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Bronchial Asthma and Acute Asthma

The International Studies on Asthma and Allergy (ISAAC) has shown that the prevalence of asthma among school age children is 10%. Asthma is a common condition that gives rise to considerable morbidity and mortality. Its prevalence is increasing and a local study found 13.8% of primary school children in Kuala Lumpur to be asthmatic. Definition Chronic airway inflammation leading to increase airway responsiveness that leads to recurrent episodes of wheezing, breathlessness, chest tightness and coughing particularly at night or early morning. Often associated with widespread but variable airflow obstruction that is often reversible either spontaneously or with treatment. Reversible and variable airflow limitation as evidenced by >15% improvement in PEFR (Peak Expiratory Flow Rate), in response to administration of a bronchodilator.

In pre-school children, epidemiological studies have delineated children with wheezing into 3 different phenotypes: Transient wheezers, Persistent wheezers and Late-onset wheezers. These phenotypes are only useful when applied retrospectively. Hence, there are recommendations to define pre-school wheezing into two main categories: Episodic (viral) wheeze. Children who only wheeze with viral infections and are well between episodes. Multiple trigger wheezers are children who have discrete exacerbations and symptoms in between these episodes. Triggers are smoke, allergens, crying, laughing and exercise.

The presence of atopy (eczema, allergic rhinitis and conjunctivitis) in the child or family supports the diagnosis of asthma . However, the absence of these conditions does not exclude the diagnosis. Thus, because of the difficulty to diagnose asthma in young children, an asthmatic predictive index can be helpful in predicting children who were going to be asthmatics. The possibility of those with negative index not becoming asthmatic by 6 years old was 95% whereas those with a positive index have a 65% chance of becoming asthmatic by 6 years old.

The child who presents with chronic cough alone (daily cough for > 4 weeks) and has never wheezed is unlikely to have asthma. These children require further evaluation for other illnesses that can cause chronic cough. MANAGEMENT OF CHRONIC ASTHMA

Patients with a new diagnosis of asthma should be properly evaluated as to their degree of asthma severity:

Note This division is arbitrary and the groupings may merge. An individual patients classification may change from time to time. There are a few patients who have very infrequent but severe or life threatening attacks with completely normal lung function and no symptoms between episodes. This type of patient remains very difficult to manage. PEFR = Peak Expiratory Flow Rate; FEV1 = Forced Expiratory Volume in One Second. In 2006, the Global Initiatives on Asthma (GINA) has proposed the management of asthma from severity based to control based. The change is due to the fact that asthma management based on severity is on expert opinion rather than evidence based, with limitation in deciding treatment and it does not predict treatment response. Asthma assessment based on levels of control is based on symptoms and the three levels of control are well controlled, partly control and uncontrolled. Patients who are already on treatment should be assessed at every clinic visit on their control of asthma

Prevention Identifying and avoiding the following common triggers may be useful Environmental allergens These include house dust mites, animal dander, insects like cockroach, mould and pollen. Useful measures include damp dusting, frequent laundering of bedding with hot water, encasing pillow and mattresses with plastic/vinyl covers, removal of carpets from bedrooms, frequent vacuuming and removal of pets from the household. Cigarette smoke Respiratory tract infections - commonest trigger in children. Food allergy - uncommon trigger, occurring in 1-2% of children Exercise Although it is a recognized trigger, activity should not be limited. Taking a -agonist prior to strenuous exercise, as well as optimizing treatment, are usually helpful.

Drug Therapy

Treatment of Chronic Asthma Asthma management based on levels of control is a step up and step down approach as shown in the table below:

Note: Patients should commence treatment at the step most appropriate to the initial severity. A short rescue course of Prednisolone may help establish control promptly. Explain to parents and patient about asthma and all therapy Ensure both compliance and inhaler technique optimal before progression to next step. Step-up; assess patient after 1 month of initiation of treatment and if control is not adequate, consider step-up after looking into factors as above. Step-down; review treatment every 3 months and if control sustained for at least 4-6 months, consider gradual treatment reduction. Monitoring During each follow up visit, three issues need to be assessed. They are: Assessment of asthma control based on: Interval symptoms. Frequency and severity of acute exacerbation. Morbidity secondary to asthma. Quality of life. Peak Expiratory Flow Rate (PEFR) or FEV1 monitoring.

Compliance to asthma therapy: Frequency. Technique. Asthma education: Understanding asthma in childhood. Reemphasize compliance to therapy. Written asthma action plan. Patients with High Risk Asthma are at risk of developing near fatal asthma (NFA) or fatal asthma (FA) . This group of patients need to be identified and closely monitored which includes frequent medical review (at least 3 monthly), objective assessment of asthma control with lung function on each visit, review of asthma action plan and medication supply, identification of psychosocial issues and referral to a paediatrician or respiratory specialist. MANAGEMENT OF ACUTE ASTHMA Assessment of Severity Initial (Acute assessment) Diagnosis - symptoms e.g. cough, wheezing. breathlessness , pneumonia Triggering factors - food, weather, exercise, infection, emotion, drugs, aeroallergens Severity - respiratory rate, colour, respiratory effort, conscious level Chest X Ray is rarely helpful in the initial assessment unless complications like pneumothorax, pneumonia or lung collapse are suspected. Initial ABG is indicated only in acute severe asthma. Management of acute asthma exacerbations Mild attacks can be usually treated at home if the patient is prepared and has a personal asthma action plan. Moderate and severe attacks require clinic or hospital attendance. Asthma attacks require prompt treatment. A patient who has brittle asthma, previous ICU admissions for asthma or with parents who are either uncomfortable or judged unable to care for the child with an acute exacerbation should be admitted to hospital. Criteria for admission Failure to respond to standard home treatment. Failure of those with mild or moderate acute asthma to respond to nebulised -agonists. Relapse within 4 hours of nebulised - agonists. Severe acute asthma.

Management of Acute Exacerbation of Bronchial Asthma in Children MILD

Observe for 60 min after Last Dose Review after 20 min, If No Improvement then treat as Moderate.

MODERATE

Observe for 60 min after Last Dose If No Improvement then for Admission and treat as Severe/Life Threatening SEVERE/LIFE THREATENING

Continue observation and review. Footnotes on Management of Acute Exacerbation of Asthma: 1. Monitor pulse, color, PEFR, ABG and O2 Saturation. Close monitoring for at least 4 hours. 2. Hydration - give maintenance fluids. 3. Role of Aminophylline debated due to its potential toxicity. To be used with caution, in a controlled environment like ICU. 4. IV Magnesium Sulphate : Consider as an adjunct treatment in severe exacerbations unresponsive to the initial treatment. It is safe and beneficial in severe acute asthma. 5. Avoid Chest physiotherapy as it may increase patient discomfort. 6. Antibiotics indicated only if bacterial infection suspected. 7. Avoid sedatives and mucolytics. 8. Efficacy of prednisolone in the first year of life is poor.

9. On discharge, patients must be provided with an Action Plan to assist parents or patients to prevent/terminate asthma attacks. The plan must include: a. How to recognize worsening asthma. b. How to treat worsening asthma. c. How and when to seek medical attention. Salbutamol MDI vs nebulizer < 6 year old: 6 x 100 mcg puff = 2.5 mg Salbutamol nebules. > 6 year old: 12 x 100 mcg puff = 5.0 mg Salbutamol nebules.