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BRONCHIAL ASTHMA IN CHILDREN BRONCHIAL ASTHMA IN CHILDREN

BRONCHIAL ASTHMA IN CHILDREN - PowerPoint Presentation

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BRONCHIAL ASTHMA IN CHILDREN - PPT Presentation

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

control asthma bronchial treatment asthma control treatment bronchial wheezing step medication children ics doses pef patients respiratory action symptoms

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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.