ASTHMA IN CHILDHOOD

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ASTHMA IN CHILDHOOD dr. Ery Olivianto, SpA Dr. dr. Wisnu Barlianto, SpA(K) Prof. Dr. dr. HMS. Chandra Kusuma, SpA(K) Child Health Department Faculty of Medicine Brawijaya University Saiful Anwar General Hospital

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ASTHMA IN CHILDHOOD. dr . Ery Olivianto, SpA Dr. dr . Wisnu Barlianto, SpA (K) Prof . D r . d r. HMS. Chandra K usuma , SpA (K) Child Health Department Faculty of Medicine Brawijaya University Saiful Anwar General Hospital. Holgate ST. J Allergy Clin Immunol 2011;128:495-505. - PowerPoint PPT Presentation

Transcript of ASTHMA IN CHILDHOOD

Page 1: ASTHMA IN CHILDHOOD

ASTHMA IN CHILDHOOD

dr. Ery Olivianto, SpADr. dr. Wisnu Barlianto, SpA(K) Prof. Dr. dr. HMS. Chandra Kusuma, SpA(K)

Child Health Department Faculty of Medicine Brawijaya UniversitySaiful Anwar General Hospital

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Old paradigma (1860)• Paroxysmal

dyspnoea• Contraction of

smooth muscle• bronchodilator

New paradigma (1950)• Inflammatory

disorder• Corticosteroids

Holgate ST. J Allergy Clin Immunol 2011;128:495-505

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Definitions

• Asthma is a chronic inflammatory disorder of the airways associated with airway hyperresponsiveness and airflow obstruction that is often reversible either spontaneously or with treatment

WAO. White Book on Allergy, 2011

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Epidemiology • World Health Organisation estimate 300 million individuals

have asthma worldwide• Current rising trends this will reach 400 million by 2025• Approximately 250,000 people die prematurely each year

from asthma• Prevalence in the 13-14 year olds ranging from 2.1% to 32.2%• Prevalence in the 6-7 year olds was similar to those in the

older children with prevalence of wheezing varying from 4.1%-32.1%

• Indonesia: 2.6% - 17.4%

WAO. White Book on Allergy, 2011Pedoman Nasional Asma Anak, 2004

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Asthma

Genetic

Allergens

Infection

Tobacco smoke

Pollutants

Nutrition

Irritants

Exercise

Weather

Stress

Bacharier LB, et al,. Allergy 2008: 63: 5–34

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Inflammatory and immune cells involved in asthmaBarnes PJ. Nat Rev Immunol 2010;8:183-192

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Asthma inflammatory cascade

Bernstein D. Pediatric for Medical Students 3rd Ed, 2011

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Asthma phenotypes

Infant (0-2 years old)

Preschool children (3-5 years old)

School children (6-12 years old)

Adolescents

Bacharier LB, et al,. Allergy 2008: 63: 5–34

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Infantile asthma

• Asthma affecting infant aged < 2 years• 3 or more episodes of marked expiratory

wheezing within the previous 6 months

Bacharier LB, et al,. Allergy 2008: 63: 5–34

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Hypothetical yearly prevalence for recurrent wheezing phenotypes in childhood

Leung DM. Pediatric Allergy 2nd Ed, 2010

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Modified Asthma Predictive Index for children (Tucson Children's Respiratory Study, Tucson, Arizona). Through a statistically optimized model for 2- to 3-year-old children with frequent wheezing in the past year, one major criterion or two minor criteria provided 77% positive predictive value and 97% specificity for persistent asthma in later childhood

Leung DM. Pediatric Allergy 2nd Ed, 2010

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Asthma phenotypes in children > 2 years

Bacharier LB, et al,. Allergy 2008: 63: 5–34

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Entry point of asthma diagnosis:

Recurrent Wheezing

and/or

Chronic Recurrent Cough

Pedoman Nasional Asma Anak, 2004

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DiagnosisCough and/or Wheeze

Clinical historyPhysical examinationMantoux test

Suggestive of asthma:• Episodic• Nocturnal• Seasonal• Exertional• Atopic

Indeterminate features or suggestive of alternative diagnosis• Neonatal onset• Failure to thrive• Chronic infection• Vomiting/choking• Focal lung or CVS signs

If possible frequent peak flowmeasurements :• Reversibility (20%)• Variability (20%)

Consider• Chest and sinus x rays• Lung function• Bronchial challenge and/or• Bronchodilator response

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….. Consider :• Sweat test• Immune function• Ciliary & Reflux studies

Bronchodilator responseNo response Response

WD/ Asthma

Assess severity and etiology

Review diagnosis and complianceif poor response to treatment

+ ve- ve

Alternative diagnosis and treatmentChest x ray if more thanmild episodic disease

Trial of antiasthma treatment Consider asthma as an associated problem

Not asthma

Pedoman Nasional Asma Anak, 2004

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Differential diagnosis of wheezing in children

Nishimuta T. Allergology International 2011;60:147-169

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Bernstein D. Pediatric for Medical Students 3rd Ed, 2011

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Classification of Asthma in Children

Chronic• Infrequent episodic

asthma• Frequent episodic

asthma• Persistent asthma

• Acute• Mild attack• Moderate attack• Severe attack

Pedoman Nasional Asma Anak, 2004

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Classification of diseaseClinical parametersand lung function

Infrequent episodic asthma Persistent asthmaFrequent episodic

asthma

Freq of attacks < 1x /month Daily> 1x /month

Duration of attacks < 1 week Daily >1 week

Between episodes No symptoms Frequent nocturnal symptoms Symptoms (+)

Sleep and activity Normal AffectMay affect

Physical exam Normal AbnormalMay affect

Controller No need Steroid/combinationSteroid/combination

Lung function (No attacks) PEF/FEV1 >80% PEF/FEV1 <60%

Variability 20-30%PEF/FEV1 60-80%

Variability (attacks) >15% > 50%> 30%

Pedoman Nasional Asma Anak, 2004

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Asthma managements

Chronic asthma

Long term management

Reliever &Controller

Acute asthma

Attack management

Reliever

Pedoman Nasional Asma Anak, 2004

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Asthma managements

Chronic asthma

Long term management

Algorithm diagnosis& treatment

Acute asthma

Attack management

Algorithm attack management

Pedoman Nasional Asma Anak, 2004

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Asthma medicationController

drug to control asthma ie attack or symptom not easily

emerge

• Inhaled steroid• LABA, ALTR

Reliever drug to relieve

asthma attack or symptoms

• -agonist• Xanthine

• anticholinergic

Pedoman Nasional Asma Anak, 2004

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Long term treatment2-agonist or theophyllineinhaled/oral intermittently

Add sodium cromoglicate

Replace with low dose inhaled steroidsContinue 2-a or/and

theophylline inhaled/oral intermittently

6-8 weeks>3 doses / week

6-8 weeksresponse (-)

Infrequent EpisodicSymptoms

Frequent episodicSymptoms

3-6 monthsEvaluation

3-6 monthsresponse (+)

6-8 weeksresponse (-)

3-6 monthsresponse (+)

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Consider :• Long acting 2-agonists, or• Slow release 2-agonists, or• Slow release theophyllines

Increase dose of inhaled steroid

Add oral steroids

6-8 weeksrespons (-)

Persistent Symptoms

3-6 monthsrespons (+)

6-8 weeksrespons (-)

3-6 monthsrespons (+)

6-8 weeksrespons (-)

3-6 monthsrespons (+)

Pedoman Nasional Asma Anak, 2004

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> 2 days/weekNeed for reliever/rescue

Nocturnal symptoms or awakening

None(less than twice/week, typically for short periods of the order of minutes and rapidly relieved by use of a rapid-acting bronchodilator)

Limitations of activities

>Twice a weekDaytime symptoms:wheezing, cough,difficult breathing

Uncontrolled(>3 features of partly con-

trolled present in any week)

Partly controlled(any measure present in any

week)

ControlledCharacteristic

None(child is fully active,

plays and runs withoutlimitation or symptoms)

None(including no nocturnalcoughing during sleep)

< 2 days/week

(typically for short periods of the order of minutes and rapidly relieved by use of a rapid-acting bronchodilator

(coughs during sleep or wakes with cough, wheezing,and/or difficult breathing)

Any

> 2 days/week

Any(cough, wheeze or difficulty breathing,during exercise,

play or laughing)

(typically last minutes or hours or recur, but partially or fully relieved by a rapid-acting bronchodilator

>Twice a week

Any(cough, wheeze or difficulty breathing,during exercise,

play or laughing)

(coughs during sleep or wakes with cough, wheezing,and/or difficult breathing)

Any

Levels of Asthma Control in Children 5 years or youngers

GINA, 2009

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Assessment of severity

Mild Moderate

SevereRespirator

y arrest imminent

Breathless WalkingCan lie down

TalkingInfant-softerShorter cryDifficult feedingPrefers sitting

At restInfant stops feedingHunched forward

Talks in Sentences Phrases Words

Alertness Maybe agitated

Usually agitated

Usually agitated

Drowsy or confused

Respiratory rate

Increased Increased Often >30x/min

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Normal rates of breathing in awake children:

Age Normal rates<2 months <60/min2-12 months <50/min1-5 years <40/min6-8 years <30/min

Accessory muscles and suprasternal retractions

Usually not Usually Usually Paradoxal thoraco-abdominal movement

Wheeze Moderate, often only end expiratory

Loud Usually loud Absence of wheeze

Pulse/min <100 100-200 >120 Bradycardia

Infants 2-12 months <160/min

Preschool age 1-2 years <120/min

School age 2-8 years <110/min

Pulsus paradoxus

Absent<10 mmHg

Maybe present10-25 mmHg

Often present20-40 mmHg

Absence suggests

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Pulsus paradoxus

Absent<10 mmHg

Maybe present10-25 mmHg

Often present20-40 mmHg

Absence suggests

PEF after initial roncho-dilator, %predicted or %personal best

Over 80% Approx. 60-80%

<60% predicted or personal best or response lasts <2 hrs

PaO2 (on air)

and/orPaCO2

NormalTest not usually necessary<45 mmHg

>60 mmHg

<45 mmHg

<60 mmHgpossible cyanosis

>45 mmHg

SaO2% >95% 91-95% <90%Pedoman Nasional Asma Anak, 2004

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Acute asthma algorithm

Clinic/ERAsses attack severity

1st management• nebulitation -agonis 3x, 20 min interval

• 3rd nebulitation + anticholinergic

Moderate attack (nebulization 2-3x,

partial response)• give O2

• asses: Moderate – ODC

• IV line

Mild attack

(nebulization 1x, complete response) • persist 1-2 hr:

discharge• symptom reappear:

Moderate attack

Severe attack (nebulization 3x,

no response)

• O2 from the start•IV line•asses: Severe -

hospitalized• CXR

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One Day Care (ODC)• Oxygen therapy• Oral steroid • Nebulized / 2 hour• Observe 8-12 hours, if stable discharge• Poor response in 12h, admission

Admission room• Oxygen therapy• Treat dehydration and acidosis • Steroid IV / 6-8 hours• Nebulized / 1-2 hours• Initial aminophylline IV, then maintenance• Nebulized 4-6x good response per 4-6 h• If stable in 24 hours discharge• Poor response ICU

Discharge• give -agonist (inhaled/oral)• routine drugs• viral infection: oral steroid • Outpatient clinic in 24-48 hours

Notes:• In severe attack, directly use -agonist + anticholinergic• If nebulizers not available, use adrenalin SC 0.01 ml/kg/times with maximal dose 0.3 ml/times •Oxygen therapy 2-4 l/min should be early treatment in moderate and severe attack

Pedoman Nasional Asma Anak, 2004

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Non responsive• Dehydration:

– inadequate intake, the longer the more– evaluate: clinically, laboratory; overcome

• Acidosis: correction• Atelectasis & mucus plug: CXR mandatory; physiotherapy

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Non responsive• Excessive use of ß-agonist down regulation

of ß-agonist receptors tachyphylaxis, subsensitivity

Systemic steroid

– reduce the edema – up regulates more ß-agonist receptors

sensitive again to ß-agonist drugs

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Choosing an Inhaler DeviceA pressurized metered-dose inhaler (MDI) with a

valved spacer (with or without a face mask, depending on the child’s age) is the preferred

delivery systemChoosing an Inhaler Device Age group Preferred device Alternative device

Younger than 4 yearsPressurized metered-dose inhaler plus dedicated spacer with face mask

Nebulized with face mask

4-5 yearsPressurized metered-dose inhaler plus dedicated spacer with mouth piece

Pressurized metered-dose inhaler plus dedicated spacer with mouth piece, or

Nebulizer with mouthpiece or face mask

GINA, 2009

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Jet nebulizer

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Ultrasonic nebulizer

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References

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References