You Can Control Your Asthma

Is it asthma?

Saleh Alharbi MBBS FAAP FCCP ABP

SBPAssistant Professor of Pediatrics

Omm Al-Qura UniversityPediatric Pulmonologist, DSFH

Is it asthma?Acute care setting

3 m.o. child. Acute wheezing illness. No response to salbutamol.

12 m.o. child. Acute wheezing illness. 3nd wheezing episode. Good response to salbutamol.

4 y.o. girl. 1st episode of wheezing. Good response to salbutamol.

2 y.o. boy. 1st episode. Severe wheezing. Poor response to salbutamol. Good response to oral steroids.

New patient

SALMA is 36 months old girl

6 “bronchitis” in year treated with antibiotics

2 pneumonia

At last ED visit, Tx: Fluxotide 125 2 puffs twice daily for 4 wks Ventolin 2 puffs q 4 hrs as needed Prednisone x 5 days

WHAT DO YOU DO?

Is it asthma?Differential/co-morbidity?What type of asthma?Best management?

What do you do?Elements to consider

Is it asthma?

What do you do?Elements to consider

Is it asthma? Differential diagnosis / co-morbidity

Clinical clues to alternative diagnosis Persistent moist cough

Excessive vomiting

Dysphagia Abnormal voice or cry Inspiratory stridor

Focal signs in chest

Finger clubbing Failure to thrive

Cystic fibrosis; bronchiectasis; protracted bronchitis; aspiration; immune disorder; ciliary dyskinesia

Gastro-oesophageal reflux± aspiration

Swallowing problems (± aspiration) Tracheal or laryngeal disorder Laryngeal problem Developmental anomaly;

bronchiectasis; tuberculosis Cystic fibrosis; bronchiectasis Cystic fibrosis; immune disorder

GINA: www.ginasthma.org

What do you do?Elements to consider

Is it asthma? Differential diagnosis / co-morbidity

Review CXR IgG, IgM, IgA Sweat test

ASTHMA IS THE MOST PREVALENT CHRONIC DISEASE OF CHILDHOOD

10% of children have diagnosed asthma

20% of children have asthma symptoms

WHAT DO YOU DO?

Is it asthma?Differential/co-morbidity?What type of asthma?Best management?

Asthma Phenotype

0

5

10

15

20

25

30

0 1 2 3 4 5 6 7 8 9

Age (years)

Inci

denc

e Episodic viral-induced wheezingPersistent asthma

Transient Wheezing

Episodic Wheezing

URT

I

URT

I

URT

I

Phenotypes & Evolution Transient wheezing

before 2-3 yrs No wheeze >3 yrs

Nonatopic wheezing Trigger=URTI Remit later in childhood (6

yrs)

Persistent wheeze Atopy, IgE, eosinophils Allergen sensitization<3yrs Parental allergy

Severe intermittent wheezing Well between URTI Atopy, IgE, eosinophils

Transient early wheezing Prematurity/parental

smoking No wheeze >3 yrs

Persistent early-onset wheezing (before age 3 yrs). Trigger=URTI No atopy/family atopy Symptoms until at age 12

yrs

Late-onset wheezing/asthma. Symptoms persist to

adulthood Atopy, IgE, eosinophils

Practall. Allergy 2008: 63: 5–34GINA: www.ginasthma.org.

Identification of Asthma Phenotypes Is Critical

Slide 16

PRACTALL Consensus Report

Is the child completely well between symptomatic

periods?

Yes No

Are colds the most

common precipitating

factor?

Is exercise the most

common or onlyprecipitating

factor?

Does the child have clinically relevant

allergic sensitization?

Yes Yes Yes No

Virus-inducedasthmaa

Exercise-inducedasthmaa

Allergen-inducedasthma

Unresolvedasthmaa,b

No No

aChildren may also be atopic.bDifferent etiologies, including irritant exposure and as-yet not evident allergies, may be included here.

Adapted from Bacharier LB, et al. Allergy. 2008;63(1):5–34.

Asthma Phenotypes in Children >2 Years of Age

IS IT ASTHMA?

Making the diagnosis of asthma may be difficult. Asthma may be considered if the following

symptoms occur: • Recurrent episodes of wheezing. • Troublesome cough at night. • Cough, wheeze or shortness of breath after

exercise. • Cough, wheeze or chest tightness after

exposure to airborne allergens or pollutants. • Colds “go to the chest” or take more than 10

days to clear.

CLINICAL MANIFESTATION

Natural history of asthma ASTHMA EXACERBATION

ASTHMA FREE PERIODREMISSION

SYMPTOMSdry coughfeeling of chest tightnessaudible musical wheezing increased work of breathingdifficulties in walking, even talkingduration - minutes, hours, daysthe expectoration of viscous sputum

ONSET: acute or insidious

SIGNS sitting position, leaning forward using the arms paleness, cyanosis sweat hyperinflation of the chest tachypnoe, tachycardia pulsus paradoxus - reduction in pulse volume during

inspiration use of accessory muscles of respiration increased percussion note auscultation: prolonged expiration, wheezing, rhonchi,

silent lung barrel chest deformity, Harrison sulci, clubbing of the

fingers

ASTHMA IN EARLY LIFEINFANTILE ASTHMA

significant number of asthmatic children demonstrates first obstructive episodes early in life 30% < 1yr of age 50-55% < 2 yr of age 80% < 5 yr of age

Onset of Symptoms inChildren With Asthma

McNicol and Williams. BMJ 1973;4:7-11; Wainwright et al. Med J Aust 1997;167:218-222.

30%

20% 30%

20%

1-2 years

>3 years

<1 year

2-3 years

Infantile asthma - criteria of diagnosis

Infantile asthma - criteria of diagnosis

3 wheezy episodes (independent of atopy)

2 wheezy episodes with atopic background (positive family or individual history)

1 wheezy episode induced by exposure to allergen

GINA recommendation recurrent wheezing

(wheezy bronchitis)

other causes excluded

positive response to therapy

DIAGNOSIS

OF ASTHMA

Tests for diagnosis and monitoring

24

In children 5 yearsand younger

25

The diagnosis of asthma has to be based

largely on:Clinical judgment:1. History2. Symptoms3. physical findings

Is it asthma?

Obstruction, reversibility, hyper reactivity

History

Physical exam

Laboratory

Intense prolonged cough with URTIs“Bronchitis”: poor response to ABGood response to asthma Rx

Signs of ObstructionReversibility with ß2-agonists

None

In children 5 yearsand younger

Trial of treatment

with SABA and ICS

Marked clinical improvement during the treatment

And deterioration when it is stopped

Supports a diagnosis of asthma

27

1. Case history characteristics of asthma episode, frequency, duration,

severity types of triggers (precipitating, agravating) the onset of the disease atopic history environmental history previous and current therapy response to medication impact of disease on child, family, school attendence psychosocial evaluation of patient/family general medical history of child

2. Physical examination

In children over 5 yearsand older Peak expiratory flow monitoring

29

PFM is useful to establish diurnal variation and the severity of obstruction

3. lung function tests

considerable (more than 20%) variabilty of peak flow rate or FEV1 over short period of time

daily variability=

response to bronchodilator when obstruction

(improvement of at least 15-20% in PEF or FEV1) measurement of bronchial hyperresponsiveness

(decreasing of at least 15-20% in PEF or FEV1 after non-specific provocation)

basic spirometry - assessment of degree of obstruction

x 100PEF evening - PEF morning

1/2 (PEF even. + PEF morn.)

3. Provocation studies:

(a) Exercise: A 15% drop in FEV1 post exercise

indicates exercise induced asthma.

(b) Metacholine challenge: A 20% reduction in

FEV1 at Metacholine concentrations < 8mg/ml indicates bronchial hyperreactivity. This is expressed as a PC20 value of eg 0.5mg/ml

(= a20% reduction in FEV1 at 0.5mg/ml Metacholine).

Measuring Airway Responsiveness

4. assessment of allergy

SERUM IgE measure of the allergy predisposition and their

degree

the concentration is age dependent total concentration specific IgE level - against specific antigens; not

more sensitive than skin test, results independent of therapy, skin lesions, dermographism, no risk of excessive (allergic/anaphylactic) reaction

normal values does not exclude allergy

Skin Prick Tests

34

4. assessment of allergy

SKIN TESTS background - recovery of IgE on the surface of

patient mast cells; interaction between allergen and IgE leads to releasing of histamine and other mediators, which acts on specific receptors in small vessels, causing increasing permeability and dilatation and axon reflex stimulation

technique: prick/puncture or intradermal, small quantity of allergenic extract is introduced into the skin

4. assessment of allergy

SKIN TESTS two control tests should be always performed:

negative control - for exclusion of nonspecific

reaction on pricking or solution used in

production of extracts;

positive control - for assessment of skin reactivity size of skin weal recorded after 15 min. - measuring the

mean diameter, positive test - a wheal at least 3 mm greater than negative control

Allergen SPECIFIC IgEAllergen SPECIFIC IgE

The advantages: - safety

- high degree of precision

- standardization - lack of dependence on the skin reactivity and medication

The disadvantages: - lack of immediately available results - high costs

• Supplement to skin testing when the clinical significance of result is doubt

• If immunotherapy is considered and lack of convincing history to confirm positive skin prick tests (concerns mites and moulds)

• Supplement to skin testing when the clinical significance of result is doubt

• If immunotherapy is considered and lack of convincing history to confirm positive skin prick tests (concerns mites and moulds)

5. other tests

CHEST X - ray - normal in asymptomatic asthma, necessary

to exclude other diseases acute asthma - hyperinflation and diagnosis

of complication BLOOD EOSINOPHIL COUNT -

increased count in about 50% of astma patients

predictive for responsiveness to therapy measure of the severity, indicates steroid requirement

SPUTUM EOSINOPHILIA positive > 20% of the total leucocytes usually present in symptomatic asthma

5. other tests

Exhaled nitric oxide (FeNO)

NO is produced in epithelial cells of the bronchial wall part of the inflammatory process

NO production increases with eosinophilic airway inflammation

Exhaled nitric oxide (FeNO)

•Measure of airway inflammation•Derived from airway epithelial cells• Relatively easily measured (hand held device) –4 years and older•Reproducible, measurement takes secs

Conclusions Asthma is a complex

inflammatory disorder

Accurate detection of asthma remains difficult