Bronchial Asthma in children.

1. Bronchial Asthma

2. Asthma is a global health problem. It is common in
people of all ages in countries through out the world.
According to WHO, more than 300 million people
worldwide are suffering from asthma and estimated
that there may be an additional 100 million
people with asthma by 2025.
Introduction

3. Prevalence in Bangladesh:
According to the first national asthma prevalence
study in Bangladesh, about 7 million people (5.2%)
suffering from asthma, majority of them are in 1-15
years of age group that is 7.4%of total paediatric
population is suffering from asthma.

4. What is Asthma ?
The term asthma is derived from a Greek word
meaning ‘panting’ or ‘labored breathing’.
Asthma is a chronic inflammatory condition of the
lung airways that causes episodic airflow
obstruction and airways hyper-responsiveness
to some provocative factors.
Asthma is characterized as a syndrome rather
than a disease.

5. According to the National Guideline,
Asthma is a chronic inflammatory disorder
causing hyper-responsiveness of airways to
certain stimuli resulting in recurrent variable
airflow limitation, at least partly reversible,
presenting as wheezing, breathlessness,
chest tightness and coughing.

6. What are the causes of asthma?
The exact etiology of asthma is still not known
but it is suggested that asthma is a multifactorial
disease and airway of the asthma patient are
highly sensitive to certain things which do not
bother people without asthma.

7. Asthma triggers

8. Asthma trigger factors:
 Allergens-
Outdoor allergen- Pollens from flowers, grass
Indoor allergen- House dust mites, dander, insects
(cockroach)
Food allergen- rarely cause an asthma attack. It
includes- beef, prawn,hilsha,seafood,duck egg,
cows milk, nuts etc.

9. Asthma trigger factors:
 Irritants:
Tobacco smoke,wood/coal burning smoke,
perfumes,sprays,cosmetics,paints,toxic gases from
automobiles & factories.

10. Cont..
Upper respiratory tract infections-
Viral infections,common cold.
Drugs-
Beta blockers,aspirin,NSAIDs etc.
Changes in season,weather & temperature-
Cold/dry air.

11. Cont..
Exercise
Stress-
Emotion- laughing,crying
Surgery,pregnancy.

13. Pathogenesis
Airflow obstruction in asthma is the result of
numerous pathologic processes.
• In the small airways, airflow is regulated by the
encircling bronchial smooth muscle.
• Constriction of these bronchiolar muscular bands
causes restriction of airflow.
• A cellular inflammatory infiltrate and exudates
(eosinophils, mast cells, lymphocytes etc) can fill
and obstruct the airways and causes epithelial
damage and desquamation.

14. Asthma Pathophysiology

16. IMMEDIATE RESPONSE
Eliciting agent: allergen or
non-specific stimulus activates:
Mast cells, platelets, alveolar
macrophages, causing release of:
Spasmogens: H,
PAF, LTC4, LTD4,
causing:
Chemotaxins:
LTB4, PAF, MNC,
ECF-A which
cause:
BRONCHOSPASM
Reversed by 
agonists &
Theophylline
Aggregation & activation of
platelets, infiltration & activation of
neutrophils, eosinophils,
monocytes/macrophages :
PAF, LTB4,
LTD4, platelet
factors&
susbstance P
Neurotensin
ODEMA, MUCOUS
SECRETION &
BRONCHOSPASM
LATE-PHASE RESPONSE
Bronchial
hyper
responsiven
ess
Endothelial
damage
& stimulation of
C Fibes and
irritant
receptors

17. MEDIATORS RESPONSIBLE
1ST GROUP: role in bronchospasm is clearly supported
by pharmacological interventions
• e.g. leukotrienes C4,D4,E4, acetylcholine
2nd GROUP:- have potent asthma like effects but their
actual clinical
role appears to be minor on the basis of lack of efficacy of
potent antagonists or synthesis inhibitors
• e.g. histamine, prostaglandin D2, PAF
3RD GROUP:- whose specific antagonists are not
available and even their role in asthma is not clear
• e.g. IL-1, TNF, IL-6, chemokines, nitric
oxide, bradykinin , endothelins ,neuropeptides..

18. Cont..
Consequently,
Airway hyper-responsiveness to numerous
provocative triggers, as well as airways edema,
basement membrane thickening, subepithelial
collagen deposition, smooth muscle and mucous
gland hypertrophy, and mucous hypersecretion;
all these processes contribute to airflow
obstruction.

19. Classification of asthma

20. A. Clinical classification:
1.Intermittent asthma: 2 or <2 nocturnal symptoms
in a month and between the episodes, patient is
symptom free & PFT normal.
2.Persistent asthma: Frequent attack >2 in a month
and in between attack, patient may or may not be
symptom free & PFT abnormal except mild
persistent variety.

21. It is further divided into three types –
a) Mild persistent: nocturnal attack of
dyspnea >2 times per month and baseline FEV1
is usually 80%-65%.
b) Moderate persistent: asthma attack
almost everyday and baseline FEV1 is between
65% – 50%.
c) Severe persistent: dyspnea to some
extent continuously for 6 months or more and
baseline FEV1 is <50%.

22. • 3. Acute exacerbation: Loss of control of any
class/ variant of asthma which may cause mild to
life threatening attack.

23. Classification of asthma contd..
Assessment of severity of acute asthma in
children
Symptoms Mild Moderate Severe
Physical
exhaustion
Talks in
Consciousness
No
Sentence
s
Consciou
s
No
Phrases
Conscious
Yes
Words
Altered
Signs
Wheeze
Pulse
Cyanosis
PEFR or FEV1
SaO2
Variable
<100
Absent
>60%
>94%
Loud
100-160
Absent
40%-60%
94%-90%
Often quiet
>160
Likely
present
<40%
<90%

24. 4.Special variant asthma:
- Seasonal asthma
- Exercise induced asthma
- Drug induced asthma
- Cough variant asthma
- Occupational asthma

25. Clinical manifestation
Cardinal features are:
•
• paroxysmal respiratory distress
• recurrent cough
• Wheeze
• Chest tightness,

26. •particularly if these symptoms:
• are frequent and recurrent
• are worse at night and early morning
• occur in response to or are worse after exercise
or other trigger
• occur apart from colds
• personal and family history of atopic disorder

27. Examination findings
• Suprasternal,intercostal & subcostal indrawing,
• Tachycardia,
• Tachypnoea,
• Hyper resonant lung fields,

28. Examination findings
• Vesicular breath sound with prolonged expiration,
• Ronchi,
• Associated allergic condition like allergic rhinitis,
conjunctivitis, eczema may present,
• Good response to rapidly acting bronchodilators
& steroids.

29. Differential diagnosis of childhood asthma
• Viral bronchiolitis
• Gastro esophageal reflux disease
• Pulmonary tuberculosis
• Laryngotracheomalacia
• Recurrent pneumonia
• Congenital heart disease
• bronchiectasis

30. Differential diagnosis of childhood asthma
• Foreign body aspiration
• Happy wheezers
• Post nasal drip syndrome
• Pulmonary eosinophilia
• Cystic fibrosis

31. Asthma is a clinical diagnosis.
A compatible clinical history plus a demonstration of
variable airflow obstruction is sufficient for the
diagnosis of asthma.
Diagnosis

32. Why we investigate Asthma patient
• For Classification and assessment of severity
• For diagnosis of concomitant illness
• For exclusion of other cause of cough, wheeze,
dyspnea, or chest tightness

33. 1. Lung function test:
- Spirometry-
FEV1 <80% of predicted value
FVC normal or reduced
FEV1/FVC ratio reduced <75%
- Reversibility test
- Exercise challenge test
- Diurnal variation of peak flow
cont..

34. 2. Chest X-ray- to exclude foreign body or chronic
chest infection
3. CBC with circulating eosinophil-shows
eosinophilia
4. Serum IgE -raised
Cont….

35. Management of asthma

36. 4. MANAGEMENT OF ACUTE EXACERBABATION
Propped –up position
Oxygen inhalation 4-6 L/min
Nebulization with salbutamol every 20 min
interval 3 times
Injection hydrocortison(4-6mg/kg/dose stat & 6
hrly)
Add Ipratropium bromide in nebulized
form 6 hourly
No improvement

37. Add Ipratropium bromide in nebulized
form 6 hourly
Add Inj Aminophylline (5mg/kg bolus then
maintenance dose of 0.5-0.7mg/kg/hr )
or Inj salbutamol (15 µgm/kg bolus )
No improvement
No improvement
ICU Care

38. Clinical scoring to identify the steps of “ step care
management”
CRITERIA SCORE
Yes No
1. Have dyspnoea everyday? 1 0
2. Nocturnal attack of dyspnoea more than
two times per month
1 0
3. Severe dypnoea necesssitate-steroid,
Nebulization or Hospitalization
1 0

39. Clinical scoring to identify the steps of “ step care
management”
CRITERIA SCORE
Yes No
4. Persistent dyspnoea for last
6months/moreOR take steroid for 1
yr/more
3 0
5. Patients baseline PEFR <60% of
predicted value
1 0
TOTAL SCORE = 0-7 Score0= step I,
Score1= step II, Score2= step III,
Score 3-4= step IV, Score 5-7= step V

40. STEP CARE MX FOR CHILDREN >5 YEARS
Step 1 Step 2 Step 3 Step 4 Step 5 Step 6
Asthma education
Environmental control
Preferre
d
SABA as
per need
Preferred
LDICS
Alternativ
Cromone
s or
Nedocro
mil or
LTRA or
Theophyll
ine
Preffered
HDICS or
LDICS+LABA
alternative
LDICS+either
LTRA or
Theophylline
Or Cromones
Preffered
HDICS+LABA
Or theophy
or LTRA
Alternative
HDICS+Laba
or
Theophylline
Or LTRA
Preffered
HDICS
+LABA+
Theophy.
Alternativ
e
HDICS
+LTRA or
Theophylli
ne
Preffered
HDICS+
LABA+
oral
corticoste
roid
Alternativ
e
HDICS+
LTRA or
Theophyll
ine+ oral
corticoste

41. STEP CARE MX FOR CHILDREN <5 YEARS
Step
1
Step 2 Step 3 Step 4 Step 5 Step 6
Preffe
red
Inhale
d
SABA
Preferr
ed
LDICS
Alterna
tive
LTRA
or
Cromo
nes
Preffer
ed
MDIC
S
Preffere
d
MDICS+
Either
LABA or
LTRA
Preffered
HDICS+
Either
LABA or
LTRA
Preffered
HDICS+
Either
LABA or
LTRA+
Oral
corticost
eroid

42. Classification on the basis of
control(working classification)
It is important and relevant for management of
asthma.On the basis of control, asthma can be
classed as-
A. Controlled
B. Partly controlled &
C. Uncontrolled

43. Levels of asthma control:
Characteristi
c
Controlled Partly
Controlled
Uncontroll
ed
Daytime
symptoms
None≤2/wk >2/wk
Limitation of
activities
None Any ≥3 features
of partly
controlled
asthma
present
Nocturnal
symptoms/
awakening
None Any

44. Levels of asthma control:
Characteristic Controlled Partly
Controlled
Uncontroll
ed
Need for
reliever/rescue
treatment
Lung Function
None
≤2/wks
Normal
>2/wk
<80%

45. Indications of antibiotics in asthma
• Fever with purulent sputum
• Suspected bacterial sinusitis
• Patients with overlapping COPD
• Presence of concomitant pneumonia
• Frequent exacerbation of asthma ( may be
associated with mycoplasma or chlamydial
infections)

46. Asthma management appliances
• Metered dose inhalers(MDIs)
• Breath actuated inhalers(Autohalers)
• Dry powder inhalers(PDIs)
• Spacers and chambers
• Nebulizers
• Flow meters

47. Drugs used in asthma:
1. Relievers:
a. Adrenoreceptor
agonists-
i. Short acting
beta agonists
• Salbutamol
• Levosalbutamol
• Terbutalin
i. Alpha & beta
agonists-
• Adrenaline
• Ephedrine
b. Xanthine
derivatives-
• Aminophylline
• Theophylline

48. Cont.
c. Anticholinergics-
• Ipratropium
2. Preventers:
a. Corticosteroids-
• Beclomethasone
• Budesonide
• Fluticasone
b. Cromones-
Sodium
cromoglycate
Nedocromil
sodium

49. Cont.
c. Leukotriene
antagonists-
• Montelukast
• Zafirlukast
3. Controllers:
a. Long acting beta
agonists-
• Salmeterol
• Bambuterol
Combination:
Fluticasone+Salmeterol
Salbutamol+Ipratropium

50. Newer modality of asthma therapy:
1.Magnesium sulfate:
40mg/kg I/V
2.Omalizumab:
It is the monoclonal antibody against IgE.
150-300mg, 2-4 weeks interval.

51. Disease modifying agents
• Methotrexate: 5-25mg weekly.
• Cyclosporine A

52. Follow up
•Good response criteria:
• Improvement almost complete
• No distress
• Physical examination- normal
• PEF>70% of predicted or personal best
In case of good response patient
may go home with rescue steroid and
step care management .

53. Follow up
•incomplete response criteria:
• Improvement partial
• Mild to moderate distress
• Physical examination- rhonchi
• PEF>50% - <70%
In case of incomplete response patient
Should be admitted to the hospital and
Management is to be continued.

54. Follow up
•Poor response criteria:
• No Improvement
• Severe symptom persists.
• Extensive rhonchi / silent chest
• PEF<50%
In case of poor response patient is to be
Admitted in ICU for further management.

55. Asthma education
• Patient education is so important that if they are
educated properly, 73% of hospital admission can
be reduced and 80% of death from asthma can
be avoided.

56. Asthma education
A. Development of rapport:
Counseling
B. Patient education:

57. Asthma education
1. Basic fact about asthma:
• Concept of disease
• Concept of airway narrowing
2. Asthma medicines and appliances:
• Concept of medication
• Use of appliances

58. Asthma education
3. Concordance:
• Need for long term therapy
• Importance of asthma management plan
• Regular peak flow monitoring
• Rescue action
4. Avoidance of risk factor

59. Asthma education
5. Prognosis and goal management:
• Natural history
• Treatment goal
6. Alleviation of misconception

60. Asthma education
7.Institutional approaches:
• Formation of asthma club
• School-based management