10. Major Risk Factors Minor Risk Factors
Parental Asthma Allergic Rhinitis
Wheezing without URTI
Eczema
Eosinophilia >4%
Loose Index Stringent Index
1 episode of wheezing in 3 years
+
1 major
> 3 episode of wheezing in 3 years
+
1 major
1 episode of wheezing in 3 years
+
2 Minor
> 3 episode of wheezing in 3 years
+
2 Minor
Conclusion: Conclusion
2.6-5.5 times likely to have asthma 4.3 – 9.8 times likely to have asthma
11. Viral Associated wheeze Early Onset Asthma
Febrile Episodes Afebrile episodes
No Personal Atopy Positive Personal Atopy
No Family history of atopy Positive Family history of atopy
Variable response to bronchodilators Predictable response to bronchodilators
12.
13. History Of presenting
Illness
Age • Birth
• Early infancy
• Early Childhood
• Adolescents
Associated symp. • Choking
• Fever
• Feeding
onset • New or recurrent
Temporal Pattern • Episodic or persistent
Control of wheeze • Difficult to control
Past Medical History
• Recurrent pneumoniae
• Neurodegenerative disease
Birth History
• Antenatal Antenatal USS.
• Natal Preterm
Family history • Atopy
14.
15. General Examination:
Denny morgan lines
allergic salute
Clubbing
Erythematous conjuntiva
Growth Charts :
Weight: Underweight
Length: Short stature
Head circumference: Macro or microcephaly
Vital Signs Temperature: fever
Systemic Examination:
Skin: Urticaria
Eczema
ENT: Boggy turbinates
Rhinorrhea
Polyps
Stridor
CNS: Features of neurodegenerative
diseases
Chest: Increased AP
Local vs generalized
Inspiratory vs expiratory
23. 1. recurrent episodic symptoms of airflow
obstruction
2. Airway flow obstruction is at least partially
reversible by administration of a bronchodilator.
3. Alternative diagnoses are excluded
Symptoms are
often worse at
night or on waking
Symptoms occur
variably over time
and vary in
intensity
Symptoms are
often triggered by
exercise, laughter,
allergens, virus
25. • Minimal need <2/wk for SABA
• Maintenance of normal daily activities
Reduction in
impairment
• Prevention of recurrent exacerbations
• minimal or no adverse effects of drugs
Reduction of
risk
32. COMPONENETS OF SEVERITY
SEVERITY
INTERMITTENT
PERSISTENT
MILD MODERATE SEVERE
IMPAIRMENT
DAY <2 times/ week
>2 times/
week
DAILY FREQUENT
SABA USE <2 times/ week
>2 times/
week
DAILY FREQUENT
NIGHT <2 times/ MONTH
>2 times/
MONTH
>5 times/
MONTH
FREQUENT
ACTIVITY NONE MINOR SOME EXTREME
>80% >60 <60%
LUNG FUNCTION
>5YEARS
FEV1% PREDICTED >80%
FEV1/FVC RATIO
>85 >80% >75 <75%
>12y
= NORMAL
NORMAL REDUCED 5%
REDUCED 5%
RISK EXACERBATIONS <2TIMES /YEAR >2TIMES /YEAR
33.
34. COMPONENETS OF CONTROL
CONTROL
WELL NOT WELL VERY POOR
IMPAIRMENT
DAY <2 times/ week >2 times/ week FREQUENT
SABA USE <2 times/ week >2 times/ week FREQUENT
NIGHT <2 times/ MONTH >2 times/ MONTH
>5 times/ MONTH
ACTIVITY MINOR SOME EXTREME
>60% <60%
LUNG FUNCTION
>5YEARS
FEV1% PREDICTED >80%
FEV1/FVC RATIO >80% >75 <75%
RISK EXACERBATIONS <2TIMES /YEAR >2TIMES /YEAR
45. Step: Step1 Step2 Step3 Step4 Step5 Step6
0-4y P SABA prn Low ICS Medium ICS Medium ICS +
LABA or LTRA
High ICS
+LABA or LTRA
High ICS
+LABA or
LTRA+steroids
A LTRA
5-11y P SABA prn Low ICS Medium ICS or
Low dose ICS +
LABA, LTRA
Medium
ICS+LABA or
LTRA
High ICS
+LABA or LTRA
High ICS
+LABA or
LTRA+steroids
A LTRA theophylline theophylline theophylline theophylline
>12y P SABA prn Low ICS Medium ICS or
Low dose ICS
+LABA or LTRA
Medium
ICS+LABA or
LTRA
High ICS
+LABA or LTRA
High ICS
+LABA or
LTRA+steroids
A or LTRA Theophylline,
Zileuton
Theophylline,
Zileuton
Omalizumab Omalizumab
100 genetic loci have been identified
high-affinity IgE receptors
T-cell antigen receptor
interleukin-4 gene
Other : ADAM-33 , B agonist receptor polymorphism
Bronchoconstriction and Bronchopspasm
Recruitment of immune cells which cause epithelial cell damage
The most common symptoms that arouse a suspicion of asthma are intermittent and repetitive episodes of cough and noisy breathing or wheezing triggered by respiratory infections, allergen or irritant exposure, exercise, or play, with symptoms often awakening the child at night
Nonspecific symptoms may include self-imposed limitation of physical activities, genera
Recurrent “croup” in an older child or frequent “clinical pneumonias” or “bronchitis” may also alert the pediatrician to consider evaluating for possible asthmal fatigue, and difficulty keeping up with peers
Birth: Congenital diaphragmatic hernias( neonatal), Bronchopulmonary dysplasia(Neonate)
Early infancy: Vascular rings
Early Childhood: Bronchiolitis , FBA
Adolescents: Atypical pneumoniae and asthma
New-onset: Previously healthy infant: bronchiolitis , incontext of urticaria , stridor: anaphylaxis
Recurrent: URTI: Viral induced wheeze, Feeds: GERD, Atopy: asthma
Episodic: viral induced wheeze, Persistent: Congenital airway abnormality: tracheomalacia, mediastinial mass
Both: asthma
Control: Recurrent wheeze is difficult to control Severe asthma or Cystic Fibrosis or anatomic abnormality
Recurrent pneumoniae: immunodeficiency or Cystic fibrosis or ciliary dyskinesia
Neurodegenerative : Swallowing dysfunction
Antenatal: Congenital diaphragmatic hernia
Preterm: intubated? BPD
FH: Atopy: Asthma
GE: DML: allergy
Clubbing: CF
Weight and Height: Chronic disorders: CF, Immunodeficiency HC: Neurodegenerative disease
Temp: Pneumoniae,
Urticaria: anaphylaxis
Eczema: AR
Boggy: AR
Rhinorrhea: VIW
PolypS: CF
NDD: swallowing dysfuntion
Local : FBA
Localized: FBA, Endobronchial mass
Generalized: Asthma
Inspiratory: obstruction: FBA, Expiratory: Edema asthma, VIW, irritants
PFTs: diagnostic, Reversibility, Hyperreactivity,
CXR:
If its new onset, worsening wheezing
Hyperinflation: generalized: Asthma, CF, Bronchiolitis, Localized: FBA
Cardiomegaly, Mediastinial masses
radioallergosorbent test: Asthma to identify triggers sometime in difficult to treat cases
Barium: TEF, GERD, vascular rings
FVC = forced vital capacity = volume exhaled after maximal inspiration through to maximal expiration
FEV1 = forced expiratory volume in 1 sec
FEV1/FVC = ratio = percent exhaled within first second
FEF25-75 = forced expiratory flow: the % exhaled between 25%-75%
PEFR = peak expiratory flow rate: highest at first because of mechanical advantage and traction of airways; also a measure of effort
AGE GENDER HEIGHT RACE
exercise challenges, methacholine, cold air, and most recently, mannitol challenges performed only when the determination of asthma is difficult despite routine evaluation.
Clinical diagnosis
< 5 years , in whom PFTs cant be performed
Recurrent: cough or wheeze
And inclusion of FH or personal history of atopy
So you don’t do PFTs to confirm
Ciliary dyskinesia or cystic fibrosis: Symptoms and signs that are not consistent with chronicity of asthma, including failure to thrive, cyanosis, and clubbing, should alert the pediatrician to alternative diagnoses such as ciliary dyskinesia or cystic fibrosis.
Foreign body aspiration : A baseline chest radiograph may help exclude other conditions that mimic asthma
Vascular ring: barium swallow
Immune dysregulation : White cell count and differential and quantitative immunoglobulins.
GERD: Symptoms sometimes related to eating, vomiting
Clinical,An upper gastrointestinal series
SABA: nil to 1 time a week
Activity: work, sport
Exacerbations: <2 a year
Adverse effect: minimise and reduce the dose as much as possible
Spirometry: A baseline spirometry should also be performed once a year during follow-up evaluations
Assessment of asthma control should not be based solely on individual single measurements and limited interactions
Asthma control represents the degree to which manifestations of asthma
are minimized and the goals of therapy are met, and should be used as a guide to either maintain or
adjust therapy.
Responsiveness refers to the ease with which prescribed therapy achieves asthma control
the degree of control can change over time; thus, constant review of symptoms and treatment every 1 to 6 months is helpful
Apart from the assessment of severity and control, the predisposition to risk for exacerbations should also be kept in mind.
For instance, a child with intermittent asthma may not need daily controller medication based on the initial assessment of severity,
but the child may still have an unexpectedly severe exacerbation triggered by, for example, a viral infection
Asthma severity index and asthma control index basically contains the following parameters. Aim is to bring the symptoms to the intermittent range of asthma severity and Spirometry results to normal physiologic
1. Basic facts about asthma
Differences between normal and asthmatic airway, preferably using models
Links between airways inflammation, hyperreactivity, and bronchoconstriction
2. Environmental exposures
Comorbid conditions
4. Also provide asthma plan for school
Meds: taste, dosing schedule, difficulties with devices, side effects, and expense
medication regimens tends to be suboptimal
Patient:; misperception of disease severity, misunderstanding instructions
Physician; failure to monitor patients regularly, and incorrect medication and dosage
1. Put your mattresses and pillows in special allergen-proof covers.
Remove all animal products from bedding (e.g. feather pillows and down comforters).
Wash your bedding every week in hot water
2. Keep the bathroom dry by using an exhaust fan or dehumidifier.
Clean sinks, tubs and showers often with a bleach solution (1 part bleach, 3 parts water).
Limit house plants as they are sources of dampness and mold.
3. During allergy season, use air conditioning instead of opening the windows at home and in the car.
hange the air conditioner filter monthly.
Shower or bathe after being outdoors
4. Keep pets outside, if possible.
Keep them off the furniture.
Keep pets out of the bedrooms.
Bathe your pets weekl
5. Some medications, such as aspirin or beta blockers
6. These chemicals are found in wine, beer, shrimp, dried fruit and processed potatoes, and can cause breathing difficulty for many people with asthma.
7. Smoking and secondhand smoke irritate the lungs. Do not use wood burning stoves or fireplaces and avoid campfires
8. Perfumes, sprays and cleaning products
9. Strong emotions, such as anger and anxiety, can lead to changes in breathing that can cause asthma symptoms or make them worse
10. Take your asthma medicine as prescribed. Warm up by exercising slowly at first. Limit exercise if you are ill or if the weather is cold and dry.
relief medication for quick relief of acute symptoms and exacerbations
controller medication for long-term control of the underlying pathophysiologic mechanism of asthma
inhaled corticosteroids (ICS), combination ICS and long-acting β-agonists (ICS-LABA), leukotriene receptor antagonists (LTRA),
5 y step 2-4 consider allergen immunotherapy
SABA > 2 d / week should alert
SABA:Excessive reliance on quick relievers has been associated with increased risk for death or worsening asthma.
ipratropium: This agent decreases vagal tone (resulting in bronchodilation)
Steroids: These drugs have broad anti-inflammatory effects and are usually used as a short 3- to 5-day course to gain initial control of asthma and to speed resolution of moderate or severe persistent exacerbation
1. Inhaled corticosteroids are recommended as the first-line treatment for most types of persistent asthma.
inhibition of inflammatory cytokines and upregulation of β2-receptor responsiveness.
improve pulmonary function, reduce the need for quick-relief medications,
2. are not intended for treating acute exacerbations or as monotherapy for persistent asthma
up to 12 hours
The FDA also specifies that LABAs should be discontinued when asthma control is achieved,
and asthma should be maintained with controllers such as ICS
3. montelukast > 6mand zafirlukast,>5y that block LTD4 receptors, Zileuton >12y
4. they need to be administered frequently (4 times a day) and are not as efficacious as ICS or leukotriene antagonists
5. omalizumab : is an anti-IgE humanized monoclonal antibody that binds circulating IgE, thereby binding the high-affinity receptor and preventing IgE-mediated allergic responses and inflammatory cascade
6. administered every 2 to 4 weeks subcutaneously
Issues to consider include the drug delivery device, dose level, formulation of the preparation, bioavailability, potency of the inhaled corticosteroid, and deposition either in the pulmonary system or in the gastrointestinal system
Allergy shots work like a vaccine. Your body responds to injected amounts of a particular allergen, given in gradually increasing doses, by develop resistance to allergen
Of great concern is that many of these fatal outcomes occur in children viewed as having mild disease..
Risk of death increase with Prior admissions to an intensive care unit, Prior intubation for asthma and sometimes when they have Difficulty perceiving airflow obstruction or its severity, Use of more than 1 canister per month