1. ”
Approach to
Chronic Wheezing & Asthma
Mostafa Moin MD
Professor of Allergy & Clinical Immunology
Immunology , Asthma & Allergy Research Institute
( IAARI )
Children Medical Center
Tehran University of Medical Sciences
2013

3. The Prevalence of Wheezing in
Pre-School Children
“ a continuous, high pitched musical sound coming from the chest”
Prevalence (%)
80
Wheezing ≥50%
70
Atopic (n=94)
Non-atopic (n=59)
60
50
Cough : 100%
40
30
20
10
0
1
2
3
4
5
6
7
8
9 10 11 12 13
Age (years)
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

4. Worldwide Prevalence of Asthma

5. A systemic review of recent asthma surveys in
Iranian children
Ch Resp.Dis , 2009:6(2):109-14

6. 


ISAAC









7. Asthma Predictive Index
77% Predictive
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)
PLUS
One major criterion OR
• 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

8. Diagnostic approach
1 - Clinical suspicion!
2 - History with focus on symptom patterns
3 - Physical examination for signs of asthma &
allergies
4 - Confirm diagnosis with objective measurement of
pulmonary function(Spirometry)
5 - Allergy testing
6 – Other possibly useful tests
7– Clinical response to treatment
9

9. 1 - Clinical Suspicion
Suspect Asthma!
 Suspect asthma in patients who have





repeated diagnoses of respiratory illnesses as :
Reactive airway diseaes
Bronchitis
Previous health records
Croup
are
Pneumonia
impotant!
Bronchiolitis
Always maintain a high index of
suspicion for asthma.
10

10. Diagnostic approach
1 - Clinical suspicion!
2 - History with focus on symptom patterns
3 - Physical examination for signs of asthma &
allergies
4 - Confirm diagnosis with objective measurement of
pulmonary function(Spirometry)
5 - Allergy testing
6 – Other possibly useful tests
7– Clinical response to treatment
11

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

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.
All that wheezes is not asthma &
many asthmatics do not wheeze!
13

13. 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
Cough may be the only symptom
Present in patients with asthma(CVA)
14

14. Exercise Induced Bronchospasm(Asthma)

15. 2 - Clinical history : Asthma triggers
Respiratory
Infections
Drugs:
NSAIDS
Beta blockers
Irritants
Endocrine
Weather changes
Cold air
Airway
Inflammation
Pets
Additives
Environment
Exercise
Emotion

16. Diagnostic approach
1 - Clinical suspicion!
2 - History with focus on symptom patterns
3 - Physical examination for signs of asthma &
allergies
4 - Confirm diagnosis with objective measurement of
pulmonary function(Spirometry)
5 - Allergy testing
6 – Other possibly useful tests
7– Clinical response to treatment
17

17. 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

18. Chronic
Severe
Asthma

19. Chronic
Severe
Asthma

21. Allergic
Rhinitis

23. Eczema – Allergic Dermatitis

24. Diagnostic approach
1 - Clinical suspicion!
2 - History with focus on symptom patterns
3 - Physical examination for signs of asthma &
allergies
4 - Confirm diagnosis with objective measurement of
pulmonary function(Spirometry)
5 - Allergy testing
6 – Other possibly useful tests
7– Clinical response to treatment
25

25. 4 - Pulmonary Function Tests
Peakflometry

26. 4 - Pulmonary Function Tests
Peak-flowmetry

27. 4 - Peakflometry Curves

28. 4 - Pulmonary Function Tests
Spirometry

29. 4 - Pulmonary Function Tests
Spirometry

30. 4 - Pulmonary Function Tests
Spirometry


FEV1 < 80% predicted
FEV1 /FVC ratio <80%
Spirometry may be normal in mild or
well- controlled asthma


PFM : More useful for monitoring
PFT : Preferred for diagnosis
31

31. 4 - Bronchoprovocation
(Reversibility of obstruction)
Findings consistent with asthma include:
Bronchodilator Challenge Test :
-12% or greater increase in FEV1 (≥200 cc)
-Inhaled or oral corticosteroids may be required
to demonstrate reversibility
Absence of response does not
exclude asthma.
32

32. 4 - Bronchoprovocation
(Bronchial Hyperreactivity)
Exercise Challenge Test :
Findings consistent with asthma include:
15% or greater decrease in FEV1
 Methacholine challenge Test :
Findings consistent with asthma
include:
20% or greater decrease in FEV1
A negative result does not exclude
the Dx. of asthma.
33

33. Diagnostic approach
1 - Clinical suspicion!
2 - History with focus on symptom patterns
3 - Physical examination for signs of asthma &
allergies
4 - Confirm diagnosis with objective measurement of
pulmonary function(Spirometry)
5 - Allergy testing
6 – Other possibly useful tests
7– Clinical response to treatment
34

34. 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
35

35. 5 – Allergy Skin testing (prick)

36. 5 - Eosinophilia ( Blood , Nasal secretions )

37. Diagnostic approach
1 - Clinical suspicion!
2 - History with focus on symptom patterns
3 - Physical examination for signs of asthma &
allergies
4 - Confirm diagnosis with objective measurement of
pulmonary function(Spirometry)
5 - Allergy testing
6 – Other possibly useful tests
7– Clinical response to treatment
38

38. 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

39. Acute
Severe
Asthma

40. Acute sinusitis

41. Diagnostic approach
1 - Clinical suspicion!
2 - History with focus on symptom patterns
3 - Physical examination for signs of asthma &
allergies
4 - Confirm diagnosis with objective measurement of
pulmonary function(Spirometry)
5 - Allergy testing
6 – Other possibly useful tests
7– Clinical response to treatment
42

42. 7 - Clinical response to RX.
Therapeutic trial of :
 SABA (eg Salbutamol)
or
 ICS (eg Beclomethasone) or OCS (PredniSone)
and then assessment of the 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.

43. 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

44. 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
45
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

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 diagnosis
47

47. Clinical Features Pointing to
Another Diagnosis!
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

48. Chronic
rhinosinusitis
Acute
bronchiolitis
GERD
Differential
Diagnosis
<5 Yr
Foreign
body
aspiration
Cardiac
asthma
Vascular
ring

49. Pneumonia
Cystic
fibrosis
Tuberculosis
Differential
Diagnosis
Bronchopulmonary
dysplasia
<5 Yr
PCD
Immune
deficiency

50. Hyperventilation
syndrome
Upper
airway
obstruction
&
CHF
Differential
Diagnosis
>5 Yr-Adults
Paranchymal
lung disease
COPD
F.B
Vocal
cord
dysfunction

51. Co-morbid Conditions that Affect Asthma
Rhinitis / Sinusitis
GERD
ASA/NSAID sensitivity
Anxiety / Depression & Noncompliance
 Obesity
 Sleep Apnea limitations
 Financial
 ABPA

52. 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

53. 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.


54. 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

55. FOREIGN BODY

56. FOREIGN BODY ASPIRATION
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(mayb
e
unilateral), fever, sputu
m production, and
occasionally, hemoptys
is

57. 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.

59. GERD and wheezes?
Signs and symptoms:






Frequent or recurrent vomiting
GERD
Frequent or persistent cough
Hearburn, gas, abdominal pain
Colic (Frequent crying and fussiness)
Aspiration
Regurgitation and re-swallowing
Feeding problem wet burp or Frequent hiccups

60. GERD and wheezes?
Signs and symptoms:







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

64. Endoscopy - Inflammation

65. The Goals of Asthma Therapy
Reduce Impairment





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
Reduce Risk



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

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

67. Stepwise Management of Asthma
Begin Rx. by severity:
STEP 4 & 5
Severe Persistent -- Sx‘sN: Continuous D: Cont...
STEP 3
Moderate Persistent -Sx‘s : N >1w – D : Daily
STEP 2
Mild Persistent -- Sx„s : N>2m D >2w
Severity
Classified by
 Symptoms(Sx‟s)
 Activity levels
 Exacerbations
 FEV1/PEFR
 PEFR variability
STEP 1
Intermittent -- Sx„s : N<2m D<2w
Note ! Severity is classified before therapy begins!

68. Stepwise Management of Asthma
by severity :
*At all levels patient should have a SABA prn
Step 5: Severe Persistent
High-dose ICS + LABA + Oral CS
Step 4 : Severe Persistent
Medium dose ICS + LABA
Step 3: Moderate Persistent
Low -dose ICS+ LABA
Step 2: Mild Persistent
Low -dose ICS , LTAs 2nd line
Step 1: Intermittent
No daily medicines , SABA p.r.n.
Pharmacological management. Thorax 2003; 58 (Suppl I): i1-i92

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

70. 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.

71. 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.

72. LEVEL OF CONTROL
controlled
REDUCE
Stepwise Management of Asthma
TREATMENT OF ACTION
maintain and find lowest
controlling step
consider stepping up to
gain control
uncontrolled
Exacerbation
DECREASE
INCREASE
partly controlled
step up until controlled
Treat exacerbation
INCREASE
TREATMENT STEPS
STEP
STEP
STEP
STEP
STEP
1
2
3
4
5

73. Pitfalls in Asthma Treatment
If good control is not achieved !
Consider possible contribution of :

Adverse environmental/allergen exposures

Co-morbidities

Poor technique

Poor adherence to therapy (Non–Compliance)

74. Identify Precipitating Factors
& Co-morbid Conditions!
Precipitating
Factors




Allergens
Irritants
(eg, environmental, tobac
co smoke)
Respiratory viruses
Medications , sulfites,
infections
GERD=gastroesophageal reflux disease.
OSA=obstructive sleep apnea.
ABPA=allergic bronchopulmonary aspergillosis.
Co-morbid
Conditions







GERD
Rhinosinusitis
Rhinitis
OSA
Obesity
ABPA
Stress, Depression,
and Psychosocial
Factors

75. Pitfalls in Asthma Treatment
Poor technique!
Drug Delivery Options

Metered dose inhalers (MDI)

Dry powder inhalers (Rota haler)

Dry powder compressed for Disc haler

Spacers / Holding chambers

Nebulizers

76. 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

77. Pitfalls in Asthma Treatment
ONLY INHALATION THERAPY!
All asthma drugs
should ideally be
taken through the
inhaled route!

78. Asthma Devices
Turbuhaler
DPI
Metered Dose
inhaler MDI
Diskus DPI

79. Spacer devices / masks

80. Inhalation Devices
Rotahaler
Dry powder
Inhaler
Metered dose
inhaler or MDI
Spacer
Space halers

81. Why use a Spacer with an Inhaler?
Inhaler alone
When an inhaler is used
alone, medicine ends up
in the mouth, throat,
stomach and lungs.
Inhaler used with spacer
device
When an inhaler is used
with a spacer device,
more medicine is
delivered to the lungs.

82. Ask the patient to demonstrate
to you the technique

83. Spacer with mask

84. Rotahaler technique of use

85. 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

86. 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!

87. -

89. National
Asthma
Guideline

90. THANKS