paed

2. Definition of Bronchial Asthma
• inflammatory disorder of the airways
• characterized by an obstruction to airflow,
• may be completely or partially reversible with
or without specific therapy.
• airway hyper-reactivity or bronchial hyper
responsiveness (BHR),

3. • It is treatable, but not yet curable
• It is not the same as allergies, but allergies
MAY cause asthma
• Not contagious
• Can be life-threatening!

4. PATHOPHYSIOLOGY
Interactions between environmental and genetic
factors result in airway inflammation
Bronchospasm, mucosal oedema, and mucus
plugs
Airway obstruction
Increased resistance to airflow and decreased
expiratory flow rates

5. Hyperinflation
Alveolar hypoventilation
Ventilation/ Perfusion
mismatch
In early stage, hypoxaemia without carbon dioxide
retention occurs. With worsening obstruction
carbon dioxide retention occurs
Respiratory alkalosis in the early stage and later
result in metabolic and respiratory acidosis

6. Bronchoconstriction
©2010

7. Pediatric Anatomy
• Compliance of infant rib cage and immature
diaphragm
– paradoxical respiration
– increased work of breathing and fatigue
• Less elastic recoil
– more prone to atelectasis
– increases V/Q mismatch
• Thicker airway wall
– greater bronchoconstriction

8. Common Asthma Triggers
Allergens
• Molds
• Dust, Dust Mites.
• Animals
• Pollen
• Food
• Pests (cockroaches)
Irritants
• Secondhand smoke
• Strong odors
• Ozone
• Chemicals/cleaning
compounds

9. Other asthma triggers
Viral respiratory infections
• colds
• Flu
Exercise
Changes in weather
• cold air
• wind
• humidity

10. Warning Signs of Asthma
• Coughing (especially
when it is not a cold)
• Wheezing (a squeaking
sound when breathing)
• Fast breathing
• Poor skin color
• Shortness of breath
• Anxiety
• Vomiting
• Hunched over posture
• Restless during sleep
• Fatigue
• Space between the ribs
may sink in when
breathing

11. Warning Signs of Asthma
• Strained breathing
• Prominent neck
muscles
• Out of breath after
physical activity
IMPORTANT: These
symptoms don’t
necessarily mean it is
asthma

12. DIAGNOSIS OF PAEDIATRIC ASTHMA
Diagnosis of asthma in children is based on
• the presence of key features and careful
consideration of alternative diagnoses
• improvement with bronchodilators
• repeated assessment of the child, questioning
the diagnosis if management is ineffective

13. • “All that wheezes is not asthma”
&
• “All asthma does not wheeze”.

14. • Other causes of recurrent wheeze in children
• • Intra bronchial foreign body
• • Recurrent lower respiratory tract
• infections
• • Mediastinal masses
• • Heart failure
• • Gastro oesophageal reflux
• • H-type tracheo oesophageal fistula
• • Immune deficiency
• • Loeffler syndrome
• • Vascular rings
• • Cystic fibrosis
• • Ciliary dyskinesia

15. • Cow milk protein intolerance
• Inhaled foreign body
• Congenital abnormalities in lung, airway or
heart
• Idiopathic

16. Features suggestive of B.A.
• Evidence A
– Exercise induced cough / wheezing
– Cough at night
– Symptoms persisting after the age of 3.
• Evidence B
– Absence of seasonal variation
– Worsening with certain exposure
– Colds repeatedly going to the chest

17. – Response to bronchodilator
– Response to steroid course
– Concomitant rhinitis/ eczema/ food allergies
– Family hx
• Evidence C
– Wheezing > than a month
• Evidence D
– Modified bronchodilator response test.

18. How Is Assessed?
• Objective measures
– Peak flow meter: measures how “fast” you can
breathe out
– Spirometer: measures how well the respiratory
system can move air in and out of the lungs
• Subjective measures
– Use of fast-acting drugs
– Number of daytime symptoms
– Number of night time symptoms
– Limitation of activities
Adapted from NAEPP, NHLBI, NIH. www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm. Accessed February 25, 2008.

20. Diagnosis of asthma using PEF
• Percentage PEF variability (Amplitude % best) =
(Highest-lowest) x 100
• Highest
• An example is illustrated below:
• Highest PEF = 400 L/min
• Lowest PEF = 300 L/min
• Amplitude = 400 L/min - 300 L/min = 100 L/min
• Percentage PEF variability (Amplitude % best) =
{100 / 400} x 100 = 25%

21. Other investigations:
Chest X- Ray
Indications
• When the diagnosis is uncertain
(At least one x-ray to rule out other conditions)
• Severe/life threatening episode responding
poorly
to therapy
(To rule out conditions like pneumothorax &
Pneumonia)

22. MANAGEMENT
Goals of asthma therapy in children
Minimal, ideally no, symptoms during the day or at night
Minimal, ideally no exacerbations
Minimal use or no necessity for the use of reliever short
acting β2 agonist
FEV1 and/or PEF over 80% of personal best or predicted
normal
Minimal, ideally no adverse effects from medications
Normal activities and rare school absences
Optimum growth of the child
Minimal effects on other family members

23. Management
Non pharmacological Pharmacological
Primary Secondary

24. Primary prevention
• Breast feeing – most beneficial in children with
maternal atopy.
• Hygiene hypothesis e.g. exposure to infections
at
early age reduces the risk.
• Maternal smoking in pregnancy increases the
risk.
• Avoidance of postnatal allergen exposure

25. Secondary prevention
Avoid/minimize:
• identified allergens e.g. food/pollen
• Smoking Active (teenagers)
Passive
• Air pollution
• Obesity
• House dust mite control
• Complementary or alternative medicine
• Generalized dietary restrictions
• Vitamin C

26. Drugs in Asthma
Relievers
• Short acting bronchodilator
• β2 agonist Anticholinergic
Salbutamol Ipratopium bromide
Terbutaline

27. Preventive/ prophylactic
• Inhaled steroids
– Budesonoid
– Beclometasone
– Fluticasone
• Long acting β2 agonist
– Salmetrol
– Formetrol
• Sodium cromogluate
• Methyl xanthines
– Theophylines
• Leukotriene inhibitors
– Montelukast
– Zafirlukast
• Oral steroids
– Prednisolone

28. Inhalant Medication Delivery Devices
Not typically
seen in school

29. Severity classification
Asthma
Intermittened Persistent
Mild moderate severe

34. • Β2 agonist-oral/inhaler
• O. Theophylines
(until symptoms )

35. • Β2 agonist-
o/neb/inhale
• Single dose
Prednisolone 2mg/kg
daily.

43. Treatment is needed quickly for
asthma
• Fever over 100 F
• Wheezing or coughing that does not get
better after giving “quick-relief” medicines
• Peak flow is less than 80% of best
• Difficulty breathing that does not get better
after asthma medicines
• Too weak or tired

44. Stepwise approach to chronic asthma
According to increasing frequency & severity
• Step 1
– β2 agonist
• Step 2
– β2 agonist + Inhaled steroids
• Step 3
– High /low dose inhaled steroid ±Long acting bd ±
Leukotriene + β2 agonist

45. • Step 4
– High dose inhaled steroid+ long acting bd
±Theohylines /iprotropium± Leukotriene
modulators ±alternate day prednisolone+β2
agonist
• Step down treatment when good control
achieved &mx with β2 agonist.

46. Bronchiolitis

47. • Bronchiolitis is a disorder most commonly caused in infants
(<2years) by viral lower respiratory tract infection.
• It is the most common LRI in this age group.
• It is characterized by
acute inflammation,
edema,
necrosis of epithelial cells lining small airways,
increased mucus production,
bronchospam.

48. MICROBIOLOGY
• Typically caused by viruses
– RSV-most common
– Parainfluenza
– Human Metapneumovirus
– Influenza
– Rhinovirus
– Coronavirus
– Human bocavirus
• Occasionally associated with Mycoplasma
pneumonia infection

49. 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

50. ENVIRONMENTAL RISK FACTORS
• Older siblings
• Concurrent birth siblings
• Passive smoke exposure
• Household crowding
• Child care attendance
• High altitude

51. 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

52. 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

53. 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

54. DIAGNOSIS
• Clinical diagnosis based on history and physical
exam
• Supported by CXR: hyperinflation, flattened
diaphragms, air bronchograms, peribronchial
cuffing, patchy infiltrates, atelectasis

55. VIRAL IDENTIFICATION
• Nasal wash or aspirate
• Rapid antigen detection for RSV,
parainfluenza, influenza, adenovirus
(sensitivity 80-90%)
• Direct and indirect immunofluorescence tests
• Culture and PCR

56. DIFFERENTIAL DIAGNOSIS
• Viral-triggered asthma
• Bronchitis or pneumonia
• Chronic lung disease
• Foreign body aspiration
• Gastroesophageal reflux or dysphagia leading to
aspiration
• Congenital heart disease or heart failure
• Vascular rings, bronchomalacia, complete tracheal
rings or other anatomical abnormalities

57. COURSE
• Depends on co-morbidities
• Usually self-limited
• Symptoms may last for weeks but generally back to
baseline by 28 days
• In infants > 6 months, average hospitalization stays
are 3-4 days, symptoms improve over 2-5 days but
wheezing often persists for over a week
• Disruption in feeding and sleeping patterns may
persist for 2-4 weeks

58. RISK FOR SEVERE DISEASE
• Toxic or ill-appearing
• Oxygen saturation < 95% on room air
• Age less than 3 months
• Respiratory rate > 70
• Atelectasis on CXR

59. Bronchiolitis – Criteria for Admission
• Persistent hypoxia
• Respiratory distress
• Inability to tolerate fluids
• Inability to ensure close follow-up
• Infants under 2 months of age - consider
• Premature infants - consider

60. • 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

61. TREATMENT
• Supportive care
• Pharmacologic therapy
• Ancillary evaluation

62. RESPIRATORY SUPPORT
• Oxygen to maintain saturations above 90-92%
• Keep saturations higher in the presence of fever,
acidosis, hemoglobinopathies
• Wean carefully in children with heart disease,
chronic lung disease, prematurity
• Mechanical ventilation for pCO2 > 55 or apnea

63. 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

64. CORTICOSTERIODS
• Not recommended in previously healthy
children with their first episode of mild to
moderate bronchiolitis
• May be helpful in children with chronic lung
disease or a history of recurrent wheezing
• Prednisone, prednisolone, dexamethasone

65. RIBAVIRIN
• Not routinely recommended due to modest
effectiveness and cost
• May be useful in infants with confirmed RSV at
risk for more severe disease
• Must be used early in the course of the illness
• True of other antiviral agents, such as those
for Influenza, as well

66. ANTIBIOTICS
• Not useful in routine bronchiolitis
• Should be used if there is evidence of
concomitant bacterial infection
– Positive urine culture
– Acute otitis media
– Consolidation on CXR

68. Moderate

69. Severe

70. SUPPORTIVE CARE
• Respiratory support and maintenance of
adequate fluid intake
• Saline nasal drops with nasal bulb suctioning
• Routine deep suctioning not recommended
• Antipyretics
• Rest

71. COMPLICATIONS
• Highest in high-risk children
• Apnea
– Most in youngest children or those with previous apnea
• Respiratory failure
– Around 15% overall
• Secondary bacterial infection
– Uncommon, about 1%, most in children requiring
intubation

72. DISCHARGE CRITERIA
• RR < 70
• Caretaker capable of bulb suctioning
• Stable without supplemental oxygen
• Adequate PO intake to maintain hydration
• Adequate home support for therapies such as
inhaled medication
• Caretaker educated and confident

73. 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