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Childhood asthma diagnosis and management
1. CHILDHOOD ASTHMA
DIAGNOSIS &
MANAGMENT
Dr. Virendra Kumar Gupta
Assistant Professor
Department Of Pediatric Gastroentero-
hepatology & Liver Transplantation
NIMS Medical College &
Hospital , Jaipur
2. Story of rahul
An 4-year-old boy rahul was brought by
his mother for recurrent cough for last 1
year, his cough gets worse at night and he
coughs a lot after running or laughing.
She also reported that he frequently had
colds which “went to the chest”.
3. Definition of asthma
Asthma is a Chronic inflammatory condition of the
airways characterized by airway
hyperresponsiveness to a variety of stimuli,
manifesting as recurrent obstruction which is
reversible either spontaneously or by medication.
4. WHEN TO SUSPECT ASTHMA
1.Frequent episodes of wheezing.
2.Cough or wheeze after exercise.
3.Cough particularly in night during periods
without viral infection.
4.Symptoms that persists after the age 3yrs
Consider asthma if any the following signs or
symptoms are present:
5. WHEN TO SUSPECT ASTHMA contd…
5.Symptoms occur or worsen in the presence
of:
• Aeroallergens
• Exercise
• Pollens
• Respiratory infections (viral)
• Strong emotional stress
• Tobacco smoke
6.Childs cold repeatedly “cough goes to the
chest” and takes more than 10 days to clear
up
7.Symptoms improve when asthma
medications are given
6. Clinical presentations of asthma
patient
Clinical presentation of asthma child may be
from absolutely normal during routine visit
to severe symptomatic during acute
exacerbation.
7. During acute episode
Child may have
• Difficult Breathing
• Coughing
• Audible Wheezing
• Chest tightness
On examination
Hunched position / squatting
Fatigued, anxious, sweating
watery/glassy eyes
Flared nostrils
Cyanosed,Tachyponea,Tachycardia
Intercostal and tracheostrenal retraction to feeble
chest movement
On auscultation loud expiratory wheeze to silent
chest
absolutely normal sensorium to agitated
8.
9. Factors that Influence Asthma
Development and Expression
Host Factors
Genetic
- Atopy
- Airway
hyperresponsiveness
Gender
Obesity
Emotional factors
Race/ ethnicity
Environmental
Factors
Indoor allergens
Outdoor allergens
Occupational sensitizers
Tobacco smoke
Air Pollution
Respiratory Infections
Diet and drugs
Family size
Socioeconomic status
10. Recognition of asthma triggers and avoiding them including smoking is
the first step towards controlling asthma
TRIGGERS
Trigger Factors are things that set off or start asthma
Can vary from person to person. An asthma attack can be induced by direct irritants
(allergens)
12. How to Diagnose
asthma
History and patterns of symptoms
1. Frequent episodes of wheezing(i.e.> once a month)
2. Cough or wheeze after exercise .
3. Cough particularly in night during periods without viral
infection
4. Symptoms occur or worsen in the presence of trigger
5. Childs cold repeatedly “cough goes to the chest” and takes
more than 10 days to clear up.
6. Symptoms improve when asthma medications are given
7. Family h/o atopy /asthma
8. Personal h/o atopy
9. Seasonal exacerbations
13. Asthma Diagnosis contd…
Investigations:
LAB investigations
CBC/DLC
ABG
Allergy test
Chest x ray
Investigations help to rule out alternate diagnose, not
to prove asthma
14. Asthma Diagnosis (investigation) contd…
Spirometry-
Use spirometry to establish
airflow obstruction:
FEV1/FVC < 80% predicted
indicate significant airflow
obstruction
FEV1/FVC 60%-80%-moderate
airflow obstruction
FEV1/FVC < 60% severe airflow
obstruction
Use spirometry to establish
reversibility:
FEV1 increases >12% and at
least 200 mL after using a short-
acting inhaled beta2-agonist
Exercise challenge/challenge
to methacholine -Worsening in
FEV1 ≥15%[*]
15. Differential diagnosis of asthma
Before labeling any patient as bronchial asthma we should
exclude condition which simulate asthma-
Congenital Anomalies with airway impingement: Vascular
rings, tracheobronchial obstruction, mediastinal mass
Bronchopulmonary dysplasia
Cystic fibrosis
Gastroesophageal reflux
Aspiration
Foreign Body Aspiration
Heart Failure
Sinusitis and allergic rhinitis
Bronchiolitis /WALRI
Pertussis
Tuberculosis
Immune system Disorders
16. How to confirm
No gold standard test to diagnose
Diagnosis is Essentially Clinical
Lung function tests are occasional
helpful
Other causes of recurrent cough
should be ruled out
17. WHEN TO LABEL
Three or more episodes of reversible airflow
obstruction
with several of these:(most accepted defination
including WHO )
1.Afebrile episodes
2.Nocturnal exacerbations
3.Family h/o atopy /asthma
4.Personal h/o atopy
5.Exercise/activity induced symptoms
6.Trigger induced symptoms
7.Seasonal exacerbations
8.Relief with bronchodilators/steroids
18. The early wheezer (<3 years)
WALRI
Febrile episode
Personal atopy
absent
Family history of
asthma atopy absent
Variable response to
bronchodilator
Early onset sthma
Afebrile episodes
Personal atopy
present
Present
Predictable good
response
20. Genetic risk factor for asthma
Multiple interacting genes
At least 20 distinct chromosomal regions
with linkage to asthma and asthma related
traits have been identified: Chromosome
5q , ADAM33 , PHF11
Asthma / atopy in family
sibling –doubles risk
one parent –doubles risk
both parent –triples risk
21. Asthma Predictive Index For
Children
Major criteria
•Parent asthma
•Atopy
•Inhalant allergen
sensitisation
MINOR CRITERIA
• Allergic rhinits
• Wheezing apart
from Colds
• Eosinophils >4%
• Food Allergen
sensitization
ONE MAJOR OR TWO MINOR CRITERIA PROVIDE A
HIGH SPECIFICITY (97%) & POSITIVE PREDICTIVE
VALUE (77%) FOR PERSISTANT ASTHMA IN TO
LATER CHILDHOOD.
22. Identify Co morbid conditions
ALLERGIC rhino sinusitis
- Morning sneezing, blocked nose, snoring , mouth
breathing
Adenoidal hypertrophy
-Frequent Colds ,ear infections, blocked nose, snoring ,
mouth breathing
Gastro esophageal reflux
-Nocturnal cough followed by vomiting
OBESITY
- asthma patients who are overweight or obese that weight
loss, in addition to improving overall health, might also
improve their asthma control
23. Classification of asthma
At one point of time-
Used to Classify acute exacerbation of asthma to
decide the severity and drug to be used to control acute
attack(reliever medication)
1. Mild
2. Moderate
3. Severe
24. Classification of asthma contd…
over a period of time to decide the need and
choice of long term controller medications
Old classification
1. Mild intermittent
2. Mild persistent
3. Moderate persistent
4. Severe persistent
New GINA classification
1. Controlled
2. partly controlled
3. Uncontrolled
25. OLD CLASSIFICATION OF ASTHMA
(from NAEPP expert panel report. Guide line for asthma diagnosis
management-updates 2002)
based on symptoms, frequency of episodes, functional impairment and
objective measure of pulmonary function
CLASSIFICATION STEP DAYS WITH
SYMP
NIGHT
WITH
SYMP
PEF
OR
FEV1
PEF
VARIA
BILITY
Severe persistent 4 continual Frequent <60 >30
Moderate
persistent
3 Daily > 1/ wk >60-
<80
>30
Mild persistent 2 > 2/ wk but < 1
time/day
> 2
/month
>80 20-30
Mild intermittent 1 < 2/ wk < 2
/month
>80 <20
PEFR or FEV1 is applicable for children over 5 year of age and
adult.
26. New GINA classification based on
Levels of Asthma Control
Characteristic
Controlled
(All of the following)
Partly controlled
(Any present in any week)
Uncontrolled
Daytime symptoms
None (2 or less
days / week)
More than
twice / week
3 or more
features of
partly
controlled
asthma
present in
any week
Limitations of
activities
None Any
Nocturnal
symptoms /
awakening
None Any
Need for rescue /
“reliever” treatment
None (2 or less /
week)
More than
twice / week
Lung function
(PEF or FEV1)
Normal
< 80% predicted or
personal best (if
known) on any day
Exacerbation None One or more / year 1 in any week
This is simple easy to remember even by patient
27. Treatment
Regular Assessment and Monitoring
Patient Education
Control of Factors Contributing to Asthma
Severity
Pharmacotherapy
Asthma Exacerbations and Their
Management
28. Identify and Reduce Exposure to Risk Factors
To improve control of asthma and reduce
medication needs, patients should take steps to
avoid the risk factors that cause their asthma
symptoms
Avoidance measures that improve control of
asthma and reduce medication needs are:
Tobacco smoke: Stay away from tobacco smoke.
Patients and parents should not smoke.
Drugs, foods, and additives: Avoid if they are
known to cause symptoms.
Occupational sensitizers: Reduce or, preferably,
avoid exposure to these agents.
29. Identify and Reduce Exposure to Risk
Factors contd…
Reasonable avoidance measures that can be recommended
but have not been shown to have clinical benefit:
• House dust mites: Wash bed linens and blankets weekly in
hot water and dry in a hot dryer or the sun. Encase pillows
and mattresses in air-tight covers (If possible, use vacuum
cleaner with filters).
• Animals with fur:. Remove animals from the home (Use air
filters)
• Cockroaches: Clean the home thoroughly and often. Use
pesticide spray—but when patient is not at home.
• Outdoor pollens and mold: Close windows and doors and
remain indoors when pollen and mold counts are highest.
• Indoor mold: Reduce dampness in the home; clean any
damp areas frequently
30. Pharmacotherapy of asthma
(Drugs)
Relievers
For treatment of
bronchospasm and to
relieve acute attack
Preventers or
controller
For long term control
of inflammation and to
prevent further attack
33. Short-acting beta2-agonists
slective beta-2 agonist:
salbutmol, levosalbutamol, terbutaline.
Non slective beta 2 agonist:-adrenaline
Short-acting beta2-agonists are available in inhaled, pill,
liquid, and injectable forms. The inhaled form is available in
metered-dose inhalers (MDIs) and as a liquid for
compressor-driven nebulizers.
Short-acting beta2-agonists are bronchodilators. They
relax the muscles lining the airways that carry air to the
lungs (bronchial tubes) within 5 minutes, increasing airflow
and making it easier to breathe. They relieve asthma
symptoms for 3 to 6 hours. They do not control the
inflammation
34. Short-acting beta2-agonists
Short-acting beta2-agonists are used to:
Provide quick relief of symptoms during asthma attacks.
Prevent asthma symptoms before exercise.
Treat symptoms in intermittent asthma.
Common side effects
Headache and dizziness.
Nausea, vomiting, and diarrhea.
Anxiety.
Nervousness or tremor (such as unsteady, shaky
hands).
35. LABA
Not used as relievers
Never use alone
Used with ICS for synergistic effects/steroid
sparing effects
Useful in nocturnal/Exercise induced
symptoms
Used only in children >4years
Salmeterol / Formoterol-not much to choose
Duration of action 12 to 24 hours
Use for mod/severe persistant asthma
36. LABA
Formoterol:
Mdi:12 µg/puff
Dpi/rota cap:12µg/cap
Dose: 1 to 2 puff/rota cap/day od/bd
Salmeterol:
Mdi:25 µg/puff
Dpi/rota cap:50 µg/cap
Dose: 1 to 2 puffs/caps od/bd
37. ICS
Anti inflammatory effect evident in 2-3 weeks
Local side effects can be minimized by
spacer/gargling
Systemic side effects negligible
Most children are controlled with medium doses.
In prolonged high doses-monitor growth and eyes
Near 20% velocity reduction of growth in 1st yr of
treatment, then growth normalizes in case of
routinely recommended inhaled doses
Completely inactivated during first pass
metabolism so has minimum side effects
38. ICS
Side effects :
Local – Oral candidiasis, dysphonia
Systemic : Adrenal suppression, Effects on bone
and linear growth
Long-term treatment with inhaled
glucocorticosteroids has not been shown to be
associated with any increase in osteoporosis
or bone fracture
Studies including a total of over 3,500 children
treated for periods of 1 – 13 years have found
no sustained adverse effect of inhaled
glucocorticosteroids on growth
39. Beclomethasone 200-500 100-200 >500-1000 >200-400 >1000 >400
Budesonide 200-400 100-200 400-800 >200-400 >800 >400
Budesonide-Neb
Inhalation Suspension
250-500 >500-1000 >1000
Ciclesonide 80 – 160 80-160 >160-320 >160-320 >320-1280 >320
Flunisolide 500-1000 500-750 >1000-2000 >750-1250 >2000 >1250
Fluticasone 100-250 100-200 >250-500 >200-500 >500 >500
Mometasone furoate 200-400 100-200 > 400-800 >200-400 >800-1200 >400
Triamcinolone acetonide 400-1000 400-800 >1000-2000 >800-1200 >2000 >1200
Drug Low Daily Dose (g) Medium Daily Dose (g) High Daily Dose (g)
> 5 y Age < 5 y > 5 y Age < 5 y > 5 y Age < 5 y
Estimate Comparative Daily Dosages for
Inhaled Glucocorticosteroids by Age
40. ICS Formulation
Inhaled medications for asthma are
available as
1. pressurized metered-dose inhalers
(pMDIs),
2. breath-actuated MDIs,
3. dry powder inhalers (DPIs)-rota cap
4. nebulizers-respule
41. Long term oral steroids
Use limited to severe persistent asthma
Minimal possible doses
Alternate morning doses preferred
Prednisolone – best option
Side effects :Excessive weight gain,
hypertension, osteoporosis, decreased
linear growth, metabolic derangement and
catarcts
42. Leukotrine antagonists
Leukotrine antagonist may be considered as
mono therapy in mild persistent asthma where
child parent refused for inhalation therapy but
certainly inferior to ICS
Add on in moderate to severe asthma
Weak anti inflammatory effect
Exercise induced asthma
Montelukast > 6 months
Zafirlukast>6 yrs
S/E : headache, abd pain, vivid dreams,
Churgg Strauss Syndrome(eiosinophilic
vasculitis) rarely.
44. Theophylline
Anti inflammatory / immunomodulator effect
Inhibitor of phosphodiesterase
Adjunct therapy for mod/severe persistent asthma
MOA : Smooth muscle relaxant, bronchodilator, respiratory
stimulant,diaphragmatic muscle contractlity improver
Disadvantage:-Low theraptic index
S/E :gastric irritation, GI h’age, CNS sym- agitation, convulsions,
coma, resp failure
100,150,200,300 mg tab available
Dose; 5 to 15 mg/kg/day in 2 divided doses
45. Treating to Achieve Asthma
Control
Those patient who are newly diagnosed asthma is
categorised according to old classification and
treatment is started accordingly.
Then monitoring and follow up is done according to
new GINA classification.
At each treatment step, reliever medication should
be provided for quick relief of symptoms as needed
At Steps 2 through 5, patients also require one or
more regular controller medications, which keep
symptoms and attacks from starting.
If asthma is not controlled on the current treatment
regimen, treatment should be stepped up until
control is achieved.
46. For newly diagnosed patient treatment is started
according to old classification
CATEGORY symptoms/day
Symptoms/night
STEP TREATMENT
Mild
intermittent/
Exercise
induced asthma
≤2days/week
≤2night/mo
1 No daily medication reqd. In case of severe
exacerbations, a course of systemic CS
recommended and sos SABA
Mild persistent
asthma
>2 d/mo but<1ep/d
>2 night/mo
2 Low dose inhaled CS and SABA sos
Alt:,Leukotriene modifier,SR theophylline
Cromolyn , nedocromiL,
Moderate
persistent
asthma
Daily
>1 night/week
3 Low to medium dose inhaled CS
And long acting inhaled beta agonists
For younger children mod to high dose inhaled
steroid is better
Alt : ,Leukotriene modifier, theophylline
Cromolyn, nedocromiL
Severe
persistent
asthma
continual
frequent
4 High dose inhaled CS
and Long acting beta agonists add one or more
Leukotriene modifier, theophylline Cromolyn,
nedocromiL if needed.
Oral CS- short course (2mg/kg/day) max 60
47.
48. Step 1 – As-needed reliever medication
Patients with occasional daytime symptoms of
short duration( mild intermittent asthma)
A rapid-acting inhaled β2-agonist is the
recommended reliever treatment
When symptoms are more frequent, and/or
worsen periodically, patients require regular
controller treatment (step 2 or higher)
Treating to Achieve Asthma Control
49.
50. Step 2 – Reliever medication plus a single
controller
for mild persistent asthma- treatment is started at
this step
A low-dose inhaled glucocorticosteroid is recommended
as the initial controller treatment for patients of all ages
Alternative controller medications include leukotriene
modifiers appropriate for patients unable/unwilling to
use inhaled glucocorticosteroids
Treating to Achieve Asthma Control
51.
52. Step 3 – Reliever medication plus one or two
controllers
For moderate persistent asthma treatment is started at
this step
For children, increase to a medium-dose inhaled
glucocorticosteroid
For adults and adolescents, combine a low-dose inhaled
glucocorticosteroid with an inhaled long-acting β2-
agonist either in a combination inhaler device or as
separate components
Inhaled long-acting β2-agonist must not be used as
monotherapy
Treating to Achieve Asthma Control
53.
54. Step 4 – Reliever medication plus two or more
controllers
For severe persistent asthma treatment is
started at this step
Selection of treatment at Step 4 depends
on prior selections at Steps 2 and 3
Where possible, patients not controlled on
Step 3 treatments patient should be
referred to a health professional with
expertise in the management of asthma
Treating to Achieve Asthma Control
55. Step 4 – Reliever medication plus two or more controllers
Medium- or high-dose inhaled glucocorticosteroid
combined with a long-acting inhaled β2-agonist
Medium- or high-dose inhaled glucocorticosteroid
combined with leukotriene modifiers
Low-dose sustained-release theophylline added
to medium- or high-dose inhaled
glucocorticosteroid combined with a long-acting
inhaled β2-agonist
Treating to Achieve Asthma Control
56.
57. Treating to Achieve Asthma Control
Step 5 – Reliever medication plus additional controller options
Addition of oral glucocorticosteroids to other
controller medications may be effective but
is associated with severe side effects
Addition of anti-IgE treatment to other
controller medications improves control of
allergic asthma when control has not been
achieved on other medications
58. controlled
partly controlled
uncontrolled
exacerbation
LEVEL OF CONTROL
maintain and find lowest
controlling step
consider stepping up to
gain control
step up until controlled
treat as exacerbation
TREATMENT OF ACTION
TREATMENT STEPS
REDUCE INCREASE
STEP
1
STEP
2
STEP
3
STEP
4
STEP
5
REDUCEINCREASE
59. Clinical Control OF Asthma
No (or minimal)* daytime symptoms
No limitations of activity
No nocturnal symptoms
No (or minimal) need for rescue medication
Normal lung function
No exacerbations
_________
* Minimal = twice or less per week
60. Monitoring to Maintain Asthma Control
When control has been achieved, ongoing monitoring is
essential to:
- maintain control
- establish lowest step/dose of treatment to minimize cost
and maximize safety.
Typically, patients should be seen one to three months
after the initial visit, and every three months thereafter .
After an exacerbation, follow-up should be offered within
two weeks to one month.
Asthma control should be monitored by the health care
professional and by the patient
61. Monitoring to Maintain Asthma
Control
At each visit, ask the questions to decide
adequacy of treatment
is the asthma management plan meeting
expected goals?
is the patient using inhalers, spacer, or peak flow
meters correctly?
is the patient taking the medications and
avoiding risk factors according to the asthma
management plan?
does the patient have any concerns?
62. Adjusting medication:
stepping up treatment
Generally, improvement should be seen within 1
month.
If asthma is not controlled on the current treatment
regimen, step up treatment.
But first review the patient’s medication technique,
compliance, and avoidance of risk factors.
If asthma is partly controlled, consider stepping up
treatment, depending on whether more effective
options are available, safety and cost of possible
treatment options, and the patient’s satisfaction with
the level of control achieved.
Monitoring to Maintain Asthma Control
63. Treating to Maintain Asthma Control
Stepping down treatment when asthma is controlled
When controlled on medium- to high-dose inhaled
glucocorticosteroids: 50% dose reduction at 3 month
intervals
When controlled on low-dose inhaled
glucocorticosteroids: switch to once-daily dosing
Monitoring is still necessary even after control is
achieved, as asthma is a variable disease; treatment
has to be adjusted periodically in response to loss of
control as indicated by worsening symptoms or the
development of an exacerbation
64. Acute Exacerbations
Exacerbations of asthma (asthma attacks)
are episodes of a progressive increase in
shortness of breath, cough, wheezing, or
chest tightness, or a combination of these
symptoms. .
It is graded as mild, moderate, severe
exacerbation.
65. Management of Acute asthma:
Steps:
(1)Assessment of severity
(2)Initiation of therapy
(3)Assessment of response
(4)Modification of therapy or additional threapy
67. IDENTIFICATION OF LIFE
THREATING ATTACK /RED
FLAG SIGNS
1. Unable to talk or cry or speak in words only
2. Cyanosis
3. Feeble chest movement
4. Absent breath sound
5. Fatigue or exhaustion
6. Agitated
7. Altered sensorium
8. Oxygen saturation < 92 %
68. Pulmonary Score Index
Score Respiratory rate
<6 years >6 years
Wheezing Accessory
muscle
Sternomastoid
activity
0 <30 <20 None None
1 31 - 45 21 – 35 Terminal
expiration with
stethoscope
Questionable
increase
2 46 – 60 36 – 50 Entire expiration
with stethoscope
Apparently
increase
3 >60 >50 During inspiration
& expiration
without
stethoscope*
Maximum
activity
69. Pulmonary Score Index
Score 0 – 3
mild
* If no wheezing due
to minimal air
exchange score >3
4 – 6
moderate
>6
severe
Those children whose score >6 should be admitted to
Pediatric ICU.
70. Initial Assessment
History, Physical Examination, PEF or FEV1
Initial Therapy
Bronchodilators , O2
Incomplete/Poor Response
Add Glucocorticosteroids
Good Response Poor Response
Discharge Admit to Hospital
Respiratory Failure
Admit to ICU
If Stable,
Discharge to
Home
Observe for at
least 4 hour
Good
Response
Emergency Department Management
Acute Asthma
71. Home treatment of acute
exacerbation (PS score ≤3)
SA ß2 agonist 4-6 puff (actuation) given one puff q2
minutes through MDI ±SPACER±FACE MASK-
every 20 minute in 1st a hour.
If symptoms improved or PEFR gets better then,
inhalation can be continued on Salbutamol 4- 6
hourly and plan for visit to treating physician.
If response ill sustained (<4 hours) start 1st dose of
rescue steriod.
Seek medical attention on the same day if inhaled
SABA is required for symptoms relief more
frequently than 3 hourly or for more than 24 hours.
72. Emergency Room management
PS 4-6 (Moderate)
•O2
•SA β2 AGONIST
nebulise with salbutamol 0.1-0.15mg/kg in 3cc NS over 5-10
min every 20 min.×3times 1st hour with 6-8L/min central
oxygen.
(or Continuous nebulization with salbutamol@: 0.1-0.5mg/kg/hr)
OR
MDI ± spacer ±Mask 1 puff q2min till 6puff reached
Give 6 puff like this every 20 min in 1st hour
OR
(If Inhaled therapy not available)
•Adrenaline /Terbutaline 0.01mg/kg sc q 20 min x 3
•Commence / Continue rescue steroid
•Continuous Assessment every one hour for 3-4 hours
73. E Room management contd….
ASSESSMENT OF RESPONSE TO INITIAL THREAPY:
After 3 doses of bronchodilator and oxygen therapy asses child if
GOOD RESPONSE:
Free of wheeze, without any breathlessness
Heart rate and respiratory rate decrease.
Auscultation: minimal or no ronchi and PEFR or FEV1 improve
to more than 80% of the predicted or personal best.
if response sustained >4 hours after last treatment at room
air.
Plan will be:
1. Discharge with Patient education
2. Continue inhaled Beta 2 every 4-6 hours till symptoms abate.
3. continue oral steriods for 3-7 days .
74. E Room management contd….
PARTIAL RESPONSE:
Breathlessness or wheezing reduced but still present
Physical examination:1.HR and RR above physiologic levels.
2.Pulsus paradoxus of 10-15 mm hg
3.O2 saturation 91-95%.
4.PEFR 50-80% of predicted normal.
Child who have shown partial response to initial therapy
having distress may be continued inhalation therapy with
ß2 agonist as frequent as every 20 minutes, even
continuously without side effect for next 2 hours.
if Ipratropium not added at onset of therapy it can started be
at the end of 1st hour.
75. E Room management contd….
PARTIAL RESPONSE:
Who have minimal symptoms after initial
therapy could be given inhalation every 2-4
hours.
if child have improved on the on continuation of
above therapy for about 2 hours he can
observed 4 hours if response sustained 4 hours
then discharge with proper advice.
if not responding(PS>3), response is illsustained
shift to ward / ICU
76. WARD MANAGEMENT OF ASTHMA
• Continue oxygen
•Start IV fluids, IV / Orals steriods
• Rescue Steroids are
IV Hydrocortisone (5-10 mg/kg) q 6 hr or
IV Methylprednisolone (1-2 mg/kg)q 6 hr or
IV / IM Dexamethasone (0.1-0.2 mg/kg) q 6 hr.
Oral prednisolone 1-2 mg/kg for 3-7 days
•Nebulie with SA β2 hourly/ back to back
•Ipratopium neb q 20 min x 3 and then q 6 hrs
if child is stable(PS score 4-6) on above therapy we can wait on
same therapy for at least 6-8 hours before intensification of therapy.
77. WARD MANAGEMENT OF ASTHMA
CONTD….
Intensify the therapy by adding iv bronchodilator:
Magnesium sulphate, Aminophylline, Terbutaline infusion,
as per need if not improving
But before intensification check that all the treatment
advised and oxygen was being given
Magnesium sulphate
dose- 25 -50 mg/kg in 1: 10 dilution of NS &
infusion over ½ hour-single dose
Aminophylline
Loading dose 5 mg/kg slow IV diluted in 5% dextrose
f/b 0.4-1 mg/kg/hr
78. WARD MANAGEMENT OF ASTHMA
CONTD….
Terbutaline
- initial bolus of 5-10μg /kg over 10 min
- f/b 2-10 μg/kg/hr by infusion
Discontinue neb β2 agonist at higher infusion rate
Dissolve 1 ml (500 μg) in 50 ml 5% dextrose
(1ml of solution = 10 μg terbutaline)
• Monitor SaO2 and Serum K+
• CBC, X- Ray chest only to identify complications.
• No subjective or objective improvement child is
detoriating (PS SCORE >6) shift to ICU.
79. Indication for transfer of child in ICU
depend upon status of child at time of
presentation and response to therapy
Indication
• life threatening attack
• severe distress
• shown poor response to therapy
• develop sign of impending respiratory failure
during therapy like hypoxia hpercarbia (PS
SCORE >6)
80. ICU MANAGEMENT
ICU Management
Continue
1. Oxygen
2. Inhaled short acting Beta agonist every 60 min or
continuous + inhaled Anticholinergics.
3. continue systemic rescue steroids.
4. Continue intensified ward plan/ intensify therapy by
adding bronchodilator: - Magnesium sulphate
Aminophylline, Terbutaline infusion.
5. Continuous monitoring with pulse oximetry and repeated
ABG are mandatory since most of these patient are not in
condition to perform PEFR
6. If indicated intubate child and start mechanical ventilation
81. ICU MANAGEMENT CONTD….
Indication of mechanical ventilation are:
Failure of maximum pharmacotherapy
Pao2<60 ,Paco2 >50
Minimal chest movements
Minimal air exchange
Severe chest retractions
Deterioration of mental status
Respiratory/ cardiac arrest
82. ICU MANAGEMENT CONTD….
Stabilize with 100% O2 with bag and mask
Do suction and nasogastric decompression
Premedication with atropine and local anesthetic
before intubation
Ideal sedative is iv ketamine (midazolam/fentanyl) in
dose of 1 to 3 mg/kg.
Paralysis with vecuronium bromide in a dose of 0.2 to
0.3 mg/ kg if required.
Volume cycled ventilators is preferred with low RR ( 8
to 12 / min) and long expiratory time (i:e ratio 1:3 to
1:4), PEEP should be minimal and isnpiratoy flow rate
should be kept high to improve gas exchange.
Tidal volume of 10 to 12 ml/kg and PIP less than of 40
to 50 cm of water should be maintained
83. ICU MANAGEMENT CONTD….
Throughout ventilation ß2 agonist are nebulised into
isnpiratoy circuit of ventilator if not responding can
nebulise with halothane1-1.5%,isoflurane 1%
Once PaCO2 value fall less than 45 mmHg and PIP
less than 35 cm H2O or no bronchospasm on
auscultation muscle paralysis can be stopped.
As muscle function return to normal patient can be
put on spontaneous ventilation if child maintain
PaCO2< 45 mmHg child can be extubated.
During recovery phase of asthma, frequency of
inhalation therapy should reduced gradually, and
shifted to oral medication.
84. Stepping down acute care
Follow the principle “last in first out”
o Discontinue terbutaline/aminophylline drip in 24
hrs
o Discontinue ipratropium neb in 24-48 hrs
o Reduce nebulisation with SA β2 agonist to q 2-4
hrly and then q 4-6 hrly
o Replace IV rescue steriod Oral steroid
85. Discharge Criteria
Pulmonary score index < 3
Sleep well at night
Feeding well
Appears comfortable
Receiving less frequent β2 agonist
86. SEASONAL ASTHMA
Is retrospective diagnosis-based on h/o in last
2-3 years, asthma attack start with onset of
particular season and persist during that season
till allergen persist otherwise child is normal
remaining part of year.
Child can be started on maintenance treatment
2 weeks in advance of start of season.
Medications are given as per the severity of
asthma
Child should be examined again after
discontinuing meds after season is over
87. EXERSIZE INDUSED ASTHMA
Managed by SABA/LABA/LTRAS
Short acting B agonists are given just
before activity as they have short duration
of action
Long acting bronchodilators/leukotriane
receptor antagonists can be given in the
morning
88. Prognosis
The prognosis for asthma vary from child to child
First thing we have to explain to
attainder/caregiver that asthma is controllable
disease if adequately treated not curable
diseases.
60% of children will symptom free after the age
10 year as airway size increase with growth of
child but still they should under continuous
monitoring they can have repeat attack any time
in life so they can not declared cured. especially
for children with mild disease.
90. 4 steps
1. Explain advantage of inhalation therapy
2. Dispel myths and fear
3. Select appropriate device
4. demonstrate how to use selected device
91. Advantage of inhalation therapy
Inhaled oral
Route direct Indirect
Dosage smaller higher
Onset of action rapid slow
Adverse effect mild or none greater
Smaller doses, target delivery, quicker action,
lesser side effect.
92. Less Drug
Without Side effects
Straight into the
Lungs
Advantage of inhalation therapy
Salbutamol 4 mg Tabs 40 Puffs of Salbutamol Inhaler
93. Dispelling myths and fear
Is inhalation therapy strong? NO
Emphasize micro organism
is inhalation therapy ‘addictive? NO
None of drug cause dependence
Is inhalation therapy expensive ? NO
Initially but not ultimately
Is inhalation therapy easy to use in children YES
First choice, but not last resort !!!
94. When given by inhaled route how
much drug does one get
Inhaler Device
MDI with spacer
Metered dose inhaler
(MDI)
Dry powder inhaler
Nebulizer
Delivery
10-15%
5-10%
5-10%
1-5%
96. Selecting the right device
Age
< 3 years – MDI + Spacer + mask
>3 years – MDI + Spacer
>6 years – MDI +Spacer
- Dry powder inhaler (DPI) is an
option
MDI + spacer is the most versatile device
97. Selecting the right device
Controller regimen
• Moderate to high dose ICS
Use MDI + spacer instead of DPI even in
older children
98. Selecting the right device
Acute episodes
• Home – MDI + spacer ±mask /DPI
• Hospital – MDI + spacer ±mask
- nebuliser in severe episodes
Do not use DPI in moderate / severe
exacerbations
100. MDI
The MDI is a device that delivers a specific and pre-
metered amount of medication to the lungs, in the
form of an aerosol spray that is inhaled by the
patient.
Two types
-pressure actuated MDI (pMDI)
-breath actuated MDI (bMDI)
102. How to Use a Spray Inhaler
Teach patients (and parents) how
to use inhaler devices.
Different devices need different
inhalation techniques.
Give demonstrations and
illustrated instructions.
Ask patients to show their
technique at every visit.
Health-care provider should
evaluate inhaler technique at each
visit.
If an inhalant is not having much
effect, it could mean the person is
not using it properly or it is blocked
or empty.
Demonstration of pMDI
104. Breath actuated MDI(bMDI)
Breath actuated MDI (bMDI)-this is
advance over pMDI. bMDI overcome
the problem coordination between
actuation and inhalation. It is actuated
at low isnpiratoy flow rate
Demonstration how to use bMDI
105. spacer
Spacers(some time also called as holding chamber) are
devices that hold the medication for few seconds after it
has been released from the MDI.
Role of spacer
Spacers overcome coordination problem of actuation
and inhalation
Increase delivery of drug to lung
can reduce potential side effects.
Dilute taste of inhaled spray
eliminate cold Freon effect
When using MDI, Spacer is must
106. Type of spacer
Small volume vs large volume
Valved vs non valved
Polyamide vs polycarbonate
109. How to clean spacer
they should cleaned once every 15 days
open the lock, separate two halves of
spacer.
Pace under simple tape water over 1-2
minute.
put in clean place to become dry
110. Baby mask with spacer
Baby mask make it easy to deliver inhaled medicine in children younger 3 years.and
those who have difficulty in good seal of lips
it is made up of soft silicon and reusable.
equiped with exhalation vent.
111. Dry powder inhalation device(DPIs)
DPIs, as their name implies, dispense
medication as dry powder formulation without
the use of propellant as in MDI.
DPIs disperse medication as dry powder(2-5
µm) without use of propellant.
DPIs are breath actuated so no coordination
problem between actuation and inhalation.
Used above 6 years
Two types
-unit dose DPIs( rotahaler and revoliser)
-multi dose DPIs(multihaler)
113. Click on icon to play
animation
A pplication
Rotahaler should
clean twice a
week. Separate
two halves of
rotahaler keep in
running tape
water over 1-2
minute. Put at
clean place to
become dry.
114. How to clean DPI
Rotahaler should clean twice a week.
Separate two halves of rotahaler.
keep in running tape water over 1-2
minute.
Put at clean place to become dry.
Revolizer should clean once a week
116. Revolizer(single dose DPI device)
The Revolizer is new generation patient friendly dry
powder inhaler device that is easy to use.
Technique of use of Revolizer DPI devices
Simply open the Revolizer, insert the rotacap, shut the
device and inhales
118. How to use multihaler
Advantage of multihaler
119. Nebuliser
Nebulizer is device used for converting a liquid
drug into a fine mist which inhaled directly into the
lungs via face mask or mouth piece.
Nebulisation chamber are small plastic device into
which drug solution is placed.
The device is driven by compressor
(electric/battery operated)or oxygen.
Gas flow of 6-8 L/min is normally required to drive
the nebuliser.
Drug inhalation is accomplished by normal tidal
breathing over 5-10 minutes.
122. Advantage of nebuliser
No efforts required ;needs only tidal
breathing.
A large dose of drug can be administered
simply and effectively.
Indication of nebuliser -
emergency treatment of acute severe asthma
Delivery of drug in diseases like cystic
fibrosis
home treatment for patient who are too ill,
short of breath, or otherwise unable to use
hand-held inhalers.
123. FILLING YOUR NEBULISER
Plug the compressor unit into the mains. Connect the
tubing from the compressor unit to the bottom of the
nebuliser chamber.
Unscrew the top of the nebuliser chamber. Open the vial
of drug solution by twisting off the top. Measure out the
correct amount of drug solution and pour into the
nebuliser chamber.
Sometimes you may need to dilute the drug solution.
Add normal saline to make total solution 3-5ml which is
required in the nebuliser chamber for it to work properly.
Screw on the top of the nebuliser chamber and attach
the face mask or mouthpiece to the top of the chamber.
124. USING YOUR NEBULIZER
Place the facemask over patient mouth and
nose and place the strap over your head.
Sit up, well supported, in a chair or in bed and
keep the nebulizer chamber upright.
Switch the compressor unit on and breath in and
out as normal. Relax whilst using nebuliser. .
Nebulisation usually completed in 5-10 minute.
A small amount of solution may be left in the
nebuliser at this stage, but this is normal.
Switch off the compressor unit and disconnect
the nebuliser chamber from the tubing.
125. CLEANING NEBULISER
Each time you use it, wash the nebuliser chamber in
warm soapy water and then rinse thoroughly with clean
water. Do not use a brush to clean the nebuliser
chamber as you may damage it.
Reconnect the nebuliser chamber to the tubing and blow
air from the compressor unit through it for a few
seconds. This will dry the nebuliser chamber and tubing.
Disconnect the nebuliser chamber from the tubing and
allow it to dry completely. Disconnect the tubing from the
compressor unit.
Once a week, rinse the nebuliser chamber with a dilute
solution of Milton or a special nebuliser cleaner. Rinse
the nebuliser chamber with clean water and then dry as
before.
Tubing and nebulisation chamber should be replaced
every six months or so.
126. Factors Involved in Non-Adherence
Medication Usage
Difficulties associated with
inhalers
Complicated regimens
Fears about, or actual
side effects
Cost
Distance to pharmacies
Non-Medication
Factors
Misunderstanding/lack of
information
Fears about side-effects
Inappropriate expectations
Underestimation of severity
Attitudes toward ill health
Cultural factors
Poor communication
127. Never overuse Reliever
More reliever needed, worse the asthma
Maximum recommended dose of
nebulised salbutamol at a time is 10 mg
Overdosage : tachycardia with rates up to
200 beats per minute and arrhythmias
Cardiac arrest and even death
128. If your patient needs to use a reliever
medication every day, or even more
than three or four times a week,
preventive/controller medication must
be added to the treatment plan
129. The Peak Flow Meter
• Useful to show
reversibility and &
Monitoring of treatment
• like a thermometer for
asthma to measure PEFR
• Economical handy
instrument
• Builds confidence in
treatment
• Gives objective values
• One ‘hard, fast blow’
Click on icon to start Animation
130. PEAK EXPIRATORY FLOW RATE
MONITORING
Home monitoring ; for moderate to severe persistent asthma
Normal PEFR ranges are determined by patient's age, gender
and height
Zone classification
GREEN ( DOING WELL ) PEFR 80 -100% ;clear , no symptoms; can
do usual activities
YELLOW (ASTHMA GETTING WORSE)
PEFR 50-80%;cough,wheeze,chest tightness, shortness of
breath; waking at night due to asthma; can do some, but not all
activities
RED (MEDICAL ALERT) PEFR < 50 %;very short breath; cannot do
usual activities
131. Doxofylline
Doxofylline is long acting oral methylxanthine derivative.
Doxofylline is phosphodiesterase inhibitors has antitussive
and bronchodilator affects
Unlike other xanthines, doxofylline lacks any significant
affinity for adenosine receptors and does not produce
stimulant effects..
Indication
For maintenance therapy in Asthma and COPD.
Side Effects
it has shown similar efficacy to theophylline but with
significantly less side effects.
Dosages
Children-6mg/kg/dose bd.
Adult:400mg od to tds.
132. Acebrophylline
ambroxol-theophylline-7-acetate
has 3 actions namely bronchodilation,
mucoregulation & anti-inflammatory action.
Indicatio
asthmatic bronchitis, Acute & Chronic bronchitis.
Contraindication
Hypersensitivity to ambroxol, theophylline,acebrophylline
Patient with hemodynamic instability,hypotensionand
arrhythmias.
Patient with renal and liver disorder.
133. Acebrophylline
Side Effects
Epigastric pain
Unlike other xanthine derivatives it has minimum side
effects like palpitations & tachycardia.
Dosage
In children 2-3 years is 2mg/kg/day two divided doses
In children 3-12 years dose is 2-3.5mg/kg/day two
divided doses
1 cap 100mg bd two week
Available as cap. 100mg,syrup100 ml (1ml-10mg)
134. Bambuterol
oral LABA
prodrug of terbutaline (Bambec and Oxeo)
Indications
Used in chronic persistent asthma as controller
It should not be used single therapy.
Contraindications
pregnancy, seriously impaired liver function.
Adverse effects
similar to that of Salbutamol
Dose- oral 10/20 mg od.
Recommended above 12 years of age
135. Allergen-specific Immunotherapy
Greatest benefit of specific immunotherapy using
allergen extracts has been obtained in the treatment of
allergic rhinitis
The role of specific immunotherapy in asthma is limited
(anti IgE, Omalizumab)
Specific immunotherapy should be considered only after
strict environmental avoidance and pharmacologic
intervention, including inhaled glucocorticosteroids, have
failed to control asthma
Perform only by trained physician
136. OMALIZUMAB
Humanised monoclonal Anti IGE
MOA:-
It binds to IgE antibody and reduces the amount of
free IgE available to mast cells, basophils and
other cells.
Indication
Add ON therapy for moderate to severe asthma
Dosage:-
150-375 mg intradermal or subcutaneous every 2-4
Weeks children > 12 yr age
side effects:-
Hypersensitivity
risk of increased incidence of parasitic infection and
malignancy
Disadvantage:- costly
137. Newer drugs in asthma control
Altrakincept:
IL-4 receptor antagonist which have important role
in pahogenesis of asthma
Soluble recombinant IL-4 receptor which acts as an
antagonist in vivo inactivates naturally occurring IL-4
without mediating cellular activation.
Nebulized form of IL-4R has a serum half-life of 1 week.
Single dose of IL-4 R, 1500 mcg. per week, appears safe
and effective in moderate asthma.
Mepolizumab:
anti IL-5 antibody.
It has been postulated to decrease eosinophil infiltration
and is particularly useful in hypereosinophilic syndromes.
Dose being 750mg/dose iv. for 3 infusions.
138. Suplatast tosilate:
It is a Dimethyl sulphonium compound
It selectively inhibits Th-2 cytokines.
There is a notable drop in the average number of
infiltrating eosinophils and CD4+ cells.
dosage:-100 mg tds.
Efalizumab:
It is a humanized IgG1 mAb against the lymphocyte
function antigen-1 (LFA-1) . Blocking of LFA-
1/intercellular adhesion molecule interactions could
inhibits the development of allergen-induced cellular
inflammatory response that inhibit the late asthmatic
response
Newer drugs in asthma control
139. Newer drugs in asthma control
Resquimod:
Resiquimod is a new immune response modifier
from the family of imidazoquinolineamines.
It inhibits allergen induced Th-2 response, airway
inflammation and airway reactivity.
Has antiviral activity can used ingenital warts, herpes
genitalis and molluscumcontagiosum.
can be administered topically and orally
IDEC -152
IgG1 anti-CD23 antibody
in patients with mild-to-moderate persistent allergic
asthma.
140. Ciclesonide, Rofleponide
On site activated steroids: e.g..
Ciclesonide, Rofleponide (under study).
Soft steroids: They have improved local,
topical selectivity and have much less
steroid effect outside target area.
141. Pranlukast
Newer generation of leukotriene receptor antagonist
Pranlukast is a cysteinyl leukotriene receptor-1
antagonist.
This drug works similarly to montelukast.
appear to be equally effective
It is currently under clinical trials
142. Advantage of various drug fixed combination
Advantages
Simpler dosage schedule improves compliance and
therefore improves treatment outcomes
Reduces inadvertent medication error
Less expensive than single ingredient drugs
Potential for drug abuse can be minimized by using one
drug of the combination for this purpose.
Eliminates drug shortages by simplifying drug storage
and handling, and thus lowers risk of being “out of stock”
143. Advantage of various drug fixed combination
Only 1 expiry date simplifies dosing
(single products may have different expiry
dates)
Procurement, management and handling
of drugs is simplified
Lower packing and shipping costs
Side effects are reduced by using one
drug of the combination for this purpose
144. Disadvantage of various drug fixed
combination
Dosing is inflexible and cannot be regulated to
patient’s needs (each patient has unique
characteristics such as weight, age,
pharmacogenetics, co-morbidity, that may alter
drug metabolism and effect).
If a patient is allergic or has a side-effect to 1
component,the FDC must be stopped and
replaced by separate inhaIer
incompatible pharmacokinetics is irrational
because of different elimination ½ lives of
individual components
147. Various fixed drug combination
formulation
Respule(Duolin)
Inhaler(Duolin)
DPI(Duolin)
Levosalbutamol+ipratropium
1.25mg+500mcg/2.5ml
50mcg+25mcg/puff
100mcg+50mcg/rotacap
There are some of irrational combination in market
like-Aerocort inhaler /rotacap contain
beclomethasone and Levosalbutamol one controller
medication and other is reliever medication which is
irrational combination
148. “Be alert to the faults of patients
which make them lie about their
taking of the prescribed medicines,
and when things go wrong,
refusing to confess that they have
not been taking their medicine.”
- Hippocrates, ‘The Father of Medicine’, 200 BC