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DIAGNOSIS,
MANAGEMENT AND
PREVENTION OF
ASTHMA IN CHILDREN
Raymund L. Manuel M.D.,
D.P.P.S.,D.P.A.P.P.
Pediatric Pulmonologist
OBJECTIVES
• To present and compare the GINA
2002 with GINA
2006 guidelines
• To update clinicians with the newer
approach to the management asthma
in children
GLOBAL INITIATIVE FOR ASTHMA
(G.I.N.A.)
Initiated in 1989
• US National Heart, Lung and Blood Institute
• National Institute of Health
• World Health Organization
• Undergone 3 major revisions (1995, 2002, 2006)
OBJECTIVES:
• To increase appreciation for global public health
perspectives of asthma
• Recommend diagnostic and management strategies
• Identify areas for future investigations
GLOBAL INITIATIVE FOR ASTHMA
(G.I.N.A.)
Undergone 3 major revisions (1995, 2002, 2006)
OPERATIONAL DEFINITION:
“ Asthma is a chronic inflammatory disorder of the airways
in which many cells and cellular elements play a role. The chronic
inflammation is associated with airway hyper responsiveness that
leads to recurrent episodes of wheezing, breathlessness, chest
tightness, and coughing, particularly at night or in the early
morning. These episodes are usually associated with widespread,
but variable, airflow obstruction within the lung that is often
reversible either spontaneously or with treatment”
GINA ASTHMA GUIDELINES:
2002 2006
Inflammation is persistent
HOST FACTORS
Genetic, e.g.,
Genes pre-disposing to atopy
Genes pre-disposing to airway hyperresponsiveness
Obesity
Sex
ENVIRONMENTAL FACTORS
Allergens
Indoor: Domestic mites, furred animals(dogs, cats, mice) cockroach
allergen, fungi, molds, yeast
Outdoor: Pollens, fungi, molds, yeasts
Infections (predominantly viral)
Occupational sensitizers
Tobacco smoke
Passive smoking
Active smoking
Outdoor/Indoor Air Pollution
Diet
Global Initiative for Asthma (GINA)
2006 updates
Lung function testing by spirometry of
Peak expiratory flow (P.E.F.) continues to
be recommended as an aid to the
diagnosis and monitoring.
Measuring the variability of airflow is the
key to both asthma diagnosis and the
assessment of asthma control.
ASTHMA: Diagnosis
Predicted normal PEFR in Filipino Children
between 6 – 17 years with height of at
least 100 cms.
Severity INTERMITTENT
PERSISTENT
Mild Moderate
Severe
REDUCE
LEVEL OF CONTROL TREATMENT OF ACTION
INCREASE
uncontrolled step up until controlled
DIAGNOSIS:
2002 2006 - 07
Reversibility of Often prompted by symptoms:
measurements episodic breathlessness
of lung function wheezing
enhances cough
confidence chest tightness
in making a Assessment of the severity of airflow
diagnosis of limitation
asthma Reversibility and variability confirms the
Diagnosis of asthma
Exacerbation ?
Yes No
Management of Chronic
Therapy
Exacerbation
Level of Control
Chronic Therapy
ASTHMA CONTROL
(GINA 2006)
Decreased bronchoprotection
Increased vulnerability to
attacks
Exacerbation ?
Yes No
Management of Chronic
Therapy
Exacerbation
Level of Control
GINA ASTHMA GUIDELINES:
2002 2006-07
Severity of Asthma
Exacerbations
MILD MODERATE SEVERE RESPIRATORY
ARREST
IMMINENT
Good Response within 1-2 Incomplete Response within 1-2 Poor Response within 1-2 hours:
hours: hours: Risk factors fro near fatal asthma
Response sustained 60 minutes Risk Factors for near fatal asthma PE : symptoms severe, drowsiness,
after last treatment PE : mild to moderate signs confusion
PE normal: no distress PEF < 60% PEF : < 30%
PEF > 70% O2 saturation: NOT IMPROVING PCO2 : > 45mmHg
O2 saturation > 90% (95% in PO2: < 60mmHg
children) ADMIT to ACUTE CARE Setting
• Oxygen ADMIT to INTENSIVE Care
• Inhaled β2-agonist ± • Oxygen
anticholinergic • Inhaled β2-
• Systemic GCS agonist+anticholinergic
• Intravenous Magnesium • IV GCS
•Monitor PEF, O2 saturation, Pulse •Consider IV β2 agonist
• Consider IV theophylline
• Possible intubation
Improved: Criteria for Discharging Home • mechanical ventilation
PEF > 60% predicted / personal best
Sustained on oral/inhaled medications
Reassess at Intervals
HOME TREATMENT:
• Continue inhaled β2 agonist Poor Response:
•Consider in most cases, oral GCS • Admit to intensive Care
•Consider adding a combination inhaler Incomplete response in 6-12 hours
•Patient education: take medicine correctly • Consider admission to Intensive Care
review action plan Improved •If No improvement within hours
close medical check up
Inhaled short acting
β2-agonists are the
mainstay of therapy in
acute asthma.
However, once response to the
initial β2-agonists is
minimal, incomplete or poor
COMBINATION of INHALED β2-
AGONIST and INHALED
ANTICHOLINERGIC is
RECOMMENDED
What is the role of
Salbutamol – Ipratropium in
acute asthmatic attacks?
INTERMITTENT
Inhaled Corticosteroids:
Cornerstone in the Management
Of Asthma
Inhaled Corticosteroids
• Most effective long-term control for persistent
asthma
• Small risk for adverse events at recommended
dosage
• Benefits of daily use
– Reduction of
• asthma symptoms
• frequency of exacerbations
• airway inflammation
• airway responsiveness
• asthma mortality
– Improvement of
• lung function
• quality of life
Inhaled Corticosteroids
Adverse Events
• Small risk for adverse events at
recommended doses
• Reduce potential for adverse events by:
– Using spacer
– Rinsing mouth
GINA ASTHMA GUIDELINES 2002,2006,2007
Maintenance Therapy:
Stepping Down
Maintenance Therapy:
Stepping Up
Maintenance Therapy:
Stepping Up
Maintenance Therapy:
2002 2006 2007
Not
IGCS mentioned Not recommended As maintenance and rescue
+ LABA As form of For children ≤ 5 Medication has shown to
therapy years reduce exacerbations in
children ≥ 4 years with
moderate & severe asthma
GINA ASTHMA GUIDELINES 2002, 2006
Indications:
Moderate-severe persistent atopic
asthmatics uncontrolled by steroids
Age 12 and above
– An immediate hypersensitivity
response to relevant environmental
allergens by appropriate diagnostic
tests (skin test, IgE antibody) should
Specific Immunotherapy
The decision to initiate immunotherapy
should
be guided by the following considerations:
This plan will help you control your Three ways to control your asthma:
- asthma and know what to do if you have 1. Follow your GREEN zone plan everyday
an asthma episode. to prevent most asthma
- Keeping your asthma under control will symptoms from starting.
help you: 2. Recognize your symptoms of an an acute
asthma attack.
- Take part in normal physical activity like
being active in exercise and in sports. Follow the YELLOW zone plan to
prevent a asthma attack from
-Sleep through the night without having
asthma episodes. getting worse.
- Prevent asthma attacks. 3. In cases of emergency , follow the RED
zone plan.
- Have the best possible peak flow number.
- Avoid side effects from medicines.
* See your doctor regularly.
* This action plan will need to be updated as
the patient’s condition changes
ASTHMA ACTION PLAN
Name_________________________
Parent________________________Guardian______________________
Address_______________________
Home phone___________________Work phone____________________
ACTION:
- Continue with your current
medication as prescribed below:
YELLOW ZONE: Acute Attack
- Presence of at least 1 of the following: (cough,
wheeze, chest tightness or shortness of breath)
- Waking at night due to asthma
- Can do some but not all usual activities
- Peak flow meter: _____ to _____
(60 to 79% of your personal best)
ACTION:
-Take your quick-relief inhaled brochodilator_______________
every 20 minutes up to 3 doses until relieved
- Proceed to ER for further evaluation & possible admission if:
1. getting worse at anytime
2. if no relief after 3 doses of inhaled β2 agonist
On your way to ER, continue your quick relief inhaled
bronchodilator every 20 minutes and take 1 dose of oral steroids
as follows:__________________
RED ZONE: EMERGENCY!!!
- Presence of any:(Trouble walking or talking due to
shortness of breath, lips and fingernails are blue)
-Quick relief medicines have not helped
-Cannot do usual activities
-Symptoms are getting worse
-Peak flow meter: _____ (< 60 % of your personal best)
ACTION:
- Proceed to ER
- Take immediately 1 dose of your quick relief inhaled
bronchodilator and continue your inhaled bronchodilator
every 20 minutes while in transit
- Take 1 dose oral steroids as follows:
How will I know if my baby has
ASTHMA?
• Infantile asthma is recurrent
wheezing in infants who are at
risk of developing persistent
symptoms beyond infancy.
• Considered a syndrome that
starts during infancy and persists
up to adulthood.
• AVan
duration of at least
Bever.Indian 6 months
Pediatrics 2004;
and
41: frequency
1101-1104 of at least 3
attacks.
Is there a way of predicting if my
baby will have asthma later in life?
ASTHMA PREDICTIVE INDEX
• Recurrent episodes of wheezing:
>3 episodes in the past year that
lasted >1day and affected sleep.
• Major criteria:
1. Physician-diagnosed atopic
dermatitis
2. Physician-diagnosed parental
asthma
• Minor criteria:
1. Peripheral blood eosinophilia ≥
4%
2. Wheezing apart from colds
How is infantile asthma managed?
When do you start steroids in
infantile asthma?
Asthma Diagnosis: Cough
Causes Percentage
Post Nasal Drip (%) 41
Asthma 24
GER 21
Chronic Bronchitis 5
Bronchiectasis 4
MISC. 5
Representative Causes of Chronic Cough from a Prospective Study
Irwin et al. Ann. Rev. Resp. Dis. 1990
GINA ASTHMA GUIDELINES 2002,2006-
07
Foods ++ + + +
Emotions + + +
House Dust Mite
Cockroach
Exposure to >0.05 mcg/gm of cockroach
allergen increases the risk of asthma.
Indications:
Moderate-severe persistent atopic
asthmatics uncontrolled by steroids
Age 12 and above
Indications:
INCREASE
uncontrolled step up until controlled
REDUCE INCREASE
TREATMENT STEPS
STEP STEP STEP STEP STEP
1 2 3 4 5
Global Initiative for Asthma (GINA)
2006 updates
7. Increased use, especially daily use, of reliever
medication is a warning of deterioration of
asthma control and indicates the need to reassess
treatment
• Exercise-induced asthma
• Nocturnal asthma
SALMETEROL VS. THEOPHYLLINE:
SLEEP AND EFFICACY OUTCOMES IN
PATIENTS WITH NOCTURNAL
ASTHMA
Salmeterol was superior to theophylline
in:
• Sustained improvement in morning PEF
• Protection from night time lung function
deterioration
• Reduction in salbutamol use
• Improvement in patient perception of
Wiegand, L Chest
sleep 1999
PHARMACOLOGICAL PROFILES
OF FORMOTEROL AND
SALMETEROL
FORMOTEROL SALMETEROL
Chemical class Formanilide Saligenin
Lipid solubility Moderate High
Selectivity for High Very high
B2-adrenoceptor
Receptor High affinity, High affinity,
binding reversible poorly reversible
Agonist activity Fullagonist Partialagonist
Onset of action 3 minutes 10-20 minutes
FDA approved >6yrs. old: 6ug BID >4yrs. old: 50ug
dose >12yrs. old: 12ug BID BID
Rapid Acting Inhaled β2 Agonists
Initial Treatment
• Oxygen to achieve O2 saturation > 90% (95% in children)
• Inhaled rapid- acting B2 agonist continuously for one hour
• Systemic glucocorticosteroids if no immediate response, or if
patient recently took oral glucocorticosteroids, or if episode is
severe
• Sedation is contraindicated in the treatment of an exacerbation
1) cyanosis
2) absence of wheeze
3) bradycardia and bradypnea
4) paradoxical thoraco-abdominal movement
5) drowsiness or confusion
6) a normal or elevated pCO2 in a patient with
severe distress
High Risk Patients
( GOOD RESPONDERS)
Patient Discharge
From the Hospital
Initial Treatment
• Oxygen to achieve O2 saturation > 90% (95% in children)
• Inhaled rapid- acting B2 agonist continuously for one hour
• Systemic glucocorticosteroids if no immediate response, or if
patient recently took oral glucocorticosteroids, or if episode is
severe
• Sedation is contraindicated in the treatment of an exacerbation
1) cyanosis
2) absence of wheeze
3) bradycardia and bradypnea
4) paradoxical thoraco-abdominal movement
5) drowsiness or confusion
6) a normal or elevated pCO2 in a patient with
severe distress
High Risk Patients
( GOOD RESPONDERS)
Patient Discharge
From the Hospital
• Do the patient’s colds “go to the chest” or take more than 10 days
to clear up?
INTERMITTENT PERSISTENT
MILD MODERATE SEVERE
Daily Controller • None IGCS 400-800µg BUD • IGCS >800µg BUD
• IGCS
Medications necessary 100-400mcg
PLUS one or more
of the following:
BUD
REDUCE
LEVEL OF CONTROL TREATMENT OF ACTION
INCREASE
uncontrolled step up until controlled
asthma education
environmental control
as needed
rapid
acting β2-
as needed rapid acting β2-
agonist SELECT agonist
SELECT ONE ADD ONE OR ADD ONE OR
ONE MORE BOTH
low-dose low-dose ICS Medium- or Oral gluco-
ICS* plus LABA high-dose ICS corticosteroid
CONTROLLER
plus LABA
leukotriene Medium- or leukotriene Anti-IgE
OPTIONS