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Preschool wheezy children
Preschool Wheezy Children

Gamal Rabie Agmy, MD, FCCP
Professor of chest Diseases, Assiut university
Definition of Asthma


A chronic inflammatory disorder of the airways



Many cells and cellular elements play a role



Chronic inflammation is associated with airway
hyperresponsiveness that leads to recurrent
episodes of wheezing, breathlessness, chest
tightness, and coughing



Widespread, variable, and often reversible
airflow limitation
Asthma Inflammation: Cells and Mediators

Source: Peter J. Barnes, MD
Mechanisms: Asthma Inflammation

Source: Peter J. Barnes, MD
Asthma Inflammation: Cells and Mediators

Source: Peter J. Barnes, MD
Asthma Pathobiology
Smooth Muscle
Dysfunction

•
•
•
•

Bronchoconstriction
Bronchial Hyperreactivity
Hypertrophy/Hyperplasia
Inflammatory Mediator
Release

Airway
Inflammation

• Inflammatory Cell
Infiltration/Activation
• Mucosal Edema
• Cellular Proliferation
• Epithelial Damage
• Basement Membrane
Thickening

Symptoms/Exacerbations
Pathology of Asthma
Factors that Exacerbate Asthma









Allergens
Respiratory infections
Exercise and hyperventilation
Weather changes
Sulfur dioxide
Food, additives, drugs
Factors that Influence Asthma
Development and Expression
Host Factors
 Genetic
- Atopy
- Airway
hyperresponsiveness
 Gender
 Obesity

Environmental Factors
 Indoor allergens
 Outdoor allergens
 Occupational sensitizers
 Tobacco smoke
 Air Pollution
 Respiratory Infections
 Diet
Is it Asthma?


Recurrent episodes of wheezing



Troublesome cough at night



Cough or wheeze after exercise



Cough, wheeze or chest tightness
after exposure to airborne allergens or
pollutants



Colds “go to the chest” or take more
than 10 days to clear
90% of the asthma problem is not seen:
The inflammation!!!

Bronchospasm= 10%
Symptoms

When this disappears…

Have we eliminated this?
Underlying
disease
Pediatric Asthma
Not all wheezing is asthma
Wheezing occurrences in children:
- single episode in 30% to 50% of children
before 5 yr of age
- 40% who wheeze before 3 yr of age continue
at 6 yr (“persistent wheezers”)
- 50% of infants who wheeze once will wheeze
again within several months
Wheezing in Children - Phenotypes
Childhood asthma phenotypes
Childhood asthma phenotypes
*A 2012 study described 2 "new" phenotypes for
young children with wheezing: "boys atopic
multiple-trigger" and "girls nonatopic uncontrolled
wheeze". JACI, 2012.
*Toward a definition of asthma phenotypes in
childhood: early viral wheezers, multitrigger
wheezers (MTWs), and nonatopic uncontrolled
wheezers (NAUWs). Some children have “allergic
bronchitis” rather than “asthma”. JACI, 2012.
Diagnosing Asthma in Young
Children – Asthma Predictive
Index
• Major criteria
– Parent with asthma
• > 4 episodes/yr of
– Physician diagnosed
wheezing lasting
atopic dermatitis
more than 1 day
affecting sleep in a
• Minor criteria
child with one MAJOR
– Physician diagnosed
or two MINOR criteria
allergic rhinitis

– Eosinophilia (>4%)
– Wheezing apart from
colds
1Adapted

from Castro-Rodriquez JA, et al. AJRCCM 2000; 162: 1403
Modified Asthma Predictive Index (API)
Cough-variant asthma
Cough-variant asthma presents as dry
cough at night. It worsens with exercise
(EIA) and nonspecific triggers (cold air).
Cough-variant asthma responds to asthma
therapy with ICS.
Cough-variant asthma is diagnosed with
pulmonary function testing (PFTs) with
response to bronchodilator. The most
common cause of chronic cough in children
is cough-variant asthma.
Guidelines National Heart, Lung, and Blood Institute (NHLBI) guidelines
for diagnosis and management of asthma

Key concepts:
- severity dictates therapy

- - distinction between intermittent and persistent asthma
- - "rule of 2s”
- - 4 levels of asthma severity - intermittent; 3 sublevels of
persistent

- - inhaled corticosteroids (ICS) preferred for all levels of
persistent asthma
- - use of asthma action plans
- - spirometry recommended
Rule of 2s
- if symptoms are present for more than 2 days per
week or for more than 2 nights per month, asthma
categorized as persistent.
- Within this category, disease must be classified as
mild, moderate, or severe. However, as severity of
asthma not constant, must monitor patients for
changes; as severity changes, therapy should
change too.
- The category of “mild intermittent” asthma was
eliminated in the 2007 guidelines - now it is just called
“intermittent” asthma.
The concepts of “impairment”, “risk”, and “control” were
introduced in the 2007 guidelines:

- impairment - refers to symptoms
- - risk - refers to likelihood that the patient will eventually
have exacerbation of asthma and present to emergency
department (ED) or hospital, or need course of oral
corticosteroids
- - control - refers to the level of patient’s asthma control
Classification of asthma severity
- impairment domain - daytime and nighttime symptoms
(rule of 2's), use of short-acting beta-agonist (SABA),
interference with normal activities
- - risk domain - number of exacerbations per year (if more
than 2, daily controller medication is needed). Increased
risk is conferred by parental history of asthma or history of
eczema.

- Childhood Asthma Control Test (ACT) is validated down to
age 4 yr. Adult ACT questionnaire should be used for
teenagers (cutoff age is 11 years).
Treatment steps

- step 1 - SABA as needed –
- step 2 - low-dose ICS monotherapy vs. leukotriene receptor
antagonist (LTRA)
- - step 3 - low-to-medium dose ICS plus long-acting betaagonist (LABA)
- - step 4 - high-dose ICS therapy plus LABA and (if needed)
systemic corticosteroids. Omalizumab (Xolair; anti-IgE
antibody) is prescribed before placing patient on daily oral
corticosteroids.
“Rule of 2s” to determine level of control

- daytime symptoms more than 2 days/wk
- rescue β2 -agonist use more than 2 times per week

- nighttime symptoms more than 2 nights/mo
- more than 2 rescue β2-agonist canisters/yr
Step Down or Step Up

When to step down therapy? If patient is well-controlled for
3 mo, consider stepping down therapy.
When to step up therapy? If the patient is not wellcontrolled, step up therapy and re-evaluate in 2 to 6 wk. If the
patient is very poorly controlled, step up therapy 2 steps,
consider short course of steroids, and reassess in 2 wk.
When to consider long-term ICS treatment

- positive API and more than 3 wheezing episodes in
previous 12 mo lasting more than 1 day and affecting
sleep
- consistent requirement for SABA treatment (more than
2 times/wk, on average, over 1-2 mo); 2 exacerbations in
6 mo requiring oral corticosteroids
Treatmnt
Inhaled corticosteroid

Relative binding affinity for glucocorticoid receptor (GR):
mometasone = fluticasone > budesonide > triamcinolone.

Relative anti-inflammatory potency: mometasone
fluticasone > budesonide = beclomethasone
triamcinolone.

=
>
Severe asthma - differential diagnosis and management
Foreign Body Aspiration
Preschool wheezy children
Preschool wheezy children
Radiographic Signs of Pneumomediastinum

Subcutaneous emphysema
Thymic sail sign
Pneumoprecardium
Ring around the artery sign
Tubular artery sign
Double bronchial wall sign
Continuous diaphragm sign
Extrapleural sign
Air in the pulmonary ligament
Preschool wheezy children
Preschool wheezy children
Preschool wheezy children
Preschool wheezy children
40

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Preschool wheezy children

  • 2. Preschool Wheezy Children Gamal Rabie Agmy, MD, FCCP Professor of chest Diseases, Assiut university
  • 3. Definition of Asthma  A chronic inflammatory disorder of the airways  Many cells and cellular elements play a role  Chronic inflammation is associated with airway hyperresponsiveness that leads to recurrent episodes of wheezing, breathlessness, chest tightness, and coughing  Widespread, variable, and often reversible airflow limitation
  • 4. Asthma Inflammation: Cells and Mediators Source: Peter J. Barnes, MD
  • 6. Asthma Inflammation: Cells and Mediators Source: Peter J. Barnes, MD
  • 7. Asthma Pathobiology Smooth Muscle Dysfunction • • • • Bronchoconstriction Bronchial Hyperreactivity Hypertrophy/Hyperplasia Inflammatory Mediator Release Airway Inflammation • Inflammatory Cell Infiltration/Activation • Mucosal Edema • Cellular Proliferation • Epithelial Damage • Basement Membrane Thickening Symptoms/Exacerbations
  • 9. Factors that Exacerbate Asthma       Allergens Respiratory infections Exercise and hyperventilation Weather changes Sulfur dioxide Food, additives, drugs
  • 10. Factors that Influence Asthma Development and Expression Host Factors  Genetic - Atopy - Airway hyperresponsiveness  Gender  Obesity Environmental Factors  Indoor allergens  Outdoor allergens  Occupational sensitizers  Tobacco smoke  Air Pollution  Respiratory Infections  Diet
  • 11. Is it Asthma?  Recurrent episodes of wheezing  Troublesome cough at night  Cough or wheeze after exercise  Cough, wheeze or chest tightness after exposure to airborne allergens or pollutants  Colds “go to the chest” or take more than 10 days to clear
  • 12. 90% of the asthma problem is not seen: The inflammation!!! Bronchospasm= 10%
  • 13. Symptoms When this disappears… Have we eliminated this? Underlying disease
  • 14. Pediatric Asthma Not all wheezing is asthma Wheezing occurrences in children: - single episode in 30% to 50% of children before 5 yr of age - 40% who wheeze before 3 yr of age continue at 6 yr (“persistent wheezers”) - 50% of infants who wheeze once will wheeze again within several months
  • 15. Wheezing in Children - Phenotypes
  • 17. Childhood asthma phenotypes *A 2012 study described 2 "new" phenotypes for young children with wheezing: "boys atopic multiple-trigger" and "girls nonatopic uncontrolled wheeze". JACI, 2012. *Toward a definition of asthma phenotypes in childhood: early viral wheezers, multitrigger wheezers (MTWs), and nonatopic uncontrolled wheezers (NAUWs). Some children have “allergic bronchitis” rather than “asthma”. JACI, 2012.
  • 18. Diagnosing Asthma in Young Children – Asthma Predictive Index • Major criteria – Parent with asthma • > 4 episodes/yr of – Physician diagnosed wheezing lasting atopic dermatitis more than 1 day affecting sleep in a • Minor criteria child with one MAJOR – Physician diagnosed or two MINOR criteria allergic rhinitis – Eosinophilia (>4%) – Wheezing apart from colds 1Adapted from Castro-Rodriquez JA, et al. AJRCCM 2000; 162: 1403
  • 20. Cough-variant asthma Cough-variant asthma presents as dry cough at night. It worsens with exercise (EIA) and nonspecific triggers (cold air). Cough-variant asthma responds to asthma therapy with ICS. Cough-variant asthma is diagnosed with pulmonary function testing (PFTs) with response to bronchodilator. The most common cause of chronic cough in children is cough-variant asthma.
  • 21. Guidelines National Heart, Lung, and Blood Institute (NHLBI) guidelines for diagnosis and management of asthma Key concepts: - severity dictates therapy - - distinction between intermittent and persistent asthma - - "rule of 2s” - - 4 levels of asthma severity - intermittent; 3 sublevels of persistent - - inhaled corticosteroids (ICS) preferred for all levels of persistent asthma - - use of asthma action plans - - spirometry recommended
  • 22. Rule of 2s - if symptoms are present for more than 2 days per week or for more than 2 nights per month, asthma categorized as persistent. - Within this category, disease must be classified as mild, moderate, or severe. However, as severity of asthma not constant, must monitor patients for changes; as severity changes, therapy should change too. - The category of “mild intermittent” asthma was eliminated in the 2007 guidelines - now it is just called “intermittent” asthma.
  • 23. The concepts of “impairment”, “risk”, and “control” were introduced in the 2007 guidelines: - impairment - refers to symptoms - - risk - refers to likelihood that the patient will eventually have exacerbation of asthma and present to emergency department (ED) or hospital, or need course of oral corticosteroids - - control - refers to the level of patient’s asthma control
  • 24. Classification of asthma severity - impairment domain - daytime and nighttime symptoms (rule of 2's), use of short-acting beta-agonist (SABA), interference with normal activities - - risk domain - number of exacerbations per year (if more than 2, daily controller medication is needed). Increased risk is conferred by parental history of asthma or history of eczema. - Childhood Asthma Control Test (ACT) is validated down to age 4 yr. Adult ACT questionnaire should be used for teenagers (cutoff age is 11 years).
  • 25. Treatment steps - step 1 - SABA as needed – - step 2 - low-dose ICS monotherapy vs. leukotriene receptor antagonist (LTRA) - - step 3 - low-to-medium dose ICS plus long-acting betaagonist (LABA) - - step 4 - high-dose ICS therapy plus LABA and (if needed) systemic corticosteroids. Omalizumab (Xolair; anti-IgE antibody) is prescribed before placing patient on daily oral corticosteroids.
  • 26. “Rule of 2s” to determine level of control - daytime symptoms more than 2 days/wk - rescue β2 -agonist use more than 2 times per week - nighttime symptoms more than 2 nights/mo - more than 2 rescue β2-agonist canisters/yr
  • 27. Step Down or Step Up When to step down therapy? If patient is well-controlled for 3 mo, consider stepping down therapy. When to step up therapy? If the patient is not wellcontrolled, step up therapy and re-evaluate in 2 to 6 wk. If the patient is very poorly controlled, step up therapy 2 steps, consider short course of steroids, and reassess in 2 wk.
  • 28. When to consider long-term ICS treatment - positive API and more than 3 wheezing episodes in previous 12 mo lasting more than 1 day and affecting sleep - consistent requirement for SABA treatment (more than 2 times/wk, on average, over 1-2 mo); 2 exacerbations in 6 mo requiring oral corticosteroids
  • 30. Inhaled corticosteroid Relative binding affinity for glucocorticoid receptor (GR): mometasone = fluticasone > budesonide > triamcinolone. Relative anti-inflammatory potency: mometasone fluticasone > budesonide = beclomethasone triamcinolone. = >
  • 31. Severe asthma - differential diagnosis and management
  • 35. Radiographic Signs of Pneumomediastinum Subcutaneous emphysema Thymic sail sign Pneumoprecardium Ring around the artery sign Tubular artery sign Double bronchial wall sign Continuous diaphragm sign Extrapleural sign Air in the pulmonary ligament
  • 40. 40