Management for pediatrics and young adults suffering from asthma How to diagnose?

1. Management of chronic
asthma
Dr Deepak Kumar

2. Scope of Presentation
• DEFINITION
• PREVALENCE
• BURDEN OF DISEASE
• FACTORS AFFECTING THE DEVELOPMENT AND EXPRESSION OF ASTHMA
• PATHOPHYSIOLOGY
• ASTHMA: MAKING A DIAGNOSIS
• INVESTIGATIONS

3. ASTHMA
Heterogeneous disease usually characterised by chronic airway
inflammation.
Defined by
• the history of respiratory symptoms (wheeze, shortness of breath, chest
tightness and cough that vary over time and in intensity)
• + variable expiratory airflow limitation.
GINA guidelines 2020

4. PREVALENCE AND BURDEN OF DISEASE
• 300 million affected worldwide.
• Affects 10million children worldwide.

5. FACTORS AFFECTING THE DEVELOPMENT AND
EXPRESSION OF ASTHMA
• Host factors
1. Genetic
2. Obesity
3. Sex
• Enviromental factors
1. Allergens
2. Occupational sensitizers and
allergens
3. Infections
4. Exposure to tobacco smoke
5. Diet
6. NSAID’s
7. Stress

6. HOST FACTORS
• GENETIC :
Complex heritable component.
Genetic markers are important risk factor in
1) pathogensis of asthma
2) deteminants of responsivness to treatment
• Polymorphism of genes on chromosome 5q, ADAM33, DPP-10 and
ORMDL3.
• Arg-Gly-16 varaiant in the beta2 receptor.

7. Sex:
male sex is a risk factor in children
Prior to 14 years, twice in males as compared to females.
Obesity:
prevalence and incidence increases
Potential contributing factors includes
- Effect of on lung mechanics
- Adipose tissue produces cytokines and adipokines
Add next slide of obesity here only
N Johnston, M Sears.Asthma exacerbations . 1: epidemiology.Thorax. 2006 Aug; 61(8):722-8.

8. ENVIRONMENTAL FACTORS
Allergens:
Well known triggers
Role is not clear.
Relationship between allergen exposure and sensitization is not
straightforward.
Sensitization of ingested allergens in early life remains a risk factor.

9. Occupational sensitizers:
Occupational agents- 15% of cases of asthma among adults.
 Immunologically mediated
Both IgE and Cell mediated allergic reactions are involved.
High exposure may cause 'irritant induced asthma' even in non atopics.
Occupational asthma, can persist after removal from exposure.

10. INFECTIONS:
RSV, RV and para-influenza virus mimics childhood asthma.
With RSV infection , there is increased risk of asthma in later childhood.
Wu P,Hartert V.T,Expert rev anti-infect Ther.2011sep 9(9)

11. Stress
• Parental stress and high family stress level- increase risk of asthma in
school age.
• Explained by low cortisol level in response to stress.
Tobacco Smoking:
• Infants of smoking mothers- 4x wheezing in 1st year of life.
• Active smoking in adolescence- slow down lung growth- decline in lung
function.
Remesh Kumar, R., Jayakumar, P.R. & Krishna Mohan, R. Indian J Pediatr (2018) 85: 295

12. Outdoor And Indoor Pollution.
Living or attending schools near high traffic density roads increases the
incidence and prevalence.
Specific pollutants can induce airway inflammation (eg, o3, NO2, and PM
<2·5 μm) and airway hyper-responsiveness.
Miller M , Marty MA Impact of environmental chemicals on lung development.Environ Health Perspect. 2018 Aug; 118(8):1155-64

13. APC T lymphocytes
T helper 2 cells
IL-4 IL-5 IL-13
B-cell
IgE
Mast cell
On repeated exposure
Activated mast cell
crosslinking
Increases mucin
Increases production of IgE
Recruits eosinophil
Activated mast cell
phospolipase
cox
LOX
PGG2
• Mucin increases
• Vasodilation
• Increased
permeability
PGD2
LTC4
LTD4
Potent Bronchoconstrictor

16. ASTHMA: MAKING A DIAGNOSIS
The diagnosis of asthma is based on:
1) H/O characterstic respiratory symptoms i.e initial clinical assesment.
2) Demonstration of variable expiratory airflow limitations i.e
Measuring lung function test.

17. Initial clinical assesment
• More than one characterstic respiratory symptoms i.e
Episodic breathlessness
wheezing
coughing
chest tightness
• Symptoms often worse at night or in early morning.
• Symptoms triggered by viral infections, exercise, allergen exposure,
change in weather, laughter, or irritants.

18. History and Family History:
• Commencement of respiratory symptoms in childhood.
• H/o allergic rhinitis or eczema.
• Family history of asthma or allergy.
Physical examination
• Physical examination is mostly normal.
• Most frequently there is expiratory wheezing on auscultation.
• Examination of upper airways may reveals signs of allergic rhinitis or nasal
polyps.

19. Asthma in children younger than 5 year
• Cough
• Wheezing
• Difficult or heavy breathing
• Reduced activity
• Past or Family history
• Therapeutic trial with low dose ICS and SABA

20. Early childhood risk factors for persistent
asthma
Major
• Eczema
• Parent asthma
• Inhalant allergen sensitization
Minor
• Allergic rhinitis
• Wheezing apart from cold
• ≥4% peripheral blood
eosinophils
• Food allergen sensitization

21. Differential Diagnosis
• Recurrent viral respiratory
infections
• Inhaled foreign body
• Bronchiectasis
• Primary ciliary dyskinesia
• Congenital heart disease
• Broncopulmonary dysplasia
Cough, running nose and
symptoms absent inbetween
sudden onset, unilateral wheeze
or hyperinflation with dec A/E.
recurrent infections, productive
cough
recurrent infections, productive
cough, sinusitis
cardiac murmers, crepts,CHF
preterm delivery, symptoms since
birth.

22. Measuring Lung Function Tests
1) Spirometry: for patients >5 years of age
Measures
airflow limitations
Reversibility
Through spirometry we can measure
1)FVC
2)FEV1
3)FEV1/FVC
4)PEF

23. Spirometry provides information such as:
• lung disease is obstuctive or restrictive.
• reversibility
• variability
• Evaluating asthma control.
Spirometry recommended for all suspected asthmatic patients.
If possible it should be documented before start of treatment.

24. PRE-REQUISITES
Patient’s height, weight, BMI, sex and race.
No medications prior to testing
• Atleast 2 hour prior to beta2 agonist
• 6-8 hours prior to ICS
Reversibility may not be present during
symptoms/infections.

25. CONTRAINDICATIONS
• Pneumothorax
• Hemoptysis
• Thoraco-abdominal surgery
• Acute disorder affecting tests like - nausea and vomiting

26. Quality of good spirometry
• Explosive start
• Performed with a maximum inspiration and expiration
• No glottis closure or cessation of airflow
• No coughs
• End of test criteria
exhaling ≥6sec with < 50ml exhaled at last 2 sec

27. How to reinforce a child > 5years
• Environment should be friendly
• Make child familiar with the instruments
• Give mouthpiece 2-3 days in advance for practice at home
• Apply nose clips.

30. Obstructive Pattern

31. RESTRICTIVE
PATTERN

34. • The FEV1/FVC ratio is normally
>0.75-0.80, and possibly >0.90 in
children. Lower values suggest
airflow limitation.
• The degree of reversibility in FEV1
>12% and >200ml from pre-
bronchodilator value indicates a
diagnosis of asthma.

35. Limitations to spirometry
• Effort dependent
• Does not exclude asthma if test normal.
• Not suitable for children <5

36. Other methods
Impulse oscillometry
• Pressure oscillations are produced.
• Rapid
• Non invasive
• Effort independent
Disadvantage:impulse used is liitle
forceful
Body plethysmography
• Measures TLC, Residual volume and
FRC.
• Rapid
• Non invasive
• Disadvantage: lung resistance,
compliance and respiratoty flow not
available

37. Impulse oscillometry
Body plethysmography

38. Peak Expiratory Flow
• Important aid in both 1)Diagnosis
2)Monitoring
• not a preferable tool, but can be used in low income settings.
• Short term PEF monitoring
• Long term PEF monitoring

39. Peak Flow Meter

41. Measurment Of Airway Responsiveness
• For patients with symptoms consistent with asthma but normal lung
function test,
Direct airway challenges(e.g inhaled methcoline or histamine)
Indirect airway challenges(e.g inhaled mannitol or an exercise
challenge)

42. Fractional concentration of exhaled nitric
oxide (FeNO)
it is a quantitative, non invasive,simple and
safe method.
Measures airway inflammation.
 It is associated with high levels of sputum
and blood eosinophilia.
During inflammation, higher-than-normal
levels of nitric oxide (NO) are released from
epithelial cells.

43. FeNO offers advantage in
1) eosinophilic airway inflammation.
2) corticosteroid responsivness.
3)Monitoring of airway inflammation.
4)Unmasking of otherwise unsuspected nonadherance to
corticosteroid therapy.

44. Limitations to FeNO
• There is currently no reference guidelines for health care providers to
guide them in the appropriate use and interpretation in clinical
practice.
• Expensive.

45. 3)Measuring allergic status:
• Presence of atopy or allergic disease increases the probability of diagnosis.
• Allergy skin prick tests are primary dignostic tool for determining a patient's
atopic status.
• Measurment of allergen specific IgE in serum.
• Provocation of airway with a suspected allergen.
• These tests are not routinely recommended.

46. Scope of seminar
General principle of asthma management
Role of non pharmacological strategy and asthma education
Clinical step wise management of asthma
Aerosol delivery devices
Assessment of asthma control
Reviewing and adjusting treatment plan
Difficult to treat and therapy resistant asthma
COVID 19 and asthma
•

47. Goals Of Asthma Management
• Achieve control of symptoms and maintain normal activity
• Prevent exacerbation
• Maintain pulmonary function
• Avoid side effects of asthma medications

48. Role of health care professionals
• Develop partnership with patient
• Improve patient’s health literacy
• Choose appropriate management plan
• Periodic review and adjustment of treatment

49. Asthma management cycle

50. Management of asthma
• Non pharmacological
• Asthma education and asthma action plan
• Pharmacological
• Management of comorbidities
• Managing difficult to treat and therapy resistant asthma

51. Non pharmacological management
• Avoid exposure to passive smoking
• Physical activity
 Avoidance of medication
• Avoidance of indoor allergens
 Domestic mites (HDM)
 Furred pets
 Rodents /Cockroaches
 Fungi

52. • Healthy diet
• Weight reduction in obese asthmatics
• Decreasing indoor pollution
 Sources; cooking and heating devices
 Gases: Nitric oxide/carbon monoxide/sulphur dioxide
• Decreasing emotional and psychological stress
• Avoidance of specific food & food chemicals

53. Asthma education
• Providing asthma information
• Formulating written asthma action plan

54. Asthma information
• Verbal discussion
• Build partnership
• Discuss diagnosis/ treatment plan & medications / potential side effects
• Allay fears and concerns
• Focus on self monitoring
• Periodic review and re evaluation/adjustment of treatment
Overall impact: Improve patient health literacy and self
reliance

55. Asthma action plan
• Written document
• Improves self managerial skill
• Short term adjustments in treatment based on symptom control
• 3 zones
• Green zone no symptoms continue controller medications.
• Yellow zone  having symptoms  use several doses of albuterolnot
improving  take oral corticosteroids /call doctor.
• Red zone  having symptoms unresponsive to albuterol  contact health
setup on emergent basis

57. Asthma action plan vs asthma education
• Dramatic improvement in overall disease outcome
• Equally effective
• Higher annual costs of the asthma action plan group
Kelso JM. Pediatr Allergy Immunol Pulmonol. 2016.
”Time spent updating an asthma action plan could be better spent reinforcing asthma
education and answering questions”

58. Approach to clinical management
Classify asthma severity
Choose appropriate treatment plan
Step up Step down

59. Classification of asthma severity
&
choosing appropriate step

60. Impairments Intermittent Mild persistent Moderate persistent Severe persistent
Day time symptoms <2 days/week >2 days/week but not
daily
Daily Throughout the day
Use of SABA <2 days/week >2days/week but not
daily
Daily Several time/day
Night time symptoms
Age 0-4 years
Age > 5 years
0
≤2 times/month
1-2 times / month
3-4 times/month
3-4 times/month
>1 time/week not
nightly
>1 / week
Often>7/week
Interference with normal
activity
None Minor limitation Some limitation Extreme limitation
Exacerbation
Age 0-4 years
Age >5 years
0-1 /year
0-1 / year
≥2 exacerbations in 6 months requiring systemic steroids or ≥ 4 wheezing
episodes lasting >1 day
≥ 2 / year
FEV1 % predicted (> 5 years
)
Normal > 80% predicted 60-80% <60%
FEV1/FVC ratio
Age 5-11 years
Age>12 years
>85%
normal
>80%
normal
75-80%
Reduced 5%
<75%
Reduced > 5%
Recommended step Step 1 Step 2 Step 3 Step 3/ step 4

61. GINA 2019
GUIDELINES
FOR
MANAGEMENT

62. What’s New in GINA 2019?
• Emphasis on personalised treatment
• No longer SABA only treatment for mild asthma
• Use of symptom driven or regular use of ICS controller medication even for mild
asthma.

65. Step 1
Patients with
symptoms <twice a
month and no
exacerbation risk
factors)
Medication 2018 2019
Adolescents and
adults
Age 6-11 years
Preferred SABA as-needed and
no controller
As-needed low dose
ICS-formoterol (off-
label).
No studies of ICS-
formoterol in
children. Continue
SABA as needed
Other options Daily low dose ICS. Low dose ICS taken
whenever SABA is
taken (off-
label). This may
involve combination
(ICS-SABA) in a
single or separate
(ICS inhaler + SABA
inhaler) inhaler/s.
Low dose ICS taken
whenever SABA is
taken (off-label).

66. Rationale behind recommendation
• Decrease in rate of severe exacerbation compared to SABA alone
therapy
• Improve adherence
• Decrease reliance on SABA as main asthma treatment
• No studies of as needed ICS formoterol in children 6-11 years
• Worse outcome and poor lung function with SABA alone

67. Rationale behind recommendation
Study Results and conclusion
Papi et al (2007); BEST study As needed ICS-LABA more effective than as needed SABA in improving morning PEF
risk of exacerbations.
Martinez et al. TREXA study ICS used as a rescue medication along with SABA is more effective than SABA
monotherapy in prevention of exacerbation in children with mild asthma
Lazarinis et al combined BUD/FORM on demand equally effective as regular budesonide and with
a lower cumulative steroid dose
Reddel et al. START study Use of low dose ICS in mild asthmatics reduced the risk of exacerbating the disease
by half compared to patients using only SABA.
O’Byrne et al. SYGMA 1 study Fixed combination of BUD-FORM used as needed in mild asthma reduced the
frequency of exacerbations by 64% compared to SABA monotherapy.
Bateman .SYGMA 2 study BUD-FORM treatment regimen protected mild asthmatics against exacerbations
equally as effectively as low-dose ICS

68. SABA vs LABA: Better reliever medication?
• Fewer hospitalizations in participants on formoterol (OR 0.84; 95% CI 0.67 to 1.04)
• Decreased risk of exacerbation in patient on formoterol therapy.
• Patients on formoterol showed a greater improvement in evening PEF.
• More improvement in quality of life as estimated using the Asthma Quality of Life
Questionnaire in formoterol group
• No statistically significant difference in the reduction of day , night time symptoms
and risk of adverse events between the two groups.
• Increased withdrawal in patients on formoterol therapy.
Welsh EJ, Cates CJ. Formoterol versus short-acting beta-agonists as relief medication for adults and children with asthma. Cochrane
Database Syst Rev. 2010

69. Step 2
Step 2 Medication 2018 2019
Preferred Daily low dose ICS Daily low dose ICS.
• As-needed low dose
ICS-formoterol (off-label)
Other options • Daily LTRA.
• Daily low dose ICS-
LABA.
Low dose ICS taken
whenever SABA is taken
(off-label)
• Daily LTRA.
• Daily low dose ICS-LABA

70. As needed ICS-formoterol vs Daily ICS
• As needed budesonide formoterol was:-
Non inferior to daily ICS in exacerbation control
Improved adherence
Low cumulative daily steroid dose
Similar control in symptom control and symptom free day
Similar improvement in baseline eosinophils and FeNO levels

71. Dosing of ICS in age 6-11 years
Inhaled corticosteroid Low dose (mcg) Medium
dose(mcg)
High dose (mcg)
Beclomethasone dipropionate 100-200 >200-400 >400
Budesonide (pMDI) 100-200 >200-400 >400
Buesonide(nebules) 250-500 >500-1000 >1000
Ciclesonide (pMDI,extrafine particle, HFA) 80 >80-160 >160
Fluticasone propionate(DPI) 50-100 >100-200 >200
Fluticasone furoate (pMDI, standard particle, HFA) 50-100 >100-200 >200

72. Dosing of ICS in age >12 years
Inhaled corticosteroids Low dose
(mcg)
Medium dose
(mcg)
High
dose(mcg)
Beclomethasone dipropionate(pMDI, 200-500 >500-1000 >1000
Budesonide(pMDI) 200-400 400-800 >800
Ciclesonide(DPI) 80-160 160-320 >320
Fluticasone propionate(pMDI, standard particle,HFA) 100-250 250-500 >500
Momentasone furoate (DPI) 200 200 400
Momenatasone furoate (pMDI, standard paticle, HFA) 200-400 200-400 >400

73. Other treatment option in step 2
Leukotriene receptor antagonist (LTRA)
• Prototype Montelukast
• As standalone therapy?
Lower efficacy compared to low dose ICS in improving pulmonary
function, symptoms and rate of exacerbation.

74. LTRA In Specific Asthma Phenotypes
• Greater efficacy than beta2-agonists in preventing exercise-induced
asthma. Wenzel, 2006
• Aspirin induces asthmatic symptoms. Gaber et al. 2008
• Improved symptom control in asthma with concomitant rhinitis . Price et
al , 2006
• Rapid resolution of the viral infection associated wheezing episodes.
Han et al. 2010

75. Not recommended
• Sustained release theophylline
oPoor efficacy
oIncrease side effects
• Nedocromil sodium and sodium cromoglycate
oLow efficacy
oBurdensome inhaler use

76. Step 3
Adults and adolescents
• Daily low dose ICS+ LABA
maintenance plus as needed
SABA
• Low dose ICS –formoterol daily
and as needed
Children 6-11 years
• Medium dose ICS
• Low dose ICS+LABA
Addition of LABA to ICS improves symptom control, lung function, decreases
risk of exacerbation but only a small decrease in reliever use.

77. Other treatment options
• Sublingual allergen immunotherapy
Adults patients with poor symptom control on ICS and with allergic
rhinitis and house dust mite sensitisation.
• Increasing ICS to medium dose
Less efficacious than addition of LABA
• Sustained release theophylline
for adults and adolescents only

78. Approved ICS- LABA combinations
• Fluticasone propionate – formoterol
• Fluticasone propionate- salmeterol
• Beclomethasone- formoterol
• Budesonide – formoterol
• Momentasone- formoterol

79. Step 4
Adults and adolescents
• Medium dose ICS formoterol
daily and as needed
• Medium dose ICS-LABA
maintenance plus as needed
SABA
Children 6-11 years
• Continue controller (medium
dose ICS+LABA ) and refer for
expert opinion

80. Other treatment option
• Tiotropium (long acting muscarinic agent)
• I
Study Age Asthma
severity
Baseline
therapy
Result
Hamelmann et al. J AllergyClin
Immunol.2016
12-17
years
Symptomatic
moderate
On daily ICS Statistically significant
improvement in peak FEV1 at
week 24.
HamelmannE. J AllergyClin
Immunol.2017
12-17
years
Symptomatic
severe
ICS+≥1
controller
Statistically significant
improvement in FEV1 compared
to placebo
SchmidtO. .EurRespir J.2016 6-11
years
Symptomatic
moderate
ICS Statistically significant
improvement in peak and
trough FEV1 levels.
Insufficient evidence to support ICS tiotropium over ICS LABA combination

81. • Add on LTRA to ICS- LABA therapy
• Increasing the dose of ICS
• Sublingual allergen immunotherapy
• Addition of sustained release theophylline(not safe in children less
than 12 years)

82. Step 5
Adults and adolescents
• High dose ICS+LABA
• Consider for phenotypic
assessment of asthma and
consideration for biologicals
and treatment of associated
comorbidity
Children 6-11 years
• Refer for phenotypic assessment
of asthma and consider for add
on therapy.

83. Other treatment options
• High dose ICS+LABA
 Only little benefit
 Trial of 3-6 months
 Increased risk of side effects including adrenal insufficiency
• Add on tiotropium
• Add on low dose oral corticosteroid

84. Biologicals In Asthma

85. Drugs Mecanishm of action Eveidence in children
Omalizumab Humanized anti-IgE
monoclonal antibody.
• Add-on treatment in > 6 years with severe persistent allergic asthma
and positive skin test or specific IgE to perennial aeroallergens,
severe asthma not controlled to traditional combination therpy.
Humbert M et al.Allergy (2005)
Dupilumab Anti–IL-4 receptor α
monoclonal antibody, blocks
both IL-4 and IL-13 signalling.
• Decreases exacerbations and improves lung function in moderate-to-
severe uncontrolled asthma. Limb SL et al. J Allergy Clin Immunol 2007
• Steroid sparing agent.Castro M et al. N Engl J Med 2018
Mepolizumab Anti-IL-5 monoclonal antibody,
selectively inhibits eosinophilic
inflammation.
• Approved in age>12 years
• Role in severe eosinophilic asthma. Ortega HG et al. N Engl J Med 2014
Reslizumab Anti-IL-5 monoclonal antibody,
inhibits activity within the IL-5
signaling pathway and reduces
blood and tissue eosinophils.
Improves lung function, asthma control and symptoms, quality of life in
uncontrolled asthma in children >12 yrs. Brusselle G.Pulm Pharmacol Ther 2017
Benralizumab Anti-IL-5 receptor α
monoclonal antibody, induces
direct, rapid, and nearly
complete depletion of
eosinophils.
Used in patients with severe, uncontrolled asthma with blood
eosinophils >300 cells per μL in children >12 years. Bleecker Eret al. Lancet
2016

86. Step in
asthma
managem
ent
Adolescents (>12 years ) and adults 6-11 years
Preferred treatment Alternative
Treatment
Preferred
Treatment
Alternative
Treatment
Step 1 As needed low dose ICS formoterol • Low dose ICS
when SABA is
taken
• Daily ICS
Taking ICS when SABA is taken
Step 2 • Daily low dose ICS plus as needed
SABA
• As needed ICS formoterol
• Low dose ICS
when SABA is
taken
• Add on LTRA
• Daily low dose
ICS+LABA
Regular low
dose ICS
• Daily LTRA
• Low dose ICS
when SABA is
taken
Step 3 • Daily low dose ICS+ LABA
maintenance plus as needed SABA
• Low dose ICS –formoterol daily
and as needed
• Medium dose ICS
• Low dose ICS +
LTRA
• Medium dose ICS
• Low dose ICS+LABA

87. Step in
asthma
managem
ent
Adolescents (>12 years ) and adults 6-11 years
Preferred treatment Alternative
Treatment
Preferred
Treatment
Alternative
Treatment
Step 4 • Low dose ICS formoterol
• Medium dose ICS-LABA
maintenance plus as needed SABA
• Add on
tiotropium
• Add on LTRA
• High dose ICS-
LABA
Continue controller refer for expert
opinion
Step 5 • High dose ICS+LABA
• Consider for phenotypic assessment of asthma and
consideration for biologicals and treatment of associated
comorbidity
Refer for phenotypic assessment
of asthma and consider for add on
therapy.

88. Asthma management in under
five

89. Step Preferred option Alternative treatment
Step 1:
Intermittent wheezing episodes
• SABA as needed
• If use ≥ 2 times/week
consider controller ICS therapy
• Oral bronchodilator not
recommended, increased side
effects
• ICS therapy in those with
positive modified API
Step 2 :
• ≥ 3 exacerbations per year
• Symptoms pattern
consistent with asthma
Daily low dose ICS X 3 months trial • LTRA
 Poor control compared to ICS
 FDA black box warning
• Episodic use of ICS
Lower efficacy compared to daily
ICS therpay
Step 3
Exacerbations persisting despite
regular ICS use X 3months
Doubling the low dose ICS • Addition of LTRA
• ICS –LABA not recommended in
≤ 4 years
Step 4 :
Not controlled on double ICS
Continue controller and refer
expert opinion
• Add on LTRA
• add Intermittent daily high dose
ICS to controller at onset of
respiratory illness
• Add on LABA (age ≥ 4years )
• Low dose daily OCS till
symptoms improve .

90. Aerosol Delivery Devices

91. Difficulties
faced by
children
Greater upper airway
deposition due to
smaller airways and
obligate nose
breathing
Erratic breathing
patterns in
children <5 years
Decreased
coordination and lack
of strength
Difficulties
mastering complex
steps of
administration
Poor hand breath
coordination
May not have the
cognitive ability

92. Meter dose inhaler
Nebuliser
Dried powder inhaler

93. MDI DPI Nebuliser
Technique of generation of aerosol Propellant based Patient driven
flow
Bernoulli’s
principle/piezoelectric
crystal
Particle size 1-10µ 1-10 µ Variable
Drug deposition 5-10% 9-30% 2-10%
Patient coordination Required Not applicable Not required
Breath hold Required Not required Not required
Patient generation of flow Not required Required Not required
Amount of drug Small doses only Small doses only Large doses possible
Use for chronic therapy Yes Yes Rarely

94. Aerosol device and interface for patients of
different ages
Birth to 4 years of
age
4–12 years of age 13 years and older
Aerosol delivery
device
pMDI with VHC
(spacer ) with
facemask
pMDI with VHC, DPI,
breath-actuated
MDI
pMDI can be used
directly (better
result if VHC is
used),DPI
Interface Mask Mouthpiece Mouthpiece

95. MDI with spacer MDI with spacer with mask

96. Reviewing response & adjusting treatment
• 1-3 months later after starting treatment
• 3-12 months regularly if sustained remission
• 1 week post occurrence of an exacerbation

97. Assessment of control

98. Impairment Well controlled Not well controlled Very poorly controlled
Day time symptoms < 2 days/week > 2 days /week or multiple
time in < 2 days/week
Throughout the day
Night time symptoms
0-4 years
5-11 years
>12 years
≤ 1/ month
≤ 1/ month
≤ 2/ month
≥ 1 / month
≥ 2 / month
1-3/ month
≥1 / month
≥ 2 / month
≥ 4 /month
SABA use < 2 days / week > 2 days/ week Several time/ day
Interference with normal
activity
None Some Extreme
Age 5-11 years
FEV1%
FEV1/FVC
>80%
>80%
60-80%
75-80%
<60%
<75%
Age >12 years
FEV1% >80% 60-80% <60%
Risk of exacerbation
0-4 years
> 5years
0-1/year
0-1/year
2-3 /year
≥2/ year
≥3/ year

99. Stepping up treatment
Before a step up always rule out
• Incorrect inhaler technique
• Poor adherence
• Modifiable risk factor
• Presence of comorbid condition
Sustained step up(2-3 months ):
Poor asthma control despite good
adherence and correct inhaler
technique
Short term(1-2 weeks) :
Increase in ICS dose during viral
infection and/or seasonal allergen
exposure
Day to day adjustments
Based on symptoms control.

100. To find the lowest treatment that controls symptoms and exacerbation and
minimises future side effects
Good asthma control achieved and maintained for 3 months
Absence of respiratory infection
Stepping down
Stepping down ICS dose by 25-50% : most feasible and safe

101. Current step Ongoing therapy Preferred step down option
Step 5 High dose ICS+LABA as controller with
oral corticosteroid (OCS)
Reduce OCS dose
Alt day OCS
Stop OCS and continue High dose ICS
Step 4
Moderate to high dose ICS-LABA as
maintenance
50% reduction in ICS dose
Stopping LABA associated with increased R/o exacerbation
Medium dose ICS-formoterol as
maintenance and reliever therapy
Shift to low dose ICS –Formoterol combination
High dose ICS+ another controller
therapy
Reduce ICS dose by 50% and continue second controller
Step 3
Low dose ICS – LABA as controller Shift from twice daily to once daily regimen
Low dose ICS-formoterol as
maintenance and reliever therapy
Shift from twice daily to once daily regimen
Medium dose ICS as controller Shift to low dose ICS as controller
Step 2 Low dose daily ICS Shift from twice daily to once daily
As needed ICS- Formoterol
Take low dose ICS whenever SABA taken

102. Difficult
To
Treat
Paediatric
Asthma

103. Difficult asthma
• Persistent ongoing symptoms due to underlying modifiable factors
• Addressal of modifiable factors lead to better control
• Not due to resistance to medication
• 40 % of children referred for investigation of ‘severe asthma’ had
identification of reversible factors, as opposed to genuine severe
therapy-resistant asthma.
Bush A, Curr Opin Allergy Clin Immunol. 2011
Bracken M, et al. Arch Dis Child. 2009.

104. Assessment of child with difficult
asthma

105. Is it really asthma ?
Alternative diagnosis When to suspect Useful diagnostic examinations
Cystic fibrosis and
bronchiectasis
Daily cough productive of sputum, clubbing,
malabsorption and failure to thrive, recurrent
chest infections, airways bacterial colonization
Sweat chloride test, Genetic tests,
Swab culture, Lung Function tests,
Chest CT
Immunodeficiency Recurrent airway infections, Systemic
infections (from a few months of age)
Immunoglobulins and specific tests
Primary ciliary dyskinesia Neonatal upper airway symptoms, Chronic
rhinosinusitis, Recurrent otitis media, Daily
wet cough, Laterality defects
Nasal NO, HSVM, EM, Genetic
tests, Immunofluorescence, Chest
CT
Protracted Bacterial
Bronchitis
Chronic wet cough, Poor response to Beta-2
agonists, Good response to prolonged course
of antibiotics
Often no need of examinations,
Swab culture, Bronchoscopy with
BAL
Airway malacia Monophonic wheeze when the child is active,
High risk setting (i.e., pt operated for tracheo-
esophageal fistula or vascular ring), Presence
of associated stridor
Lung function test (truncated
expiratory flow in spirometry),
Flexible bronchoscopy, Dynamic CT
Ullmann N, et al. Front Pediatr. 2018

106. • Alternative diagnosis
• When to suspect
• Useful diagnostic examinations
Alternative diagnosis When to suspect Useful diagnostic examinations
Habit cough Prolonged dry, honking cough; Absence of
cough during sleep; Absence of any physical
findings
Medical investigations should be
avoided
Vocal cord dysfunction Absence of structural abnormalities,
Sudden worsening of “asthma” symptoms,
No response to asthma medications
Video of an attack, Laryngoscopy
during attack
Ullmann N, et al. Front Pediatr. 2018

107. Addressing modifiable risk factors
Adherence to medication
• 40 % children have poor inhaler technique and 15 % use an
inappropriate device
• ≥ 80 % admitted as severe exacerbation had non-compliance with
inhaled therapy
• ≥ 50 % of children were found to have poor prescription uptake with
Bracken M, et al. Arch Dis Child. 2009
Gamble J, et al. Am J Respir Crit Care Med. 2009

108. • Factors contributing to poor
adherence
a) Poor inhaler technique
b) Burdensome regimen
c) Multiple different inhalers
d) Lack of routine/ forgetfulness
e) Cost
f) Concerns about side effect
g) Poor prescription uptake
• Effective interventions
a) Checking and correcting
inhaler technique
b) Physical demonstration
c) Shared decision making
regarding medication choice
and regimen
d) Monitoring of dispensing
records

109. Assessment of child’s environment
• Allergen exposure
• Cigarette smoke exposure
• Any damp and/or visible fungal spores in the house
• Heating system
• Indoor allergen: domestic mites, furred animals, cockroaches, fungi
Inner City Asthma Study (ICAS) demonstrated improvements in morbidity in sensitized asthmatics by
reducing indoor allergens through multifaceted interventions

110. Psychosocial factors
• Due to stress and perception of symtpoms
• Stress- development of unpleasant stimulus causes constriction
of airways. Ritz T, et al. Biol Psychol. 2010.
• Laughing, crying, panic attacks, anger Hyperventilationairway
narrowing.
• Doubtful efficacy of psychological intervention on asthma control
(Cochrane review )

111. Managing comorbidities
Comorbity Role in asthma management
Obesity • Associated with variable degree of airway inflammation
• Associated with OSA and GERD
• Reduction in lung volumes due to abdominal fat
• Increased risk of steroid resistance
• 5-10% weight reduction can lead to control of symtoms. Scott HA et al, 2013
Chronic rhinosinusitis • Poor asthma control, more exacerbations and emergency visits difficulty achieving
symptom control. Valovirta E, et al BMC Pulm Med. 2006
• 7% of all asthmatics have Chronic rhinosinusitis with nasal polyps
• in 26–48% of patients with Chronic rhinosinusitis with nasal polyps have asthma
reported. Promsopa C et al. Int Forum Allergy Rhinol. 2016
• Medical and surgical therapy of chronic rhinosinusitis improved the clinical course of
asthma. Ragab S, et al. Eur Respir J. 2006

112. Managing comorbidity contd..
Comorbity Role in asthma management
GERD • Average prevalence of GERD in paediatric asthma 27%. Thakkar et al
• Causal relationship not established
• severe cough increases intra-abdominal pressure and changes the pressure
gradient between stomach and oesophagus
• hyper-inflated lungs alter the relation between crural diaphragm and gastro
• oesophageal junction,
• Some asthma medicines like beta-agonist decreases LES pressure
• No effect of lansoprazole on symptom control and lung function. Holbrook JT et al.
JAMA 2012
Food allergy • In National Cooperative Inner City Asthma Study (NCICAS) children with asthma
from the inner city had high the prevalence of food sensitization , with 45% of the
children having serologic evidence of IgE-mediated sensitization to at least 1 of the
6 most common food allergens (milk, egg, wheat, soy, peanut, or fish) .
• Causal relationship not established.

113. Severe therapy resistant asthma
• Persistent symptoms and evidence of airway inflammation despite
high-dose inhaled (800 lg/day budesonide or equivalent) and oral
corticosteroid therapy.
• Factors promoting ongoing inflammation excluded

114. Investigations
• Skin prick testing to identify aeroallergens/ food allergens
• Total serum IgE levels
• Specific IgE RAST to common allergens
• Sputum eosinophil count
• Assessment of corticosteroid responsiveness

115. Assessment of corticosteroid responsiveness
• No clear paediatric definition
• Response assessment : 2 weeks of oral prednisolone or single
intramuscular dose of triamcinolone
• Criterion (Adams et al. Pediatr Drugs 2013)
• Non steroid responsiveness consider steroid sparing therapy
(i) Symptoms control (ACT score increase to [20/25 or a rise of at least 5 points);
(ii) FEV1 rises to normal or by C15 % predicted, no residual bronchodilator response);
(iii) Normal levels of sputum eosinophils or normalization of FeNO

116. Steroid sparing agents
Omalizumab
 Approved in age >6 years
 Atopic asthma with raised serum IgE levels
Methotrexate and azathioprine
 Use associated with decreased cumulative steroid dose
 Increased risk of side effects
 Limited studies in children
Antifungal therapy (itraconazole)
 Consider in case of sensitisation to mould
 IL-5 antibody therapy: mepolizumab
Anti-IL-13 antibody therapy lebrikizumab

117. Strategies for primary prevention
Brooke I. Polk Leonard B.
Bacharier. Immunol Allergy
Clin North Am 2019

118. COVID 19 And asthma
Interim guidance (as per GINA 2020) on management of asthma in
COVID pandemic
• Continue medication particularly ICS
• Availability of written asthma action plan
• Avoid use of nebulisers/ preferably use MDI
• Avoid spirometry in suspect/confirmed cases

119. Take home message
• Personalised asthma management
• Improving asthma education and patients/ caregiver health literacy
• Emphasis on asthma medication and inhalation device technique
• Periodic review and adjustment of treatment
• Equal emphasis on pharmacological and non pharmacological
management
• Step based management of asthma

120. Thank you