Department of pediatrics Definition Asthma is a chronic disease involving the respiratory system in which the airways occasionally constrict become inflammated and are lined with excessive amounts of ID: 230192
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Slide1
BRONCHIAL ASTHMA IN CHILDREN
Department of pediatricsSlide2
Definition
Asthma
is a chronic
disease
involving the respiratory system in which the
airways
occasionally
constrict, become
inflammated
,
and
are
lined with excessive amounts of
mucus
often in response to one or more triggers.
Slide3
Epidemiology
Bronchial asthma (BA) is one from the most frequent chronic diseases in children and its incidence continues to increase in the last years. Conformable to ISAAC data (International Study of Asthma and Allergy in Children), BA affects 5-20% of children on the earth globe, this index varying in different countries (in USA - 5-10%, in Canada, UK - 25-30%, in Greece, China – 3-6%).Slide4
Risk factors for BA development in children
Familial antecedents of BA and other allergic diseases.
Contact with home dust containing
dust mite:
Dermatophagoides pteronyssinus.
Contact with fur-bearing animals (cat, dog, etc.).
Contact with mould (species of fungi
Alternaria,
A
spergillus, Candida, Penicillium
).
Contact with the pollen of different plants.
Smoke of cigarettes, after woods burning.
Presence of cockroaches.Slide5
Risk factors for BA development in children
Alimentary (fish, egg, cow’s milk etc.) and drug allergens
Meteorological factors (cold air, fog).
Physical activity
Environmental pollution
Presence of gastroesophageal reflux.
Drugs and vaccines (antibiotics – penicillin, cephasoline, tetracycline etc., sulfonamides, NSAID, colorants, etc.)
Viral infections
Stress factorsSlide6
Clinical classification of bronchial asthma
Atopic (allergic) asthma
Nonatopic (nonallergic) asthma
Status asthmaticusSlide7
Particular forms of bronchial asthma
BA provoked by physical effort
Cough
variant of BA
Aspirinic BASlide8
Classification of BA in function of severity
Type of BA
Exacerbations of BA
Nocturnal accesses
PEF and PEF variability
Intermittent
< 1 time per week
Asymptomatic, normal PEF between accesses
≤ 2 times per month
>80%
<20%
Mild persistent
>1 time per week, but <1time per day. Exacerbations can affect the activity
> 2 times per month
>80%
20 – 30%
Moderate persistent
Daily. Exacerbations affect the activity
>1 time per week
60-80%
>30%
Severe persistent
Permanently. Limited physical activity
Frequent
<60%
>30% Slide9
Clinical picture of BAAnamnesis
Which
questions must be given in the case of BA suspicion:
Had the patient
episodes of wheezing,
inclusively repeated
?
Has the patient nocturnal cough?
Has the patient cough and wheezing after physical effort?
Had the patient episodes of wheezing and cough after the contact with aeroallergens and pollutants?
Had the patient episodes of wheezing after supported respiratory infection?
Is decreasing the degree of symptoms expression after
antiasthmatic
drugs receiving? Slide10
Recommendations for personal and hereditary
antecedents assessment:
Presence of
dyspnea
,
wheezing, cough and thorax oppression episodes, with
evaluation
of duration and conditions of improving.
Familial antecedents of bronchial asthma.
Risk factors
Asthmatic symptoms are manifesting concomitantly (the thoracic oppression is less constant) and have common:
- Variability
in time (are episodic);
- Preferentially
nocturnal appearance;
- Appearance
due to trigger factor (physical effort, exposition to allergens, strong laugh, etc.).
- Personal
, familial and environmental factors.Slide11
Characteristics of asthmatic attacks:
Quick appearance with expiratory
dyspnea
,
prolonged expiration and wheezing, pronounced sensation of thoracic oppression, lack of air (sensation of suffocation).
Duration from 20 – 30 min until a few hours.
Spontaneous disappearance or at administration of ß
2
-adrenomymetics with short action.
They appear more frequently in night.
The attacks appear suddenly and end also suddenly with tormenting cough with elimination of mucous, viscous, “pearl” sputum in small quantity.Slide12
Suggestive symptoms for bronchial asthma diagnosis in children:
Frequent episodes of wheezing (more than 1 episode per month);
Cough ± wheezing induced by physical activity;
Nocturnal cough out of viral infection periods;
Lack of wheezing seasonal variations.Slide13
There are 3 categories of wheezing:
Precocious transitory wheezing; is associated with presence of such risk factors as prematurity, smoking parents,
dyspnea
until 3 years;
Persistent wheezing with precocious
onset
(until 3 years); recurrent episodes of wheezing associated with acute viral infections (predominantly with respiratory
syncitial
virus, in children under 2 years, and other viruses, in older children), without atopic manifestations or familial antecedents of
atopy
;
the symptoms persist until the school age and can be present in 12
years old
children in significant proportion;
Wheezing (asthma with tardy
onset,
after 3 years age); in this group asthma evolves in childhood period and even in adults; children present signs of
atopy
(
most frequent – atopic dermatitis) and air pathways pathology characteristic for asthma.Slide14
Predictive signs for childhood asthma (preschool, school age):
Wheezing until 3 years;
Presence of major risk factor (familial antecedents of asthma);
Two from three minor risk factors
(
eosinophilia
,
wheezing without cough, allergic rhinitis).Slide15
Physical examination:Basic principles:
The signs of respiratory system affection can be absent.
Inspection:
- Sitting position (orthopnea) with accessory respiratory muscles involvement;
- Tachypnea.
At percussion:
- Diffuse increased sonority and down placed diaphragm.
Auscultatively:
- Diminished vesicular murmur;
- Dry
coarse
, polyphonic, disseminated crackles, predominantly at expiration, that can be heard at distance (wheezing);
- Moist and subcrepitant crackles in more advanced bronchial hypersecretion.Slide16
Causes of bronchial asthma exacerbations:
Insufficient bronchodilator treatment.
Long-term defect of the basic treatment.
Viral respiratory infections.
Changes of weather
Stress
Long time exposure to triggers. Slide17
Appreciation of bronchial asthma exacerbations severity
Symptom
Mild
Moderate
Severe
Imminence of respiratory stopping
Dyspnea
-
appears during gait;
The child can stay in bed
-in older children it appears at speaking, in small children the crying becomes more short and slow; feeding difficulties.
- the child prefers to sit down.
- appears in rest;
- refusal to eat;
- forced position (sit down, inclined forward) Slide18
Appreciation of bronchial asthma exacerbations severity
Symptom
Mild
Moderate
Severe
Imminence of respiratory stopping
Speaking
-propositions
-expressions
-words
State of alertness
-can be agitated
-as a rule, agitated
-as a rule, agitated
-inhibited or in confusion state
Frequency of respiration
-increased
-increased
-sometimes> 30/min.
Participation of accessory respiratory muscles with
supraclavicular
retraction
-as a rule, absent
-as a rule, absent
-as a rule, present
Paradoxical
thoraco-
abdominal movement Slide19
Appreciation of bronchial asthma exacerbations severity
Symptom
Mild
Moderate
Severe
Imminence of respiratory stopping
Moist crackles
Moderately expressed, often, only at expiration
Sonorous
Sonorous
Absent
Frequency of cardiac contractions
< 100
100 – 120
> 120
Bradycardia
Paradoxical pulse
Absent
Can be present
Often is present
Absent Slide20
Appreciation of bronchial asthma exacerbations severity
Symptoms
Mild
Moderate
Severe
Imminence of respiratory stopping
PEF in % from predicted after bronchodilator using
>80%
60 – 80%
<60%
Pa O
2
at air respiration,
Pa CO
2
>60mm Hg
<45mm Hg
>60mm Hg
<45mm Hg
<60 mm Hg
>45 mm
SaO
2
%
(with air)
>95%
91-95%
<90% Slide21
Normal frequency of respiration in children
Age Frequency of respiration
< 2
months <60/min
2 – 12
months <50/min
1 – 5
years <40/min
6 – 8
years <30/minSlide22
Normal frequency of cardiac contractions (FCC) in children
Suckling babies
2 – 12
months <160/min
Little age
1 – 2
years
<120/min
Preschool
and
school
age
2
– 8
years
<110/minSlide23
The diagnosis of BA in children has the following basic aspects:
● atopic
background: allergic rhinitis, atopic dermatitis, alimentary allergy, atopic manifestation in family;
● clinically
: paroxysmal
dyspnea
with wheezing;
● functionally
: reversible bronchial obstruction;
● therapeutically
: efficient response at short action bronchodilators and inhalator corticosteroids treatment.Slide24
The algorhythm
for BA diagnosis in suckling baby and
infant (by
Martinez,
modified
)
Major criteria:
● hospitalizations
at severe form of
bronchiolitis
or
wheezing
;
● ≥
3 episodes of
wheezing
during respiratory infections in the last 6 months;
● presence of asthma in one of parents;
●atopic dermatitis;
●
sensibilization to pneumoallergens
. Slide25
Minor criteria:
●
rhinorrhea in the absence of flu;
●
wheesing
in the absence of flu;
● eosinophilia (≥ 5%);
● alimentary allergy;
● male.Slide26
Risk for persistent wheezing/asthma:
One from first 2 major criteria + another major criterion;
One from first 2 major criteria + 2 minor criteria.Slide27
PARACLINICAL INVESTIGATIONS IN BRONCHIAL ASTHMA
Obligatory investigations:
PEF-metry;
Spirography;
Test with bronchodilator
Skin tests with allergens;
Pulsoxymetry;
Hemoleukogram;
General analysis of sputum;
ECG; total and specific IgE
X-ray chest in 2 proiections. Slide28
PARACLINICAL INVESTIGATIONS IN BRONCHIAL ASTHMA
Recommended
investigations:
Bronchoscopy (at necessity);
Echo
C
G;
Oxymetry of arterial blood;
Acido – basic
state
e
valuation;
Provoking tests (effort, acetylcholine, metacholine);
Pulmonary, mediastinal CT (at necessity)
General urine analysis;
Biochemical serologic indexes (total protein, glucose, creatinin, urea, LDH, AST, ALT, bilirubin and its fractions);
Ionogram.Slide29
Spirography:
It allows to appreciate the severity and reversibility of bronchial obstruction;
It allows to differentiate from restrictive affections.Slide30
PEF-metry:
It allows the appreciation and monitoring of bronchial obstruction severity and reversibility.
The formula for calculation of PEF in% towards to predicted value in%:
PEF
= minimal PEF of given day/predicted PEF x 100%.
24 hours variability of PEF is calculating after formula:
24
hours variability = 2(evening PEF – morning PEF)/(evening PEF + morning PEF) X 100%.Slide31
Pharmacological tests:
The test with ß
2
-agonist (bronchodilator test) –
spirographic
or
PEF-
metry
values performed after 15 min from inhalation of short action ß
2
-agonist are compared with the usual data before inhalation; increasing of PEF values ≥20%
shows
the obstruction reversibility and is suggestive for BA.Slide32
Physical effort test:
The
spirography or PEF-metry is performed initially and at 5-10 min after nonstandard physical effort (running or physical exercises), but sufficient for increase the pulse rate (until 140 – 150/min). Decreasing of PEF ≥20% is suggestive for asthma (effort bronchospasm).Slide33
Examination of sputum:
Eosinophils (in proportion of 10 – 90%), octoedric Charcot – Layden phospholypase crystals are suggestive for atopic asthma.
Curschmann’s spirals (agglomerations of mucus).Slide34
Hemogram and immunoglobulins
Hemogram
shows eosinophilia in some cases.
Immunoglobulins:
- Total serum IgE increased in atopic asthma.
- Specific IgE to certain allergen are increased.Slide35
X-ray chest:
Is obligatory only in the first accesses, when the diagnosis is not clear.
In BA access – signs of pulmonary hyperinflation (flat diaphragm with reduced movements, hypertransparence of pulmonary areas, widening of retrosternal space, horizontal ribs).
It can be indicated for disease complications (pneumothorax, pneumomediastinum, atelectasis due to mucus plugs) or associated affections (pneumonias, pneumonitis etc.) finding.
Slide36
General assessment of gas exchange
It is
necessary in patients with signs of respiratory insufficiency, in these having SaO
2
less than
90%.Slide37
Allergy skin testing (
skin-prick
test,
scarification probes)
It is
performed by the
allergologist
and aims to detect
IgE
-induced
allergic reactions. It is usually carried out by the method of scarification: skin scarification of
4-5
mm with applying a drop of
standard allergen
in
concentration of 5000 U / ml (1 unit =0.00001 mg protein nitrogen / 1 ml).Slide38
Appreciation of allergic reaction by skin scarification test
Test appreciation
Conventional sign
The visual image of allergic reaction
Negative
-
It is the same as the control test
Uncertain
-/+
Local redness, without swelling
Weakly positive
+
Swelling papule, 2-3 mm diameter and peri-papular redness
Positive
++
Swelling papule with a diameter >3mm<5mm and peri-papular redness
Intense positive
Excessively positive
+++
++++
Swelling papule with 5-10 mm diameter and peri-papular redness
Swelling papule with more than 10 mm diameter, peri-papular redness and pseudopodies
Slide39
DIFFERENTIAL DIAGNOSIS
In children less than 5 years,
it is performed with another affections
occuring with wheesing:
Viral
bronchiolitis;
Cystic fibrosis;
Foreign body aspiration;
Upper respiratory pathways obstruction;
Bronchopulmonal displasia;
Intrathoracic respiratory pathways malformations;
Congenital cardiac diseases;
Kartagener’s syndrome;
Immune deficiencies;
Chronic sinusitis;
Gastroesophageal reflux;
Tbc;
Mediastinal adenopathies;
Tumors.Slide40
DIFFERENTIAL DIAGNOSIS
In
children older 5 years age,
it is performed with the same affections as in big child or
adult:
Cardiovascular pathology;
Upper respiratory pathways
obstruction
;
F
oreign bodies
aspiration
;
Cystic fibrosis;
Syndrome of hyperventilation, panic, vocal chords dysfunction;
Pulmonary interstitial pathology;
Gastroesophageal reflux;
Rhinosinusal pathology.Slide41
Hospitalization criteria for patients with BA:
Severe access;
Inefficacity of broncholytic therapy during 1 – 2 hours;
Duration of exacerbation more than 1 – 2 weeks;
Impossibility to accord medical care at home;
Unsatisfactory living conditions;
Presence of increased risk factors for death due to BA.Slide42
Criteria for hospitalization in intensive care departaments for patients with BA:
Mental deterioration;
Paradoxic pulse >15-20 mm Hg;
Severe pulmonary hyperinflation;
Severe hypercapnia > 80 mm Hg;
Cyanosis resistant to oxygenotherapy;
Unstable hemodynamics.Slide43
General principles of drug treatment in bronchial asthma:
The inhalatory therapy is the most recommended in all children, the used devices for drug inhalation must be individualised for every case in function of its peculiarities and characteristics of used inhaler. In general lines, administration using
metered-dose-inhaler
(MDI) with
spacer
versus nebulizing therapy is more preferable, due to some advantages of MDI (reduced risk of adverse effects, more decreased cost etc.). Administration through nebulizers presents a lot of disadvantages: not precise dose, increased cost, necessity of special apparatus.
Slide44
General principles of drug treatment in bronchial asthma:
Drugs
administered through inhalation are preferable due to their increased therapeutic index: high concentrations of medicaments are relieved directly in respiratory pathways, with strong therapeutic effects and reduced number of systemic adverse effects.
Slide45
General principles of drug treatment in bronchial asthma:
Devices
for medication administered through inhalation: pressure inhalers with measured dose (MDI), dry powder inhalers, turbohalers, diskhalers, nebulizers.
Spacers
(or retention camera) make easier the use of inhalers, reduce systemic absorption and secondary effects of inhaled glucocorticoids.Slide46
General principles of drug treatment in bronchial asthma:
Two
types of medication help in asthma control:
controlers
, or drugs that prevent the symptoms and accesses, and
relievers
, or drugs, used for access treatment and having rapid effect.
The
choice of medication depends from the control level of BA at moment and from curent medication.
If
curent medication does not ensure the adequate control of BA, the indication of superior advanced step of treatment is necessary.Slide47
General principles of drug treatment in bronchial asthma:
If
BA is controled 3 months, the decreasing of supporting volume for control maintaining minimal necessary dose establishing (passing to inferior step) is possible.
The
therapy with adequate doses of short acting inhalatory ß
2
-agonists is recommended in accesses (if inhalers are not available, the bronchodilators can be administered per os or i/v.
In
hospitals in the case of hypoxemic patient the oxygen is given.Slide48
General principles of drug treatment in bronchial asthma:
The
not
recommended
treatment in
accesses: sedatives, mucolytics, physiotherapy, hydration with
high
volume of liquids.
Antibiotics
not treat the accesses, but are indicated in the case of concomitant pneumonias or other bacterial infections.Slide49
The key
moments in the treatment of BA by steps:
Each step includes variants of therapy serving as alternative in the choice of BA control treatment, although are not similar to efficacy.
The
efficacy of treatment increases from I step to V step and depends from accessibility and certainity of drug.
The
steps 2-5 include combinations of urgent medications, at necessity,of systemic control treatment.
In
majority of patients with persistent BA, which anteriorly didn’t administered control treatment, is necessary to iniciate the treatment from the 2-nd step.Slide50
The key
moments in the treatment of BA by steps:
If at primary examination we determine the absence of BA control, the treatment begins from the 3-rd step.
The patients must use relievers (short action bronchodilators) at each step.
The systemic use of urgent medication is a sign of uncontrolled BA, which indicates the necessity of control therapy volume increasing.
Reducing or absence of necessity in relievers represent the goal of treatment and, also, a criterion of efficacity.Slide51
The I step of BA treatment:
It is indicated to patients:
-
Which
didn’t receive anteriorly control medication and which manifest episodic symptoms of BA (cough,
humid
crackles, dyspnoea ≤ 2 times per week, very rare with nocturnal symptoms);
-
In
period between accesses the disease manifestations and nocturnal disturbance are absent or pulmonary function is normal.
Urgent medication:
-
short
action inhaled ß
2
-agonists
are recommended;
-
the
inhalatory anticholinergics (ipratropium bromide, oxitropium bromide), peroral short action ß
2
-agonists (salbutamol), short action theophyllin can be the
alternative medicaments.
Control
medication is not necessary.Slide52
The II step of BA treatment:
It is indicated to the patients with symptoms of persistent asthma, which anteriorly didn’t administered control medication.
Urgent medication:
-
Recommended
– inhalatory corticosteroids (ICS) in small doses;
-
Alternative
– antileukotrienes are indicated to the following
patients
:
-who
don’t
accept to use ICS;
-
with hard supported ICS adverse reactions;
- with concomitant allergic rhinitis.
The initiation of therapy is
not recommended
with:
-
Theophylline
retard
, that possesses minimal anti-inflammatory effect and reduced efficacy in control therapy, but has multiple adverse reactions;
-
Chromones
(
inhibitors of mast cells
degranulation
)
having decreased efficacy, although they are distinguished by increased inoffensiveness.Slide53
The III step of BA treatment:
It is indicated to the patients with symptoms of disease showing the absence of adequate control in the treatment at the steps I and II.
Urgent medication:
Recommended -
short
action inhaled ß
2
-agonists (salbutamol,
phenoterol).Slide54
The III step of BA treatment:
Control
medication
one or two drugs for disease evolution control
:
- Small
doses of ICS in combination with long action inhaled ß
2
-agonists in one self inhaler with still fixed doses of drugs or two different inhalers
;
- Small doses of ICS in combination with leukotrienes (montelucast, zafirlucast);
- Small doses of ICS in combination with small doses of theophylline retard;
- Increasing of ICS small doses until medium doses.Slide55
The III step of BA treatment:
Small doses of ICS, as a rule, are sufficient due to additive effect of this combination, the dose is increasing, if over 3-4 months of treatment the BA control was not obtained.
The monotherapy with formoterol and salmeterol is not recommended, they are using in combination with ICS (fluticazon, budesonid).Slide56
Note:
The using of
spacers
for intensifying of drugs getting into respiratory pathways and for decreasing of diverse
o
ropharingean
adverse reactions is recommended for patients receiving medium and high doses of ICS;
The patients in which the control on III step is not succeeded, need consulting of specialist with experience in BA treatment for excluding an alternative diagnosis or of cases of BA difficult to treat.Slide57
The IV step of BA treatment:
It is indicated to the patients with symptoms of disease showing the absence of control in the treatment at the 3-rd step.
The choice of drug in the therapy at IV step depends from anterior indications at 2-nd and 3-rd steps.
Urgent medication:
Recommended -
short action inhaled ß
2
-agonists
Control medication
includes two or more drugs for disease evolution control:
-
ICS
in medium and high doses in combination with long action inhaled ß
2
-agonist;
-
ICS
and long action inhaled ß
2
-agonist and, supplementarly, small doses of retard theophyllin.Slide58
Note:
Small and medium doses of ICS, in combination with antileukotrienes, amplify the clinical effect smaller comparatively with combination of ICS and long action inhaled ß
2
-agonist;
Increasing of ICS dose (from medium to high) in majority of patients ensures only nonsignificant increasing of clinical effect, and administration of high doses is recommended only in quality of probe with duration of 1-3 months, when the control of BA at combination of ICS medium doses and long action inhaled ß
2
-agonist was not obtained.
Long-term administration of high doses of ICS is followed by increased risk of adverse effects. Slide59
The V step of BA treatment:
It is indicated to the patients with uncontrolled, severe BA, on the background of IV step therapy.
Urgent medication:
Recommended:
short action inhaled ß
2
-agonists.
Control medication
includes supplementary drugs for IV step medication for disease evolution control:
-
administration
of CS per os
can amplify the effect of treatment, but has severe adverse effects, therefore they must be given only in severe,
uncontro
l
led
forms of BA on the background of 4-th step therapy;
-
administration
of anti-IgE antibodies,
supplementarly to another drugs, makes easy the control of BA, when the control of BA didn’t obtained with
control
l
er
drugs, inclusively with high doses of ICS and CS per os.Slide60
Specific immunotherapy
It is indicated only in the period when the allergic BA is
control
l
ed
.Slide61
THE FOLLOW-UP OF PATIENTS WITH BRONCHIAL ASTHMA
-
The patients return to medical consultation at I month after first visit, ulteriorly – in every 3 months.
-
After
exacerbation, the medical visits have place after 2 – 4 weeks.
-
If the BA control is established, the regular maintaining visits, at 1 – 6 months, remain essential, depending from situation.
Slide62
THE FOLLOW-UP OF PATIENTS WITH BRONCHIAL ASTHMA
-
The number of visits at physician and determining of control level depends from initial severity of patology at concret patient and from degree of patient’s knowledge about the necessary measures for BA adequate control.
-
The
control level must be determined in certain time intervals both by physician, and by patient.
-
Patients
who administered high doses of ICS or CS per os are included in the risk group for osteoporosis and fractures (it is necessary to perform tomodensitometry of bones and administration of biphosphates).Slide63
Continuous monitoring
It
is
essential in realization of therapeutic goals. The schemes of treatment, the medications and level of BA control are analysed and modified during this visits.Slide64
ADEQUATE MANAGEMENT OF BRONCHIAL ASTHMA
Minimal or inexistent symptoms, including nocturnal symptoms.
Minimal episods or accesses of BA.
Absence of urgent visits at physician or hospital.
Minimal need of urgent medications.
Absence of physical activity and sport practise limitation.
Pulmonary function is about
norma.
Secondary effects caused by medication are minimal or inexistent.
Prevention of deceases caused by BA.