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1. ASTHMA1 Ped(6-C) TUCOM
CHILDHOOD ASTHMA: Chronic disease of the airways that may cause:
 Wheezing
 Breathlessness
 Chest tightness
 Nighttime or early morning coughing
Episodes are usually associated with heightens “twitchiness” of the airways—airways hyper
responsiveness (AHR)—to provocative exposures, but variable, airflow obstruction within the
lung that is often reversible either spontaneously or with treatment.
Pathophysiology of Asthma: ‫مهم‬
1. Genetic predisposition: Chromosome: 5Q31-Q33
2. Results from repeated exposure to allergens in the individual already equipped with the genetic
predisposition
3. Upon exposure to an allergen, there is a release of IgE antibodies
4. IgE antibody binds with the antigen
5. IgE allergen complex - then attaches itself to the mast cells on the nasal and bronchial mucosa
6. Release of numerous chemical mediators
EPIDEMIOLOGY:
Worldwide, childhood asthma appears to be increasing in prevalence, despite considerable
improvements in management.
In 56 countries found a wide range in asthma prevalence, from 1.6 to 36.8%.
Approximately 80% of all asthmatics report disease onset prior to 6 yrs. of age.
Only a minority will go on to have persistent asthma in later childhood.
ETIOLOGY:
 Genetics: More than 22 locations 15 autosomal chromosomes have been linked to asthma.
 Environment:
1- Common respiratory viruses.
2- Indoor and home allergen exposures in sensitized individuals
3- Environmental tobacco smoke and air pollutants (ozone, sulfur dioxide) Cold dry air and strong
odors

2. ASTHMA2 Ped(6-C) TUCOM
Potential Asthma Triggers:
1- Allergens
2- Infections
3- Exercise
4- Abrupt changes in the weather{ Cold, dry air}
5- Common Viral infections
6- Aeroallergens
 Animal dander
 Dust mite
 Pollen
 Air pollutants
 Exposure to airway irritants, such as tobacco smoke
Asthma Exacerbations:
1- Recurrent asthma episodes, involving
a. Shortness of breath
b. Coughing
c. Wheezing
d. Chest pain or tightness
2- Range in severity from
o Mild intermittent
o Severe persistent
Burden of Asthma:
1- Increases risk for early death
2- Compromises child’s quality of life
3- Affects family’s quality of life
4- Increased costs associated with Increased utilization of health care
Early Childhood Risk Factors:
1- Parental Asthma
2- Allergy
 Atopic dermatitis
 Allergic rhinitis
 Food allergy
 Inhalant allergen sensitization
 Food allergen sensitization
 Severe lower respiratory tract infections
 Wheezing apart from colds
 Male gender
 Low birth weight
 Tobacco smoke exposure

3. ASTHMA3 Ped(6-C) TUCOM
Clinical Manifestations:
Symptoms:
1. Intermittent dry cough(common)
2. Expiratory wheezing(common)
3. Shortness of breath
4. worse at night
5. Chest tightness
6. Chest pain
7. Fatigue
8. Difficulty keeping up with peers in physical activities
Signs:
1. Expiratory wheezing
2. Prolonged expiratory phase
3. Decreased breath sounds
4. Crackles/ rales
5. Accessory muscle use
6. Nasal flaring
7. Absence of wheezing in severe cases
8. Pulses paradoxus
LABORATORY FINDINGS (Spirometry= )
Lung function tests can help to confirm the diagnosis of asthma and determine disease severity.
Airflow Limitation:
1. Low FEV1
2. FEV1/ FVC ratio < 0.80
Radiology:
1. Often normal
2. Hyperinflation (flattening of the diaphragms)
3. peribronchial thickening
4. Helpful in identifying masqueraders (aspiration pneumonitis, bronchiolitis obliterans)
5. Asthma exacerbations (atelectasis, pneumomediastinum, pneumothorax). CT scans may be
needed.
6. Other tests, such as allergy testing to assess sensitization to inhalant allergens, help with the
management and prognosis of asthma.
NOTE: 88% of asthmatic children had inhalant allergen sensitization by allergy prick skin testing.

4. ASTHMA4 Ped(6-C) TUCOM
TREATMENT notes:
Treat all “persistent” asthma with anti-inflammatory controller medication
Daily controller therapy is not recommended for mild intermittent asthma.
The “three strikes” rule
1. Day time asthma symptoms at least 3 times per wk.
2. Awakens at night at least 3 times per mo.,
3. Experiences asthma exacerbations that requires short courses of systemic corticosteroids at least 3 times a yr.
Then that patient should receive daily controller therapy
Regular assessment and Monitoring:
1. Asthma severity:
1. Directs initial level of therapy
2. Determined at the time of diagnosis
3. Categories: Intermittent, Persistent
4. Determined by the most severe level of symptoms
1. Asthma control: Important for adjusting therapy:
1. Regular Clinic visits every 2-6 weeks until good control established
2.
3. Two or more Asthma checkup per year for maintaining Asthma control

5. ASTHMA5 Ped(6-C) TUCOM

6. ASTHMA6 Ped(6-C) TUCOM
Managing Asthma:
Asthma Management Goals:
1. Achieve and maintain control of symptoms
2. Maintain normal activity levels, including exercise
3. Maintain pulmonary function as close to normal levels as possible
4. Prevent asthma exacerbations
5. Avoid adverse effects from asthma medications
6. Prevent asthma mortality
Indications of a Severe Attack:
1. Breathless at rest
2. Hunched forward
3. Speaks in words rather than complete sentences
4. Agitated
5. Peak flow rate less than 60% of normal
Control of Factors Contributing to Severity:
1. Eliminate/ reduce environmental exposures
2. Tobacco smoke elimination/ reduction
3. Allergen exposure elimination/ reduction
4. Treat co morbid conditions: Rhinitis, Sinusitis, GER
Treatment:
A) Inhaled Corticosteroids:
1. Treatment of choice for persistent Asthma (except for the mild intermittent category)
2. Improve lung function
3. Reduce hospitalizations (reduce urgent care visits)
4. May lower the risk of death due to Asthma
5. ICS reduce asthma symptoms
6. prednisone use for asthma exacerbations by about 50%
B) Systemic Corticosteroids:
1. Used mainly in treatment of exacerbations
2. Rarely in patients with severe disease
3. Common: Prednisolone, Methylprednisolone
4. When used in long term, cause adverse effects

7. ASTHMA7 Ped(6-C) TUCOM
Principles of Asthma Pharmacotherapy:
1. Leukotriene pathway modifiers or sustained-release theophylline (only for patients >5 yrs. of
age) are alternatives for mild persistent asthmatics.
2. Combination of a low-to-medium dose ICS with a long-acting β-agonist or a leukotriene modifier
or theophylline is a mainstay therapy for moderate persistent asthma in older children.
3. For infants and young children, medium-dose ICS alone it is considered a preferred treatment for
moderate persistent asthma.
4. Severe persistent asthmatics should receive high-dose ICS, a long-acting bronchodilator, and
routine oral corticosteroids if needed.
5. SABAs are the recommended quick-reliever medications for symptoms and exercise
pretreatment for all asthma severity levels
C) Long Acting β-Agonists(LABAs):
1. Salmeterol, Formoterol: are considered to be daily controller medications
2. Not used as monotherapy or as “rescue” medication for acute asthma symptoms or
exacerbations
3. LABAs use should be stopped once optimal Asthma control is achieved
D) Leukotriene Modifying Agents:
1. Leukotriene synthesis inhibitor: Zileuton (Not approved for children < 12 years)
2. Leukotriene Receptor Antagonists (LTRA): Montelukast> 1 yr., Zafirlukast> 5 yr
3. Decrease need for rescue β-agonist use
E) Non-steroidal Anti- Inflammatory Agents:
1. Cromolyn and nedocromil are non-corticosteroid anti-inflammatory agents that can inhibit
allergen-induced asthmatic responses and reduce exercise induced bronchospasm.
2. Inhibit exercise induced bronchospasm
3. Can be used in combination of SABA for exercise induced bronchospasm
F) Theophylline:
1. Can reduce Asthma symptoms and need for SABA use (alternative monotherapy controller agent for
older children and adults with mild persistent asthma)
2. Not used as first line anymore (It is no longer considered a first-line agent for small children in whom there
is significant variability in the absorption and metabolism of different theophylline preparations, necessitating
frequent dose monitoring (blood levels) and adjustments)
3. May be used in corticosteroid dependent children
4. Can cause cardiac arrhythmias, seizures and death
Rescue Drugs:
Short Acting Beta Agonists: Albuterol, Levalbuterol, Terbutaline, Pirbuterol
1. Drugs of choice for acute Asthma symptoms
2. Overuse may be associated with increased risk of death
Anticholinergic Agents: Ipratropium bromide
Used in combination with Albuterol.

8. ASTHMA8 Ped(6-C) TUCOM
G) SHORT-ACTING INHALED β-AGONISTS:
ipratropium bromide is much less potent than the β-agonists.
1. Inhaled ipratropium is primarily used in the treatment of acute severe asthma.
2. When used in combination with albuterol, ipratropium can improve lung function and reduce
the rate of hospitalization in children who present to the emergency department with acute
asthma.
Acute Exacerbations (Status asthmaticus):
1. Dyspnea at rest
2. Peak flows < 40% of personal best
3. Accessory muscle use
4. Failure to respond to initial treatment
Management of Acute Exacerbation (Status asthmaticus) (‫)مهم‬
1. Brief assessment
2. Close monitoring of clinical status, hydration, and oxygenation
3. Intubation and mechanical ventilation
4. Administration of SABA: Repeated doses or continuously, every 20 mines. for 1 hour
5. Inhaled anticholinergic in addition of SABA (Inhaled ipratropium)
6. Oxygen: Hypoxemia/ moderate to severe exacerbation
7. Systemic Corticosteroids: Instituted early for moderate to severe exacerbation and failure to
respond to early treatment
8. Intramuscular injection of epinephrine or other β-agonist in severe cases.
Home Management of Asthma Exacerbations
1. Immediate treatment with “rescue” SABA
2. Short course of oral corticosteroid therapy
3. Injectable forms of epinephrine
4. Portable oxygen at home.
5. Call for emergency support services.
PROGNOSIS:
1. Recurrent coughing and wheezing occurs in 35% of pre–school-age children.
2. ⅓ continue to have persistent asthma into later childhood.
3. ⅔ improve on their own through the preteen years.
Note: That entire wheeze is not asthma & Asthma does not always wheeze
)‫بينهما‬ ‫(تجمع‬ ‫الموصل‬ ‫وطب‬ ‫تكريت‬ ‫طب‬ ‫محاظرات‬ ‫من‬ ‫معدلة‬ ‫المحاظرة‬ ‫هذه‬
Ahmed E AlBayaty 2017-07-28
Pediatrics sixth year stage