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Childhood asthma & TB

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Pediatric Asthma
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Childhood asthma & TB

  1. 1. Childhood asthma GETA .B (MD) 08/05/2018
  2. 2. Out line • Definition • Epidemiology • Etiology / Risk factors • Natural history & pathogenesis • Clinical presentation • Laboratory studies • Treatment
  3. 3. CHILDHOOD ASTHMA • Definition Asthma is a chronic, inflammatory disease of lung airways characterized by: • Symptoms of cough, wheezing, dyspnea, & chest tightness that occur in paroxysms • Airway narrowing, often reversible, and • ↑se in the existing bronchial hyper- responsiveness
  4. 4. Epidemiology The CDC's 2006 National Health Interview Survey estimated • a lifetime asthma prevalence of 13.5%, and prevalence of 9.6% among children ≤18yrs in 2009 – But ranges from 1.6 to 36.8 in different locale
  5. 5. Epidemio… • 80% of all asthmatics report disease onset prior to 6yr of age. • Allergy in young children has emerged as a major risk factor for the persistence of childhood asthma.
  6. 6. Epidemiologic risk factors • Gender – boys > girls (14 vs 10%) but in adults F>M = 8.9 vs 5.6 • Race / ethnicity : high in African-Americans & Puerto Ricans • Socioeconomic status : more prevalent in poor … • Locale : urban > rural
  7. 7. Etiology Not clearly determined but multifactorial • Environmental exposures – Recurrent viral infections of the airways – Other airways exposures – tobacco smoke, indoor allergens … and • Inherent biological and genetic vulnerabilities. – More than 22 loci on 15 autosomal chromosomes
  8. 8. Triggers • Viruses • Dust • Allergens (pollen) • Cold Air • Cigarette smoke • Exercise • Stress/emotional • Animals
  9. 9. Early Childhood Risk Factors for Persistent Asthma • Parental asthma • Allergy – Atopic dermatitis – Allergic rhinitis – Food allergy – Inhalant allergen sensitization – Food allergen sensitization • Severe lower respiratory tract infection – Pneumonia – Bronchiolitis requiring hospitalization • Wheezing apart from colds • Male gender • Low birth weight • Environmental tobacco smoke exposure
  10. 10. AHR - airways hyperresponsiveness ETS - environmental tobacco smoke Etiology and pathogenesis of asthma
  11. 11. MAJOR CRITERIA MINOR CRITERIA Parent asthma Allergic rhinitis Eczema Wheezing apart from colds Inhalant allergen sensitization Eosinophils ≥ 4% Food allergen sensitization Asthma Predictive Index for Children For preschool age children with frequent wheezing in the past year, one major criterion OR two minor criteria provide a high specificity (97%) and positive predictive value (77%) for persistent asthma into later childhood
  12. 12. Types of asthma • There are 2 main types of childhood asthma: (1) Recurrent wheezing in early childhood; and (2) Chronic asthma associated with allergy that persists into later childhood and often adulthood • A 3rd type typically emerges in females who develop obesity and early-onset puberty (by 11yr of age).
  13. 13. Natural history Wheezing during the first six years 1. intermittent symptoms at an early age - viral illnesses 2. Later-onset with more persistent symptoms - cxzed by • Atopy and • A positive family history of asthma, and • Are at an increased risk for asthma later in life.
  14. 14. Natural history Wheezing in later childhood • Patients younger than 15years diagnosed with severe asthma had, when compared to older patients, significantly higher five-year rates of improvement (80 vs 61%) and remission (23 vs 14%). • Patients diagnosed with mild disease were unlikely to develop severe disease within five years, regardless of age
  15. 15. Pathophysiology • Asthma is an inflammatory process – mediated by helper T lymphocytes and other immune cells. • Airways inflammation is linked to – AHR or hypersensitivity of airways smooth muscle to numerous provocative exposures that act as triggers,
  16. 16. Pathophysiology • Airways inflammation… – airways edema, – basement membrane thickening – type IV collagen, – Desquamation of the epithelial lining, – smooth muscle and mucous gland hypertrophy, & – mucus hypersecretion
  17. 17. Clinical manifestations • Approximately 80% of children with asthma develop symptoms before 5yrs of age • Intermittent dry coughing & wheezing • Breathlessness, chest tightness or pressure – older • Intermittent, nonfocal chest “pain” – younger children.
  18. 18. Clinical manifestations • Daytime symptoms, often linked with physical activities or play • Poor school performance and fatigue – May be due to sleep deprivation from nocturnal symptoms. • Response to asthma medications (bronchodilators) • Symptoms can be triggered by numerous events
  19. 19. Clinical manifestations PHYSICAL EXAMINATION • Normal in the absence of an acute exacerbation. • Abnormalities that may be observed include : – An increased A-P diameter of the chest - air trapping. – Decreased air entry or wheezing on auscultation. – A prolonged expiratory phase on auscultation.
  20. 20. Clinical manifestations • Crackles (or rales) and rhonchi • Signs of rhinitis and sinusitis - nasal discharge, inflamed nasal mucosa, sinus tenderness, • Eczema/atopic dermatitis. • Nasal polyps (glistening, gray, mucoid masses within the nasal cavities)
  21. 21. Laboratory findings Pulmonary Function Testing • Forced expiratory airflow measures – in diagnosing and monitoring asthma and – in assessing efficacy of therapy. • Spirometry – for children > 6 yrs
  22. 22. • Spirometric volume-time curves 1. FEV1 - 2. FVC - total volume of air exhaled during a forced expiratory effort. • Note that subject 2's FEV1 & FEV1/FVC ratio are smaller than subject 1's --- airflow limitation. • Also, subject 2's FVC is very close to what is expected Subject 1 – non-asthmatic Subject 2 - asthmaric
  23. 23. Spirometry (in clinic) 1. Airflow limitation • Low FEV1 (relative to percentage of predicted norms) • FEV1/FVC ratio <0.80 2. Bronchodilator response (to inhaled β-agonist) • Improvement in FEV1 ≥12% or ≥200 mL* 3. Exercise challenge • Worsening in FEV1 ≥15%* 4. Daily peak flow or FEV1 monitoring: day to day and/or AM-to-PM variation ≥20%* Lung Function Abnormalities in asthma * Main criteria consistent with asthma
  24. 24. Laboratory findings • Bronchoprovocation • Can be helpful in diagnosis & management. • inhaled methacholine, histamine, and cold or dry air. – The degree of AHR correlates with asthma severity and airways inflammation. • A negative study may exclude a diagnosis of asthma
  25. 25. Laboratory findings Exercise challenges • aerobic exertion or “running” for 6–8 min • identify children with exercise-induced bronchospasm. – FEV1 typically decreases during or after exercise by >15%.
  26. 26. Laboratory findings Measuring exhaled nitric oxide (FENO), • a marker of airway inflammation in asthma, Peak expiratory flow (PEF) • PEF variation >20% is consistent with asthma Allergy tests Sweat chloride test
  27. 27. Radiology - Chest radiogram • Findings consistent with asthma, such as – hyperinflation, – peribronchial thickening, and – mucoid impaction with atelectasis. – Complications
  28. 28. Radiology – chest CT • Bronchiectasis is clearly seen on CT scan and • implicates an asthma masquerader such as – cystic fibrosis, – allergic bronchopulmonary mycoses (aspergillosis), – ciliary dyskinesias…
  29. 29. Asthma management • National Asthma Education and Prevention Program - NAEPP. – 4 principle components to optimal asthma mgt 1. Regular assessment & monitoring 2. Control of factors contributing to asthma severity 3. Asthma pharmacotherapy
  30. 30. The key elements to optimal asthma management
  31. 31. Optimal goals
  32. 32. Managing Asthma in Children
  33. 33. Asthma management 1. Regular assessment & monitoring • Asthma checkups Every 2 - 4 wk until good control • 2 - 4 per yr to maintain good control • Lung function monitoring – Annually, or more often
  34. 34. Asthma mgt – regular ass’t • Assess the optimal goals by determining the: (1) frequency of asthma symptoms during the day, at night, and with physical exercise; (2) frequency of “rescue” SABA use and refills; (3) number and severity of asthma exacerbations since the last visit; and (4) participation in school, sports, and other activities
  35. 35. Asthma mgt – regular ass’t Lung function testing (spirometry) • PEF (Peak expiratory flow) monitoring at home if – children with poor symptom perception, – other causes of chronic coughing, – moderate to severe asthma, or – history of severe exacerbations
  36. 36. Asthma mgt – regular ass’t PEF • 80–100% of personal best - good control; • 50–80% necessitates increased awareness & Rx; • <50%  poor control & increased likelihood of an exacerbation, requiring immediate intervention. • The NAEPP guidelines recommend at least once-daily PEF monitoring
  37. 37. Asthma management 2. Control of factors contributing to asthma severitiy • Eliminate or reduce problematic environmental exposures • Treat co-morbid conditions: rhinitis, sinusitis, gastroesophageal reflux • Annual influenza vaccination
  38. 38. Asthma management 3. ASTHMA PHARMACOTHERAPY • Long-term-control Vs quick-relief medications • Classification of asthma severity • Step-up, step-down approach • Asthma exacerbation management The “three strikes” rule for determining if an asthmatic child should receive controller therapy
  39. 39. Asthma mgt - pharmacotherapy The “three strikes” rule • If an asthmatic child – has symptoms or uses quick-relief medication at least 3 times per wk, – awakens at night due to asthma at least 3x / mo, – requires a refill for a quick-relief inhaler prescription at least 3 times per yr,
  40. 40. Asthma mgt - pharmacotherapy The “three strikes” rule • if an asthmatic child… – experiences asthma exacerbations > 3x/ yr, or – requires short courses of systemic corticosteroids >3 x/yr, then • That patient should receive daily controller therapy.
  41. 41. Asthma mgt - pharmacotherapy Principles of Asthma Pharmacotherapy • For younger children (<5 yr of age), management is primarily based on symptoms • A major objective of this approach is to identify and treat all “persistent” asthma with anti-inflammatory controller medication.
  42. 42. Asthma mgt - pharmacotherapy Principles of Asthma Pharmacotherapy • The classification of asthma severity is based on the parameters: (1) frequency of daytime and (2) nighttime symptoms, (3) degree of airflow obstruction by spirometry, and/or (4) PEF variability
  43. 43. CLASSIFN STEP DAYS WITH SYMPTOMS NIGHTS WITH SYMPTOMS FOR ADULTS AND CHILDREN AGE > 5 YEARS WHO CAN USE A SPIROMETER OR PEAK FLOW METER FEV1 or PEF[*] % Predicted Normal PEF Variability (%) Severe persistent 4 Continual Frequent ≤60 >30 Moderate persistent 3 Daily >1/wk >60–<80 >30 Mild persistent 2 >2/wk, but <1/day >2/mo ≥80 20–30 Mild intermitte nt 1 ≤2/wk <2/mo ≥80 <20 Classification of Asthma Severity From NAEPP Expert Panel Report NIH publication no: 02–5075
  44. 44. Managing Children (≤5Yr) with Acute or Chronic Asthma
  45. 45. For all patients – quick relief Bronchodilator as needed for symptoms: -Preferred treatment: -inhaled SABA by nebulizer or face mask and space/holding chamber -Alternative treatment: Oral β2-agonist Managing Infants and Young Children (≤5Yr) with Acute or Chronic Asthma
  46. 46. For all patients – quick relief With viral respiratory infection -Bronchodilator q 4–6 hr up to 24 hr; -Consider systemic corticosteroid if exacerbation is severe or history of previous severe exacerbations -Use of SABA >2x/wk in intermittent asthma (daily, or increasing use in persistent asthma)  need to initiate (increase) long-term-control therapy. Managing Children (≤5Yr) with Acute or Chronic Asthma
  47. 47. Step down Review treatment every 1 to 6 mo; a gradual stepwise reduction in treatment may be possible. Managing Infants and Young Children (≤5 Yr of Age) with Acute or Chronic Asthma
  48. 48. ↑Step up If control is not maintained, Review patient medication technique, adherence, and environmental control. • Classify severity: assign patient to most severe step in which any feature occurs. • There are very few studies on asthma therapy for infants. • Gain control as quickly as possible (a course of short systemic corticosteroids may be required) Managing Infants and Young Children (≤5 Yr of Age) with Acute or Chronic Asthma
  49. 49. Managing Asthma in Children >5Yr of Age
  50. 50. Managing Asthma in Children >5Yr of Age Quick Relief - All Patients • inhaled SABA: 2–4 puffs as needed for symptoms. • Intensity of treatment will depend on severity of exacerbation; •up to 3 treatments at 20-minute intervals or •a single nebulizer treatment as needed. • Course of systemic corticosteroids may be needed.
  51. 51. Managing Asthma in Children >5Yr of Age Quick Relief All Patients • Use of SABA >2 times/wk in intermittent asthma (daily, or increasing use in persistent asthma)  need to initiate (increase) long-term-controller NB: SABAs are the recommended quick-reliever medications for symptoms and exercise pretreatment for all asthma severity levels.
  52. 52. Asthma Exacerbations and Their Management Asthma exacerbations • acute or subacute episodes of progressively worsening symptoms and airflow obstruction. • Obstruction can become extensive  life- threatening respiratory insufficiency.
  53. 53. Asthma Exacerbations and Their Management … mgt The optimal management of a child  comprehensive assessment • Focused history • Clinical assessment • Risk factors for asthma morbidity & death • Treatment
  54. 54. Asthma Exacerbations and Their Management Acute asthma exacerbations mgt • SABAs - increase pulmonary blood flow with increasing dosage and frequency. • When airways obstruction is not resolved with SABA use, •  Ventilation-perfusion mismatch  significant hypoxemia, which can perpetuate bronchoconstriction and further worsen the condition.
  55. 55. Home Management of Asthma Exacerbations • written action plan - recognition & mgt of exacerbations • immediate treatment with “rescue” medication – inhaled SABA, up to 3 treatments in 1 hr. – A good response  • resolution of symptoms within 1 hr, • no further symptoms over the next 4 hr, and • improvement in PEF to at least 80% of personal best.
  56. 56. Home Management of Asthma Exacerbations If the child has an incomplete response i.e • persistent symptoms &/or PEF <80% of personal best, – a short course of oral corticosteroid therapy (prednisone for 4 days) – Contact clinician
  57. 57. Home Management of Asthma Exacerbations • For patients with severe asthma and/or • a history of life-threatening episodes, – providing an injectable form of epinephrine and – portable oxygen at home should be considered.
  58. 58. Emergency Department Management of Asthma Exacerbations Primary goals:- • correction of hypoxemia, • rapid improvement of airflow obstruction, and • prevention of progression or recurrence of symptoms. Interventions are based on • clinical severity on arrival, • response to initial therapy, and • risk factors associated with asthma morbidity &
  59. 59. Emergency Department Management of Asthma Exacerbations Indications of a severe exacerbation include • Signs of severe respiratory distress • a silent chest with poor air exchange, • severe airflow limitation (PEF or FEV1 <50% of personal best or predicted values), and • mental status changes
  60. 60. Emergency Department Management of Asthma Exacerbations Initial treatment includes • supplemental oxygen, • inhaled SABA every 20 min for 1 hr, &, if necessary, • systemic corticosteroids - oral or IV. Inhaled ipratropium may be added if no significant response is seen with the 1st inhaled β-agonist Rx.
  61. 61. Emergency Department Management of Asthma Exacerbations • An IM injection of epinephrine in severe cases. – Oxygen continued for at least 20 min after the last injection to compensate for possible ventilation-perfusion abnormalities caused by SABAs. • monitor clinical status, hydration, and oxygenation
  62. 62. Emergency Department Management of Asthma Exacerbations Discharge to home if there is – sustained improvement in symptoms, – normal physical findings, – PEF >70% of predicted or personal best, – an oxygen saturation >92% on room air for 4 hr. Discharge medications – inhaled β-agonist up to every 3–4 hr plus – a 3–7 day course of an oral corticosteroid. Optimize controller therapy - addition of ICS
  63. 63. Hospital Management of Asthma Exacerbations Indication – status asthmaticus • moderate to severe exacerbations not improving within 1–2 hr of intensive treatment • high-risk features for asthma morbidity or death. • severe respiratory distress, and concern for potential respiratory failure and arrest.
  64. 64. Hospital Management of Asthma Exacerbations Interventions for status asthmaticus 1. Supplemental oxygen, 2. frequently or continuously administered inhaled bronchodilator And 3. Systemic corticosteroid therapy
  65. 65. Hospital Management of Asthma Exacerbations SAβAs - • Adverse effects - tremor, irritability, tachycardia, and hypokalemia. • Thus, ongoing cardiac monitoring, & oximetry Inhaled ipratropium bromide • is often added every 6 hr if no remarkable improvement • synergistic effect in relieving severe bronchospasm • beneficial in patients with mucous hypersecretion
  66. 66. Hospital Management of Asthma Exacerbations Monitoring • arterial blood gas, complete blood cell counts, • serum electrolytes, and chest radiograph to monitor for – respiratory insufficiency, – co-morbidities, infection, and/or – dehydration. • especially important in infants and young children
  67. 67. Hospital Management of Asthma Exacerbations • Several therapies, including parenterally administered – epinephrine, – β-agonists, – methylxanthines, – magnesium sulfate (25–75 mg/kg, maximum dose 2.5 g, intravenously over 20 min) have demonstrated some benefit as adjunctive therapies in severe status asthmaticus patients
  68. 68. Childhood Tuberculosis GETA . B(MD) 07/05/2018
  69. 69. outline • Epidemiogy • Etiology • Transmission • pathogenesis • Clinical Manifestation • Diagnosis • Managment • Prevention
  70. 70. Epidemiology • one-third of world population is infected with M.TB. • There were an estimated 0.5million TB cse among children<15yr old • Theree were 74000 TB death among HIV negative children • Number of TB death is unacceptably high given that most are preventable
  71. 71. Continuing • There are 22 high burden countries acounted for 82% of all estimated case worldwide . • Ethiopia is the 7th burdened country.
  72. 72. Etiology • Mycobacterium tuberculosis complex. –M.Tuberculosis –M.Bovis –M.Africanum –M.Microti –M.Cantti • M.TB – Most important cause of human Tuberculosis – non spor forming,non motil,slow growing,obligat aerobic,grow best 37-41 degree
  73. 73. Transmission • Transmission is person to person(usually by air born mucus droplet nucli. • Rarely occurs by diract contact with an infected discharge or contaminated fomite. • Risk of transmission increase with index case: • smear positive TB • Extensive upper lobe infiltration • Copious production of sputum • Sever and forcefull cough • Not treated
  74. 74. Continuing • Enviroment – Poorly ventilation – Overcrowding – Intimacy Younger children (<7yr) rarely infect others M.Bovies transmited by ingestion of cow milk.
  75. 75. Continuing • The risk of infection of susceptible individual is high with close,prolonged,indoor exposure to aperson with sputum positive pulmonary TB.
  76. 76. Pathogenesis • lung is portal of entry in more than 98%of the case. • Bacilli multiply initially within alveoli and alveolar duct. • Most cleared by macrophages. • Primary complex formed through portal of entry and regional lymphe nodes.
  77. 77. Continuing • Disseminated TB occurs if – circulating number of bacilli is large. – Host immune response is inadequet. • Cell mediated immunity developes 2-12wks after infection along with tissue hypersensitivity.
  78. 78. Clinical presentation • Pulmonary • Commonest 70% • all lobes of lung are at equaly risk of initial infection • cough,Fever,night sweat anorexia ,decreased appetit • Failur to thrive • Common site of reactivation is apex of upper lobe
  79. 79. Continuing • when Ag load is small and tissue hypersensitivity is high granuloma will formed • when both Ag and sensitivity are high incomplit tissue necrosis results in formation of caseous material. • When degree of tissue sensitivity is low it results in diffuse reaction
  80. 80. Continuing • Extrapulmonary – TB lymphadenities – pleural TB – TB pericardities – CNS TB • Stage 1 • stage 2 • stage 3
  81. 81. Continuing • Common permanent disabilities are – Blindness – Deafness – Paraplagia – Diabetic insipidus – Mental retardation • Diagnosis is mainly by high degree of suspension .
  82. 82. Continuing • GI/peritoneal TB – Most commonly affected areas are ileum,jejunum and appendex. – Presentas abdominal pain, diarrhea/constipation. – I.testinal obstruction. • Renal TB • Urin cultur positive in 80-90%.. • Bone and Joint TB. • Cutaneus TB.
  83. 83. Diagnosis • Sputum AFB • Chest X-ray • CBC • Sputum cultur • TB could be smear positive and smear negative
  84. 84. Managment • Chemotherapy/Anti TB 2RHZE/4RH • Nutritional Rehablitation • Sceaning of the family(index case, other contacts). • follow up(Adherance,responce,drug side effact)
  85. 85. Continuing • Steroid in TB indication – Meningities. – pericardities. – Adrenal inssufficiency. – airway obstruction. – Bilateral pleurl effusion with respiratory problem • 60 mg/ day for 4 wk then tper every 1-2 wk. • Indication of pyridoxin – breast feed infants. – severly malnourished children. – HIV infected Children.
  86. 86. prevention • Ventilation • Early diagnosis and treatment
  87. 87. THANK YOU

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