Download bronchial asthma in children

BRONCHIAL ASTHMA IN
CHILDREN
Department of pediatrics
Definition

Asthma is a chronic disease involving the
respiratory system in which the airways
occasionally constrict, become
inflammated, and are lined with excessive
amounts of mucus
often in response to one or more triggers.
Epidemiology

Bronchial asthma (BA) is one from the most
frequent chronic diseases in children and its
incidence continues to increase in the last
years. Conformable to ISAAC data
(International Study of Asthma and Allergy in
Children), BA affects 5-20% of children on the
earth globe, this index varying in different
countries (in USA - 5-10%, in Canada, UK - 2530%, in Greece, China – 3-6%).
Risk factors for BA development in
children





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Familial antecedents of BA and other allergic
diseases.
Contact with home dust containing dust mite:
Dermatophagoides pteronyssinus.
Contact with fur-bearing animals (cat, dog, etc.).
Contact with mould (species of fungi Alternaria,
Aspergillus, Candida, Penicillium).
Contact with the pollen of different plants.
Smoke of cigarettes, after woods burning.
Presence of cockroaches.
Risk factors for BA development in
children
 Alimentary (fish, egg, cow’s milk etc.) and drug
allergens
 Meteorological factors (cold air, fog).
 Physical activity
 Environmental pollution
 Presence of gastroesophageal reflux.
 Drugs and vaccines (antibiotics – penicillin,
cephasoline, tetracycline etc., sulfonamides,
NSAID, colorants, etc.)
 Viral infections
 Stress factors
Clinical classification of bronchial
asthma
Atopic (allergic) asthma
 Nonatopic (nonallergic) asthma
 Status asthmaticus

Particular forms of bronchial asthma
BA provoked by physical effort
 Cough variant of BA
 Aspirinic BA

Classification of BA in function of severity
Type of BA
Exacerbations of
BA
Nocturnal
accesses
PEF and PEF
variability
Intermittent
< 1 time per week
Asymptomatic,
normal PEF
between accesses
≤ 2 times per
month
>80%
<20%
Mild persistent
>1 time per week,
but <1time per day.
Exacerbations can
affect the activity
> 2 times per
month
>80%
20 – 30%
Moderate
persistent
Daily. Exacerbations >1 time per week
affect the activity
60-80%
>30%
Severe persistent
Permanently.
Limited physical
activity
<60%
>30%
Frequent
Clinical picture of BA
Anamnesis
Which questions must be given in the case of BA suspicion:
 Had the patient episodes of wheezing, inclusively
repeated?
 Has the patient nocturnal cough?
 Has the patient cough and wheezing after physical
effort?
 Had the patient episodes of wheezing and cough after
the contact with aeroallergens and pollutants?
 Had the patient episodes of wheezing after supported
respiratory infection?
 Is decreasing the degree of symptoms expression after
antiasthmatic drugs receiving?
Recommendations for personal and hereditary
antecedents assessment:
Presence of dyspnea, wheezing, cough and thorax
oppression episodes, with evaluation of duration and
conditions of improving.
 Familial antecedents of bronchial asthma.
 Risk factors
 Asthmatic symptoms are manifesting concomitantly
(the thoracic oppression is less constant) and have
common:
- Variability in time (are episodic);
- Preferentially nocturnal appearance;
- Appearance due to trigger factor (physical effort,
exposition to allergens, strong laugh, etc.).
- Personal, familial and environmental factors.

Characteristics of asthmatic attacks:
Quick appearance with expiratory dyspnea,
prolonged expiration and wheezing, pronounced
sensation of thoracic oppression, lack of air
(sensation of suffocation).
 Duration from 20 – 30 min until a few hours.
 Spontaneous disappearance or at administration of
ß2-adrenomymetics with short action.
 They appear more frequently in night.
 The attacks appear suddenly and end also
suddenly with tormenting cough with elimination
of mucous, viscous, “pearl” sputum in small
quantity.

Suggestive symptoms for bronchial asthma
diagnosis in children:
 Frequent episodes of wheezing (more than
1 episode per month);
 Cough ± wheezing induced by physical
activity;
 Nocturnal cough out of viral infection
periods;
 Lack of wheezing seasonal variations.
There are 3 categories of wheezing:
Precocious transitory wheezing; is associated with
presence of such risk factors as prematurity, smoking
parents, dyspnea until 3 years;
 Persistent wheezing with precocious onset (until 3 years);
recurrent episodes of wheezing associated with acute viral
infections (predominantly with respiratory syncitial virus, in
children under 2 years, and other viruses, in older children),
without atopic manifestations or familial antecedents of
atopy; the symptoms persist until the school age and can be
present in 12 years old children in significant proportion;
 Wheezing (asthma with tardy onset, after 3 years age); in
this group asthma evolves in childhood period and even in
adults; children present signs of atopy (most frequent –
atopic dermatitis) and air pathways pathology characteristic
for asthma.

Predictive signs for childhood asthma
(preschool, school age):
Wheezing until 3 years;
 Presence of major risk factor (familial
antecedents of asthma);
 Two from three minor risk factors
(eosinophilia, wheezing without cough,
allergic rhinitis).

Physical examination:
Basic principles:
The signs of respiratory system affection can be absent.
Inspection:
- Sitting position (orthopnea) with accessory respiratory
muscles involvement;
- Tachypnea.
 At percussion:
- Diffuse increased sonority and down placed diaphragm.
 Auscultatively:
- Diminished vesicular murmur;
- Dry coarse, polyphonic, disseminated crackles,
predominantly at expiration, that can be heard at distance
(wheezing);
- Moist and subcrepitant crackles in more advanced
bronchial hypersecretion.


Causes of bronchial asthma exacerbations:
Insufficient bronchodilator treatment.
 Long-term defect of the basic treatment.
 Viral respiratory infections.
 Changes of weather
 Stress
 Long time exposure to triggers.

Appreciation of bronchial asthma
exacerbations severity
Symptom
Mild
Moderate
Severe
Dyspnea
-appears during
gait;
The child can
stay in bed
-in older
children it
appears at
speaking, in
small children
the crying
becomes more
short and slow;
feeding
difficulties.
- the child
prefers to sit
down.
- appears in
rest;
- refusal to eat;
- forced
position (sit
down, inclined
forward)
Imminence
of
respiratory
stopping
Appreciation of bronchial asthma
exacerbations severity
Symptom
Mild
Moderate
Severe
Speaking
-propositions
-expressions
-words
State of
alertness
-can be agitated -as a rule,
agitated
-as a rule,
agitated
Frequency of
respiration
-increased
-increased
-sometimes>
30/min.
Participation of
accessory
respiratory
muscles with
supraclavicular
retraction
-as a rule,
absent
-as a rule,
absent
-as a rule,
present
Imminence
of respiratory
stopping
-inhibited or in
confusion state
Paradoxical
thoracoabdominal
movement
Appreciation of bronchial asthma
exacerbations severity
Symptom
Mild
Moderate
Severe
Imminence
of
respiratory
stopping
Moist crackles
Moderately
expressed,
often, only at
expiration
Sonorous
Sonorous
Absent
Frequency of
cardiac
contractions
< 100
100 – 120
> 120
Bradycardia
Paradoxical
pulse
Absent
Can be present Often is
present
Absent
Appreciation of bronchial asthma
exacerbations severity
Symptoms
Mild
Moderate
Severe
PEF in % from
predicted after
bronchodilator
using
>80%
60 – 80%
<60%
Pa O2 at air
respiration,
Pa CO2
>60mm Hg
>60mm Hg
<60 mm Hg
<45mm Hg
<45mm Hg
>45 mm
SaO2% (with
air)
>95%
91-95%
<90%
Imminence
of
respiratory
stopping
Normal frequency of respiration in
children
Age
< 2 months
2 – 12 months
1 – 5 years
6 – 8 years
Frequency of
respiration
<60/min
<50/min
<40/min
<30/min
Normal frequency of cardiac
contractions (FCC) in children
Suckling babies
2 – 12 months
<160/min
Little age 1 – 2 years
<120/min
Preschool and school age 2 – 8 years
<110/min
The diagnosis of BA in children has the
following basic aspects:
● atopic background: allergic rhinitis, atopic
dermatitis, alimentary allergy, atopic
manifestation in family;
● clinically: paroxysmal dyspnea with wheezing;
● functionally: reversible bronchial obstruction;
● therapeutically: efficient response at short
action bronchodilators and inhalator
corticosteroids treatment.
The algorhythm for BA diagnosis in
suckling baby and infant
(by
Martinez, modified)
Major criteria:
● hospitalizations at severe form of bronchiolitis
or wheezing;
● ≥ 3 episodes of wheezing during respiratory
infections in the last 6 months;
● presence of asthma in one of parents;
●atopic dermatitis;
●sensibilization to pneumoallergens.
Minor criteria:
●
●
●
●
●
rhinorrhea in the absence of flu;
wheesing in the absence of flu;
eosinophilia (≥ 5%);
alimentary allergy;
male.
Risk for persistent
wheezing/asthma:
One from first 2 major criteria + another
major criterion;
 One from first 2 major criteria + 2 minor
criteria.

PARACLINICAL INVESTIGATIONS IN
BRONCHIAL ASTHMA
Obligatory investigations:
 PEF-metry;
 Spirography;
 Test with bronchodilator
 Skin tests with allergens;
 Pulsoxymetry;
 Hemoleukogram;
 General analysis of sputum;
 ECG; total and specific IgE
 X-ray chest in 2 proiections.
PARACLINICAL INVESTIGATIONS
IN BRONCHIAL ASTHMA
Recommended investigations:
 Bronchoscopy (at necessity);
 EchoCG;
 Oxymetry of arterial blood;
 Acido – basic state evaluation;
 Provoking tests (effort, acetylcholine,
metacholine);
 Pulmonary, mediastinal CT (at necessity)
 General urine analysis;
 Biochemical serologic indexes (total protein,
glucose, creatinin, urea, LDH, AST, ALT, bilirubin
and its fractions);
 Ionogram.
Spirography:
It allows to appreciate the severity and
reversibility of bronchial obstruction;
 It allows to differentiate from restrictive
affections.

PEF-metry:
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
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It allows the appreciation and monitoring of
bronchial obstruction severity and reversibility.
The formula for calculation of PEF in% towards
to predicted value in%:
PEF = minimal PEF of given day/predicted PEF x
100%.
24 hours variability of PEF is calculating after
formula:
24 hours variability = 2(evening PEF – morning
PEF)/(evening PEF + morning PEF) X 100%.
Pharmacological tests:

The test with ß2-agonist (bronchodilator
test) – spirographic or PEF-metry values
performed after 15 min from inhalation of
short action ß2-agonist are compared
with the usual data before inhalation;
increasing of PEF values ≥20% shows the
obstruction reversibility and is suggestive
for BA.
Physical effort test:

The spirography or PEF-metry is performed
initially and at 5-10 min after nonstandard
physical effort (running or physical exercises),
but sufficient for increase the pulse rate (until
140 – 150/min). Decreasing of PEF ≥20% is
suggestive for asthma (effort bronchospasm).
Examination of sputum:
Eosinophils (in proportion of 10 – 90%),
octoedric Charcot – Layden
phospholypase crystals are suggestive for
atopic asthma.
 Curschmann’s spirals (agglomerations of
mucus).

Hemogram and immunoglobulins
Hemogram shows eosinophilia in some
cases.
 Immunoglobulins:
- Total serum IgE increased in atopic asthma.
- Specific IgE to certain allergen are
increased.

X-ray chest:
Is obligatory only in the first accesses, when the
diagnosis is not clear.
 In BA access – signs of pulmonary hyperinflation (flat
diaphragm with reduced movements,
hypertransparence of pulmonary areas, widening of
retrosternal space, horizontal ribs).
 It can be indicated for disease complications
(pneumothorax, pneumomediastinum, atelectasis due
to mucus plugs) or associated affections (pneumonias,
pneumonitis etc.) finding.

General assessment of gas exchange
It is necessary in patients with signs of
respiratory insufficiency, in these having
SaO2 less than 90%.
Allergy skin testing (skinprick test, scarification probes)
It is performed by the allergologist and
aims to detect IgE-induced
allergic reactions. It is usually carried
out by the method of scarification: skin
scarification of 4-5 mm with applying a
drop of standard allergen in
concentration of 5000 U / ml
(1 unit =0.00001 mg protein
nitrogen / 1 ml).
Appreciation of allergic reaction by skin
scarification test
Test appreciation
Conventional sign
The visual image of allergic
reaction
Negative
-
It is the same as the control test
Uncertain
-/+
Local redness, without swelling
Weakly positive
+
Swelling papule, 2-3 mm diameter and
peri-papular redness
Positive
++
Swelling papule with a diameter
>3mm<5mm and peri-papular redness
Intense positive
+++
Swelling papule with 5-10 mm diameter
and peri-papular redness
Excessively positive
++++
Swelling papule with more than 10 mm
diameter, peri-papular redness and
pseudopodies
DIFFERENTIAL DIAGNOSIS
In children less than 5 years, it is performed with another
affections occuring with wheesing:
 Viral bronchiolitis;
 Cystic fibrosis;
 Foreign body aspiration;
 Upper respiratory pathways obstruction;
 Bronchopulmonal displasia;
 Intrathoracic respiratory pathways malformations;
 Congenital cardiac diseases;
 Kartagener’s syndrome;
 Immune deficiencies;
 Chronic sinusitis;
 Gastroesophageal reflux;
 Tbc;
 Mediastinal adenopathies;
 Tumors.
DIFFERENTIAL DIAGNOSIS
In children older 5 years age, it is performed
with the same affections as in big child or adult:
 Cardiovascular pathology;
 Upper respiratory pathways obstruction;
 Foreign bodies aspiration;
 Cystic fibrosis;
 Syndrome of hyperventilation, panic, vocal
chords dysfunction;
 Pulmonary interstitial pathology;
 Gastroesophageal reflux;
 Rhinosinusal pathology.
Hospitalization criteria for patients with BA:
 Severe access;
 Inefficacity of broncholytic therapy during 1 –
2 hours;
 Duration of exacerbation more than 1 – 2
weeks;
 Impossibility to accord medical care at home;
 Unsatisfactory living conditions;
 Presence of increased risk factors for death
due to BA.
Criteria for hospitalization in intensive care
departaments for patients with BA:
Mental deterioration;
 Paradoxic pulse >15-20 mm Hg;
 Severe pulmonary hyperinflation;
 Severe hypercapnia > 80 mm Hg;
 Cyanosis resistant to oxygenotherapy;
 Unstable hemodynamics.

General principles of drug treatment in
bronchial asthma:

The inhalatory therapy is the most recommended in all
children, the used devices for drug inhalation must be
individualised for every case in function of its
peculiarities and characteristics of used inhaler. In
general lines, administration using metered-dose-inhaler
(MDI) with spacer versus nebulizing therapy is more
preferable, due to some advantages of MDI (reduced
risk of adverse effects, more decreased cost etc.).
Administration through nebulizers presents a lot of
disadvantages: not precise dose, increased cost,
necessity of special apparatus.
General principles of drug treatment in
bronchial asthma:
 Drugs administered through inhalation are
preferable due to their increased therapeutic
index: high concentrations of medicaments are
relieved directly in respiratory pathways, with
strong therapeutic effects and reduced
number of systemic adverse effects.
General principles of drug treatment in
bronchial asthma:
 Devices for medication administered through
inhalation: pressure inhalers with measured
dose (MDI), dry powder inhalers, turbohalers,
diskhalers, nebulizers.
 Spacers (or retention camera) make easier the
use of inhalers, reduce systemic absorption
and secondary effects of inhaled
glucocorticoids.
General principles of drug treatment in
bronchial asthma:
Two types of medication help in asthma control:
controlers, or drugs that prevent the symptoms
and accesses, and relievers, or drugs, used for
access treatment and having rapid effect.
 The choice of medication depends from the
control level of BA at moment and from curent
medication.
 If curent medication does not ensure the
adequate control of BA, the indication of
superior advanced step of treatment is necessary.

General principles of drug treatment in
bronchial asthma:



If BA is controled 3 months, the decreasing of
supporting volume for control maintaining
minimal necessary dose establishing (passing to
inferior step) is possible.
The therapy with adequate doses of short acting
inhalatory ß2-agonists is recommended in
accesses (if inhalers are not available, the
bronchodilators can be administered per os or
i/v.
In hospitals in the case of hypoxemic patient the
oxygen is given.
General principles of drug treatment in
bronchial asthma:
 The not recommended treatment in
accesses: sedatives, mucolytics, physiotherapy,
hydration with high volume of liquids.
 Antibiotics not treat the accesses, but are
indicated in the case of concomitant
pneumonias or other bacterial infections.


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The key moments in the treatment of BA
by steps:
Each step includes variants of therapy serving as
alternative in the choice of BA control treatment,
although are not similar to efficacy.
The efficacy of treatment increases from I step to
V step and depends from accessibility and
certainity of drug.
The steps 2-5 include combinations of urgent
medications, at necessity,of systemic control
treatment.
In majority of patients with persistent BA, which
anteriorly didn’t administered control treatment,
is necessary to iniciate the treatment from the 2nd step.




The key moments in the treatment of BA
by steps:
If at primary examination we determine the
absence of BA control, the treatment begins from
the 3-rd step.
The patients must use relievers (short action
bronchodilators) at each step.
The systemic use of urgent medication is a sign of
uncontrolled BA, which indicates the necessity of
control therapy volume increasing.
Reducing or absence of necessity in relievers
represent the goal of treatment and, also, a
criterion of efficacity.
The I step of BA treatment:
It is indicated to patients:
- Which didn’t receive anteriorly control medication and
which manifest episodic symptoms of BA (cough, humid
crackles, dyspnoea ≤ 2 times per week, very rare with
nocturnal symptoms);
- In period between accesses the disease manifestations and
nocturnal disturbance are absent or pulmonary function is
normal.
 Urgent medication:
- short action inhaled ß2-agonists are recommended;
- the inhalatory anticholinergics (ipratropium bromide,
oxitropium bromide), peroral short action ß2-agonists
(salbutamol), short action theophyllin can be the alternative
medicaments.
 Control medication is not necessary.

The II step of BA treatment:
It is indicated to the patients with symptoms of persistent asthma,
which anteriorly didn’t administered control medication.
 Urgent medication:
- Recommended – inhalatory corticosteroids (ICS) in small doses;
- Alternative – antileukotrienes are indicated to the following
patients:
-who don’t accept to use ICS;
-with hard supported ICS adverse reactions;
- with concomitant allergic rhinitis.
 The initiation of therapy is not recommended with:
- Theophylline retard, that possesses minimal anti-inflammatory
effect and reduced efficacy in control therapy, but has multiple
adverse reactions;
- Chromones (inhibitors of mast cells degranulation) having
decreased efficacy, although they are distinguished by increased
inoffensiveness.

The III step of BA treatment:
 It is indicated to the patients with
symptoms of disease showing the absence
of adequate control in the treatment at the
steps I and II.
 Urgent medication:
- Recommended - short action inhaled ß2agonists (salbutamol, phenoterol).
The III step of BA treatment:

Control medication one or two drugs for
disease evolution control:
- Small doses of ICS in combination with long
action inhaled ß2-agonists in one self inhaler with
still fixed doses of drugs or two different inhalers;
- Small doses of ICS in combination with
leukotrienes (montelucast, zafirlucast);
- Small doses of ICS in combination with small
doses of theophylline retard;
- Increasing of ICS small doses until medium
doses.
The III step of BA treatment:
 Small doses of ICS, as a rule, are sufficient
due to additive effect of this combination,
the dose is increasing, if over 3-4 months of
treatment the BA control was not
obtained.
 The monotherapy with formoterol and
salmeterol is not recommended, they are
using in combination with ICS (fluticazon,
budesonid).
Note:
 The using of spacers for intensifying of drugs
getting into respiratory pathways and for
decreasing of diverse oropharingean adverse
reactions is recommended for patients
receiving medium and high doses of ICS;
 The patients in which the control on III step is
not succeeded, need consulting of specialist
with experience in BA treatment for excluding
an alternative diagnosis or of cases of BA
difficult to treat.
The IV step of BA treatment:
It is indicated to the patients with symptoms of
disease showing the absence of control in the
treatment at the 3-rd step.
 The choice of drug in the therapy at IV step depends
from anterior indications at 2-nd and 3-rd steps.
 Urgent medication:
 Recommended - short action inhaled ß2-agonists
 Control medication includes two or more drugs for
disease evolution control:
- ICS in medium and high doses in combination with
long action inhaled ß2-agonist;
- ICS and long action inhaled ß2-agonist and,
supplementarly, small doses of retard theophyllin.

Note:
Small and medium doses of ICS, in combination with
antileukotrienes, amplify the clinical effect smaller
comparatively with combination of ICS and long action
inhaled ß2-agonist;
 Increasing of ICS dose (from medium to high) in
majority of patients ensures only nonsignificant
increasing of clinical effect, and administration of high
doses is recommended only in quality of probe with
duration of 1-3 months, when the control of BA at
combination of ICS medium doses and long action
inhaled ß2-agonist was not obtained.
 Long-term administration of high doses of ICS is
followed by increased risk of adverse effects.

The V step of BA treatment:
It is indicated to the patients with uncontrolled, severe BA,
on the background of IV step therapy.
 Urgent medication:
 Recommended: short action inhaled ß2-agonists.
 Control medication includes supplementary drugs for IV
step medication for disease evolution control:
- administration of CS per os can amplify the effect of
treatment, but has severe adverse effects, therefore they
must be given only in severe, uncontrolled forms of BA on
the background of 4-th step therapy;
- administration of anti-IgE antibodies, supplementarly to
another drugs, makes easy the control of BA, when the
control of BA didn’t obtained with controller drugs,
inclusively with high doses of ICS and CS per os.

Specific immunotherapy

It is indicated only in the period when the
allergic BA is controlled.
THE FOLLOW-UP OF PATIENTS
WITH BRONCHIAL ASTHMA
- The patients return to medical
consultation at I month after first visit,
ulteriorly – in every 3 months.
- After exacerbation, the medical visits have
place after 2 – 4 weeks.
- If the BA control is established, the
regular maintaining visits, at 1 – 6 months,
remain essential, depending from situation.
THE FOLLOW-UP OF PATIENTS
WITH BRONCHIAL ASTHMA
- The number of visits at physician and determining of
control level depends from initial severity of patology
at concret patient and from degree of patient’s
knowledge about the necessary measures for BA
adequate control.
- The control level must be determined in certain time
intervals both by physician, and by patient.
- Patients who administered high doses of ICS or CS
per os are included in the risk group for osteoporosis
and fractures (it is necessary to perform
tomodensitometry of bones and administration of
biphosphates).
Continuous monitoring
It is essential in realization of therapeutic
goals. The schemes of treatment, the
medications and level of BA control are
analysed and modified during this visits.
ADEQUATE MANAGEMENT OF
BRONCHIAL ASTHMA
Minimal or inexistent symptoms, including
nocturnal symptoms.
 Minimal episods or accesses of BA.
 Absence of urgent visits at physician or hospital.
 Minimal need of urgent medications.
 Absence of physical activity and sport practise
limitation.
 Pulmonary function is about norma.
 Secondary effects caused by medication are
minimal or inexistent.
 Prevention of deceases caused by BA.
