The PRACTALL consensus report describes asthma in children as “repeated attacks of airway obstruction and intermittent symptoms of increased airway responsiveness

The PRACTALL consensus report describes asthma in children as “repeated attacks of

airway obstruction and intermittent symptoms of increased airway responsiveness to

triggering factors, such as exercise, allergen exposure and viral infections”.

DIAGNOSIS AND TREATMENT OF ASTHMA IN CHILDHOOD: A PRACTALL CONSENSUS REPORT

L. B. Bacharier, A. Boner, K.-H. Carlsen, P. A. Eigenmann, T. Frischer, M. Gçtz, P. J. Helms, J. Hunt, A. Liu, N. Papadopoulos, T. Platts-Mills, P.

Pohunek, F. E. R. Simons, E. Valovirta, U. Wahn, J. Wildhaber – The European Pediatric Asthma Group Allergy 2008; 63: 5

The PRACTALL consensus report describes asthma in children as “repeated attacks of

airway obstruction and intermittent symptoms of increased airway responsiveness to

triggering factors, such as exercise, allergen exposure and viral infections”.

DIAGNOSIS AND TREATMENT OF ASTHMA IN CHILDHOOD: A PRACTALL CONSENSUS REPORT

L. B. Bacharier, A. Boner, K.-H. Carlsen, P. A. Eigenmann, T. Frischer, M. Gçtz, P. J. Helms, J. Hunt, A. Liu, N. Papadopoulos, T. Platts-Mills, P.

Pohunek, F. E. R. Simons, E. Valovirta, U. Wahn, J. Wildhaber – The European Pediatric Asthma Group Allergy 2008; 63: 5 This definition becomes more

difficult to apply confidently in infants and children of preschool age who present with recurrent

episodes of coughing and/or wheezing.

1 2 3 4 5 6 7 8 9 10 11 12 13 Age (years)

Incidence of pediatric wheezing18 -

16 –

14 -

12 -

10 -

8 -

6 -

4 -

2 -

0

PRACTALL CONSENSUS REPORT: INCIDENCE AND PREVALENCE OF PEDIATRIC

ASTHMA

Incid

en

ce (

in %

)

1 2 3 4 5 6 7 8 9 10 11 12 13 Age (years)

Incidence of pediatric wheezing18 -

16 –

14 -

12 -

10 -

8 -

6 -

4 -

2 -

0


ASTHMA

Incid

en

ce (

in %

) According to prospective birth cohort studies, up to 50% of all

infants and children younger than 3 years will have at least 1 episode

of wheezing. However, 60% of children with infantile wheeze will

be healthy at school age.


ASTHMA

***

*

* **

* * ** * *

**

*

* ** * * * *

**

***

A COMMUNITY-BASED STUDY OF EPIDEMIOLOGY OF ASTHMAYunginger ARRD 1992, 146: 888

%

4000 –

3000 –

2000 –

1000 –

0 <1 1-4 5-9 10-14 15-29 30-49 >50yrs

Annual incidence rates of asthma per 100.000person-years by sex and age

females

males From Jan 1, 1964 through Dec 31, 1983

Population-based computer-linked medical diagnosis

A COMMUNITY-BASED STUDY OF EPIDEMIOLOGY OF ASTHMAYunginger ARRD 1992, 146: 888

%

4000 –

3000 –

2000 –

1000 –

0 <1 1-4 5-9 10-14 15-29 30-49 >50yrs

Annual incidence rates of asthma per 100.000person-years by sex and age

females

males From Jan 1, 1964 through Dec 31, 1983

Population-based computer-linked medical diagnosis

Asthma shows its peak of incidence

in the first 1-4 years of life and 80% of asthma has its onset before the age of 4

years.

Hypothetical peak prevalence for 3 different wheezing phenotypes

PRACTALL CONSENSUS REPORT:

WHEEZING PATTERNS


WHEEZING PATTERNS

1.Transient (early) wheezing

2.Nonatopic wheezing

3.Persistent asthma

4.Severe intermittent wheezing


ASTHMA PHENOTYPES

No


AGE AND ASTHMA PHENOTYPES Preschool childrenPreschool children (ages 3 to 5 years)

Virus-induced asthma > allergen-induced asthma > exercise induced asthma

School childrenSchool children (ages 6 to 12 years)Allergen-induced asthma > virus-induced asthma >

exercise induced asthma

AdolescentsAdolescents (older than 12 years)Allergen-induced asthma > virus-induced asthma >

exercise induced asthma

1) According to the PRACTALL consensus report, age and triggers can be used to define different phenotypes of disease.

2) These phenotypes are likely to be useful because they recognize the heterogeneity of childhood asthma.

3)Asthma phenotypes do not represent separate diseases, but are part of the

“asthma syndrome”.

PRACTALL CONSENSUS REPORT: ASTHMA

PHENOTYPES


PHENOTYPES

1) Allergen-induced asthma is more common in school-age children than in children of preschool age.

2) If a clinically relevant association between exposure and symptom occurrence is suspected, allergen-induced asthma is the likely diagnosis.

3)The risk of acquiring atopy and allergic asthma continues during adolescence.

Allergen-induced asthma


PHENOTYPES 1) Exercise-induced asthma can be a unique

phenotype in children aged 3 to 5 years. 2) It may be the primary clinical manifestation in

patients with mild intermittent disease (ie, isolated exercise-induced asthma).

3) Patients with isolated exercise-induced asthma are free of symptoms for extended periods in the absence of triggers.

4)Asthma symptoms in isolated EIA are frequently reported in association with viral infections of the upper respiratory tract, though.

Exercise-induced asthma

PREVALENCE OF EXERCISE-INDUCED ASTHMA IN

CHILDREN

In the general population is between 6% and 13%.

Among adolescent athletes EIA estimates reach 12%.

EIA is found in up to 90% of asthmatics and in EIA is found in up to 90% of asthmatics and in up to 40% of patients with allergic up to 40% of patients with allergic rhinitis. rhinitis.

EIA is usually more prevalent in childrenmore prevalent in children than in adults, most likely because children are physically more active.

PREVALENCE OF EXERCISE-INDUCED ASTHMA IN

CHILDREN

In the general population is between 6% and 13%.

Among adolescent athletes EIA estimates reach 12%.

EIA is found in up to 90% of asthmatics and in EIA is found in up to 90% of asthmatics and in up to 40% of patients with allergic up to 40% of patients with allergic rhinitis. rhinitis.

EIA is usually more prevalent in children than in adults, most likely because children are physically more active.

It is very likely that EIA It is very likely that EIA may frequently go may frequently go

undiagnosed.undiagnosed.

1) It is estimated that 91% of individuals with EIA have a history of asthma or allergy, making it the premier risk factor for EIA.

2)A child’s response to exercise may change markedly from day to day.

3)Response depends on the mode of exercise (eg, treadmill running, biking on ergometer, swimming), environmental conditions, and the child’s airway responsiveness that in turn may be affected by viral infections, exposure to allergens, and the current use of medications.

DETERMINANTS OF AND RISK FACTORS FOR EXERCISE-INDUCED

ASTHMA

DETERMINANTS OF AND RISK FACTORS FOR EXERCISE-INDUCED

ASTHMA 4)The severity of bronchospasm in EIA is

believed to be related to the level of ventilation, to heat and water loss from the respiratory tree, and the rate of airway rewarming and rehydration after exercise.

5)Reduction of the temperature and humidity of the inspired air enhances bronchoconstriction caused by isocapnic hyperventilation.


PHENOTYPES Virus-induced asthma

1)Viral infections are the most common trigger of wheezing in preschool children and are still very frequent among school-age children.

2) If symptoms are usually preceded by a cold, are transient and disappear completely between episodes, virus-induced asthma is the most likely diagnosis according to the consensus report.


PATHOPHYSIOLOGYInteractions between airway tissue damage in early life caused by viral infections and inhalant allergens in asthma etiology.

Interactions between airway tissue damage in early life caused by viral infections and inhalant allergens in asthma etiology.

Low TH1 competence during infancy is associated with

increased risk for respiratory infection and respiratory

allergy.


PATHOPHYSIOLOGY


DIAGNOSIS

1.Asthma should be suspected in any suspected in any infantinfant with recurrent wheezingrecurrent wheezing and coughingcoughing episodes.

2.2.DiagnosisDiagnosis is often only possible through long-term follow-up, observations of the child´s response to bronchodilator response to bronchodilator and/or anti-inflammatory treatmentand/or anti-inflammatory treatment and consideration of the extensive differential diagnoses.

There should be an identifiable trigger usually a viral infection

Airways obstruction is reversible with bronchodilators

Usually more than 3 episodes

TO DIAGNOSE ASTHMA IN INFANTS THINK OF THE “3R”

Reactivity

Reversibility

Recurrence

Finder Curr. Probl. Pediatr. 1999; 29: 65


CASE HISTORYWheezing and/or coughing.Specific triggers, such as exposure to passive

smoke or cold air, pets, humidity, mold and dampness, respiratory infections, exercise/activity, coughing after laughing or crying.

Altered sleep patterns (ie, awakening, night cough, sleep apnea).

Number of exacerbations in the past year. Nasal symptoms, including runny nose,

itching, sneezing, and blocking.

In all children, ask about:

Noisy breathing or vomiting associated with cough.

Retractions of the chest.

Difficulty with feeding (eg, grunting sounds, poor sucking.

Changes in respiratory rate.

In infants (younger than 2 yrs), ask about:


CASE HISTORY

Shortness of breath (day or night).Fatigue (eg, decrease in play activity compared with

peers, increased irritability. Avoidance of other activities, such as sleep out or

visit to friends with pets.Complaints about not feeling well.Poor school performance or school absences.Reduced frequency or intensity of physical activity

(eg, in sports or gym classes).Specific triggers (eg, sports, exercise/activity.)

In children (older than 2 yrs), ask about:


CASE HISTORY

Shortness of breath (day or night).Fatigue (eg, decrease in play activity compared with

peers, increased irritability. Avoidance of other activities, such as sleep out or

visit to friends with pets.Complaints about not feeling well.Poor school performance or school absences.Reduced frequency or intensity of physical activity

(eg, in sports or gym classes).Specific triggers (eg, sports, exercise/activity.)

In children (older than 2 yrs), ask about:


CASE HISTORY

Adolescents should also be asked if they smoke.

PHYSICAL EXAMINATION

Listening to forced expiration and a nasal examination

..

atopic eczema or dermatitisdry skindark rings under the eyes (allergic shiners)irritated conjunctivaepersistent edema of the nasal mucosa,

nasal discharge,allergic salut and allergic crease on the

bridge of the nose.

Key clinical signs suggesting an atopic phenotype Key clinical signs suggesting an atopic phenotype include:include:Key clinical signs suggesting an atopic phenotype Key clinical signs suggesting an atopic phenotype include:include:

ASSESSING LUNG FUNCTION

FEV1

FEV1/FVC

FEF25-75

ASSESSING LUNG FUNCTION

FEV1

FEV1/FVC

FEF25-75

An increase in (FEV1) of >12% suggests a

significant bronchodilation.

OTHER TESTS

a)Exercise testing

b)Exhaled nitric oxide

c)Eosinophil counting

d)Measures of bronchial hyperresponsiveness

e)Skin Prick Tests

f)Serum specific IgE

OTHER TESTS

a)Exercise testing

b)Exhaled nitric oxide

c)Eosinophil counting

d)Measures of bronchial hyperresponsiveness

e)Skin Prick Tests

f)Serum specific IgE

In vitro testing for allergen-specific IgE does not provide

more accurate results than skin prick testing but may be useful if skin prick testing cannot be

performed.

Aspiration of a foreign body.

Cystic fibrosis.

Structural abnormalities.

Aggravating factors, such as gastroesophageal reflux and rhinitis, must be excluded.

DIFFERENTIAL DIAGNOSIS AND COMORBIDITIES

PRACTALL CONSENSUS REPORT: PHARMACOLOGIC MANAGEMENT OF

PEDIATRIC ASTHMA

Control of symptoms.

Prevention of exacerbations.

To allow the child to maintain normal activities.

Without producing possible adverse medication side effects.

Goals of pharmacotherapy

DEFINING AND EVALUATING ASTHMA CONTROL

Daytime symptoms twice or less per week

No limitations of activities because of asthma.

Night-time symptoms 0 to 1 per month (0-2 per month if child is 12 years or older).

Reliever/rescue medication use is twice or less per week.

Normal lung function (if able to measure).

0 to 1 exacerbations in the last year.

Asthma is well controlled when all of the following are achieved and maintained:

RELIEVER MEDICATIONS

a) Short-acting ß-2 agonists

b) Ipratropium bromide

The consensus report stresses that reliever medications are taken as

needed for immediate relief of acute symptoms and before exercise to

prevent exercise-induced bronchospasm.

According to the consensus report, controller medications decrease the swelling and inflammation in the airways and may reduce mucous buildup.

Medications for long-term control should be taken daily to help maintain control of asthma and prevent exacerbations.

The main goal of regular controller therapy is to reduce bronchial inflammation.

CONTROLLER MEDICATIONS: (Inhaled corticosteroids - Leukotriene receptor

antagonists Long-acting beta-agonists)

ALGORITHM OF PREVENTIVE PHARMACOLOGIC TREATMENT FOR ASTHMA IN CHILDREN >2 YEARS OF AGE (PRACTALL

GUIDELINES) Bacharier Allergy 2008; 63: 5

ASTHMA TREATMENT IN CHILDREN AGED 0 TO 2 YEARS

A diagnosis of asthma should be considered if more than 3 episodes of reversible bronchial obstruction have been documented within the previous 6 months.

Intermittent ß2 agonists are the first choice.

Leukotriene Receptor Antagonists (LTRAs) have been shown to reduce asthmatic episodes in children aged 2 to 5 years, and there is some evidence that they may be beneficial in children 2 years and younger.


A daily controller therapy with LTRAs for viral-induced asthma (long- or short-term treatment) should be considered.

Nebulized or inhaled (metered-dose inhaler [MDI] and spacer) corticosteroids can be used as daily controller therapy for persistent asthma, especially if severe or requiring frequent oral corticosteroid therapy.


Evidence of atopy/allergy lowers the threshold for use of ICS and they may be used as first-line treatment in such cases.

Use of oral corticosteroids (eg, 1-2 mg/kg prednisone) for 3 to 5 days during acute and frequently recurrent obstructive episodes is considered.

MANAGEMENT OF ACUTE ASTHMA EPISODES

Inhaled short-acting ß2 agonists (spacer): Two to four puffs (200 µg salbutamol equivalent) every 10 to 20 minutes for up to 1 hour. Children who have not improved should be referred to a hospital.

Nebulized ß2 agonists: 2.5 to 5 mg salbutamol equivalent can be repeated every 20 to 30 minutes.

Ipratropium bromide: This should be mixed with a nebulized ß2 agonist solution at 250 µg/dose and given every 20 to 30 minutes.

MANAGEMENT OF ACUTE ASTHMA EPISODES

High-flow O2 (if available) to ensure normal oxygenation.

Oral and IV glucocorticosteroids are of similar efficacy. Steroid tablets are preferable to inhaled steroids. A dose of 1 or 2 mg/kg prednisone or prednisolone should be given; treatment for up to 3 days is usually sufficient.

LISTS COMMON ALLERGENS AND POTENTIAL

AVOIDANCE STRATEGIES Allergen

Pets

Avoidance measure

Remove pet and clean home, especially carpets and upholstered surfaces.Encourage schools to ban pets

Comments

Allergen levels will typically take up to 6 months after removal of the pet from the household to fall enough to reduce asthmatic reactions. However, there is very little evidence that not having a pet will decrease the risk of sensitization.


AVOIDANCE STRATEGIES Dust mites

Avoidance measureWash bedding and clothing

in hot water every 1–2 weeks at >56°C.

Freeze stuffed toys once per week.

Encase mattress, pillows and quilts in impermeable covers.

Use dehumidifying device and ventilate room regularly.


AVOIDANCE STRATEGIES Cockroaches

Avoidance measureClean home. Use professional pest

control. Encase mattress and

pillows in impermeable covers.


AVOIDANCE STRATEGIES Mold Avoidance measure

Wash moldy surfaces with weak bleach solution.

Use dehumidifying equipment.

Fix leaks. Remove carpets.Use High Efficiency Particle

Arrestor filtration.

IMMUNOTHERAPY

A.Subcutaneous immunotherapy has been shown to be effective in allergic asthma.

B.Efficacy in young children younger than 5 years is less well documented for sublingual immunotherapy.

C.Anti-IgE antibodies. Omalizumab licensed for children 12 years and older with severe, allergic asthma and proven IgE-mediated sensitivity to inhaled allergens is administered via subcutaneous injection every 2 to 4 weeks, depending on patient weight and total serum IgE level.

NON-PHARMACOLOGICAL MANAGEMENT

OF ALLERGEN-INDUCED ASTHM

Prevention

Primary preventionPrimary prevention: Elimination of any risk or etiological factor before it causes sensitization.

Secondary preventionSecondary prevention: Diagnosis and therapy at the earliest point in disease development.

Tertiary preventionTertiary prevention: Limitation of disease effect


OF ALLERGEN-INDUCED ASTHM

Avoidance of allergens

Exposure to allergens leads to sensitization.

Typical avoidable allergens include: - pets, - dust mites, - mold, - cockroaches,and - foods.


OF ALLERGEN-INDUCED ASTHMAAvoidance of triggersAvoidance of triggers should be part of the

general strategy for asthma management.Key avoidable triggers are tobacco smoke,

other irritants, and some allergens.Tobacco smoke should be eliminated from

the environment of all children.Infections and stress should be avoided.Physical exercise, although a possible

trigger itself, should be encouraged when appropriate.

Controller Therapy: Inhaled corticosteroids

A first-line treatment for persistent asthma.Should be introduced as initial maintenance

treatment when asthma control is inadequate. Atopy and poor lung function can predict favorable

response.If control is inadequate on low dose, identify

reasons. If indicated, an increased ICS dose or additional

therapy with LTRAs or LABAs should be considered.Effect in older children disappears as soon as

treatment is discontinued.New evidence does not support a disease-modifying

role after cessation of treatment in preschool children.

PHARMACOLOGIC MANAGEMENT OF ALLERGEN-INDUCED ASTHMA

Controller Therapy: Leukotriene receptor antagonists

Alternative first-line treatment for persistent asthma.

Evidence supports LTRA as initial controller therapy for mild asthma in children with allergic asthma.

Younger age (younger than 10 years) and high levels of urinary leukotrienes can predict favorable response.

Therapy for patients who cannot or will not use ICS.Useful also as add-on therapy to ICS: Different and

complementary mechanisms of action. Suggested for viral-induced asthma in young

children.Benefit shown in children as young as 6 months.May be particularly useful if the patient has

concomitant rhinitis.


Controller therapy: Long-acting ß-agonists

Add-on to ICS for partially controlled/uncontrolled asthma.

Efficacy not as well documented in children.Use should be restricted to add-on therapy

to ICS, when indicated.Combination LABA/ICS therapies may be

licensed for use in children older than 4 or 5 years.


IMMUNOTHERAPYCombination of immunotherapy with other

therapies allows a broad therapeutic approach that addresses the pathophysiologic mechanism of allergy.

Early intervention with immunotherapy may prevent the progression from monosensitization to polysensitization.

Subcutaneous immunotherapy has been shown to be effective in allergic asthma in some patients.

Effective sublingual immunotherapy may be an attractive alternative to injection.

Injection immunotherapy should only be performed in a proper environment.

ANTI IGE ANTIBODIES

Benefit-to-risk ratio of this relatively new agent is being defined.

Licensed for children 12 years of age and older with severe, allergic asthma and proven IgE-mediated sensitivity to inhaled allergens

Asthma education is an integral part of asthma management:

Identification and avoidance of triggers.

Understanding the uses of prescribed medications, and the importance of compliance and monitoring.

Proper use of inhalation devices.

PRACTALL CONSENSUS REPORT:EDUCATIONEDUCATION

Physical examination should include regular assessment of the child´s height and weight, along with respiratory signs and symptoms.

Lung function measurement.

The nasal airway should also be assessed.

PRACTALL CONSENSUS REPORT:MONITORINGMONITORING

Documents

The PRACTALL consensus report describes asthma in children as “repeated attacks of airway obstruction and intermittent symptoms of increased airway responsiveness