1. Paediatric
Asthma
Prepared by
malek ahmad
University of malaya

2. •Common in infancy
•Small airways obstruction due to inflammation 20 to viral infection
•Decreased lung function since birth due to small airway calibre
•Risk factor: smoking mother ( pregnancy / prematurity)
•Common in males and resolves by 5 years age
Transient early
wheezing
•Normal lung function at early life
•LRI; viral infection (RSV) leads to wheezing during first 10 years of life
•Less severe persistent wheezing and symptoms improve during
adolescent
Non-atopic
wheezing
•Lung function normal at birth
•Recurrent wheeze develops with allergic sensitisation , increased blood
IgE and positive skin prick tests to common allergens
•Persistence symptoms and decreased lung function later in childhood
•Risk factors: FH, allergy, eczema
•Exposure to smoke / prematurity not risk factors
Ig-E mediated
wheezing
(atopic
asthma)

3. Recurrent wheeze in infancy
Transient early
wheezing
Non-atopic
wheezing
IgE-mediated
wheezing (atopic
asthma)
Recurrent
aspiration of feeds
CF
Cow’s milk protein
intolerance
Inhaled foreign
body
Congenital
abnormality of
lung, airway or
heart
Idiopathic

5. Pathophysiology
Environmental factors + genetic predisposition
Bronchial inflammation
Bronchial hyperreactivity + trigger factors
Oedema + bronchoconstriction + increase mucus production
Air narowwing
Symptoms manifestation
Emotional,
chemicals
Smoking,
weather,
URTI,
allergen,
Chest
tightness
Breathlessness
Cough,
wheeze

11. NF-κB plays a key
role in regulating
the immune
response to
infection
Involved in cellular
responses to
stimuli (cytokines)
Nuclear factor
kappa-light-
chain-enhancer
of activated B
cells

12. Bronchoconstriction
Excessive mucus
production
Mucosal oedema
due to inflammation
Eosinophils,
lymphocytes,
mast cells,
neutrophils
Increase
airway
responsiveness

14. Atopy and allergy
Asthma Eczema
Allergic
rhinitis
Allergic
conjuctivitis
Urticaria and
angioedema
Drug and
food allergies
Inherited predisposition to sensitisation to allergen
40% of children , assymptomatic
Increased risk of allergic disease
Allergic disease

15. Clinical features
Symptoms
Wheezing
Cough (night/
activities)
Chest
tightness
SOB
Sputum
production
Difficulty in
feeding /
exercise
Signs
Hyperinflated
chest
Generalised
polyphonic
expiratory wheeze
Prolonged
expiratory phase
Harrison’s sulci
Eczema, allergic
rhinitis
Wet cough, club,
poor growth – CF /
bronchiectasis

17. Diagnosis of asthma
Suspected in any child with wheezing more than 1 occasion
•Present of episodic symptoms of airflow obstruction
•Symptoms are at least partially reversible
•Alternative diagnoses are excluded
To establish diagnosis, clinician must confirm:
Diagnosis made from Hx of recurrent wheeze with exacerbation (viral respiratory infection)
•Symptoms (frequency, seasonal / perennial , continous / intermittent, daytime / nightime, onset
and duration )
•School missed due to asthma
•Asthma affect sport or general activities
•Sleep disturbed
•Interval symptoms between exacerbations
Assess the pattern
Determine the precipitant or aggravating factors

18. Investigation
Complete history
• For common allergen to diagnosis of atopy and identify trigger allergens
Skin prick test
• Rule out other conditions
CXR
• For >5y
• Diurnal variability ( morning < evening) and day-to-day variability
• Bronchodilator responsiveness, increase by more than 10% to 15%
PEFR

19. Reliever / bronchodilator Drugs Note
Selective adrenergic agonist:
Inhaled B2 agonist
Salbutamol/albuterol (short)
Terbutaline (short )
Formoterol(long)
Salmeterol(long)
Short – rapid onset (2-4h),
used in acute asthma
Long – 12h, used with
inhaled corticosteroid,
exercise induced asthma
Non-selective adrenergic
agonist
Isoproterenol
Ephinepherine Mist
Anticholinergic Ipratropium bromide (short) Tiotroprium (long )
Methylxanthines Theophylline
Systemic glucocorticosteroids Prednisolone
Controller / preventative / prophylaxis Drugs Notes
Inhaled glucocorticosteroids Beclomethasone
Budesonide
Fluticasone
Mometasone
Impaired growth
adrenal suppressi
alter bone
metabolism
Systemic glucocorticosteroids Prednisolone (oral) SP. asthma
Methylxanthines Theophylline V, headache
Long acting oral B2 agonist: leukotriene modifiers Montelukast Add on therapy

21. GINA guidelines

25. Acute asthma
Wheeze and tachypnoea
• 2-5y, RR> 50 breaths/min
• >5y, RR> 30 breaths/min
Tachycardia
• 2-5y, PR> 130 bpm
• >5y, PR> 120 bpm
Accessory muscle usage and chest recession
Pulses paradoxus - BP declines in inhales and increases in exhales
Breathlessness interferes with talking
Cyanosis, fatigue, drowsiness > silent chest
Arterial O2 saturation (<92% imply severe and live threatening)
Measure of PEFR in school age children

26. Criteria for hospital admission
Despite high dose of inhaled bronchodilator, they:
Not responded adequately clinically
Exhausted
Marked reduction in predicted PEFR
<92% of O2 saturation
Investigation
CXR- severe SOB and
unusual features
Arterial blood gases –
life threatening

28. Metered-dose Inhaler

31. Assessment of child with asthma
Acute
Determine the severity
Breathlessness to talk and eat??
Increased work of breathing- Severe tachypnoea: >30bpmthing
•Moderate: intercostal
•Severe: accessory neck muscle
•Life-threatening: poor respi effort
Chest recession
Auscultation – wheeze / silent chest , Pulse - Severe > 120bpm
Consciousness, exhaustion, cyanosis (tongue)
•Moderate - > 50%
•Severe - < 50%
•Life threatening - <33%
Peak flow (% predicted)
•Moderate - >92%
•Severe - < 92%
O2 saturation
Triggers ??
Chronic
Growth and nutrition
Peak flow/spirometry
Chest: hyperinflation, harrison’s sulci, wheeze
Allergic disorder
•Sputum
•Clubbing
•Growth failure
Sought other causes if:
•PEFR daily
•Severity and frequency of symptoms
•Exercise tolerance
•Interference with life: school, sleep
•Appropriate use of preventer and reliever
•Inhaler technique
Monitor
Triggers ??