CHILDHOOD ASTHMA

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CHILDHOOD ASTHMA

• By M.A. Kibel
• and
• E. Weinberg

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Question 1

• How would you define asthma?

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Answer 1

• DEFINITION OF ASTHMA
• A lung disease characterised by
• Airway obstruction (or narrowing)
• usually reversible, either spontaneously or with
  treatment
• Airway inflammation
• Airway hyper responsiveness to a variety of
  stimuli

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• Asthma is a condition characterised by
  episodes of cough, wheezing and breathing
  difficulty due to reversible
• narrowing of the airways, in response to
  various stimuli. Airway narrowing and
  obstruction result from a combination of

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1 continued

• airway smooth muscle spasm
• oedema of the mucosa
• plugging of smaller airways by mucus
• inflammation

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• "Any child, regardless of age, who has had three
  or more episodes of wheezing and/or
  dyspnoea,should be considered as having asthma
  until proved otherwise".

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Question 2

• How common is asthma?

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Answer 2

• In industrialised countries asthma occurs in 1 to
  2 out of every 10 school children. Limited
  studies in South Africa show a prevalence of
  between 3.5 and 6, and it appears to be less
  prevalent

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• in rural than in urban settings. It is certainly
  the commonest chronic disorder of childhood, and
  hospital admissions for asthma show a rising
  incidence world-wide.

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Question 3

• What causes asthma?

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Answer 3

• Inflammation is now known to be the key factor in
  the pathology of asthma. Exposure to allergens
  and other irritants activate pulmonary mast
  cells, setting off immediate bronchospasm,

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3 continued

• followed later by inflammation, in which
  eosinophil and lymphocytic infiltration,
  subepithelial collagen deposition and epithelial
  damage are all involved.
• The cascade of effects leading to the asthmatic
  attack are shown in the following 2 slides

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THE ASTHMATIC INFLAMMATORY CASCADE
Inflammatory Stimuli
Cell Activation/Mediator Release Eosinophils
Mast Cells Mascrophages Neutrophils
T cells Bronchial epithelial cells
ASTHMATIC INFLAMATION
Bronchial Hyperresponsiveness
Clinical Asthma
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THE ASTHMATIC INFLAMMATORY CASCADE
Inflammatory Stimuli Allergens
Infections Generic factors Environmental
factors Other
Cell Activation/Mediator Release
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Question 4

• What factors can bring on asthma?

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Answer 4

• There are many factors that precipitate attacks.
  Most important are
• allergen exposure
• viral respiratory infections
• irritants tobacco smoke
• other forms of smoke
• exercise
• climatic change
• emotional factors

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Question 5

• What are the key elements in the history which
  will lead you to the diagnosis?

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Answer 5

• Diagnosing Asthma the Medical History
• Review
• symptom onset, duration, frequency pattern
• Possible allergic components
• Precipitating aggrevating factors, including
  lifestyle changes
• Management treatment history
• Family history

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5 continued

• full family history must be taken. There are
  often other family members with asthma or other
  allergies. A history of night-time coughing or
  wheezing, or such symptoms after exercise are
  strong pointers to a diagnosis of asthma.
  Details as to seasonality and exposure to
  possible allergens such as pets or grasses must
  be elicited.

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Question 6

• What are the findings on clinical examination?

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Answer 6

• Diagnosing Asthma The Physical Exam
• Examine the character of breath sounds
• Check for non-wheezing signs of asthma
• Note other allergic diseases
• Look for generalised lung hyperinfection
• However
• Typically, signs and symptoms are episodic
• physical exam maybe completely normal
• Exclude asthma look - a - likes

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6 Continued

• While a thorough examination of the respiratory
  system may elicit abnormalities, these are often
  lacking at the time of examination. Simple
  respiratory function tests are an essential part
  of the clinical examination, and can readily be
  carried out in children of 5 years and older.

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Question 7

• How is respiratory function testing performed?

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Answer 7

• A peak flow meter is the simplest and cheapest
  method to estimate the maximum flow of air during
  expiration.
• Reference must be made to a chart of normal
  values, based on the child's height.

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7 continued

• A reduction of 15 after exercise, or an
  improvement of 15 after inhalation of a beta2
  agonist are strong evidence of asthma.

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Question 8

• How may these objective measurements of lung
  function be used?

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Answer 8

• Objective Measures of Lung Function Enable the
  Physician to
• Diagnose
• airflow obstruction
• reversibility
• Monitor
• changes over time
• daily variation
• Manage Exacerbations
• severity of obstruction
• response to therapy

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8 Continued

• In younger children a therapeutic trial with a
  bronchodilator can be used to establish the
  diagnosis. A significant lessening in symptoms
  strongly favours the diagnosis of asthma.
  Parents can be given an asthma diary to record
  the frequency and severity of symptoms.

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Question 9

• What are the important conditions which can mimic
  asthma?

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Answer 9

• Ascariasis
• Tuberculous mediastinal glands
• Cystic Fibrosis

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9 Continued

• Although the list of conditions which can cause
  recurrent cough and/or wheezing is a long one, 3
  disorders stand out because of their importance
  and/or frequency they should always be
  considered.

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Question 10

• What are the important environmental triggers?

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Answer 10
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10 Continued

• The major allergens in Southern Africa are
• House dust mite
• cat
• dog
• grasses

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Question 11

• How would you treat an acute attack?

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Answer 11

• Managing Acute Exacerbations in the Emergency
  Department Initial Treatment
• Inhaled short-acting B2 agonist x3 doses over 60
  to 90 minutes - or
• subcultaneous B2 agonist x3 doses over 60 to 90
  minutes

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• Supplemental oxygen for
• hypoxemic patients
• all patients if oximeter is unavailable
• Consider systemic corticosteroids if
• no response within 1 - 2 hours - or
• patient is regularly taking oral steroids.

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• Beta2 agonists in inhaled form are the most
  useful preparations, and the metered dose inhaler
  (MDI) is the most convenient and cost- effective
  method of administration (examples salbutamol
  and fenoterol). In young children who cannot
  inhale the aerosol efficiently, a paper cup can
  be used as a face mask. A hole is cut in the
  base of the cup large enough to take the mouth
  piece of the MDI.

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• Specially designed spacer devices are also
  available for this purpose.
• Nebulisers are convenient for home use. These are
  simply air compressors which nebulise the
  solution via a face mask. Infants and young
  children often respond better to ipratropium
  bromide solution, which can be added to the beta2
  agonist solution.

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11 continued

• DOSAGES AND METHODS OF ADMINISTRATION OF
  SALBUTAMOL, FENOTEROL, IPRATROPIUM
• Infants and under 5's spacer/cup 3 puffs
  2-3 hr
  nebuliser 0.5 ml in 1ml saline
• 5 - 8 years powder inhaler 1
  every 3-4 hrs
• over 8 years MDI
  2 puffs 2- 3 hrs

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Question 12

• When should an attack be regarded as severe?

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Managing Acute Exacerbations in the Hospital
Assess severity
Initial treatment
Severe episode
Reassess
Moderate Episode
Incomplete Response
Poor response
Good Response
Admit to Hospital
Not Improved
Admit to ICU
Discharge
Improved
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• Status asthmaticus should be diagnosed when
• There is no response to 2 puffs of beta agonist,
  30 minutes apart, or to 2 nebulisations.
• the child is anxious, with breathing so laboured
  that speech is not possible.

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• child uses accessary muscles of respiration, with
  marked chest hyperinflation.
• diminished breath sounds with intense wheezing on
  auscultation.
• pulsus paradoxicus greater than 10 mm during
  inspiration.

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Question 13

• What are the important principles of management?

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Answer 13

• THE 4 H'S
• HOSPITALISE
• TREAT HYPOXIA
• ADMINISTER HYDROCORTISONE
• HYDRATE ADEQUATELY

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Question 14

• What are the asthma triggers in the environment
  that we can most easily modify?

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Answer 14

• Tobacco smoke. Smoking parents harm their
  children the greater the exposure to passive
  smoking the worse the symptoms. This is the most
  important preventable factor.
• House dust mite. Use the minimum of curtains and
  carpeting. Beat mattress and bedding outside
  regularly, and expose them to sunlight.
• Avoid SULPHUR DIOXIDE in cool drinks

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Question 15

• What can we do to lessen exposure to house mites?

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Answer 15

• Measures to Control House Dust Mites
• Essential
• encase mattress and pillow in an airtight cover
• wash bedding weekly in hot water
• avoid lying on upholstered furniture
• Desirable
• reduce indoor humidity to lt50
• remove carpets from bedroom and those laid over
  concrete

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Question 16

• What are the most important agents we use in
  chronic management?

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Answer 16

• Short acting inhaled beta-2 agonists
• Sodium cromoglycate
• Ketotifen
• Inhaled steroids
• Oral steroids

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16 continued

• Theophylline preparations were the main standby
  of treatment for many years. They are no longer
  recommended as a first choice because of the
  narrow range between effective action and
  unwanted side effects.
• Newer, long acting beta-2 agonists will have an
  increasing role, particularly in night time
  attacks.

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Question 17

• What agents are NOT recommended for management of
  asthma?

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Answer 17

• AGENTS NOT RECOMMENDED
• Tranquillisers
• Antihistamines
• Mucolytics
• Ionisers
• Desensitisation
• Physiotherapy
• Antibiotics (only used if bacterial
  infection is strongly suspected)

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• Tranquillisers Anxiety in acute asthma is a
  danger sign requiring immediate oxygen, steroids
  and bronchodilators, NOT respiratory suppression.
• Antihistamines These are not recommended,
  including a form combined with steroids
  (Celestamine), which is widely used in practice.
• Mucolytics and Ionisers These are ineffective
  in asthma.

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Question 18

• Give a plan of action for management of chronic
  asthma.

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Answer 18

• Desensitisation Ineffective, and may be
  dangerous.
• Physiotherapy Ineffective, and may be dangerous
  in acute attack.

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Question 19

• Give a plan of action for management of chronic
  asthma.

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Answer 19

• Firstly it is necessary to assess severity. This
  is done using 4 criteria
• (1) Frequency of attacks
• (2) Night time cough or wheeze
• (3) Previous admissions
• (4) Peak expiratory flow rate.

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Question 20

• How would you manage a mild case?

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Answer 20

• Allergen avoidance
• Intermittent bronchodilator
• Sodium chromoglycate before exercise

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Question 21

• How would you manage a moderate case?

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Answer 22

• Regular bronchodilator
• Regular sodium cromoglycate
• Possibly inhaled steroids

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Question 23

• How would you manage a severe case?

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Answer 23

• Bronchodilator/ home nebuliser
• Inhaled steroids
• Possibly oral steroids

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Question 24

• What should be the aims of management of chronic
  asthma?

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Answer 24

• To reduce to the minimum the number of attacks
• to avoid hospital admission
• to encourage full participation in school
  activities, including sport
• to ensure uninterrupted sleep at night
• to promote normal growth and development

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Question 25

• How would you handle regular episodes of coughing
  and wheezing at night?

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Answer 25

• Long Acting Theophyllines
• microphylline granules
• Nuelin SA
• Theodur
• Long Acting Beta-2 Agonists
• Foradil
• Serevent

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25 continued

• This usually indicates poor asthma control and
  the need for more effective therapy, including
  environmental control. There is a role here for
  long-acting theophyllines taken at bed-time, or
  for the newer long acting beta-2 agonists.

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Conclusion

• Many children at school who cough or wheeze in
  the cold or after PE have asthma, and go
  unrecognised. Deaths may occur because children
  have not been able to use their inhalers before
  vigorous exercise. What are the important
  messages about asthma in school-children?

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• Education of teachers about asthma is important
• as is good liaison with doctors and nurses
• School non-attendance may be due to poor
• Children should be allowed to keep their MDI's on
  them and take responsibility for their use (see
  next slide).

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