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ASTHMA MANAGEMENT AND PREVENTION IN CHILDREN

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Title: ASTHMA MANAGEMENT AND PREVENTION IN CHILDREN


1
ASTHMA MANAGEMENT AND PREVENTION IN CHILDREN
  • Thanaphirat Mamaethong

2
  • Asthma is one of the most common chronic diseases
  • The prevalence is increasing, especially among
    children
  • The prevalence of asthma symptoms in children
    varies from 0 to 30 percent
  • The highest prevalence occurring in Australia,
    New Zealand and England

3
DEFINITION OF ASTHMA
  • Asthma is a chronic inflammatory disorder of the
    airways in which many cells and cellular elements
    play a role.
  • The chronic inflammation causes an associated
    increase in airway hyperresponsiveness
  • Recurrent episodes of wheezing, breathlessness,
    chest tightness, and coughing, particularly at
    night or in the early morning.

4
  • These episodes are usually associated with
    widespread but variable airflow obstruction that
    is often reversible either spontaneously or with
    treatment.

5
NATURAL HISTORY OF ASTHMA
  • Asthma in children and adults is frequently found
    in association with atopy
  • The production of abnormal amounts of IgE
    directed to epitopes expressed on common
    environmental allergens
  • For most patients with asthma, the disease begins
    prior to 6 years of age.

6
Infancy
  • Asthma may develop during the first few months of
    life, but it is often difficult to diagnosis
  • The condition most commonly associated with
    wheezing is thought to be respiratory viral
    infection.
  • Those children who continue to wheeze in later
    childhood apparently have asthma related to
    atopy.
  • Indicating the possible deleterious effect of
    asthma on the development of the lung

7
Childhood
  • The predominant feature associated with asthma in
    children is allergy.
  • It has often been suggested that childhood asthma
    will disappear when the patient reaches
    adulthood.
  • disappears in 30 to 50 percent of children
    (especially males) at puberty, but often
    reappears in adult life.

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  • The prognosis of asthma appears to be worse when
    the child has eczema or a family history of
    eczema
  • 5 to 10 percent of children with asthma that is
    considered to be trivial have severe asthma in
    later life.

9
Pathophysiology
10
  • result in airway inflammation, which limits
    airflow from bronchospasm, mucosal edema, and
    mucus plugs.
  • Although many of the mediators responsible
    cytokines,chemokines, and growth factors
  • These factors are produced by mast cells,
    lymphocytes, eosinophils, basophils, epithelial
    cells, dendritic cells, and smooth muscle cells.

11
  • Airway inflammation in asthma may represent a
    loss of normal balance between two "opposing"
    populations of Th lymphocytes.
  • Two types of Th lymphocytes have been
    characterized
  • Th1 cells produce IL-2 and IFN-a, which are
    critical in cellular defense mechanisms in
    response to infection.
  • Th2, in contrast, generates a family of cytokines
    (IL-4, -5, -6, -9, and -13) that can mediate
    allergic inflammation.

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Airway pathology
  • There is evidence of both acute and chronic
    inflammation that is irregularly distributed
    throughout the airways, including the smallest
    airways (less than 2 mm in diameter), and the
    parenchyma.

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  • Trophic changes
  • hypertrophy and hyperplasia of airway smooth
    muscle
  • increase in goblet cell number
  • enlargement of submucous glands
  • remodeling of the airway connective tissue

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RELATIONSHIP OF AIRWAY PATHOLOGY TO DISORDERED
LUNG FUNCTION
  • Airway Hyperresponsiveness
  • Airflow Limitation
  • Acute bronchoconstriction.
  • Swelling of the airway wall.
  • Chronic mucus plug formation.
  • Airway wall remodeling.

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  • Chronic inflammation of the airways is associated
    with increased BHR, which leads to bronchospasm
    and typical symptoms.
  • In some patients with chronic asthma, airflow
    limitation may be only partially reversible
    because of airway remodeling that occurs

24
Mechanism
  • Airway obstruction causes increased resistance to
    airflow and decreased expiratory flow rates.
  • Decreased ability to expel air and may result in
    hyperinflation.
  • The resulting overdistention helps maintain
    airway patency, thereby improving expiratory
    flow however, it also alters pulmonary mechanics
    and increases the work of breathing

25
  • In the early stages, when V/Q mismatch results in
    hypoxia, hypercarbia is prevented by the ready
    diffusion of CO2 across alveolar capillary
    membranes.
  • Hyperventilation triggered by the hypoxic drive
    also causes a decrease in PaCO2.
  • An increase in alveolar ventilation in the early
    stages of an acute exacerbation prevents
    hypercarbia.

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  • With worsening obstruction and increasing V/Q
    mismatch, CO2 retention occurs. In the early
    stages, respiratory alkalosis results from
    hyperventilation.
  • Later, the increased work of breathing, increased
    oxygen consumption, and increased cardiac output
    result in metabolic acidosis.
  • Respiratory failure leads to respiratory acidosis.

27
RISK FACTORS
  • Host factors
  • Genetic predisposition
  • Atopy
  • Airway hyperresponsiveness
  • Gender
  • Race

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  • Environmental factors
  • allergens and occupational sensitizers
  • viral and bacterial infections
  • diet
  • tobacco smoke
  • socioeconomic status
  • family size

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  • Exposure to allergens and respiratory (viral)
    infections are the main factors responsible for
    causing exacerbations of asthma and/or the
    persistence of symptoms

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DIAGNOSING ASTHMA
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CLINICAL DIAGNOSIS
  • Symptoms episodic breathlessness, wheezing,and
    chest tightness.
  • Seasonal variability of symptoms
  • Positive family history of asthma and atopic
    disease

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Physical Examination
  • May be normal
  • The most usual abnormal physical finding is
    wheezing on auscultation
  • However, some people with asthma mayhave normal
    auscultation but significant airflow limitation
    when measured objectively

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  • Dyspnea, airflow limitation (wheeze), and
    hyperinflation are more likely to be present if
    patients are examined during symptomatic periods.
  • Physical signs reflecting severity cyanosis,
    drowsiness, difficulty speaking, tachycardia,
    hyperinflated chest, use of accessory muscles,
    and intercostal recession.

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  • There are two general patterns of wheezing in
    infancy
  • Infants who have recurrent episodes of wheeze
    associated with acute viral respiratory
    infections, come from nonatopic families,no atopy
    themselves. These infants usually outgrow their
    symptoms in the preschool years and have no
    evidence of subsequent asthma.
  • Other infants with asthma have an atopic
    background often associated with eczema. Symptoms
    in these children often persist through childhood
    and into adult life. In these children
    characteristics of airway inflammation can be
    found even in infancy.

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  • In young children with frequent wheezing, a
    parental history of asthma along with the
    presence of other atopic manifestations in the
    child are significantly associated with the
    presence of asthma at age 6.
  • Although in these young children there is the
    possibility of over treatment, the episodes of
    wheezing may be shortened and reduced in
    intensity by the effective use of
    anti-inflammatory medications and bronchodilators
    rather than antibiotics.

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  • Asthma can often be diagnosed on the basis of
    symptoms.
  • However, measurements of lung function, and
    particularly the reversibility of lung function
    abnormalities, greatly enhance diagnostic
    confidence in children 5 years and older.

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Measurements of Lung Function
  • Forced expiratory volume in 1 second (FEV1)
  • Forced vital capacity (FVC)
  • Peak expiratory flow (PEF)

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FEV1/FVC ratios
  • FEV1/FVC ratios of lt 80 percent, are suggestive
    of airflow limitation
  • Where at least a 12 percent improvement in FEV1
    either spontaneously, after inhalation of a
    bronchodilator, or in response to a trial of
    glucocorticosteroid therapy favors a diagnosis of
    asthma

43
Peak expiratory flow
  • An important aid in the diagnosis and subsequent
    treatment of asthma is the PEF meter
  • At least a 15 percent improvement after
    inhalation of a bronchodilator or in response to
    a trial of glucocorticosteroid therapy favors a
    diagnosis of asthma

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  • A diurnal variation in PEF of more than 20
    percent is considered to be diagnostic of asthma

45
Methods
  • Diurnal PEF variability is as the amplitude (the
    difference between the prebronchodilator morning
    value and the postbronchodilator value from the
    evening before), expressed as a percentage of the
    mean daily PEF value.
  • The minimum morning prebronchodilator PEF over 1
    week, expressed as a percent of the recent best
    (MinMax).
  • This latter method has been suggested to be the
    best PEF index of airway lability

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  • For patients with symptoms consistent with
    asthma, but normal lung function
  • Measurements of airway responsiveness to
    methacholine, histamine, or exercise challenge
    may help establish a diagnosis of asthma
  • These measurements are sensitive for a diagnosis
    of asthma, but have low specificity

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Bronchial provocation tests
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Exercise challenge
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Other diagnostic considerations in children
include the following
  • The presence of recurrent nocturnal cough in an
    otherwise healthy child should raise asthma as a
    probable diagnosis.
  • A trial of asthma medication is probably the most
    confident way to make a diagnosis of asthma in
    children.
  • The use of diary cards to record symptoms and PEF
    (in children over 5 years of age) readings are
    important tools in childhood asthma management.

53
  • Some children with asthma present symptom with
    exercise. If there is doubt in the diagnosis, a
    6-minute running protocol followed by measurement
    of PEF showing a 15 percent drop or symptoms
    following exercise can help establish a diagnosis
    of asthma.
  • Allergy skin tests, can help in the
    identification of risk factors
  • Asthma should be considered if the child's colds
    repeatedly "go to the chest" or take more than 10
    days to clear up, or if the child improves when
    asthma medication is given.

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DIFFERENTIAL DIAGNOSIS
  • An important step in ensuring diagnosis of asthma
    is the demonstration of reversible and variable
    airflow limitation, preferably by spirometry.
  • Another diagnosis to consider in both children
    and adults is pseudoasthma, most often caused by
    vocal cord dysfunction

55
  • Very rare causes of recurrent wheezing,
    particularly in early infancy
  • cystic fibrosis, recurrent milk aspiration,
    primary ciliary dyskinesia syndrome, primary
    immune deficiency, congenital heart disease,
    congenital malformations causing narrowing of
    intrathoracic airways and foreign body
    aspiration.
  • Chest radiography is an important diagnostic test
    to exclude such alternative causes of wheezing.

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CLASSIFY ASTHMA SEVERITY
  • Intermittent, mild persistent, moderate
    persistent, or severe persistent
  • Based on the combined assessments of symptoms and
    lung function in children over 5 years of age
  • Severity of asthma will determine the type of
    treatment required

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  • The presence of one of the features of severity
    is sufficient to place a child in that category.
  • Children with intermittent asthma but severe
    exacerbations should be treated as having
    moderate persistent asthma.
  • Children at any level of severityeven
    intermittent asthmacan have severe attacks.

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Exacerbations
  • Episodic worsening is a major feature of asthma.
  • There are multiple triggers for exacerbations,
    including stimuli that
  • produce bronchoconstriction only (inciters)
    cold air, fog, or exercise
  • promote airways inflammation (inducers)
    exposure to allergens, occupational sensitizers,
    ozone, or respiratory virus infection.

62
A SIX-PART ASTHMA MANAGEMENT PROGRAM
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A six-part management program includes
  • Part 1. Educate children/families to develop a
    partnership in asthma care.
  • Part 2. Assess and monitor asthma severity.
  • Part 3. Avoid exposure to risk factors.
  • Part 4. Establish individual medication plans for
    long-term management in infants and preschool
    children, school children, and adolescents with
    asthma.
  • Part 5. Establish individual plans to manage
    asthma attacks.
  • Part 6. Provide regular follow up care.

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The goals for successful management of asthma are
  • Minimal or no symptoms, including nighttime
    symptoms
  • Minimal asthma episodes or attacks
  • No emergency visits to physicians or hospitals
  • Minimal need for reliever medications
  • No limitations on physical activities and
    exercise
  • Nearly normal lung function
  • Minimal or no side effects from medication.

65
Part 1 Educate Children/Families To Develop a
Partnership in Asthma Care.
  • Children and their families can be actively
    involved in managing their asthma to prevent
    problems. They can learn to
  • Avoid risk factors.
  • Take medications correctly.
  • Understand the difference between "controller"
    and "reliever medications.
  • Monitor their status using symptoms and, if
    available, PEF in children over 5 years of age.
  • Recognize signs that asthma is worsening and take
    action.
  • Seek medical help as appropriate.

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Part 2 Assess and Monitor Asthma Severity.
  • Monitoring includes review of symptoms and,
    measurement of lung function in children over 5
    years of age.
  • PEF monitoring at every physician visit helps in
    evaluating the child's response to therapy and
    adjusting treatment accordingly.
  • PEF greater than 80 percent of the child's
    personal best suggests good control.

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  • Long-term PEF monitoring at home can help
    children and their families recognize early signs
    of worsening asthma before symptoms occur.
  • Regular visits (at 1 to 6 month intervals as
    appropriate) are essential, even after control of
    asthma is established.
  • At each visit review the questions

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Part 3 Avoid Exposure to Risk Factors.
  • To improve the control of asthma and reduce
    medication needs, children should avoid exposure
    to risk factors

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Part 4 Establish Individual Medication Plans for
Long-Term Management in Infants and Preschool
Children, School Children, and Adolescents With
Asthma.
  • Childhood and adult asthma share the same
    underlying pathophysiological mechanisms.
  • However, because of the processes of physical and
    cognitive growth and development, the effects,
    and adverse effects, of asthma and asthma
    treatments in children differ from those in
    adults.
  • Many asthma medications are metabolized faster in
    children than in adults, and young children tend
    to metabolize drugs faster than older children.

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Select Medications
  • Two types of medication help control asthma
  • Controller medications that keep symptoms and
    attacks from starting
  • Reliever medications that work quickly to treat
    attacks or relieve symptoms.

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  • Inhaled medications are preferred
  • Because of their high therapeutic ratio high
    concentrations of low doses of drug are delivered
    directly to the airways with potent therapeutic
    effects and few systemic side effects.

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  • Devices available to deliver inhaled medication
    include
  • Pressurized metered-dose inhalers (pMDIs),
    breath-actuated metered dose inhalers, dry powder
    inhalers (DPIs), and nebulizers.
  • Spacer devices make inhalers easier to use.
  • Spacers also reduce systemic absorption and side
    effects of inhaled glucocorticosteroids.

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Controller Medications
  • inhaled glucocorticosteroids
  • systemic glucocorticosteroids
  • leukotriene modifiers
  • sodium cromoglycate (cromolyn sodium)
  • Nedocromil sodium
  • Methylxanthines
  • long-acting inhaled ?2-agonists,
  • long-acting oral ?2-agonists.

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Reliever Medications
  • ?2-agonists.
  • Anticholinergic agents.

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  • A stepwise approach
  • The number and frequency of medications increase
    (step up) as the need for asthma therapy
    increases,
  • and decreases (step down)when asthma is under
    control.

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  • Step up if control is not achieved and sustained.
    Generally,improvement should be achieved within 1
    month.
  • Step down if control is sustained for at least 3
    months
  • Review treatment every 3 to 6 months once asthma
    is under control.

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  • Consult with an asthma specialist when other
    conditions complicate asthma, the child does not
    respond to therapy, or treatment at steps 3 or 4
    is required.

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Part 5 Establish Individual Plans to Manage
Asthma Attacks
  • Do not underestimate the severity of an attack
    severe asthma attacks may be life threatening.

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  • Children/adolescents at high risk for
    asthma-related death includethose with
  • History of near-fatal asthma.
  • Hospitalization or emergency visit for asthma
    within the past year, or prior intubation for
    asthma.
  • Current use of, or recent withdrawal from, oral
    glucocorticosteroids.
  • Over-dependence on rapid-acting inhaled
    ?2-agonists.
  • History of psychosocial problems or denial of
    asthma or its severity.
  • History of noncompliance with asthma medication
    plan.

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Patients should immediately seek medical care
if...
  • The attack is severe
  • The response to the initial bronchodilator
    treatment is not prompt and sustained for at
    least 3 hours.
  • There is no improvement within 2 to 6 hours after
    oral glucocorticosteroid treatment is started.
  • There is further deterioration.

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Asthma attacks require prompt treatment
  • Inhaled rapid-acting ?2-agonists are essential.
    If inhaled medications are not available, oral
    bronchodilators may be considered.
  • Oral glucocorticosteroids introduced early in the
    course of a moderate or severe attack help to
    reverse the inflammation and speed recovery.
  • Oxygen is given at health centers or hospitals if
    the patient is hypoxemic.

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  • Methylxanthines are not recommended if used in
    addition to high doses of inhaled ??2-agonist.
  • However, theophylline can be used if inhaled
    ?2-agonists are not available. If the patient is
    already taking theophylline on a daily basis,
    serum concentration should be measured before
    adding short-acting theophylline.
  • Epinephrine (adrenaline) may be indicated for
    acute treatment of anaphylaxis and angioedema.

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Therapies not recommended for treating attacks
include
  • Sedatives (strictly avoid).
  • Mucolytic drugs (may worsen cough).
  • Chest physical therapy/physiotherapy (may
    increase patient discomfort).
  • Hydration with large volumes of fluid for adults
    and older children (may be necessary for younger
    children and infants).
  • Antibiotics (do not treat attacks but are
    indicated for patients who also have pneumonia or
    bacterial infection such as sinusitis).

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  • Mild attacks can be treated at home if the
    child/family is prepared and there is a personal
    asthma management plan that includes action steps

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  • Moderate attacks may require, and severe attacks
    usually require, care in a clinic or hospital

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Monitor Response to Treatment
  • Evaluate symptoms and, as much as possible, peak
    flow.
  • In hospital, also assess oxygen saturation
    consider arterial blood gas measurement in
    patients with suspected hypoventilation,
    exhaustion, severe distress, or peak flow 30-50
    percent predicted.

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Part 6 Provide Regular Followup Care
  • Children with asthma and their families need
    regular supervision and support by a health care
    professional
  • Once asthma control is established, regular
    followup visits, continue to be essential.
  • During these visits, monitor and review treatment
    plans, medications, and level of asthma control.

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SPECIAL CONSIDERATIONS ARE REQUIRED IN MANAGING
ASTHMA IN RELATION TO
  • Pregnancy
  • Surgery
  • Physical activity
  • Rhinitis
  • Sinusitis and nasal polyps
  • Occupational asthma
  • Respiratory infections
  • Gastroesophageal reflux
  • Aspirin-induced asthma.

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REFERENCES
  • GLOBAL STRATEGY FOR ASTHMA MANAGEMENT AND
    PREVENTION, UPDATED 2005, the Global Initiative
    for Asthma (GINA) program
  • POCKET GUIDE FOR ASTHMA MANAGEMENT AND PREVENTION
    IN CHILDREN, Updated 2005, the Global Initiative
    for Asthma (GINA) program
  • Is asthma curable?, ???????? ????????????,
    ??????????????????????? 2, ???? 2540
  • Asthma ,Girish Sharma, MD., www.eMedicine.com

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THANK YOU
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