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A PAPER PRESENTATION ON PEDIATRIC ASTHMA BY Mr. NAMDEO SHINDE M. PharmSATARA COLLEGE OF PHARMACY DEGAON, SATARA.(MH) INDIA.
ASTHMA - DEFINITION• A disease characterized by an increased responsiveness of the airways to various stimuli resulting in airway obstruction that is reversible either spontaneously or as a result of treatment• Acute asthma - presence of active symptoms from airway obstruction and/or inflammation• Chronic asthma - absence of extended periods free of symptoms without treatment
Asthma is a chronic respiratory disorder in which there is primarily swelling ofairways in the lungs. The airways are therefore narrowed making it difficult tobreathe Normal Inflamed (untreated) Regular Inhaled Steroid Partly Treated
• As per WHO, India has 30 million asthmatics which is 10% of the global asthmatic population• The prevalence of asthma is higher in children. Today, up to 1 out of 10 children in India has asthma.• Asthma is the most common chronic condition in children• As per a study, Asthma in children has doubled over the past 5 years and is rapidly increasing• There will be an additional 100million asthmatics worldwide by 2025
Kashmir lockdown claims the life of a young asthma patientIndian Express, 9th July 2010Mohali boy dies of asthma attack Tribune, 16th April 2010 >1 year after the death of Akruti Bhatia in Delhi ~ 180,000 people die of asthma each year ……….almost all of these are preventable
Factors Influencing the Development and Expression of Asthma Host factors –• Genetic 1. Genes predisposing to atopy 2. Genes predisposing to airway hyper responsiveness• Obesity• Sex
Asthma is the swelling of the airways and excessive mucus production whichcauses cough and difficulty in breathing. When the swollen lungs come into thecontact with any of the following, an asthma attack is triggeredDust and smoke Pollen from plants Chalk dust in school Physical exertion and exerciseChange in weather Strong emotions Furry animals & such as laughing bird feathers and crying
Other Challenges• Most of the children are below 5 years of age, who cannot tell their problems• Parents are proxy story teller, who may mislead the doctor• PEF cannot be performed in children below 5 years of age• Fear of addiction to inhalation therapy• Physicians lack of knowledge and time
Risk factors of Asthma in younger children• Sensitization to allergen.• Maternal diet during pregnancy and/ or lactation.• Pollutants (particularly environmental tobacco smoke).• Microbes and their products.• Respiratory (viral) infections.• Psychosocial factors.
The prevalence of childhood asthma has continued toincrease on the Indian subcontinent over the past 10 yrs ISAAC Phase 3 Thorax 2007;62:758
Symptomatology• Cough – 90%• Wheezing – 74%• Exercise induced wheeze or cough – 55% Ind J Ped 2002;69:309-12
When does Asthma begin?• By 1 year – 26%• 1-5 years – 51.4%• > 5 years – 22.3% 77% Of Asthma Begins In Children Less Than 5 Years Ind J Ped 2002;69:309-12
Physical Examination (Look)• General Attitude And Well Being• Deformity Of The Chest• Character Of Breathing• Thorough Auscultation Of Breath Sounds• Signs Of Any Other Allergic Disorders On The Body• Growth And Development Status CHILDHOOD ASTHMA by KHUBCHANDANI R.P. et al
What all features one should look for specifically?Cough• Persistent/ recurrent / nocturnal/ exercise-inducedAssociated conditions• Eczema• Allergic Rhinitis Weight/Height CHILDHOOD ASTHMA by KHUBCHANDANI R.P. et al
What all investigations can be performed in asthmatic children? (PERFORM)Peak expiratory flow rate: It is highly suggestive of asthma when:• >15% increase in PEFR after inhaled short acting β2 agonist• >15% decrease in PEFR after exercise• Diurnal variation > 10% in children not on bronchodilator OR >20% In children on bronchodilator 1. Asthma by Consensus, IAP 2003 2. CHILDHOOD ASTHMA by KHUBCHANDANI R.P. et al
Differential diagnosisAge Common Uncommon RareLess than Bronchiolitis Aspiration pneumonia Asthma6 months Gastro- Bronchopulmonary Foreign body aspiration esophageal dysplasia reflux Congestive heart failure Cystic fibrosis6 months Bronchiolitis Aspiration pneumonia Congestive heart failure- Foreign body Asthma2 years aspiration Bronchopulmonary dysplasia Cystic fibrosis Gastro-esophageal reflux2 - 5 years Asthma Cystic fibrosis Aspiration pneumonia Foreign body Gastro-esophageal reflux Bronchiolitis aspiration Viral pneumonia Congestive heart failure Gastro-esophageal reflux IPAG 2007
Confirm Asthma if, If the child is having 3 attacks of airway obstruction in last 1 yr. If the child gets 1 attack of asthmatic symptoms after the age of 2 yrs. Irrespective of age in an attack in children with allergy (eczema, food allergy etc.) or history of atopy. If the child does not become free of symptoms when infection has ceased or has persistent symptoms for more than a month. Respir Med. 2000;94(4):299-327
Impact of Asthma on Childreno 3rd-ranking cause of hospitalization among children under 15o Almost 13 million school days missed each yearo Affects sleep patterns, concentrationo Impairs ability to enjoy & partake in physical activities If not managed properly may contribute to significant morbidity and mortality Advance data from Vital and Health Statistics, NCHS,2003 Asthma Prevalence, Health Care Use and Mortality, CDC, 2003-2005
Asthma Treatments• Classified into Controllers and Relievers• Controllers – medications to be taken on daily long term basis.• Relievers – medications to be used on as-needed basis to relieve symptoms quickly.
• Choosing an inhaler device for children with asthma *- Age group Preferred device Alternative device Pressurized metered-dose inhaler Younger than 4 years plus dedicated spacer with face Nebulizer with face mask mask Pressurized metered-dose inhaler 4-5 years plus dedicated spacer with Nebulizer with mouthpiece mouthpiece Dry powder inhaler or breath actuated pressurized metered- dose inhaler or pressurized Nebulizer with mouthpiece Older than 6 years metered-dose inhaler with spacer with mouthpiece *Based on efficacy of drug delivery, cost effectiveness, safety, ease of use, and convenience . GINA 2009
Asthma management and prevention• The goals for successful management of asthma are 1. Achieve and maintain control of symptoms 2. Maintain normal activity levels, including exercise 3. Avoid adverse effects from asthma medications 4. Prevent asthma mortality
Tablet/ Syrup Medicine by InhalersHigher dose Much lower dose (1/20th of oral)More side effects Much less side effectsTakes time to act Almost immediate onset of action
To summarize…Diagnosis• Asthma is an inflammatory illness• Diagnosis of asthma is clinical, and relies on history• All asthma does not wheeze• In children < 3 yrs, WALRI is an important differential diagnosis• 2 out of 3 children outgrow their asthma• A family history of asthma / atopy increases risk of asthma
To summarize…Long term management • Patient education is a very important part of asthma management • Drugs control, but do not cure asthma • Clinical grading over time, decides long term management plan • Mild intermittent asthma does not merit controllers • Inhaled steroids are mainstay of long term asthma management • Treatment should be stepped up or stepped down depending upon patient response
CONCLUSION So, today an asthma patient inAny interiors of India can be given the same quality of treatment as an asthma patient in New York … and far more economically
Cipla has created an educational website with the help of doctors www.breathefree.com Please inform one and all about the website