Pediatric 2

Lecturer : Dr Asma Ahmed

Chapter 2
Respiratory
Asthma and Bronchiolitis
 Introduction
Asthma
Definition :
Asthma is a chronic lung disease affecting people of all
ages .
Its caused by inflammation and muscle tightening around
The airways , which makes it harder to breath .
 Epidemiology
• Worldwide: Overall 1 – 18%
– Among pre-schools 4-32%%
– The estimated current asthma prevalence in general
increased between 2001 and 2009
• (9.6 % among children ≤18 years in 2009)
• Africa: ranges 5 - <20%
Prevalence increasing 2-3 fold over past decade
 Pathophysiology
• Allergen
– Sensitized mast cell degranulation 
• Histamine, leukotriene release - bronchospasm &
inflammation
– TH2 stimulation – B cell - IgE release –
• Eosinophil, release of inflammatory mediators –
inflammation ; mucosal oedema + mucous
secretion
• Neuronal stimulation (exercise, cold, irritants)
– bronchospasm, mucosal secretions
• Underlying hyper-reactive airway
 PATHOGENESIS

Acute Chronic Airway

Inflammation Inflammation Remodelling

Symptoms Exacerbations Bronchial hyperreactivity

Broncho-constriction Cell recruitment Cellular proliferation
Oedema Epithelial damage Extra-cellular matrix
Secretions Structural changes increase
 Inducers and triggers of asthma
Allergens Triggers / Irritants
-Dust -Respiratory -Emotions
-Cockroach saliva viruses -Cold air
-Cat/dog dander -Smoke (tobacco, -Weather
-Mouse urine cooking fuel) changes
-Grass pollen -Aerosolized -Exercise
chemicals -Drugs (NSAID)
-Mould
 Signs of mild asthma exacerbation

 Respiratory rate may be increased

 Accessory muscles not used
 Moderate Exp wheeze
 Pulse normal for age
 Pulsus Paradoxus absent or less than 10 mm Hg
 PEF over 80 % after initial bronchodilator
 Oxygen Sats > 95 % in air
 Signs of moderate asthma exacerbation

 Respiratory rate increased, agitated.

 Use of accessory muscles
 Loud Wheeze
 Pulse increased
 Pulsus Paradoxus may be present 10-25mm Hg
 PEF 60 % after Initial bronchodilator
 Oxygen Sats 91 – 95 % in air
 Signs of severe asthma exacerbation

 Agitated, Respiratory rate increased

 Use of accessory muscles
 Loud wheeze
 Pulse increased
 Pulsus Paradoxus 20 – 40 mm Hg
 PEF < 60% after initial bronchodilator (of predicted or
personal best)
 Oxygen saturation <90 % in air
 Diagnosing Asthma in a Child
HISTORY-HISTORY-HISTORY
Suspect asthma if a child has recurrent and/or persistent:
 Wheeze, cough, breathlessness,
• Children / parent may report…
AND are responsive to bronchodilators

Other relevant history supporting asthma

 Personal history of atopy
 Family history of atopy
 Diagnostic Tests in Children
Therapeutic trial
 Response to bronchodilators (reduction of cough, wheeze)
 + response to corticosteroids

Pulmonary function testing (PFT) – only above 6 years

• Peak expiratory flow rate
• Spirometry

Other tests
 Exercise tolerance test (in exercise-induced asthma)
 Allergen skin prick test
 Four Components of Asthma Care

1. Develop patient/family/doctor partnership (work

together!)
2. Identify and reduce exposure to risk factors
3. Assess current level of control, treat, and monitor
asthma
4. Manage asthma exacerbations
 Treatment:
Goals
Achieve GOOD CONTROL of symptoms
Maintain normal activity levels including
exercise
Maintain pulmonary function as close to normal as
possible
Prevent asthma exacerbations & mortality
Avoid adverse effects from asthma medications
 Medications to Treat Asthma
Relievers: Quick Relief

 Taken to relieve symptoms

 For rapid relaxation of airway muscles

 Inhaled beta2-agonists
 Inhaled anti-cholinergics
 Medications to Treat Asthma:
Long-Term Control

• Taken daily over a long period of time

• Used to reduce inflammation, relax airway muscles, and
improve symptoms and lung function
 Inhaled corticosteroids
 Long-acting beta2-agonists
 Leukotriene receptor antagonists
 Treatment Steps 1 to 5
Step 1 Step 2 Step 3 Step 4 Step 5

Asthma education Environmental control

Rapid acting ß2 As needed rapid-acting- ß2-agonist

agonist PRN
Select one Select one Add one or Add both
more
Low-dose Medium dose Medium-or- Oral
inhaled ICS high-dose ICS corticosteroid
Controlled ICS* plus LABA (lowest dose)
options
Leukotriene Low-dose ICS Leukotriene Anti-IgE
modifier ** + LABA modifier treatment
Low-dose ICS Sustained
+ leukotriene release
modifier theophyline

Asthma in Children. Hodan 2014 16

 Treatment Step 2
Add Low-dose ICS
Step 1 Step 2 Step 3 Step 4 Step 5

Asthma education Environmental control

Rapid acting ß2 As needed rapid-acting- ß2-agonist

agonist PRN
Select one Select one Add one or Add both
more
Low-dose Medium dose Medium-or- Oral
inhaled ICS high-dose ICS corticosteroid
Controlled ICS* plus LABA (lowest dose)
options
Leukotriene Low-dose ICS Leukotriene Anti-IgE
modifier ** + LABA modifier treatment
Low-dose ICS Sustained
+ leukotriene release
modifier theophyline

Asthma in Children. Hodan 2014 17

 Treatment Step 3
Increase ICS and/or add LTRA/LABA
Step 1 Step 2 Step 3 Step 4 Step 5

Asthma education Environmental control

Rapid acting ß2 As needed rapid-acting- ß2-agonist

agonist PRN
Select one Select one Add one or Add both
more
Low-dose Medium dose Medium-or- Oral
inhaled ICS high-dose ICS corticosteroid
Controlled ICS* plus LABA (lowest dose)
options
Leukotriene Low-dose ICS Leukotriene Anti-IgE
modifier ** + LABA modifier treatment
Low-dose ICS Sustained
+ leukotriene release
modifier theophyline

Asthma in Children. Hodan 2014 18

 Treatment Steps 4 to 5
Increase ICS and/or add LTRA/LABA: REFER
Step 1 Step 2 Step 3 Step 4 Step 5

Asthma education Environmental control

Rapid acting ß2 As needed rapid-acting- ß2-agonist

agonist PRN
Select one Select one Add one or Add both
more
Low-dose Medium dose Medium-or- Oral
inhaled ICS high-dose ICS corticosteroid
Controlled ICS* plus LABA (lowest dose)
options
Leukotriene Low-dose ICS Leukotriene Anti-IgE
modifier ** + LABA modifier treatment
Low-dose ICS Sustained
+ leukotriene release
modifier theophyline

Asthma in Children. Hodan 2014 19

 BRONCHIOLITIS
INTRODUCTION :

 Common cause of illness in young children

 Common cause of hospitalization in young children
 Associated with chronic respiratory symptoms in
adulthood
 May be associated with significant morbidity or mortality
 Definition
 Acute infectious inflammation of the bronchioles
resulting in wheezing and airways obstruction in children
less than 2 years old
 MICROBIOLOGY

 Typically caused by viruses

– RSV
– Parainfluenza
– Human Metapneumovirus
– Influenza
– Rhinovirus
– Coronavirus
– Human bocavirus
 Occasionally associated with Mycoplasma pneumonia
infection
 EPIDEMIOLOGY
 Typically less than 2 years with peak incidence 2 to 6
months
 May still cause disease up to 5 years
 One of the leading cause of hospitalizations in infants
and young children
 Accounts for 60% of all lower respiratory tract illness in
the first year of life
 RISK FACTORS OF SEVERITY
 Prematurity
 Low birth weight
 Age less than 6-12 weeks
 Chronic pulmonary disease
 Hemodynamically significant cardiac disease
 Immunodeficiency
 Neurologic disease
 Anatomical defects of the airways
 ENVIRONMENTAL RISK FACTORS
 Older siblings
 Passive smoke exposure
 Household crowding
 Child care attendance
 PATHOGENESIS
 Viruses penetrate terminal bronchiolar cells--directly
damaging and inflaming
 Pathologic changes begin 18-24 hours after infection
 Bronchiolar cell necrosis, ciliary disruption, peribronchial
lymphocytic infiltration
 Edema, excessive mucus, sloughed epithelium lead to
airway obstruction and atelectasis
 CLINICAL FEATURES
 Begin with upper respiratory tract symptoms: nasal
congestion, rhinorrhea, mild cough, low-grade fever
 Progress in 3-6 days to rapid respirations, chest
retractions, wheezing
 EXAM
• Tachypnea
– 80-100 in infants
– 30-60 in older children
 Prolonged expiratory phase, rhonchi, wheezes and
crackles throughout
 Possible dehydration
 Possible conjunctivitis or otitis media
 Possible cyanosis or apnea
 DIAGNOSIS
 Clinical diagnosis based on history and physical exam
 Supported by CXR:
hyperinflation, flattened diaphragms, air bronchograms,
peribronchial cuffing, patchy infiltrates, atelectasis
 HOSPITALIZATION
 Children with severe disease
 Toxic with poor feeding, lethargy, dehydration
 Moderate to severe respiratory distress (RR > 70,
dyspnea, cyanosis)
 Apnea
 Hypoxemia
 Parent unable to care for child at home
 TREATMENT
 Supportive care
 Pharmacologic therapy
 Ancillary evaluation
 ANCILLARY TESTING
 Most useful in children with complicating symptoms--
fever, signs of lower respiratory tract infection
 CBC--to help determine bacterial illness
 Blood gas--evaluate respiratory failure
 CXR--evaluate pneumonia, heart disease
 SUPPORTIVE CARE
 Respiratory support and maintenance of adequate fluid
intake
 Saline nasal drops with nasal suctioning
 Routine deep suctioning not recommended
 Antipyretics
 Rest
 MONITORING
 For determining deteriorating respiratory status
 Continuous HR, RR and oxygen saturation
 Blood gases if in ICU or has severe distress
 Change to intermittent monitoring as status consistently
improves
 RESPIRATORY SUPPORT
 Oxygen to maintain saturations above 90-92%
 Keep saturations higher in the presence of fever, acidosis
 Wean carefully in children with heart disease, chronic
lung disease, prematurity
 Mechanical ventilation for pCO2 > 55 or apnea
 FLUID ADMINISTRATION
 IV fluid administration in face of dehydration due to
increased need (fever and tachypnea) and decreased
intake (tachypnea and respiratory distress)
 Monitor for fluid overload as ADH levels may be elevated
 DISCHARGE CRITERIA
 RR < 70
 Caretaker capable of suctioning
 Stable without supplemental oxygen
 Adequate PO intake to maintain hydration
 Adequate home support for therapies such as inhaled
medication
 Caretaker educated and confident
 PREVENTION
 Good hand washing
 Avoidance of cigarette smoke
 Avoiding contact with individuals with viral illnesses
 Influenza vaccine for children > 6 months and household
contacts of those children