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Asthma Inflammation
Genetic
Environmental factors
Allergens
1. Indoor Domestic mites, furred animals (dogs, cats, mice),
cockroach allergens, fungi, molds, yeasts.
2. Outdoor Pollens, fungi, molds, yeasts.
Infections (predominantly viral)
Occupational sensitizers
Tobacco smoke
1. Passive smoking
2. Active smoking
Indoor/Outdoor air pollution
Diet
Psychosocial factors.
Underdiagnosed/
Misdiagnosed
Fear of steroids
Acceptance of
Asthma
diagnosis/label
Heterogenous
Disease/varying
phenotypes
Heavy
nebulisation
Issues in
Pediatric Asthma
Cough or
Wheeze
Choice of right
device
Lack of
knowledge &
time vs.
more patients
Poor patient/
parent
education
Other Challenges
Most of the children are below 5 years of age, who
cannot tell their problems
Parents are proxy story teller, who may mislead
the doctor
PEF cannot be performed in children below 5 years
of age
Fear of addiction to inhalation therapy
Physicians lack of knowledge and time
Clinical Features
Recurrent Wheeze
Recurrent Cough
Recurrent Breathlessness
Activity Induced Cough/Wheeze
Nocturnal Cough/Breathlessness
Tightness Of Chest
Asthma by Consensus, IAP 2003
Symptomatology
Cough 90%
Wheezing 74%
Exercise induced wheeze or
cough 55%
Tools to Diagnosis
Good History Taking (ASK)
a diagnosis
of
asthma
should
be
considered
Does the child use any medication when
symptoms occur? How often?
Physical Examination
(Look)
Febrile episodes
Personal atopy absent
Family history of asthma /
atopy absent
Variable response to
bronchodilators
Afebrile episodes
Family history of
asthma / atopy present
Predictable good
response to
bronchodilators
Differential diagnosis
Age
Common
Uncommon
Rare
Less
than
6
months
Bronchiolitis
Gastroesophageal
reflux
Aspiration pneumonia
Bronchopulmonary
dysplasia
Congestive heart
failure
Cystic fibrosis
Asthma
Foreign body
aspiration
6
months
2 years
Bronchiolitis
Foreign body
aspiration
Aspiration pneumonia
Asthma
Bronchopulmonary
dysplasia
Cystic fibrosis
Gastro-esophageal
reflux
Congestive heart
failure
2-5
years
Asthma
Foreign body
Cystic fibrosis
Gastro-esophageal
Aspiration
pneumonia
IPAG 2007
Co morbid conditions
Allergic Rhinitis
Colds, ear infections
Sneezing in the morning
Blocked nose, snoring, mouth breathing
Diagnostic
Tool
Differential
diagnosis
Physical
examination
IPAG 2007
IPAG 2007
NORDIC CONSENSUS
Confirm Asthma if,
If the child is having 3 attacks of airway obstruction in
last 1 yr.
IAP GUIDELINES
3 Or More Episodes Of Airflow Obstruction With
Several Of The Following:
Afebrile Episodes
Personal Atopy Or Family H/O Atopy / Asthma
Nocturnal Exacerbations
Exercise/Activity Induced Symptoms
Trigger Induced Symptoms
Seasonal Exacerbations
Relief With Bronchodilators Oral Steroid
BTS 2008
BTS 2008
Asthma Treatments
Classified into Controllers and Relievers
To summarize
Diagnosis
Asthma is an inflammatory illness
Diagnosis of asthma is clinical, and relies on history
All asthma does not wheeze
In children < 3 yrs, WALRI is an important differential diagnosis
2 out of 3 children outgrow their asthma
A family history of asthma / atopy increases risk of asthma
To summarize
Long term management
Patient education is a very important part of asthma management
Drugs control, but do not cure asthma
Clinical grading over time, decides long term management plan
Mild intermittent asthma does not merit controllers
Inhaled steroids are mainstay of long term asthma management
Treatment should be stepped up or stepped down depending upon
patient response
Thank You