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Pediatric Asthma. Asthma is the most common chronic disease of childhood and the leading cause of childhood morbidity from chronic disease as measured by school absences, emergency department visits, and hospitalizations.
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Asthma is the most common chronic disease of childhood and the leading cause of childhood morbidity from chronic disease as measured by school absences, emergency department visits, and hospitalizations. • Asthma leads to recurrent episodes of wheezing, breathlessness, chest tightness and coughing (particularly at night or early morning). • Clinical symptoms in children 5 years and younger are variable and non-specific. • Widespread, variable, and often reversible airflow limitation.
Source: Peter J. Barnes, MD Mechanism – Asthma Inflammation
Factors Influencing the Development and Expression of Asthma Host factors – • Genetic • Genes predisposing to atopy • Genes predisposing to airway hyper responsiveness • Obesity • Sex
Environmental factors – • Allergens – • Indoor – Domestic mites, furred animals (dogs, cats, mice), cockroach allergens, fungi, molds, yeasts. • Outdoor – Pollens, fungi, molds, yeasts. • Infections (predominantly viral) • Occupational sensitizers • Tobacco smoke • Passive smoking • Active smoking • Indoor/Outdoor air pollution • Diet
Risk factors of Asthma in younger children Sensitization to allergen. Maternal diet during pregnancy and/ or lactation. Pollutants (particularly environmental tobacco smoke). Microbes and their products. Respiratory (viral) infections. Psychosocial factors.
The prevalence of childhood asthma has continued to increase on the Indian subcontinent over the past 10 yrs ISAAC Phase 3 Thorax 2007;62:758
Other Challenges Most of the children are below 5 years of age, who cannot tell their problems Parents are proxy story teller, who may mislead the doctor PEF cannot be performed in children below 5 years of age Fear of addiction to inhalation therapy Physicians lack of knowledge and time
Clinical Features Recurrent Wheeze Recurrent Cough Recurrent Breathlessness Activity Induced Cough/Wheeze Nocturnal Cough/Breathlessness Tightness Of Chest Asthma by Consensus, IAP 2003
Symptomatology Cough – 90% Wheezing – 74% Exercise induced wheeze or cough – 55% Ind J Ped 2002;69:309-12
Typical features of Asthma Afebrile episodes Personal atopy Family history of atopy or asthma Exercise /Activity induced symptoms History of triggers Seasonal exacerbations Relief with bronchodilators Asthma by Consensus, IAP 2003
When does Asthma begin? By 1 year – 26% 1-5 years – 51.4% > 5 years – 22.3% 77% Of Asthma Begins In Children Less Than 5 Years Ind J Ped 2002;69:309-12
Tools to Diagnosis Good History Taking (ASK) Careful Physical Examination (LOOK) Investigations (PERFORM) – above 5 years only CHILDHOOD ASTHMAbyKHUBCHANDANI R.P. et al
History taking (Ask) Has the child had an attack or recurrent episode of wheezing (high-pitched whistling sounds when breathing out)? Does the child have a troublesome cough which is particularly worse at night or on waking? Is the child awakened by coughing or difficult breathing? Does the child cough or wheeze after physical activity (like games and exercise) or excessive crying? Does the child experience breathing problems during a particular season? CHILDHOOD ASTHMAbyKHUBCHANDANI R.P. et al
History taking (Ask) Does the child cough, wheeze, or develop chest tightness after exposure to airborne allergens or irritants e.g. smoke, perfumes, animal fur? Does the child’s cold frequently ‘go to the chest’ or take more than 10 days to resolve? Does the child use any medication when symptoms occur? How often? Are symptoms relieved when medication is used? If the answer is ‘yes’ to any of the questions, a diagnosis of asthma should be considered CHILDHOOD ASTHMAbyKHUBCHANDANI R.P. et al
Physical Examination (Look) General Attitude And Well Being Deformity Of The Chest Character Of Breathing Thorough Auscultation Of Breath Sounds Signs Of Any Other Allergic Disorders On The Body Growth And Development Status CHILDHOOD ASTHMAbyKHUBCHANDANI R.P. et al
What all features one should look for specifically? Dyspnea Expiratory wheeze Accessory muscle movement Difficulty in feeding, talking, getting to sleep Irritability CHILDHOOD ASTHMAbyKHUBCHANDANI R.P. et al
What all features one should look for specifically? Cough Persistent/ recurrent / nocturnal/ exercise-induced Associated conditions Eczema Allergic Rhinitis Weight/Height CHILDHOOD ASTHMAbyKHUBCHANDANI R.P. et al
What all investigations can be performed in asthmatic children? (PERFORM) Peak expiratory flow rate: It is highly suggestive of asthma when: >15% increase in PEFR after inhaled short acting β2 agonist >15% decrease in PEFR after exercise Diurnal variation > 10% in children not on bronchodilator OR >20% In children on bronchodilator 1.Asthma by Consensus, IAP 2003 2. CHILDHOOD ASTHMAbyKHUBCHANDANI R.P. et al
The Early Wheezer (< 3Years) Early onset asthma Afebrile episodes Personal atopy present Family history of asthma / atopy present Predictable good response to bronchodilators WALRI (wheeze associated lower respiratory tract infections) or Viral Associated wheeze Febrile episodes Personal atopy absent Family history of asthma / atopy absent Variable response to bronchodilators Asthma by Consensus, IAP 2003
Bronchiolitis in children Commonest cause of wheezing in children between 6 months to 3 years Resembles asthma Diagnosis essentially clinical Common viruses causing bronchiolitis in children: Respiratory syncytial virus (RSV)
Clinical manifestations of RSV disease Rhinorrhoea Pharyngitis Cough Low grade fever Wheezing Increased respiratory rate
Differential diagnosis IPAG 2007
Co morbid conditions Allergic Rhinitis Colds, ear infections Sneezing in the morning Blocked nose, snoring, mouth breathing Gastro esophageal reflux (GER) Nocturnal cough followed by vomiting Eczema
IPAG Diagnosis Characterize the problem Establish chronicity Exclude non-respiratory or other causes Exclude infectious diseases Consider patient’s age Use diagnostic aids International Primary Care Airways Group 2007
Childhood Asthma Diagnosis (6-14 years) IPAG 2007
Childhood Asthma Diagnosis (6-14 years) IPAG 2007
NORDIC CONSENSUS Respir Med. 2000;94(4):299-327
IAP GUIDELINES 3 Or More Episodes Of Airflow Obstruction With Several Of The Following: • Afebrile Episodes • Personal Atopy Or Family H/O Atopy / Asthma • Nocturnal Exacerbations • Exercise/Activity Induced Symptoms • Trigger Induced Symptoms • Seasonal Exacerbations • Relief With Bronchodilators ± Oral Steroid Asthma by Consensus, The Indian Academy of Pediatrics 2003
GINA The following symptoms are highly suggestive of a diagnosis of asthma: frequent episodes of wheeze (more than once a month) activity-induced cough or wheeze nocturnal cough in periods without viral infections absence of seasonal variation in wheeze symptoms that persist after age 3 A simple clinical index based on: presence of a wheeze before the age of 3 presence of one major risk factor (parental history of asthma or eczema) or two of three minor risk factors (eosinophilia, wheezing without colds, and allergic rhinitis) has been shown to predict the presence of asthma in later childhood Global Initiative for Asthma 2008
GINA A useful method for confirming the diagnosis of asthma in children 5 years and younger is a trial of treatment with short-acting bronchodilators and inhaled glucocorticosteroids Children 4 to 5 years old can be taught to use a PEF meter, but to ensure reliability parental supervision is required Use of spirometry and other measures recommended for older children such as airway responsiveness and markers of airway inflammation is difficult and several require complex equipment making them unsuitable for routine use GINA 2008
BTS Initial assessment of children suspected of having asthma should be based on: presence of key features in the history and clinical examination careful consideration of alternative diagnoses Using a structured questionnaire may produce a more standardised approach to the recording of presenting clinical features and the basis for a diagnosis of asthma British Thoracic Society 2008
Clinical features that increase the probability of asthma More than one of the following symptoms: wheeze, cough, difficulty breathing, chest tightness, particularly if these symptoms: ◊ are frequent and recurrent ◊ are worse at night and in the early morning ◊ occur in response to, or are worse after, exercise or other triggers, such as exposure to pets, cold or damp air, or with emotions or laughter ◊ occur apart from colds Personal history of atopic disorder Family history of atopic disorder and/or asthma Widespread wheeze heard on auscultation History of improvement in symptoms or lung function in response to adequate therapy BTS 2008
Clinical features that lower the probability of asthma Symptoms with colds only, with no interval symptoms Isolated cough in the absence of wheeze or difficulty breathing History of moist cough Prominent dizziness, light-headedness, peripheral tingling Repeatedly normal physical examination of chest when symptomatic Normal peak expiratory flow (PEF) or spirometry when symptomatic No response to a trial of asthma therapy Clinical features pointing to alternative diagnosis BTS 2008
What do you understand by phenotypes? Phenotypes “the visible properties of an organism that are produced by the interaction of genotype and the environment” -Webster’s New Collegiate Dictionary
Pre-school “Asthma phenotypes”Wheezing is common in young children but is it asthma? Prevalence of wheeze Atopic asthma Non-atopic viral induced wheeze Transient wheeze 0 3 6 11 Age Years Martinez Pediatrics 2002;109:362
Asthma phenotypes in childhood Transient linked with smoking during pregnancy viral RTIs not associated with atopy remits by school age Impaired lung function at birth
Asthma phenotypes in childhood Persistent not associated with atopy: - associated with viral RTIs (RSV), - may remit during school age - LTRAs have been found to be beneficial associated with atopy: - bronchial responsiveness, impaired lung function - parental history of asthma - most ongoing during school age
Classification of Asthma The goal of the treatment is to achieve and maintain control for prolonged periods with due regard to the safety of treatment, potential for adverse effects, and the cost of treatment required to achieve this goal. Assessment of asthma control should include control of the clinical manifestations, control of the expected future risk to the patient such as exacerbations, accelerated decline in the lung function, and side-effects of the treatment. The achievement of good clinical control of asthma leads to reduced risk of exacerbations.
*Any exacerbation should be prompt review of maintenance treatment to ensure that it is adequate. #Lung function is not a reliable test for children 5 years and younger. GINA 2009
