ASTHMA

IN PEDIARIC AGE GROUP

Asthma: is a common long-term inflammatory disease of the airways of the
lungs. It is characterized by variable and recurring symptoms,
reversible airflow obstruction, and easily triggered bronchospasms.
Asthma is the most common chronic disease of childhood, with up to 20% of
children being affected.
Asthma is still a leading cause of emergency department visits, hospital
admission, absence from school, limitations in activity and sleep.
The variability in disease prevalence between countries most likely reflects
the major role played by the gene–environment interaction in disease
expression.
In adults, females are more likely than males to have asthma, but in children
the reverse is true.
Etiology:
All phenotypes of asthma are multifactorial disorders which are the result of a
complex interplay between genetic and environmental factors.
In the susceptible host, immune responses to common airways exposures
(e.g., respiratory viruses, allergens, tobacco smoke, air pollutants) can
stimulate prolonged, pathogenic inflammation and aberrant repair of injured
airways tissues. Lung dysfunction (Airways hyperresponsiveness AHR),
reduced airflow and airway remodeling develop.
These pathogenic processes in the growing lung during early life adversely
affect airways growth and differentiation, leading to altered airways at mature
ages.
Once asthma has developed, ongoing inflammatory exposures appear to
worsen it, driving disease persistence and increasing the risk of severe
exacerbations.
Pathogenesis:
Airflow obstruction in asthma is the result of numerous pathologic processes.
In the small airways, airflow is regulated by smooth muscle encircling the
airway lumen; bronchoconstriction of these bronchiolar muscular bands
restricts or blocks airflow.
A cellular inflammatory infiltrate and exudates distinguished by eosinophils,
and other inflammatory cell types (neutrophils, monocytes, lymphocytes,
mast cells, basophils), can fill and obstruct the airways and induce epithelial
damage and desquamation into the airways lumen.
Hypersensitivity or susceptibility to a variety of provocative exposures or
triggers can lead to airways inflammation, AHR, edema, basement membrane
thickening, subepithelial collagen deposition, smooth muscle and mucous
gland hypertrophy, and mucus hypersecretion—all processes that contribute
to airflow obstruction.
• Approximately 80% of all asthmatic patients report disease onset prior to 6 yr of
age. However, of all young children who experience recurrent wheezing, only a
minority go on to have persistent asthma in later childhood.
• Allergy in young children with recurrent cough and/or wheeze is the strongest
identifiable factor for the persistence of childhood asthma.
Early Childhood Risk Factors for Persistent Asthma:
Minor risk factor Major risk factor

Allergy: Parental asthma*

• Allergic rhinitis Atopic dermatitis (eczema)*
• Food allergy Inhalant allergen sensitization*
• Food allergen sensitization
Severe lower respiratory tract infection:
• Pneumonia
• Bronchiolitis requiring hospitalization
Wheezing apart from colds
Male gender
Low birth weight
Environmental tobacco smoke exposure
Reduced lung function at birth
Formula feeding rather than breastfeeding
Types of Childhood Asthma:
There are 2 common types of childhood asthma based on different natural courses:
(1) Transient Nonatopic Wheezing: recurrent wheezing in early childhood, primarily
triggered by common respiratory viral infections, usually improves by school age.
(2) Persistent Atopy-Associated Asthma: chronic asthma associated with allergy that
persists into later childhood and often adulthood. School-age children with mild-
moderate persistent asthma generally improve as teenagers, with some (about 40%)
developing intermittent disease. Milder disease is more likely to remit.
Inhaled corticosteroid controller therapy for children with persistent asthma does
not alter the likelihood of outgrowing asthma in later childhood; however, because
children with asthma generally improve with age, their need for controller therapy
subsequently lessens and often resolves.
Reduced growth and progressive decline in lung function can be features of
persistent, problematic disease.
Clinical Manifestation:
Intermittent dry coughing and expiratory wheezing are the most common
chronic symptoms of asthma.
Older children and adults report associated shortness of breath and chest
congestion and tightness.
younger children are more likely to report intermittent, nonfocal chest pain.
Respiratory symptoms can be worse at night, associated with sleep, especially
during prolonged exacerbations triggered by respiratory infections or inhalant
allergens.
Daytime symptoms, often linked with physical activities (exercise-induced) or
play, are reported with greatest frequency in children.
Asking about previous experience with asthma medications (bronchodilators)
may provide a history of symptomatic improvement with treatment that
supports the diagnosis of asthma.
The presence of risk factors, such as a history of other allergic conditions(allergic
rhinitis, allergic conjunctivitis, atopic dermatitis, food allergies), parental asthma,
and/or symptoms apart from colds, supports the diagnosis of asthma.
Physical findings may be subtle. During routine clinic visits, children with asthma
typically present without abnormal signs, Some may exhibit a dry, persistent cough.
The chest findings are often normal. Deeper breaths can sometimes elicit
otherwise undetectable wheezing.
Wheezing may not be prominent if there is poor aeration from airway obstruction.
As the attack progresses, cyanosis, diminished air movement, retractions, agitation,
inability to speak, tripod sitting position, diaphoresis, and pulsus paradoxus
(decrease in blood pressure of >15 mm Hg with inspiration) may be observed.
In clinic, quick resolution (within 10 min) or convincing improvement in symptoms
and signs of asthma with administration of an inhaled short-acting β-agonist (SABA
; e.g., albuterol) is supportive of the diagnosis of asthma.
• Asthma Triggers:
1. Common viral infections of respiratory tract.
2. aeroallergens in sensitized asthmatic patients:
• Indoor Allergens: Animal dander • Dust mites • Cockroaches • Molds
• Seasonal Aeroallergens: Pollens (trees, grasses, weeds) • Seasonal molds.
3. Air pollutants: Environmental tobacco smoke • Ozone • Nitrogen dioxide • Sulfur dioxide
• Particulate matter • Wood- or coal-burning smoke • Mycotoxins Endotoxin • Dust.
4. Strong or noxious odors or fumes: Perfumes, hairsprays • Cleaning agents
5. Occupational exposures: Farm and barn exposures • Formaldehydes, cedar, paint
fumes
6. Cold dry air.
7. Exercise crying.
8. Laughter.
9. Hyperventilation.
10. Comorbid conditions: Rhinitis • Sinusitis • Gastroesophageal reflux
11. Drugs: Aspirin and other nonsteroidal antiinflammatory drugs • β-Blocking agents
LABORATORY AND IMAGING STUDIES:
While no single test or study can confirm the diagnosis of asthma, many elements
contribute to establishing the diagnosis.
Objective measurements of pulmonary function (spirometry) aid in the diagnosis and
direct the treatment of asthma.
Spirometry is used to monitor response to treatment, assess degree of reversibility to
therapeutic intervention, and measure the severity of an asthma exacerbation.
Children older than 5 years of age can usually perform spirometry maneuvers.
For younger children who cannot perform spirometry maneuvers or peak flow, a
therapeutic trial of controller medications aids in the diagnosis of asthma.
Allergy skin testing should be included in the evaluation of all children with persistent
asthma but not during an exacerbation of symptoms. Positive skin test results,
identifying sensitization to aeroallergens (e.g., pollens, mold, dust mite, pet dander),
correlate strongly with bronchial allergen provocative challenges.
• Forced expiratory volume (FEV) measures how much air a person can exhale
during a forced breath. The amount of air exhaled may be measured during
the first (FEV1), second (FEV2), and/or third seconds (FEV3) of the forced
breath.
• Forced vital capacity (FVC) is the total amount of air exhaled during the FEV
test.
• Forced expiratory volume and forced vital capacity are lung function tests
that are measured during spirometry. Forced expiratory volume is the most
important measurement of lung function. It is used to:
1. Diagnose obstructive lung diseases such as asthma and chronic obstructive
pulmonary disease (COPD). A person who has asthma or COPD has a lower FEV1
result than a healthy person.
2. See how well medicines used to improve breathing are working.
3. Check if lung disease is getting worse. Decreases in the FEV1 value may mean the
lung disease is getting worse.
• An x-ray should be performed with the first episode of asthma or with
recurrent episodes of undiagnosed cough or wheeze to exclude anatomic
abnormalities. Repeat chest x-rays are not needed with new episodes
unless there is fever (suggesting pneumonia) or localized findings on
physical examination.
• Allergy skin testing should be included in the evaluation of all children with
persistent asthma but not during an exacerbation of symptoms. Positive
skin test results, identifying sensitization to aeroallergens (e.g., pollens,
mold, dust mite, pet dander), correlate strongly with bronchial allergen
provocative challenges.
Classification of asthma:
Severity Classification: Intrinsic disease severity while not taking asthma medications.
a) Intermittent.
b) Persistent:
• Mild
• Moderate
• Severe.
Control Classification: Clinical assessment while asthma being managed and treated:
a) Well controlled.
b) Not well controlled.
c) Very poorly controlled.
Management Patterns:
a) Easy-to-control: well controlled with low levels of daily controller therapy
b) Difficult-to-control: well controlled with multiple and/or high levels of controller therapies.
c) Exacerbators: despite being well controlled, continue to have severe exacerbations.
d) Refractory: continue to have poorly controlled asthma despite multiple and high levels of
controller therapies.
• Classification of asthma severity and control is based on the domains of
impairment and risk.
• impairment consists of an assessment of the patient's recent symptom
frequency (daytime and nighttime), SABA use for quick relief, ability to engage
in normal or desired activities, and airflow compromise evaluated by
spirometry in children ≥5 yr.
• Risk refers to the likelihood of developing severe asthma exacerbations.
• Childhood asthma is characterized by minimal day-to-day impairment, with
the potential for frequent, severe exacerbations most often triggered by viral
infections.
• adults with asthma have greater impairment with less potential for risk.
• even in the absence of frequent symptoms, persistent asthma can be
diagnosed and longterm controller therapy initiated.
• For children ≥5 yr, 2 exacerbations requiring oral corticosteroids in 1 yr
qualifies them as having persistent asthma.
• infants and preschool-aged children who have risk factors for asthma and 4 or
more episodes of wheezing over the past year that lasted longer than 1 day
and affected sleep, or 2 or more exacerbations in 6 mo requiring systemic
corticosteroids, qualifies them as having persistent asthma.
Management of asthma
Management of asthma should have the following components:
(1) assessment and monitoring of disease activity;
(2) education to enhance patient and family knowledge and skills for self-
management;
(3) identification and management of precipitating factors and comorbid
conditions that worsen asthma.
(4) appropriate selection of medications to address the patient's needs.
The long-term goal of asthma management is attainment of optimal asthma
control.
1- Regular Assessment and Monitoring:
Asthma severity is the intrinsic intensity of disease, and assessment is
generally most accurate in patients not receiving controller therapy.
Therefore, assessing asthma severity directs the initial level of therapy.
The 2 general categories are intermittent asthma and persistent asthma, the
latter being further subdivided into mild, moderate, and severe.
asthma control is dynamic and refers to the day-to-day variability of an
asthmatic patient.
In children receiving controller therapy, assessment of asthma control is
important in adjusting therapy and is categorized in 3 levels: well controlled,
not well controlled, and very poorly controlled.
Responsiveness to therapy is the ease or difficulty with which asthma control
is attained by treatment.
2- Patient Education:
Specific educational elements in the clinical care of children with asthma are
believed to make an important difference in home management and in
adherence of families to an optimal plan of care, eventually impacting patient
outcomes.
Every visit presents an important opportunity to educate the child and family,
allowing them to become knowledgeable partners in asthma management,
because optimal management depends on their daily assessments and
implementation of any management plan.
All children with asthma should benefit from a written Asthma Action Plan.This
plan has two main components: (1) a daily “routine” management plan
describing regular asthma medication use and other measures to keep asthma
under good control; and (2) an action plan to manage worsening asthma,
describing indicators of impending exacerbations, identifying what medications
to take, and specifying when and how to contact the regular physician and/or
obtain urgent/emergency medical care.
3- Control of Factors Contributing to Asthma Severity:
Controllable factors that can worsen asthma can be generally grouped as (1) environmental
exposures and (2) comorbid conditions
Environmental exposures Treat Comorbid Conditions
*Eliminate or Reduce Problematic Environmental Exposures. Rhinitis
Environmental tobacco smoke elimination or reduction in Sinusitis
home and automobiles Gastroesophageal reflux
* Allergen exposure elimination or reduction in sensitized
asthmatic patients: • Animal danders: pets (cats, dogs,
rodents, birds) • Pests (mice, rats) • Dust mites •
Cockroaches • Molds
* Other airway irritants: • Wood- or coal-burning smoke
• Strong chemical odors and perfumes (e.g., household
cleaners) • Dusts
4- Principles of Asthma Pharmacotherapy:
The goals of therapy are to achieve a well-controlled state by reducing the
components of both impairment (e.g., preventing or minimizing symptoms,
infrequently needing quick-reliever medications, maintaining “normal” lung
function and normal activity levels) and risk (e.g., preventing recurrent
exacerbations, reduced lung growth, and medication adverse effects).
Principle of asthma pharmakotherapy: There are 6 treatment steps.
• Patients at Treatment Step 1 have intermittent asthma.
• Children with mild persistent asthma are at Treatment Step 2 . Children with
moderate persistent asthma can be at Treatment Step 3 or 4 .
• Children with severe persistent asthma are at Treatment Steps 5 and 6 .
• Initially, airflow limitation and the pathology of asthma may limit the delivery and
efficacy of ICS such that stepping up to higher doses and/or combination therapy
may be needed to gain asthma control. Furthermore, ICS requires weeks to
months of daily administration for optimal efficacy to occur. Combination
pharmacotherapy can achieve relatively immediate improvement while also
providing daily ICS to improve long-term control and reduce exacerbation risk.
• Asthma therapy can be stepped down after good asthma control has been
achieved and maintained for at least 3 mo.
• When asthma is not well controlled, therapy should be escalated by increasing
controller treatment step by 1 level and closely monitoring for clinical
improvement.
• For a child with very poorly controlled asthma, the recommendations are to
consider a short course of prednisone, or to increase therapy by 2 steps, with
reevaluation in 2 wk.
• If step-up therapy is being considered, it is important to check inhaler technique
and adherence, implement environmental control measures, and identify and
treat comorbid conditions.
 Drugs used in asthma
Inhaled Corticosteroids:
Inhaled corticosteroids are the most effective antiinflammatory medications for the
treatment of chronic, persistent asthma and are the preferred therapy when
initiating long-term control therapy.
Early intervention with inhaled corticosteroids reduces morbidity but does not alter
the natural history of asthma.
Inhaled corticosteroids are available as inhalation aerosols, dry powder inhalers, and
a nebulizer solution.
Low-to-medium dose inhaled corticosteroids may decrease growth velocity, although
these effects are small (approximately 1 cm in the first year of treatment), generally
not progressive, and may be reversible.
Inhaled corticosteroids do not have clinically significant adverse effects on
hypothalamic-pituitary-adrenal axis function, glucose metabolism, subcapsular
cataracts, or glaucoma when used at low-to-medium doses in children.
Rinsing the mouth after inhalation and using large volume spacers help lessen the
local adverse effects of dysphonia and candidiasis and decrease systemic absorption
from the gastrointestinal tract.
Leukotriene Modifiers:
Leukotrienes, synthesized via the arachidonic acid metabolism cascade, are
potent mediators of inflammation and smooth muscle bronchoconstriction.
Leukotriene modifiers are oral, daily-use medications that inhibit these biologic
effects in the airway.
Zafirlukast is approved for children older than 5 years of age and is given twice
daily. Montelukast is dosed once daily at night.
Pediatric studies show the usefulness of leukotriene modifiers in mild asthma
and the attenuation of exercise-induced bronchoconstriction.
These agents may be helpful as steroid-sparing agents in patients with asthma
that is more difficult to control.
Nonsteroidal Antiinflammatory Agents:
Cromolyn and nedocromil are considered nonsteroidal antiinflammatory
drugs (NSAIDs), although they have little efficacy as a long-term controller for
asthma. They can block EIB and bronchospasm caused by allergen challenge.
Although both drugs are considered alternative controller agents for children
with mild persistent asthma, the 2016 GINA guidelines no longer recommend
cromolyn or nedocromil. Because they inhibit EIB and allergen-triggered
responses, cromolyn (nedocromil is no longer available in the United States)
can be used as an alternative or add-on to SABAs for these specific
circumstances.
Long-Acting β2:
Long-acting β2-Agonists -agonists, formoterol and salmeterol, have twice daily
dosing and relax airway smooth muscle for 12 hours but do not have any
significant antiinflammatory effects.
Adding a long-acting bronchodilator to inhaled corticosteroid therapy is more
beneficial than doubling the dose of inhaled corticosteroids.
Multiple formulations are available. Formoterol is approved for use in children
older than 5 years of age for maintenance asthma therapy and for prevention
of exercise-induced asthma. It has a rapid onset of action similar to albuterol
(15 minutes).
Salmeterol is approved for children 4 years of age or older and has an onset of
30 minutes. Because combination inhalers administer two medications
simultaneously, compliance is generally improved.
Theophylline:
Theophylline was more widely used previously, but because current management is
aimed at inflammatory control, its popularity has declined.
It is mildly to moderately effective as a bronchodilator and is considered an
alternative, add-on treatment to low- and medium-dose inhaled corticosteroids.
However, its therapeutic window is narrow necessitating monitoring of blood levels.
Biologics:
Omalizumab is a humanized anti-IgE monoclonal antibody that prevents binding of
free IgE to high-affinity receptors on basophils and mast cells. It is approved for
moderate to severe allergic asthma in children 6 years of age and older. Omalizumab
is delivered by subcutaneous injection every 2-4 weeks, depending on body weight
and pretreatment serum IgE level.
Mepolizumab is an add-on maintenance therapy for severe asthma in patients aged
12 years and older. It is an anti-interleukin-5 monoclonal antibody injected
subcutaneously every 4 weeks. Mepolizumab decreases the production and survival
of eosinophils, a major inflammatory cell involved in asthma pathogenesis.
Short-Acting β2-Agonists:
Short-acting β2 -agonists such as albuterol and levalbuterol are effective
bronchodilators that exert their effect by relaxing bronchial smooth muscle
within 5-10 minutes of administration. These effects last 4-6 hours.
Generally, a short-acting β2 is prescribed for acute symptoms and as
prophylaxis before-agonist allergen exposure and exercise.
The inhaled route is preferred because adverse effects—tremor, prolonged
tachycardia, and irritability—are less.
Overuse of β2-agonists implies inadequate control, and a change in
medications may be warranted. The definition of bronchodilator overuse
depends on the severity of the child’s asthma.
Oral Corticosteroids:
Short bursts of oral corticosteroids (3-10 days) are administered to children
with acute exacerbations. The usual dose is 1-2 mg/kg/day of prednisone for 5
days.
Oral corticosteroids are available in liquid or tablet formulations.
Prolonged use of oral corticosteroids can result in systemic adverse effects
such as hypothalamic-pituitary-adrenal suppression, cushingoid features,
weight gain, hypertension, diabetes, cataracts, glaucoma, impaired immunity,
osteoporosis, and growth suppression.
Children with severe asthma may require oral corticosteroids over extended
periods. The dose should be tapered as soon as possible to the minimum
effective dose, preferably administered on alternate days.
Complications of asthma:
1. Status asthmaticus: is an acute exacerbation of asthma that does not
respond adequately to therapeutic measures and may require
hospitalization. Intravenous magnesium sulfate is administered in the
emergency department if there is clinical deterioration despite treatment
with β2-agonists, ipratropium,and systemic corticosteroids.
2. Respiratory failure.
3. Pneumonia
4. Atelactasis.
5. dehadration
PROGNOSIS:
For some children, symptoms of wheezing with respiratory infections subside
in the preschool years, whereas others have more persistent asthma
symptoms.
Atopy is the strongest predictor for wheezing continuing into persistent asthma