BRONCHIAL ASTHMA IN CHILDREN

1. BRONCHIAL ASTHMA IN CHILDREN Department of pediatrics

2. Definition • Asthma is a chronic disease involving the respiratory system in which the airways occasionally constrict, become inflammated, and are lined with excessive amounts of mucus often in response to one or more triggers.

3. Epidemiology • Bronchial asthma (BA) is one from the most frequent chronic diseases in children and its incidence continues to increase in the last years. Conformable to ISAAC data (International Study of Asthma and Allergy in Children), BA affects 5-20% of children on the earth globe, this index varying in different countries (in USA - 5-10%, in Canada, UK - 25-30%, in Greece, China – 3-6%).

4. Risk factors for BA development in children • Familial antecedents of BA and other allergic diseases. • Contact with home dust containing dust mite: Dermatophagoides pteronyssinus. • Contact with fur-bearing animals (cat, dog, etc.). • Contact with mould (species of fungi Alternaria, Aspergillus, Candida, Penicillium). • Contact with the pollen of different plants. • Smoke of cigarettes, after woods burning. • Presence of cockroaches.

5. Risk factors for BA development in children • Alimentary (fish, egg, cow’s milk etc.) and drug allergens • Meteorological factors (cold air, fog). • Physical activity • Environmental pollution • Presence of gastroesophageal reflux. • Drugs and vaccines (antibiotics – penicillin, cephasoline, tetracycline etc., sulfonamides, NSAID, colorants, etc.) • Viral infections • Stress factors

6. Clinical classification of bronchial asthma • Atopic (allergic) asthma • Nonatopic (nonallergic) asthma • Status asthmaticus

7. Particular forms of bronchial asthma • BA provoked by physical effort • Cough variant of BA • Aspirinic BA

8. Classification of BA in function of severity

9. Clinical picture of BAAnamnesis Which questions must be given in the case of BA suspicion: • Had the patient episodes of wheezing, inclusively repeated? • Has the patient nocturnal cough? • Has the patient cough and wheezing after physical effort? • Had the patient episodes of wheezing and cough after the contact with aeroallergens and pollutants? • Had the patient episodes of wheezing after supported respiratory infection? • Is decreasing the degree of symptoms expression after antiasthmaticdrugs receiving?

10. Recommendations for personal and hereditary antecedents assessment: • Presence of dyspnea, wheezing, cough and thorax oppression episodes, with evaluation of duration and conditions of improving. • Familial antecedents of bronchial asthma. • Risk factors • Asthmatic symptoms are manifesting concomitantly (the thoracic oppression is less constant) and have common: - Variability in time (are episodic); - Preferentially nocturnal appearance; - Appearance due to trigger factor (physical effort, exposition to allergens, strong laugh, etc.). - Personal, familial and environmental factors.

11. Characteristics of asthmatic attacks: • Quick appearance with expiratory dyspnea, prolonged expiration and wheezing, pronounced sensation of thoracic oppression, lack of air (sensation of suffocation). • Duration from 20 – 30 min until a few hours. • Spontaneous disappearance or at administration of ß2-adrenomymetics with short action. • They appear more frequently in night. • The attacks appear suddenly and end also suddenly with tormenting cough with elimination of mucous, viscous, “pearl” sputum in small quantity.

12. Suggestive symptoms for bronchial asthma diagnosis in children: • Frequent episodes of wheezing (more than 1 episode per month); • Cough ± wheezing induced by physical activity; • Nocturnal cough out of viral infection periods; • Lack of wheezing seasonal variations.

13. There are 3 categories of wheezing: • Precocious transitory wheezing; is associated with presence of such risk factors as prematurity, smoking parents, dyspneauntil 3 years; • Persistent wheezing with precocious onset (until 3 years); recurrent episodes of wheezing associated with acute viral infections (predominantly with respiratory syncitialvirus, in children under 2 years, and other viruses, in older children), without atopic manifestations or familial antecedents of atopy; the symptoms persist until the school age and can be present in 12 years old children in significant proportion; • Wheezing (asthma with tardy onset, after 3 years age); in this group asthma evolves in childhood period and even in adults; children present signs of atopy (most frequent – atopic dermatitis) and air pathways pathology characteristic for asthma.

14. Predictive signs for childhood asthma (preschool, school age): • Wheezing until 3 years; • Presence of major risk factor (familial antecedents of asthma); • Two from three minor risk factors (eosinophilia, wheezing without cough, allergic rhinitis).

15. Physical examination:Basic principles: • The signs of respiratory system affection can be absent. • Inspection: - Sitting position (orthopnea) with accessory respiratory muscles involvement; - Tachypnea. • At percussion: - Diffuse increased sonority and down placed diaphragm. • Auscultatively: - Diminished vesicular murmur; - Dry coarse, polyphonic, disseminated crackles, predominantly at expiration, that can be heard at distance (wheezing); - Moist and subcrepitant crackles in more advanced bronchial hypersecretion.

16. Causes of bronchial asthma exacerbations: • Insufficient bronchodilator treatment. • Long-term defect of the basic treatment. • Viral respiratory infections. • Changes of weather • Stress • Long time exposure to triggers.

17. Appreciation of bronchial asthma exacerbations severity

18. Appreciation of bronchial asthma exacerbations severity

19. Appreciation of bronchial asthma exacerbations severity

20. Appreciation of bronchial asthma exacerbations severity

21. Normal frequency of respiration in children Age Frequency of respiration < 2 months <60/min 2 – 12 months <50/min 1 – 5 years <40/min 6 – 8 years <30/min

22. Normal frequency of cardiac contractions (FCC) in children Suckling babies 2 – 12 months <160/min Little age 1 – 2 years <120/min Preschool andschool age 2 – 8 years <110/min

23. The diagnosis of BA in children has the following basic aspects: ● atopic background: allergic rhinitis, atopic dermatitis, alimentary allergy, atopic manifestation in family; ● clinically: paroxysmal dyspneawith wheezing; ● functionally: reversible bronchial obstruction; ● therapeutically: efficient response at short action bronchodilators and inhalator corticosteroids treatment.

24. The algorhythmfor BA diagnosis in suckling baby and infant (by Martinez, modified) Major criteria: ● hospitalizations at severe form of bronchiolitisor wheezing; ● ≥ 3 episodes of wheezing during respiratory infections in the last 6 months; ● presence of asthma in one of parents; ●atopic dermatitis; ●sensibilization to pneumoallergens.

25. Minor criteria: ● rhinorrhea in the absence of flu; ● wheesing in the absence of flu; ● eosinophilia (≥ 5%); ● alimentary allergy; ● male.

26. Risk for persistent wheezing/asthma: • One from first 2 major criteria + another major criterion; • One from first 2 major criteria + 2 minor criteria.

27. PARACLINICAL INVESTIGATIONS IN BRONCHIAL ASTHMA Obligatory investigations: • PEF-metry; • Spirography; • Test with bronchodilator • Skin tests with allergens; • Pulsoxymetry; • Hemoleukogram; • General analysis of sputum; • ECG; total and specific IgE • X-ray chest in 2 proiections.

28. PARACLINICAL INVESTIGATIONS IN BRONCHIAL ASTHMA Recommended investigations: • Bronchoscopy (at necessity); • EchoCG; • Oxymetry of arterial blood; • Acido – basic stateevaluation; • Provoking tests (effort, acetylcholine, metacholine); • Pulmonary, mediastinal CT (at necessity) • General urine analysis; • Biochemical serologic indexes (total protein, glucose, creatinin, urea, LDH, AST, ALT, bilirubin and its fractions); • Ionogram.

29. Spirography: • It allows to appreciate the severity and reversibility of bronchial obstruction; • It allows to differentiate from restrictive affections.

30. PEF-metry: • It allows the appreciation and monitoring of bronchial obstruction severity and reversibility. • The formula for calculation of PEF in% towards to predicted value in%: PEF = minimal PEF of given day/predicted PEF x 100%. • 24 hours variability of PEF is calculating after formula: 24 hours variability = 2(evening PEF – morning PEF)/(evening PEF + morning PEF) X 100%.

31. Pharmacological tests: • The test with ß2-agonist (bronchodilator test) – spirographicor PEF-metryvalues performed after 15 min from inhalation of short action ß2-agonist are compared with the usual data before inhalation; increasing of PEF values ≥20% shows the obstruction reversibility and is suggestive for BA.

32. Physical effort test: • The spirography or PEF-metry is performed initially and at 5-10 min after nonstandard physical effort (running or physical exercises), but sufficient for increase the pulse rate (until 140 – 150/min). Decreasing of PEF ≥20% is suggestive for asthma (effort bronchospasm).

33. Examination of sputum: • Eosinophils (in proportion of 10 – 90%), octoedric Charcot – Layden phospholypase crystals are suggestive for atopic asthma. • Curschmann’s spirals (agglomerations of mucus).

34. Hemogram and immunoglobulins • Hemogram shows eosinophilia in some cases. • Immunoglobulins: - Total serum IgE increased in atopic asthma. - Specific IgE to certain allergen are increased.

35. X-ray chest: • Is obligatory only in the first accesses, when the diagnosis is not clear. • In BA access – signs of pulmonary hyperinflation (flat diaphragm with reduced movements, hypertransparence of pulmonary areas, widening of retrosternal space, horizontal ribs). • It can be indicated for disease complications (pneumothorax, pneumomediastinum, atelectasis due to mucus plugs) or associated affections (pneumonias, pneumonitis etc.) finding.

36. General assessment of gas exchange It is necessary in patients with signs of respiratory insufficiency, in these having SaO2 less than 90%.

37. Allergy skin testing (skin-prick  test, scarification probes) It is performed by the allergologist and aims to detect IgE-induced allergic reactions. It is usually carried out by the method of scarification: skin scarification of 4-5 mm with  applying a drop of  standard allergen in concentration of 5000 U / ml (1 unit =0.00001 mg protein nitrogen / 1 ml).

38. Appreciation ofallergic reaction by skin scarification test

39. DIFFERENTIAL DIAGNOSIS In children less than 5 years, it is performed with another affections occuring with wheesing: • Viral bronchiolitis; • Cystic fibrosis; • Foreign body aspiration; • Upper respiratory pathways obstruction; • Bronchopulmonal displasia; • Intrathoracic respiratory pathways malformations; • Congenital cardiac diseases; • Kartagener’s syndrome; • Immune deficiencies; • Chronic sinusitis; • Gastroesophageal reflux; • Tbc; • Mediastinal adenopathies; • Tumors.

40. DIFFERENTIAL DIAGNOSIS In children older 5 years age, it is performed with the same affections as in big child or adult: • Cardiovascular pathology; • Upper respiratory pathways obstruction; • Foreign bodies aspiration; • Cystic fibrosis; • Syndrome of hyperventilation, panic, vocal chords dysfunction; • Pulmonary interstitial pathology; • Gastroesophageal reflux; • Rhinosinusal pathology.

41. Hospitalization criteria for patients with BA: • Severe access; • Inefficacity of broncholytic therapy during 1 – 2 hours; • Duration of exacerbation more than 1 – 2 weeks; • Impossibility to accord medical care at home; • Unsatisfactory living conditions; • Presence of increased risk factors for death due to BA.

42. Criteria for hospitalization in intensive care departaments for patients with BA: • Mental deterioration; • Paradoxic pulse >15-20 mm Hg; • Severe pulmonary hyperinflation; • Severe hypercapnia > 80 mm Hg; • Cyanosis resistant to oxygenotherapy; • Unstable hemodynamics.

43. General principles of drug treatment in bronchial asthma: • The inhalatory therapy is the most recommended in all children, the used devices for drug inhalation must be individualised for every case in function of its peculiarities and characteristics of used inhaler. In general lines, administration using metered-dose-inhaler (MDI) with spacer versus nebulizing therapy is more preferable, due to some advantages of MDI (reduced risk of adverse effects, more decreased cost etc.). Administration through nebulizers presents a lot of disadvantages: not precise dose, increased cost, necessity of special apparatus.

44. General principles of drug treatment in bronchial asthma: • Drugs administered through inhalation are preferable due to their increased therapeutic index: high concentrations of medicaments are relieved directly in respiratory pathways, with strong therapeutic effects and reduced number of systemic adverse effects.

45. General principles of drug treatment in bronchial asthma: • Devices for medication administered through inhalation: pressure inhalers with measured dose (MDI), dry powder inhalers, turbohalers, diskhalers, nebulizers. • Spacers (or retention camera) make easier the use of inhalers, reduce systemic absorption and secondary effects of inhaled glucocorticoids.

46. General principles of drug treatment in bronchial asthma: • Two types of medication help in asthma control: controlers, or drugs that prevent the symptoms and accesses, and relievers, or drugs, used for access treatment and having rapid effect. • The choice of medication depends from the control level of BA at moment and from curent medication. • If curent medication does not ensure the adequate control of BA, the indication of superior advanced step of treatment is necessary.

47. General principles of drug treatment in bronchial asthma: • If BA is controled 3 months, the decreasing of supporting volume for control maintaining minimal necessary dose establishing (passing to inferior step) is possible. • The therapy with adequate doses of short acting inhalatory ß2-agonists is recommended in accesses (if inhalers are not available, the bronchodilators can be administered per os or i/v. • In hospitals in the case of hypoxemic patient the oxygen is given.

48. General principles of drug treatment in bronchial asthma: • The not recommendedtreatment in accesses: sedatives, mucolytics, physiotherapy, hydration with highvolume of liquids. • Antibiotics not treat the accesses, but are indicated in the case of concomitant pneumonias or other bacterial infections.

49. The keymoments in the treatment of BA by steps: • Each step includes variants of therapy serving as alternative in the choice of BA control treatment, although are not similar to efficacy. • The efficacy of treatment increases from I step to V step and depends from accessibility and certainity of drug. • The steps 2-5 include combinations of urgent medications, at necessity,of systemic control treatment. • In majority of patients with persistent BA, which anteriorly didn’t administered control treatment, is necessary to iniciate the treatment from the 2-nd step.

50. The keymoments in the treatment of BA by steps: • If at primary examination we determine the absence of BA control, the treatment begins from the 3-rd step. • The patients must use relievers (short action bronchodilators) at each step. • The systemic use of urgent medication is a sign of uncontrolled BA, which indicates the necessity of control therapy volume increasing. • Reducing or absence of necessity in relievers represent the goal of treatment and, also, a criterion of efficacity.