Approach to Chronic wheezing & asthma an update 2013

Approach toChronic Wheezing & Asthma

Mostafa Moin MD Professor of Allergy & Clinical Immunology

Immunology , Asthma & Allergy Research Institute

( IAARI )

Children Medical Center Tehran University of Medical Sciences

1392 2013

وخرد جان خداوند ” “بنام

دکتر ابوالحسن ”“فرهودی

بنيانگذار آلرژي و ايمونولوژي

باليني در ايران

ياد و خاطره استاد گرامي باد

” العليم “وهوالحكيم

The Prevalence of Wheezing in Pre-School Children

Atopic (n=94)Non-atopic (n=59)

8070

60

50

40

30

20

10

01 2 3 4 5 6 7 8 9 10 11 12 13

Age (years)

Prevalence (%)

Illi S, von Mutius E, Lau S, et al. Perennial allergen sensitisation early in life and chronic asthma in children: a birth cohort study. Lancet. 2006;368(9537):763–770

≥50%

“ a continuous, high pitched musical sound coming from the chest”

Wheezing

Cough : 100%

Worldwide Prevalence of Asthma

شيوع عالئم آسم در كودكان ايراني بر اساس

فراتحليل مطالعات كشوري A systemic review of recent asthma surveys in Iranian children

دكتر مصطفي معين ، دكتر عباس انتظاري و همكاران

Ch Resp.Dis , 2009:6(2):109-14

چكيده: سابقه و هدف

برآورد شيوع آسم در كشور روش بررسي: مقاله ، پايان نامه و گزارش 142جستجوي اينترنتي

تحقيق در ايران1378-83سالهاي با پروتكل استاندارد جهانيISAAC يافته ها:19 ، سال 18 نفر ، افراد زير 61076 مطالعه درصد 35/4 درصد(كرمان)7/2شيوع

(تهران) درصد13/14 كشورميانگين شيوع عالئم آسم در : نتيجه گيري روند روبه شيوع باالتر از ميانگين جهاني

كشور افزايش بار بيماري در

Asthma Predictive Index

Identify high risk children (2 and 3 yr of age):

≥3-4 wheezing episodes in the past year (at least one must be MD diagnosed)

PLUSOR

One major criterion• Parent with

asthma• Atopic dermatitis• Aero-allergen

sensitivity

Two minor criteria• Food sensitivity• Eosinophilia (≥4%) • Wheezing not

related to infection

Modified from: Castro-Rodriguez JA, Holberg CJ, Wright AL, et al. A clinical index to define risk of asthma in young children with recurrent wheezing. Am J Respir Crit Care Med. 2000;162(4 Pt 1):1403–1406

77% Predictive

Diagnostic approach

1 - Clinical suspicion!2 - History with focus on symptom patterns3 - Physical examination for signs of asthma &

allergies4 - Confirm diagnosis with objective

measurement of pulmonary function(Spirometry)

5 - Allergy testing6 – Other possibly useful tests7– Clinical response to treatment

9

1 - Clinical Suspicion Suspect Asthma!

Suspect asthma in patients who have repeated diagnoses of respiratory illnesses

as : Reactive airway diseaes Bronchitis Croup Pneumonia Bronchiolitis

10

Always maintain a high index of suspicion for

asthma.

Previous health records are impotant!

Diagnostic approach





11

Key History Points

Symptoms Pattern of Symptoms Precipitating Factors (Triggers) Development of Disease Living Situation Disease Impact Patient`s Perception Family & Medical History

12

2 - Clinical history : Wheezing Asthma?

Wheezing with URIs is very common in small children but :

Many of these children will not develop asthma.

Asthma medications may benefit patients who wheeze whether or not they have asthma.

13

All that wheezes is not asthma & many asthmatics

do not wheeze!

2 - Clinical history : Cough - Asthma?

Consider asthma in children with: Recurrent episodes of cough with or

without wheezing Nocturnal awakening because of cough Cough that is associated with

exercise/play

14

Cough may be the only symptom

Present in patients with asthma(CVA)

15

Exercise Induced Bronchospasm(Asthma)

Airway Inflammatio

n

Drugs:NSAIDSBeta blockers

Respiratory Infections

Irritants

Environment

Additives Emotion

Pets

Weather changesCold air

Endocrine

Exercise

2 - Clinical history : Asthma triggers

Diagnostic approach





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3 - Physical Examination Respiratory examination• Evidence for obstructive respiratory

disease -R.R , R.distress , Chest deformity, Cough ,

Wheeze ,…• May be normal in patients with asthma General examination• Evidence for atopic disease : -A.rhinitis , A.dermatitis , Siusitis ,

Adenoids..• Absence of clubbing

18

19

ChronicSevere Asthma

20

ChronicSevereAsthma

21

?

22

AllergicRhinitis

24

Eczema – Allergic Dermatitis

Diagnostic approach





25

Peakflometry4 - Pulmonary Function Tests

Peak-flowmetry4 - Pulmonary Function Tests

4 -Peakflometry Curves

Spirometry4 - Pulmonary Function Tests

4 - Pulmonary Function Tests Spirometry

Spirometry FEV1 < 80% predicted FEV1 /FVC ratio <80%

PFM : More useful for monitoring PFT : Preferred for diagnosis

31

Spirometry may be normal in mild or well- controlled asthma

4 - Pulmonary Function Tests

(Reversibility of obstruction)

-12% or greater increase in FEV1 (≥200 cc)

-Inhaled or oral corticosteroids may be required to demonstrate reversibility

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Absence of response does not exclude

asthma.

4 - Bronchoprovocation

Findings consistent with asthma include:Bronchodilator Challenge Test :

(Bronchial Hyperreactivity)

Findings consistent with asthma include:

20% or greater decrease in FEV1

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A negative result does not exclude the Dx. of

asthma.

4 - Bronchoprovocation

Methacholine challenge Test :

Exercise Challenge Test :Findings consistent with asthma include:15% or greater decrease in FEV1

Diagnostic approach





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5 - Allergy Testing

Evidence for allergy common in pediatric patients with asthma.

May help guide environmental control Skin testing (prick &/or intradermal) the “gold standard.” In vitro (RAST) testing an alternative in

some situtions. Eosinophils in blood & nasal secretions

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36

5 – Allergy Skin testing (prick)

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5 - Eosinophilia ( Blood , Nasal secretions )

Diagnostic approach





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6 - Other Possibly Useful Tests (To exclude other diseases)

Chest x-ray (not in every exacerbation!)

Sinus x-ray Sweat chloride (polyp) pH probe , Barium swallow ,

Sonography Rhinolaryngoscopy Bronchoscopy

39

40

Acute Severe Asthma

Acute sinusitis

Diagnostic approach





42

Therapeutic trial of : SABA (eg Salbutamol)or ICS (eg Beclomethasone) or OCS

(PredniSone) and then assessment of the response to

Rx.

7 - Clinical response to RX.

Steroids should be prescribed on a case by case basis, particularly in severe attacks and the practise of prescribing them unnecessarily should be stopped.

Remember…!

The diagnosis of asthma in children is a clinical one.

Based on recognizing a characteristic pattern of episodic symptoms in the absence of an alternative explanation

BTS guideline 2008

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 Are worse with triggers: exercise ,exposure to

pets, cold or damp air, emotions or laughter Occur apart from colds

45

Clinical Features that Increase the Probability of Asthma Cont,d:

Personal history of atopic disorder

Family history of atopic disorder and /or asthma

Widespread wheeze heared on auscultation

History of improvement in symptoms or lung function in response to adequate therapy

46

Clinical Features that Decrease the Probability of Asthma:

Isolated cough in the absence of wheeze or difficulty breathing

History of moist cough Prominent dizziness, light-headedness,

peripheral tingling Repeatedly normal PE of chest when

symptomatic Normal spirometry or PFM when symptomatic No response to a trial of asthma therapy Clinical features pointing to alternative

diagnosis47

Failure to gain weight Clubbing Fatty stools Productive sputum Other chest findings eg crackles, unequal

BS Inspiratory noises Barking cough Early onset rhinorhoea GERD symptoms Absence of nocturnal symptoms 48

Clinical Features Pointing to Another Diagnosis!

Chronicrhinosinusitis

Differential

Diagnosis<5 Yr

Acute bronchioliti

s

Foreign body

aspiration

GERD

Cardiacasthma

Vascular ring

Differential

Diagnosis<5 Yr

PCD

Immunedeficiency

Tuberculosis

Broncho-pulmonarydysplasia

Cysticfibrosis

Pneumonia

Differential

Diagnosis>5 Yr-Adults

Hyperventilation syndrome

Upper airway

obstruction&

F.B

Vocalcord

dysfunction

CHF

Paranchymal lung disease

COPD

Rhinitis / SinusitisGERDASA/NSAID sensitivityAnxiety / Depression & Obesity Sleep Apnea Financial ABPA

Co-morbid Conditions that Affect Asthma

limitations

Noncompliance

Clinical Picture of Bronchiolitis

Mild Upper Respiratory Tract Infection for 2-3 days

Gradual onset of Respiratory Distress

Paroxysmal Spasmodic Cough Wheezes Dyspnea Irritability + - Feeding difficulty due to

tachypnea

Differences between Bronchiolitis and Asthma

1-Asthma is not common in the first year.

2- The following may favors the diagnosis of Asthma:

- 1-Positive family history, 2-repeated attacks, 3-markedly prolonged expiration, 4-onset may be sudden without preceding URT infection, 5-there will be eosinophilia and 6-favourable response to bronchodilators.

A chest X-ray demonstrating lung hyperinflation with a flattened diaphragm and bilateral atelectasis in the right apical and left basal regions in a 16-day- old infant with Severe bronchiolitis

FOREIGN BODY

Clinical picture

First phase Immediately

following the incident

Choking, gagging, coughing, wheezing, and/or stridor

Associated temporary cyanotic episode

Second phase Asymptomatic

period Can last from

minutes to months following the incident

Third phase Renewed

symptomatic period

Airway inflammation or infection occurs

Of cough, wheexing(maybe unilateral), fever, sputum production, and occasionally, hemoptysis

FOREIGN BODY ASPIRATION

Expiratory chest radiograph in a 12-month-old- boy with a 2-month history of wheezing demonstrates continued hyperlucency and hyperexpansion of the right hemithorax. A greater mediasstinal shift is noted toward the left lung field. A corn kernel was removed from the patients right mainstem bronchus during bronchoscopy.

FOREIGN BODY ASPIRATION

Signs and symptoms: Frequent or recurrent vomiting Frequent or persistent cough Hearburn, gas, abdominal pain Colic (Frequent crying and fussiness) Regurgitation and re-swallowing Feeding problem wet burp or Frequent

hiccups

GERD and wheezes?

Aspiration

GERD

Recurrent choking or gagging Poor sleep habits typically with

frequent waking Arching their necks and back during

or after eating Frequent ear infections or sinus

congestion Poor growth Breathing problems Recurrent wheezing

GERD and wheezes?Signs and symptoms:

Endoscopy - Inflammation

Prevent symptoms Require infrequent use of short- acting beta2-

agonists(≤2 days/ week) Maintain (near) “normal” pulmonary function Maintain normal activity levels Meet patients and families expectation of and

satisfaction

Prevent recurrent exacerbations of asthma and minimize the need for ED visits or hospitalizations

Prevent progressive loss of lung function Provide optimal pharmacotherapy with minimal or no

adverse effects

Reduce Impairment

Reduce Risk

The Goals of Asthma Therapy

Global Initiative for Asthma (GINA). Revised 2009. Available at: www.ginasthma.org.

Stepwise Management of Asthma

STEP 4 Severe Persistent -- Sx‘s- N: Continuous D: Cont...

STEP 3Moderate Persistent --Sx‘s : N >1w – D : Daily

STEP 2Mild Persistent -- Sx‘s : N>2m D >2w

STEP 1Intermittent


68

& 5 Symptoms(Sx’s) Activity levels Exacerbations FEV1/PEFR PEFR variability

Note ! Severity is classified before therapy begins!

Begin Rx. by severity:

-- Sx‘s : N<2m D<2w

Severity Classified by

Pharmacological management. Thorax 2003; 58 (Suppl I): i1-i92


by severity :

Step 1: Intermittent No daily medicines , SABA p.r.n.

Step 5: Severe Persistent High-dose ICS + LABA + Oral CS

Step 4 : Severe PersistentMedium dose ICS + LABA

Step 3: Moderate PersistentLow -dose ICS+ LABA

Step 2: Mild Persistent Low -dose ICS , LTAs 2nd line

*At all levels patient should have a SABA prn

Global Initiative for Asthma (GINA). Revised 2009. Available at: www.ginasthma.org.


Step-down Therapy

Step down once control is achieved: After 2–3 months 25% reduction over 2–3 months

Follow-up monitoring: Every 1–6 months Assess symptoms. Review medication use. Objective monitoring (PEF or

spirometry) Review medication.

Step-up Therapy

Indications: Symptoms, need for quick-relief

medication, exercise intolerance, decreased lung function.

May need a short course of oral steroids.

Continue to monitor: Follow and reassess every 1–6

months Step down when appropriate.

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controlled

partly controlled

uncontrolled

Exacerbation

LEVEL OF CONTROL

maintain and find lowest controlling step

consider stepping up to gain control

step up until controlled

Treat exacerbation

TREATMENT OF ACTION

TREATMENT STEPSDECREASE INCREASE

STEP1

STEP2

STEP3

STEP4

STEP5

REDU

CEIN

CREA

SE


If good control is not achieved !

Adverse environmental/allergen exposures Co-morbidities Poor technique Poor adherence to therapy (Non–Compliance)

Consider possible contribution of :

Pitfalls in Asthma Treatment

Identify Precipitating Factors & Co-morbid Conditions!

PrecipitatingFactors Allergens Irritants (eg,

environmental, tobacco smoke)

Respiratory viruses Medications , sulfites,

infections

Co-morbidConditions GERD Rhinosinusitis Rhinitis OSA Obesity ABPA Stress, Depression,

and Psychosocial Factors

GERD=gastroesophageal reflux disease. OSA=obstructive sleep apnea. ABPA=allergic bronchopulmonary aspergillosis.

Drug Delivery Options

Metered dose inhalers (MDI) Dry powder inhalers (Rota haler) Dry powder compressed for Disc

haler Spacers / Holding chambers Nebulizers

Pitfalls in Asthma TreatmentPoor technique!

Common Pitfalls in

Management of Asthma Late &/or mis-diagnosis Late &/or mis-therapy Poor perception of symptoms Poor adherence Poor knowledge(patient

& family)

Poor relation between the patient , physician & family Prolonged exposure to triggers Smoking or exposure to ETS Poverty Psycho-social problems

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All asthma drugs should ideally be taken through the

inhaled route!

ONLY INHALATION THERAPY!

Pitfalls in Asthma Treatment

Asthma Devices

Metered Dose inhaler

Turbuhaler

Diskus DPI

MDI DPI

Spacer devices / masks

Inhalation Devices

SpacerSpace halers

RotahalerDry powder

Inhaler

Metered dose

inhaler or MDI

Why use a Spacer with an Inhaler?

When an inhaler is used alone, medicine ends up in the mouth, throat, stomach and lungs.

When an inhaler is used with a spacer device, more medicine is delivered to the lungs.

Inhaler alone Inhaler used with spacer device

Ask the patient to demonstrate to you the

technique

Spacer with mask

Rotahaler technique of use

Therapy to avoid! Sedatives & hypnotics Cough syrups & Mucolytics Anti-histamines (routinely!) Antibiotics (routinely!) Corticosteroid injections (routinely!) Combination tablets Immunosuppressive drugs Chest physiotherapy Immunotherapy Maintenance oral prednisone >10mg/day

Conclusions :

Good asthma control Risk factor control Compliance Inhaler technique Step up/down treatment as

appropriate Suitable treatment for acute

exacerbation Patient & Family Education:… Be always up-to-date!

- راهنمای آسم و آلرژیبیماران و خانواده ها

National Asthma Guideline

THANKSمتشكرم

Health & Medicine

Approach to Chronic wheezing & asthma an update 2013