childhood asthma


Presentation Description

Pediatric Asthma Epidemiology , compliance and asthma tests , Genetic,allergen,Microbes,Pollutants,Respiratory (viral) infections,Epidemiological trend,Asthma Burden in Developing countries (INDIA),features of Asthma,Tools to Diagnosis,History taking (Ask),IPAG Diagnosis,SPIROMETRY,NORDIC CONSENSUS,GINA


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Pediatric Asthma Epidemiology , compliance and asthma tests Presented by Dr pankaj yadav

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Asthma is the most common chronic disease of childhood and the leading cause of childhood morbidity from chronic disease as measured by school absences, emergency department visits, and hospitalizations. Asthma leads to recurrent episodes of wheezing, breathlessness, chest tightness and coughing (particularly at night or early morning). Clinical symptoms in children 5 years and younger are variable and non-specific. Widespread, variable, and often reversible airflow limitation.

Factors Influencing the Development and Expression of Asthma:

Factors Influencing the Development and Expression of Asthma Host factors – Genetic Genes predisposing to atopy Genes predisposing to airway hyper responsiveness Obesity Sex

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Environmental factors – Allergens – Indoor – Domestic mites, furred animals (dogs, cats, mice), cockroach allergens, fungi, molds, yeasts. Outdoor – Pollens, fungi, molds, yeasts. Infections (predominantly viral) Occupational sensitizers Tobacco smoke Passive smoking Active smoking Indoor/Outdoor air pollution Diet

Risk factors of Asthma in younger children:

Risk factors of Asthma in younger children Sensitization to allergen. Maternal diet during pregnancy and/ or lactation. Pollutants (particularly environmental tobacco smoke). Microbes and their products. Respiratory (viral) infections. Psychosocial factors.

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The prevalence of childhood asthma has continued to increase on the Indian subcontinent over the past 10 yrs ISAAC Phase 3 Thorax 2007;62:758

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23.5% Population: Age distribution 40.9%

Epidemiological trend Bronchial Asthma :

Epidemiological trend Bronchial Asthma Global Burden of Asthma Around 300 m. patients (currently) Expected by 2025: 100 m. additional Loss of DALYs : About 15 m./year (around 1% of all DALYs lost) Accounts for in every 250 deaths • Considerable economic costs The UK has one of the highest prevalences for childhood asthma internationally, with about 15% children affected. The prevalence is 8-10 times higher in developed countries than in developing countries.

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The prevalence of 'any wheeze' over recent months (usually taken as within the last year) amongst children has risen from about 10% in the 1960s to 20-30% in the 1990s. There is some evidence of a possible flattening of this rise from the late 1990s onwards. An increasing percentage of currently wheezing children also have a diagnosis of asthma. There is still a significant morbidity associated with the disease, particularly severe childhood asthma, despite therapeutic advances. Prevalence is higher in lower socioeconomic groups in urban areas. There are gender differences. Boys are affected more before puberty (3 times greater prevalence). Prevalence is equal in adolescence, but adult-onset asthma is more common in women. The increasing prevalence of asthma is mirrored by the increasing prevalence of childhood obesity. Prospective studies suggest that obesity increases the risk of subsequent asthma, although the underlying mechanisms are unclear, but obesity also increases the clinical severity of asthma and reduces quality of life for childrenwith asthma.

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The overall burden of Asthma in India is estimated at more than 15 million . According to the study done by A.Anuradha1, V.Lakshmi Kalpana1,S.Narsingara. et al. The type of asthma is distributed as cough-variant-asthma (50.83%), nocturnal asthma (17.5%), allergic asthma (20.83%) and occupational asthma (10.83%). Regarding family history,59.16% showed genetic predisposition irrespective of sex. Among asthmatics, 20% were having atopicdermatitis . Twenty-five percent were smokers, 20% were alcoholics and 44.16% were with diabetics. Advancing age, usual residence in urban area and lower socio-economic status were associated with significantly higher odds of having asthma. The present study shows that asthma is an important public health issue in urban areas.

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Asthma Burden in Developing countries (INDIA) 1. Wide variations – High magnitude 2. Increase in prevalence with rapid industrialization and urbanization 3. High levels of pollution – important role 4. Role of infections, smoking and under-nutrition 5. Under diagnosis and under treatment 6. Limited drug availability 7. Difficulties of management at different levels of health-care

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Other Challenges:

Other Challenges Most of the children are below 5 years of age, who cannot tell their problems Parents are proxy story teller, who may mislead the doctor PEF cannot be performed in children below 5 years of age Fear of addiction to inhalation therapy Physicians lack of knowledge and time

Clinical Features:

Clinical Features Recurrent Wheeze Recurrent Cough Recurrent Breathlessness Activity Induced Cough/Wheeze Nocturnal Cough/Breathlessness Tightness Of Chest Asthma by Consensus, IAP 2003


Symptomatology Cough – 90% Wheezing – 74% Exercise induced wheeze or cough – 55% Ind J Ped 2002;69:309-12

Typical features of Asthma:

Typical features of Asthma Afebrile episodes Personal atopy Family history of atopy or asthma Exercise /Activity induced symptoms History of triggers Seasonal exacerbations Relief with bronchodilators Asthma by Consensus, IAP 2003

When does Asthma begin?:

When does Asthma begin? By 1 year – 26% 1-5 years – 51.4% > 5 years – 22.3% 77% Of Asthma Begins In Children Less Than 5 Years Ind J Ped 2002;69:309-12

Tools to Diagnosis:

Tools to Diagnosis Good History Taking (ASK) Careful Physical Examination (LOOK) Investigations (PERFORM) – above 5 years only CHILDHOOD ASTHMA by KHUBCHANDANI R.P. et al

History taking (Ask):

History taking (Ask) Has the child had an attack or recurrent episode of wheezing (high-pitched whistling sounds when breathing out)? Does the child have a troublesome cough which is particularly worse at night or on waking? Is the child awakened by coughing or difficult breathing? Does the child cough or wheeze after physical activity (like games and exercise) or excessive crying? Does the child experience breathing problems during a particular season? CHILDHOOD ASTHMA by KHUBCHANDANI R.P. et al

History taking (Ask):

History taking (Ask) Does the child cough, wheeze, or develop chest tightness after exposure to airborne allergens or irritants e.g. smoke, perfumes, animal fur? Does the child’s cold frequently ‘go to the chest’ or take more than 10 days to resolve? Does the child use any medication when symptoms occur? How often? Are symptoms relieved when medication is used? CHILDHOOD ASTHMA by KHUBCHANDANI R.P. et al If the answer is ‘yes’ to any of the questions, a diagnosis of asthma should be considered

Physical Examination (Look):

Physical Examination (Look) General Attitude And Well Being Deformity Of The Chest Character Of Breathing Thorough Auscultation Of Breath Sounds Signs Of Any Other Allergic Disorders On The Body Growth And Development Status CHILDHOOD ASTHMA by KHUBCHANDANI R.P. et al

What all features one should look for specifically?:

What all features one should look for specifically? Dyspnea Expiratory wheeze Accessory muscle movement Difficulty in feeding, talking, getting to sleep Irritability CHILDHOOD ASTHMA by KHUBCHANDANI R.P. et al

What all features one should look for specifically?:

What all features one should look for specifically? Cough Persistent/ recurrent / nocturnal/ exercise-induced Associated conditions Eczema Allergic Rhinitis Weight/Height CHILDHOOD ASTHMA by KHUBCHANDANI R.P. et al

How to rule out the mimics?:

How to rule out the mimics?

The Early Wheezer (< 3Years):

The Early Wheezer (< 3Years) Early onset asthma Afebrile episodes Personal atopy present Family history of asthma / atopy present Predictable good response to bronchodilators WALRI (wheeze associated lower respiratory tract infections) or Viral Associated wheeze Febrile episodes Personal atopy absent Family history of asthma / atopy absent Variable response to bronchodilators Asthma by Consensus, IAP 2003

Bronchiolitis in children:

Bronchiolitis in children Commonest cause of wheezing in children between 6 months to 3 years Resembles asthma Diagnosis essentially clinical Common viruses causing bronchiolitis in children: Respiratory syncytial virus (RSV)

Clinical manifestations of RSV disease:

Clinical manifestations of RSV disease Rhinorrhoea Pharyngitis Cough Low grade fever Wheezing Increased respiratory rate

Differential diagnosis:

Differential diagnosis Age Common Uncommon Rare Less than 6 months Bronchiolitis Gastro-esophageal reflux Aspiration pneumonia Bronchopulmonary dysplasia Congestive heart failure Cystic fibrosis Asthma Foreign body aspiration 6 months - 2 years Bronchiolitis Foreign body aspiration Aspiration pneumonia Asthma Bronchopulmonary dysplasia Cystic fibrosis Gastro-esophageal reflux Congestive heart failure 2 - 5 years Asthma Foreign body aspiration Cystic fibrosis Gastro-esophageal reflux Viral pneumonia Aspiration pneumonia Bronchiolitis Congestive heart failure Gastro-esophageal reflux IPAG 2007

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Identifying Co-morbidities

Co morbid conditions:

Co morbid conditions Allergic Rhinitis Colds, ear infections Sneezing in the morning Blocked nose, snoring, mouth breathing Gastro esophageal reflux (GER) Nocturnal cough followed by vomiting Eczema

Guidelines for confirming Childhood Asthma diagnosis:

Guidelines for confirming Childhood Asthma diagnosis

IPAG Diagnosis:

IPAG Diagnosis Characterize the problem Establish chronicity Exclude non-respiratory or other causes Exclude infectious diseases Consider patient’s age Use diagnostic aids International Primary Care Airways Group 2007



Method – how to perform :

Method – how to perform 4 normal breaths Inhale as deeply as possible Exhale to normal depth 3 normal breaths Exhale as much as possible 3 normal breaths Inhale as much as possible Exhale as fast and completely as possible 4 normal breaths



What all investigations can be performed in asthmatic children? (PERFORM):

What all investigations can be performed in asthmatic children? (PERFORM) Peak expiratory flow rate: It is highly suggestive of asthma when: >15% increase in PEFR after inhaled short acting β2 agonist >15% decrease in PEFR after exercise Diurnal variation > 10% in children not on bronchodilator OR >20% In children on bronchodilator 1. Asthma by Consensus, IAP 2003 2. CHILDHOOD ASTHMA by KHUBCHANDANI R.P. et al

Early Childhood Asthma Diagnosis (below 6 years):

Early Childhood Asthma Diagnosis (below 6 years) Diagnostic Tool Findings that Support Diagnosis Differential diagnosis The diagnosis of asthma in children under age 6 is primarily one of exclusion. Physical examination If the child does not appear acutely ill and is growing, and there is no evidence specifically indicating another cause of symptoms, a trial of therapy is warranted. Trial of therapy (bronchodilators) Improvement with treatment supports a diagnosis of asthma. Frequent reassessment Health care professionals should always be prepared to reconsider the diagnosis if management is ineffective or if the clinical situation changes. IPAG 2007

Childhood Asthma Diagnosis (6-14 years):

Childhood Asthma Diagnosis (6-14 years) IPAG 2007

Childhood Asthma Diagnosis (6-14 years):

Childhood Asthma Diagnosis (6-14 years) IPAG 2007


NORDIC CONSENSUS Respir Med. 2000;94(4):299-327


IAP GUIDELINES 3 Or More Episodes Of Airflow Obstruction With Several Of The Following: • Afebrile Episodes • Personal Atopy Or Family H/O Atopy / Asthma • Nocturnal Exacerbations • Exercise/Activity Induced Symptoms • Trigger Induced Symptoms • Seasonal Exacerbations • Relief With Bronchodilators ± Oral Steroid Asthma by Consensus, The Indian Academy of Pediatrics 2003


GINA The following symptoms are highly suggestive of a diagnosis of asthma: frequent episodes of wheeze (more than once a month) activity-induced cough or wheeze nocturnal cough in periods without viral infections absence of seasonal variation in wheeze symptoms that persist after age 3 A simple clinical index based on: presence of a wheeze before the age of 3 presence of one major risk factor (parental history of asthma or eczema) or two of three minor risk factors (eosinophilia, wheezing without colds, and allergic rhinitis) has been shown to predict the presence of asthma in later childhood Global Initiative for Asthma 2008


GINA A useful method for confirming the diagnosis of asthma in children 5 years and younger is a trial of treatment with short-acting bronchodilators and inhaled glucocorticosteroids Children 4 to 5 years old can be taught to use a PEF meter, but to ensure reliability parental supervision is required Use of spirometry and other measures recommended for older children such as airway responsiveness and markers of airway inflammation is difficult and several require complex equipment making them unsuitable for routine use GINA 2008


BTS Initial assessment of children suspected of having asthma should be based on: presence of key features in the history and clinical examination careful consideration of alternative diagnoses Using a structured questionnaire may produce a more standardised approach to the recording of presenting clinical features and the basis for a diagnosis of asthma British Thoracic Society 2008

Clinical features that increase the probability of asthma :

Clinical features that increase the probability of asthma More than one of the following symptoms: wheeze, cough, difficulty breathing, chest tightness, particularly if these symptoms: ◊ are frequent and recurrent ◊ are worse at night and in the early morning ◊ occur in response to, or are worse after, exercise or other triggers, such as exposure to pets, cold or damp air, or with emotions or laughter ◊ occur apart from colds Personal history of atopic disorder Family history of atopic disorder and/or asthma Widespread wheeze heard on auscultation History of improvement in symptoms or lung function in response to adequate therapy BTS 2008

Clinical features that lower the probability of asthma :

Clinical features that lower the probability of asthma Symptoms with colds only, with no interval symptoms Isolated cough in the absence of wheeze or difficulty breathing History of moist cough Prominent dizziness, light-headedness, peripheral tingling Repeatedly normal physical examination of chest when symptomatic Normal peak expiratory flow (PEF) or spirometry when symptomatic No response to a trial of asthma therapy Clinical features pointing to alternative diagnosis BTS 2008

Asthma management and prevention:

Asthma management and prevention The goals for successful management of asthma are Achieve and maintain control of symptoms Maintain normal activity levels, including exercise Maintain pulmonary function as close to normal as possible Prevent asthma exacerbations Avoid adverse effects from asthma medications Prevent asthma mortality

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Five interrelated components of therapy are required to achieve and maintain control of asthma- Develop Patient/Doctor partnership Identify and reduce exposure to risk factors Assess, treat, and monitor asthma Manage asthma exacerbations Special considerations

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Develop Patient/Doctor partnership - Effective management of asthma requires the development of a partnership between the person with asthma and the health care team. Patients can learn to – Avoid risk factors Take medications correctly

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3. Understand the difference between controller and reliever medications 4. Monitor their status using symptoms and, if relevant, PEF 5. Recognize signs that asthma is worsening and take action 6. Seek medical help as appropriate

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Education should be integral part of all interactions between health care professional and patients. Using variety of methods such as discussions, demonstrations, written materials, group classes, video/audio tapes, dramas and patient support groups helps reinforce educational messages. Health care professional and patients should prepare a written personal asthma action plan that is medically appropriate and practical. Additional self-management plans can be found on –

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Assess, Treat and Monitor Asthma – The goal of asthma treatment can be reached in most patients through a continuous cycle that involves – assessing, treating and monitoring asthma. Each patient should be assessed to establish his/her current treatment regimen, adherence to the current regimen, and level of asthma control. Each patient is assigned to one of five treatment steps. At each treatment step, reliever medication should be provided for quick relief of symptoms as needed.

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Monitoring is essential to maintain control and establish the lowest step and dose of treatment to minimize cost and maximize safety. If asthma is not controlled , step up the treatment. Improvement is generally seen within 1 month. If asthma is partly controlled , consider stepping up treatment, depending more effective options available, safety and cost of possible treatment and patient’s satisfaction with the level of control achieved. If controlled asthma is maintained for at least 3 months, step down with a gradual, stepwise reduction in treatment. The goal is to decrease treatment to the least medication necessary to maintain control.

To summarize…:

To summarize… Asthma is an inflammatory illness Diagnosis of asthma is clinical , and relies on history All asthma does not wheeze In children < 3 yrs, WALRI is an important differential diagnosis 2 out of 3 children outgrow their asthma A family history of asthma / atopy increases risk of asthma Diagnosis

To summarize…:

To summarize… Patient education is a very important part of asthma management Drugs control, but do not cure asthma Clinical grading over time, decides long term management plan Mild intermittent asthma does not merit controllers Inhaled steroids are mainstay of long term asthma management Treatment should be stepped up or stepped down depending upon patient response Long term management

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