Dr. Olulode Olufemi S.

05/06/15

 Chronic

cause

disease of the airways that may

Wheezing
Breathlessness
Chest tightness
Nighttime or early morning coughing

Episodes

are usually associated with

widespread, but variable, airflow
obstruction within the lung that is often
reversible either spontaneously or with
treatment.
05/06/15

 Allergens
Infections
Exercise
Abrupt

changes in the weather

Exposure to airway irritants, such as
tobacco smoke

05/06/15

 Recurrent

asthma episodes, involving

Shortness of breath
Coughing
Wheezing
Chest pain or tightness

Range

in severity from

Mild intermittent
Severe persistent

05/06/15

 Increases

risk for early death

Compromises childs quality of
life
Affects familys quality of life
Increased costs associated with
Increased utilization of health
care

05/06/15

Most common cause of school absence

An average of 9.7 days per year for asthma

Most prevalent cause of childhood disability

(long-term reduction in ability to do normal
activities)

In 1994-95, 1.4% of U.S. children

experienced some disability due to asthma
This is 21% of all children with asthma

SES disadvantage doubles rate of disability

Children with asthma have higher rates of
social and emotional problems

05/06/15

Asthma is the most common chronic disease

among children
It has increased at epidemic rates since the
early 1980s
Most common cause of ED visits,
hospitalization and missed school days
In past 2 decades, African American children
had 2-4 times more ED visits than other races
Studies show a rise in worldwide prevalence
Seems to be more prevalent in affluent
nations

05/06/15

Etiology of asthma is due to the

interaction of environmental and genetic
factors
Atopy, the genetically inherited susceptibility to
asthma, cannot account for epidemic.

Probably NOT due to outdoor air quality

Indoor air contaminants may be a factor

Tighter construction trapping contaminants.

Children spending more time indoors.

05/06/15

10.1% Overall

05/06/15

Low-income populations, minorities, and

children living in inner cities experience
more ED visits, hospitalizations, and
deaths due to asthma than the general
population.

The burden of asthma falls

disproportionately on non-Hispanic black,
American Indian/Alaskan Native and some
Hispanic populations.
05/06/15

10

 By

gender

Males 0 17 years are more likely than

girls to have asthma or experience an
asthma attack
By

race/ethnicity

Higher for Black non-Hispanic children

Higher for Hispanic children

05/06/15

11

 Current

asthma prevalence is higher

among
children than adults
boys than girls
women than men
Asthma

morbidity and mortality is

higher among
African Americans than Caucasians.

05/06/15

12

 Groups
Wheeze
> 4 attacks
(0.1 - 4.7)
Night Cough

6 - 7 Yrs
5.6 %

1.5%
(0.5 - 3.5)
12.3%
(3.3 - 27)

(0.8 - 14.6)

13-14 Yrs
6.0%

(1.6 - 17.8)

1.6%

14.1%
(3.8 - 32.2)

3.7%
Ever had Asthma
(1.0 - 14.4)(1.12.4)

4.5%

Shah, Amdekar, Mathur, IJMS,6,2000,213-22

05/06/15

13

05/06/15

14

05/06/15

15

05/06/15

16

Parental Asthma
Allergy

Atopic dermatitis
Allergic rhinitis
Food allergy
Inhalant allergen sensitization
Food allergen sensitization

05/06/15

17

Severe lower respiratory tract infections

Wheezing apart from colds
Male gender
Low birth weight
Tobacco smoke exposure
Exposure to chlorinated swimming pools
Possible use of Acetaminophen

05/06/15

18

Common Viral infections

Aeroallergens

Animal dander
Dust mite
Cockroaches
Molds
Pollen

05/06/15

19

Air pollutants
Ozone
Sulfur dioxide
Particulate matter
Dust
Tobacco smoke
Strong/ noxious fumes
Cold, dry air
Exercise

05/06/15

20

Occupational exposures
Farm and barn exposure
Formaldehyde, paint fumes

Crying, laughter,
hyperventilation
Co morbid conditions: Rhinitis,
Sinusitis

05/06/15

21

Symptoms:
Intermittent dry cough
Expiratory wheezing
Shortness of breath
Chest tightness
Chest pain
Fatigue
Difficulty keeping up with peers in
physical activities

05/06/15

22

Signs:
Expiratory wheezing
Prolonged expiratory phase
Decreased breath sounds
Crackles/ rales
Accessory muscle use
Nasal flaring
Absence of wheezing in severe
cases
Pulses paradoxus

05/06/15

23

Spirometry:
Feasible

in children >6 years of age

Monitoring Asthma and efficacy of
treatment
Measures FVC, FEV 1 and FEV1/FVC
Ratio
Normal values for children available on
the basis of height, gender and ethnicity.

05/06/15

24

Airflow Limitation:
Low FEV1
FEV1/ FVC ratio < 0.80
Bronchodilator response to -agonist:
Improvement in FEV1 12%
Exercise challenge:
Worsening of FEV1 15%
Daily peak flow or FEV1 AM-PM variation
20%

05/06/15

25

05/06/15

26

05/06/15

27

Often

normal
Hyperinflation
Helpful in identifying masqueraders

05/06/15

28

05/06/15

29

Asthma severity:

Directs initial level of therapy

Determined at the time of diagnosis
Categories: Intermittent, Persistent
Determined by the most severe level of
symptoms
Asthma control: Important for adjusting therapy
Regular Clinic visits every 2-6 weeks until good
control established
Two or more Asthma check ups per year for
maintaining Asthma control

05/06/15

30

05/06/15

31

05/06/15

32

05/06/15

33

05/06/15

34

Achieve and maintain control of

symptoms
Maintain normal activity levels, including
exercise
Maintain pulmonary function as close to
normal levels as possible
Prevent asthma exacerbations
Avoid adverse effects from asthma
medications
Prevent asthma mortality

05/06/15

35

 Develop

with a physician
Tailor to meet individual needs
Educate patients and families about
all aspects of plan
Recognizing symptoms
Medication benefits and side effects
Proper use of inhalers and Peak Expiratory Flow
(PEF) meters

05/06/15

36

 Breathless

at rest
Hunched forward
Speaks in words rather than complete
sentences
Agitated
Peak flow rate less than 60% of normal

05/06/15

37

Have an individual management plan

containing
Your medications (controller and quick-relief)
Your asthma triggers
What to do when you are having an asthma
attack

Educate yourself and others about

Asthma Action Plans
Environmental interventions

Seek help from asthma resources

Join an asthma support group

05/06/15

38

Asthma action plan for management of

exacerbation

Regular follow up visits

Monitor lung functions annually
Improve adherence to treatment

05/06/15

39

Eliminate/ reduce environmental exposures

Tobacco smoke elimination/ reduction
Allergen exposure elimination/ reduction
Treat co morbid conditions: Rhinitis,
Sinusitis, GER

05/06/15

40

Initiate with higher level controller therapy

Step-down, once good control is achieved
If child has had well controlled asthma for at
least 3 months, consider decreasing dose or
number of controller medications.
Step up for poorly controlled asthma

05/06/15

41

 All

persistent Asthmatics require

daily controller medications

05/06/15

42

Treatment of choice for persistent Asthma

Improve lung function
Reduce use of rescue medicines
Reduce ED visits, hospitalizations
May lower the risk of death due to Asthma

05/06/15

43

Used mainly in treatment of exacerbations

Rarely in patients with severe disease
Common: Prednisolone, Prednisone,
Methyprednisolone
When used in long term, cause adverse
effects

05/06/15

44

Salmeterol, Formoterol
Not used as monotherapy
Major role as ad-on agents with ICS
LABA use should be stopped once optimal
Asthma control is achieved

05/06/15

45

Leukotriene synthesis inhibitor: Zileuton

(Not approved for children < 12 years)
Leukotriene Receptor Antagonists:
Montelukast, Zafirlukast

05/06/15

46

Cromolyn, Nedocromil
Inhibit exercise induced bronchospasm
Can be used in combination of SABA for
exercise induced bronchospasm

05/06/15

47

Can reduce Asthma symptoms and need for

SABA use
Narrow therapeutic window
Not used as first line anymore
May be used in corticostroid dependent
children
Can cause cardiac arrhythmias, seizures
and death

05/06/15

48

Anti IgE monoclonal antibody

Blocks IgE mediated allergic response
Approved for children > 12 years with
moderate to severe Asthma
Given sub cutaneously every 2-4 weeks

05/06/15

49

Short Acting Beta Agonists: Albuterol,

Levalbuterol, Terbutaline, Pirbuterol
Drugs of choice for acute Asthma symptoms
Overuse may be associated with increased
risk of death
Use of at least 1 MDI/ month or at least 3
MDI/ year indicates inadequate Asthma
control
Anticholinergic Agents: Ipratropium bromide
Used in combination with Albuterol

05/06/15

50

Dyspnea at rest
Peak flows < 40% of personal best
Accessory muscle use
Failure to respond to initial treatment

05/06/15

51

Brief assessment
Administration of SABA: Repeated doses or
continuously, every 20 mins. for 1 hour
Inhaled anticholinergic in addition of SABA
Oxygen: Hypoxemia/ moderate to severe
exacerbation
Systemic Corticosteroids: Instituted early
for moderate to severe exacerbation and
failure to respond to early treatment
Intramuscular beta agonist in severe cases.

05/06/15

52

05/06/15

53