Asthma in Children

Mohd Afiq Mastuki

Overview
Definition
Prevalence
Pathophysiology
Diagnosis
Physical signs and symptoms
Investigation
Treatment
Follow-up
Asthma in adolescence
Asthma Action Plan
What is Asthma?
Chronic airway inflammation leading to
increased airway responsiveness that
leads to:
recurrent episodes of wheezing,
breathlessness,
chest tightness
coughing,
particularly at night or early morning.
often associated with airflow obstruction

Asthma is one of the most common chronic
diseases worldwide with an estimated 300
million affected individuals
Prevalence increasing in many countries,
especially in children
A major cause of school/work absence

Prevalence in Malaysia
In primary school children is reported as 13.8%;
In children aged 13-14 years it is 9.6%
The prevalence of self-reported asthma in adults as
reported in a Ministry of Health Third National
Health and Morbidity Survey is 4.1%.
In the same study, the Chinese recorded
significantly lower prevalence of asthma (2.4%)
than other races (5.6%)
[source: national health and morbidity survey
(NHMS3) 2006]
Source: Peter J.
Barnes, MD
Environmental factors Genetic predisposition
Bronchial inflammation (eosinophils, neutrophils, lymphocytes, mast cells,
mediators, cytokines)
Bronchial hyperactivity + trigger factors
Oedema, Bronchoconstriction, Increased
mucus production
Airways narrowing
Symptoms: cough, wheeze,
breathlessness, chest tightness
Precipitants of asthmatic attack
Animal with fur
Domestic dust mites
Pollen
Exercise
Dust
Smoke
Respiratory Tract
Infection
Strong emotional
expression
Aerosol chemicals

Cold weather
Cold drinks
Certain food/fruits
And many others
Diagnosing Asthma:
Medical History
Symptoms
Coughing
Wheezing
Shortness of breath
Chest tightness
Symptom Patterns
Severity
Family History
Diagnosing Asthma
Troublesome cough, particularly at night
Awakened by coughing
Coughing or wheezing after physical
activity
Breathing problems during particular
seasons
Coughing, wheezing, or chest tightness
after allergen exposure
Colds that last more than 10 days
Relief when medication is used

Wheezing sounds during normal breathing
Hyperexpansion of the thorax
Increased nasal secretions or nasal polyps
Atopic dermatitis, eczema, or other allergic
skin conditions
Physical Examination
Signs of chronic illness
Harrison sulci (indrawing of the ribs, forming symmetrical
horizontal grooves above the costal margins)
hyperinated chest
eczema / dry skin
hypertrophied turbinates

Signs in acute exacerbation
tachypnoea
expiratory wheeze, rhonchi, prolonged expiratory phase
hyperinated chest
accessory muscles
cyanosis
drowsiness
tachycardia

NOTE: ABSENCE OF PHYSICAL FINDINGS
DOES NOT EXCLUDE ASTHMA!
Classification of severity of Asthma

INVESTIGATIONS
Full Blood Count
Arterial blood gases
For acute severe asthma
Chest X-ray
Ordered if there is suspicion of complications, e.g.
pneumonia, pneumothorax or collapse.
PEFR (pre and post neb)
Medications to Treat Asthma
Medications
come in several
forms.

Two major
categories of
medications are:
Long-term
control
Quick relief
The choice of treatment should be guided by:
Level of asthma control
Current treatment
Pharmacological properties and availability
of the various forms of asthma treatment
Economic considerations

Medications to Treat Asthma:
Long-Term Control
Taken daily over a long period of time
Used to reduce inflammation, relax airway
muscles, and improve symptoms and lung
function
Inhaled corticosteroids
Long-acting beta
2
-agonists
Leukotriene modifiers

Medications to Treat Asthma:
Quick-Relief
Used in acute
episodes

Generally short-
acting beta
2
agonists

Medications to Treat Asthma:
How to Use a Spray Inhaler
The health-care
provider should
evaluate inhaler
technique at each
visit.

Source: What You and Your Family Can Do About Asthma by the Global Initiative for Asthma Created
and funded by NIH/NHLBI
Medications to Treat Asthma:
Inhalers and Spacers
Spacers can help
patients who have
difficulty with inhaler
use and can reduce
potential for adverse
effects from
medication.
Medications to Treat Asthma:
Nebulizer
Machine produces a
mist of the medication
Used for small children
or for severe asthma
episodes
No evidence that it is
more effective than an
inhaler used with a
spacer
Drug Doses for Asthma

SUMMARY OF TREATMENT IN CHILDREN < 5 YRS OLD
SUMMARY OF TREATMENT IN CHILDREN 5-12 YRS OLD
Clinical Control of Asthma
Determine the initial level of control to
implement treatment (assess patient
impairment)

Maintain control once treatment has been
implemented (assess patient risk)

Levels of Asthma Control
(Assess patient impairment)
Assess Patient Risk
Features that are associated with increased
risk of adverse events in the future include:
Poor clinical control
Frequent exacerbations in past year
Ever admission to critical care for asthma
Low FEV
1
, exposure to cigarette smoke,
high dose medications
Any exacerbation
should prompt review
of maintenance
treatment
Factors Involved in Non-Adherence
Medication
Difficulties associated with
inhalers
Complicated regimens
Fears about, or actual side
effects
Cost
Distance to pharmacies
Non-Medication Factors
Misunderstanding/lack of
information
Fears about side-effects
Inappropriate expectations
Underestimation of severity
Attitudes toward ill health
Cultural factors
Poor communication

ACUTE ASTHMA
The Initial Assessment in Management
of Acute Asthma

Criteria of Admission
failure to respond to standard home
treatment
failure of those with mild or moderate acute
asthma to respond to nebulised -agonists
relapse within 4 hours of nebulised -
agonists
severe acute asthma
Management of Acute Asthma
Initial (Acute assessment)
1. Diagnosis- symptoms e.g. cough, wheezing.
breathlessness , pneumonia
2. Triggering factors - food, weather, exercise,
infection, emotion, drugs, aeroallergens
3. Severity - respiratory rate, colour, respiratory
effort, conscious level
Management Considerations
monitor pulse, colour, PEFR, ABG and SpO. Close monitoring for at
least 4 hours.
hydration - give maintenance uids.
role of aminophylline debated due to its potential toxicity. To be
used with caution.
antibiotics indicated only if bacterial infection suspected.
avoid sedatives and mucolytics.
efficacy of prednisolone in the rst year of life is poor.
on discharge, patients must be provided with an Asthma Action
Plan to assist
parents or patients to prevent/terminate asthma attacks. The plan
must include:
how to recognize worsening asthma
how to treat worsening asthma
how & when to seek medical attention
Algorithm for Management of Acute
Asthma
Drug Doses for Acute Asthma

Prevention
Identifying and avoiding the following common triggers may be useful
1. environmental allergens
These include house dust mites, animal dander, insects like
cockroach, mould and pollen.
Useful measures include damp dusting, frequent laundering of
bedding with hot water,
encasing pillow and mattresses with plastic/vinyl covers, removal
of carpets from bedrooms, frequent vacuuming and removal of
pets from the household.
2. cigarette smoke
3. respiratory tract infections - commonest trigger in children.
4. food allergy - uncommon trigger, occurring in 1-2% of children
5. exercise
Although it is a recognised trigger, activity should not be limited.
Taking a -agonist prior to strenuous exercise, as well as
optimizing treatment, are usually hepful.
ASTHMA ACTION PLAN
An action plan is a personalised plan for the patient
to manage his asthma himself.
It should be discussed and agreed upon by the
medical caregiver and the patient and is based on
symptoms and/or peak flow measurement.
It should ideally be written rather than verbal. An
action plan helps the patient to recognise and act
upon symptoms without having to wait for a medical
consultation.
It may be based on a traffic lights system.
GREEN ZONE
AMBER ZONE
RED ZONE
Serangan asma
4 semburan ubat pelega
Pernafasan tidak
bertambah baik
Ulang 4 semburan ubat
pelega
Pernafasan masih tidak
bertambah baik
Pernafasan bertambah
baik
Bagi
4 semburan 4jam sekali untuk 1 hari,
kemudian 6 jam sekali 1 hari,
8 jam sekali 1 hari,
Kemudian guna masih perlu jika
pernafasan tetap elok.
Serangan asma berulang-
ulang
HANTAR
HOSPITAL !
FOLLOW UP
Before discharge from ward parents/ caregiver
should receive
Asthma education
Instruction on recognition signs of recurrence and
worsening asthma
Determination and avoidance of the precipitant factors
Asthmatic diary
Supply of the metered dose inhaler
Careful review of the inhaler technique
Appointment of further follow up.


Assessment during Follow Up
1. assess severity
2. response to therapy
interval symptoms
frequency and severity of acute exacerba on
morbidity secondary to asthma
quality of life
PEF monitoring on each visit
3. compliance
frequency and technique, reason and excuses
4. education
technique, factual information, written action plan, PEF
monitoring may not be practical for all asthmatics but is
essential especially for those have poor perception of
symptoms and those with life threatening attacks
Asthma Diary
Tarikh/Hari Masa Gejala Punca Tindakan ibu Kesan
Batuk
Nafas berbunyi
Hidung kembang
Ruam
Selsema
Kahak
Demam
Air cond
Sejuk pagi
Hujan
Balik dari luar
Ubat pam salbutamol
Sapu vicks di dada
Ok
Tak Ok
Asthma Diary

1. Ubat pam- Coklat (Budesonide)
Pagi 1 pam
Malam 1 pam
2. Biru (Salbutamol) 4 pam
Tiap-tiap 4 jam untuk 3 hari
Tiap-tiap 6 jam untuk 3 hari
Tiap-tiap 8 jam untuk 3 hari
Bila perlu

MDI WITH AEROCHAMBER
Cleaning the
AeroChamber:
Powder collects in the
AeroChamber and around
the Flow Indicator Valve.
This should be cleaned
well at least once a week.
Wash the mouthpiece
and AeroChamber once a
week.
Steps to follow to clean:
Place in sink with warm
soapy water.
Gently shake the
AeroChamber to loosen
particles.
Place in clear water to
rinse soap off.
Shake gently, place
upright on a clean cloth
or paper towel.
Air dry.


THANK YOU