How to manage a child with asthma and managing Asthma Exacerebations

1. Childhood Asthma Management
Dr.C.S.N.Vittal

2. Definition of asthma
Asthma is a heterogeneous disease, characterized by
chronic airway inflammation resulting in episodic airflow
obstruction.
It is defined by the history of respiratory symptoms such
as wheeze, shortness of breath, chest tightness and cough
that vary over time and in intensity, together with variable
expiratory airflow limitation.

3. Childhood Asthma
Bronchospasm Inflammation
• is characterized by
– Airway obstruction
– which is
reversible
– Airway
inflammation

4. INDUCERS
Allergens, Chemical sensitizers,
Air pollutants, Virus infections
TRIGGERS
Allergens,
Exercise
Cold Air, SO2
Particulates
SYMPTOMS
Cough Wheeze
Chest tightness
Dyspnea
Airway
Hyper responsiveness Airflow Limitation
4
Inflammation

5. Mucus
hypersecretion
Hyperplasia
Eosinophil
Mast cell
Allergen
Th2 cell
Vasodilatation
New vessels
Plasma leak
Edema
Neutrophil
Mucus plug
Macrophage/
dendritic cell
Bronchoconstriction
Hypertrophy / hyperplasia
Cholinergic
reflex
Epithelial shedding
Sub epithelial
fibrosis
Sensory nerve
activation
Nerve activation
MODERN VIEW OF ASTHMA
IAP UG Teaching slides 2015-16

6. Chronic inflammation
Structural changes
Acute
inflammation
Steroid
response
Time
INFLAMMATION IN ASTHMA
Airway
remodeling
IAP UG Teaching slides 2015-16

7. TRIGGERS
Drugs:
• NSAIDs
• Aspirin
• ß-blockers

8. Diagnosis of asthma
Classical features
• Persistent cough, wheezing and
dyspnea are seen in 30%
Atypical features
• Cough-variant asthma
• Nocturnal asthma
• Activity-induced asthma
• Persistent cough after an URI
• Recurrent pneumonia at different
sites/ same site (middle lobe)

9. INVESTIGATIONS
• Sputum
examination for
eosinophils and
Curschmanns
spiral bodies –
rarely needed
• Pulmonary
function tests –
Gold Standard
• Spirometry
• Peak Expiratory
flow rate
9
• Routine blood counts may not help
• Peripheral smear may show eosinophilia
• X–ray chest to rule out tuberculosis

10. SPIROMETRY
10
Useful in children above 6 years
• An objective measure of airflow limitation.
• Low FEV1 (relative to percentage of predicted)
• FEV1/FVC ratio < 0.80
• Bronchodilator response (to inhaled β-agonist):
– Improvement in FEV1 ≥12% and ≥200 mL*
• Exercise challenge:
– Worsening in FEV1 ≥15%*
• Daily peak flow or FEV1 monitoring:
– day to day and/or am-to-pm variation ≥20%*
* MAIN criteria consistent with asthma.

11. Lung Function Tests
11
• PEFR Monitoring :
• Simple and inexpensive home-use
tools to measure airflow and can be
helpful in a number of
circumstances.

12. Differential Diagnosis
12
Early infancy
Birth – 6 months
Infancy – Early
childhood
6 months – 3 years
Late Childhood
> 3 years
Aspiration syndromes
(Gastroesophageal
Reflux etc.)
Bronchiolitis Asthma
Bronchiolitis Transient wheezing of
childhood (TWC)
Transient wheezing of
childhood (TWC)
Foreign body inhalation
(Rarely)
Foreign body inhalation,
CHD, TB
Congenital heart
disease

13. CLASSIFICATION OF ASTHMA SEVERITY
(0 - 4 yrs old Children)
Components of
Severity
Intermittent Persistent
Mild Moderate Severe
Symptoms < 2 days / week > 2 days / week
But not daily
Daily Throughout the
day
Night
Awakenings
0 1-2 / month 3- 4 / month > 1 / week
SABA use < 2 days / week > 2 days / week But
not daily
Daily Several times
per day
Interference
with normal
activity
None Minor limitation Some
limitation
Extremely
limited

14. Asthma Management
• Asthma management is aimed at
reducing airways inflammation by
minimizing proinflammatory
environmental exposures, using daily
controller anti-inflammatory
medications, and controlling
comorbid conditions that can worsen
asthma.

15. Asthma
Medications
Relievers
• Selective short - acting
2-agonists
- Salbutamol
- Terbutaline
• Non selective
-agonist
- Adrenaline
• Inhaled steroids
• Beclomethasone
dipropionate
• Budesonide
• Fluticasone propionate
• Ciclosenide
• Mast cell stabilizers
• Sodium cromoglicate
• Nedocromil Sodium
Controllers

16. Detailed history / examination
for asthma
History / examination supports
asthma diagnosis?
Perform spirometry / PEF
with reversibility test
Results support asthma
diagnosis?
Treat for ASTHMA
YES
Diagnostic
flow-chart
for asthma in
clinical
practice
YES
YES
Patient with
respiratory symptoms
Are the symptoms typical of
asthma?
No

17. Detailed history / examination
for asthma
History / examination supports
asthma diagnosis?
Perform spirometry / PEF
with reversibility test
Results support asthma
diagnosis?
Treat for ASTHMA
YES
Diagnostic
flow-chart
for asthma in
clinical
practice
YES
YES
No
Further history and tests for
alternative diagnoses
Alternative diagnosis confirmed?
Patient with
respiratory symptoms
Are the symptoms typical of
asthma?
Treat for alternative diagnosis
YES
No

18. Detailed history / examination
for asthma
History / examination supports
asthma diagnosis?
Perform spirometry / PEF
with reversibility test
Results support asthma
diagnosis?
Treat for ASTHMA
YES
Diagnostic
flow-chart
for asthma in
clinical
practice
YES
YES
No
Further history and tests for
alternative diagnoses
Alternative diagnosis confirmed?
Patient with
respiratory symptoms
Are the symptoms typical of
asthma?
Treat for alternative diagnosis
YES
Repeat on another
occasion or arrange
other tests
Confirms asthma diagnosis?
Consider trial of treatment for
most likely diagnosis, or refer
for further investigations
No
No
YES
No
No

19. Detailed history / examination
for asthma
History / examination supports
asthma diagnosis?
Perform spirometry / PEF
with reversibility test
Results support asthma
diagnosis?
Treat for ASTHMA
YES
Diagnostic
flow-chart
for asthma in
clinical
practice
YES
YES
No
Further history and tests for
alternative diagnoses
Alternative diagnosis confirmed?
Patient with
respiratory symptoms
Are the symptoms typical of
asthma?
Treat for alternative diagnosis
YES
Repeat on another
occasion or arrange
other tests
Confirms asthma diagnosis?
Consider trial of treatment for
most likely diagnosis, or refer
for further investigations
No
No
YES
No
Empiric treatment with
ICS and prn SABA
Review response
Diagnostic testing
within 1-3 months
Clinical urgency, and
other diagnoses unlikely
No

20. The written asthma
action plan should
include:
• the patient’s usual
asthma medications
• when and how to
increase medications,
and start OCS
• how to access medical
care if symptoms fail to
respond

21. © Global Initiative for Asthma
GINA assessment of symptom control
A. Symptom control
In the past 4 weeks, has the patient had:
Well-
controlled
Partly
controlled
Uncontrolled
• Daytime asthma symptoms more
than twice a week? Yes No
None of
these
1-2 of
these
3-4 of
these
• Any night waking due to asthma? Yes No
• Reliever needed for symptoms*
more than twice a week? Yes No
• Any activity limitation due to asthma? Yes No
GINA 2015, Box 2-2A
Level of asthma symptom control
*Excludes reliever taken before exercise, because many people take this routinely

22. © Global Initiative for Asthma
GINA assessment of symptom control
A. Symptom control
In the past 4 weeks, has the patient had:
Well-
controlled
Partly
controlled
Uncontrolled
• Daytime asthma symptoms more
than twice a week? Yes No
None of
these
1-2 of
these
3-4 of
these
• Any night waking due to asthma? Yes No
• Reliever needed for symptoms*
more than twice a week? Yes No
• Any activity limitation due to asthma? Yes No
B. Risk factors for poor asthma outcomes
ASSESS PATIENT’S RISKS FOR:
• Exacerbations
• Fixed airflow limitation
• Medication side-effects
GINA 2015 Box 2-2B (1/4)
Level of asthma symptom control

23. © Global Initiative for Asthma
Assessment of risk factors for poor asthma outcomes
Potentially modifiable risk factors for exacerbations
• ICS not prescribed; poor ICS adherence; incorrect inhaler technique
• high SABA use
• low FEV1, especially if < 60% predicted
• higher bronchodilator reversibility
• major psychological or socioeconomic problems
• exposures: smoking; allergen exposure if sensitised
• comorbidities: obesity; chronic rhinosinusitis; confirmed food allergy
• sputum or blood eosinophilia;
• pregnancy
Having
any of
these risk
factors
increases
the
patient’s
risk of
exacerbati
ons even if
they have
few
asthma
symptoms
Risk factors for medication side-effects include:
Systemic: frequent OCS; long-term, high dose and/or potent ICS; also taking
P450 inhibitors
Local: high-dose or potent ICS; poor inhaler technique
Risk factors for developing fixed airflow limitation : preterm birth, low birth
weight and greater infant weight gain; lack of ICS treatment; exposure to
tobacco smoke, noxious chemicals or occupational exposures; low FEV1;
chronic mucus hypersecretion; and sputum or blood eosinophilia

24. The control-based asthma management cycle
GINA 2015, Box 3-2
Diagnosis
Symptom control & risk factors
(including lung function)
Inhaler technique & adherence
Patient preference
Asthma medications
Non-pharmacological strategies
Treat modifiable risk factors
Symptoms
Exacerbations
Side-effects
Patient satisfaction
Lung function

25. © Global Initiative for Asthma
Stepwise approach to control asthma symptoms
and reduce risk
GINA 2017, Box 3-5 (1/8)
Symptoms
Exacerbations
Side-effects
Patient satisfaction
Lung function
Other
controller
options
RELIEVER
REMEMBER
TO...
• Provide guided self-management education (self-monitoring + written action plan + regular review)
• Treat modifiable risk factors and comorbidities, e.g. smoking, obesity, anxiety
• Advise about non-pharmacological therapies and strategies, e.g. physical activity, weight loss, avoidance of
sensitizers where appropriate
• Consider stepping up if … uncontrolled symptoms, exacerbations or risks, but check diagnosis, inhaler
technique and adherence first
• Consider adding SLIT in adult HDM-sensitive patients with allergic rhinitis who have exacerbations despite
ICS treatment, provided FEV1 is >70% predicted
• Consider stepping down if … symptoms controlled for 3 months + low risk for exacerbations.
Ceasing ICS is not advised.
STEP 1 STEP 2
STEP 3
STEP 4
STEP 5
Low dose ICS
Consider low
dose ICS
Leukotriene receptor antagonists (LTRA)
Low dose theophylline*
Med/high dose ICS
Low dose ICS+LTRA
(or + theoph*)
As-needed short-acting beta2-agonist (SABA) As-needed SABA or
low dose ICS/formoterol#
Low dose
ICS/LABA**
Med/high
ICS/LABA
Diagnosis
Symptom control & risk factors
(including lung function)
Inhaler technique & adherence
Patient preference
Asthma medications
Non-pharmacological strategies
Treat modifiable risk factors
PREFERRED
CONTROLLER
CHOICE
Add tiotropium*
High dose ICS
+ LTRA
(or + theoph*)
Add low dose
OCS
Refer for
add-on
treatment
e.g.
tiotropium,*
anti-IgE,
anti-IL5*
SLIT added as
an option

28. STEP 1:
• As-needed SABA with no controller
(this is indicated only if symptoms are
rare, there is no night waking due to
asthma, no exacerbations in the last
year, and normal FEV1).
• Other options: regular low dose ICS
for patients with exacerbation risks

29. STEP 2:
• Regular low dose ICS plus as-needed
SABA
• Other options:
– LTRA are less effective than ICS;
– ICS/LABA leads to faster improvement in symptoms and
FEV1 than ICS alone but is more expensive and the
exacerbation rate is similar.
– For purely seasonal allergic asthma, start ICS immediately
and cease 4 weeks after end of exposure.

30. STEP 3:
• Low dose ICS/LABA either as maintenance
treatment plus as-needed SABA, or as
ICS/formoterol maintenance and reliever therapy
• For patients with ≥1 exacerbation in the last year,
low dose BDP/formoterol or BUD/formoterol
maintenance and reliever strategy is more effective
than maintenance ICS/LABA with as-needed SABA.
• Other options:
– Medium dose ICS

31. STEP 4:
• Low dose ICS/formoterol maintenance and
reliever therapy, or medium dose ICS/LABA as
maintenance plus as-needed SABA
• Other options:
– Add-on tiotropium by mist inhaler for patients ≥12
years with a history of exacerbations;
– high dose ICS/LABA, but more side-effects and little
extra benefit;
– extra controller, e.g. LTRA or slow-release
theophylline

32. STEP 5:
• Refer for expert investigation and add-on treatment
• Add-on treatments include
– tiotropium by mist inhaler for patients with a
history of exacerbations (age ≥12 years),
– omalizumab (anti-IgE) for severe allergic asthma,
and
– mepolizumab (anti-IL5) for severe eosinophilic
asthma (age ≥12 years).
– Sputum-guided treatment, if available, improves
outcomes.
• Other options: Some patients may benefit from low
dose OCS but long-term systemic side-effects occur.

33. Stepping down treatment when
asthma is well-controlled
• Consider stepping down treatment
once good asthma control has been
achieved and maintained for 3
months, to find the lowest treatment
that controls both symptoms and
exacerbations, and minimizes side-
effects.

34. NON-PHARMACOLOGICAL STRATEGIES
AND INTERVENTIONS
• Smoking cessation advice
• Allergen avoidance
• Avoid drugs probably triggering asthma
• Some common triggers for asthma
symptoms (e.g. exercise, laughter)
should not be avoided

35. Inhaled Medication Deliveries
Age of the Child Inhalation Device Advised
0 to 5 years pMDI with static-treated spacer and mask
(or mouth piece as soon as child is capable
of using)
> 5 years Choice of :
• pMDI with spacer and mouth piece
• DPI (rinse or gargle after inhaling ICS,
breath-actuated pMDI
• Nebulizer – 2nd choice at any age

36. Acute Severe Asthma
A severe episode of asthma due
to severe airflow obstruction
which is refractory to the
usually effective
bronchodilator therapy.
Definition :

37. Acute Severe Asthma
Red Flag
Signals
• Too breathless to talk (1-2 words)
• Too breathless to feed
• Respirations > 50 per minute
• Pulse > 140 per minute, poor volume
• Excessive Diaphoresis

38. Acute Severe Asthma
Life Threatening
Features
• Cyanosis (with 60% oxygen)
• Silent chest on auscultation
• Feeble respiratory effort
• Fatigue or exhaustion
• Agitation
• Reduced level of consciousness

39. Acute Severe Asthma
• Investigations :
– Hypercarbia pCO2 > 40 mm Hg
– Rate of rise of pCO2 > 5 mm Hg/hr
– Hypoxia (pO2 < 60 mm Hg with supplemental oxygen)
– Metabolic acidosis ( - BE > 7-10)
– Peak expiratory flow < 50 %
– FEV1 < 30% expected, no improvement 1 hr. after
aerosol therapy
– Chest radiograph (pneumotharax, pneumomediastinum)
– Pulsus paradoxus > 20 mm og Hg

40. Acute Severe Asthma
Principles of Management
The goal is to rapidly reverse the
acute air flow obstruction with
consequent relief of respiratory
distress.

41. Assessment of severity of acute asthma
Modified Pulmonary Index Score (MPIS)
Age < 3 years
Point
s
SpO2 Accessory
muscle use
I / E
ratio
Wheeze HR RR
0 > 95% None 2:1 None, good
aeration
< 120 < 30
1 93-05% Mild 1:1 End exp 121 – 140 31 - 45
2 90-92% Moderate 1:2 Insp/Exp;
Good aeration
141 – 160 46 - 60
3 < 90% Severe 1:3 Insp/Exp;
Poor aeration
> 160 > 60
•MPIS < 7 - Mild
exacerbation
•MPIS 7-10 - Moderate
exacerbation
•MPIS ≥ 10 - Severe
exacerbation

42. Assessment of severity of acute asthma
Becker Asthma Score
Score Respiratory Rate
(per min)
Wheezing I / E ratio Accessory
muscle use
0 < 30 None 1:1.5 None
1 30 - 40 Terminal
expiration
1:2 1 site
2 41 - 50 Entire
expiration
1:3 2 sites
3 > 50 Inspiration and
entire
expiration
>1:3 3 sites or neck
strap muscle use
• Score < 4 is mild
• Score of > 4 is moderate asthmaticus
• Score of 7 and above is severe and need PICU
admission

43. ALGORITHM FOR MANAGEMENT OF ACUTE SEVERE ASTHMA
Medications Ventilation

45. INDICATIONS FOR INTUBATION
Absolute
•Cardiac arrest
•Comatose child
•Severe respiratory
distress
• Silent chest,
exhaustion
Relative
• Hypoxemia pO2<60 mm
Hg in 60% oxygen
• pCo2> 65 mm Hg & or
pCo2 rising by > 5mm
Hg/hr.
• Metabolic acidosis
(–BE > 8 – 10)

46. Helium Oxygen Therapy For children who are not improving with
conventional therapy or children who are receiving high-pressure mechanical
ventilatory support, heliox may be a reasonable adjunct therapy

47. Treatment of Comorbid Conditions
Allergic Rhinitis/Sinusitis
a. Intranasal steroid spray Budesonide 100
mcg twice a day or Fluticasone 50 mcg
once a day
b. Oral antihistamines
Gastroesophageal Reflux
– Ant reflux treatment.
– Oral Theophylline to be avoided.

48. • Dr.C.S.N.Vittal