ASTHMA MANAGEMENT AND
PREVENTION IN CHILDREN
Dr.A.Sundararajaperumal D.C.H
II yr M.D.(T.B & Chest diseases)
Dept. of .Thoracic Medicine
G.G.H & M.M.C
ASTHMA
• Asthma is a chronic inflammatory condition
of the lung airways resulting in episodic
(reversible) airflow obstruction.
• Chronically inflamed airways are
hyperresponsive;obstructed and airflow is
limited by bronchoconstriction, mucus plugs
and inflammation.
12/07/21 SRP 2
Asthma - Prevalence
P M
A U
A A I
N U K
40 K L U
I N Z
J S
35 I A S
N D
A
30 D S Y A
P I
25 O I S
N
C A A
20 T I
H 38
E N 36
15 I
A A 34
S
10 N N 26
I 18
A 14
5 A 13
9
5
0 2
COUNTRIES
PREVALENCE OF ASTHMA SYMPTOMS , ISAAC - 1990
12/07/21 SRP 3
Etiology
• Its an interplay between Genetics and Environmental factors
Genetics
TWIN studies- 0.74 concordance betn. Monozygotic twins
0.35 concordance betn. Dizygotic twins
Consistently linked with foci containing pro allergic, pro inflammatory genes
( IC-4 gene cluster on chromosome 5)
Environment
-RSV infection,Tobacco smoke,air pollutants-O3,SO2,
-Cold dry air, strong odors-trigger
12/07/21 SRP 4
Pathogenesis
AIRWAYS OBSTRUCTION
Small air way- smooth muscle encircling the airway lumen-
Broncho constriction
Cellular inflammatory infiltrate, excess mucus production,
edema of surrounding tissue
AIRWAYS INFLAMMATION,HYPERRESPONSIVENESS,AND
Remodeling.
Epithelial damage, sub epithelial collagen deposition with
basement membrane thickening and mucus gland and
smooth muscle hypertrophy
persistent airways inflammation and hyperresponsiveness
underlie the chronic basis of asthma
12/07/21 SRP 5
EARLY PHASE LATE PHASE
Takes place after 6- 8 hours
Occurs in ½ - 2 hrs.
Continued cellular infiltration
Mast cell degranulation
with release of cytokines &
occur inflammatory mediators
Prime mediators Prime mediators-ECF, NCF,
Histamine MBP
PAF Response- airway
hyperreactivity,capillary leak,
Response –
mucosal edema, mucous
bronchoconstriction plugging.
12/07/21 SRP 6
Clinical features of Asthma
• Dry cough, Expiratory wheeze, Chest
tightness and dyspnoe.
• Provoked by physical exertion/airway irritant
• Worse at night.
Reversible
12/07/21 SRP 7
Complications
• Hypoxic seizures
• Resp. Failure
• Death
12/07/21 SRP 8
Factors Modifying The Course Of
Asthma
• Poor outcome / Favoring Asthma • Favourable Outcome
– Allergic diathesis
– Wheezing < 3/ years
– LBW
– Male – Breast Fed Infants
– Very early onset
– Rhinitis
– Parental Asthma
– Recurrent exposure to triggers
– Exposure to Tobacco Smoke
12/07/21 SRP 9
Molds
Pollen
URI
Pets TRIGGERS Dust mites
Pest
12/07/21 SRP 10
Causes of wheeze ?
All that wheezes is not asthma !!
Differential diagnosis of asthma based on age
Infancy
1. Bronchiolitis
2. Aspiration syndromes (GER)
3. Congenital anomalies – vascular rings,
laryngeal webs/ cyst/ stenosis
4. CVS (L
12/07/21
R shunts
SRP
with CCF) 11
Older children
1. Foreign body aspiration
2. Sinusitis/ adenoids
3. Tuberculosis
4. Bronchiectasis, Cystic fibrosis
5. Vocal cord dysfunction
6. External airway compression
7. Interstitial lung disease
8. Hypersensitivity pneumonitis
12/07/21 SRP 12
Investigations
Asthma is a clinical diagnosis .
Peak expiratory flow meter- helps in diagnosis and assessment of
severity of asthma
[ ↑ of 60 l/min or ≥ 20% of pre bronchodilator PEF or diurnal variation
of ≥ 20%]
Above 6yrs spirometry – to confirm diagnosis.
Spirometry shows reversible and variable airflow limitation.
[ Low FEV1, FEV1 /FVC ratio < 0.8, an ↑ in FEV1≥ 12% or 200ml,post
bronchodilator]
12/07/21 SRP 13
Radiology
• Chest radiographs - often appear to be normal, aside from subtle and
nonspecific findings of hyperinflation
• Chest radiographs are helpful in identifying abnormalities that are
hallmarks of asthma masqueraders (e.g., aspiration pneumonitis,
hyperlucent lung fields in bronchiolitis obliterans), and complications
during asthma exacerbations (e.g., atelectasis, pneumothorax).
• Other tests, such as allergy testing to assess sensitization to inhalant
allergens, help with the management and prognosis of asthma.
12/07/21 SRP 14
Asthma Care
Goal
To achieve and maintain control of the clinical
manifestations of the disease for prolonged period,
Normal Activity
Prevent Sleep disturbance
Experience little to NO adverse effects of Drugs
12/07/21 SRP 15
Components
1. Develop patient / family / doctor partnership
2. Identify and reduce exposure to risk factors
3. Assess, treat, and monitor asthma
4. Manage asthma exacerbations
12/07/21 SRP 16
Levels of Asthma Control
Characteristic Controlled Partly Controlled Uncontrolled
Day time None or˂2 ˃ 2 episodes/week
symptoms episodes / week
Limitation of None Any 3 or more
activities features of partly
Nocturnal None Any controlled
symptoms / asthma present
awakening in any week
Need for reliever / None ˃ 2 /week
rescue treatment
Lung Function Normal ˂ 80% predicted or
(PEF or FEV1) personal best
Exacerbations None 1 or more /year One in any week
12/07/21 SRP 17
Management Approach Based on control
Level of control Treatment action
Controlled Maintain and find lowest controlling
step
Partly controlled Consider stepping up to gain control
Uncontrolled Step up until controlled
Exacerbation Treat as exacerbation
12/07/21 SRP 18
Step1 Step2 Step3 Step4 Step5
Asthma Education – Environmental control
As needed rapid As needed rapid acting ,ß2 - agonist
acting,ß2 -agonist
Select one Select one Add one or more Add one or both
Low dose inhaled Low dose ICS plus Medium or high Oral
ICS LABA dose ICS plus glucocorticosteroid
LABA
Leukotriene Medium or high Leukotriene Anti IgE treatment
modifier dose ICS Modifier
Low dose ICS plus Sustained release
LM theophylline
Low dose ICS
Plus sustained
release
theophylline
12/07/21 SRP 19
DRUGS
Controllers
• Glucocorticosteroids
• β2 Agonists
• Sodium cromoglycate/Nedocromil
• Antileukotrienes
• Immunomodulators
12/07/21 SRP 20
Releivers
• Short acting β2-agonists
• Anticholinergics
• Short-acting theophylline
• Epinephrine
12/07/21 SRP 21
Β2 Agonists
Binds to the beta2-adrenergic receptor,
producing smooth muscle relaxation
following adenylate cyclase activation and
increase in cyclic AMP ,producing functional
antagonism of bronchoconstriction.
12/07/21 SRP 22
SABA
• Inhaled SABA: • SYSTEMIC SABA:
• Salbutamol • ALBUTEROL
• Albuterol • TERBUTALINE
• Levalbuterol
• Pirbuterol
12/07/21 SRP 23
LABA
• Inhaled LABA:
• Formoterol
• Salmeterol
• Bambuterol
• Oral:
• Albuterol sustained release
12/07/21 SRP 24
Drugs – beta stimulants
• 1. Relax contracted bronchial smooth muscle
• 2. Prevent bronchial smooth muscle contraction by various
stimuli
• 3. Increase mucous clearance
• 4. Prevent mast cell mediator release
• 5. Prevent edema induced by histamine .
12/07/21 SRP 25
Potential Adverse Effects
• Tachycardia,
• Skeletal muscle tremor.
• Hypokalemia.
• Increased lactic acid.
• Headache.
• Hyperglycemia.
12/07/21 SRP 26
Drugs – STERIODS
• Mechanisms of action due to anti-inflammatory
properties
• Block late reaction to Allergen .
• Reduce airway hyper responsiveness.
• Inhibit cytokine production, adhesion protein activation, and
inflammatory cell migration and activation.
• Inhibit microvascular leakage
12/07/21 SRP 27
Inhaled (ICS):
• Beclomethasone dipropionate
• Budesonide
• Fluticasone propionate
• Flunisolide
• Triamcinolone acetonide
• Mometasone furoate
12/07/21 SRP 28
Systemic steroids
• Methylprednisolone
• Prednisolone
• Prednisone
• Hydrocortisone
12/07/21 SRP 29
Uses of steroids
• For short-term (3–10days) “burst”: to gain
prompt control of exacerbation in asthma
along with SABA.
• For long-term prevention of symptoms in
severe persistent asthma.
• Suppression, control, and Reversal of
inflammation.
12/07/21 SRP 30
Glucocorticoid Low Dose Medium Dose High Dose
Beclomethasone
42, 84 μg/puff (40 μg/puff HFA–propellant) 84–336 μg (2–8 puffs of 42 336–672 μg (8–16 puffs of 42 μg/puff or 4–8 >672 μg (> 16 puffs of 42
μg/puff or1–4 puffs of 84 puffs of 84 μg/puff) μg/puff or> 8 puffs of 84
μg/puff) μg/puff)
Budesonide
Turbuhaler (DPI) 200 μg/inhalation 200–400 μg (1–2 inhalations) 400–800 μg (2–4 inhalations) > 800 μg (>4 inhalations)
Respules (nebulizer) 250, 500 μg/vial 500 μg QD 1000 μg 2000 μg
Flunisolide
250 μg/puff (MDI) 500–750 μg (2–3 puffs) 1000–1250 μg (4–5 puffs) > 1250 μg (>5 puffs)
Fluticasone
44, 110, 220 μg/puff (MDI) 88–176 μg (2–4 puffs of 44 176–440 μg (4–10 puffs of 44 μg/puff or2–4 > 440 μg (>4 puffs of 110
μg/puff) puffs of 110 μg/puff or1–2 puffs of 220 μg/puff or > 2 puffs of 220
μg/puff) μg/puff)
Triamcinolone
100 μg/puff (MDI with spacer) 400–800 μg (4–8 puffs) 800–1200 μg (8–12 puffs) >1200 μg (> 12 puffs)
12/07/21 SRP 31
Adverse systemic steroids
• Reversible abnormalities in glucose
metabolism,
• Increased appetite,
• Fluid retention, weight gain,
• Facial flushing,
• Mood alteration,
• Hypertension,
• Peptic ulcer,
• Aseptic necrosis.
• Adrenocortical suppression
• Herpes virus infections,
• Varicella, tuberculosis,
12/07/21 SRP 32
Drugs – cromolyns
• Mast Cell Stabilization
• Inhibition of degranulation by a variety of stimuli, including cell-bound
IgE allergen.
• Interferes with chloride channel function.
• Inhibition of leukotriene production.
• No bronchodilator
12/07/21 SRP 33
Cromolyns Sodium and Nedocromil
Indications
• Long-term prevention of symptoms in mild persistent
asthma.
• may modify inflammation.
Preventive treatment prior to exposure to exercise or
known allergen
12/07/21 SRP 34
Methyl Xanthines
• Theophylline
• Deriphylline
• Aminophylline
12/07/21 SRP 35
Drugs – Methyl xanthines
MECHANISM OF ACTION
• Phosphodiesterase inhibition
• Adenosine R antagonist
• Anti inflammatory effect
• Inhibition of ca influx
• Increases strength of resp muscles-diaphragm
Therapeutic Advantages
Relaxes bronchial smooth muscle
Decreases mast cell mediator release
Increases mucocilliary clearance
Prevents microvascular leakiness
12/07/21 SRP 36
Methyl Xanthines – Adverse Effects
• Nausea,Vomiting,Head ache
• Seizures
• Tachycardia,Arrhythmias
12/07/21 SRP 37
Anticholinergics
Competitive inhibition of
muscarinic cholinergic
• Ipratropium receptors.
bromide
Reduces intrinsic vagal tone of
the airways.
May block reflex
DRUG OF CHOICE FOR bronchoconstriction secondary
BETA BLOCKER INDUCED to irritants or to reflux
BRONCHOSPASM esophagitis.
May decrease mucous gland
secretion.
12/07/21 SRP 38
Anticholinergics - Adverse Effects
• Drying of mouth & respiratory secretions
• Blurred vision
12/07/21 SRP 39
Leukotriene Receptor Antagonists (LTRA)
Selective competitive inhibitor of CysLT1
receptor.
ZAFIRLUKAST
MONTELUKAST – 4 mg OD.
12/07/21 SRP 40
Immunomodulators:
• Omalizumab (anti-IgE) is a monoclonal antibody
that prevents binding of IgE to the high-affinity
receptors on basophils and mast cells.
• Omalizumab is used as adjunctive therapy for
patients ≥12 years of age who have allergies and
severe persistent asthma .
• Anaphylaxis may occur
12/07/21 SRP 41
MDI drugs and dosage
MDI g / puff Interval in hours
Salbutamol 100 6-8
Terbutaline 250 6-8
Salmeterol 25 12
Ipratropium 20 8
Beclomethasone dipropionate 50/100/200 8 - 12
Budesonide 100/200 12
Fluticasone 25/50/125 12
Cromolyn 5mg/puff 6-8
12/07/21 SRP 42
Drug dosage – DPI
.
Drug Dose (mcg capsules) Interval (hours)
Salbutamol 200 6-8
Salmeterol 50 12
Beclomethasone 100/200 8-12
Budesonide 100/200 12
Fluticasone 100/250 12
12/07/21 SRP 43
THANK
YOU
12/07/21 SRP 45
THANK
YOU
12/07/21 SRP 47
NAEPP Classification Of Disease
Severity
DISEASE DAY NIGHT PEFR/or DIURNAL
SEVERITY SYMPTOM SYMPTOM FEV1 VARIATION
FEV1
MILD <3days/ wk <3nights/ mo >80% <20%
INTERMITTENT
MILD >3days/ wk 3-4 nights/ >80% 20 – 30%
PERSISTENT <1/day mo
MODERATE DAILY >1night/wk 60–80% >30%
PERSISTENT
SEVERE CONTINOUS FREQUENT <60% >30%
PERSISTENT
12/07/21 SRP 48
Stepwise Approach To Asthma Management
STEP 4 SEVERE HIGH DOSE ICS+LONG
PERSISTENT ACTING 2 AGONIST+ORAL
STEROIDS
STEP 3 MODERATE HIGH DOSE ICS OR LOW
PERSISTENT DOSE ICS+LONG ACTING 2
AGONIST
STEP 2 MILD LOW DOSE ICS OR INHALED
PERSISTENT CROMOGLYCOLOATE
STEP 1 MILD OCCASIONAL USE OF
INTERMITTENT RELIEVER MEDICATIONS
12/07/21 SRP 49
Severe persistent
High ICS+LABA,
Oral Steroids
MODERATE PERSISTENT
HIGH DOSE ICS OR
LOW DOSE ICS +LABA
STEP UP IF NOT MILD PERSISTENT STEP DOWN IF
LOW DOSE ICS OR CONTROLLED
CONTROLLED CROMOGLYCOLATE OR
LTRA
Mild Intermittent
No Daily medication
Short acting 2 Agonist
ACUTE EXACERBATIONS CAN OCCUR AT ANY STEP
FOR ACUTE EPISODE- INHALED 2 AGONIST+ANTICHOLINERGICS+
ORAL STEROIDS
12/07/21 SRP 50
12/07/21 SRP 51
Acute Asthma - Assessment of Severity
MILD- PS <3(PEFR >70) ; MOD. - PS 4-6 (PEFR 40 - 70) ; SEV.
- PS >6 (PEFR <40)
If wheezing absent , score > 3
Respiratory Rate
Accessory Muscle
Score Wheezing
< 6 yrs > 6 yrs Use
No apparent
0 < 30 < 20 None
activity
Terminal Questionable
1 31 - 45 21 - 35
Expiration increase
2 46 - 60 36 - 50 Entire Expiration Increase apparent
Inspiration &
3 > 60 > 50 Maximal activity
Expiration
Pulmonary score (PS)
12/07/21 SRP 52
Life Threatening Asthma – Red Flag Signs
H/ o recurrent episodes Accessory muscles
of wheeze acting.
Posture – sitting/ Wheeze / Silent chest
bending forward Tachycardia/bradycardia
Altered sensorium Cyanosis
Sao2 < 90%
Speech – sentences/
Pulmonary score>6.
phrases/ words
12/07/21 SRP 53
100% Oxygen 5-6/min
Assess Maintain SaO2 > 95%
Nebulised Salbutamol
*3
Nebulised Ipratropium
Establish IV access
Reassess IV hydrocortisone 10mg/kg stat
Good response Poor response
Admit in ICU
Continue Neb. 4th hrly
Aminophylline infusion 5mg/kg in 20 ml NS over 20 min
Avoid triggers
Mag.Sulphate 25mg/kg in 20ml NS over 20 min
Daily preventor therapy
Regular follow-up No response
Terbutaline 10g/kg stat 2 g/kg/hr
Look for
Metabolic derangements, Pneumonia, Pneumothorax
Worsens
Consider Mechanical Ventilation
12/07/21 SRP 54
Clinical Features
Typical features
Onset after 3yrs
Afebrile episodes
Personal atopy
Atopy/ asthma in parents
Exercise induced exacerbations
Absence of Seasonal variations
Nocturnal cough during periods without viral infections
Relief with bronchodilators
12/07/21 SRP 55
Peak Expiratory Flow Meter
Thermometer
Mini-wrights peak flow meter
• Uses:-
Diagnosis
Assessment of severity
Warning of impending attacks
Effectiveness of medication
Long term follow up
.
12/07/21 SRP 56
Spirometry
Most informative lung function test
Measures lung volumes hence the physiological status.
Done using spirometers
Indices measured are-
• Forced vital capacity( FVC)
• Forced expiratory Volume
in one sec (FEV1)
• FEV1 / FVC ratio
• Forced expiratory flow
measurement
(FEF – 25-75%)
Influenced by age,race,sex,wt,ht
12/07/21 SRP 57
