ASTHMA MANAGEMENT AND

PREVENTION IN CHILDREN

Dr.A.Sundararajaperumal D.C.H
II yr M.D.(T.B & Chest diseases)
Dept. of .Thoracic Medicine
G.G.H & M.M.C
ASTHMA
• Asthma is a chronic inflammatory condition
of the lung airways resulting in episodic
(reversible) airflow obstruction.
• Chronically inflamed airways are
hyperresponsive;obstructed and airflow is
limited by bronchoconstriction, mucus plugs
and inflammation.

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 Asthma - Prevalence

P M
A U
A A I
N U K
40 K L U
I N Z
J S
35 I A S
N D
A
30 D S Y A
P I
25 O I S
N
C A A
20 T I
H 38
E N 36
15 I
A A 34
S
10 N N 26
I 18
A 14
5 A 13
9
5
0 2
COUNTRIES
PREVALENCE OF ASTHMA SYMPTOMS , ISAAC - 1990
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Etiology
• Its an interplay between Genetics and Environmental factors
Genetics
TWIN studies- 0.74 concordance betn. Monozygotic twins
0.35 concordance betn. Dizygotic twins
Consistently linked with foci containing pro allergic, pro inflammatory genes
( IC-4 gene cluster on chromosome 5)

Environment
-RSV infection,Tobacco smoke,air pollutants-O3,SO2,
-Cold dry air, strong odors-trigger

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Pathogenesis
AIRWAYS OBSTRUCTION
Small air way- smooth muscle encircling the airway lumen-
Broncho constriction
Cellular inflammatory infiltrate, excess mucus production,
edema of surrounding tissue
AIRWAYS INFLAMMATION,HYPERRESPONSIVENESS,AND
Remodeling.
Epithelial damage, sub epithelial collagen deposition with
basement membrane thickening and mucus gland and
smooth muscle hypertrophy
persistent airways inflammation and hyperresponsiveness
underlie the chronic basis of asthma

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EARLY PHASE LATE PHASE

Takes place after 6- 8 hours

Occurs in ½ - 2 hrs.
Continued cellular infiltration
Mast cell degranulation
with release of cytokines &
occur inflammatory mediators
Prime mediators Prime mediators-ECF, NCF,
Histamine MBP

PAF Response- airway

hyperreactivity,capillary leak,
Response –
mucosal edema, mucous
bronchoconstriction plugging.

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Clinical features of Asthma
• Dry cough, Expiratory wheeze, Chest
tightness and dyspnoe.
• Provoked by physical exertion/airway irritant
• Worse at night.
Reversible

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Complications
• Hypoxic seizures
• Resp. Failure
• Death

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 Factors Modifying The Course Of
Asthma
• Poor outcome / Favoring Asthma • Favourable Outcome
– Allergic diathesis
– Wheezing < 3/ years
– LBW

– Male – Breast Fed Infants

– Very early onset

– Rhinitis
– Parental Asthma

– Recurrent exposure to triggers

– Exposure to Tobacco Smoke

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 Molds
Pollen

URI

Pets TRIGGERS Dust mites

Pest

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 Causes of wheeze ?
All that wheezes is not asthma !!

Differential diagnosis of asthma based on age

Infancy
1. Bronchiolitis
2. Aspiration syndromes (GER)
3. Congenital anomalies – vascular rings,
laryngeal webs/ cyst/ stenosis
4. CVS (L
12/07/21
R shunts
SRP
with CCF) 11
 Older children
1. Foreign body aspiration
2. Sinusitis/ adenoids
3. Tuberculosis
4. Bronchiectasis, Cystic fibrosis
5. Vocal cord dysfunction
6. External airway compression
7. Interstitial lung disease
8. Hypersensitivity pneumonitis
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Investigations
Asthma is a clinical diagnosis .
Peak expiratory flow meter- helps in diagnosis and assessment of
severity of asthma
[ ↑ of 60 l/min or ≥ 20% of pre bronchodilator PEF or diurnal variation
of ≥ 20%]
Above 6yrs spirometry – to confirm diagnosis.

Spirometry shows reversible and variable airflow limitation.

[ Low FEV1, FEV1 /FVC ratio < 0.8, an ↑ in FEV1≥ 12% or 200ml,post
bronchodilator]

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 Radiology
• Chest radiographs - often appear to be normal, aside from subtle and
nonspecific findings of hyperinflation

• Chest radiographs are helpful in identifying abnormalities that are

hallmarks of asthma masqueraders (e.g., aspiration pneumonitis,
hyperlucent lung fields in bronchiolitis obliterans), and complications
during asthma exacerbations (e.g., atelectasis, pneumothorax).

• Other tests, such as allergy testing to assess sensitization to inhalant

allergens, help with the management and prognosis of asthma.

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Asthma Care
Goal

To achieve and maintain control of the clinical

manifestations of the disease for prolonged period,
Normal Activity

Prevent Sleep disturbance

Experience little to NO adverse effects of Drugs

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 Components
1. Develop patient / family / doctor partnership

2. Identify and reduce exposure to risk factors

3. Assess, treat, and monitor asthma

4. Manage asthma exacerbations

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 Levels of Asthma Control
Characteristic Controlled Partly Controlled Uncontrolled

Day time None or˂2 ˃ 2 episodes/week

symptoms episodes / week

Limitation of None Any 3 or more

activities features of partly
Nocturnal None Any controlled
symptoms / asthma present
awakening in any week
Need for reliever / None ˃ 2 /week
rescue treatment
Lung Function Normal ˂ 80% predicted or
(PEF or FEV1) personal best
Exacerbations None 1 or more /year One in any week
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 Management Approach Based on control

Level of control Treatment action

Controlled Maintain and find lowest controlling

step

Partly controlled Consider stepping up to gain control

Uncontrolled Step up until controlled

Exacerbation Treat as exacerbation

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 Step1 Step2 Step3 Step4 Step5

Asthma Education – Environmental control

As needed rapid As needed rapid acting ,ß2 - agonist

acting,ß2 -agonist

Select one Select one Add one or more Add one or both

Low dose inhaled Low dose ICS plus Medium or high Oral
ICS LABA dose ICS plus glucocorticosteroid
LABA

Leukotriene Medium or high Leukotriene Anti IgE treatment

modifier dose ICS Modifier

Low dose ICS plus Sustained release

LM theophylline

Low dose ICS

Plus sustained
release
theophylline
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DRUGS
Controllers

• Glucocorticosteroids
• β2 Agonists
• Sodium cromoglycate/Nedocromil
• Antileukotrienes
• Immunomodulators

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Releivers

• Short acting β2-agonists

• Anticholinergics
• Short-acting theophylline
• Epinephrine

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Β2 Agonists

Binds to the beta2-adrenergic receptor,

producing smooth muscle relaxation
following adenylate cyclase activation and
increase in cyclic AMP ,producing functional
antagonism of bronchoconstriction.

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SABA

• Inhaled SABA: • SYSTEMIC SABA:

• Salbutamol • ALBUTEROL
• Albuterol • TERBUTALINE
• Levalbuterol
• Pirbuterol

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LABA

• Inhaled LABA:

• Formoterol
• Salmeterol
• Bambuterol

• Oral:
• Albuterol sustained release

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Drugs – beta stimulants
• 1. Relax contracted bronchial smooth muscle

• 2. Prevent bronchial smooth muscle contraction by various

stimuli

• 3. Increase mucous clearance

• 4. Prevent mast cell mediator release

• 5. Prevent edema induced by histamine .

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Potential Adverse Effects
• Tachycardia,
• Skeletal muscle tremor.
• Hypokalemia.
• Increased lactic acid.
• Headache.
• Hyperglycemia.

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Drugs – STERIODS
• Mechanisms of action due to anti-inflammatory
properties

• Block late reaction to Allergen .

• Reduce airway hyper responsiveness.

• Inhibit cytokine production, adhesion protein activation, and

inflammatory cell migration and activation.

• Inhibit microvascular leakage

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Inhaled (ICS):

• Beclomethasone dipropionate
• Budesonide
• Fluticasone propionate
• Flunisolide
• Triamcinolone acetonide
• Mometasone furoate

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Systemic steroids

• Methylprednisolone
• Prednisolone
• Prednisone
• Hydrocortisone

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Uses of steroids
• For short-term (3–10days) “burst”: to gain
prompt control of exacerbation in asthma
along with SABA.

• For long-term prevention of symptoms in

severe persistent asthma.

• Suppression, control, and Reversal of

inflammation.
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Glucocorticoid Low Dose Medium Dose High Dose

Beclomethasone

42, 84 μg/puff (40 μg/puff HFA–propellant) 84–336 μg (2–8 puffs of 42  336–672 μg (8–16 puffs of 42 μg/puff or 4–8 >672 μg (> 16 puffs of 42 
μg/puff or1–4 puffs of 84  puffs of 84 μg/puff) μg/puff or> 8 puffs of 84 
μg/puff) μg/puff)

Budesonide

Turbuhaler (DPI) 200 μg/inhalation 200–400 μg (1–2 inhalations) 400–800 μg (2–4 inhalations) > 800 μg (>4 inhalations)

Respules (nebulizer) 250, 500 μg/vial 500 μg QD 1000 μg 2000 μg

Flunisolide

250 μg/puff (MDI) 500–750 μg (2–3 puffs) 1000–1250 μg (4–5 puffs) > 1250 μg (>5 puffs)

Fluticasone

44, 110, 220 μg/puff (MDI) 88–176 μg (2–4 puffs of 44  176–440 μg (4–10 puffs of 44 μg/puff or2–4 > 440 μg (>4 puffs of 110 
μg/puff) puffs of 110 μg/puff or1–2 puffs of 220  μg/puff or > 2 puffs of 220 
μg/puff) μg/puff)

Triamcinolone

100 μg/puff (MDI with spacer) 400–800 μg (4–8 puffs) 800–1200 μg (8–12 puffs) >1200 μg (> 12 puffs)

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Adverse systemic steroids
• Reversible abnormalities in glucose
metabolism,
• Increased appetite,
• Fluid retention, weight gain,
• Facial flushing,
• Mood alteration,
• Hypertension,
• Peptic ulcer,
• Aseptic necrosis.
• Adrenocortical suppression
• Herpes virus infections,
• Varicella, tuberculosis,
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Drugs – cromolyns

• Mast Cell Stabilization

• Inhibition of degranulation by a variety of stimuli, including cell-bound

IgE allergen.

• Interferes with chloride channel function.

• Inhibition of leukotriene production.

• No bronchodilator

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Cromolyns Sodium and Nedocromil
Indications

• Long-term prevention of symptoms in mild persistent

asthma.

• may modify inflammation.

Preventive treatment prior to exposure to exercise or

known allergen
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Methyl Xanthines

• Theophylline
• Deriphylline
• Aminophylline

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Drugs – Methyl xanthines
MECHANISM OF ACTION
• Phosphodiesterase inhibition
• Adenosine R antagonist
• Anti inflammatory effect
• Inhibition of ca influx
• Increases strength of resp muscles-diaphragm
Therapeutic Advantages
Relaxes bronchial smooth muscle
Decreases mast cell mediator release
Increases mucocilliary clearance
Prevents microvascular leakiness

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Methyl Xanthines – Adverse Effects

• Nausea,Vomiting,Head ache
• Seizures
• Tachycardia,Arrhythmias

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Anticholinergics
Competitive inhibition of
muscarinic cholinergic
• Ipratropium receptors.
bromide

Reduces intrinsic vagal tone of

the airways.

May block reflex

DRUG OF CHOICE FOR bronchoconstriction secondary
BETA BLOCKER INDUCED to irritants or to reflux
BRONCHOSPASM esophagitis.

May decrease mucous gland

secretion.

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Anticholinergics - Adverse Effects

• Drying of mouth & respiratory secretions

• Blurred vision

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Leukotriene Receptor Antagonists (LTRA)

Selective competitive inhibitor of CysLT1

receptor.

ZAFIRLUKAST
MONTELUKAST – 4 mg OD.

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Immunomodulators:
• Omalizumab (anti-IgE) is a monoclonal antibody
that prevents binding of IgE to the high-affinity
receptors on basophils and mast cells.

• Omalizumab is used as adjunctive therapy for

patients ≥12 years of age who have allergies and
severe persistent asthma .

• Anaphylaxis may occur

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 MDI drugs and dosage

MDI g / puff Interval in hours

Salbutamol 100 6-8

Terbutaline 250 6-8

Salmeterol 25 12

Ipratropium 20 8

Beclomethasone dipropionate 50/100/200 8 - 12

Budesonide 100/200 12

Fluticasone 25/50/125 12

Cromolyn 5mg/puff 6-8

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Drug dosage – DPI
.
Drug Dose (mcg capsules) Interval (hours)

Salbutamol 200 6-8

Salmeterol 50 12

Beclomethasone 100/200 8-12

Budesonide 100/200 12

Fluticasone 100/250 12

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THANK
YOU
12/07/21 SRP 45
THANK
YOU
12/07/21 SRP 47
 NAEPP Classification Of Disease
Severity
DISEASE DAY NIGHT PEFR/or DIURNAL
SEVERITY SYMPTOM SYMPTOM FEV1 VARIATION
FEV1
MILD <3days/ wk <3nights/ mo >80% <20%
INTERMITTENT
MILD >3days/ wk 3-4 nights/ >80% 20 – 30%
PERSISTENT <1/day mo

MODERATE DAILY >1night/wk 60–80% >30%

PERSISTENT

SEVERE CONTINOUS FREQUENT <60% >30%

PERSISTENT
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Stepwise Approach To Asthma Management

STEP 4 SEVERE HIGH DOSE ICS+LONG

PERSISTENT ACTING 2 AGONIST+ORAL
STEROIDS
STEP 3 MODERATE HIGH DOSE ICS OR LOW
PERSISTENT DOSE ICS+LONG ACTING 2
AGONIST
STEP 2 MILD LOW DOSE ICS OR INHALED
PERSISTENT CROMOGLYCOLOATE
STEP 1 MILD OCCASIONAL USE OF
INTERMITTENT RELIEVER MEDICATIONS

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 Severe persistent
High ICS+LABA,
Oral Steroids

MODERATE PERSISTENT
HIGH DOSE ICS OR
LOW DOSE ICS +LABA

STEP UP IF NOT MILD PERSISTENT STEP DOWN IF

LOW DOSE ICS OR CONTROLLED
CONTROLLED CROMOGLYCOLATE OR
LTRA

Mild Intermittent
No Daily medication
Short acting 2 Agonist

ACUTE EXACERBATIONS CAN OCCUR AT ANY STEP

FOR ACUTE EPISODE- INHALED 2 AGONIST+ANTICHOLINERGICS+

ORAL STEROIDS
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12/07/21 SRP 51
 Acute Asthma - Assessment of Severity
MILD- PS <3(PEFR >70) ; MOD. - PS 4-6 (PEFR 40 - 70) ; SEV.
- PS >6 (PEFR <40)
If wheezing absent , score > 3
Respiratory Rate
Accessory Muscle
Score Wheezing
< 6 yrs > 6 yrs Use

No apparent
0 < 30 < 20 None
activity
Terminal Questionable
1 31 - 45 21 - 35
Expiration increase
2 46 - 60 36 - 50 Entire Expiration Increase apparent
Inspiration &
3 > 60 > 50 Maximal activity
Expiration
Pulmonary score (PS)
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Life Threatening Asthma – Red Flag Signs

H/ o recurrent episodes Accessory muscles

of wheeze acting.

Posture – sitting/ Wheeze / Silent chest

bending forward Tachycardia/bradycardia

Altered sensorium Cyanosis

Sao2 < 90%
Speech – sentences/
Pulmonary score>6.
phrases/ words
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 100% Oxygen 5-6/min
Assess Maintain SaO2 > 95%
Nebulised Salbutamol
*3
Nebulised Ipratropium
Establish IV access

Reassess IV hydrocortisone 10mg/kg stat

Good response Poor response

Admit in ICU
Continue Neb. 4th hrly
Aminophylline infusion 5mg/kg in 20 ml NS over 20 min
Avoid triggers
Mag.Sulphate 25mg/kg in 20ml NS over 20 min
Daily preventor therapy
Regular follow-up No response
Terbutaline 10g/kg stat  2 g/kg/hr
Look for
Metabolic derangements, Pneumonia, Pneumothorax
Worsens

Consider Mechanical Ventilation

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 Clinical Features
Typical features
Onset after 3yrs
Afebrile episodes
Personal atopy
Atopy/ asthma in parents
Exercise induced exacerbations
Absence of Seasonal variations
Nocturnal cough during periods without viral infections
Relief with bronchodilators

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Peak Expiratory Flow Meter
Thermometer
Mini-wrights peak flow meter

• Uses:-
Diagnosis
Assessment of severity
Warning of impending attacks
Effectiveness of medication
Long term follow up

.
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Spirometry
Most informative lung function test
Measures lung volumes hence the physiological status.
Done using spirometers
Indices measured are-
• Forced vital capacity( FVC)
• Forced expiratory Volume
in one sec (FEV1)
• FEV1 / FVC ratio
• Forced expiratory flow
measurement
(FEF – 25-75%)
Influenced by age,race,sex,wt,ht
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