Dr.

KANUPRIYA CHATURVEDI

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 Chronic disease of the airways that
may cause
 Wheezing
 Breathlessness
 Chest tightness
 Nighttime or early morning coughing

 Episodes are usually associated with

widespread, but variable, airflow
obstruction within the lung that is
often reversible either spontaneously
or with treatment.
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 Allergens
 Infections
 Exercise
 Abrupt changes in the weather
 Exposure to airway irritants, such as
tobacco smoke

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 Recurrent asthma episodes, involving
◦ Shortness of breath
◦ Coughing
◦ Wheezing
◦ Chest pain or tightness
 Range in severity from
◦ Mild intermittent
◦ Severe persistent

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 Increases risk for early death
 Compromises child’s quality of
life
 Affects family’s quality of life
 Increased costs associated with
Increased utilization of health
care

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 Most common cause of school absence
◦ An average of 9.7 days per year for asthma
 Most prevalent cause of childhood disability
(long-term reduction in ability to do normal
activities)
 In 1994-95, 1.4% of U.S. children
experienced some disability due to asthma
◦ This is 21% of all children with asthma
 SES disadvantage doubles rate of disability
 Children with asthma have higher rates of
social and emotional problems

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 Asthma is the most common chronic disease
among children
 It has increased at epidemic rates since the
early 1980s
 Most common cause of ED visits,
hospitalization and missed school days
 In past 2 decades, African American children
had 2-4 times more ED visits than other races
 Studies show a rise in worldwide prevalence
 Seems to be more prevalent in affluent nations

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 Etiology of asthma is due to the interaction
of environmental and genetic factors
◦ Atopy, the genetically inherited susceptibility to
asthma, cannot account for epidemic.
 Probably NOT due to outdoor air quality
 Indoor air contaminants may be a factor
◦ Tighter construction trapping contaminants.
◦ Children spending more time indoors.

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10.1% Overall

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 Low-income populations, minorities, and
children living in inner cities experience
more ED visits, hospitalizations, and deaths
due to asthma than the general population.

 The burden of asthma falls

disproportionately on non-Hispanic black,
American Indian/Alaskan Native and some
Hispanic populations.

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 By gender
◦ Males 0 – 17 years are more likely than
girls to have asthma or experience an
asthma attack
 By race/ethnicity
◦ Higher for Black non-Hispanic children
◦ Higher for Hispanic children

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 Current asthma prevalence is higher
among
◦ children than adults
◦ boys than girls
◦ women than men
 Asthma morbidity and mortality is
higher among
◦ African Americans than Caucasians.

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◦ Groups 6 - 7 Yrs 13-14 Yrs
◦ Wheeze 5.6 % 6.0%
(0.8 - 14.6) (1.6 - 17.8)

◦ > 4 attacks 1.5% 1.6%

(0.1 - 4.7) (0.5 - 3.5)

◦ Night Cough 12.3% 14.1%

(3.3 - 27) (3.8 - 32.2)

◦ Ever had Asthma 3.7% 4.5%

(1.0 - 14.4) (1.12.4)

Shah, Amdekar, Mathur, IJMS,6,2000,213-22

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100%
90%
80%
70%
60%
50% Urban
40% Rural
30%
20%
10%
0%
Past BD Nocturnal Recent Diagnosed Exercise
Cough Wheeze Asthma Induced

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9.00%

8.00%

7.00%
8.40%
6.00%

5.00%
5.80%
4.00%

3.00%

2.00%
2.52%
1.00%

0.00%

Total Boys Girls

Source - H. Paramesh, E. Cherian. Ind. Joul of Pediatr 2002

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 Parental Asthma
 Allergy
 Atopic dermatitis
 Allergic rhinitis
 Food allergy
 Inhalant allergen sensitization
 Food allergen sensitization

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 Severe lower respiratory tract infections
 Wheezing apart from colds
 Male gender
 Low birth weight
 Tobacco smoke exposure
 Exposure to chlorinated swimming pools
 Possible use of Acetaminophen

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 Common Viral infections
 Aeroallergens
 Animal dander
 Dust mite
 Cockroaches
 Molds
 Pollen

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 Air pollutants
 Ozone
Sulfur dioxide
Particulate matter
Dust
Tobacco smoke
 Strong/ noxious fumes
 Cold, dry air
 Exercise

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 Occupational exposures
 Farm and barn exposure
 Formaldehyde, paint fumes
 Crying, laughter, hyperventilation
 Co morbid conditions: Rhinitis,
Sinusitis

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Symptoms:
 Intermittent dry cough
 Expiratory wheezing
 Shortness of breath
 Chest tightness
 Chest pain
 Fatigue
 Difficulty keeping up with peers in
physical activities

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Signs:
 Expiratory wheezing
 Prolonged expiratory phase
 Decreased breath sounds
 Crackles/ rales
 Accessory muscle use
 Nasal flaring
 Absence of wheezing in severe
cases
 Pulses paradoxus

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Spirometry:

 Feasible in children >6 years of age

 Monitoring Asthma and efficacy of
treatment
 Measures FVC, FEV 1 and FEV1/FVC
Ratio
 Normal values for children available on
the basis of height, gender and
ethnicity.

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Airflow Limitation:
 Low FEV1
 FEV1/ FVC ratio < 0.80
Bronchodilator response to β-agonist:
 Improvement in FEV1 ≥ 12%
Exercise challenge:
 Worsening of FEV1 ≥ 15%
Daily peak flow or FEV1 AM-PM variation ≥
20%

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 Often normal
 Hyperinflation
 Helpful in identifying masqueraders

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 Asthma severity:
Directs initial level of therapy
Determined at the time of diagnosis
Categories: Intermittent, Persistent
Determined by the most severe level of
symptoms
 Asthma control: Important for adjusting therapy
 Regular Clinic visits every 2-6 weeks until good
control established
 Two or more Asthma check ups per year for
maintaining Asthma control

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 Achieve and maintain control of
symptoms
 Maintain normal activity levels, including
exercise
 Maintain pulmonary function as close to
normal levels as possible
 Prevent asthma exacerbations
 Avoid adverse effects from asthma
medications
 Prevent asthma mortality

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 Develop with a physician
 Tailor to meet individual needs
 Educate patients and families about all
aspects of plan
◦ Recognizing symptoms
◦ Medication benefits and side effects
◦ Proper use of inhalers and Peak Expiratory Flow
(PEF) meters

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 Breathless at rest
 Hunched forward
 Speaks in words rather than
complete sentences
 Agitated
 Peak flow rate less than 60% of
normal

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 Have an individual management plan
containing
◦ Your medications (controller and quick-relief)
◦ Your asthma triggers
◦ What to do when you are having an asthma attack
 Educate yourself and others about
◦ Asthma Action Plans
◦ Environmental interventions
 Seek help from asthma resources
 Join an asthma support group

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Asthma action plan for management of
exacerbation

 Regular follow up visits

 Monitor lung functions annually
 Improve adherence to treatment

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 Eliminate/ reduce environmental exposures
 Tobacco smoke elimination/ reduction
 Allergen exposure elimination/ reduction
 Treat co morbid conditions: Rhinitis,
Sinusitis, GER

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 Initiate with higher level controller therapy
 Step-down, once good control is achieved
 If child has had well controlled asthma for at
least 3 months, consider decreasing dose or
number of controller medications.
 Step up for poorly controlled asthma

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 All persistent Asthmatics require daily
controller medications

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 Treatment of choice for persistent Asthma
 Improve lung function
 Reduce use of rescue medicines
 Reduce ED visits, hospitalizations
 May lower the risk of death due to Asthma

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 Used mainly in treatment of exacerbations
 Rarely in patients with severe disease
 Common: Prednisolone, Prednisone,
Methyprednisolone
 When used in long term, cause adverse
effects

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 Salmeterol, Formoterol
 Not used as monotherapy
 Major role as ad-on agents with ICS
 LABA use should be stopped once optimal
Asthma control is achieved

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 Leukotriene synthesis inhibitor: Zileuton (Not
approved for children < 12 years)
 Leukotriene Receptor Antagonists:
Montelukast, Zafirlukast

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 Cromolyn, Nedocromil
 Inhibit exercise induced bronchospasm
 Can be used in combination of SABA for
exercise induced bronchospasm

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 Can reduce Asthma symptoms and need for
SABA use
 Narrow therapeutic window
 Not used as first line anymore
 May be used in corticostroid dependent
children
 Can cause cardiac arrhythmias, seizures and
death

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 Anti IgE monoclonal antibody
 Blocks IgE mediated allergic response
 Approved for children > 12 years with
moderate to severe Asthma
 Given sub cutaneously every 2-4 weeks

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 Short Acting Beta Agonists: Albuterol,
Levalbuterol, Terbutaline, Pirbuterol
 Drugs of choice for acute Asthma symptoms
 Overuse may be associated with increased
risk of death
 Use of at least 1 MDI/ month or at least 3
MDI/ year indicates inadequate Asthma
control
 Anticholinergic Agents: Ipratropium bromide
Used in combination with Albuterol

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 Dyspnea at rest
 Peak flows < 40% of personal best
 Accessory muscle use
 Failure to respond to initial treatment

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 Brief assessment
 Administration of SABA: Repeated doses or
continuously, every 20 mins. for 1 hour
 Inhaled anticholinergic in addition of SABA
 Oxygen: Hypoxemia/ moderate to severe
exacerbation
 Systemic Corticosteroids: Instituted early for
moderate to severe exacerbation and failure
to respond to early treatment
 Intramuscular beta agonist in severe cases.

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