Transcript of Child asthma
- 1. DR S RAGHU M.D., ASST PROF DEPT. T B & CD GUNTUR MEDICAL
COLLEGE GUNTUR Dr s. raghu m.d., Associate professor Department of
TB & CD R I M S medical college ONGOLE
- 2. 100 m2 10,000 L blood pass every 24 hrs 10,000 L blood pass
every 24 hrs 10,000 L air in & out every 24 hrs 10,000 L air in
& out every 24 hrs 350 L of O2 delivered every day350 L of O2
delivered every day 100 m2 10,000 L blood pass every 24 hrs 10,000
L blood pass every 24 hrs 10,000 L air in & out every 24 hrs
10,000 L air in & out every 24 hrs 350 L of O2 delivered every
day350 L of O2 delivered every day
- 3. Definition: Asthma is a chronic inflammatory disorder of the
airways in which many cells & cellular events play a role. The
chronic inflammation is ass with airway hyperresponsiveness that
leads to recurrent episodes of wheezing, breathlessness, chest
tightness & coughing, particularly at night or in the early
morning. These episodes are usually ass with widespread but
variable airflow obstruction within the lung that is often
reversible either spontaneously or with treatment. GINA 2011
- 4. Asthma is a Chronic Inflammatory Disease characterized by
Airway Hyperresponsiveness to a variety of stimuli resulting in
Bronchospasm which reverses, spontaneously or with treatment.
- 5. 150 million people in the world(including many children) do
not take breathing for granted WHO says- asthma is becoming most
common chronic disease in children
- 6. Asthma is a chronic disease most responsible for days off
school. Night-time awakenings can affect a childs concentration in
school next day Asthma significantly affects sports and
recreational activities Missed days of school can affect a child's
future career ( WHO estimates 14 million school days are lost every
year due to Asthma across the globe )
- 7. What happens in Asthma. Spasm & Swelling
- 8. 20 million people with asthma 10-15% of children are
sufferer Spread over rural & urban sector Not sparing affluent
class
- 9. Growing urbanisation & life style change Junk food 3
major pollens Parthenium, Casuarina and Eucalyptus have increased
Increase in no. of industries and automobiles Smoking Ind J Ped
2002;69:309-12
- 10. By 1 year 26% 1-5 years 51.4% > 5 years 22.3% Ind J Ped
2002;69:309-12 77% of all asthma begin in children less than 5
years
- 11. Commonest chronic disease in children. More than 77% of the
children present below the age of 5 years, The presentation closely
mimics many conditions common in this age group The diagnostic
modalities both spirometry and peak expiratory flow rate cannot be
used in children below the age of 5 yrs
- 12. Parents are proxy story tellers on behalf of the patients,
and may exaggerate or undermine the nature of the disease. All this
may lead to delayed diagnosis. Acceptance of inhalation therapy is
another hurdle in the management of asthma
- 13. Recurrent cough with or without breathlessness Nocturnal
cough without viral respiratory tract infection Recurrent
breathlessness
- 14. Tightness of chest Seasonal variability Triggers Exercise
induced exacerbation Family or personal history of
asthma/atopy/allergy
- 15. What are the Triggers? * Infections (Viral)
*Strongsmells,perfumes deodorants * Pets * House dust * Pollen *
Tobacco smoke * Pollution * Climate (Cold days Humid days) *
Exercise * Emotion * Food Additives Colouring agents preservatives
* Drugs
- 16. Pollution
- 17. Allergens Irritants Pollution
- 18. Normal individual Allergen stimulates production of IgE, in
equal no. to allergen. Allergen destroyed Allergic individual
Allergen stimulates excess production of IgE. Some Allergens get
destroyed. Rest cause allergic reaction.
- 19. Associated conditions Eczema Rhinitis Hay fever Relief with
bronchodilators with or without oral steroids Weight &
Height
- 20. Afebrile episodes Personal atopy
- 21. step 1 Good Clinical History step 2 Careful Physical
Examination step 3 Investigations
- 22. Spirometry Spirometry can be performed when diagnosis is in
doubt as well as for periodic monitoring of asthma. Disadvantages
Cannot be done in children below the age of 5 yrs Technical
expertise required
- 23. Measurement of Peak expiratory flow rate (PEFR) with a peak
flow meter The peak expiratory flow rate is the easiest to perform
in children above the age of 5 yrs. It can help the patient assess
the presence of wheezing and can help in self- monitoring.
- 24. It is highly suggestive of asthma if there is: 20% increase
in PEFR after inhaled short-acting beta2 agonist 20% decrease in
PEFR after exercise Diurnal variation 20% in children not on
bronchodilator
- 25. Normally a diurnal variation 3 years (most likely asthma)
Aspiration Syndromes Bronchiolitis Asthma Bronchiolitis Transient
Wheezing of Childhood (TWC) TWC Congenital Heart Disease Early
onset asthma foreign body aspiration Congenital Malformations of
Respiratory Tract Foreign body aspiration congenital heart disease
Congenital Heart Disease Infection like TB, etc
- 28. Stridor/Noisy breathing Viral mediated hyper-reactive
airways Tuberculosis and Pertussis Foreign body Tropical
eosinophilia
- 29. Presence of these can make control of asthma difficult and
hence they should be identified and treated: Allergic Rhinitis
Adenoidal Hypertrophy Gastro Oesophageal Reflux Disease (GORD or
GERD)
- 30. All Asthma Does Not Wheeze Recurrent cough Tightness of
chest
- 31. Firstly, and most importantly, it is necessary to inform
about the chronic nature of asthma, including the fact of acute
exacerbations in between episodes Emphasize on the point that this
disease is controllable but not curable.
- 32. Also, emphasize on the fact that inhalation therapy is the
gold standard treatment for asthma. At the same time, the myths and
the misconceptions about inhalation therapy should be resolved.
Discuss the selected regime and address the concerns regarding
steroid use.
- 33. Discuss the usage and maintenance of the inhaler device.
Also advise on bringing the device along for each follow-up.
Emphasize on the need for a regular follow-up. Explain the need for
adherence with the treatment .
- 34. Advise regarding avoidance of triggers. Note that diet has
a limited role in the causation of asthma. Patients / parents
should be advised to maintain a diary to record the significant
events and carry it with them every time they go for a
follow-up.
- 35. By significant events, we mean daytime cough, night time
cough, reliever medication use, emergency visits, etc. Educate
regarding the management of acute exacerbations at home prior to
visiting a doctor
- 36. Viral infections Smoke - cigarettes, kitchen, etc. Fungi,
mold, spores Pets Food items known to cause asthma Aspirin/NSAID
sensitivity Beta-blocker-induced bronchospasm Obesity
- 37. Humidity Weather Industrial and automobile pollution
- 38. Oral Inhaled Parenteral Tablets Syrup Metered dose inhaler
(MDI) Dry powder inhaler (DPI) Injections Which is the best route
for anti-asthmatic drugs??? Nebulizers
- 39. WHY INHALATION THERAPY? Small doses of Drug High Local
Concentration Low Systemic Concentration Efficacy Safty
- 40. Less Drug Without Side effects Straight into the Lungs Why
Inhaled Therapy ? Salbutamol 4 mg Tabs 40 Puffs of salbutamol
Inh
- 41. The health-care provider should evaluate inhaler technique
at each visit.
- 42. Symptoms Nocturnal symptoms FEV1/PEF Intermittent 1 time a
week but < 1 time a day >2 times a month 80% predicted
Variability 20 - 30% Moderate persistent Daily attacks affect
activity >1 time a week 60 - 80% predicted Variability > 30%
Severe persistent Continuous limited physical activity Frequent 60%
predicted Variability > 30%
- 43. Characteristic Controlled Partly controlled (Any present in
any week) Uncontrolled Daytime symptoms None (2 or less / week)
More than twice / week 3 or more features of partly controlled
asthma present in any week Limitations of activities None Any
Nocturnal symptoms / awakening None Any Need for rescue / reliever
treatment None (2 or less / week) More than twice / week Lung
function (PEF or FEV1) Normal < 80% predicted or personal best
(if known) on any day Exacerbation None One or more / year 1 in any
week
- 44. A dose response study using budesonide in children with
moderate and severe persistent asthma indicated that 83% achieved
control of exercise induced asthma with a dose of 400 mcg/day .
There is little risk of systemic effects if inhaled corticosteroids
are used in doses of less than 400 g/day (beclomethasone
equivalent). von Berg A, Engelstatter R, Minic P, Sreckovic M,
Garcia MLG, Latos L et al.
- 45. Following commencement of therapy, the dose of inhaled
corticosteroid should be titrated according to clinical response,
aiming for the minimum dose that will provide continuing control of
asthma symptoms. While the majority of studies of inhaled
corticosteroids in children have employed twice daily dosing,
studies with ciclesonide have demonstrated that that once daily
dosing is effective .
- 46. The dose of inhaled corticosteroid delivered to the lungs
will depend on many factors including the delivery device, the age
of the child, individual variation in inhaler technique, and
adherence. Pedersen S, Engelstatter R, Weber H-J, Hirsch S, Barkai
L, Eneryk A et al.
- 47. Majority of studies have used 2mg/kg oral prednisolone ,
(maximum 60 mg) given initially and subsequently daily doses of
1mg/kg if required.
- 48. Duration of therapy will generally be up to 3 days (a 5 day
course has not been shown to confer any advantage over a 3 day
course in non hospitalized children , but in patients with severe
persistent asthma a more prolonged course may occasionally be
needed with tapering of the dose to prevent asthma relapse.
- 49. Although a recent comparison of oral
dexamethasone(0.6mg/kg) with oral prednisololone (2mg/kg)
demonstrated that a shorter course of dexamethasone provided equal
benefit and was better tolerated , concerns were raised about the
greater potential for adrenal suppression with dexamethasone
related to its longer half-life.
- 50. While there appears to be no definite advantage of
parenteral over oral corticosteroids , intravenous corticosteroids
(methylprednisolone in an initial dose of 2mg/kg, up to 60mg,
subsequent doses 1mg/kg every 6 hours on day 1, then every 12 hours
on day 2, then daily) will be needed if the child is extremely ill,
unconscious, or cannot tolerate oral medication. Hydrocortisone
8-10mg/kg (max 300mg) initially then 4-5mg/kg/dose can be used as
an alternative parenteral corticosteroid.
- 51. Short bursts of oral corticosteroids (3 to 10 days) are
administered to children with acute asthma exacerbations. The
initial starting dose is 1 to 2 mg/kg/day of prednisone followed by
1 mg/kg/day over the next 2 to 5 days. (nelson text book of
paeds)
- 52. controlled partly controlled uncontrolled exacerbation
LEVEL OF CONTROL maintain and find lowest controlling step consider
stepping up to gain control step up until controlled treat as
exacerbation TREATMENT OF ACTION TREATMENT STEPS REDUCE INCREASE
STEP 1 STEP 2 STEP 3 STEP 4 STEP 5 REDUCEINCREASE
- 53. Infants Nebulizer Children < 4 years Nebulizer/ MDI with
spacer with facemask 4 -6year MDI with Spacer >6 years DPI
>12years MDI Acute episodes Nebulizer
- 54. The prescribed treatment can be considered effective when:
The child is normal and asymptomatic He/she is not awakened by
symptoms of asthma He/she can go to school and have a normal
lifestyle He/she can play with the peers without getting any
symptoms
- 55. Exacerbations of asthma (asthma attacks) are episodes of a
progressive increase in shortness of breath, cough, wheezing or
chest tightness or a combination of these symptoms.
- 56. The economic costs of asthma are estimated to be more than
those of HIV/AIDS and tuberculosis combined.
- 57. Oxygen is given if the patient is hypoxemic (achieve O2
saturation of 92%- 95%). Inhaled rapid-acting 2 -agonists such as
salbutamol or levosalbutamol in adequate doses are essential First
hour 2-4 puffs Every 20 mts Mild 2-4 puffs 3-4 hrs moderate 6-10
puffs 1-2 hrs
- 58. Oral glucocorticosteroids 0.51 mg of prednisolone/kg or
equivalent introduced early in the course of a moderate or severe
attack help to reverse the inflammation and speed recovery
- 59. Methylxanthines are not recommended routinely. However,
theophylline can be used if inhaled 2- agonists are not available.
If the patient is already taking theophylline on a daily basis,
serum concentration should be measured before adding short- acting
theophylline.
- 60. Sedatives (strictly avoid). Mucolytic drugs (may worsen
cough). Chest physical therapy/physiotherapy (may increase patient
discomfort).
- 61. Hydration with large volumes of fluid in case of adults and
older children (may be necessary for younger children and infants).
Antibiotics (do not treat attacks, but are indicated for patients
who also have pneumonia or bacterial infection such as
sinusitis).
- 62. A subcutaneous or intramuscular injection of epinephrine
(adrenaline) may be indicated for acute treatment of anaphylaxis
and angio-oedema, but is not routinely indicated during asthma
attacks. Intravenous magnesium sulphate has not been well-studied
in young children and is usually used when all the above
fails.
- 63. Asthma is the most common chronic disorder affecting
children 5%-10% Up to 2-3 children in each classroom may be
affected by asthma It is a serious disease and can be fatal
- 64. A majority of children affected by asthma are undiagnosed,
misdiagnosed or unlabeled Over 50% of children remain uncontrolled
and hence can affect school performance
- 65. Traditional treatment Occasional RelieversIdeal treatment
Regular Controllers Steroid
- 66. Minimal (ideally no) chronic symptoms Minimal (ideally no)
need for as needed use of relievers No emergency visits (Near)
normal PEF Minimal (infrequent) exacerbations PEF circadian
variation of less than 20 percent No limitations on activities,
including exercise Minimal (or no) adverse effects from
medicine
- 67. Routes of administration of anti-asthma drugs Advantages of
inhalation therapy over oral route Drug therapy for asthma
Differences between relievers and controllers
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