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Respiratory disease Tracheo-bronchial hyperreactive Diffuse narrowing Reversible (disappear with or without treatment)
Atopic history
Prevalence of asthma
Primary school children (6-13 year old) Secondary school children (12-18 year old) 4 17 % 5.7 7.4 %
Hospitalized children
2.7% with asthma, usually with other diseases such a pneumonia or ARI
Triggers of asthma
Respiratory infection (viral, mycoplasma) Exercise Allergens : - Inhaled - Ingested (rare) Irritants (cigarette smoke, air pollution) Weather changes Medications (ASA) Chemical (tartrazine, sulfites, menosodium glutemate) Emotional stress Gastroesophageal reflux
? Avoidance
Immune response Th2, IgE, IgG4, IgG1
BHR
b2-agonist
Wheezing
Platts-Mills et al. Ciba foundation 1997
Vascular Permeability & oedema Inflammatory Mediator release Mucus secretion & bronchoconstriction
Smooth muscle & mucous gland proliferation Epiteliel cell Activation & proliferation
Airway remodelling
Symptoms (Bronchoconstriction)
On going inflammation
Persistent symptoms
Exacerbation > 1 x/month, there is sign and symptom in between Quality of life limited
Severity of asthma
Eczema Family history of atopy Smoking (active/passive) Level of lung function Treatment
DIAGNOSIS
Cough and/or Wheeze Clinical history Physical examination Mantoux test
Indeterminate features or suggestive of alternative diagnosis Neonatal onset
Failure to thrive Chronic infection Vomiting/choking Focal lung or CVS signs
Suggestive of asthma:
Episodic Nocturnal Seasonal Exertional Atopy
Consider Chest and sinus x rays Lung function Bronchial challenge and/or Bronchodilator response
Bronchodilator response
Response
No response
WD/ Asthma Assess severity and aetiology Chest x ray if more than mild episodic disease
Trial of antiasthma treatment
- ve
+ ve
Not asthma
Treatment
Treatment of attack :
b2 agonist Ephinephrin Theophyllin/aminophyllin Steroid : inhaled, nebulized, oral : subcutan : oral, I.V. : oral, I.M.
Prevention of attack :
Avoidance
Medicine
: triggers (including enhancers, inducers) especially improve indoor environment. : steroid, DSCG, antileukotrien, ketotifen, cetirizine.
Longterm management
ORAL STEROID
LABA LABA increase GR nuclear translocation LABA prolong GR nuclear residency time LABA prime GR for activation byMAPKdependent phosphorylation
Enhance antiinflammatory activity of steroid
% Days
50
40 30 20
10 0
Control Bedroom
Percentage of days (+ SE) on wich wheezing was noticed, medication was given, and abnormally low peak expiratory flow rate (PEFR) was recorded during 4 week study period
PC20 Histamine Mg/ml >8 8 4 2 1 0.5 0.25 0.12 0.06 0.03 Dust free Bedroom
Initial End of trial
Control Bedroom
Concentration of aerosolized histamine required to reduce the 1-second forced expiratory volume (FEV1) by 20% (PC20 histamine) at start and end of trial period
Conclusions
Asthma prevalence: increase Classifications of childhood asthma: infrequent episodic asthma, frequent episodic asthma, and persistent asthma Longterm management: Inhalation therapy