22. Bronchial asthma in childhood. Flashcards
when does asthma show its peak incidence ?
first 1-4 years of life
80% of asthma has its onset before the age of 4 years
how can paediatric asthma phenotypes according to age ?
3-5 = virus induced asthma are the most common
usually preceded by a cold
they are transient and disappear completely between episodes
6-12 years - most commonly allergen induced asthma
adolescents >12 years
allergen induced asthma
what is the asthma predictive index ?
identify high risk children (2-3 years of age)
≥4 wheezing episodes in the past year
::
one major criteria
Parent with asthma
• Atopic dermatitis
• Aero-allergen sensitivity
two minor criteria Food sensitivity • Peripheral eosinophilia (≥4%) • Wheezing not related to infection
what are the symptoms of asthma ?
REVERSIBLE!!
also be worse at night - awake at night
cough
wheeze
prolonged expiratory phase
dyspnea
chest tightness
prolonged expiratory phase
Increased work of breathing (“belly breathing,” use of accessory muscles, including subcostal, intercostal, or supraclavicular retractions, nasal flaring), tripod positioning
lethargic
Nasal symptoms, including runny nose, itching, sneezing, and blocking
Difficulty with feeding
symptoms in acute asthma and severe ?
Accessory muscles of respiration
Retractions are present
hr more than 100
Pulsus paradoxus
Loud expiratory wheezing or really severe - Loud biphasic (expiratory and inspiratory) wheezing can be heard
Oxyhemoglobin saturation with room air is 91- 95% Suprasternal retractions (really severe less than 91percent)
what are the signs and symptoms in status asthmatics ?
acute and very severe
Paradoxical thoracoabdominal movement
Wheezing may be absent (in patients with the most
severe airway obstruction)
Severe hypoxemia may manifest as bradycardia
Pulsus paradoxus may disappear; this finding suggests respiratory muscle fatigue
what is the diagnosis of asthma ?
Diagnosis is often only possible through:
- long-term follow-up
- observations of the child ́s
bronchodilat or and/or anti
response to
inflammatory treatment- # and consideration of the extensive differential diagnoses.or 3R
reactivity - identifiable trigger usually a viral infection
reversibility - Airways obstruction is reversible with bronchodilators
recurrence - more than 3 episodes
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In children who are at least five years of age
bronchodilator spirometry
reversibility is deemed significant when there is a greater than 12 % improvement from baseline or an increase of over 200 ml in FEV1
with baseline spirometry of
FEV1:
FEV1 <80 percent = mild obstruction
<60 percent = moderate
<40 percent - severe
Fev1/fvc <80 percent
F25-75 (the difference between the forced expiratory volume at 25% and 75%)
FVC (Forced vital capacity)
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Skin Prick Tests- GOLDEN STANDARD
Eosinophil counting
Serum specific IgE - is not better than skin prick testing
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provocation testing
exercise
methacholine challenge - test is positive if there is a reduction in FEV1 greater than 20% from baseline. A normal test is adequate to rule out asthma,
A chest x-ray may reveal hyperinflated lungs
what is the pharmacological therapy for asthma ?
STEP 1. - delivers used as needed
short acting SABA - nebulizer or inhaler
Albuterol and levalbuterol are examples ofshort-acting bronchodilators
low dose ICS
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STEP 2 - controllers
low-dose inhaled corticosteroid (ICS).
or
LTRA
Montelukast / cromolyn
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step 3
0 to 4-year-old
double low dose ICS
5 to 11 year age medium-dose ICS or low dose ICS + long-acting beta-agonist (LABA) or leukotriene receptor antagonist (LTRA).
For those ages 12 years through adulthood, the preferred choice :
low dose of ICS + LABA
or
medium-dose ICS.
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step 4
0 to 4-year-
medium dose ICS + montelukast. (/LABA??)
5 and above,
a medium dose ICS + LABA
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Step 5
0-4 years is high dose ICS + montelukast (/LABA??)
5 and above,
a high dose ICS + LABA.
also recommends consideration of omalizumab for ages 12 and above. a monoclonal antibody indicated for moderate to severe persistent asthma with
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Step 6
0-4 years
high dose ICS + (??LABA) or montelukast or oral corticosteroids
for ages 5-11 years – high dose ICS + LABA + oral systemic corticosteroid;
ages 12 and up,
high dose ICS + LABA + oral corticosteroid are preferred.
Omalizumab may be a consideration for appropriate patients with allergy.
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Theophylline is a medication that may be an alternative medication in Steps 2 through 6. However, its use requires caution due to its narrow therapeutic range and potential side effects, including diuresis, tremors, and headaches.
For children 6-11 years, theophylline is not recommended
what is the dose of albuterol?
2.5 - 5 mg of nebulized albuterol should be given as initial management and can be re-dosed every 20 minutes.
If the child is 5 years or older, 5 mg is the recommended dose
what is the dose for ICS
Budesonide inhaled suspension for nebulization (Pulmicort Respules)
0.25, 0.5, 1 mg
0-4
low
0.25- 0.5 mg
medium
>0.5 – 1 mg
high
>1 mg
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beclometasone dipropioate
40 or 80 mcg/puff
for 4-11 -
low
80-160 mcg daily
medium
160- 320 mcg daily
high
>320 mcg
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12 and more
low
80-240 mcg
medium
240- 480 mcg
high
480 mcg
what is the dosing of montelukast ?
0-4 years 4 mg (granules) PO once daily in evening
5 - 15 5 mg (chewable tablet) PO once daily in evening
15 and more 10 mg (conventional tablet) PO once daily in evening
what is the dosing for LABA + ICS ?
Very Low Dose ICS + LABA
Fluticasone50mcg / Salmeterol 25mcg) 1
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low dose =
above 2 puff twice daily
Fluticasone 100mcg / Salmeterol 50mcg
1 puff twice daily
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medium dose
250 mcg/50 mcg
1 inhalation BID
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high dose
500 mcg/50 mcg
1 inhalation BID
how to assess severity of asthma ?
step 1
for 5 years and above
Intermittent
symptoms = < 2 days/week
Nighttime awakenings = < 2x/month
Short acting beta2-agonist control = < 2 days/week
Interference w/ normal activity = none
Lung function = Normal FEV1 between exacerbations
· FEV1 >80% predicted · FEV1/FVC >85%
Mild
2 days/week but not daily
3-4x/month
> 2 days/week but not daily
Minor limitation
· FEV1 >80% predicted
FEV1/FVC >80%
step 2
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Moderate
Daily
> 1x/week but not nightly
Daily
Some limitation
· FEV1 = 60-80% predicted
FEV1/FVC = 75-80%
step 3
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Severe
Throughout the day
Often 7x/week
Several times per day
Extremely limited
· FEV1 <60% predicted
· FEV1/FVC <75%
step 3
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0-4 years
risk - exacerbation requiring oral systemic corticosteroids
intermittent - 0-1 year
mild moderate and severe
2 or more exacerbation in 6 months requiring oral systemic corticosteroids
or
4 or more wheezing episodes in a year lasting more than a day
how do you evaluate the stepwise approach ?
in 2-6 weeks depending on severity evaluate the level of asthma if no benefit achieved consider adjusting therapy
check adherence to inhaler , inhaler technique and environmental control
step down if asthma is well controlled for atleasr 3 months
for mild asthma no daily medication however if the need arises to use the inhaler two times a day then need to consider starting control therapy for long term
how do we know f asthma is well controlled ?
step up , revaluate 2-6 weeks
well controlled symptoms less than 2 days a week nigh time awakenings less than once a month interface with normal activity - none SABA - 2 or less times a day needed exacerbation 0-1 year
not well controlled symptoms - 2 or more a week night time awakening - more than once a month interference with normal activity saba - more than 2 days a week exacerbation - 2-3/year
very poor control symptoms - through out the day night time awakening - more than once a month activity - extremely limited saba - several times a day exacerbation - >3/ year
consider short course of oral systemic corticosteroids
step up 1-2
revaluate within 2 weeks
