Management of Bronchial Asthma in Children

Definition: Bronchial Asthma

The most common chronic disease of childhood . It is a chronic inflammatory disorder of the airways.

Chronically inflammed airways are hyper-responsive when exposed to various triggers.

Clinical Picture:

1. Frequent episodes of cough and /or wheezing

2. Activity-induced cough or wheeze

3. Cough particularly at night

4. Symptoms occur or worsen in the presence triggers such as;

a. house dust mite or companion animalb. exercise c. pollensd. respiratory viral infectionse. exposure to tobacco smokingf. strong emotional expression

Alternative Causes of recurrent Wheezing:

1. recurrent viral infections

2. chronic rhino sinusitis

3. congenital heart disease

4. GERD

5. congenital malformation causing airway narrowing

6. foreign body inhalation

Diagnostic Procedure:

1. CBC

2. IgE

3. Allergy Skin testing

4. Pulmonary Function Testing

5. X-ray Chest

Classification by Level of Control:Levels of asthma control in children 5 years and younger

Charachteristic Controlled Partly controlled Uncontrolled.

Daytime symptoms: wheezing cough difficult breathing

None.

Less than twice/week, typically for short periods ,rapidly relieved by the use of rapid acting bronchodilator

More than twice/week,typically for short periods ,rapidly relieved by the use of rapid acting bronchodilator

More than twice/week, typically last minutes or hours , recur, partially or fully relieved with rapid acting bronchodilator

Limitation of activities None.

Child is fully active ,plays and runs without symptoms

Any.

May cough, wheeze or have difficulty breathing during exercise vigorous play or laughing

Any.

May cough, wheeze or have difficulty breathing during exercise vigorous play or laughing

Nocturnal symptoms/ awakening

None.

No nocturnal coughing during sleep

Any.

Typically coughs during sleep or wakes with cough, wheezing,and/or difficult breathing

Any.

Typically coughs during sleep or wakes with cough, wheezing,and/or difficult breathing

Need forreliever/rescue treatment

< 2 days/week > 2 days/week > 2 days/week

Classification by Level of Control:

In older children, the FEV1 and PEF readings can help in assessment of control

Lung functionFEVI or PEF

Controlled>80% predicted

Partly controlled< 80% predicted

Uncontrolled60% - <80%

VARIABILITY <20% 20-30% >30%

Management:

A. Assessing Asthma Control

Each patient should be assessed to establish:-

1. Current treatment regimen

2. Adherence to current regimen and level of asthma control

3. Current impairment (day and night symptoms, activity level impairment, need for rescue medications)

B. Treatment to Achieve Control

Inhaled Medications are preferred because they deliver drugs directly to the airways where they are needed, resulting in

therapeutic effect with fewer systemic side effects.

Management:

Devices recommended to deliver inhaled medications for children include

1. Nebulizer

2. Pressurized metered dose inhalers pMDI

3. Spacer Devices

4. Diskus

5. Turbuhalers

Management:

Management:

• Children younger than 4 years of age, should use pMDI plus a spacer with a face mask or a nebulizer with a face mask.

• Children aged 4-5 years can use a spacer with mouthpiece .

• Older children can use discus device or if necessary a nebulizer with face mask.

• Among young children inhaler technique may be poor and should be monitored closely.

• Teach family members how to use the specific inhaler device

Management:

A. Reliever Medications

- Rapid acting b2 agonists(ventolin)

B. Controller medications

- Inhaled glucocorticoids

- Leucotriene modifiers

Management:

C. Monitoring to maintain Control

Patients should be seen 1-3 months after the initial visit , and every 3 months thereafter , after an exacerbation, follow up should be offered within 2 weeks.

Teach the family how to monitor control with PFM measurements

Productive Clinic Visit:

1. Family and patient education

2. Explain basic facts about asthma, environmental control

3. Teach, demonstrate, and have patient show proper technique for inhaled medication use peak flow measures.

4. Written two- part asthma management plan

5. Regular follow-up visits: monitor lung functions annually

ACUTE EXACERBATION MANAGEMENT:

A. Clinical Assessment

• Vital Signs, breathlessness, use of accessory muscles, retractions, alteration in mental status

• Pulse Oximetry

• Lung function

B. Treatment

1. Oxygen – mask or nasal cannula – Monitor Oxygen saturation to maintain > 92%

2. Inhaled short-acting B-agonists – Ventolin nebulizer

3. Systemic Corticosteroid

- Hydrocortisone

- Methyl Prednisone

4. Anticholinergics

- Atrovent

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