• 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.

Asthma Inflammation – Cells and Mediators

Mechanism – Asthma Inflammation

Source: Peter J. Barnes, MDSource: Peter J. Barnes, MD

Asthma Inflammation

Factors Influencing the Development and Expression of Asthma

Host factors –

• Genetic

1. Genes predisposing to atopy

2. Genes predisposing to airway hyper responsiveness

• Obesity

• Sex

Environmental factors –

• Allergens –

1. Indoor – Domestic mites, furred animals (dogs, cats, mice),

cockroach allergens, fungi, molds, yeasts.

2. Outdoor – Pollens, fungi, molds, yeasts.

• Infections (predominantly viral)

• Occupational sensitizers

• Tobacco smoke

1. Passive smoking

2. 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.

Fear of steroids

Heavynebulisation

Choice of right device

Oral vs. Inhaled Lack of knowledge &

time vs. more patients

Poor patient/parent

education

Cough or Wheeze

Heterogenous Disease/varying

phenotypes

Acceptance of Asthma

diagnosis/label

Underdiagnosed/Misdiagnosed

Issues in Pediatric Asthma

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 ASTHMA by KHUBCHANDANI 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 ASTHMA by KHUBCHANDANI 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?

CHILDHOOD ASTHMA by KHUBCHANDANI R.P. et al

If the answer is ‘yes’ to any of the questions, a diagnosis of asthma should be considered

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 StatusCHILDHOOD ASTHMA by KHUBCHANDANI 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 ASTHMA by KHUBCHANDANI 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 ASTHMA by KHUBCHANDANI 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 20032. CHILDHOOD ASTHMA by KHUBCHANDANI 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 associatedlower 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

Differential diagnosisAge Common Uncommon Rare

Less than6 months

BronchiolitisGastro-esophagealreflux

Aspiration pneumoniaBronchopulmonary dysplasiaCongestive heart failureCystic fibrosis

AsthmaForeign body aspiration

6 months -2 years

BronchiolitisForeign bodyaspiration

Aspiration pneumoniaAsthmaBronchopulmonary dysplasiaCystic fibrosisGastro-esophageal reflux

Congestive heart failure

2 - 5 years

AsthmaForeign bodyaspiration

Cystic fibrosisGastro-esophageal refluxViral pneumonia

Aspiration pneumoniaBronchiolitisCongestive heart failureGastro-esophageal reflux

IPAG 2007

Co morbid conditions

• Allergic RhinitisColds, ear infectionsSneezing in the morningBlocked nose, snoring, mouth breathing

• Gastro esophageal reflux (GER)Nocturnal cough followed by vomiting• Eczema

Early Childhood Asthma Diagnosis (below 6 years)

Diagnostic Tool

Findings that Support Diagnosis

Differential diagnosis

The diagnosis of asthma in children under age 6 is primarilyone of exclusion.

Physical examination

If the child does not appear acutely ill and is growing, andthere is no evidence specifically indicating another cause ofsymptoms, a trial of therapy is warranted.

Trial of therapy (bronchodilators)

Improvement with treatment supports a diagnosis of asthma.

Frequent reassessment

Health care professionals should always be prepared toreconsider the diagnosis if management is ineffective or ifthe clinical situation changes.

IPAG 2007

Childhood Asthma Diagnosis (6-14 years)

IPAG 2007

Childhood Asthma Diagnosis (6-14 years)

IPAG 2007

NORDIC CONSENSUSConfirm Asthma if,

If the child is having 3 attacks of airway obstruction in last 1 yr.

If the child gets 1 attack of asthmatic symptoms after the age of 2 yrs.

Irrespective of age in an attack in children with allergy (eczema, food allergy etc.) or history of atopy.

If the child does not become free of symptoms when infection has ceased or has persistent symptoms for

more than a month.

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

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

Asthma Treatments

• Classified into Controllers and Relievers

• Controllers – medications to be taken on daily long term basis.

• Relievers – medications to be used on as-needed basis to

relieve symptoms quickly.

Asthma management and prevention

• The goals for successful management of asthma are

1. Achieve and maintain control of symptoms

2. Maintain normal activity levels, including exercise

3. Maintain pulmonary function as close to normal as possible

4. Prevent asthma exacerbations

5. Avoid adverse effects from asthma medications

6. Prevent asthma mortality

Assess, Treat and Monitor Asthma –

• The goal of asthma treatment can be reached in most patients through a continuous cycle that involves – assessing, treating and monitoring asthma.

• Each patient should be assessed to establish his/her current treatment regimen, adherence to the current regimen, and level of asthma control.

• Each patient is assigned to one of five treatment steps.

• At each treatment step, reliever medication should be provided for quick relief of symptoms as needed.

To summarize…

• Asthma is an inflammatory illness

• Diagnosis of asthma is clinical, and relies on history

• All asthma does not wheeze

• In children < 3 yrs, WALRI is an important differential diagnosis

• 2 out of 3 children outgrow their asthma

• A family history of asthma / atopy increases risk of asthma

Diagnosis

To summarize…

• Patient education is a very important part of asthma management

• Drugs control, but do not cure asthma

• Clinical grading over time, decides long term management plan

• Mild intermittent asthma does not merit controllers

• Inhaled steroids are mainstay of long term asthma management

• Treatment should be stepped up or stepped down depending upon patient

response

Long term management

Thank You