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Asthma

Management pediatric asthma


British Thoracic Society; Scottish Intercollegiate Guidelines Network. 2005
Update to the British Guideline on the Management of Asthma, originally
published in 2003.

Initial treatment is based on severity of clinical condition as determined


by PEFR or the Paediatric Asthma Severity Score (performed by admitting
doctor).

Initial treatment is multidose 2 agonists via metered dose inhalers


with spacer (+/- mask/mouthpiece).

Oral steroids to be given early.

Inhaled Ipratropium bromide to be given early in moderate and


severe asthma/wheeze.

Intravenous Aminophylline and 2 agonists to be added if severe


episode.

Consider the use of intravenous Magnesium sulphate if response


unsatisfactory.
PASS (Paediatric Asthma Severity Score)
0

Wheeze

None

Moderate

Severe/absent

Work of breathing

None

Moderate

Severe

Prolonged Expiration

None

Moderate

Severe

Diagnosis
Objective Measurements Spirometry is the gold standard of objective measurements
for asthma. Airflow obstruction is indicated by reduced FEV1 (forced expiratory volume in
1 second) and a reduced FEV1:FVC (forced vital capacity) ratio. Since spirometry should
be a part of routine care, physicians who treat many asthma patients should have a

spirometer in the office. An adequate unit with automated printouts and predicted values
can now be purchased for less than $2000.

Epidemiology
Asthma is a reversible obstructive lung disease, caused by
increased reaction of the airways to various stimuli. It is a chronic
inflammatory condition with acute exacerbations. Asthma can be a
life-threatening disease if not properly managed.

Asthma is one of the most common chronic disorders in


childhood, currently affecting an estimated 7.1 million children
under 18 years; of which 4.1 million suffered from an asthma attack
or episode in 2011.1

An asthma episode is a series of events that results in


narrowed airways. These include: swelling of the lining, tightening of
the muscle, and increased secretion of mucus in the airway. The
narrowed airway is responsible for the difficulty in breathing with the
familiar wheeze.

Asthma is characterized by excessive sensitivity of the lungs to


various stimuli. Triggers range from viral infections to allergies, to
irritating gases and particles in the air. Each child reacts differently
to the factors that may trigger asthma, including:
respiratory infections and colds
cigarette smoke
allergic reactions to such allergens as pollen,
mold, animal dander, feather, dust, food, and cockroaches
indoor and outdoor air pollutants, including ozone
and particle pollution
exposure to cold air or sudden temperature
change
excitement/stress
exercise
Secondhand smoke can cause serious harm to children. An
estimated 400,000 to one million children with asthma have their
condition worsened by exposure to secondhand smoke.2

Asthma can be a life-threatening disease if not properly


managed. In 2011, 3,345 deaths were attributed to asthma.
However, deaths due to asthma are rare among children. The
number of deaths increases with age. In 2011, 169 children under
15 died from asthma compared to 633 adults over 85.3

Asthma is the third leading cause of hospitalization among


children under the age of 15. Approximately 29 percent of all
asthma hospital discharges in 2010 were in those under 15,
however only 20% of the U.S. population was less than 15
years old.4

THE CLINICAL PROBLEM

Asthma is a chronic inflammatory disease of the airways that is


characterized by variable narrowing of the airways
Symptoms: intermittent dyspnea, wheezing, and nighttime or earlymorning coughing.
Asthma is clinically heterogeneous, and its pathophysiology is
complex.3 Airway eosinophilic inflammation is typical, but many
patients with mild asthma have persistently noneosinophilic disease.
Airway hyperresponsiveness is a consistent feature; irreversible
airflow obstruction develops in some patients, presumably as a
consequence of remodeling of the airway wall. Short periods of loss
of asthma control may occur as a result of exposure to nonspecific
triggers, such as fumes, strong smells, or exercise. Moderate or
severe exacerbations are usually due to exposure to allergens or
viruses, particularly human rhinovirus.
*The development of asthma in children is influenced by genetic
predisposition as well as by environmental factors, including viral
infection and sensitization to aeroallergens (e.g., house dust mites
or animal dander).
*Persons who are born and raised on a farm have a reduced risk of
allergy and asthma, probably because they have been exposed to a
wide variety of microorganisms.

*Risk factors for the development of asthma in middle-aged and


older adults are diverse and include work-related exposures (e.g.,
isocyanates or cleaning products) and lifestyle factors (e.g., smoking
or obesity).