2. • Asthma is the most common chronic disease of childhood and the
leading cause of childhood morbidity from chronic disease as
measured by school absences, emergency department visits, and
hospitalizations.
• Asthma leads to recurrent episodes of wheezing, breathlessness,
chest tightness and coughing (particularly at night or early morning).
Clinical symptoms in children 5 years and younger are variable and
non-specific.
• Widespread, variable, and often reversible airflow limitation.
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3. Factors Influencing the Development
and Expression of Asthma
Host factors –
Genetic
1.Genes predisposing to atopy
2. Genes predisposing to airway hyper responsiveness
3.Obesity
4.Sex
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5. 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.drpankajyadav05@gmail.com
6. The prevalence of childhood asthma has continued to
increase on the Indian subcontinent over the past 10 yrs
ISAAC Phase 3 Thorax 2007;62:758
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7. Epidemiological trend Bronchial
Asthma
Global Burden of Asthma
Around 300 m. patients (currently)
Expected by 2025: 100 m. additional
Loss of DALYs : About 15 m./year
(around 1% of all DALYs lost)
Accounts for in every 250 deaths
• Considerable economic costs
The UK has one of the highest prevalences for childhood asthma
internationally, with about 15% children affected.
The prevalence is 8-10 times higher in developed countries than in
developing countries.
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8. The prevalence of 'any wheeze' over recent months (usually taken as
within the last year) amongst children has risen from about 10% in the
1960s to 20-30% in the 1990s. There is some evidence of a possible
flattening of this rise from the late 1990s onwards. An increasing
percentage of currently wheezing children also have a diagnosis of
asthma.
There is still a significant morbidity associated with the disease,
particularly severe childhood asthma, despite therapeutic advances.
Prevalence is higher in lower socioeconomic groups in urban areas.
There are gender differences. Boys are affected more before puberty (3
times greater prevalence). Prevalence is equal in adolescence, but
adult-onset asthma is more common in women.
The increasing prevalence of asthma is mirrored by the increasing
prevalence of childhood obesity. Prospective studies suggest that
obesity increases the risk of subsequent asthma, although the
underlying mechanisms are unclear, but obesity also increases the
clinical severity of asthma and reduces quality of life for childrenwith
asthma.
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9. The overall burden of Asthma in India is estimated at
more than 15 million .
According to the study done by A.Anuradha1, V.Lakshmi
Kalpana1,S.Narsingara. et al. The type of asthma is
distributed as cough-variant-asthma (50.83%), nocturnal
asthma (17.5%), allergic asthma (20.83%) and occupational
asthma (10.83%). Regarding family history,59.16% showed
genetic predisposition irrespective of sex. Among
asthmatics, 20% were having atopicdermatitis. Twenty-
five percent were smokers, 20% were alcoholics and
44.16% were with diabetics.
Advancing age, usual residence in urban area and lower
socio-economic status were associated with significantly
higher odds of having asthma. The present study shows
that asthma is an important public health issue in urban
areas.
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10. Asthma Burden in Developing countries (INDIA)
1. Wide variations – High magnitude
2. Increase in prevalence with rapid industrialization
and urbanization
3. High levels of pollution – important role
4. Role of infections, smoking and under-nutrition
5. Under diagnosis and under treatment
6. Limited drug availability
7. Difficulties of management at different levels of
health-care
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11. Fear of steroids
Heavy
nebulisation
Choice of right
device
Oral vs. Inhaled Lack of
knowledge &
time vs.
more patients
Poor patient/
parent
education
Cough or
Wheeze
Heterogenous
Disease/varying
phenotypes
Acceptance of
Asthma
diagnosis/label
Underdiagnosed/
Misdiagnosed
Issues in
Pediatric Asthma
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12. 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
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13. Clinical Features
Recurrent Wheeze
Recurrent Cough
Recurrent Breathlessness
Activity Induced Cough/Wheeze
Nocturnal Cough/Breathlessness
Tightness Of Chest
Asthma by Consensus, IAP 2003drpankajyadav05@gmail.com
15. Typical features of Asthma
Afebrile episodes
Personal atopy
Family history of atopy or asthma
Exercise /Activity induced symptoms
History of triggers
Seasonal exacerbations
Relief with bronchodilators Asthma by Consensus, IAP 2003drpankajyadav05@gmail.com
16. 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
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17. Tools to Diagnosis
Good History Taking (ASK)
Careful Physical Examination (LOOK)
Investigations (PERFORM) – above 5 years only
CHILDHOOD ASTHMA by KHUBCHANDANI R.P. et al
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18. History taking (Ask)
Has the child had an attack or recurrent episode of
wheezing (high-pitched whistling sounds when breathing
out)?
Does the child have a troublesome cough which is
particularly worse at night or on waking?
Is the child awakened by coughing or difficult breathing?
Does the child cough or wheeze after physical activity (like
games and exercise) or excessive crying?
Does the child experience breathing problems during a
particular season?
CHILDHOOD ASTHMA by KHUBCHANDANI R.P. et al
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19. History taking (Ask)
Does the child cough, wheeze, or develop chest tightness
after exposure to airborne allergens or irritants e.g. smoke,
perfumes, animal fur?
Does the child’s cold frequently ‘go to the chest’ or take
more than 10 days to resolve?
Does the child use any medication when symptoms occur?
How often?
Are symptoms relieved when medication is used?
CHILDHOOD ASTHMA by KHUBCHANDANI R.P. et al
If the answer is ‘yes’ to any of the questions,
a diagnosis of asthma should be considered
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20. 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
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21. What all features one should look for specifically?
Dyspnea
Expiratory wheeze
Accessory muscle movement
Difficulty in feeding, talking, getting to sleep
Irritability
CHILDHOOD ASTHMA by KHUBCHANDANI R.P. et al
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22. What all features one should look for specifically?
Cough
Persistent/ recurrent / nocturnal/ exercise-
induced
Associated conditions
Eczema
Allergic Rhinitis
Weight/Height
CHILDHOOD ASTHMA by KHUBCHANDANI R.P. et al
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23. How to rule out the mimics?
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24. The Early Wheezer (< 3Years)
Early onset asthma
Afebrile episodes
Personal atopy present
Family history of asthma /
atopy present
Predictable good response to
bronchodilators
WALRI (wheeze associated
lower respiratory tract
infections)
or Viral Associated wheeze
Febrile episodes
Personal atopy absent
Family history of asthma / atopy
absent
Variable response to
bronchodilators
Asthma by Consensus, IAP 2003drpankajyadav05@gmail.com
25. Bronchiolitis in children
Commonest cause of wheezing in children
between 6 months to 3 years
Resembles asthma
Diagnosis essentially clinical
Common viruses causing bronchiolitis in
children:
Respiratory syncytial virus (RSV)
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31. IPAG Diagnosis
Characterize the problem
Establish chronicity
Exclude non-respiratory or other
causes
Exclude infectious diseases
Consider patient’s age
Use diagnostic aids
International Primary Care Airways Group 2007drpankajyadav05@gmail.com
32. SPIROMETRY
SPIROMETRY IS A PULMONARY FUNCTION
TEST THAT MEASURES THE VOLUME OF AIR
AN INDIVIDUAL INHALES OR EXHALES AS A
FUNCTION OF TIME.
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33. Method – how to perform
1. 4 normal breaths
2. Inhale as deeply as possible
3. Exhale to normal depth
4. 3 normal breaths
5. Exhale as much as possible
6. 3 normal breaths
7. Inhale as much as possible
8. Exhale as fast and
completely as possible
9. 4 normal breaths
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34. ROLE OF SPIROMETRY IN
ASTHMA
HELPS TO MAKE DIAGNOSIS
ASSESS DEGREE OF AIRFLOW OBSTRUCTION
TO PREDICT WHETHER OBSTRUCTION IS
REVERSIBLE
AIDS IN MANAGEMENT OF ASTHMA
TO MONITOR PROGRESSION OF DISEASE
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35. 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 aldrpankajyadav05@gmail.com
36. Early Childhood Asthma Diagnosis
(below 6 years)
Diagnostic Tool Findings that Support Diagnosis
Differential
diagnosis
The diagnosis of asthma in children under age 6 is primarily
one of exclusion.
Physical
examination
If the child does not appear acutely ill and is growing, and
there is no evidence specifically indicating another cause of
symptoms, a trial of therapy is warranted.
Trial of therapy
(bronchodilators)
Improvement with treatment supports a diagnosis of
asthma.
Frequent
reassessment
Health care professionals should always be prepared to
reconsider the diagnosis if management is ineffective or if
the clinical situation changes.
IPAG 2007drpankajyadav05@gmail.com
39. NORDIC CONSENSUS
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):299-327drpankajyadav05@gmail.com
40. IAP GUIDELINES
3 Or More Episodes Of Airflow Obstruction With Several
Of The Following:
• Afebrile Episodes
• Personal Atopy Or Family H/O Atopy / Asthma
• Nocturnal Exacerbations
• Exercise/Activity Induced Symptoms
• Trigger Induced Symptoms
• Seasonal Exacerbations
• Relief With Bronchodilators ± Oral Steroid
Asthma by Consensus, The Indian Academy of Pediatrics 2003drpankajyadav05@gmail.com
41. GINA
The following symptoms are highly suggestive of a
diagnosis of asthma:
frequent episodes of wheeze (more than once a month)
activity-induced cough or wheeze
nocturnal cough in periods without viral infections
absence of seasonal variation in wheeze
symptoms that persist after age 3
A simple clinical index based on:
presence of a wheeze before the age of 3
presence of one major risk factor (parental history of
asthma or eczema) or two of three minor risk factors
(eosinophilia, wheezing without colds, and allergic
rhinitis) has been shown to predict the presence of
asthma in later childhood
Global Initiative for Asthma 2008drpankajyadav05@gmail.com
42. GINA
A useful method for confirming the diagnosis of asthma in
children 5 years and younger is a trial of treatment with
short-acting bronchodilators and inhaled
glucocorticosteroids
Children 4 to 5 years old can be taught to use a PEF meter,
but to ensure reliability parental supervision is required
Use of spirometry and other measures recommended for
older children such as airway responsiveness and markers of
airway inflammation is difficult and several require complex
equipment making them unsuitable for routine use
GINA 2008drpankajyadav05@gmail.com
43. BTS
Initial assessment of children suspected of having
asthma should be based on:
presence of key features in the history and clinical examination
careful consideration of alternative diagnoses
Using a structured questionnaire may produce a more
standardised approach to the recording of presenting
clinical features and the basis for a diagnosis of asthma
British Thoracic Society 2008drpankajyadav05@gmail.com
44. Clinical features that increase the probability of asthma
More than one of the following symptoms: wheeze, cough, difficulty
breathing, chest tightness, particularly if these symptoms:
◊ are frequent and recurrent
◊ are worse at night and in the early morning
◊ occur in response to, or are worse after, exercise or other triggers,
such as exposure to pets, cold or damp air, or with emotions or
laughter
◊ occur apart from colds
Personal history of atopic disorder
Family history of atopic disorder and/or asthma
Widespread wheeze heard on auscultation
History of improvement in symptoms or lung function in response to
adequate therapy
BTS 2008drpankajyadav05@gmail.com
45. Clinical features that lower the probability of asthma
Symptoms with colds only, with no interval symptoms
Isolated cough in the absence of wheeze or difficulty breathing
History of moist cough
Prominent dizziness, light-headedness, peripheral tingling
Repeatedly normal physical examination of chest when symptomatic
Normal peak expiratory flow (PEF) or spirometry when symptomatic
No response to a trial of asthma therapy
Clinical features pointing to alternative diagnosis
BTS 2008drpankajyadav05@gmail.com
46. 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. Maintain pulmonary function as close to normal as possible
4. Prevent asthma exacerbations
5. Avoid adverse effects from asthma medications
6. Prevent asthma mortality
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47. Five interrelated components of therapy are required to achieve
and maintain control of asthma-
1. Develop Patient/Doctor partnership
2. Identify and reduce exposure to risk factors
3. Assess, treat, and monitor asthma
4. Manage asthma exacerbations
5. Special considerations
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48. Develop Patient/Doctor partnership -
Effective management of asthma requires the development of a
partnership between the person with asthma and the health care
team.
Patients can learn to –
1. Avoid risk factors
2. Take medications correctly
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49. 3. Understand the difference between controller and reliever
medications
4. Monitor their status using symptoms and, if relevant, PEF
5. Recognize signs that asthma is worsening and take action
6. Seek medical help as appropriate
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50. Education should be integral part of all interactions between health care
professional and patients.
Using variety of methods such as discussions, demonstrations, written
materials, group classes, video/audio tapes, dramas and patient support
groups helps reinforce educational messages.
Health care professional and patients should prepare a written personal
asthma action plan that is medically appropriate and practical.
Additional self-management plans can be found on –
1. www.asthma.org.uk
2. www.nhlbisupport.com/asthma/index.html
3. www.asthmaz.co.nz
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51. Assess, Treat and Monitor Asthma –
The goal of asthma treatment can be reached in most patients
through a continuous cycle that involves – assessing, treating and
monitoring asthma.
Each patient should be assessed to establish his/her current
treatment regimen, adherence to the current regimen, and level of
asthma control.
Each patient is assigned to one of five treatment steps.
At each treatment step, reliever medication should be provided for
quick relief of symptoms as needed.
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52. Monitoring is essential to maintain control and establish the lowest step and
dose of treatment to minimize cost and maximize safety.
If asthma is not controlled, step up the treatment. Improvement is generally
seen within 1 month.
If asthma is partly controlled, consider stepping up treatment, depending
more effective options available, safety and cost of possible treatment and
patient’s satisfaction with the level of control achieved.
If controlled asthma is maintained for at least 3 months, step down with a
gradual, stepwise reduction in treatment. The goal is to decrease treatment
to the least medication necessary to maintain control.
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53. To summarize…
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
Diagnosis
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54. To summarize…
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
Long term management
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