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Bashar S. Shihabuddin, MD, FAAP, FACEPPediatric Emergency Medicine

I have no conflicts of interest to disclose

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Identify the clinical features of asthma Identify other causes of wheezing/cough Develop an asthma treatment plan Be familiar with medications commonly used

for asthma Identify barriers to asthma care and how to

deal with them

Affects 17.7 million people 6.3 million children under 18

In 2010, 1.8 million people visited an ED for asthma-related care and 439,000 people were hospitalized because of asthma

Average LOS = 3.6 days Economic cost in 2007 was $56 BILLION In 2014; 187 child deaths and 3464 adult deaths were

due to asthma

http://www.cdc.gov/asthma/asthmadata.htm accessed 08/03/2016http://www.aaaai.org/about-aaaai/newsroom/asthma-statistics accessed

08/03/2016

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0

2

4

6

8

10

1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010

Percent

Year

http://www.cdc.gov/asthma/asthmadata.htm accessed 08/03/2016

0

1

2

3

4

5

6

7

8

9

10

0

2

4

6

8

10

12

14

16

18

20

22

24

26

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Perce

nt

Total number of persons in m

illions

http://www.cdc.gov/asthma/asthmadata.htm accessed 08/03/2016

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In 2012:◦ 292,000 adults had asthma (F>>M)◦ 123,100 children had asthma (M>F)◦ $57.9 Million in hospitalization costs

https://www.ok.gov/health/Wellness/Chronic_Disease_Service/Asthma/index.html accessed 08/03/2016

InflammationSmooth muscle

constrictionMucus

production & edema

InflammationSmooth muscle

constrictionMucus

production & edema

ObstructionAir trappingObstructionAir trapping

CoughWheezing

Chest tightnessProlonged exhalation

Shortness of breath

CoughWheezing

Chest tightnessProlonged exhalation

Shortness of breath

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Chronic disease of the airway Strict definition requires pulmonary function

testing before and after challenge with irritant or allergen

Term is often used when wheezing, cough and shortness of breath develop in response to a trigger

Link HW. ‘Pediatric Asthma in a Nutshell’, Pediatr Rev. 2014 Jul;35(7):287-98. doi: 10.1542/pir.35-7-287.

Viral respiratory tract infections Exercise Weather changes Exposure to tobacco—or other—smoke Air pollution Cold or hot air Perfumes Drugs (salicylic acid, beta-blockers)

Link HW. ‘Pediatric Asthma in a Nutshell’, Pediatr Rev. 2014 Jul;35(7):287-98. doi: 10.1542/pir.35-7-287.

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Asthma Predictive Index Pulmonary Function Test Peak Flow Meters Allergy Testing

Link HW. ‘Pediatric Asthma in a Nutshell’, Pediatr Rev. 2014 Jul;35(7):287-98. doi: 10.1542/pir.35-7-287.

Major Criteria Minor CriteriaParental asthma Allergic RhinitisEczema Wheezing apart

from colds

Blood eosinophils>4%

Children younger than 3 years of age with 3 or more episodes of wheezing

One major or 2 minor criteria have higher risk of asthma

Castro-Rodriguez JA.,’ The Asthma Predictive Index: a very useful tool for predicting asthma in young children.’ J Allergy Clin Immunol. 2010

Aug;126(2):212-6. doi: 10.1016/j.jaci.2010.06.032.

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Establish a baseline to compare daily measurements

Helpful in patients with poor perception of their asthma

Can be used to adjust treatment Not for routine use

Link HW. ‘Pediatric Asthma in a Nutshell’, Pediatr Rev. 2014 Jul;35(7):287-98. doi: 10.1542/pir.35-7-287.

Most asthmatics will have a positive immediate type allergy skin test

Results have to be interpreted with clinical findings

Link HW. ‘Pediatric Asthma in a Nutshell’, Pediatr Rev. 2014 Jul;35(7):287-98. doi: 10.1542/pir.35-7-287.

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Aspiration Bronchiolitis Vocal cord dysfunction Cystic fibrosis Bronchiectasis

Common in younger children (<5 years) More common in males Sudden onset of symptoms in previously

healthy child, especially with history of ingestion or choking

Radiographs of chest AP and lateral If the thoracic inlet is not visualized then

radiographs of the neck

Green SS., ‘Ingested and Aspirated Foreign Bodies’, Pediatr Rev. 2015 Oct;36(10):430-6; quiz 437. doi: 10.1542/pir.36-10-430

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Viral lower respiratory tract infection in children less than 2 years old

Clinical signs and symptoms:◦ Rhinorrhea◦ Cough◦ Tachypnea◦ Wheezing◦ Rales◦ Grunting/nasal flaring/retractions

Seasonal component

Ralston SL, Lieberthal AS, Meissner HC et al.,’ Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis.’, Pediatrics.

2014 Nov;134(5):e1474-502. doi: 10.1542/peds.2014-2742.

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Involuntary closure of the vocal cords Typically occurs during exercise in highly

competitive teens Symptoms rarely occur spontaneously No response to asthma therapies and self-

limited in most times Often with inspiratory stridor Spirometry can differentiate this from asthma

Link HW. ‘Pediatric Asthma in a Nutshell’, Pediatr Rev. 2014 Jul;35(7):287-98. doi: 10.1542/pir.35-7-287.

Volume (L) Volume (L)

Flow

(L/s

)Expiration

Inspiration

AsthmaNormal

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Findings Possible DiagnosisCoughing and choking with food or drink

Oropharyngeal dysphagia with aspiration

Poor growth Cystic fibrosis or immunodefiencyChronic runny nose and sinus infections

Cystic fibrosis or immotile cilia syndrome

Chronic wet productive cough Bronchiectasis

Link HW. ‘Pediatric Asthma in a Nutshell’, Pediatr Rev. 2014 Jul;35(7):287-98. doi: 10.1542/pir.35-7-287.

Symptoms only with exercise Typically self-limiting but frustrating Diagnosis is by history and if a formal

diagnosis is needed spirometry with exercise Treatment is with beta-agonist premedication

15 minutes before exercising

Link HW. ‘Pediatric Asthma in a Nutshell’, Pediatr Rev. 2014 Jul;35(7):287-98. doi: 10.1542/pir.35-7-287.

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DiagnoseSeverityTriggers

DiagnoseSeverityTriggers

MedicationsEducation

MedicationsEducation

Follow upReview

Follow upReview