2013 Update

Asthma Training Module

based on

Asthma By Consensus
IAP
National Guidelines for the Management of Childhood Asthma

2013 Update

Asthma Training Module

Protected under copyright.
Any further usage of this presentation implies that you have read and accepted the terms of use of this module. The material is meant for the training of a registered medical practitioner only. The module provides overall guidelines for managing childhood asthma. The decision for individual case management should be based on their own merit.

Todays tasks
Must know

Basic pathophysiology Diagnosis of asthma Long term management Managing acute attac s !emonstration time

"at#h for these sym$ols

This symbol calls for interaction with the spea er

interact !

PEP Talk

This symbol indicates a Parent "ducation Point

Basi#s % $ri#k and mortar &

Asthma
$haracteri%ed by
Airway

#hroni# inf lammation hy'er res'onsi(eness o$stru#tion%re(ersi$le

IN!)C*+, Allergens Maternal smo ing' $hemicals' Air pollutants' (irus infections

Geneti# 'ro'ensity IN-.AMMATI/N

Airway ,yper-responsiveness

Airflow Limitation

T+IGG*+,
")ercise $old Air' *+2 Particulates (irus infections

,0MPT/M ,

Inf lammation in asthma

,u'erim'osed a#ute inf lammation

Chroni# inf lammation

,tru#tural #hanges

Airway remodeling

Time

!iagnosis of asthma
The story begins00

Clini#al e(aluation
Ascertain diagnosis 1dentify #o%mor$id #onditions Thin of alternate diagnosis 2rade se(erity 1dentify triggers

!iagnosis of asthma

.ets look at some #ase histories

Case11Ar'it
& year old Arpit was seen for recurrent cough for about 3 year. ,is mother reported that he fre5uently had colds which went to the chest

"hat further 2uestions will you ask3

interact !

Ask for11

6ecurrent #ough3 6ecurrent whee4e3 6ecurrent $reathlessness3 A#ti(ity5stress indu#ed cough7whee%e8 No#turnal cough8 Tightness of chest8

Symptoms of airf low obstruction

And 2ualifiers of asthma

+e#urrent e'isodes of airflow obstruction with several of the following9
6 Afe$rile episodes Personal atopy or -amily h5o ato'y 7 asthma No#turnal e)acerbations ,tress5A#ti(ity induced symptoms Trigger induced symptoms ,easonal e)acerbations +elief with $ron#hodilators : oral steroid

Ar'it #ontinued

"hat do you e7'e#t to find when you e7amine Ar'it3

interact !

.ook for11
,igns of airf low o$stru#tion /ther features of ato'y
Ato'i# dermatitis 5 2enerali%ed whee4e Prolonged e7'iration *#4ema Allergi# rhinitis 5

#on8un#ti(itis In the hy'erinf interval period, be normal $hest lation chest examination may

Ar'it #ontd
Arpit<s mother reported that every episode started with a cold and snee%ing. Arpit often reported an earache and had ta en multiple courses of antibiotics for ear infections. =1s Arpit a mouth breather and snorer 8> 1 as ed0

"hat is the rele(an#e of this history3

interact !

 Ascertain diagnosis

Identify #o%mor$id #onditions

Thin of alternate diagnosis 2rade se(erity 1dentify triggers

Co mor$id #onditions
Allergi# rhinosinusitis

PEP Talk

*nee%ing in the morning' nasal itching 6unning 7Bloc ed nose' snoring' mouth breathing

Adenoidal hy'ertro'hy

$olds' ear infections Bloc ed nose' snoring' mouth breathing

Gastroeso'hageal ref lu7 disease 9G*+!:

?octurnal cough 7 vomiting Theophylline 7 +ral @2 agonist usage

.ook for11
*igns of allergic rhino-sinusitis

?asal mucosa B edema' pale or violaceous $lear nasal discharge 7Bloc ed nose Post nasal drip $obblestone pharyn)

 Ascertain diagnosis 1dentify co-morbid conditions

Think of alternate diagnosis

2rade se(erity 1dentify triggers

Think of alternate diagnosis&

If 'resentation is $elow si7 months of age

Consider
(irus associated whee%e Aspiration syndromes e.g. 2" reflu) disease $ongenital airway anomalies $ongenital heart disease Cloo for murmursD

Think of alternate diagnosis&

If lo#ali4ing signs are 'resent

Ene5ual air entry Enilateral emphysema 6adiological locali%ation

Consider airway obstruction

Foreign body aspiration $ongenital anomalies

Think of alternate diagnosis&

"ith 'ersistent res'iratory sym'toms

Consider
6hino sinusitis Foreign Body Tuberculosis Pertussis

Think of alternate diagnosis&

If unusual features 'resent

Failure to thrive Multiple multifocal infections $lubbing $onsanguinity Malabsorption

Consider

$ystic fibrosis Primary ciliary dys inesia 1mmunodeficiency

Ar'it1 #ontinued

;ow will you 'ro#eed to in(estigate Ar'it3

interact !

Asthma is a #lini#al diagnosis

Typical history $B$ B may show eosino'hilia <ray chest-may be normal5hy'erinf lated Predi#ta$le $ron#hodilator res'onse

Investi ations help to rule out alternate dia noses, not to prove asthma!

Breaking the news&

=Arpit has asthma> 1 told the mother. *he loo ed bewildered. =?obody told me that> she said. =My previous doctor called it Gallergic bronchitis< and the family physician says its Gasthmatic bronchitis<>

"hat will you tell her3

interact !

"hats in a name 3

Acceptance of the diagnosis is the f irst step to successful management

=But doctor> she e)claimed' =AsthmaH And no breathlessness80 Are you sure8>

;ow do you #on(in#e this an7ious lady3

interact !

The asthma i#e$erg

Breathlessness 0 the tip

PEP Talk

ugh o c t n e r 6ecur 6ecu rrent whee %e h g u co l a n r ?octu Ti ghtne ss of chest

All Asthma !oes Not "hee4e

Arpit<s mother as s whether lung function testing 7 allergy testing will help to prove what 1 am telling her8

$an P"F6 help in the diagnosis 8 As ed the physician who accompanied the an)ious family8

,'irometry 5P*-+5 Allergy testing

,'irometry
when clinical diagnosis is in doubt B older children "ffort dependent- proper techni5ue critical

PEP Talk

Peak f low
has a limited role in diagnosis Best used for monitoring

Allergy testing 5 Ig* le(els 5 +A,T have no role in diagnosis

Demonstration time

Coming to terms
=1 now understand what you have said so far0> said Arpit<s mom. =Tell me' doc' what e)actly is asthma8>

,im'lify the story for her

interact !

Asthma #om'onents
;ealthy Airway
Alveolar partition

P"P Tal

Asthmati# Airway
1nflammation and swelling Mucus and plasma outpouring

*mooth muscle "pithelium CliningD

*mooth muscle constriction

"pithelial shedding 7 damage

The first time whee4er

1ts December. Amit' Arpit<s younger brother is = months old. ,e presents with a whee%e for the first time along with a fever' cold and cough. =?ot againH> e)claimed the parentsH

,ow will you manage this case and counsel the family8

interact !

A#ute Bron#hiolitis
First episode of whee%ing in a young child Cup to 2 yrsD *tarts with cory%a' usually with fever $lustered in winter and rainy months ?o atypical features

The first time whee4er

I ! episodes of airflow obstruction A?D

PEP Talk

a family h7o asthma7atopy or personal h7o atopy "ollow up #or other $uali#yin #eatures be#ore assi nin a dia nosis o# asthma

+isk fa#tors for Asthma

+ther atopies

PEP Talk

atopic dermatitis Allergic rhinitis 7 conJunctivitis

Asthma 7 atopy in family

sibling - dou$les ris one parent - dou$les ris $oth parents - tri'les ris

As compared to general population

The early whee4er

1ndu' who is Arpit<s neighbour' has come to see you. *he is eighteen months old and she has been getting recurrent cough' cold' fever and whee%ing since she Joined a creche si) months ago..

$ould this be asthma8 Kill she outgrow this8

interact !

*'isodi# 9(iral: "hee4er

Associated with a febrile viral respiratory infections Discrete episodes of whee%ing Kell between episodes Esually no personal or family history of atopy

Another early whee4er

*ushil' > years old' has been getting recurrent cough' cold and whee%ing with fever since 8oining the #re#he as well. ,e also starts whee%ing when e7'osed to #igarette smoke or his visit to his farmhouse.

$ould this be asthma8

interact !

Multi trigger whee4er

Triggers apart from viral E6T1 Afebrile episodes also present Discrete episodes +ften symptomatic between episodes *trongly suspect asthma when associated with personal and family history of atopy

#!

)nder fi(e whee4ers

% a mi7ed $ag

All that whee%es is ?+T asthma

"pisodic CviralDwhee%er Multi-trigger whee%er Khee%er with atypical features Acute Bronchiolitis

##

)nder ? whee4ing % summary

,ummary so far11
Diagnosis is #lini#al
6ecurrent episodes of airflow obstruction are present Airway obstruction is reversible Alternative diagnoses are e)cluded $o-morbid conditions are identified The under-; whee%er is a mi)ed bag

Managing asthma%long term Managing under ? whee4ing

*ome pharmacology and essentials of inhaled therapy.

!rugs
+elie(ers
Esed in a need based manner for treatment of bronchospasm and to relieve acute attac s

Controllers
Esed on daily long term basis for control of inflammation and to prevent further attac s

Controllers
Inhaled
Corti#osteroids9IC,: .ong a#ting inhaled >%agonists 9.ABA:

/ral
.eukotriene antagonists Theo'hylline % ,+ /ral 'rednisolone

Inhaled Corti#osteroids
*stimated e2ui'otent daily doses of IC, Children @ A> years
Drug
Budesonide Fluticasone Beclomethasone

Low dose CLgD 344-244 344-244 344-244

Medium dose ,igh dose CLgD CLgD M244-#44 M244-;44 M244-#44 M#44 M;44 M#44

Inhaled Corti#osteroids
*stimated e2ui'otent daily doses of IC, Children B A> years
Drug
Budesonide Fluticasone $iclesonide Beclomethasone

Low dose CLgD 344-#44 344-2;4 /4-3&4 244-;44

Medium dose ,igh dose CLgD CLgD M#44-/44 M2;4-;44 M3&4-!24 M;44-3444 M/44 M;44 M!24 M3444

"hy ,teroids 3
,u'erim'osed a#ute inf lammation A#ute inf lammation

,ystemi# steroids

Chroni# inf lammation

Airway remodeling

Chroni# inf lammation Inhaled steroids

Airway remodeling

,tru#tural #hanges

,tru#tural #hanges

Time

Time

Inhaled steroids
%'ra#ti#e 'oints
Anti%inf lammatory effe#t evident in 3-2 wee s.

PEP Talk

Local adverse effects B thrush7dysphonia minimi4ed $y s'a#er5gargling Esually re5uired inhaled doses- negligi$le systemi# effects Prolonged high dose - monitor growth and eyes CcataractsD.

In practice, most children need low doses

PEP Talk

Uncontrolled asthma is more li%ely to cause rowth #ailure than usually needed doses o# inhaled steroids

.ABA 9,almeterolC -ormoterol:

%'ra#ti#e 'oints
+nly as add on to 1$* and never alone as controller *teroid sparing and synergistic effect with 1$* Advised for use M # years of age for want of data in younger children +ral LABA have no role in asthma management

.eukotriene antagonists
% 'ra#ti#e 'oints
Kea antiBinflammatory effect compared to 1$* Add-on in moderate 7severe asthma 1nferior to 1$* in mild persistent asthma Eseful in ")ercise induced asthma May be used when concomitant allergic rhinitis Montelu ast approved for M & months of age

,+%Theo'hylline
% 'ra#ti#e 'oints
Anti%inf lammatory5immunomodulator $urrently used as a #ontroller Esed as adJunct to inhaled steroids Colder childrenD

&o role o# syrup #ormulations

Monitor ad(erse effe#ts- clinically and blood levels Beware f lu#tuations in levels - fever' anti TB treatment' anticonvulsants' 5uinolones' macrolides

.ong term oral steroids

% 'ra#ti#e 'oints
Ese limited to severe persistent asthma Minimal possible dose Alternate day morning dose is preferred Cto reduce ,P a)is suppressionD. Prednisolone - best option Monitor growth Cheight7weightD' eyes' s in' bone density' immune suppression' ,PA suppression.

!rug deli(ery % inhaled route

1nhalation Device Delivery
MD1 with spacer 34- 3;N Metered dose inhaler CMD1D ; - 34N Dry powder inhaler CDP1D ; - 34N ?ebuli%er 3- ;N

+ole of s'a#ers

PEP Talk

"liminate need for hand - breath #o%ordination +edu#e lo#al side effe#ts of inhaled steroids Im'ro(e drug deli(ery !ilute taste of inhaled sprays. "liminate #old freon effect Cwith $F$D

'hen usin ()Is, *pacer is a must

Ty'es of s'a#ers
*mall volume vs large volume (alved vs non valved Polyamide vs polycarbonate

Use any spacer but

USE A SPACER

+ole of mask
*pacer with well fitting mas

PEP Talk

Below O ! years or anyone who cannot breathe consciously through mouthpiece of spacer.

*pacer alone

Above O ! years' or +nce a child learns to breathe through mouthpiece mas should be removed.

;ow do you initiate inhaled thera'y3

interact !

The D ste's
3. ")plain advantages of inhaled therapy
2. Dispel myths and fears !. *elect an appropriate device #. Demonstrate how to use the selected device

Ad(antages of inhaled thera'y

Inhaled
6oute Dose +nset of action Direct *mall 6apid

PEP Talk

/ral
1ndirect ,igher *low

Adverse effects Mild-none 2reater Smaller dose, target delivery, quic er action, lesser side e##ects

The D ste's
")plain advantages of inhaled therapy

2. Dispel myths and fears

!. *elect an appropriate device #. Demonstrate how to use the selected device

!is'elling myths and fears

1s inhaler therapy Gstrong<8

PEP Talk

N/ *m'hasi4e mi#rograms

1s inhaler therapy Gaddictive<8 N/ None of the drugs #ause de'enden#e 1s inhaler therapy e)pensive8 N/ Initially yesC $ut ultimately N/ 1s inhaler therapy easy for children to use8 0*,

+he #irst choice, not the last resort ,,,

The D ste's
")plain advantages of inhaled therapy Dispel myths and fears

!. *elect an appropriate device

#. Demonstrate how to use the selected device

The right de(i#e

$riteria for selection

PEP Talk

Age $ontroller use Acute episodes

,ele#ting the right de(i#e

Age

PEP Talk

I O! years B MD1 P spacer P mas M O! years B MD1 P spacer M & years B MD1 P spacer - Dry Powder 1nhalerCDP1D is an option

()I - spacer is the most versatile device

,ele#ting the right de(i#e

$ontroller regimen

PEP Talk

Moderate to high dose 1$*

Ese MD1 P spacer instead of DP1 even in older children

,ele#ting the right de(i#e

Acute episodes

PEP Talk

,ome ,ospital

- MD1 P spacer P mas 7 DP1 - MD1 P spacer P mas - ?ebuliser in severe episodes

!o not use !PI in moderate"se#ere e$acerbations

The D ste's
")plain advantages of inhaled therapy Dispel myths and fears *elect an appropriate device

#. Demonstrate how to use the selected device

Demonstration time

Managing the under ? whee4er

Amit 9re#a':
E the first time whee4er
1ts December. Amit' Arpit<s younger brother is = months old. ,e presents with a whee%e for the first time along with a fever' cold and cough. =?ot againH> e)claimed the parentsH

,ow will you manage him8

interact !

Bron#hiolitis
Management

A#ute e'isode

+)ygen in severe cases +ral 7 nebulised @2 agonists ?ebulised adrenaline is preferred *ymptomatic therapy

.ong term thera'y

?ot indicated

Indu 9re#a':
% the early whee4er
1ndu' who is Arpit<s neighbour' has come to see you. *he is eighteen months old and she has been getting recurrent cough' cold' fe(er and whee%ing since she 8oined a #re#he si) months ago..

,ow should she be treated8

interact !

*'isodi# 9(iral: "hee4er

Management
A#ute e'isode

+)ygen in severe cases +ral71nhaled @2 agonists *teroids B when severe or with associated ris factors

.ong term thera'y

1f severe or fre5uent episodes CM once a monthD Daily 1$* may be beneficial 1ntermittent LT6A- Limited effect

,ushil 9re#a':
E the multi trigger whee4er
*ushil' > years old' has been getting recurrent cough' cold and whee%ing with fever since 8oining the #re#he as well. ,e also starts whee%ing when e7'osed to #igarette smoke or his visit to his farmhouse.

*hould he be treated as asthma8

interact !

Multi trigger whee4er

Management

A#ute e'isode

+)ygen Cin severe casesD Treat with inhaled or oral bronchodilators depending on severity. @2 agonists are main stay of therapy Ese steroids early' particularly if personal 7 family history of atopy present

Multi%trigger whee4er
Management

.ong Term Thera'y

A trial of 1$* C#44 mcg per dayD

1f no clear benefit within #-& wee s of initial therapy B $onsider alternative diagnoses 1f good response' give for /-32 wee s and stop.

1f recurrence on stopping' label and treat as asthma LT6A - a less effective alternative

Ba#k to long term management of asthma

0and the story of Arpit and his friends

Management Goals
-reedom from

PEP Talk

,ym'toms including nocturnal cough A#ute asthma atta#ks *mergen#y doctor7hospital (isits

Minimal need for relie(ers Minimal ad(erse effe#ts from drugs Normal

Physi#al a#ti(ity including participation in sports Growth $harts .ung fun#tion

Management strategy
Identify and a(oid triggers )se controllers Treat acute attac s with 6elievers *du#ate family regarding management Monitor and modify therapy to maintain control

+e#a'itulating
#lini#al e(aluation
Ascertain diagnosis 1dentify co-morbid conditions Thin of alternate diagnosis

Grade se(erity
1dentify triggers

Grading se(erity
%#er a period of time
helps to decide regarding need and choice of controller medications for long term control

At a point in time
helps to decide regarding the level of care and drugs for an acute e)acerbation

Grading se(erity
1
Intermitte nt
,ym'toms of airf low o$stru#tion
QI once a wee Q Asym'tomati# and normal $etween atta#ks

Night time sym'toms

Q I twice a month

Peak e7'iratory f low 9P*-:

Q M /4 N of personal best Q I 24 N diurnal variationRR

FF &ormal diurnal variation . /10 0 in 12" values! 3owest 12" levels are seen on wa%in and hi hest levels about 12 hours later!

Grading se(erity
2
Mild 'ersistent
,ym'toms of airf low o$stru#tion
Q M once a wee but I once a day

Peak Night time e7'iratory sym'toms f low 9P*-:

Q M twice a month
Q M /4 N of personal best Q 24-!4 N diurnal variation

Grading se(erity
3
Moderate 'ersistent
,ym'toms of airf low o$stru#tion Peak Night time e7'iratory sym'toms f low 9P*-:
Q &4 - /4 N of personal best Q M !4 N diurnal variation

Q M once a day Q M once a wee Q Attac s affect activity

Grading se(erity
4
,e(ere 'ersistent
,ym'toms Pea Night time of airf low e)piratory sym'toms o$stru#tion flow CP"FD
Q $ontinuous Q Limited physical activity Q Fre5uent
Q I &4 N of personal best Q M !4 N diurnal variation

Grading se(erity %sim'lified

-re2uen#y of sym'toms

daily7wee ly7 monthly7 or less

!uration of sym'toms

day or two7 wee or so7 or more

Grading se(erity % sim'lified

Inter(al $etween sym'toms

no symptoms7 some cough7 nocturnal cough

,e(erity of sym'toms

,ospitali%ations7 1$E

Asthma
Treatment
A(oid triggers ,te' A % Intermittent 1nhaled 7 oral short acting @2 agonists as re5uired ?o controllers

Asthma
Treatment
A(oid triggersG Treat a#ute e'isodes ,te' > % Mild Persistent Preferred treatment 9

Low dose 1$*

Alternative treatment

Leu otriene antagonists

,te' A % *A @2 agonists prn

Asthma
Treatment
A(oid triggersGTreat a#ute e'isodes ,te' H % Moderate Persistent Preferred treatment 9

Low dose 1$* P inhaled LABA Medium dose 1$* Cin children I ; yearsD
Alternati(e treatment9

Low dose 1$* P Leu otriene antagonist 7 *6 theophylline CM ; yearsD

,te' > % Low dose 1$* ,te' A % *A @2 agonists prn

Asthma
Treatment
A(oid triggersG Treat a#ute e'isodes ,te' D % ,e(ere Persistent Preferred treatment 9

Medium7,igh dose 1$*P LABA

If un#ontrolled addI

+ral steroid7 Anti-1g"

,te' H B Add LABA ,te' > % Low dose 1$* ,te' A % *A @2 agonists prn

?ow let <s plan Arpit <s management0

;istory % re#a'
& year old Arpit was seen for recurrent cough since about 3 year. +n en5uiry' the cough bothered him once every two months lasted for three to four days. The cough was much more in the early morning hours.

;ow will you grade and treat Ar'it3

interact !

Grading se(erity

Arpit has intermit tent asthma

The #ru7 of the matter

C%&'R%((ERS ))
%r

&% C%&'R%((ERS ))
'hat is the question*

No #ontrollers
Intermittent asthma

1nfre5uent Cmonthly or lessD' short duration C2-! daysD' mild episodes

+owe#er, se#ere e$acerbations, e#en if infrequent, qualify for controller therapy

Asthma
Treatment 9re#a'11:
,te' A % Intermittent 1nhaled 7 oral short acting @2 agonists as re5uired ?o controllers A(oid triggers

Clini#al e(aluation1
Ascertain diagnosis 1dentify co-morbid conditions Thin of alternate diagnosis 2rade severity

Identify triggers

Triggers 5 're#i'itants
Allergens Irritants Pre#i'itants

PEP Talk

(iral infections

Inhaled aller ens4 irritants and viral in#ections are the most important tri ers

Irritants
,moke

PEP Talk

Avoid to$a##o smoke' agar$attis' fumes from kerosene sto(e' wood' cow dung

-ine dust

Avoid chal ' sprays' talcs

,trong odors

Do not use strong perfumes

Mos2uito re'ellent mats

#oils

Advise use of mos5uito nets' long clothing

Allergens
!ust mite antigen

PEP Talk

6emove #ar'ets 5 u'holstery Cotton sheets rather than woolens. ")pose mattresses to sunlight "ash soft toys periodically

Co#kroa#h antigen

Preserve unused coo ed foods in covered containers

Allergens
Molds and s'ores

Attend to dam' walls 7 lea ages. $lean air%#onditioner filters monthly

Animal dander 5Pollen

Avoid f lowers5'erfumes indoors *tay indoors during harvesting season.

Pets

Bathe pets wee ly Ma e them sleep outdoors

=*hould we change our home and move to a dry

climate8> as ed the an)ious granddad. =Khat food stuffs should we avoid8> as ed the grandma.

Khat will you advise these senior citi%ens8

interact !

PEP Talk
)iet . over.emphasi5ed ,,, 6 eneral avoid list to all patients is irrational!

6ddress the environment rather than chan e the address

Ar'it #ontd
A year later' Arpit<s parents stated that he was whee%ing a lot more often. ,e needed the reliever puffs more than twice a wee .

1s he still 1ntermittent8 ,ow will you treat him now 8

interact !

Gradation of se(erity
6sthma is a dynamic condition! 6t presentation, asthma se#erity is raded to uide introduction o# medication! 7n therapy, the titration o# medications is based on the assessment o# asthma control!

Assessment of Asthma Control

.e(el of Control Controlled
9All of the following: Partly Controlled 9Any measure 'resent in any week:
More than twice7wee Any Any

)n#ontrolled

Chara#teristi#
!aytime sym'toms .imitations of a#ti(ities
?one Ctwice or less7wee D ?one

?one No#turnal sym'toms5awakenin g

Need for relie(er5 res#ue treatment .ung fun#tion 9P*or -*JA: *7a#er$ations

?one Ctwice or less7wee D ?ormal

More than twice7wee I /4N predicted or personal best Cif nownD +ne or more7yearR

Three or more features of 'artly #ontrolled asthma 'resent in any week

?one

+ne in any wee S

Ar'its .e(els of Asthma Control

.e(el of Control Controlled
9All of the following: Partly Controlled 9Any measure 'resent in any week:
More than twice7wee Any Any

)n#ontrolled

Chara#teristi#
!aytime sym'toms .imitations of a#ti(ities
?one Ctwice or less7wee D ?one

?one No#turnal sym'toms5awakenin g

Need for relie(er5 res#ue treatment .ung fun#tion 9P*or -*JA: *7a#er$ations

?one Ctwice or less7wee D ?ormal

More than twice7wee I /4N predicted or personal best Cif nownD +ne or more7yearR

Three or more features of 'artly #ontrolled asthma 'resent in any week

?one

+ne in any wee S

Asthma %treatment
1f control is not achieved with current regimen' then treatment is to be stepped up until control is achieved. 1f asthma is partly controlled' then increase in treatment should be considered subJect to safety and cost

Ar'it#ontd
Arpit is 'artly #ontrolled.
,e needs stepping up of therapy Cfrom step A to step >D ,e now needs regular controller therapy.

Asthma
Treatment 9re#a':
A(oid triggersG Treat a#ute e'isodes ,te' > % Mild Persistent Preferred treatment 9

Low dose 1$*

Alternative treatment

Leu otriene antagonists

,te' A % *A @2 agonists prn

,an8ana
*anJana is a A year old who weighs 23 g. *he has been hospitali%ed for whee%ing at least thrice in the last & months and has had fre5uent midnight visits to the "6. *he has been referred to you after an acute episode and is not receiving any interval therapy.

;ow will you grade and manage ,an8ana 3

interact !

*anJana has moderate 'ersistent asthma.

Asthma
Treatment 9+e#a':
A(oid triggersG Treat a#ute e'isodes ,te' H % Moderate Persistent Preferred treatment 9

Low dose 1$* P inhaled LABA Medium dose 1$* Cin children I ; yearsD
Alternati(e treatment9

Low dose 1$* P Leu otriene antagonist 7 *6 theophylline CM ; yearsD

,te' > % Low dose 1$* ,te' A % *A @2 agonists prn

,an8ana 11 #ontd
*anJana followed up # wee s later. *he was not better. 1 wondered whyH =Kho gives the medicines to *anJana> 1 as ed her mom8 =1 taught her initially> she replied =now she is old enough to ta e them on her own>. =Are you8> 1 as ed *anJana. *he coyly loo ed away000

"hat do you think is going wrong3

interact !

+easons for non%adheren#e

1ntentional
Feel better CGcured<D Denial of diagnosis Fear side effects7addiction Don<t notice any benefit in the initial phase Fear of Ginvalid< label $omple) regimen $ost

PEP Talk

Enintentional
Forget treatment Poor supervision Misunderstand regimen Enable to use delivery system "mpty canister

,an8ana#ontd
*he was seen si) wee s later. *he was now adherent and the mother was supervising therapy. *he still wo e the night coughing and whee%ed fre5uently.

"hat would $e your a''roa#h now3

interact !

I# a child re$uires rescue steroids 4 82 . a onists #re$uently,

explore reasons #or poor control!

Poor #ontrol of asthma

,ummary
$hec Diagnosis
6ule out alternate diagnosis $o morbid conditions

$hec the following

The !Ds
Dose Device Delivery

Triggers

Adherence

Functional

Poor #ontrol of asthma

,ummary
$hec Diagnosis
6ule out D7D $o morbid conditions

$hec the following

The !Ds
Dose Device Delivery

Triggers

Adherence

Functional

Trial of rescue steroid

T;* DT; ! *tep up B !rug dose 7 regimen

Asthma
Treatment 9+e#a'11:
A(oid triggersG Treat a#ute e'isodes ,te' D % ,e(ere Persistent Preferred treatment 9

Medium7,igh dose 1$*P LABA

If un#ontrolled addI

+ral steroid7 Anti-1g"

,te' H B Add LABA ,te' > % Low dose 1$* ,te' A % *A @2 agonists prn

A$$as
Abbas is a . year old boy with moderate 'ersistent asthma on therapy. ,e reported a nocturnal cough and snee%ed every morning. ,is mother was regular with the inhalers and the techni5ue was appropriate as chec ed in the clinic.

"hat #ould $e wrong now3

interact !

Co%mor$id #onditions 9re#a'11:

Allergi# rhinosinusitis 2"6 +besity

Allergi# rhinitis
Intermittent
I # days per wee or I # wee s

Persistent
T # days per wee and T # wee s

Mild
normal sleep U no impairment of daily activities' sport' leisure U normal wor and school U no troublesome symptoms

Moderate%se(ere
one or more items abnormal sleep impairment of daily activities' sport' leisure abnormal wor and school troublesome symptoms

in untreated 'atients

Allergi# rhinitis
!rugs a''ro(ed for #hildren

To'i#al
?asal steroids
Mometasone furoate U Fluticasone furoate9 T 2 years Fluticasone propionate9 T# years Budesonide T & years

/ral
Antihistaminics
$etiri%ine U Desloratadine9 T & months of age Loratadine9 T 2 years Fe)ofenadine9 T & years

?asal Antihistaminics
A%elastine9 T ; years +lopatadine T 32 yrs

LT6A
Montelu ast9 T & months of age.

Allergi# +hinitis I Treatment

Intermittent Persistent

Co%mor$id #onditions 9re#a'11:

2astroesophageal reflu) disease C2"6DD

May cause whee%ing 7 e)acerbate underlying asthma especially in 2 subgroups9

Difficult-to-control asthma Voung infants with severe recurrent whee%ing episodes

1nvestigate with 2"6 scintiscan72# hour esophageal p, monitoring or both

Co%mor$id #onditions 9re#a'11:

2astroesophageal reflu) disease C2"6DD

Trial of Anti%ref lu7 treatment with PP1 can be given in such cases for /-32 wee s Although recent data has failed to show a therapeutic benefit in children with severe asthma and proven 2"6D. +ral bronchodilators7theophylline to be avoided

Co%mor$id #onditions 9re#a'11:

/$esity

Diet 7 life style modification Physical activities

-ollow u' 1 1 11
Khenever *anJana' Abbas or Arpit visit your office'

"hat will you ask or look for3

interact !

At #lini# %follow u'

, ym'toms and signs

bronchodilator usage nocturnal symptoms school absenteeism limitation of activity growth monitoring

P arental #on#erns

+egimen prescribed

I nhaler thera'y% !eli(ery5!rugs C om'lian#e 9Adheren#e: * n(ironment control

+n a subse5uent visit' *anJana<s dad as ed if there was an obJective way of monitoring her. =$ould they predict an attac and start early treatment 8>' he as ed *anJana<s mom had a similar 5uery regarding spirometry0

"hat will you ad(ise them3

interact !

Monitoring
"ssentially #lini#al P*-+ if

PEP Talk

Traina$le i.e. age above ; years Tena$le i.e. well initiated to therapy Afforda$le

,'irometry if

Age BKyearsC Afforda$leC A(aila$le

Demonstrationtime

Cases
*anJana' Arpit and Abbas ept well on their regimes. +n the ne)t visit' the parents en5uired =what ne)t8>

"hat will you answer them3

interact !

"ell #ontrolled asthma

,te''ing down treatment
Khile using 1$* alone Cmed to high dosesD

?LN reduction at H months interval

Khile using 1$*PLABA

reduce 1$* alone by ?LN while continuing LABA. Khen control is maintained reduce 1$* till low dose is reached when LABA can be stopped

Khen control achieved at low dose 1$* alone

switch to once a day therapy

"ell #ontrolled asthma

,to''ing treatment

Good #ontrol continues on low dose 1$* O 3 year

,to' controller regimen Trigger a(oidan#e continues "ritten ;ome management 'lan for acute episodes C,te' A regimeD

Follow up H%K monthly for A%> years $ounsel regarding 'ossi$le future resum'tion of controller' if recurrences.

"hat ne7t 3
*anJana stays well. At one of the visits the parents as =1s she now cured8>

"hat will you tell the 'arents3

interact !

Natural history

PEP Talk

6e-emphasi%e that drugs #ontrol but do not cure' As asthma among children often remits' control can be considered as good as cure. 1dentify those at risk for 'ersisten#e

Natural history of asthma

PEP Talk

+isk fa#tors for asthma 'ersisting into adulthood

-emale *#4ema +nset after age of ! years ,e(ere disease Parental history of atopy 7 asthma

Case
*ailesh is a . year old with mild 'ersistent symptoms. =,e<s in trouble every year between ?ovember and March>' says the mother. 1 confirm this seeing his past records over two years.

"hat do you #on#lude and how will you manage ,ailesh3

interact !

,easonal asthma
Management

Daily controller regimen

*tart a few wee s 'rior to anti#i'ated onset of symptoms continue through the season

"ncourage indoor activities during such seasons

Case
Daphin plays interschool bas etball. "very time he starts his game' he is whee%ing within minutes. =Kill 1 be able to play the finals8> he as s an)iously

"ill you let him 'lay and what will you ad(ise him3

interact !

PEP Talk

Daphin has *7er#ise Indu#ed Asthma

PEP Talk

Daphin has *7er#ise Indu#ed Asthma Bron#ho#onstri#tion 2xercise

.the only tri er the asthmatic child should conquer and not avoid

*7er#ise indu#ed asthma

*cenarios
$hild has asthma
e)ercise is one o# the tri ers for bronchoconstriction

$hild does not have asthma

e)ercise is the only tri er for bronchoconstriction

*7er#ise indu#ed asthma

non 'harma#ologi#al a''roa#hes

$hoice of game ?ose breathing Avoid e)ercise on cold mornings *low deep breathing Karming up

*7er#ise indu#ed asthma

Pharma#ologi#al ad(i#e

-or #ontrol

*uitable controller regimen Cconsider LT6A7 LABA with 1$*D 1$*P LT6A 7 1$* P LABA 1n addition 9 1nhaled *A @2 agonist - 3;-!4 min before planned e)ercise.

-or treatment

1nhaled *A @2 agonist

Case
Mrs 6eddy had heard of your interest in asthma. *he came you as ing to confirm the diagnosis. *he en5uired whether homeopathy would have an answer. *he had also heard about fish therapyH

"ill you lose your tem'er3

interact !

+ela71and e7'lain

PEP Talk

Limited scientific literature on acupuncture' homeopathy Benefits of Voga ?o scientific literature on Gfish therapy< etc Current e(iden#e does not suggest $enefits1

Case11
Mrs *hah brought her / year old. *he had come on a very busy clinic day. Vou 5uic ly tell her the diagnosis and advise her the inhaled steroid regime. *he does not follow up. Vou diagnosed rightC 'res#ri$ed right' but later learn that they have gone to a colleague for a second opinion and are continuing with himH

"hy did you lose this 'atient3

interact !

The need of the hour&

6t the #irst meetin

ive your patient

your time and not 9ust your prescription!

Parent *du#ation Points

3. ?ature of disease-need for $ontrollers 2. Drugs control' do not cure !. 1nhaler therapy issues #. *teroid issues ;. Esage of inhaler device and regime &. Time ta en to note benefit .. Triggers /. Diary of events A. Acute home care 34. ?eed for follow up

+:2 +2& C7((6&)(2&+*

Managing a#ute e'isodes

*ome Pharmacology

+elie(ers
,hort%a#ting >%agonists
*albutamol Terbutaline

Anti#holinergi#s
1pratropium bromide

Non sele#ti(e %agonist

Adrenaline

,teroids Methyl7anthines
C*elect situationsD

Magnesium sul'hate

Inhaled >%agonists
!rugs of #hoi#e. *albutamol 7 Levo-*albutamol7 Terbutaline are similar. *evere acute episode B nebuliser preferred Dose - 4.3; mg7 g7dose Cminimum dose 2.;mgD or say as rough guideline9 I # years - 4.; ml of salbutamol nebuliser soln
M # years - 3 ml of salbutamol nebuliser soln

Dilute in saline only' ?"("6 distilled water

Beware of hy'okalemia with high dose nebuli%ation.

+es#ue ,teroids
*arly usage - reduces morbidity7 hospitali%ation /ral 'rednisolone 3 mg7 g for !-. days.

?o tapering needed 7 ?o adverse effects

In8e#ta$les do not confer 5uic er benefit.

,ydrocortisoneC # mg7 gD 5 &hr or 1( Methylprednisolone C3-2 mg7 gD 5&hr 1( 7 1M De)amethasone C4.3 B 4.2 mg 7 WgD 5 & hr

if patient unable to ta e orally Cdrowsy7distressed7vomitingD

;igh dose inhaled 5 ne$ulised steroids%not 'ro(en

Anti#holinergi#s
I'ratro'ium $romide Additi(e effect to @2 agonist in acute severe asthma Ne$ soln E L1? ml @AyrC AmlBA yr C$ompatible with @2 agonist solution.D Limit use to >D hours to prevent atropine li e effects Ce.g.feverD

Magnesium ,ul'hate
Me#hanism of a#tion 9

acts through a different pathway C calcium channelD in the airway has immediate bronchodilator and mild anti inflammatory effects
>?%?L mg5kg IJ slow infusion dissol(ed in ?L ml ,aline o(er HL minutes 9total ma7imum dose%>g:

!ose9

To7i#ity I

Tachycardia7bradycardia' hypotension' muscle wea ness at higher serum level

Amino'hylline
6etains its role as reliever in acute severe attac s

improves diaphragmatic contractility mucociliary function inflammatory modulation

!ose9

Loading dose ; mg7 g B slow diluted IJ $olus with ?M !e7trose CAvoid if patient on *6 theophyllineD Followed by 4.;B3.4mg7 g7hr as infusion CAvoid subse5uent bolus dosesD

To7i#ity

2l ' $ardiac' $?* Monitor levels if possible

/7ygen
Maintain *a+2 M A2N.

,ypo)ia is mainly due to ( 7 X mismatch.

@Bagonists may parado)ically worsen hypo)ia Initially use oxy en to nebulise 82 a onists

/ral drugs as relie(ers

+ral @2 agonists for intermittent airflow obstruction.

+ral prednisolone for rescue therapy

Managing a#ute e'isodes

Bac to Arpit and his friends

Case11
Arpit decides to help his mother with Diwali cleaning. ,e starts coughing continuously soon after and his mother rushes him to the clinic0

"hat 2uestions will you ask the mother3

interact !

!uring an a#ute e'isode

*n2uire

Duration 8 6elievers ta en8 - 6esponse8 Brittleness C6apid worseningD $ontroller7 trigger factors +n regular controller8 ?umber and severity of previous attac s Last theophylline dose Cif relevantD

Case #ontd
+n e)amination' Arpit has a respiratory rate of #& per minute and a mild increase in accessory muscle activity. ,e appears comfortable and is able to tal in sentences. Auscultation reveals a whee%e towards the end of e)piration.

;ow will you grade Ar'its a#ute atta#k and manage him3

Grading se(erity
%#er a period of timehelps to decide regarding need and choice of controller medications for long term control

At a point in time helps to decide regarding the level of care drugs for an acute e)acerbation and

Pulmonary s#ore inde7

,#ore
4 3

+es'iratory +ate @K years BK years

I !4 !3B#; I 24 23B!;

"hee4ingF
?one Terminal e)piration with stethoscope "ntire e)piration with stethoscope During inspiration and e)piration without stethoscope

A##essory mus#le ,ternomastoid a#ti(ity

?o apparent activity Xuestionable increase

2 !

#&B&4 M &4

!&B;4 M ;4

1ncrease apparent Ma)imal activity

,#ore

4B! #B& M&

Mild Moderate *evere

R1f no whee%ing due to minimal air e)change' scoreM!

'hose children whose score is ,

- should be admitted to a pediatric ICU

;ome management
P, N H 9mild grade:
*A @2 agonist9 2 - # actuations through MD1 P spacer P mas 6epeat every 3; - 24 mins for ma) ! times 1f response ill sustained CI # hrsD' start 3st dose of rescue steroid

Case11
*anJana calls you in the middle of the night. *he is proceeding to the casualty once again. Vou rush in to see her and find her to have a respiratory rate of #4 per min. *he has suprasternal recessions and auscultation reveals whee%e throughout e)piration.

Assess her se(erity and manage her

interact !

Pulmonary s#ore inde7

,#ore
4 3

+es'iratory +ate @K years BK years

I !4 !3B#; I 24 23B!;

"hee4ingF
?one Terminal e)piration with stethoscope "ntire e)piration with stethoscope During inspiration and e)piration without stethoscope

A##essory mus#le ,ternomastoid a#ti(ity

?o apparent activity Xuestionable increase

2 !

#&B&4 M &4

!&B;4 M ;4

1ncrease apparent Ma)imal activity

,#ore

4B! #B& M&

Mild Moderate *evere

R1f no whee%ing due to minimal air e)change' scoreM!

'hose children whose score is ,

- should be admitted to a pediatric ICU

* +oom 'lan
P, D%K 9moderate:
+2 *A @2 agonist

?ebulised 5 24 min ) ! or MD1 P spacer P mas 2 puffs 5 2 min or so till & puffs reached. 2ive & puffs li e this 5 24 min in the first hour. or Cif inhaled therapy not availableD Terbutaline single dose7Adrenaline 4.43mg7 g sc 5 24 min ) !

$ommence 7 $ontinue rescue steroid $ontinuous assessment for #-& hours 1f good responseCP* I!D' decrease nebulisation to !-# hourly

*anJana does not respond to this treatment. +ne hour later' her respiratory rate has gone up to ;4 per minute. Vou decide to admit her to the ward. =Khat do we do ne)t8> as s your resident doctor

/utline your 'lan to him

interact !

"ard 'lan
$ontinue +)ygen' 1(7oral steroid *tart 1( fluids *A @2 nebuli%ation - hourly7 bac -to-bac 1pratropium neb 5 24 min ) ! and then 5 & hours Monitor *a+2 and serum WP $B$' Y-6ay chest only to identify complications Pulmonary score 5 3;-!4 minutes

Intensify if not $etter

1( Magnesium *ulfate $onsider blood gas studies if *a+2 I A2N 1( aminophylline bolus followed by continuous iv infusion Cs ip loading dose if already on *6 theophyllineD Terbutaline infusion if no response to aminophylline $onsider transfer to P1$E facility

Vour resident doctor is new but means well. =Khat complications should 1 e)pect8> he as s and =*ir7Madam' no antibiotics8 > he continues with a bewildered loo .

"hat will you tea#h this young lad3

interact !

Com'li#ations
Atelectasis *econdary infection Pneumothora) Pneumomediastinum *ubcutaneous emphysema Therapy related

+ole of anti$ioti#s
Limited role $onsider only in those with
purulent secretions and radiological evidence of pneumonia.

;acterial in#ections seldom tri

er asthma

!o not routinely use

Antibiotics Mucolytics $ough suppressants *edatives $hest Physiotherapy *team inhalation

Case
!& hours later *anJana is showing signs of improvement. +n your morning round' you find her sitting up comfortably sipping her tea. *he says she slept well through the night. +n e)amination she is mildly tachypnoeic and her whee%e is now only in the terminal phase of respiration. =$an 1 go home8> she as s

"hen will you de#ide to dis#harge her3

interact !

,te''ing down a#ute #are

Follow the principle =last in first out>

Discontinue terbutaline 7aminophylline drip in 2# hours Discontinue ipratropium neb in 2# hours 6educe *A @2 agonist to 5 2-# hrly and then 5 #&hrly 6eplace iv steroid with oral steroid

!is#harge #riteria
Pulmonary score I ! *lept well at night Feeding well Appears comfortable. ?ot on any continuous infusions and receiving less fre5uent 2 agonists Csay & hourlyD

Cases1 #ontd

"hat will you ad(ise Ar'it and ,an8ana when they are ready to go home3

interact !

!is#harge 'lan
1nhaled *A @2 agonist MD1 P spacer P mas 5 #-& hour till symptoms abate $ontinue course of rescue steroid for !-. days CTapering not necessaryD "ducate regarding home plan 7 long term strategy Plan follow up visit within .-3# days 6eview compliance' trigger elimination' controller regime

Case1
Meanwhile' 6aJu' a / year old with asthma is brought to the hospital in an ambulance with o)ygen by mas . ,e is too $reathless to s'eak' is sweating and 5uite agitated. +n e)amination his nails are dusky and on auscultation you hardly perceive any air entry. ,e has shown no response to ! doses of nebuli%ed bronchodilator given while he was rushed in with sirens blaring.

=ACT -A,TO $eg the 'arents1

interact !

Asthma
P+ed f lag signs
Enable to tal or cry $yanosis Feeble chest movements Absent breath sounds Fatigue or e)haustion Agitated Altered sensorium +)ygen saturation I A2N

Treat or +efer3
+2 to be continued but monitor *a+2 1nJ adrenaline 7 terbutaline sc 1nhaled 2 agonist P 1pratropium to be started 1nJ *teroids and iv fluid therapy Arrange proper transport to 1$E

)o not send the patient without ivin initial therapy!

'reat and refer.

IC) 'lan
$ontinue 7 initiate intensified ward plan Blood gas studies Possible intubation and mechanical ventilation with etamine and mida%olam 7 fentanyl iv infusion Paralysis with vecuronium' if re5uired

To summari4e
!iagnosis
Asthma is an inflammatory illness Diagnosis of asthma is clinical' and relies on history All asthma does not whee%e 1n children I ? yrs' consider differential diagnosis before labelling Many children outgrow their asthma A family history of asthma 7 atopy increases ris of asthma

To summari4e
.ong term management
Patient education is a very important part of asthma management Drugs control' but do not cure asthma $linical grading over time' decides long term management plan 1ntermittent asthma does not merit controllers 1nhaled steroids are mainstay of long term asthma management Treatment should be stepped up or stepped down depending upon patient response

To summari4e
A#ute management
2rading at a point in time decides management *A inhaled @2 agonists are used to manage acute e)acerbations Fre5uent use of *A @2 agonists indicate poor control of asthma

!e(i#es

Ta ing care of the home environment reduces e)acerbations of asthma

MD1 should always be used with spacer

.adies and gentlemenC

1t<s time to ac nowledge0

Asthma Training Module

Con#e't and #reation

+a8u Qhu$#handani +! Qhare A8it Ga8endragadkar ,ailesh Gu'ta 9.ate: Ritu Jora Indu Qhosla !a'hin -ernandes

>LAH +e(ision Team

!r1 +a8u Qhu$#handani !r1 A8it Ga8endragadkar !r1 Jarinder ,ingh !r1 ,ushil Qa$ra !r1 G1+1 ,ethi !r1 ,udarshan +eddy

National ATM Team >LAA

TE *EWEMA6A? 6+,1T $ A26AKAL D""PAW E26A 6AZ"*,KA6 DAVAL TA?MAV AMLAD1 *A1L"*, 2 2EPTA VW AMD"WA6 6P W,EB$,A?DA?1 , PA6AM"*, (A61?D"6 *1?2, *KAT1 V B,A(" 26 *"T,1

President' 1AP U $hairperson

President-"lect' 1AP U $o$hairperson 1mm. Past President' 1AP (ice President' 1AP U Kriting $ommittee *ecretary 2eneral' 1AP U ?ational $onvener Treasurer' 1AP Advisor Advisor Advisor Advisor Advisor Advisor

National ATM Team >LAA

S NAGABHUSHANA A BALA$,A?D6A? D (1ZAVA*"WA6A? ** WAMAT, *E*,1L WEMA6 WAB6A B * *,A6MA P *ED"6*,A? 6"DDV 6AZ T1LAW * *A?ZAV P6AD""P *1,A6" APE6BA WEMA6 2,+*, WAL1 W1?WA6 2,+*, 2AETAM 2,+*, PALLAB $,ATT"6Z"" ?ational $onvener ?ational $oordinator Zoint ?ational $oordinator Zoint ?ational $oordinator *EB,A*1* 6+V ZA2D1*, $,1??APPA P6A,ALAD WEMA6 A *E6"*, BABE *+MA*,"WA6 A6 ?$ 2+K61*,A?WA6 D"(A6AZ ( 6A1$,E6 W ?A2A6AZE 1?DE *A?Z""( W,+*LA *,A6AD A2A6W"DWA6

+e(ision done 9>LL=:

A Balachandran , Paramesh * ?agabhushana D (iJayase haran 2 6 *ethi 2autam 2hosh Z $hinnappa W W 2hosh L *ubramanium Mahesh Babu * Balasubramanian

*o *hivbalan * W Wabra 6aJu Whubchandani *hishir Moda (arinder *ingh *ubhasis 6oy Pallab $hatterJee *uresh babu T E *u umaran ? W *ubramanya

+e(ision done % >LLS

!r P1,1 ,uresh Ba$u !r Gautam Ghosh
$hairpersons' 1AP 6espiratory $hapter

!r1 ,1 Naga$hushana'
$oordinator' ATM ' 1AP 6espiratory chapter

!r Mahesh Ba$u !r Q Q Ghosh *ecretary'

1AP 6espiratory $hapter

And team

Idea
T E *u umaran *achidananda Wamat *wati Bhave

*pecial than s
Academic grant from