ASTHMA

IN CHILDREN
 GROUP 3
NAME ID NRC
1.OSMAN NASHO 2021010497 216628/91/1
2. Christine Mbinga 19060618 288249/71/1
3. Nyoni Richard 2021011002 293686/15/1
4. Chilekwa Luumuno 2021011020 157886/69/1
5. Bellings Mwinga 2021010465 459878/74/1
 WHAT IS ASTHMA?

INTRODUCTION

chronic inflammatory disorder of the airways, associated

with airway hyper responsiveness leading to recurrent
wheezy episodes, breathlessness, chest tightness and
persistent cough
ANATOMY OF THE RESPIRATORY SYSTEM
 ANATOMY OF THE RESPIRATORY SYSTEM

The respiratory system is divided into the upper respiratory tract and the
lower respiratory tract. The upper respiratory tract includes the external
nose, the nasal cavity, the pharynx, and associated structures; the lower
respiratory tract includes the larynx, the trachea, the bronchi, and the
lungs.
 CLASSIFICATION OF ASTHMA

•Intermittent.

•Mild persistent.

•Moderate persistent.

•Severe persistent.
 Intermittent asthma
Asthma is considered intermittent if without treatment any of the
following are true:
•Symptoms (difficulty breathing, wheezing, chest tightness, and
coughing):
• Occur on fewer than 2 days a week.
• Do not interfere with normal activities.
•Nighttime symptoms occur on fewer than 2 days a month.
 MILD PERSISTENT ASTHMA

Asthma is considered mild persistent if without treatment any of

the following are true:
•Symptoms occur on more than 2 days a week but do not occur
every day.
•Attacks interfere with daily activities.
•Nighttime symptoms occur 3 to 4 times a month.
 Moderate persistent asthma

Asthma is considered moderate persistent if without treatment any of the

following are true:
•Symptoms occur daily. Inhaled short-acting asthma medication is
used every day.
•Symptoms interfere with daily activities.
•Nighttime symptoms occur more than 1 time a week, but do not
happen every day.
 Severe persistent asthma

Severe persistent asthma

Asthma is considered severe persistent if without
treatment any of the following are true:
•Symptoms:
• Occur throughout each day.
• Severely limit daily physical activities.
•Nighttime symptoms occur often, sometimes every night.
 RISK FACTORS FOR ASTHMA

• Factors influencing the development and expression of asthma

• Host factors
• Genetic
• Genes pre-disposing to atopic
• Genes pre-disposing to airway hyper-responsiveness
• Obesity
• Sex

• Environmental factors
• Allergens
• Indoor: Domestic mites, furred animals (dogs, cats, mice), cockroach allergens, fungi, moulds, yeasts
• Outdoor: Pollens, fungi, moulds, yeasts
• Infections (predominantly viral)
• Occupational sensitizers
• Tobacco smoke
• Passive smoking
• Active smoking
• Outdoor/Indoor Air Pollution
• Diet-western diet
 Triggers of
episodes of Asthma
• Exercise
• Viral infections
• Weather changes
• Emotional factors
• Allergens
• Endocrine factors- endocrine changes such as puberty may
increase symptoms of Asthma
PATHOPHYSIOLOGY OF
ASTHMA
 EARLY REACTION
• Starts within 10 minutes of exposure to an allergen
• Allergens interact with specific mast cells bound IgE
• This leads to release of histamine, leukotrienes,
prostaglandins, platelet activating factor and bradykinin
from mast cells
• All these mediators cause bronchoconstriction, mucosal
oedema and mucous secretions- manifesting as airway
obstruction
 LATE REACTION

• Occurs 3-4 hours later, peaks about 8-12 hours

• release of mast cell mediators not prevented by
premedication with beta agonist but by steroids
• Airway resistance more during expiration
• Lungs are hyper inflated
• Elasticity and compliance reduced
• Increased work of breathing-dyspnea
 Clinical features

• Recurrent cough, worse at night

• Cough may non productive in the early phase
• Wheezing
• Dyspnoea with prolonged expiration
• In severe episodes
• Air hunger, cyanosis
• Child may develop cyanosis
• Hyper-resonant chest
• Decreased airflow
 Diagnosis
• Symptom patterns (wheeze, cough, breathlessness)
which occur recurrently, during sleep, or with triggers
such as activity, laughing or crying are consistent with a
diagnosis of asthma
o The presence of atopy or allergic sensitization provides
additional predictive support, as early allergic
sensitization increases the likelihood that a wheezing
child will have asthma.
 Differential diagnosis
o Infections, e.g.
- Recurrent respiratory tract infections
- Chronic rhino-sinusitis
- Bronchiolitis
- Tuberculosis
o Congenital problems, e.g.
- Tracheomalacia
- Congenital heart disease
o Foreign body aspiration- has localized wheezing
 INVESTIGATIONS
o CXR –
o Shows bilateral and symmetrical air trapping in case of sthima
o to identify anatomical anomalies and to rule out differentials
o Spirometry
o FEV1, FVC, and PEFR
o Skin tests /allergy test– radioallergosorbent testing (RAST) help
identify environmental triggers
o Acute attack:
o ABGs – Hypercarbia and acidosis indicate severe and life threatening disease
and impending respiratory arrest
 Clinical Control of Asthma in Children

 For children with a confirmed diagnosis of

asthma, control can be achieved with a
pharmacologic intervention strategy developed
in partnership between the family/caregiver and
the health care practitioner.

 Inhaled therapy constitutes the cornerstone of

asthma treatment in this young age group.
 Acute Exacerbations of Asthma in
Children 5

Early symptoms of an acute exacerbation:

 Increase in wheeze or shortness of breath
 Increase in coughing, especially at night
 Reduced exercise tolerance
 Impairment of daily activities, including feeding
 A poor response to reliever medication
 Acute Exacerbations of Asthma in
Children

An action plan should be provided to the family members

and caregivers to:
 Recognize an asthma attack and initiate treatment
 Recognize a severe episode
 Identify when urgent treatment is necessary
 Provide specific recommendations for follow-up care
 Key Messages: Pharmacologic Therapy

 A pressurized metered dose inhaler with a valved

spacer (with or without a face mask depending on the
child’s age) is the preferred delivery system.
 A low-dose inhaled glucocorticosteroid is
recommended as the preferred initial treatment to
control asthma
 If low-dose inhaled glucocorticosteroid does not control
symptoms, and the child is using optimal technique
and is adherent to therapy, doubling the initial dose of
glucocorticosteroid may be the best option
 Key Messages: Pharmacologic
Intervention

 When doubling the initial dose of inhaled

glucocorticosteroid fails to achieve and maintain asthma
control, the child’s inhalation technique and compliance
with the medication regimen should be carefully assessed
and monitored.
 Use of oral glucocorticosteroids should be restricted to the
treatment of acute severe exacerbations, whether viral-
induced or otherwise
 To avoid under and over-treatment continued need for
asthma treatment should be regularly assessed (e.g., every
 Global Strategy for Asthma Management and
Prevention in Children 5 Years and Younger

Levels of Asthma Control

Characteristic Controlled PartlyControlled
(any measure present in any week)
Uncontrolled
(>3 features of partly con- trolled
present in any week)

Daytime symptoms: None >Twice a week >Twice a week

wheezing, cough, (less than twice/week, typically for (typically for short periods of the (typically last minutes or hours or
difficult breathing short periods of the order of minutes order of minutes and rapidly relieved recur, but partially or fully relieved by
and rapidly relieved by use of a rapid- by use of a rapid-acting a rapid-acting bronchodilator
acting bronchodilator) bronchodilator

Limitations of activities None

(child is fully active,
Any
(cough, wheeze or difficulty
Any
plays and runs without breathing,during exercise, play or (cough, wheeze or difficulty
limitation or symptoms) laughing) breathing,during exercise, play or
laughing)

Nocturnal symptoms or awakening None Any (ANY

(including no nocturnal (coughs during sleep or wakes with coughs during sleep or wakes with
coughing during sleep) cough, wheezing, cough, wheezing,
and/or difficult breathing) and/or difficult breathing)

Need for reliever/rescue < 2 days/week > 2 days/week > 2 days/week

Any exacerbation should prompt review

of maintenance treatment
 Clinical Control of Asthma in
Children 5
• Asthma is controlled (all of the following):
 No (or minimal)* daytime symptoms
 No limitations of activity (Child is fully active, plays and
runs without limitations of symptoms)
 No nocturnal symptoms (including no nocturnal
coughing during sleep)
 No (or minimal) need for rescue medication
• _________
• * Minimal = twice or less per week
 Clinical Control of Asthma in
Children 5
• Asthma is uncontrolled:
 Daytime symptoms >2 times/week (last minutes or
hours or recur)
 Any limitations of activity (May cough, wheeze or have
difficulty breathing during exercise, vigorous play, or
laughing)
 Any nocturnal symptoms (typically coughs during sleep
or wakes with cough, wheezing, and/or difficult
breathing)
 Need for rescue medication > 2 days/week
 Classification of Severity Asthma exacerbations
Sign Sign Severe exacerbation Life-Threatening exacerbation

Sa02 Sa02 < 92% < 92%

RR RR
2-5 years 2-5 years > 50/ min > 50/ min

> 5 years > 5 years > 30/ min > 30/ min
HR HR
2-5 years 2-5 years > 130/min > 130/min

> 5 years > 5 years > 120/min > 120/min

Effort of breathing Effort of breathing Use of accessory neck muscles Poor respiratory effort

Wheeze Wheeze Expiratory and inspiratory Silent chest

Speech Speech Speaking with difficulty Unable to speak

Level of consciousness Level of consciousness Altered Altered

 Treatment acute exacerbation
episodes
• I. Moderate exacerbation:
• Salbutamol nebulization 2.5 mg<2 years, 5 mg>2 years
• Start prednisolone early 2 mg/kg (Max 40 mg) PO OD for 3 days
• Discharge if improving
• If not improving, admit and continue with regular salbutamol
• II. Severe exacerbation:
• High flow Oxygen 5-10L/min
• Salbutamol as for moderate exacerbation
• Add ipratropium bromide via spacer or nebulizer 4-6 hourly
• 125 mcg< 1 year
• 250 mcg if 1-5 years
• 500 mcg>5 years
• Give prednisolone PO, If not improving or vomiting switch to IV hydrocortisone
at 4 mg/kg 6 hourly
• The next step is IV aminophyilline 5 mg/kg stat over 20min followed by
infusion at 1 mg/kg/hour, Admit to Paediatric ICU/highly dependent unit ,
Regular reviews a must decide accordingly
• III. Life-threatening asthma:
• Admit to PICU and treat as for severe exacerbation
• In addition, Do FBC, ESR, U&Es, blood culture, Portable CXR and
blood gases if available
• Available options include:
• IV salbutamol 15 mcg/kg over 10 minutes then 1-5 mcg/kg/min
infusion
• IV aminophylline 5 mg/kg over 20 minutes1 mg/kg/hour infusion
• IV 50% magnesium sulphate 40 mg/kg over 20 min (Max 2
grams) Diluted 1:5 in 0.9% saline
• If not improving prepare for intubation and mechanical
ventilation
• Discharge plan:
• Patient can be discharge when stable on 4 hourly
salbutamol inhalations
• To complete 3 days course of prednisolone.
• Patient/parent education to be done on the ward.
• Patients with mild exacerbation of asthma can be
reviewed at the local clinic
• Those with moderate, severe or life-threatening
exacerbations should be booked/planned for early
reviews after discharge