainment a better quality of life Reduction in health care use Determine the initial level of control to implement

treatment Maintain control once treatment has been implemented

Levels of Asthma Control(Assess patient impairment)

Characteristic Controlled(All of the following)

Partially controlled(Any present in any week)

Uncontrolled

Daytime symptoms Twice or less per week

More than twice per week

3 or more features of partly controlled asthma present in any week

Limitations of activities None Any

Nocturnal symptoms / awakening None Any

Need for rescue / “reliever” treatment

Twice or less per week

More than twice per week

Lung function (PEF or FEV1)

Normal< 80% predicted or

personal best (if known) on any day

Assessment of Future Risk (risk of exacerbations, instability, rapid decline in lung function, side effects)

Assess Patient Risk Features that are associated with increased risk of adverse events in the future include:

Poor clinical control

Frequent exacerbations in past year

Ever admission to critical care for asthma

Low FEV1,exposure to cigarette smoke, high dose medications

•Depending on level of asthma control, the patient is assigned to one of the treatment steps•Treatment is adjusted in a continuous cycle driven by changes in asthma control status. The cycle involves: - Assessing Asthma Control - Treating to Achieve Control - Monitoring to Maintain Control•A stepwise approach to pharmacological therapy is recommended •The aim is to accomplish the goals of therapy with the least possible medication

Pharmacotherapy of asthma

Relievers For treatment of

bronchospasm and to relieve acute attack

Preventers/controller For long term control of

inflammation and to prevent further attack

Reliever Medications

Rapid-acting inhaled β2-agonistsSystemic glucocorticosteroids Anticholinergics Theophylline Short-acting oral β2-agonists

Preventers/controller medication

Inhaled

Corticosteroids (ICS)

Long acting B2 agonist

Cromolyn sodium

Oral

Leucotriene antagonist

Theophylline – SR

Oral prednisolone

Anti Ig E

Short acting beta-2 agonists Selective : Salbutmol, levosalbutamol, terbutaline. Non selective : Adrenaline

•Available in inhaled, pill, liquid, and injectable forms.

• Act as bronchodilators. They relax the muscles lining the airways that carry air to the lungs (bronchial tubes) within 5 minutes, increasing airflow and making it easier to breathe. They relieve asthma symptoms for 3 to 6 hours.

•Prevent asthma symptoms before exercise.

• Do not control the inflammation.

Long acting Beta-2 agonist•Drugs : Salmeterol : 12 µg/puff, 12µg/cap 1 to 2 puff/rota cap/day od/bd Formoterol : 25 µg/puff, 50 µg/cap 1 to 2 puff/rota cap/day od/bd•Not used as relievers•Used with ICS for synergistic effects/steroid sparing effects•Used in children >4years•Duration of action 12 to 24 hours•Prevent asthma symptoms before exercise•Useful in nocturnal/Exercise induced symptoms

ICSMost effective long term therapy available

Anti inflammatory effect evident in 2-3 weeks

Local side effects can be minimized by spacer/gargling

Systemic side effects negligible

Most children are controlled with medium doses

In prolonged high doses-monitor growth and eyes

oral steroidsUse limited to severe asthma

Should be used in minimal possible doses

Alternate morning doses preferred

Preferred drug : Prednisolone

Side effects :Excessive weight gain, hypertension, osteoporosis,

decreased linear growth, metabolic derangement and cataract

Drugs : Montelukast 4mg/day (2-5yr), 5mg/day (5-12yr),

10mg/day (>12yr)

Zafirlukast

May be considered as mono therapy in mild asthma where child’s

parents refused for inhalation therapy

Add on in moderate to severe asthma

Weak anti inflammatory effect (inferior to ICS)

Prevent exacerbation in exercise induced asthma

Leukotrine antagonists

TheophyllineInhibitor of phosphodiesterase

Act as smooth muscle relaxant, bronchodilator, respiratory stimulant,

diaphragmatic muscle contractility improver

Anti inflammatory + immunomodulator effect

Adjunct therapy for mod/severe asthma

Disadvantage : Low therapeutic index

Dose : 10 to 16 mg/kg/day in 2 divided doses

Management of Asthma in children

6 -11 years and adolescents

Initial treatment for adolescents and children 6–11 years

•Start reliever medication•Start controller treatment early (For best results)•Indications for regular low-dose ICS - any of:

Asthma symptoms more than twice a monthWaking due to asthma more than once a monthAny asthma symptoms + any risk factors for exacerbations

•Consider starting at a higher step if:Troublesome asthma symptoms on most daysWaking from asthma once or more a week

Initial treatment for adolescents and children 6–11 years

•If initial asthma presentation is with an exacerbation:

Give a short course of oral steroids and start regular controller

treatment (e.g. high dose ICS or medium dose ICS/LABA, then step down)

•After starting initial controller treatment

Review response after 2-3 months, or according to clinical urgency

Adjust treatment (including non-pharmacological treatments)

Consider stepping down when asthma has been well-controlled for 3

months

Stepwise management -pharmacotherapy

*For children 6-11 years, theophylline is not recommended, and preferred Step 3 is medium dose ICS

**For patients prescribed BDP/formoterol or BUD/ formoterol maintenance and reliever therapy

# Tiotropium by soft-mist inhaler is indicated as add-on treatment for adults (≥18 yrs) with a history of exacerbations

GINA 2015, Box 3-5 (2/8) (upper part)

DiagnosisSymptom control & risk factors(including lung function)Inhaler technique & adherencePatient preference

Asthma medicationsNon-pharmacological strategiesTreat modifiable risk factors

SymptomsExacerbationsSide-effectsPatient satisfactionLung function

Other controller

options

RELIEVER

STEP 1 STEP 2STEP 3

STEP 4

STEP 5

Low dose ICS

Consider low dose ICS

Leukotriene receptor antagonists (LTRA)Low dose theophylline*

Med/high dose ICSLow dose ICS+LTRA

(or + theoph*)

As-needed short-acting beta2-agonist (SABA) As-needed SABA or low dose ICS/formoterol**

Low dose ICS/LABA*

Med/high ICS/LABA

Refer for add-on

treatment e.g.

anti-IgE

PREFERRED CONTROLLER

CHOICE

Add tiotropium#High dose ICS + LTRA (or + theoph*)

Add tiotropium#Add low dose OCS

Step 1 – as-needed inhaled short-acting beta2-agonist (SABA)


CHOICE

Other controller

options

RELIEVER

STEP 1 STEP 2 STEP 3

STEP 4

STEP 5

Low dose ICS




(or + theoph*)


Low dose ICS/LABA*

Med/high ICS/LABA

Refer for add-on

treatment e.g.

anti-IgE



Step 1 – as-needed reliever inhaler

Preferred option: as-needed inhaled short-acting beta2-agonist (SABA)

Reserved for patients with infrequent symptoms (less

than twice a month) of short duration, and with no risk

factors for exacerbations

Other options : Add regular low dose inhaled corticosteroid (ICS) for

patients at risk of exacerbations

Step 2 – low-dose controller + as-needed inhaled SABA


CHOICE

Other controller

options

RELIEVER


STEP 4

STEP 5

Low dose ICS




(or + theoph*)


Low dose ICS/LABA*

Med/high ICS/LABA

Refer for add-on

treatment e.g.

anti-IgE



Step 2 – Low dose controller + as-needed SABA

• Preferred option: regular low dose ICS with as-needed inhaled SABA• Other options:

– Leukotriene receptor antagonists (LTRA) with as-needed SABA• Less effective than low dose ICS

– Combination low dose ICS/long-acting beta2-agonist (LABA) with as-needed SABA

• Reduces symptoms and increases lung function compared with ICS• More expensive, and does not further reduce exacerbations

– Intermittent ICS with as-needed SABA for purely seasonal allergic asthma with no interval symptoms

• Start ICS immediately symptoms commence, and continue for 4 weeks after pollen season ends


Step 3 – one or two controllers + as- needed inhaled reliever

Other controller

options

RELIEVER


STEP 4

STEP 5

Low dose ICS




(or + theoph*)


Low dose ICS/LABA*

Med/high ICS/LABA

Refer for add-on

treatment e.g.

anti-IgE


CHOICE



Step 3 – one or two controllers + as-needed inhaled reliever• Before step-up - Check inhaler technique and adherence, confirm diagnosis• Preferred options: Adolescent - Combination of low dose ICS/LABA maintenance with as-needed SABA Children 6-11 years: preferred option is medium dose ICS with as-needed SABA• Other options

– Adolescents: Increase ICS dose or add LTRA or theophylline (less effective than ICS/LABA)– Children 6-11 years – add LABA (similar effect as increasing ICS)


Step 4 – two or more controllers + as- needed inhaled reliever

Other controller

options

RELIEVER


STEP 4

STEP 5

Low dose ICS




(or + theoph*)


Low dose ICS/LABA*

Med/high ICS/LABA

Refer for add-on

treatment e.g.

anti-IgE


CHOICE



Step 4 – two or more controllers + as-needed inhaled reliever

• Before step-up - Check inhaler technique and adherence• Preferred option Adolescent : 1. Combination of low dose ICS/formoterol as maintenance and reliever regimen

2. Combination of medium dose ICS/LABA with as-needed SABA Children 6–11 years: Refer for expert advice

• Other options (Adolescents)– Trial of high dose combination ICS/LABA– Increase dosing frequency (for budesonide-containing inhalers)– Add-on LTRA or low dose theophylline

Step 5 – higher level care and/or add-on treatment

GINA 2015, Box 3-5, Step 5 (8/8)

Other controller

options

RELIEVER


STEP 4

STEP 5

Low dose ICS




(or + theoph*)


Low dose ICS/LABA*

Med/high ICS/LABA

Refer for add-on

treatment e.g.

anti-IgE


CHOICE



Step 5 – higher level care and/or add-on treatment

• Preferred option : Referral for specialist investigation and

consideration of add-on treatment– Add-on omalizumab (anti-IgE) for patients with moderate

or severe allergic asthma.• Other add-on treatment options:

– Sputum-guided treatment: this is available in specialized centers; reduces exacerbations and/or corticosteroid dose

– Add-on low dose oral corticosteroids (≤7.5mg/day prednisone equivalent)

Inhaled corticosteroid Total daily dose (mcg)Low Medium High

Beclometasone dipropionate (CFC) 200–500 >500–1000 >1000

Beclometasone dipropionate (HFA) 100–200 >200–400 >400

Budesonide (DPI) 200–400 >400–800 >800

Ciclesonide (HFA) 80–160 >160–320 >320

Fluticasone propionate (DPI or HFA) 100–250 >250–500 >500

Mometasone furoate 110–220 >220–440 >440

Triamcinolone acetonide 400–1000 >1000–2000 >2000

Low, medium and high dose inhaled corticosteroids (≥ 12 yrs)

• This is not a table of equivalence, but of estimated clinical comparability• Most of the clinical benefit from ICS is seen at low doses

Low, medium and high dose inhaled corticosteroids (Children 6–11 yrs)

Inhaled corticosteroid Total daily dose (mcg)Low Medium High

Beclometasone dipropionate (CFC) 100–200 >200–400 >400

Beclometasone dipropionate (HFA) 50–100 >100–200 >200

Budesonide (DPI) 100–200 >200–400 >400

Budesonide (nebules) 250–500 >500–1000 >1000

Ciclesonide (HFA) 80 >80–160 >160

Fluticasone propionate (DPI) 100–200 >200–400 >400

Fluticasone propionate (HFA) 100–200 >200–500 >500

Mometasone furoate 110 ≥220–<440 ≥440

Triamcinolone acetonide 400–800 >800–1200 >1200

Reviewing response and adjusting treatment

•Asthma should be reviewed in -o1-3 months after treatment started, then every 3-12 months

oAfter an exacerbation, within 1 week

•Stepping up asthma treatmentoSustained step-up, for at least 2-3 months if asthma poorly controlled

oShort-term step-up, for 1-2 weeks, e.g. with viral infection or allergen

oDay-to-day adjustment - For patients prescribed low-dose ICS/

formoterol maintenance and reliever regimen

•Consider stepping down -

When symptoms have been well controlled and lung function stable

for ≥3 months

No respiratory infection, patient not travelling.

•Stepping down ICS doses by 25–50% at 3 month intervals is feasible and

safe

for most patients

Stepping down controller treatment

Management of asthma in children 5 years and younger

Stepwise management - pharmacotherapy

GINA 2015, Box 6-5 (3/8)

Infrequentviral wheezing and no or few interval symptoms

Symptom pattern consistent with asthma and asthma symptoms not well-controlled, or ≥3 exacerbations per year

Symptom pattern not consistent with asthma but wheezing episodes occur frequently, e.g. every 6–8 weeks. Give diagnostic trial for 3 months.

Asthma diagnosis, and not well-controlled on low dose ICS

Not well-controlled on double ICS

First check diagnosis, inhaler skills, adherence, exposures

CONSIDER THIS STEP FOR

CHILDREN WITH:

RELIEVER

Other controller

options


CHOICE

As-needed short-acting beta2-agonist (all children)

Leukotriene receptor antagonist (LTRA)Intermittent ICS

Low dose ICS + LTRA Add LTRA Inc. ICS

frequencyAdd intermitt

ICS

Daily low dose ICS

Double ‘low dose’

ICS

Continue controller & refer for specialist

assessment

STEP 1 STEP 2STEP 3

STEP 4

Step 1 – As-needed inhaled SABA

GINA 2015, Box 6-5 (5/8)








CHILDREN WITH:

RELIEVER

Other controller

options


CHOICE





ICS

Daily low dose ICS


ICS


assessment

STEP 1 STEP 2STEP 3

STEP 4

• Preferred option:

As-needed inhaled SABA

Not effective in all children

• Other options

– Oral bronchodilator therapy is not recommended.

– For children with intermittent viral-induced wheeze and no interval

symptoms, if as-needed SABA is not sufficient, consider intermittent

ICS.

Step 1 – As-needed inhaled SABA

Step 2 – initial controller + as-needed SABA

GINA 2015, Box 6-5 (6/8)








CHILDREN WITH:

RELIEVER

Other controller

options


CHOICE





ICS

Daily low dose ICS


ICS


assessment

STEP 1 STEP 2STEP 3

STEP 4

Step 2 – initial controller + as-needed SABA• Indication

– Child whose symptoms not well-controlled, or ≥3 exacerbations/yr– May also be used as a diagnostic trial for children with frequent wheezing episodes

• Preferred option: regular daily low dose ICS + as-needed inhaled SABA• Other options depend on symptom pattern

– (Persistent asthma) – regular leukotriene receptor antagonist (LTRA)– (Intermittent viral-induced wheeze) – regular LTRA – (Frequent viral-induced wheeze with interval symptoms) – consider episodic or as-needed ICS, but give a trial of regular ICS first

Step 3– medium dose ICS+ as-needed inhaled SABA








CHILDREN WITH:

RELIEVER

Other controller

options


CHOICE





ICS

Daily low dose ICS


ICS


assessment

STEP 1 STEP 2STEP 3

STEP 4

Step 3 – medium dose ICS+ as-needed inhaled SABA

• Indication

– When symptoms not well-controlled on low dose ICS

– First check symptoms are due to asthma, and check adherence, inhaler

technique and environmental exposures


Medium dose ICS with as-needed inhaled SABA

• Other options:

Consider adding LTRA to low dose ICS

Step 4 – Refer for expert assessment








CHILDREN WITH:

RELIEVER

Other controller

options


CHOICE





ICS

Daily low dose ICS


ICS


assessment

STEP 1 STEP 2STEP 3

STEP 4

Step 4 – Refer for expert assessment• Indication

– When symptoms not well-controlled on medium dose ICS


Continue controller treatment and refer for expert assessment

• Other options (preferably with specialist advice)

– Higher dose ICS and/or more frequent dosing (for a few weeks)

– Add LTRA, theophylline or low dose OCS (for a few weeks only)

– ICS + LABA not recommended in this age group

Inhaled corticosteroid Low daily dose (mcg)

Beclometasone dipropionate (HFA) 100

Budesonide (pMDI + spacer) 200

Budesonide (nebulizer) 500

Fluticasone propionate (HFA) 100

Ciclesonide 160

Mometasone furoate Not studied below age 4 years

Triamcinolone acetonide Not studied in this age group

Low dose inhaled corticosteroids (mcg/day) for children ≤5 yrs

A. Symptom control

In the past 4 weeks, has the child had: Well-controlled

Partly controlled

Uncontrolled

• Daytime asthma symptoms for more than few minutes, more than once/week?

Yes No

None of these

1-2 of these

3-4 of these

• Any activity limitation due to asthma? (runs/plays less than other children, tires easily during walks/playing)

Yes No• Reliever needed more than once a

week?

Yes No• Any night waking or night coughing

due to asthma?

Yes No B. Risk factors for poor asthma outcomesASSESS CHILD’S RISK FOR:• Exacerbations within the next few months• Fixed airflow limitation• Medication side-effects

Assessment of asthma control in children ≤5 years

Age Preferred device Alternate device

0–3 years Pressurized metered dose inhaler plus dedicated spacer with face mask

Nebulizer with face mask

4–5 years Pressurized metered dose inhaler plus dedicated spacer with mouthpiece

Pressurized metered dose inhaler plus dedicated spacer with face mask, or nebulizer with mouthpiece or face mask

Inhaler device for children ≤5 years

Management of Acute Exacerbation in children 6 – 11 yr

and adolescents

Component 4

• A flare-up or exacerbation is an acute or sub-acute worsening of symptoms and

lung function compared with the patient’s usual status

• Consider management of worsening asthma as a continuum

Self-management with a written asthma action plan

Management in primary care

Management in the emergency department and hospital

Follow-up after any exacerbation

Management of Acute Exacerbation

Identify patients at risk of asthma-related deathAny history of near-fatal asthma requiring intubation and ventilation

Hospitalization or emergency care for asthma in last 12 months

Not currently using ICS, or poor adherence with ICS

Currently using or recently stopped using OCS

Over-use of SABAs, especially if more than 1 canister/month

Lack of a written asthma action plan

History of psychiatric disease or psychosocial problems

Confirmed food allergy

Written asthma action plans – medication options•Increase inhaled reliever

Increase frequency as needed

Adding spacer for pMDI may be helpful

•Early and rapid increase in inhaled controller

Up to maximum ICS of 2000mcg BDP/day or equivalent

Options depend on usual controller medication and type of LABA

•Add oral corticosteroids if needed

Children: 1-2mg/kg/day up to 40mg, usually 3-5 days

Morning dosing preferred to reduce side-effects

Tapering not needed if taken for less than 2 weeks

Managing exacerbations in primary care

PRIMARY CARE Patient presents with acute or sub-acute asthma exacerbation

ASSESS the PATIENTIs it asthma?Risk factors for asthma-related death?Severity of exacerbation?

MILD or MODERATETalks in phrases, prefers sitting to lying, not agitatedRespiratory rate increasedAccessory muscles not usedPulse rate 100–120 bpmO2 saturation (on air) 90–95%PEF >50% predicted or best

SEVERETalks in words, sits hunched forwards, agitatedRespiratory rate >30/minAccessory muscles in usePulse rate >120 bpmO2 saturation (on air) <90%PEF ≤50% predicted or best

LIFE-THREATENINGDrowsy, confused

or silent chest

START TREATMENTSABA 4–10 puffs by pMDI + spacer, repeat every 20 minutes for 1 hour

Prednisolone:children 1–2 mg/kg,

max. 40 mg

Controlled oxygen(if available): target saturation 93–95% (children: 94-98%)

TRANSFER TO ACUTE CARE FACILITY

While waiting: give inhaled SABA and ipratropium bromide, O2,

systemic corticosteroid

URGENT

WORSENING

START TREATMENTSABA 4–10 puffs by pMDI + spacer, repeat every 20 minutes for 1 hourPrednisolone:adults 1 mg/kg, max. 50 mg, children 1–2 mg/kg, max. 40 mgControlled oxygen(if available): target saturation 93–95% (children: 94-98%)

CONTINUE TREATMENTwith SABA as neededASSESS RESPONSE AT 1 HOUR (or earlier)

TRANSFER TO ACUTE CARE FACILITY

While waiting: give inhaled SABA and ipratropium bromide, O2,

systemic corticosteroid

WORSENING

ARRANGE at DISCHARGEReliever:continue as neededController:start, or step up. Check inhaler technique, adherencePrednisolone:continue, usually for 5–7 days (3-5 days for children) Follow up: within 2–7 days

ASSESS FOR DISCHARGESymptoms improved, not needing SABAPEF improving, and >60-80% of personal best or predictedOxygen saturation >94% room airResources at homeadequate

FOLLOW UP Reliever: reduce to as-neededController:continue higher dose for short term (1–2 weeks) or long term (3 months), depending on background to exacerbationRisk factors: check and correct modifiable risk factors that may have contributed to exacerbation, including inhaler technique and adherence Action plan:Is it understood? Was it used appropriately? Does it need modification?

IMPROVING

WORSENING

Managing exacerbations in acute care settings

INITIAL ASSESSMENTA: airway B: breathing C: circulation

Are any of the following present?

Drowsiness, Confusion, Silent chest

Further TRIAGE BY CLINICAL STATUS

according to worst feature

Consult ICU, start SABA and O2, and prepare patient for intubation

MILD or MODERATETalks in phrasesPrefers sitting to lyingNot agitatedRespiratory rate increasedAccessory muscles not usedPulse rate 100–120 bpmO2 saturation (on air) 90–95%PEF >50% predicted or best

SEVERETalks in wordsSits hunched forwardsAgitatedRespiratory rate >30/minAccessory muscles being usedPulse rate >120 bpmO2 saturation (on air) < 90%PEF ≤50% predicted or best

NO

YES

MILD or MODERATETalks in phrasesPrefers sitting to lyingNot agitatedRespiratory rate increasedAccessory muscles not usedPulse rate 100–120 bpmO2 saturation (on air) 90–95%PEF >50% predicted or best

SEVERETalks in wordsSits hunched forwardsAgitatedRespiratory rate >30/minAccessory muscles being usedPulse rate >120 bpmO2 saturation (on air) < 90%PEF ≤50% predicted or best

Short-acting beta2-agonistsConsider ipratropium bromideControlled O2 to maintain saturation 93–95% (children 94-98%)Oral corticosteroids

Short-acting beta2-agonistsIpratropium bromide Controlled O2 to maintain saturation 93–95% (children 94-98%)Oral or IV corticosteroidsConsider IV magnesiumConsider high dose ICS


Short-acting beta2-agonistsConsider ipratropium bromideControlled O2 to maintain saturation 93–95% (children 94-98%)Oral corticosteroids

Short-acting beta2-agonistsIpratropium bromide Controlled O2 to maintain saturation 93–95% (children 94-98%)Oral or IV corticosteroidsConsider IV magnesiumConsider high dose ICS

If continuing deterioration, treat as

severe and re-assess for ICU

ASSESS CLINICAL PROGRESS FREQUENTLY MEASURE LUNG FUNCTION

in all patients one hour after initial treatment

FEV1 or PEF 60-80% of predicted or personal best and symptoms improved

MODERATEConsider for discharge planning

FEV1 or PEF <60% of predicted or personal best,or lack of clinical response

SEVEREContinue treatment as above

and reassess frequently


Management of Acute Exacerbation in children ≤ 5 yr

Initial assessment of acute asthma exacerbations

Symptoms Mild SevereAltered consciousness No Agitated, confused or drowsy

Oximetry on presentation (SaO2)

>95% <92%

Speech† Sentences Words

Pulse rate <100 beats/min >200 beats/min (0–3 years)>180 beats/min (4–5 years)

Central cyanosis Absent Likely to be present

Wheeze intensity Variable Chest may be quiet

© Global Initiative for AsthmaGINA 2015, Box 6-8 (2/3)

PRIMARY CARE Child presents with acute or sub-acute asthma exacerbation or acute wheezing episode

ASSESS the CHILDConsider other diagnosesRisk factors for hospitalization Severity of exacerbation?

MILD or MODERATEBreathless, agitated Pulse rate ≤200 bpm (0-3 yrs) or ≤180 bpm (4-5 yrs) Oxygen saturation ≥92%

MONITOR CLOSELY for 1-2 hoursTransfer to high level care if any of: • Lack of response to salbutamol over 1-2 hrs• Any signs of severe exacerbation• Increasing respiratory rate• Decreasing oxygen saturation

START TREATMENTSalbutamol 100 mcg two puffs by pMDI + spacer or 2.5mg by nebulizer Repeat every 20 min for the first hour if neededControlled oxygen (if needed and available): target saturation 94-98% URGENT

Worsening, or lack of

improvement

SEVERE OR LIFE THREATENINGany of:

Unable to speak or drink Central cyanosis Confusion or drowsinessMarked subcostal and/or sub-glottic retractionsOxygen saturation <92%Silent chest on auscultation Pulse rate > 200 bpm (0-3 yrs)or >180 bpm (4-5 yrs)

TRANSFER TO HIGH LEVEL CARE (e.g. ICU)

While waiting give:Salbutamol 100 mcg 6 puffs by pMDI+spacer (or 2.5mg nebulizer). Repeat every 20 min as needed.Oxygen (if available) to keep saturation 94-98% Prednisolone 2mg/kg (max. 20 mg for <2 yrs; max. 30 mg for 2–5 yrs) as a starting doseConsider 160 mcg ipratropium bromide (or 250 mcg by nebulizer). Repeat every 20 min for 1 hour if needed.

Primary care management of acute asthma or wheezing

Primary care management of acute asthma or wheezing

MONITOR CLOSELY for 1-2 hoursTransfer to high level care if any of: • Lack of response to salbutamol over 1-2 hrs• Any signs of severe exacerbation• Increasing respiratory rate• Decreasing oxygen saturation

Worsening, or lack of

improvement

TRANSFER TO HIGH LEVEL CARE (e.g. ICU)

While waiting give:Salbutamol 100 mcg 6 puffs by pMDI+spacer (or 2.5mg nebulizer). Repeat every 20 min as needed.Oxygen (if available) to keep saturation 94-98% Prednisolone 2mg/kg (max. 20 mg for <2 yrs; max. 30 mg for 2–5 yrs) as a starting doseConsider 160 mcg ipratropium bromide (or 250 mcg by nebulizer). Repeat every 20 min for 1 hour if needed.

Worsening, or failure to respond to

10 puffs salbutamol over 3-4 hrs

FOLLOW UP VISIT Reliever: Reduce to as-neededController: Continue or adjust depending on cause of exacerbation, and duration of need for extra salbutamolRisk factors: Check and correct modifiable risk factors that may have contributed to exacerbation, including inhaler technique and adherenceAction plan: Is it understood? Was it used appropriately? Does it need modification? Schedule next follow up visit

DISCHARGE/FOLLOW-UP PLANNINGEnsure that resources at home are adequate.Reliever: continue as neededController: consider need for, or adjustment of, regular controller Check inhaler technique and adherenceFollow up:within 1-7 daysProvide and explain action plan

CONTINUE TREATMENT IF NEEDEDMonitor closely as aboveIf symptoms recur within 3-4 hrs• Give extra salbutamol 2-3 puffs per hour• Give prednisolone 2mg/kg (max. 20mg for <2 yrs; max. 30mg for 2-5 yrs) orally

IMPROVING

IMPROVING

Managing exacerbations in acute care settings if….

Features of severe exacerbation at initial or subsequent assessment

Child is unable to speak or drink

Cyanosis

Subcostal retraction

Oxygen saturation <92% when breathing room air

Silent chest on auscultation

Lack of response to initial bronchodilator treatment

Lack of response to 6 puffs of inhaled SABA (2 separate puffs, repeated

3 times) over 1-2 hours

Persisting tachypnea despite 3 administrations of inhaled SABA

Indication for transfer of child in ICU• Child presenting with life threatening attack

• Child with severe distress has shown poor response to therapy after observed for

few hours

• Develop sign of impending respiratory failure during therapy like hypoxia (Po2 <60

mm Hg), hpercarbia (Pco2 > 45 mm Hg).

ICU management Continue oxygen

Inhaled short acting Beta agonist every 60 min or continuous + inhaled

Anticholinergics.

Continue systemic rescue steroids.

Continue intensified ward plan/ intensify therapy by adding bronchodilator: -

Magnesium sulphate, Aminophylline, Terbutaline infusion.

Continuous monitoring with pulse oximetry and repeated ABG are mandatory

since most of these patient are not in condition to perform PEFR

If indicated intubate child and start mechanical ventilation

Failure of maximum pharmacotherapy

Pao2<60 ,Paco2 >45

Minimal chest movements

Minimal air exchange

Severe chest retractions

Deterioration of mental status

Respiratory/ cardiac arrest

Indication of mechanical ventilation

Stepping down acute care • Follow the principle “last in first out”

Discontinue terbutaline/aminophylline drip in 24 hrs

Discontinue ipratropium neb in 24-48 hrs

Reduce nebulisation with SA β2 agonist to q 2-4 hrly and then q 4-6 hrly

Replace IV rescue steriod Oral steroid

• Discharge Criteria :

Pulmonary score index < 3

Sleep well at night

Feeding well

Appears comfortable

Receiving less frequent β2 agonist

Seasonal Asthma• Asthma attack start with onset of particular season and persist during that season

till allergen persist otherwise child is normal remaining part of year.

• Child can be started on controller drugs 2 weeks in advance of start of season.

• Medications are given as per the severity of asthma

• Child should be examined again after discontinuing meds after season is over

Exercise Induced Asthma• Symptoms and bronchoconstriction typically worsen after cessation of

exercise

• Managed by SABA/LABA/LTRAS

• Short acting B agonists are given just before activity as they have short

duration of action

• Long acting bronchodilators / leukotriene receptor antagonists can be

given in the morning

Primary prevention of asthma Avoid exposure to allergen

Avoid exposure to tobacco smoke in pregnancy and early life

Encourage vaginal delivery

Advise breast-feeding for its general health benefits

Where possible, avoid use of paracetamol (acetaminophen)

and broad-spectrum antibiotics in the first year of life.

Asthma medicationinhalation therapy

Inhalation therapy• To get the maximum amount of medication into your lungs

with minimum side effects.

• Use a spacer with a puffer to minimize side effects and

deliver more medication to lungs

• Asthma improves more rapidly

• Better control is maintained

• Less medication is needed

Inhaler Device• MDI with spacer • Metered dose

inhaler (MDI)• Dry powder inhaler• Nebulizer

Delivery10-15%5-10%

5-10%1-5%

Drug delivery by inhalation device

INHALERS

Two types : 1. Aerosol inhaler

2. Dry powder inhaler

Aerosol inhalers•These inhalers use an aerosol canister to produce a fine mist of medication.

•Two types:

1 Puffers (pMDI)- Press and breathe

2 Autohalers - As you breathe in; your breath will activate the device

PufferUsing your puffer :1. Remove the cover from the puffer mouthpiece2. Hold the puffer upright and shake vigorously3. Breathe out4. Tilt the chin up5. Put the puffer mouthpiece in your mouth and create a seal with your lips6. Start to breathe in through your mouth, then fire one puff of medication and continue to breathe in steadily and deeply7. Remove the puffer from your mouth, close your mouth and hold your breath for 10 seconds8. Breathe out through your nose9. The length of time between inhalation is 15- 20 seconds10. Replace the cover

Puffers require good coordination so it is important to press down on the canister and breathe in at the same time.

Cleaning your puffer

1. Remove metal canister. Do not wash canister

2. Wash the plastic casing only. Rinse the mouthpiece through the top

and bottom under warm running water for at least 30 seconds. Wash

mouthpiece cover

3. Allow to air dry

4. Reassemble

Puffer

SpacerUsing your spacer1. Assemble the spacer2. Remove the cap from the puffer and shake the puffer well3. Attach the puffer to the end of the spacer4. Place the mouthpiece of the spacer in your mouth and close your lips around it. If using a spacer with a facemask, place the facemask over the mouth and nose to ensure a good seal 5. Press down on the puffer canister once to fire the medication into the spacer6. Breathe in and out normally for 4 - 5 breaths7. To take more medication, shake the puffer and repeat steps

Cleaning your spacer• About every month the spacer should be washed in clean

soapy warm water. • Allowed to drip dry. • Do not rinse or wipe dry.

Role of spacer• Spacers overcome coordination problem of actuation and

inhalation• Increase delivery of drug to lung• Can reduce potential side effects.

Spacer

Dry powder inhalation device(DPIs)• DPIs disperse medication as dry powder(2-5 µm) without use of propellant.• DPIs are breath actuated so no coordination problem between actuation and inhalation.• Used above 6 years

Two types -unit dose DPIs( rotahaler and revoliser) -multi dose DPIs(multihaler)

Rotahaler (single dose DPI device)How to use

•Insert a capsule into the rotahaler .

•Twist the rotahaler to break the capsule

•Inhale deeply to get powder into the airway

•Several breath may be required

•Does not require the coordination of the aerosol

Revolizer (single dose DPI device)How to use

• Simply open the Revolizer,

• Insert the rotacap

• Shut the device and inhales

How to clean DPI

• Rotahaler should be cleaned twice a week.• Separate two halves of rotahaler.• keep in running tape water over 1-2 minute.• Put at clean place to become dry.• Revolizer should be cleaned once a week.

Multihaler (multi dose DPI device)How to use1. To load a dose, hold the DPI with mouthpiece up to ensure proper loading of the medication. 2. Twist the grip fully in one direction as far as it will go and then fully back again. You will hear a click. The DPI is now loaded with a dose.3. Breathe out away from the device 4. Place the device in your mouth and breathe in as forcefully and deeply

as you can.5. Hold your breath for 10 seconds.6. Take the DPI away from your mouth and exhale slowly.7. If more than one dose is prescribed, repeat steps 1 through 5 for each dose.

Nebulizer Nebulizer is device used for converting a liquid drug into a fine mist which inhaled directly into the lungs via face mask or mouth piece. The device is driven by compressor (electric/battery operated)or oxygen. Gas flow of 6-8 L/min is normally required to drive the nebulizer. Drug inhalation is accomplished by normal tidal breathing over 5-10 minutes.

Nebulizer Two types - 1. Jet nebulizer 2. Ultrasonic nebulizer

Jet nebulizer Ultrasonic nebulizer

NebulizerHow to use• Plug the compressor unit into the mains. • Connect the tubing from the compressor unit to the bottom of the nebuliser chamber. • Unscrew the top of the nebuliser chamber. • Measure out the correct amount of drug solution and pour into the nebuliser chamber. • Add normal saline to make total solution 4-5ml which is required in the nebuliser chamber for it to work properly.• Screw on the top of the nebuliser chamber and attach the face mask or mouthpiece to the top of the chamber.

• Place the facemask over patient mouth and nose and place the strap over your head. • Sit up, well supported, in a chair or in bed and keep the nebulizer chamber upright. • Switch the compressor unit on and breath in and out as normal. • Nebulisation usually completed in 5-10 minute. • A small amount of solution may be left in the nebuliser at this stage. • Switch off the compressor unit and disconnect the nebuliser chamber from the tubing.

Nebulizer

Advantage• Provide therapy for patients who cannot use other inhalation

modalities (MDI, DPI)• Allow administration of large doses of medicine• Patient coordination not required• Effective with tidal breathing• Dose modification possible• Can be used with supplemental oxygen

Nebulizer

Nebulizer

Disadvantage• Decreased portability• Longer set-up and administration time• Higher cost• Electrical power source required• Contamination possible

Allergen specific immunotherapy• Allergen immunotherapy (also termed desensitization) is a medical treatment aiming at patients suffering from allergies that are insufficiently controlled by symptomatic treatments.

• Greatest benefit of specific immunotherapy using allergen extracts has been obtained in the treatment of allergic rhinitis

• The role of specific immunotherapy in asthma is limited

• Specific immunotherapy should be considered only after strict environmental avoidance and pharmacologic intervention, including inhaled glucocorticosteroids, have failed to control asthma

•Perform only by trained physician treatments.

What’s New1. Dry powder inhalers can be used to deliver SABA in mild or moderate

exacerbations.

2. While arranging transfer to acute care facility, give inhaled ipratropium bromide

as well as SABA, systemic corticosteroids, and oxygen.

3. Pre-school children with acute exacerbations or wheezing episodes –

a. Parent-administered oral steroids or high dose ICS not generally encouraged

b. A new flow-chart for management of acute exacerbations or wheezing

episodes

4. High usage of SABA is a risk factor for exacerbations.

5. Very high usage of SABA (e.g. >200 doses/month) is a risk factor for asthma-

related death

6. Breathing exercises –

a. Evidence level down-graded from A to B following review of quality of

evidence and a new meta-analysis

b. The term ‘breathing exercises’ (not ‘techniques’) is used

7. If cardioselective beta-blockers are indicated for acute coronary events, asthma is

not an absolute contra-indication.

What’s New

Date post:	13-Jan-2017
Category:	Health & Medicine
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Childhood asthma

Health & Medicine