Asthma

Basics
DESCRIPTION

Characterized by 3 components:
1. Reversible airway obstruction
2. Airway inflammation
3. Airway hyperresponsiveness to a variety of stimuli

Diagnosis (the 3 Rs)

1. Recurrence: Symptoms are recurrent.
2. Reactivity: Symptoms are brought on by a specific occurrence or exposure (trigger).
3. Responsive: Symptoms diminish in response to bronchodilator or anti-inflammatory agent.

CLINICAL:

Pitfalls:
1. Not recognizing that asthma can manifest as chronic cough; wheezing may not be evident
2. Reluctance to label child with having asthma (using terms such as reactive airways
disease or bronchitis)
3. Frequent antibiotic or cough medicine use to treat asthma symptoms

4. Recurrent pneumonias often are actually asthma exacerbations; subsegmental

atelectasis on chest x-ray misdiagnosed as an infiltrate
5. Underreporting of asthma symptoms; beware the child who doesnt like to play sports;
he/she may have learned that exercise causes dyspnea
6. Poor adherence with therapy when symptoms are controlle
7. Failure to use inhaled medications properly: Inhaled medication use must be taught and
reviewed at each visit. A fixed-volume holding chamber should always be used with a
pressurized metered-dose inhaler (pMDI), regardless of patient age. pMDIs should be
refilled based on the number of doses used, not by estimating contents by shaking or
spraying.
EPIDEMIOLOGY
Incidence

Most common chronic illness in children

Death from asthma in children more than tripled from 1979 to 1996, but has been decreasing since
then, perhaps due to better recognition and increased use of anti-inflammatory medications. The
incidence of death from asthma does not seem to correlate with severity.

BASICS-EPIDEMIOLOGY-Prevalence

Wheezing in children is extremely common in the industrialized world (cumulative prevalence, 30

60%).

In younger children, most episodes occur following viral infections.

>50% of children who wheeze in early childhood stop wheezing by age 6 years.

14% of all young children (40% of those who wheeze during infancy) continue to wheeze.

RISK FACTORS
Genetics

Children of asthmatics have higher incidence of asthma.

1. 67% risk if neither parent has asthma
2. 20% risk if 1 parent has asthma
3. 60% risk if both parents have asthma

Several genes are known to be associated with the development of atopy and bronchial muscle
responsiveness.

PATHOPHYSIOLOGY

Immune and inflammatory responses in the airways are triggered by an array of environmental
antigens, irritants, or infectious organisms.

Atopy and asthma are related.

1. Eosinophilia and the ability to make excess IgE in response to antigen is associated with
increased airway reactivity.
2. Asthma is more common in children who have allergic rhinitis and eczema.

Viral infections, particularly respiratory syncytial virus (RSV), during infancy may play a role in the
development of asthma or may modify the severity of asthma.

Exposure to cigarette smoke and other airway irritants influences the development and severity of
asthma.

Airway is stimulated and primary inflammatory mediators released.

Airway is invaded by inflammatory cells (mast cells, basophils, eosinophils, macrophages, neutrophils,
B and T lymphocytes).

Inflammatory cells respond to and produce various mediators (cytokines, leukotrienes, lymphokines),
augmenting the inflammatory response.

Airway epithelium is inflamed and becomes disrupted, and basal membrane is thickened.

Airway smooth muscle is hyperresponsive, and bronchoconstriction ensues.

Airway smooth muscle hypertrophy and airway epithelial hyperplasia are characteristic chronic
changes resulting from poorly controlled asthma.

Diagnosis

SIGNS AND SYMPTOMS

History

Inquire about these symptoms: Coughing, wheezing, shortness of breath, chest tightness:
1. Frequency of symptoms defines severity.
2. Precipitating factor (trigger)
3. Response to bronchodilator or anti-inflammatory medication
4. Family history of asthma or atopy

Pattern of symptoms:
1. Perennial versus seasonal
2. Continuous versus acute
3. Duration and frequency of episodes
4. Diurnal variation/nocturnal symptoms

Do any of the following set off the breathing difficulty?

1. Infections (upper respiratory, sinusitis)
2. Exposure to dust (mites), animal dander, pollen, mold
3. Cold air or weather changes
4. Exercise or play
5. Environmental stimulants (e.g., cigarette smoke, strong odors, pollutants)
6. Emotional factors (e.g., laughing, crying, fear)
7. Drug intake (aspirin, nonsteroidal anti-inflammatory drugs, -blockers)
8. Food additives
9. Endocrine factors (e.g., menses, pregnancy, thyroid dysfunction)

Review of systems:
1. Symptoms of complicating factors (gastroesophageal reflux, sinusitis, allergies)
2. Dyspepsia, sour taste (gastroesophageal reflux); throat clearing, purulent nasal discharge,
halitosis, cephalalgia, or facial pain (sinusitis); nasal itching, (allergic salute), eye rubbing,
sneezing, watery nasal discharge (allergies)

Impact of asthma:
1. Number of hospitalizations/intensive care unit admissions
2. Number of emergency room visits/doctors office visits
3. Asthma attack frequency
4. Number of missed school days/parent workdays
5. Limitation on activity

6. Number of courses of systemic steroids needed

Environmental history:
1. Type of home
2. Location of home (urban, suburban, rural)
3. Heating system/air conditioning
4. Use of humidifier
5. Presence of molds, cockroaches, rodents
6. Fireplace
7. Carpeting
8. Stuffed animals
9. Pets
10.Exposure to cigarette smoke

Physical Exam

Pulmonary examination may be normal when asymptomatic.

Assess work of breathing:

1. Level of distress
2. Intercostal/supraclavicular muscle retractions

Chest shape (i.e., normal versus barrel-shaped)

Lung auscultation:
1. Wheezing
2. End-expiratory involuntary cough
3. Prolonged expiratory phase
4. Crackles or coarse breath sounds
5. Stridor (indicates extrathoracic airway obstruction)

Head, eyes, ears, nose, and throat examination. Signs of allergies or sinusitis:
1. Watery or itchy eyes
2. Allergic shiners
3. Dennie lines
4. Nasal congestion
5. Boggy nasal turbinates
6. Nasal polyps
7. Postnasal drip

General examination (vital signs):

1. Blood pressure (pulsus paradoxus)
2. Respiratory rate (tachypnea)

Skin: Evidence of eczema

Extremities: Digital clubbing (very rare in asthma; suggests alternative diagnosis)

Physical examination trick: Forced-exhalation maneuver to observe for wheezes or for precipitating
coughing

TESTS
LABORATORY

Pulmonary function tests:

1. Essential for the assessment and ongoing care of children with asthma
2. Spirometry measures the degree of airway obstruction and the response to bronchodilators.
3. Values obtained can measure absolute degree of airway obstruction.
4. Serial values can follow progress of disease and response to treatment.
5. Children as young as 45 years old can usually perform spirometry with practice.

Provocational testing:
1. Exercise challenge: Determines effect of exercise on triggering airway obstruction
2. Cold-air challenge: Indirect test of airway hyperresponsiveness
3. Methacholine challenge: A positive test supports the diagnosis of asthma (useful in cases
for which history is equivocal and pulmonary function test is normal), measures the degree
of airway hyperreactivity

Allergy evaluation:
1. Blood tests (eosinophil count, IgE level)
2. Skin testing (best test for assessing allergen sensitivity)
3. RAST testing (not as accurate as skin testing)
4. Sputum/nasal examination for presence of eosinophilia

Other studies:
1. Gastroesophageal reflux evaluation
2. pH probe
3. Milk scan
4. Barium swallow (confirms normal anatomy)

Peak flow meter (home testing):

1. Measures peak flow rate (PEFR)

2. Effort dependent
3. Assesses central, not peripheral airway obstruction
4. Used with patients who have poor symptom recognition or labile asthma
5. Dips in peak flow rate precede onset of clinical asthmatic symptoms.
6. Peak flow rate should be performed at least once a day.
7. Peak flow rate values are divided into 3 zones:

Green: 80% of baseline

Yellow: 5080% of baseline

Red: 50% of baseline

8. Specific peak flow rate guidelines should be individualized for each patient based on the
best measurement obtained during a 14-day period when the child is well.
IMAGING

Chest x-ray should be obtained if the diagnosis is uncertain or there is not the expected response to
treatment, to rule out congenital lung malformations or obvious vascular malformations.
1. Findings can be normal.
2. Common findings are peribronchial thickening, subsegmental atelectasis, and
hyperinflation.

Sinus CT is useful if symptoms suggest sinusitis.

Chest CT should be performed if bronchiectasis or anatomic abnormality is suspected.

DIAGNOSTIC PROCEDURES
Bronchoscopy can rule out:

Anatomic malformations

Foreign bodies

Mucus plugging

Vocal cord dysfunction

Assess for aspiration (lipid-laden macrophages)

DIFFERENTIAL DIAGNOSIS

Infectious:
1. Pneumonia
2. Bronchiolitis
3. Chlamydia infection
4. Laryngotracheobronchitis
5. Sinusitis

6. Immune deficiency

Mechanical:
1. Extrinsic airway compression
2. Vascular ring
3. Foreign body
4. Vocal cord dysfunction
5. Tracheobronchomalacia

Miscellaneous:
1. Cystic fibrosis
2. Bronchopulmonary dysplasia
3. Pulmonary edema
4. Gastroesophageal reflux
5. Recurrent aspiration
6. Bronchiolitis obliterans

Treatment
GENERAL MEASURES
DIET

Avoid foods or food additives (if truly allergic).

Food-induced asthma is uncommon.

SPECIAL THERAPY
Comp-Alt-Medicine

Miscellaneous drugs used in severe cases

Steroid-sparing agents:
1. Troleandomycin (TAO): Macrolide antibiotic; decreases clearance of corticosteroids, thus
prolonging the effects of corticosteroids on the lung; lower corticosteroid dosing required
2. Methotrexate: Potent immunosuppressive drug; needs further investigation in children
3. Cyclosporine: Shown to have steroid-sparing effect in adult population with asthma; side
effects are significant and may limit use
4. Magnesium sulfate (MgSO4): Used intravenously as a smooth muscle relaxer in severe
acute asthma exacerbation

Helium:
1. May improve airflow in severe asthma
2. Can improve ventilation and potentially oxygenation

Immunotherapy:
1. Efficacy in asthma is controversial
2. Most effective if a single antigen can be identified
3. Used only in select cases if medical management and environmental control measures are
ineffective

MEDICATIONS

Corticosteroids (anti-inflammatory agents):

1. Most effective anti-inflammatory agents
2. Inhaled: Reduce airway inflammation and hyperresponsiveness more than any other
inhaled agents; inhibit production and release of cytokines and arachidonic acidassociated
metabolites; enhance -adrenoceptor responsiveness; side effects include oral thrush; may
minimally affect growth velocity at moderate or high doses
3. Dosage individualized to each patient. Agents vary in topical potency and systemic
bioavailability; available as pMDIs, dry-powder inhalers (DPIs), or
nebulized. Fluticasone (Flovent) 44, 110, 220 mcg/puff pMDI; budesonide(Pulmicort) 200
mcg/puff DPI; 250- and 500-mcg vials for nebulizer; beclomethasone (Beclovent, Vanceril,
Qvar) 40, 42, 80, 84 mcg/puff; triamcinolone (Azmacort) 100 mcg/puff; flunisolide (Aerobid)
250 mcg/puff
4. Oral: Used for asthma exacerbations or for severe asthma that cannot be otherwise
controlled. Exacerbations: Prednisone 12 mg/kg/d for 37 days or longer; usually tapered
if >7 days of therapy required or if systemic steroids are used frequently. Ongoing therapy:
0.51 mg/kg/d daily or every other day for patients with severe asthma. Undesirable sideeffect profile. When used daily, assess bone density and for cataract formation at least
yearly.
5. IV: Methylprednisolone (Solumedrol) 12 mg/kg IV q612h until improved and able to take
oral medication

Leukotriene modifiers (anti-inflammatory agents):

1. Block the synthesis and/or action of leukotrienes
2. 5-Lipoxygenase inhibitors, zileuton: May cause hepatic dysfunction
3. Leukotriene receptor antagonists: Aafirlukast (10 mg; Accolate) and montelukast (4, 5, and
10 mg; Singulair)
4. Indicated as monotherapy for mild or exercise-induced asthma and in combination with an
inhaled corticosteroid for more effective symptom control or using a lower dose of inhaled
corticosteroid

Mast-cell stabilizers
1. Weak anti-inflammatory agents
2. Preparations: Cromolyn sodium(Intal); nedocromil sodium (Tilade)
3. Decrease bronchial hyperresponsiveness

4. Can be used prior to exercise for exercise-induced symptoms

5. No significant side effects
6. Inhaled: Nebulizer; MDI

2-Agonists (bronchodilators): Indication is for relief of acute bronchoconstriction (quick-relief

medicine); used as needed in people with asthma who have breakthrough symptoms; used prior to
exercise in exercise-induced bronchospasm; regular use or overuse associated with worsened control
of asthma; routes include inhaled (most effective, metered-dose inhaler or nebulizer) and oral (least
effective, most side effects); short-acting (46 hours) preparations include albuterol (Ventolin,
Proventil, ProAir), terbutaline (Brethaire, Brethine), and metaproterenol (Alupent); a single-isomer
preparation of albuterol(Xopenex) may have a slightly longer duration of action and perhaps fewer
side effects; longer-acting (up to 12 hours) preparations include salmeterol (Serevent), available as
pMDI and DPI, can be used daily in conjunction with anti-inflammatory agent for improved symptom
control. Fixed combination products of inhaled corticosteroid and a long-acting beta agonist (Advair,
Symbicort) are available as DPIs and pMDIs.
1. Theophylline (bronchodilator): 2nd-line agent used when more conventional therapies are
unsuccessful; indications are chronic, poorly controlled asthma, and nocturnal asthma (if no
gastroesophageal reflux); adjunctive therapy with 2 drugs and steroids in hospitalized
patients in selected cases; route (oral or IV); serum levels must be routinely monitored
(therapeutic levels are 1020 mg/mL). Side effects are seen with increased levels. Many
factors affect theophylline levels. Increased levels are seen with erythromycin,
ciprofloxacin, cimetidine, viral illnesses, fever. Decreased levels are seen
with phenobarbital, phenytoin, rifampin.

Anticholinergic agents (bronchodilators): Adjunctive bronchodilators, may be useful in patients who

only partially respond to -agonists; preparations include Ipratropium bromide MDI or ampule for
nebulization (Atrovent)

Monoclonal antibodies against IgE (Xolair) can be given as a monthly SC injection in severe asthma
patients with moderately high IgE levels.

Follow-up Recommendations
Long-term follow-up is essential to maintain normal activity and pulmonary function. All patients should use a
valved holding chamber with pMDIs, and technique for all inhaled medications should be reviewed regularly.
DISPOSITION
FOLLOWUP-DISPOSITION-Issues-for-Referral

A patient who requires hospitalization more than once a year, or who has required intensive care

A patient who requires frequent bursts of systemic corticosteroids

A patient whose airway obstruction is not easily reversible

A patient who has clinical features suggesting another pulmonary process

EXPECTED COURSE/PROGNOSIS
With proper therapy and good adherence to treatment regimen: Excellent

POSSIBLE COMPLICATIONS
Morbidity:

Frequent hospitalizations and absence from school

Psychologic impact of having a chronic illness

Decline in lung function over time

PATIENT MONITORING
Signs that may indicate problems:

Increased symptoms (cough day or night, wheeze)

Exercise limitations or symptoms during exercise

Decrease in peak flow rate

Increasing use of inhaled bronchodilators

Subject not improving on enhanced home therapy

Patient Teaching Medication

ACTIVITY

Most patients with asthma can participate fully in sports, even at a high level, with close follow-up.
Extra medications such as albuterol and/or cromolyn may be required before vigorous exercise. All
athletes should have their quick-relief medications on hand at all times.

Athletes with asthma may need to report their medications to the governing bodies of their sport.

PREVENTION

Patient and caregiver education is mandatory to establish provider/caregiver partnership and ensure
adherence with treatment plan.

Every patient/caregiver should be taught that asthma is a chronic, inflammatory condition that can be
controlled with proper therapy.

All medications should be explained and potential risks (side effects) and benefits reviewed.

A written asthma management plan should be provided, outlining daily therapy and an action plan for
managing exacerbations of asthma.

Environmental counseling:
1. Avoid airborne irritants (tobacco smoke, wood stoves, noxious fumes).
2. Minimize dust-mite exposure.
3. Minimize stuffed animals, quilts, books, and clutter.
4. Use dust miteproof coverings on mattresses, pillows, and box springs.
5. Wash pillows, blankets, and sheets in hot water.
6. Avoid molds by decreasing relative humidity to 50%.
7. Remove pets from childs bedroom, and from house if patient is allergic to the animal.

Additional Reading
Allen JL, Bryant-Stephens T, Pawlowski NA. The Childrens Hospital of Philadelphia Guide to
Asthma. Philadelphia: Wiley-Liss; 2004.
Frequently Asked Questions

Q: Will my child outgrow his or her asthma?

A: Family history and allergies affect the ultimate outcome. Wheezing during the 1st 3 years of life is
extremely common, with 4050% of all children wheezing at some time. Many of these children do not
develop asthma and outgrow their illness by school age. Some patients develop asthma again as
young adults.

Q: Can my child become dependent on asthma medications?

A: Children do not become dependent on these medications as they would with narcotic agents.
Daily asthma medications are required to maintain airway patency and to control airway inflammation.

Q: Will my child be on medications for the rest of his or her life?

A: This depends on the severity of the asthma. The types, doses, and frequency of asthma
medications will change over a patients lifetime.

Q: Do inhaled steroids affect patient growth?

A: There is some transient and slight decrease in growth velocity seen in children who receive
moderate-dose inhaled corticosteroids (~0.5 mg/d). Ultimate height does not seem to be affected.