Asthma is a chronic inflammatory disease of the airways characterized by episodic obstruction, bronchial hyperresponsiveness, and reversibility of airflow obstruction. It has both genetic and environmental causes. Childhood asthma affects 13.1% of children in the US, with boys and children in poor families at higher risk. There are two main types - recurrent wheezing in early childhood triggered by viruses, and chronic asthma associated with allergy. Treatment involves assessment, education, trigger management, and medications to reduce bronchoconstriction and inflammation.

2. Definition of Asthma
• A chronic inflammatory disease of the airways
with the following clinical features:
 Episodic and/or chronic symptoms of airway
obstruction
 Bronchial hyperresponsiveness to triggers
 Evidence of at least partial reversibility of the
airway obstruction
 Alternative diagnoses are excluded

3. Etiology
• Although the cause of childhood asthma has not been determined,
contemporary research implicates a combination of
• Environmental exposures and
• Inherent biologic and
• Genetic vulnerabilities .

4. Epidemiology
• Asthma is a common chronic disease, causing
considerable morbidity.
• In 2007, 9.6 million children (13.1%) had been
diagnosed with asthma in their lifetimes.
• Boys (14% vs 10% girls) and
• Children in poor families (16% vs 10% not
poor) are more likely to have asthma.
• Approximately 80% of all asthmatic patients
report disease onset prior to 6 yr of age.

5. Types of Childhood Asthma
• There are 2 main types of childhood asthma:
• (1) recurrent wheezing in early childhood,
primarily triggered by common viral infections
of the respiratory tract, and
• (2) chronic asthma associated with allergy
that persists into later childhood and often
adulthood.

6. Pathogenesis
• Airflow obstruction : bronchoconstriction of
bronchiolar smooth muscular bands restricts or
blocks airflow.
• Inflammation: cellular (eosinophils and
others) , cytokines (IL-4, IL-5, IL-13) and
chemokines mediate this inflammatory
process.

7. • Intermittent dry coughing
• expiratory wheezing
• shortness of breath and
chest tightness
• Respiratory symptoms
can be worse at night
• Daytime symptoms,
often linked with physical
activities or play.
• limitation of physical
activities, general fatigue.
• Personal atopy (allergic
rhinitis, allergic
conjunctivitis, atopic
dermatitis, food allergies),
• Family history of atopy or
asthma
• Trigger Induced Symptoms
• Seasonal exacerbations
• Relief with
bronchodilators.
Clinical Manifestations and
Diagnosis

8. Asthma Predictive Index
 Identify high risk children:
• ≥ 3 wheezing episodes in the past year
PLUS
OR
 One major criterion
• Parent with asthma
• Atopic dermatitis
• Aero-allergen
sensitivity
 Two minor criteria
• Food sensitivity
• Peripheral
eosinophilia (≥4%)
• Wheezing not
related to infection
Modified from: Castro-Rodriguez JA, Holberg CJ, Wright AL, et al. A clinical index to define risk of asthma in young children with recurrent
wheezing. Am J Respir Crit Care Med. 2000;162(4 Pt 1):1403–1406

9. Treatment
• Management of asthma should have the following
components:
• (1) assessment and monitoring of disease activity;
• (2) education to enhance the patient's and family's
knowledge and skills for self-management;
• (3) identification and management of precipitating
factors and co-morbid conditions that may worsen
asthma; and
• (4) appropriate selection of medications to address the
patient's needs.
• The long-term goal of asthma management is
attainment of optimal asthma control.

10. In general ???
 There are two main types of drugs used for treating asthma.
Medications to reduce bronchoconstrictions:
o Beta 2 Agonist
o Anticholinergics
o Theophylline
Medications to reduce inflammations:
o Steroids ( oral, Parenteral & Inhalers)
o Not steroids:
• Leukotriene modifiers ( montelukast is available worldwide;
zafirlukast and pranlukast only in Japanese Guideline for Childhood
Asthma(JGCA).
 Cromolyn & Nedocromil (Reduction of mast cell degranulation)
Treatment

11. Farther more ???
 Quick- relief medications:
o Short acting Beta Agonists (SABA’s)
o Systemic corticosteroids
o Anticholinergics
Long-term control medications:
o Corticosteroids (mainly ICS, occasionally OCS).
o Long Acting Beta Agonists (LABA’s) including
salmeterol and formoterol,
o Leukotriene Modifiers (LTM)
o Cromolyn & Nedocromil
o Methylxanthines: (Sustained-release theophylline)

12. 1. MANAGEMENT OF CHRONIC ASTHMA.
2. MANAGEMENT OF ACUTE ASTHMA
MANAGEMENT OF ASTHMA

13.  Classifying Asthma Severity into intermittent, mild,
moderate, or severe persistent asthma depending on
symptoms of impairment and risk
• Once classified, use the 6 steps depending on the
severity to obtain asthma control with the lowest
amount of medication
Controller medications should be considered if:
• Use of SABA’s (salbutamol) more then twice a week.
• 2 episodes of oral steroids in 6 months, or
• >4 exacerbations/year,
MANAGEMENT OF CHRONIC ASTHMA

14. MANAGEMENT OF CHRONIC ASTHMA

16. Management of chronic asthma in children aged under 5
Step 1 mild intermittent asthma - ISABA as needed.
Step 2 regular preventer therapy - add ICS 200-400 micrograms/day or a LRA if
inhaled steroid cannot be used.
Step 3 add-on therapy -
for children aged over 2 years, consider the addition of a leukotriene
antagonist or inhaled steroid 200-400 micrograms/day (dependent on what
drug they received already as Step 2).
For children under 2 years, consider proceeding to Step 4.
Step 4 persistent poor control - refer to a respiratory paediatrician.

17. Management of chronic asthma in children aged More 5 years
Step 1 mild intermittent asthma - ISABA as needed.
Step 2 regular preventer therapy - add ICS 200-400 micrograms/day
Step 3 add-on therapy -
 add in a long-acting inhaled beta2 agonist (LABA) but if response is poor,
stop.
If the asthma is still not controlled, increase the dose of inhaled
corticosteroid to 400 micrograms/day and then
add either a leukotriene receptor antagonist or slow-release theophylline.
Step 4 persistent poor control - increase inhaled steroid to 800 micrograms/day
Step 5 : continuous or frequent use of oral steroids - use in the lowest dose to
provide control whilst maintaining high-dose inhaled steroids and refer to
respiratory paediatricians.

18. • How often should asthma be reviewed?
– 1-3 months after treatment started, then every 3-12 months
– After an exacerbation, within 1 week
• Stepping up asthma treatment
– Sustained step-up, for at least 2-3 months if asthma poorly controlled
• Important: first check for common causes (symptoms not due to asthma,
incorrect inhaler technique, poor adherence)
– Short-term step-up, for 1-2 weeks, e.g. with viral infection or allergen
• May be initiated by patient with written asthma action plan
• Stepping down asthma treatment
– Consider step-down after good control maintained for 3 months
– try to reduce therapy (usually by 25-50%)
– Find each patient’s minimum effective dose, that controls both
symptoms and exacerbations.
Reviewing response and adjusting
treatment
GINA 2014

19. Inhaled Medication deliveries

20. MANAGEMENT OF ACUTE ASTHMA
• Assessment of Severity
• Initial (Acute assessment)
• • Diagnosis
• - symptoms e.g. cough, wheezing. breathlessness , pneumonia
• • Triggering factors
• - food, weather, exercise, infection, emotion, drugs, aeroallergens
• • Severity
• - respiratory rate, colour, respiratory effort, conscious level
• Chest X Ray is rarely helpful in the initial assessment unless
complications like pneumothorax, pneumonia or lung collapse are
suspected.
• Initial ABG is indicated only in acute severe asthma.

22. Management of acute asthma
exacerbations
• Mild attacks can be usually treated at home if the
patient is prepared and has a personal asthma action
plan.
• Moderate and severe attacks require clinic or hospital
attendance.
 Criteria for admission
 Failure to respond to standard home treatment.
 Failure of those with mild or moderate acute asthma to
respond to nebulised β₂-agonists.
 Relapse within 4 hours of nebulised β₂- agonists.
 Severe acute asthma.

23. Footnotes on Management of Acute
Exacerbation of Asthma:
• 1. Monitor pulse, colour, PEFR, ABG and O2 Saturation. Close
monitoring for at least 4 hours.
• 2. Hydration - give maintenance fluids.
• 3. Role of Aminophylline debated due to its potential toxicity. To
be used with caution, in a controlled environment like ICU.
• 4. IV Magnesium Sulphate : Consider as an adjunct treatment in
severe exacerbations unresponsive to the initial treatment. It is
safe and beneficial in severe acute asthma.
• 5. Avoid Chest physiotherapy as it may increase patient discomfort.
• 6. Antibiotics indicated only if bacterial infection suspected.
• 7. Avoid sedatives and mucolytics.
• 8. Efficacy of prednisolone in the first year of life is poor.

25. Previous American
Guidelines ???

28. © Global Initiative for Asthma
Managing exacerbations in acute care settings
GINA 2014, Box 4-4 (1/4)
NEW!

29. © Global Initiative for AsthmaGINA 2014, Box 4-4 (2/4)

30. © Global Initiative for AsthmaGINA 2014, Box 4-4 (3/4)

31. © Global Initiative for AsthmaGINA 2014, Box 4-4 (4/4)

32. © Global Initiative for Asthma
Managing exacerbations in acute care settings
GINA 2014, Box 4-4 (1/4)
NEW!

33. • Recurrent coughing and wheezing occurs in 35% of
preschool-aged children.
• Of these, approximately one third continue to have
persistent asthma into later childhood, and
approximately two thirds improve on their own through
their teen years.
• Asthma severity by the ages of 7-10 yr of age is
predictive of asthma persistence in adulthood.
• Children with moderate to severe asthma and with
lower lung function measures are likely to have
persistent asthma as adults.
• In general, complete remission for 5 yr in childhood
is uncommon.
Prognosis

34. • A “hygiene hypothesis” purports that naturally occurring microbial
exposures in early life might drive early immune development away
from allergic sensitization, persistent airways inflammation, and
remodeling.
• Several nonpharmacotherapeutic measures with numerous
positive health attributes—
 avoidance of environmental tobacco smoke (beginning prenatally),
 prolonged breastfeeding (>4 mo),
 an active lifestyle, and a healthy diet—might reduce the likelihood
of asthma development.
 Immunizations are currently not considered to increase the
likelihood of development of asthma; therefore, all standard
childhood immunizations are recommended for children with
asthma, including varicella and annual influenza vaccines.
Prevention

35. THANKS FOR YOUR
ATTENTION