Bronchial Asthma

Diagnosing and Management

Presented By:
Ahmad Salah Shaheen
Under Supervision:
Dr.Abdulhakim El.Silwy
Assistant Professor of Pediatrics
Thamar University
College of Medicine
 Objectives
• To better understand how to differentiate between
infants who wheeze and go on to develop asthma
and those who wheeze but do not go on to have
asthma
• To discuss management strategies for treating
children with a high risk of developing asthma
• To discuss possible prevention therapies for
asthma in children four years old or younger
 What is Asthma?
• Disease of chronic
inflammatory disorder of the
airways
• Characterized by
• Airway inflammation
• Airflow obstruction
• Airway
hyperresponsiveness
• Reversible process

Cookson W. Nature 1999; 402S: B5-11

http://health.allrefer.com/health/asthma-normal-versus-asthmatic-bronchiole.html
 Asthmatic Inflammation
Normal Early Asthmatic Late Asthmatic Subacute/Chronic
Airway Response Response Inflammation

Inhaled trigger
chemotactic factors

cytokines

Bronchoconstriction Recruitment and Neural &

Mast Cells activation of vascular 
Alveolar macrophages inflammatory cells effects
Mucosal Odema 
Mucous Secretion
 What Causes Asthma?
• Asthma is a complex trait
• Heritable and environmental factors contribute to its
pathogenesis.
• The inheritance of Asthma is most compatible
 with one affected parent ………..25% risk
 with two affected parents ……….50% risk
• Onset appears early in life and severity remains
constant
• Multiple interacting genes
• At least 20 distinct chromosomal regions with linkage
to asthma and asthma related traits have been
identified: Chromosome 5q31 , ADAM33 , PHF11
 Neuroendocrine Mechanisms-
Stress and Asthma
• Common clinical observations of adverse relationship
between stress and human disease
• Adverse effects of psychological stress on asthma have
been documented.
• Depression and stress can augment humoral immunity and
favor production of IgE
• Growing set of data provide evidence for association
between chronic psychological stress and the pathogenesis
of atopy and asthma
• Marshall G, Ann Allergy Asthma Immunol. 2004;93:S11-S17
 Potential Risk Factors1
• Host factors • Environmental factors (cont)
• Genetic predisposition • Tobacco smoke
• Atopy • Air pollution
• Airway • Respiratory infections
hyperresponsiveness
• Male Gender • Socioeconomic status
• Race/Ethnicity • Family size
• Maternal smoking • Diet and drugs
• Environmental factors • Obesity
• Indoor allergens
• Outdoor allergens
• Occupational sensitizer
Masoli M, et al. The Global Burden of Asthma: Executive Summary of the
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 Wheezing in Infants
• Group 1: Low Lung function: children improve
within a few years and "outgrow" their asthma
• Group 2: Non-Atopic, viral-induced asthma:
also outgrow asthma after a somewhat longer
period of time (nonatopic wheezing).
• Group 3: Atopic Asthma: in contrast, children
who will go on to develop persistent wheezing
beyond infancy and early childhood usually
have a family history of asthma and allergies
and present with allergic symptoms very early
in life (atopy-associated asthma).
Differential Diagnosis of Wheezing
• Asthma
• Congenital Anomalies with airway impingement: Vascular
rings, tracheobronchial obstruction, mediastinal mass
• H-Type Tracheoesophageal Fistula
• Bronchopulmonary dysplasia
• Cystic fibrosis
• Gastroesophageal reflux
• Aspiration
• Foreign Body Aspiration
• Heart Failure
• Sinusitis and allergic rhinitis
• Bronchiolitis
• Pertussis
• Tuberculosis
• Immune system Disorders
 Diagnosing Asthma-Not Easy
• Clinical diagnosis supported by the certain historical,
physical and laboratory findings
• History of episodic symptoms of airflow obstruction
(e.g.. breathlessness, wheezing, and COUGH)
especially if triggered by inhaled allergen or
exercise-response to therapy!
• Physical: wheeze, hyperinflation, tachypnea with
prolonged expiration
• Laboratory:
esinophilia of blood and sputum
High IgE level
Allergy skin test
PFT >4 year, exhaled nitric oxide (eNO),
spirometry
ABGs and pH
• Exclude other possibilities
 Diagnosing Asthma in Young
Children – Asthma Predictive Index
• > 4 episodes/yr of • Major criteria
wheezing lasting more • Parent with asthma
than 1 day affecting • Physician diagnosed
sleep in a child with atopic dermatitis
one MAJOR or two
MINOR criteria • Minor criteria
• Physician diagnosed
allergic rhinitis
• Eosinophilia (>4%)
• Wheezing apart from
colds
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Adapted from Castro-Rodriquez JA, et al. AJRCCM 2000; 162: 1403
 Asthma Diagnosis Made
• Identify precipitating factors
• Identify comorbid conditions that may
aggravate asthma (GERD, allergies etc)
• Assess the patient/families knowledge and
self management skills
• Classify asthma severity using the
Guidelines from the NAEPP (Expert Panel)
 Assessing Asthma Severity
Use Impairment and Risk
• Impairment
• Symptoms: night time symptoms, reliever
use (SABA), miss school/work, quality of life
• Lung function- spirometry (FEV0.5), eNO
• Risk
• Recurrent exacerbations including ED visits
and hospitalization (may be normal between
events)
• At times, hard to differential between
impairment and risk
 Classifying Asthma Severity in
Children
• Break down into intermittent, mild, moderate, or
severe persistent asthma depending on symptoms of
impairment and risk
• Once classified, use the 4 steps depending on the
severity to obtain asthma control with the lowest
amount of medication
• Controller medications (inhaled steroids) should be
considered if >4 exacerbations/year, 2 episodes of oral
steroids in 6 months, or use of SABA’s (albuterol) more
then twice a week
• The usual treatment for an acute exacerbation is a
high-dose of SABA and a burst of systemic
glucocorticosteroids administered orally or
intravenously.
 Asthma: Goals of Treatment1
• Control chronic and nocturnal symptoms
• Maintain normal activity levels and exercise
• Maintain near-normal pulmonary function
• Prevent acute episodes of asthma
• Minimize emergency department (ED)
visits and hospitalizations
• Avoid adverse effects of asthma medications
Global Initiative for Asthma. GINA workshop report: global strategy
1

for asthma management and prevention. Available at:

http://www.ginasthma.org. Accessed October 13, 2006.
 Steps of Therapy
• Step 1: intermittent- use SABA
• Step 2: mild persistent-use SABA plus one of:
ICS OR montelukast OR cromolyn alternatives
• Step 3: moderate persistent: SABA + ICS +
LABA and/or montelukast
• Step 4: severe persistent: SABA + LABA+ ICS
and/or montelukast + alternate day
predinsolone
• Step down:
Step down treatment when good control
achievement + SABA
• Consult asthma specialist if step 3 or higher
(consider at step 2)
 Maintaining Control
• Monitor carefully- every 6 months if stable,
more often if not
• If stable after 3 months, try to reduce therapy
(usually by 25-50%)
• Inhaled steroids are safe even in the young at
mild to moderate doses with only a slight
decrease in growth velocity. Higher doses have
been shown to affect growth, cause cataracts
and reduce bone density
• Response to therapy is very important in this
age group!
 Status Asthmaticus
Is acute severe and life threating asthma defined as an
increasing severe asthma that is not response to drugs that
are usually effective
Sign of Severity:
 Too breathless to feed or speak
 RR>50/min
 PR>140 bpm
 Pulsus paradoxus >15
 PEFR <50% predicted
Signs of life-threating:
 Restless due hypoxia
 Drowsiness (hypercabnea)
 Exhaustion
 Cyanosis
 Silent chest
 PEFR<33%
 Treatment of Status Ashmaticus
O2 (high flow) 6L/min
Nebulized SABA
(salbutamol .05-.15 mg/kg at interval 20-30 min
for one hour then should be continued every 1-2 hour)

No Response
Check PCo2 and pH Response

1-Aminophylline
Oral predinsolone
2- IV Hydrocortisone
2mg/kg/day
3- +/-nebulized Ipratropium
Divided for 3-5 days
bromide
4-Nebulized SABA every
1-2 hour should be cont. ß2-agonists and O2
5-adequate hydration Improved As required
6- +/- Antibiotics

No improvement
Discharge plan
Artificial Respiration
 Inhaled Corticosteroid
• Preferred treatment alone or in combination
for all persistent categories of asthma
• Safe when use is monitored
• Reduces asthma symptoms, bronchial
hyperreactivity, exacerbations and
hospitalizations, need for rescue
medications
• Improves lung function, quality of life
• May prevent airway remodeling….!!
 Role of ICS in Asthma
• Trials show that among children with asthma (or at risk for
asthma), controller therapy with ICS is efficacious in
controlling asthma symptoms
• However, ICS, do not change the natural clinical course of
the disease.
• PEAK trial 285 children aged 2 to 3 years at high risk for
asthma were randomized to therapy with either an ICS
(fluticasone, 88 μg twice daily for 2 years) or placebo
• Results showed significantly better clinical outcomes and
lung function outcomes in children treated with fluticasone
than in those treated with placebo
• However, clinical differences between groups rapidly
disappeared a few weeks after discontinuation of regular
treatments.
Guilbert et al. Long-term inhaled corticosteroids in preschool children at high risk
for asthma, N Engl J Med 354 (2006), pp. 1985–1997
 Asthma Prevention
• There has been remarkable progress in
pharmacotherapy, education and environmental
measures in treating asthma
• However, no single action has been demonstrated
to decrease the risk of developing asthma
• Genetic and environmental influences
• Prevention will depend on factors influencing the
development and progression of asthma
 Is Environmental Control Helpful?
• Single allergen reduction not
effective
• “…Treatment by means of
allergen avoidance requires the
definition of what patients are
allergic to, and additional
measures beyond the use of
mattress covers and education”
Thomas Platts-Mills

http://health.allrefer.com/health/asth
ma-common-asthma-triggers.html
 Tailored Environmental
Intervention

• Randomized, controlled trial of environmental

intervention
• Intervention resulted in
• Reduction in asthma symptoms, disruption in
caretakers plans, caretaker’s and child’s sleep,
asthma-related visits to the ER or clinic
• Reduction in asthma symptoms were correlated to
reduction in allergens
• No difference in reduction of allergens in
homes with carpets or without carpets
Morgan WJ, et al. N Engl J Med 2004; 351: 1068-80.
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