Dr. KANUPRIYA CHATURVEDI

104/18/23

Chronic disease of the airways that may cause

Wheezing Breathlessness Chest tightness Nighttime or early morning coughing

Episodes are usually associated with widespread, but variable, airflow obstruction within the lung that is often reversible either spontaneously or with treatment.

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Allergens Infections Exercise Abrupt changes in the weather Exposure to airway irritants, such as tobacco smoke

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Recurrent asthma episodes, involving ◦Shortness of breath ◦Coughing ◦Wheezing ◦Chest pain or tightness

Range in severity from ◦Mild intermittent◦Severe persistent

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Increases risk for early death Compromises child’s quality of life

Affects family’s quality of life Increased costs associated with Increased utilization of health care

504/18/23

Most common cause of school absence◦ An average of 9.7 days per year for asthma

Most prevalent cause of childhood disability (long-term reduction in ability to do normal activities)

In 1994-95, 1.4% of U.S. children experienced some disability due to asthma◦ This is 21% of all children with asthma

SES disadvantage doubles rate of disability Children with asthma have higher rates of

social and emotional problems

604/18/23

Asthma is the most common chronic disease among children

It has increased at epidemic rates since the early 1980s

Most common cause of ED visits, hospitalization and missed school days

In past 2 decades, African American children had 2-4 times more ED visits than other races

Studies show a rise in worldwide prevalence Seems to be more prevalent in affluent

nations

704/18/23

Etiology of asthma is due to the interaction of environmental and genetic factors◦ Atopy, the genetically inherited susceptibility to

asthma, cannot account for epidemic. Probably NOT due to outdoor air quality Indoor air contaminants may be a factor

◦ Tighter construction trapping contaminants.◦ Children spending more time indoors.

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10.1% Overall10.1% Overall

904/18/23

Low-income populations, minorities, and children living in inner cities experience more ED visits, hospitalizations, and deaths due to asthma than the general population.

The burden of asthma falls disproportionately on non-Hispanic black, American Indian/Alaskan Native and some Hispanic populations.

1004/18/23

By gender◦Males 0 – 17 years are more likely than

girls to have asthma or experience an asthma attack

By race/ethnicity◦Higher for Black non-Hispanic children◦Higher for Hispanic children

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Current asthma prevalence is higher among◦children than adults◦boys than girls◦women than men

Asthma morbidity and mortality is higher among◦African Americans than Caucasians.

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◦Groups 6 - 7 Yrs 13-14 Yrs

◦ Wheeze 5.6 % 6.0% (0.8 - 14.6)

(1.6 - 17.8)

◦ > 4 attacks 1.5% 1.6% (0.1 - 4.7) (0.5 - 3.5)

◦ Night Cough 12.3% 14.1% (3.3 - 27) (3.8 - 32.2)

◦ Ever had Asthma 3.7% 4.5% (1.0 - 14.4) (1.12.4)

Shah, Amdekar, Mathur, IJMS,6,2000,213-22

1304/18/23

0%10%20%30%40%50%60%70%80%90%

100%

Past BD NocturnalCough

RecentWheeze

DiagnosedAsthma

ExerciseInduced

Urban

Rural

1404/18/23

8.40%

2.52%

5.80%

0.00%

1.00%

2.00%

3.00%

4.00%

5.00%

6.00%

7.00%

8.00%

9.00%

Total Boys Girls

Source - H. Paramesh, E. Cherian. Ind. Joul of Pediatr 2002

1504/18/23

1604/18/23

Parental Asthma Allergy Atopic dermatitis Allergic rhinitis Food allergy Inhalant allergen sensitization Food allergen sensitization

1704/18/23

Severe lower respiratory tract infections Wheezing apart from colds Male gender Low birth weight Tobacco smoke exposure Exposure to chlorinated swimming pools Possible use of Acetaminophen

1804/18/23

Common Viral infections Aeroallergens Animal dander Dust mite Cockroaches Molds Pollen

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Air pollutants Ozone Sulfur dioxide Particulate matter Dust Tobacco smoke Strong/ noxious fumes Cold, dry air Exercise

2004/18/23

Occupational exposures Farm and barn exposure Formaldehyde, paint fumes

Crying, laughter, hyperventilation

Co morbid conditions: Rhinitis, Sinusitis

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Symptoms:Intermittent dry coughExpiratory wheezingShortness of breathChest tightnessChest painFatigueDifficulty keeping up with peers in physical activities

2204/18/23

Signs:Expiratory wheezingProlonged expiratory phaseDecreased breath soundsCrackles/ ralesAccessory muscle useNasal flaringAbsence of wheezing in severe casesPulses paradoxus

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Spirometry:

Feasible in children >6 years of ageMonitoring Asthma and efficacy of treatmentMeasures FVC, FEV 1 and FEV1/FVC RatioNormal values for children available on the basis of height, gender and ethnicity.

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Airflow Limitation:Low FEV1FEV1/ FVC ratio < 0.80Bronchodilator response to β-agonist:Improvement in FEV1 ≥ 12%Exercise challenge:Worsening of FEV1 ≥ 15%Daily peak flow or FEV1 AM-PM variation ≥ 20%

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2704/18/23

Often normalHyperinflationHelpful in identifying masqueraders

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2904/18/23

Asthma severity: Directs initial level of therapy Determined at the time of diagnosis Categories: Intermittent, Persistent Determined by the most severe level of symptoms Asthma control: Important for adjusting

therapy Regular Clinic visits every 2-6 weeks until good

control established Two or more Asthma check ups per year for

maintaining Asthma control

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Achieve and maintain control of symptoms

Maintain normal activity levels, including exercise

Maintain pulmonary function as close to normal levels as possible

Prevent asthma exacerbations Avoid adverse effects from asthma

medications Prevent asthma mortality

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Develop with a physician Tailor to meet individual needs Educate patients and families about all aspects of plan◦ Recognizing symptoms◦ Medication benefits and side effects◦ Proper use of inhalers and Peak Expiratory Flow

(PEF) meters

3604/18/23

Breathless at rest Hunched forward Speaks in words rather than complete sentences

Agitated Peak flow rate less than 60% of normal

3704/18/23

Have an individual management plan containing◦ Your medications (controller and quick-relief)◦ Your asthma triggers◦ What to do when you are having an asthma

attack Educate yourself and others about

◦ Asthma Action Plans ◦ Environmental interventions

Seek help from asthma resources Join an asthma support group

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Asthma action plan for management of exacerbation

Regular follow up visits Monitor lung functions annually Improve adherence to treatment

3904/18/23

Eliminate/ reduce environmental exposures Tobacco smoke elimination/ reduction Allergen exposure elimination/ reduction Treat co morbid conditions: Rhinitis,

Sinusitis, GER

4004/18/23

Initiate with higher level controller therapy Step-down, once good control is achieved If child has had well controlled asthma for at

least 3 months, consider decreasing dose or number of controller medications.

Step up for poorly controlled asthma

4104/18/23

All persistent Asthmatics require daily controller medications

4204/18/23

Treatment of choice for persistent Asthma Improve lung function Reduce use of rescue medicines Reduce ED visits, hospitalizations May lower the risk of death due to Asthma

4304/18/23

Used mainly in treatment of exacerbations Rarely in patients with severe disease Common: Prednisolone, Prednisone,

Methyprednisolone When used in long term, cause adverse

effects

4404/18/23

Salmeterol, Formoterol Not used as monotherapy Major role as ad-on agents with ICS LABA use should be stopped once optimal

Asthma control is achieved

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Leukotriene synthesis inhibitor: Zileuton (Not approved for children < 12 years)

Leukotriene Receptor Antagonists: Montelukast, Zafirlukast

4604/18/23

Cromolyn, Nedocromil Inhibit exercise induced bronchospasm Can be used in combination of SABA for

exercise induced bronchospasm

4704/18/23

Can reduce Asthma symptoms and need for SABA use

Narrow therapeutic window Not used as first line anymore May be used in corticostroid dependent

children Can cause cardiac arrhythmias, seizures

and death

4804/18/23

Anti IgE monoclonal antibody Blocks IgE mediated allergic response Approved for children > 12 years with

moderate to severe Asthma Given sub cutaneously every 2-4 weeks

4904/18/23

Short Acting Beta Agonists: Albuterol, Levalbuterol, Terbutaline, Pirbuterol

Drugs of choice for acute Asthma symptoms Overuse may be associated with increased

risk of death Use of at least 1 MDI/ month or at least 3

MDI/ year indicates inadequate Asthma control

Anticholinergic Agents: Ipratropium bromide Used in combination with Albuterol

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Dyspnea at rest Peak flows < 40% of personal best Accessory muscle use Failure to respond to initial treatment

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Brief assessment Administration of SABA: Repeated doses or

continuously, every 20 mins. for 1 hour Inhaled anticholinergic in addition of SABA Oxygen: Hypoxemia/ moderate to severe

exacerbation Systemic Corticosteroids: Instituted early

for moderate to severe exacerbation and failure to respond to early treatment

Intramuscular beta agonist in severe cases.

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