ASTHMA IN CHILDHOOD
dr. Ery Olivianto, SpADr. dr. Wisnu Barlianto, SpA(K) Prof. Dr. dr. HMS. Chandra Kusuma, SpA(K)
Child Health Department Faculty of Medicine Brawijaya UniversitySaiful Anwar General Hospital
Old paradigma (1860)• Paroxysmal
dyspnoea• Contraction of
smooth muscle• bronchodilator
New paradigma (1950)• Inflammatory
disorder• Corticosteroids
Holgate ST. J Allergy Clin Immunol 2011;128:495-505
Definitions
• Asthma is a chronic inflammatory disorder of the airways associated with airway hyperresponsiveness and airflow obstruction that is often reversible either spontaneously or with treatment
WAO. White Book on Allergy, 2011
Epidemiology • World Health Organisation estimate 300 million individuals
have asthma worldwide• Current rising trends this will reach 400 million by 2025• Approximately 250,000 people die prematurely each year
from asthma• Prevalence in the 13-14 year olds ranging from 2.1% to 32.2%• Prevalence in the 6-7 year olds was similar to those in the
older children with prevalence of wheezing varying from 4.1%-32.1%
• Indonesia: 2.6% - 17.4%
WAO. White Book on Allergy, 2011Pedoman Nasional Asma Anak, 2004
Asthma
Genetic
Allergens
Infection
Tobacco smoke
Pollutants
Nutrition
Irritants
Exercise
Weather
Stress
Bacharier LB, et al,. Allergy 2008: 63: 5–34
Inflammatory and immune cells involved in asthmaBarnes PJ. Nat Rev Immunol 2010;8:183-192
Asthma inflammatory cascade
Bernstein D. Pediatric for Medical Students 3rd Ed, 2011
Asthma phenotypes
Infant (0-2 years old)
Preschool children (3-5 years old)
School children (6-12 years old)
Adolescents
Bacharier LB, et al,. Allergy 2008: 63: 5–34
Infantile asthma
• Asthma affecting infant aged < 2 years• 3 or more episodes of marked expiratory
wheezing within the previous 6 months
Bacharier LB, et al,. Allergy 2008: 63: 5–34
Hypothetical yearly prevalence for recurrent wheezing phenotypes in childhood
Leung DM. Pediatric Allergy 2nd Ed, 2010
Modified Asthma Predictive Index for children (Tucson Children's Respiratory Study, Tucson, Arizona). Through a statistically optimized model for 2- to 3-year-old children with frequent wheezing in the past year, one major criterion or two minor criteria provided 77% positive predictive value and 97% specificity for persistent asthma in later childhood
Leung DM. Pediatric Allergy 2nd Ed, 2010
Asthma phenotypes in children > 2 years
Bacharier LB, et al,. Allergy 2008: 63: 5–34
Entry point of asthma diagnosis:
Recurrent Wheezing
and/or
Chronic Recurrent Cough
Pedoman Nasional Asma Anak, 2004
DiagnosisCough and/or Wheeze
Clinical historyPhysical examinationMantoux test
Suggestive of asthma:• Episodic• Nocturnal• Seasonal• Exertional• Atopic
Indeterminate features or suggestive of alternative diagnosis• Neonatal onset• Failure to thrive• Chronic infection• Vomiting/choking• Focal lung or CVS signs
If possible frequent peak flowmeasurements :• Reversibility (20%)• Variability (20%)
Consider• Chest and sinus x rays• Lung function• Bronchial challenge and/or• Bronchodilator response
….. Consider :• Sweat test• Immune function• Ciliary & Reflux studies
Bronchodilator responseNo response Response
WD/ Asthma
Assess severity and etiology
Review diagnosis and complianceif poor response to treatment
+ ve- ve
Alternative diagnosis and treatmentChest x ray if more thanmild episodic disease
Trial of antiasthma treatment Consider asthma as an associated problem
Not asthma
Pedoman Nasional Asma Anak, 2004
Differential diagnosis of wheezing in children
Nishimuta T. Allergology International 2011;60:147-169
Bernstein D. Pediatric for Medical Students 3rd Ed, 2011
Classification of Asthma in Children
Chronic• Infrequent episodic
asthma• Frequent episodic
asthma• Persistent asthma
• Acute• Mild attack• Moderate attack• Severe attack
Pedoman Nasional Asma Anak, 2004
Classification of diseaseClinical parametersand lung function
Infrequent episodic asthma Persistent asthmaFrequent episodic
asthma
Freq of attacks < 1x /month Daily> 1x /month
Duration of attacks < 1 week Daily >1 week
Between episodes No symptoms Frequent nocturnal symptoms Symptoms (+)
Sleep and activity Normal AffectMay affect
Physical exam Normal AbnormalMay affect
Controller No need Steroid/combinationSteroid/combination
Lung function (No attacks) PEF/FEV1 >80% PEF/FEV1 <60%
Variability 20-30%PEF/FEV1 60-80%
Variability (attacks) >15% > 50%> 30%
Pedoman Nasional Asma Anak, 2004
Asthma managements
Chronic asthma
Long term management
Reliever &Controller
Acute asthma
Attack management
Reliever
Pedoman Nasional Asma Anak, 2004
Asthma managements
Chronic asthma
Long term management
Algorithm diagnosis& treatment
Acute asthma
Attack management
Algorithm attack management
Pedoman Nasional Asma Anak, 2004
Asthma medicationController
drug to control asthma ie attack or symptom not easily
emerge
• Inhaled steroid• LABA, ALTR
Reliever drug to relieve
asthma attack or symptoms
• -agonist• Xanthine
• anticholinergic
Pedoman Nasional Asma Anak, 2004
23
Long term treatment2-agonist or theophyllineinhaled/oral intermittently
Add sodium cromoglicate
Replace with low dose inhaled steroidsContinue 2-a or/and
theophylline inhaled/oral intermittently
6-8 weeks>3 doses / week
6-8 weeksresponse (-)
Infrequent EpisodicSymptoms
Frequent episodicSymptoms
3-6 monthsEvaluation
3-6 monthsresponse (+)
6-8 weeksresponse (-)
3-6 monthsresponse (+)
24
Consider :• Long acting 2-agonists, or• Slow release 2-agonists, or• Slow release theophyllines
Increase dose of inhaled steroid
Add oral steroids
6-8 weeksrespons (-)
Persistent Symptoms
3-6 monthsrespons (+)
6-8 weeksrespons (-)
3-6 monthsrespons (+)
6-8 weeksrespons (-)
3-6 monthsrespons (+)
Pedoman Nasional Asma Anak, 2004
> 2 days/weekNeed for reliever/rescue
Nocturnal symptoms or awakening
None(less than twice/week, typically for short periods of the order of minutes and rapidly relieved by use of a rapid-acting bronchodilator)
Limitations of activities
>Twice a weekDaytime symptoms:wheezing, cough,difficult breathing
Uncontrolled(>3 features of partly con-
trolled present in any week)
Partly controlled(any measure present in any
week)
ControlledCharacteristic
None(child is fully active,
plays and runs withoutlimitation or symptoms)
None(including no nocturnalcoughing during sleep)
< 2 days/week
(typically for short periods of the order of minutes and rapidly relieved by use of a rapid-acting bronchodilator
(coughs during sleep or wakes with cough, wheezing,and/or difficult breathing)
Any
> 2 days/week
Any(cough, wheeze or difficulty breathing,during exercise,
play or laughing)
(typically last minutes or hours or recur, but partially or fully relieved by a rapid-acting bronchodilator
>Twice a week
Any(cough, wheeze or difficulty breathing,during exercise,
play or laughing)
(coughs during sleep or wakes with cough, wheezing,and/or difficult breathing)
Any
Levels of Asthma Control in Children 5 years or youngers
GINA, 2009
Assessment of severity
Mild Moderate
SevereRespirator
y arrest imminent
Breathless WalkingCan lie down
TalkingInfant-softerShorter cryDifficult feedingPrefers sitting
At restInfant stops feedingHunched forward
Talks in Sentences Phrases Words
Alertness Maybe agitated
Usually agitated
Usually agitated
Drowsy or confused
Respiratory rate
Increased Increased Often >30x/min
Normal rates of breathing in awake children:
Age Normal rates<2 months <60/min2-12 months <50/min1-5 years <40/min6-8 years <30/min
Accessory muscles and suprasternal retractions
Usually not Usually Usually Paradoxal thoraco-abdominal movement
Wheeze Moderate, often only end expiratory
Loud Usually loud Absence of wheeze
Pulse/min <100 100-200 >120 Bradycardia
Infants 2-12 months <160/min
Preschool age 1-2 years <120/min
School age 2-8 years <110/min
Pulsus paradoxus
Absent<10 mmHg
Maybe present10-25 mmHg
Often present20-40 mmHg
Absence suggests
Pulsus paradoxus
Absent<10 mmHg
Maybe present10-25 mmHg
Often present20-40 mmHg
Absence suggests
PEF after initial roncho-dilator, %predicted or %personal best
Over 80% Approx. 60-80%
<60% predicted or personal best or response lasts <2 hrs
PaO2 (on air)
and/orPaCO2
NormalTest not usually necessary<45 mmHg
>60 mmHg
<45 mmHg
<60 mmHgpossible cyanosis
>45 mmHg
SaO2% >95% 91-95% <90%Pedoman Nasional Asma Anak, 2004
Acute asthma algorithm
Clinic/ERAsses attack severity
1st management• nebulitation -agonis 3x, 20 min interval
• 3rd nebulitation + anticholinergic
Moderate attack (nebulization 2-3x,
partial response)• give O2
• asses: Moderate – ODC
• IV line
Mild attack
(nebulization 1x, complete response) • persist 1-2 hr:
discharge• symptom reappear:
Moderate attack
Severe attack (nebulization 3x,
no response)
• O2 from the start•IV line•asses: Severe -
hospitalized• CXR
One Day Care (ODC)• Oxygen therapy• Oral steroid • Nebulized / 2 hour• Observe 8-12 hours, if stable discharge• Poor response in 12h, admission
Admission room• Oxygen therapy• Treat dehydration and acidosis • Steroid IV / 6-8 hours• Nebulized / 1-2 hours• Initial aminophylline IV, then maintenance• Nebulized 4-6x good response per 4-6 h• If stable in 24 hours discharge• Poor response ICU
Discharge• give -agonist (inhaled/oral)• routine drugs• viral infection: oral steroid • Outpatient clinic in 24-48 hours
Notes:• In severe attack, directly use -agonist + anticholinergic• If nebulizers not available, use adrenalin SC 0.01 ml/kg/times with maximal dose 0.3 ml/times •Oxygen therapy 2-4 l/min should be early treatment in moderate and severe attack
Pedoman Nasional Asma Anak, 2004
Non responsive• Dehydration:
– inadequate intake, the longer the more– evaluate: clinically, laboratory; overcome
• Acidosis: correction• Atelectasis & mucus plug: CXR mandatory; physiotherapy
Non responsive• Excessive use of ß-agonist down regulation
of ß-agonist receptors tachyphylaxis, subsensitivity
Systemic steroid
– reduce the edema – up regulates more ß-agonist receptors
sensitive again to ß-agonist drugs
Choosing an Inhaler DeviceA pressurized metered-dose inhaler (MDI) with a
valved spacer (with or without a face mask, depending on the child’s age) is the preferred
delivery systemChoosing an Inhaler Device Age group Preferred device Alternative device
Younger than 4 yearsPressurized metered-dose inhaler plus dedicated spacer with face mask
Nebulized with face mask
4-5 yearsPressurized metered-dose inhaler plus dedicated spacer with mouth piece
Pressurized metered-dose inhaler plus dedicated spacer with mouth piece, or
Nebulizer with mouthpiece or face mask
GINA, 2009
35
Jet nebulizer
36
Ultrasonic nebulizer
References
References