Understanding Childhood Asthma

Presented by
Dr pankaj yadav
Drpankajyadav05@gmail.com
drpankajyadav05@gmail.com

• Asthma is the most common chronic disease of childhood and the
leading cause of childhood morbidity from chronic disease as
measured by school absences, emergency department visits, and
hospitalizations.
• Asthma leads to recurrent episodes of wheezing, breathlessness,
chest tightness and coughing (particularly at night or early morning).
Clinical symptoms in children 5 years and younger are variable and
non-specific.
• Widespread, variable, and often reversible airflow limitation.

Factors Influencing the Development
and Expression of Asthma
Host factors –
 Genetic
1.Genes predisposing to atopy
2. Genes predisposing to airway hyper responsiveness
3.Obesity
4.Sex

Environmental factors –
Allergens –
1. Indoor – Domestic mites, furred animals (dogs, cats, mice),
cockroach allergens, fungi, molds, yeasts.
2. Outdoor – Pollens, fungi, molds, yeasts.
Infections (predominantly viral)
Occupational sensitizers
Tobacco smoke
1. Passive smoking
2. Active smoking
Indoor/Outdoor air pollution
Diet drpankajyadav05@gmail.com

Risk factors of Asthma in younger children
• Sensitization to allergen.
• Maternal diet during pregnancy and/ or lactation.
• Pollutants (particularly environmental tobacco smoke).
• Microbes and their products.
• Respiratory (viral) infections.
• Psychosocial factors.drpankajyadav05@gmail.com

The prevalence of childhood asthma has continued to
increase on the Indian subcontinent over the past 10 yrs
ISAAC Phase 3 Thorax 2007;62:758

Epidemiological trend Bronchial
Asthma
 Global Burden of Asthma
Around 300 m. patients (currently)
Expected by 2025: 100 m. additional
Loss of DALYs : About 15 m./year
(around 1% of all DALYs lost)
 Accounts for in every 250 deaths
• Considerable economic costs
The UK has one of the highest prevalences for childhood asthma
internationally, with about 15% children affected.
The prevalence is 8-10 times higher in developed countries than in
developing countries.

The prevalence of 'any wheeze' over recent months (usually taken as
within the last year) amongst children has risen from about 10% in the
1960s to 20-30% in the 1990s. There is some evidence of a possible
flattening of this rise from the late 1990s onwards. An increasing
percentage of currently wheezing children also have a diagnosis of
asthma.
There is still a significant morbidity associated with the disease,
particularly severe childhood asthma, despite therapeutic advances.
Prevalence is higher in lower socioeconomic groups in urban areas.
There are gender differences. Boys are affected more before puberty (3
times greater prevalence). Prevalence is equal in adolescence, but
adult-onset asthma is more common in women.
The increasing prevalence of asthma is mirrored by the increasing
prevalence of childhood obesity. Prospective studies suggest that
obesity increases the risk of subsequent asthma, although the
underlying mechanisms are unclear, but obesity also increases the
clinical severity of asthma and reduces quality of life for childrenwith
asthma.

The overall burden of Asthma in India is estimated at
more than 15 million .
According to the study done by A.Anuradha1, V.Lakshmi
Kalpana1,S.Narsingara. et al. The type of asthma is
distributed as cough-variant-asthma (50.83%), nocturnal
asthma (17.5%), allergic asthma (20.83%) and occupational
asthma (10.83%). Regarding family history,59.16% showed
genetic predisposition irrespective of sex. Among
asthmatics, 20% were having atopicdermatitis. Twenty-
five percent were smokers, 20% were alcoholics and
44.16% were with diabetics.
Advancing age, usual residence in urban area and lower
socio-economic status were associated with significantly
higher odds of having asthma. The present study shows
that asthma is an important public health issue in urban
areas.

Asthma Burden in Developing countries (INDIA)
1. Wide variations – High magnitude
2. Increase in prevalence with rapid industrialization
and urbanization
3. High levels of pollution – important role
4. Role of infections, smoking and under-nutrition
5. Under diagnosis and under treatment
6. Limited drug availability
7. Difficulties of management at different levels of
health-care


Fear of steroids
Heavy
nebulisation
Choice of right
device
Oral vs. Inhaled Lack of
knowledge &
time vs.
more patients
Poor patient/
parent
education
Cough or
Wheeze
Heterogenous
Disease/varying
phenotypes
Acceptance of
Asthma
diagnosis/label
Underdiagnosed/
Misdiagnosed
Issues in
Pediatric Asthma

Other Challenges
Most of the children are below 5 years of age, who cannot
tell their problems
Parents are proxy story teller, who may mislead the doctor
PEF cannot be performed in children below 5 years of age
Fear of addiction to inhalation therapy
Physicians lack of knowledge and time

Clinical Features
Recurrent Wheeze
Recurrent Cough
Recurrent Breathlessness
Activity Induced Cough/Wheeze
Nocturnal Cough/Breathlessness
Tightness Of Chest
Asthma by Consensus, IAP 2003drpankajyadav05@gmail.com

Symptomatology
Cough – 90%
Wheezing – 74%
Exercise induced wheeze or cough – 55%
Ind J Ped 2002;69:309-12drpankajyadav05@gmail.com

Typical features of Asthma
Afebrile episodes
Personal atopy
Family history of atopy or asthma
Exercise /Activity induced symptoms
History of triggers
Seasonal exacerbations
Relief with bronchodilators Asthma by Consensus, IAP 2003drpankajyadav05@gmail.com

When does Asthma begin?
By 1 year – 26%
1-5 years – 51.4%
> 5 years – 22.3%
77% Of Asthma
Begins In Children
Less Than 5 Years
Ind J Ped 2002;69:309-12

Tools to Diagnosis
Good History Taking (ASK)
Careful Physical Examination (LOOK)
Investigations (PERFORM) – above 5 years only
CHILDHOOD ASTHMA by KHUBCHANDANI R.P. et al

History taking (Ask)
Has the child had an attack or recurrent episode of
wheezing (high-pitched whistling sounds when breathing
out)?
Does the child have a troublesome cough which is
particularly worse at night or on waking?
Is the child awakened by coughing or difficult breathing?
Does the child cough or wheeze after physical activity (like
games and exercise) or excessive crying?
Does the child experience breathing problems during a
particular season?

History taking (Ask)
Does the child cough, wheeze, or develop chest tightness
after exposure to airborne allergens or irritants e.g. smoke,
perfumes, animal fur?
Does the child’s cold frequently ‘go to the chest’ or take
more than 10 days to resolve?
Does the child use any medication when symptoms occur?
How often?
Are symptoms relieved when medication is used?
If the answer is ‘yes’ to any of the questions,
a diagnosis of asthma should be considered

Physical Examination (Look)
General Attitude And Well Being
Deformity Of The Chest
Character Of Breathing
Thorough Auscultation Of Breath Sounds
Signs Of Any Other Allergic Disorders On The
Body
Growth And Development Status

What all features one should look for specifically?
Dyspnea
Expiratory wheeze
Accessory muscle movement
Difficulty in feeding, talking, getting to sleep
Irritability

What all features one should look for specifically?
Cough
Persistent/ recurrent / nocturnal/ exercise-
induced
Associated conditions
Eczema
Allergic Rhinitis
Weight/Height

How to rule out the mimics?

The Early Wheezer (< 3Years)
Early onset asthma
Afebrile episodes
Personal atopy present
Family history of asthma /
atopy present
Predictable good response to
bronchodilators
WALRI (wheeze associated
lower respiratory tract
infections)
or Viral Associated wheeze
Febrile episodes
Personal atopy absent
Family history of asthma / atopy
absent
Variable response to
bronchodilators
Asthma by Consensus, IAP 2003drpankajyadav05@gmail.com

Bronchiolitis in children
Commonest cause of wheezing in children
between 6 months to 3 years
Resembles asthma
Diagnosis essentially clinical
Common viruses causing bronchiolitis in
children:
Respiratory syncytial virus (RSV)

Clinical manifestations of RSV disease
Rhinorrhoea
Pharyngitis
Cough
Low grade fever
Wheezing
Increased respiratory rate

Differential diagnosis
Age Common Uncommon Rare
Less than
6 months
Bronchiolitis
Gastro-
esophageal
reflux
Aspiration pneumonia
Bronchopulmonary dysplasia
Congestive heart failure
Cystic fibrosis
Asthma
Foreign body aspiration
6 months -
2 years
Bronchiolitis
Foreign body
aspiration
Asthma
Bronchopulmonary dysplasia
Cystic fibrosis
Gastro-esophageal reflux
2 - 5 years Asthma
Foreign body
aspiration
Cystic fibrosis
Viral pneumonia
Bronchiolitis
IPAG 2007drpankajyadav05@gmail.com

Co morbid conditions
Allergic Rhinitis
Colds, ear infections
Sneezing in the morning
Blocked nose, snoring, mouth breathing
Gastro esophageal reflux (GER)
Nocturnal cough followed by vomiting
Eczema

Guidelines for confirming
Childhood Asthma diagnosis

IPAG Diagnosis
Characterize the problem
Establish chronicity
Exclude non-respiratory or other
causes
Exclude infectious diseases
Consider patient’s age
Use diagnostic aids
International Primary Care Airways Group 2007drpankajyadav05@gmail.com

SPIROMETRY
SPIROMETRY IS A PULMONARY FUNCTION
TEST THAT MEASURES THE VOLUME OF AIR
AN INDIVIDUAL INHALES OR EXHALES AS A
FUNCTION OF TIME.

Method – how to perform
1. 4 normal breaths
2. Inhale as deeply as possible
3. Exhale to normal depth
4. 3 normal breaths
5. Exhale as much as possible
6. 3 normal breaths
7. Inhale as much as possible
8. Exhale as fast and
completely as possible
9. 4 normal breaths

ROLE OF SPIROMETRY IN
ASTHMA
HELPS TO MAKE DIAGNOSIS
ASSESS DEGREE OF AIRFLOW OBSTRUCTION
TO PREDICT WHETHER OBSTRUCTION IS
REVERSIBLE
AIDS IN MANAGEMENT OF ASTHMA
TO MONITOR PROGRESSION OF DISEASE

What all investigations can be performed in
asthmatic children? (PERFORM)
Peak expiratory flow rate: It is highly
suggestive of asthma when:
>15% increase in PEFR after inhaled short
acting β2 agonist
>15% decrease in PEFR after exercise
Diurnal variation > 10% in children not on
bronchodilator OR
>20% In children on bronchodilator
1. Asthma by Consensus, IAP 2003
2. CHILDHOOD ASTHMA by KHUBCHANDANI R.P. et aldrpankajyadav05@gmail.com

Early Childhood Asthma Diagnosis
(below 6 years)
Diagnostic Tool Findings that Support Diagnosis
Differential
diagnosis
The diagnosis of asthma in children under age 6 is primarily
one of exclusion.
Physical
examination
If the child does not appear acutely ill and is growing, and
there is no evidence specifically indicating another cause of
symptoms, a trial of therapy is warranted.
Trial of therapy
(bronchodilators)
Improvement with treatment supports a diagnosis of
asthma.
Frequent
reassessment
Health care professionals should always be prepared to
reconsider the diagnosis if management is ineffective or if
the clinical situation changes.

Childhood Asthma Diagnosis (6-14 years)

NORDIC CONSENSUS
Confirm Asthma if,
If the child is having 3 attacks of airway obstruction in
last 1 yr.
If the child gets 1 attack of asthmatic symptoms after
the age of 2 yrs.
Irrespective of age in an attack in children with
allergy (eczema, food allergy etc.) or history of atopy.
If the child does not become free of symptoms when
infection has ceased or has persistent symptoms for
more than a month.
Respir Med. 2000;94(4):299-327drpankajyadav05@gmail.com

IAP GUIDELINES
3 Or More Episodes Of Airflow Obstruction With Several
Of The Following:
• Afebrile Episodes
• Personal Atopy Or Family H/O Atopy / Asthma
• Nocturnal Exacerbations
• Exercise/Activity Induced Symptoms
• Trigger Induced Symptoms
• Seasonal Exacerbations
• Relief With Bronchodilators ± Oral Steroid
Asthma by Consensus, The Indian Academy of Pediatrics 2003drpankajyadav05@gmail.com

GINA
 The following symptoms are highly suggestive of a
diagnosis of asthma:
 frequent episodes of wheeze (more than once a month)
 activity-induced cough or wheeze
 nocturnal cough in periods without viral infections
 absence of seasonal variation in wheeze
 symptoms that persist after age 3
 A simple clinical index based on:
 presence of a wheeze before the age of 3
 presence of one major risk factor (parental history of
asthma or eczema) or two of three minor risk factors
(eosinophilia, wheezing without colds, and allergic
rhinitis) has been shown to predict the presence of
asthma in later childhood
Global Initiative for Asthma 2008drpankajyadav05@gmail.com

GINA
A useful method for confirming the diagnosis of asthma in
children 5 years and younger is a trial of treatment with
short-acting bronchodilators and inhaled
glucocorticosteroids
Children 4 to 5 years old can be taught to use a PEF meter,
but to ensure reliability parental supervision is required
Use of spirometry and other measures recommended for
older children such as airway responsiveness and markers of
airway inflammation is difficult and several require complex
equipment making them unsuitable for routine use
GINA 2008drpankajyadav05@gmail.com

BTS
 Initial assessment of children suspected of having
asthma should be based on:
 presence of key features in the history and clinical examination
 careful consideration of alternative diagnoses
 Using a structured questionnaire may produce a more
standardised approach to the recording of presenting
clinical features and the basis for a diagnosis of asthma
British Thoracic Society 2008drpankajyadav05@gmail.com

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
◊ occur in response to, or are worse after, exercise or other triggers,
such as exposure to pets, cold or damp air, or with emotions or
laughter
◊ occur apart from colds
Personal history of atopic disorder
Family history of atopic disorder and/or asthma
Widespread wheeze heard on auscultation
History of improvement in symptoms or lung function in response to
adequate therapy
BTS 2008drpankajyadav05@gmail.com

Clinical features that lower the probability of asthma
Symptoms with colds only, with no interval symptoms
Isolated cough in the absence of wheeze or difficulty breathing
History of moist cough
Prominent dizziness, light-headedness, peripheral tingling
Repeatedly normal physical examination of chest when symptomatic
Normal peak expiratory flow (PEF) or spirometry when symptomatic
No response to a trial of asthma therapy
Clinical features pointing to alternative diagnosis
BTS 2008drpankajyadav05@gmail.com

Asthma management and prevention
The goals for successful management of asthma are
1. Achieve and maintain control of symptoms
2. Maintain normal activity levels, including exercise
3. Maintain pulmonary function as close to normal as possible
4. Prevent asthma exacerbations
5. Avoid adverse effects from asthma medications
6. Prevent asthma mortality

Five interrelated components of therapy are required to achieve
and maintain control of asthma-
1. Develop Patient/Doctor partnership
2. Identify and reduce exposure to risk factors
3. Assess, treat, and monitor asthma
4. Manage asthma exacerbations
5. Special considerations

Develop Patient/Doctor partnership -
Effective management of asthma requires the development of a
partnership between the person with asthma and the health care
team.
Patients can learn to –
1. Avoid risk factors
2. Take medications correctly

3. Understand the difference between controller and reliever
medications
4. Monitor their status using symptoms and, if relevant, PEF
5. Recognize signs that asthma is worsening and take action
6. Seek medical help as appropriate

Education should be integral part of all interactions between health care
professional and patients.
Using variety of methods such as discussions, demonstrations, written
materials, group classes, video/audio tapes, dramas and patient support
groups helps reinforce educational messages.
Health care professional and patients should prepare a written personal
asthma action plan that is medically appropriate and practical.
Additional self-management plans can be found on –
1. www.asthma.org.uk
2. www.nhlbisupport.com/asthma/index.html
3. www.asthmaz.co.nz

Assess, Treat and Monitor Asthma –
The goal of asthma treatment can be reached in most patients
through a continuous cycle that involves – assessing, treating and
monitoring asthma.
Each patient should be assessed to establish his/her current
treatment regimen, adherence to the current regimen, and level of
asthma control.
Each patient is assigned to one of five treatment steps.
At each treatment step, reliever medication should be provided for
quick relief of symptoms as needed.

Monitoring is essential to maintain control and establish the lowest step and
dose of treatment to minimize cost and maximize safety.
If asthma is not controlled, step up the treatment. Improvement is generally
seen within 1 month.
If asthma is partly controlled, consider stepping up treatment, depending
more effective options available, safety and cost of possible treatment and
patient’s satisfaction with the level of control achieved.
If controlled asthma is maintained for at least 3 months, step down with a
gradual, stepwise reduction in treatment. The goal is to decrease treatment
to the least medication necessary to maintain control.

To summarize…
Asthma is an inflammatory illness
Diagnosis of asthma is clinical, and relies on history
All asthma does not wheeze
In children < 3 yrs, WALRI is an important differential diagnosis
2 out of 3 children outgrow their asthma
A family history of asthma / atopy increases risk of asthma
Diagnosis

To summarize…
Patient education is a very important part of asthma management
Drugs control, but do not cure asthma
Clinical grading over time, decides long term management plan
Mild intermittent asthma does not merit controllers
Inhaled steroids are mainstay of long term asthma management
Treatment should be stepped up or stepped down depending upon
patient response
Long term management

Thank Youdrpankajyadav05@gmail.com

Understanding Childhood Asthma

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