Investigation

Usually diagnosed from the history and examination and no investigations are needed. History Taking Current symptoms Pattern of symptoms Precipitating factors Present treatment Previous hospital admission Typical exacerbations Home/ school environment Impact on life style History of atopy (allergy) Response to prior treatment Prolonged URTI symptoms Family history

Sometimes, specific investigations are required to confirm the diagnosis, or explore the severity and phenotype in more detail.

Pulmonary Function Testing: I. Spirometry II. Bronchoprovocation challenges (To see whether your airway is hyper responsive) III. Exercise challenges IV. Peak expiratory flow (PFE). (Most children over 5 years of age can use a peak flow meter)
Radiology: Chest Radiographs Allergy testing (Skin-prick testing )

Management

Acute Management

Chronic

Managing Acute 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 nebulized -agonists. Relapse within 4 hours of nebulized - agonists. Severe acute asthma.

Monitoring Acute Asthma

Monitor pulse, color, PEFR, ABG and O2 Saturation. Close monitoring for at least 4 hours. Hydration - give maintenance fluids. Role of Aminophylline debated due to its potential toxicity. To be used with caution, in a controlled environment like ICU. 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. Avoid Chest physiotherapy as it may increase patient discomfort. Antibiotics indicated only if bacterial infection suspected. Avoid sedatives and mucolytics. Efficacy of prednisolone in the first year of life is poor.

On discharge, patients must be provided with an Action Plan to assist parents or patients to prevent/terminate asthma attacks.

Preventing Chronic Asthma

Identifying and avoiding the following common triggers Environmental allergens Cigarette smoke Respiratory tract infections - commonest trigger in children. Food allergy - uncommon trigger, occurring in 1-2% of children Exercise

Monitoring Chronic Asthma

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.

Epidemiology of Asthma Among Malaysian Children

Primary school children : 13.8% Children aged 13-14 : 9.6% Adult ( self-reported) in National Health and Morbidity Survey (NHMS) : 4.1% Prevalence was higher in rural (4.5%) than in Urban areas (4.0%). However, another study was conducted by Universiti Putra Malaysia in 2010 ,shows that prevalence of asthma among urban children was the highest (5.7%), followed by industrial area (5.2%), and rural children (4.6%). Prevalence was also higher in those with lower educational status (5.6%)and lower income (4.7%)

Grading of Acute Exacerbation

1. 2. 3. Diagnosis : symptoms (eg; cough, wheezing, breathlessness, pneumonia) Triggering factors : food, weather, exercise, infection, emotion, drugs Severity: respiratory rate, colour, respiratory effort, conscious level

Parameter

Mild

Moderate

Severe

Life threatening

Breathless

When walking

When talking

At rest Infants: stop feeding

words Usually agitated Unable to speak Drowsy/ confused/coma Poor resp effort Paradoxical thoracoabdominal mov. Silent chest

Talks in Alertness

Sentences Maybe agitated

Phrases Usually agitated

Resp. Rate Accessory Muscle usage/ retractions Wheeze

Normal to mildly increased Absent

Increased Present- moderate

Markedly increased Present- severe

Moderate, often only end expiratory >95% <100 >80%

Loud

Usually loud

SpO2 (on air) Pulse/ min PEFR1

92-95% 100-120 60-80%

<92% >120 (>5yrs) >160 (infants) <60%

Cyanosis, <92% Bradycardia Unable to perform

Grading of Chronic Asthma

1. 2. Based on severity Based on levels of control

Classification

Daytime symptoms

Nocturnal symptoms

FEV1/ PEFR (%)

Intermittent
Mild persistent Moderate persistent Severe persistent

<1/week
>1/week Daily Continual daily

<1/month
>2/month >1/week Daily

>80
>80 >60-80 <60

Evaluation of the background of newly diagnosed asthma

Category Clinical Parameters

Intermittent

Daytime symptoms less than once a week

Nocturnal symptoms less than once a month No exercise induced symptoms Brief exacerbations not affecting sleep and activity Normal lung function Persistent (Threshold for preventive treatment) Daytime symptoms more than once a week Nocturnal symptoms more than twice a month Exercise induced symptoms

Mild Persistent

Exacerbations > 1x/month affect sleep/activity

PEFR / FEV1 > 80%

Continued..

Moderate Persistent

Daytime symptoms daily Nocturnal symptoms more than once a week Exercise induced symptoms
Exacerbations >2x/month affect sleep, activity PEFR/ FEV1 60-80%

Severe Persistent

Daytime symptoms daily Daily nocturnal symptoms Daily exercise induced symptoms Frequent exacerbations >2x/month affect sleep, activity PEFR/ FEV1 < 60%

Asthma Severity based to Control Based

Proposed by *The Global Initiatives for Asthma (GINA). Based on symptoms and 3 levels of control: 1. Well controlled 2. Partly control 3. Uncontrolled

*A medical guidelines organization which works with public health officials and health care professionals globally to reduce asthma prevalence.

Level of Asthma Control (GINA 2006)

Characteristics Controlled All of the following: none None None Partly controlled Any measure present in any week >2/week Any Any >3 features of partly controlled asthma present in any week Uncontrolled

Daytime symptoms Limitation of activities Nocturnal symptoms/ awakening Need for reliever Lung function test Exacerbations

None None none

>2/week <80% predicted >1/ year One in any week

Asthmatic Predictive Index

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.

A clinical index to define Risk of Asthma in young children with Recurrent Wheeze Positive Index ( >3 wheezing episodes / year during first 3 years Major criteria Plus one Major criteria or two Minor criteria Eczema Parental asthma

Positive aeroallergen skin test

Minor criteria Positive skin test Wheezing without URTI Eosinophillia (>4%)

Treatment
Drug Therapy
Delivery System available & recommendation for diff. ages Age (years) <5 5-8 >8 Oral + MDI + Spacer + + + MDI + Mask + Spacer + Dry Powder Inhaler +

*MDI = metered-dose inhaler

Treatment for Chronic Asthma

Management Based Control Reduce
STEP 1 Intermittent
As needed rapid acting - agonists

Increase
STEP 4 Severe Persistent STEP 5 Severe Persistent

STEP 2 Mild Persistent

As needed rapid acting - agonists

STEP 3 Moderate Persistent

Controller Options

Select One

Select One

Add One / more

Add One / both

Low dose Inhaled steroids Leukotriene modifier

Low dose ICS + long acting - agonists

Med / High dose ICS + long acting - agonists Leukotriene modifier SR Theophylline

Oral Glucocorticoids Lowest dose Anti-IgE

Med / High dose ICS

Low dose ICS + Leukotriene modifier

Low dose ICS + SR Theophylline

Drug Treatment

Drugs Used in Treatment of Acute Asthma

Drug B2-agonists (causes bronchodilation of the small airways) Salbutamol Nebulizer solution 5mg/ml or 2.5 mg/ml nebule 0.15 mg/kg/dose (max 5mg) or < 2 y/o : 2.5 mg/dose > 2 y/o : 5.0 mg/dose Cont: 500 mcg/kg/hour Bolus: 5-10 mcg/kg over 10min Infusion: 0.5-1.0 mcg/kg/min, increase by 1.0 mcg/kg/min every 15min to a max of 20 mcg/kg/min 0.2-0.3 mg/kg/dose or <20kg : 2.5 mg/dose >20kg : 5.0 mg/dose 5-10 mcg/kg/dose 0.12-1.5 mg/dose Formulation Dosage

Intravenous

Terbutaline

Nebuliser solution 10mg/ml, 2.5 mg/ml or 5 mg/ml respule

Parenteral Fenoterol Nebuliser solution

Drug Corticosteroid Prednisolone Hydrocortisone Methylprednisolone Other agents Ipratropium bromide Aminophylline oral

Formulation

Dosage

1-2 mg/kg/day in divided doses (for 3-7 days) 4-5 mg/kg/dose 6 hourly 1-2 mg/kg/dose 6-12 hourly

intravenous intravenous

Nebuliser solution (250 mcg/ml) Intravenous

<5 y/o : 250 mcg 4-6 hourly >5 y/o : 500 mcg 4-6 hourly 6 mg/kg slow bolus (if not previously on theophylline) followed by infusion 0.5-1.0 mg/kg/hr 4mg granules 5mg/ tablet on night chewable 10mg/tablet ON

Montelukast

Oral

Drugs Used in Treatment of Chronic Asthma

Drug
Relieving drugs B2-agonists Salbutamol Oral Metered dose inhaler Dry powder inhaler Oral 0.15mg/kg/dose TDS-QID/PRN 100-200 mcg/dose QID-PRN 100-200 mcg/dose QID-PRN 0.075 mg/kg/dose TDS-QID/PRN 250-500 mcg/dose QID/PRN 500-1000 mcg/dose QID/PRN (max 4000 mcg/daily) 200 mcg/dose QID/PRN

Formulation

Dosage

Terbutaline

Fenoterol

Metered dose inhaler

Ipratropium bromide

Metered dose inhaler

40-60mcg /dose TDS/QID/PRN

Drug Preventive drugs Corticosteroid Prednisolone Beclomethasone Diproprionate Budesonide Oral

Formulation

Dosage

1-2 mg/kg/day in divided doses <400 mcg/day : low dose 400-800 mcg/day : Moderate 8001200 mcg/day: High

Metered dose inhaler Dry powder inhaler

Fluticasone Propionate

Metered dose inhaler Dry powder inhaler

<200 mcg/day : Low 200-400 mcg/day : Moderate 400-600 mcg/day : High 160 microgram daily 320 microgram daily 20mg QID 1-2mg QID or 5-10mg BID-QID

Ciclesonide

Metered dose inhaler

Sodium cromoglycate

Dry powder inhaler Metered dose inhaler

Theophylline

Oral syrup Slow release

5 mg/kg/dose TDS/QID 10 mg/kg/dose BD

Drug Long acting B2-agonist Salmetrol Combination Salmetrol / fluticasone

Formulation

Dosage

Metered dose inhaler Dry powder inhaler

50-100 mcg/dose BD 50-100 mcg/dose BD

Metered dose inhaler Dry powder inhaler

25/50 mcg, 25/125mcg, 25/250mcg 50/100 mcg, 50/250mcg, 50/500mcg

Budesonide / formoterol
Antileukotrienes (leukotriene modifier) Montelukast

Dry powder inhaler

160/4.5mcg, 80/4.5mcg

Oral

4mg granules 5mg/tablet on night chewable 10mg/tablet ON

Devices used Pressured Metered Dose Inhaler (PMDI)

Used with spacer Appropriate for all age groups 0-2 years use spacer and facemask > 2 years use spacer alone Spacer is recommended as it increases drug deposition in the lungs Useful for acute asthma attacks when poor inspiratory effort may impair the use of inhalers direct to the mouth

Breath-Actuated Metered Dose Inhalers

> 6 years old Useful for delivering beta-agonists when out and about in older children Dont have to press canister to release the drug Do not require a spacer Medicine comes out automatically as the individual breathes in

Steps for Use

1. Shake gently and remove the cap from the mouthpiece. 2. Hold the inhaler upright and flip open the lever or take off the cap. If the inhaler is new or has not been used in the last 48 hours it must be primed. Point the inhaler away from you. Lift the lever on top of the canister. Push the test fire slide button on the bottom while holding the inhaler upright. Lower the lever and repeat the steps to release the second prime spray. 3. Tilt your chin up slightly and breathe out. 4. Place your lips around the mouthpiece and begin breathing in slowly. 5. Breathe in slowly through your mouth for 3 to 5 seconds. The inhaler will release a puff of medicine. 6. Hold your breath for 10 seconds and then breathe our slowly. 7. Close the flip lever and replace the cap over the mouthpiece.

Dry Powder Inhaler

> 4 years old Needs good inspiratory flow Less efficient in severe asthma and an acute attack Also used when children are out and about Rely on the individuals force of inspiration Medication is commonly held either in a capsule for manual loading or a proprietary form (pellet) from inside the inhaler. Once loaded or actuated, the operator puts the mouthpiece of the inhaler into their mouth and takes a deep inhalation, holding their breath for 5-10 seconds