BRONCHIAL ASTHMA IN CHILDREN Department of pediatrics
Slide 2
Definition Asthma is a chronic disease involving the
respiratory system in which the airways occasionally constrict,
become inflammated, and are lined with excessive amounts of mucus
often in response to one or more triggers.
Slide 3
Epidemiology Bronchial asthma (BA) is one from the most
frequent chronic diseases in children and its incidence continues
to increase in the last years. Conformable to ISAAC data
(International Study of Asthma and Allergy in Children), BA affects
5-20% of children on the earth globe, this index varying in
different countries (in USA - 5-10%, in Canada, UK - 25- 30%, in
Greece, China 3-6%).
Slide 4
Risk factors for BA development in children Familial
antecedents of BA and other allergic diseases. Contact with home
dust containing dust mite: Dermatophagoides pteronyssinus. Contact
with fur-bearing animals (cat, dog, etc.). Contact with mould
(species of fungi Alternaria, Aspergillus, Candida, Penicillium).
Contact with the pollen of different plants. Smoke of cigarettes,
after woods burning. Presence of cockroaches.
Slide 5
Risk factors for BA development in children Alimentary (fish,
egg, cows milk etc.) and drug allergens Meteorological factors
(cold air, fog). Physical activity Environmental pollution Presence
of gastroesophageal reflux. Drugs and vaccines (antibiotics
penicillin, cephasoline, tetracycline etc., sulfonamides, NSAID,
colorants, etc.) Viral infections Stress factors
Slide 6
Clinical classification of bronchial asthma Atopic (allergic)
asthma Nonatopic (nonallergic) asthma Status asthmaticus
Slide 7
Particular forms of bronchial asthma BA provoked by physical
effort Cough variant of BA Aspirinic BA
Slide 8
Classification of BA in function of severity Type of
BAExacerbations of BA Nocturnal accesses PEF and PEF variability
Intermittent< 1 time per week Asymptomatic, normal PEF between
accesses 2 times per month >80% 1 time per week, but 2 times per
month >80% 20 30% Moderate persistent Daily. Exacerbations
affect the activity >1 time per week60-80% >30% Severe
persistentPermanently. Limited physical activity Frequent30%
Slide 9
Clinical picture of BA Anamnesis Which questions must be given
in the case of BA suspicion: Had the patient episodes of wheezing,
inclusively repeated? Has the patient nocturnal cough? Has the
patient cough and wheezing after physical effort? Had the patient
episodes of wheezing and cough after the contact with aeroallergens
and pollutants? Had the patient episodes of wheezing after
supported respiratory infection? Is decreasing the degree of
symptoms expression after antiasthmatic drugs receiving?
Slide 10
Recommendations for personal and hereditary antecedents
assessment: Presence of dyspnea, wheezing, cough and thorax
oppression episodes, with evaluation of duration and conditions of
improving. Familial antecedents of bronchial asthma. Risk factors
Asthmatic symptoms are manifesting concomitantly (the thoracic
oppression is less constant) and have common: - Variability in time
(are episodic); - Preferentially nocturnal appearance; - Appearance
due to trigger factor (physical effort, exposition to allergens,
strong laugh, etc.). - Personal, familial and environmental
factors.
Slide 11
Characteristics of asthmatic attacks: Quick appearance with
expiratory dyspnea, prolonged expiration and wheezing, pronounced
sensation of thoracic oppression, lack of air (sensation of
suffocation). Duration from 20 30 min until a few hours.
Spontaneous disappearance or at administration of 2 -adrenomymetics
with short action. They appear more frequently in night. The
attacks appear suddenly and end also suddenly with tormenting cough
with elimination of mucous, viscous, pearl sputum in small
quantity.
Slide 12
Suggestive symptoms for bronchial asthma diagnosis in children:
Frequent episodes of wheezing (more than 1 episode per month);
Cough wheezing induced by physical activity; Nocturnal cough out of
viral infection periods; Lack of wheezing seasonal variations.
Slide 13
There are 3 categories of wheezing: Precocious transitory
wheezing; is associated with presence of such risk factors as
prematurity, smoking parents, dyspnea until 3 years; Persistent
wheezing with precocious onset (until 3 years); recurrent episodes
of wheezing associated with acute viral infections (predominantly
with respiratory syncitial virus, in children under 2 years, and
other viruses, in older children), without atopic manifestations or
familial antecedents of atopy; the symptoms persist until the
school age and can be present in 12 years old children in
significant proportion; Wheezing (asthma with tardy onset, after 3
years age); in this group asthma evolves in childhood period and
even in adults; children present signs of atopy (most frequent
atopic dermatitis) and air pathways pathology characteristic for
asthma.
Slide 14
Predictive signs for childhood asthma (preschool, school age):
Wheezing until 3 years; Presence of major risk factor (familial
antecedents of asthma); Two from three minor risk factors
(eosinophilia, wheezing without cough, allergic rhinitis).
Slide 15
Physical examination: Basic principles: The signs of
respiratory system affection can be absent. Inspection: - Sitting
position (orthopnea) with accessory respiratory muscles
involvement; - Tachypnea. At percussion: - Diffuse increased
sonority and down placed diaphragm. Auscultatively: - Diminished
vesicular murmur; - Dry coarse, polyphonic, disseminated crackles,
predominantly at expiration, that can be heard at distance
(wheezing); - Moist and subcrepitant crackles in more advanced
bronchial hypersecretion.
Slide 16
Causes of bronchial asthma exacerbations: Insufficient
bronchodilator treatment. Long-term defect of the basic treatment.
Viral respiratory infections. Changes of weather Stress Long time
exposure to triggers.
Slide 17
Appreciation of bronchial asthma exacerbations severity
SymptomMildModerateSevereImminence of respiratory stopping
Dyspnea-appears during gait; The child can stay in bed -in older
children it appears at speaking, in small children the crying
becomes more short and slow; feeding difficulties. - the child
prefers to sit down. - appears in rest; - refusal to eat; - forced
position (sit down, inclined forward)
Slide 18
Appreciation of bronchial asthma exacerbations severity
SymptomMildModerateSevere Imminence of respiratory stopping
Speaking-propositions-expressions-words State of alertness -can be
agitated-as a rule, agitated -inhibited or in confusion state
Frequency of respiration -increased -sometimes> 30/min.
Participation of accessory respiratory muscles with supraclavicular
retraction -as a rule, absent -as a rule, present Paradoxical
thoraco- abdominal movement
Slide 19
Appreciation of bronchial asthma exacerbations severity
SymptomMildModerateSevereImminence of respiratory stopping Moist
cracklesModerately expressed, often, only at expiration Sonorous
Absent Frequency of cardiac contractions < 100100 120>
120Bradycardia Paradoxical pulse AbsentCan be presentOften is
present Absent
Slide 20
Appreciation of bronchial asthma exacerbations severity
SymptomsMildModerateSevereImminence of respiratory stopping PEF in
% from predicted after bronchodilator using >80%60 80%60mm Hg
60mm Hg 95%91-95%
Appreciation of allergic reaction by skin scarification test
Test appreciationConventional signThe visual image of allergic
reaction Negative -It is the same as the control test Uncertain
-/+Local redness, without swelling Weakly positive +Swelling
papule, 2-3 mm diameter and peri-papular redness Positive
++Swelling papule with a diameter >3mm
Criteria for hospitalization in intensive care departaments for
patients with BA: Mental deterioration; Paradoxic pulse >15-20
mm Hg; Severe pulmonary hyperinflation; Severe hypercapnia > 80
mm Hg; Cyanosis resistant to oxygenotherapy; Unstable
hemodynamics.
Slide 43
General principles of drug treatment in bronchial asthma: The
inhalatory therapy is the most recommended in all children, the
used devices for drug inhalation must be individualised for every
case in function of its peculiarities and characteristics of used
inhaler. In general lines, administration using
metered-dose-inhaler (MDI) with spacer versus nebulizing therapy is
more preferable, due to some advantages of MDI (reduced risk of
adverse effects, more decreased cost etc.). Administration through
nebulizers presents a lot of disadvantages: not precise dose,
increased cost, necessity of special apparatus.
Slide 44
General principles of drug treatment in bronchial asthma: Drugs
administered through inhalation are preferable due to their
increased therapeutic index: high concentrations of medicaments are
relieved directly in respiratory pathways, with strong therapeutic
effects and reduced number of systemic adverse effects.
Slide 45
General principles of drug treatment in bronchial asthma:
General principles of drug treatment in bronchial asthma: Devices
for medication administered through inhalation: pressure inhalers
with measured dose (MDI), dry powder inhalers, turbohalers,
diskhalers, nebulizers. Spacers (or retention camera) make easier
the use of inhalers, reduce systemic absorption and secondary
effects of inhaled glucocorticoids.
Slide 46
General principles of drug treatment in bronchial asthma:
General principles of drug treatment in bronchial asthma: Two types
of medication help in asthma control: controlers, or drugs that
prevent the symptoms and accesses, and relievers, or drugs, used
for access treatment and having rapid effect. The choice of
medication depends from the control level of BA at moment and from
curent medication. If curent medication does not ensure the
adequate control of BA, the indication of superior advanced step of
treatment is necessary.
Slide 47
General principles of drug treatment in bronchial asthma: If BA
is controled 3 months, the decreasing of supporting volume for
control maintaining minimal necessary dose establishing (passing to
inferior step) is possible. The therapy with adequate doses of
short acting inhalatory 2 -agonists is recommended in accesses (if
inhalers are not available, the bronchodilators can be administered
per os or i/v. In hospitals in the case of hypoxemic patient the
oxygen is given.
Slide 48
General principles of drug treatment in bronchial asthma: The
not recommended treatment in accesses: sedatives, mucolytics,
physiotherapy, hydration with high volume of liquids. Antibiotics
not treat the accesses, but are indicated in the case of
concomitant pneumonias or other bacterial infections.
Slide 49
The key moments in the treatment of BA by steps: Each step
includes variants of therapy serving as alternative in the choice
of BA control treatment, although are not similar to efficacy. The
efficacy of treatment increases from I step to V step and depends
from accessibility and certainity of drug. The steps 2-5 include
combinations of urgent medications, at necessity,of systemic
control treatment. In majority of patients with persistent BA,
which anteriorly didnt administered control treatment, is necessary
to iniciate the treatment from the 2- nd step.
Slide 50
The key moments in the treatment of BA by steps: If at primary
examination we determine the absence of BA control, the treatment
begins from the 3-rd step. The patients must use relievers (short
action bronchodilators) at each step. The systemic use of urgent
medication is a sign of uncontrolled BA, which indicates the
necessity of control therapy volume increasing. Reducing or absence
of necessity in relievers represent the goal of treatment and,
also, a criterion of efficacity.
Slide 51
The I step of BA treatment: It is indicated to patients: -
Which didnt receive anteriorly control medication and which
manifest episodic symptoms of BA (cough, humid crackles, dyspnoea 2
times per week, very rare with nocturnal symptoms); - In period
between accesses the disease manifestations and nocturnal
disturbance are absent or pulmonary function is normal. Urgent
medication: - short action inhaled 2 -agonists are recommended; -
the inhalatory anticholinergics (ipratropium bromide, oxitropium
bromide), peroral short action 2 -agonists (salbutamol), short
action theophyllin can be the alternative medicaments. Control
medication is not necessary.
Slide 52
The II step of BA treatment: It is indicated to the patients
with symptoms of persistent asthma, which anteriorly didnt
administered control medication. Urgent medication: - Recommended
inhalatory corticosteroids (ICS) in small doses; - Alternative
antileukotrienes are indicated to the following patients: -who dont
accept to use ICS; -with hard supported ICS adverse reactions; -
with concomitant allergic rhinitis. The initiation of therapy is
not recommended with: - Theophylline retard, that possesses minimal
anti-inflammatory effect and reduced efficacy in control therapy,
but has multiple adverse reactions; - Chromones (inhibitors of mast
cells degranulation) having decreased efficacy, although they are
distinguished by increased inoffensiveness.
Slide 53
The III step of BA treatment: It is indicated to the patients
with symptoms of disease showing the absence of adequate control in
the treatment at the steps I and II. Urgent medication: -
Recommended - short action inhaled 2 - agonists (salbutamol,
phenoterol).
Slide 54
The III step of BA treatment: Control medication one or two
drugs for disease evolution control: - Small doses of ICS in
combination with long action inhaled 2 -agonists in one self
inhaler with still fixed doses of drugs or two different inhalers;
- Small doses of ICS in combination with leukotrienes (montelucast,
zafirlucast); - Small doses of ICS in combination with small doses
of theophylline retard; - Increasing of ICS small doses until
medium doses.
Slide 55
The III step of BA treatment: Small doses of ICS, as a rule,
are sufficient due to additive effect of this combination, the dose
is increasing, if over 3-4 months of treatment the BA control was
not obtained. The monotherapy with formoterol and salmeterol is not
recommended, they are using in combination with ICS (fluticazon,
budesonid).
Slide 56
Note: The using of spacers for intensifying of drugs getting
into respiratory pathways and for decreasing of diverse
oropharingean adverse reactions is recommended for patients
receiving medium and high doses of ICS; The patients in which the
control on III step is not succeeded, need consulting of specialist
with experience in BA treatment for excluding an alternative
diagnosis or of cases of BA difficult to treat.
Slide 57
The IV step of BA treatment: It is indicated to the patients
with symptoms of disease showing the absence of control in the
treatment at the 3-rd step. The choice of drug in the therapy at IV
step depends from anterior indications at 2-nd and 3-rd steps.
Urgent medication: Recommended - short action inhaled 2 -agonists
Control medication includes two or more drugs for disease evolution
control: - ICS in medium and high doses in combination with long
action inhaled 2 -agonist; - ICS and long action inhaled 2 -agonist
and, supplementarly, small doses of retard theophyllin.
Slide 58
Note: Small and medium doses of ICS, in combination with
antileukotrienes, amplify the clinical effect smaller comparatively
with combination of ICS and long action inhaled 2 -agonist;
Increasing of ICS dose (from medium to high) in majority of
patients ensures only nonsignificant increasing of clinical effect,
and administration of high doses is recommended only in quality of
probe with duration of 1-3 months, when the control of BA at
combination of ICS medium doses and long action inhaled 2 -agonist
was not obtained. Long-term administration of high doses of ICS is
followed by increased risk of adverse effects.
Slide 59
The V step of BA treatment: It is indicated to the patients
with uncontrolled, severe BA, on the background of IV step therapy.
Urgent medication: Recommended: short action inhaled 2 -agonists.
Control medication includes supplementary drugs for IV step
medication for disease evolution control: - administration of CS
per os can amplify the effect of treatment, but has severe adverse
effects, therefore they must be given only in severe, uncontrolled
forms of BA on the background of 4-th step therapy; -
administration of anti-IgE antibodies, supplementarly to another
drugs, makes easy the control of BA, when the control of BA didnt
obtained with controller drugs, inclusively with high doses of ICS
and CS per os.
Slide 60
Specific immunotherapy It is indicated only in the period when
the allergic BA is controlled.
Slide 61
THE FOLLOW-UP OF PATIENTS WITH BRONCHIAL ASTHMA - The patients
return to medical consultation at I month after first visit,
ulteriorly in every 3 months. - After exacerbation, the medical
visits have place after 2 4 weeks. - If the BA control is
established, the regular maintaining visits, at 1 6 months, remain
essential, depending from situation.
Slide 62
THE FOLLOW-UP OF PATIENTS WITH BRONCHIAL ASTHMA - The number of
visits at physician and determining of control level depends from
initial severity of patology at concret patient and from degree of
patients knowledge about the necessary measures for BA adequate
control. - The control level must be determined in certain time
intervals both by physician, and by patient. - Patients who
administered high doses of ICS or CS per os are included in the
risk group for osteoporosis and fractures (it is necessary to
perform tomodensitometry of bones and administration of
biphosphates).
Slide 63
Continuous monitoring It is essential in realization of
therapeutic goals. The schemes of treatment, the medications and
level of BA control are analysed and modified during this
visits.
Slide 64
ADEQUATE MANAGEMENT OF BRONCHIAL ASTHMA Minimal or inexistent
symptoms, including nocturnal symptoms. Minimal episods or accesses
of BA. Absence of urgent visits at physician or hospital. Minimal
need of urgent medications. Absence of physical activity and sport
practise limitation. Pulmonary function is about norma. Secondary
effects caused by medication are minimal or inexistent. Prevention
of deceases caused by BA.