• Asthma is the most common chronic disease of childhood and the

leading cause of childhood morbidity from chronic disease as

measured by school absences, emergency department visits, and

hospitalizations.

• Asthma leads to recurrent episodes of wheezing, breathlessness,

chest tightness and coughing (particularly at night or early morning).

Clinical symptoms in children 5 years and younger are variable and

non-specific.

• Widespread, variable, and often reversible airflow limitation.

Asthma Inflammation – Cells and Mediators

Mechanism – Asthma Inflammation

Source: Peter J. Barnes, MDSource: Peter J. Barnes, MD

Asthma Inflammation

Factors Influencing the Development and Expression of Asthma

Host factors –

• Genetic

1. Genes predisposing to atopy

2. Genes predisposing to airway hyper responsiveness

• Obesity

• Sex

Environmental factors –

• Allergens –

1. Indoor – Domestic mites, furred animals (dogs, cats, mice),

cockroach allergens, fungi, molds, yeasts.

2. Outdoor – Pollens, fungi, molds, yeasts.

• Infections (predominantly viral)

• Occupational sensitizers

• Tobacco smoke

1. Passive smoking

2. Active smoking

• Indoor/Outdoor air pollution

• Diet

Risk factors of Asthma in younger children

• Sensitization to allergen.

• Maternal diet during pregnancy and/ or lactation.

• Pollutants (particularly environmental tobacco smoke).

• Microbes and their products.

• Respiratory (viral) infections.

• Psychosocial factors.

Prevalence of Childhood asthma

The prevalence of childhood asthma has continued to increase on the Indian subcontinent over the past 10 yrs

ISAAC Phase 3 Thorax 2007;62:758

Fear of steroids

Heavynebulisation

Choice of right device

Oral vs. Inhaled Lack of knowledge &

time vs. more patients

Poor patient/parent

education

Cough or Wheeze

Heterogenous Disease/varying

phenotypes

Acceptance of Asthma

diagnosis/label

Underdiagnosed/Misdiagnosed

Issues in Pediatric Asthma

Other Challenges• Most of the children are below 5 years of age, who cannot tell

their problems

• Parents are proxy story teller, who may mislead the doctor

• PEF cannot be performed in children below 5 years of age

• Fear of addiction to inhalation therapy

• Physicians lack of knowledge and time

Clinical Features

• Recurrent Wheeze

• Recurrent Cough

• Recurrent Breathlessness

• Activity Induced Cough/Wheeze

• Nocturnal Cough/Breathlessness

• Tightness Of Chest

Asthma by Consensus, IAP 2003

Symptomatology

• Cough – 90%• Wheezing – 74%• Exercise induced wheeze or cough – 55%

Ind J Ped 2002;69:309-12

Typical features of Asthma

• Afebrile episodes

• Personal atopy

• Family history of atopy or asthma

• Exercise /Activity induced symptoms

• History of triggers

• Seasonal exacerbations

• Relief with bronchodilators Asthma by Consensus, IAP 2003

When does Asthma begin?

• By 1 year – 26%• 1-5 years – 51.4%• > 5 years – 22.3%

77% Of Asthma Begins In Children Less Than 5 Years

Ind J Ped 2002;69:309-12

Tools to Diagnosis

• Good History Taking (ASK)

• Careful Physical Examination (LOOK)

• Investigations (PERFORM) – above 5 years only

CHILDHOOD ASTHMA by KHUBCHANDANI R.P. et al

History taking (Ask)

• Has the child had an attack or recurrent episode of wheezing (high-pitched whistling sounds when breathing out)?

• Does the child have a troublesome cough which is particularly worse at night or on waking?

• Is the child awakened by coughing or difficult breathing?

• Does the child cough or wheeze after physical activity (like games and exercise) or excessive crying?

• Does the child experience breathing problems during a particular season?

CHILDHOOD ASTHMA by KHUBCHANDANI R.P. et al

History taking (Ask)• Does the child cough, wheeze, or develop chest tightness

after exposure to airborne allergens or irritants e.g. smoke, perfumes, animal fur?

• Does the child’s cold frequently ‘go to the chest’ or take more than 10 days to resolve?

• Does the child use any medication when symptoms occur? How often?

• Are symptoms relieved when medication is used?

CHILDHOOD ASTHMA by KHUBCHANDANI R.P. et al

If the answer is ‘yes’ to any of the questions, a diagnosis of asthma should be considered

Physical Examination (Look)• General Attitude And Well Being

• Deformity Of The Chest

• Character Of Breathing

• Thorough Auscultation Of Breath Sounds

• Signs Of Any Other Allergic Disorders On The Body

• Growth And Development StatusCHILDHOOD ASTHMA by KHUBCHANDANI R.P. et al

What all features one should look for specifically?

Dyspnea• Expiratory wheeze• Accessory muscle movement• Difficulty in feeding, talking, getting to sleep• Irritability

CHILDHOOD ASTHMA by KHUBCHANDANI R.P. et al

What all features one should look for specifically?

Cough• Persistent/ recurrent / nocturnal/ exercise-induced

Associated conditions• Eczema• Allergic Rhinitis

Weight/Height

CHILDHOOD ASTHMA by KHUBCHANDANI R.P. et al

What all investigations can be performed in asthmatic children? (PERFORM)

Peak expiratory flow rate: It is highly suggestive of asthma when:

• >15% increase in PEFR after inhaled short acting β2 agonist

• >15% decrease in PEFR after exercise

• Diurnal variation > 10% in children not on bronchodilator OR >20% In children on bronchodilator

1. Asthma by Consensus, IAP 20032. CHILDHOOD ASTHMA by KHUBCHANDANI R.P. et al

How to rule out the mimics?

The Early Wheezer (< 3Years)

Early onset asthma

• Afebrile episodes

• Personal atopy present

• Family history of asthma / atopy present

• Predictable good response to bronchodilators

WALRI (wheeze associatedlower respiratory tract infections)or Viral Associated wheeze

• Febrile episodes• Personal atopy absent• Family history of asthma / atopy

absent• Variable response to

bronchodilators

Asthma by Consensus, IAP 2003

Bronchiolitis in children

• Commonest cause of wheezing in children between 6 months to 3 years

• Resembles asthma

• Diagnosis essentially clinical

• Common viruses causing bronchiolitis in children:– Respiratory syncytial virus (RSV)

Clinical manifestations of RSV disease

• Rhinorrhoea

• Pharyngitis

• Cough

• Low grade fever

• Wheezing

• Increased respiratory rate

Differential diagnosisAge Common Uncommon Rare

Less than6 months

BronchiolitisGastro-esophagealreflux

Aspiration pneumoniaBronchopulmonary dysplasiaCongestive heart failureCystic fibrosis

AsthmaForeign body aspiration

6 months -2 years

BronchiolitisForeign bodyaspiration

Aspiration pneumoniaAsthmaBronchopulmonary dysplasiaCystic fibrosisGastro-esophageal reflux

Congestive heart failure

2 - 5 years

AsthmaForeign bodyaspiration

Cystic fibrosisGastro-esophageal refluxViral pneumonia

Aspiration pneumoniaBronchiolitisCongestive heart failureGastro-esophageal reflux

IPAG 2007

Co morbid conditions

• Allergic RhinitisColds, ear infectionsSneezing in the morningBlocked nose, snoring, mouth breathing

• Gastro esophageal reflux (GER)Nocturnal cough followed by vomiting• Eczema

Guidelines for confirming Childhood Asthma diagnosis

IPAG Diagnosis

• Characterize the problem• Establish chronicity• Exclude non-respiratory or other causes• Exclude infectious diseases• Consider patient’s age• Use diagnostic aids

International Primary Care Airways Group 2007

Early Childhood Asthma Diagnosis (below 6 years)

Diagnostic Tool

Findings that Support Diagnosis

Differential diagnosis

The diagnosis of asthma in children under age 6 is primarilyone of exclusion.

Physical examination

If the child does not appear acutely ill and is growing, andthere is no evidence specifically indicating another cause ofsymptoms, a trial of therapy is warranted.

Trial of therapy (bronchodilators)

Improvement with treatment supports a diagnosis of asthma.

Frequent reassessment

Health care professionals should always be prepared toreconsider the diagnosis if management is ineffective or ifthe clinical situation changes.

IPAG 2007

Childhood Asthma Diagnosis (6-14 years)

IPAG 2007

Childhood Asthma Diagnosis (6-14 years)

IPAG 2007

NORDIC CONSENSUSConfirm Asthma if,

If the child is having 3 attacks of airway obstruction in last 1 yr.

If the child gets 1 attack of asthmatic symptoms after the age of 2 yrs.

Irrespective of age in an attack in children with allergy (eczema, food allergy etc.) or history of atopy.

If the child does not become free of symptoms when infection has ceased or has persistent symptoms for

more than a month.

Respir Med. 2000;94(4):299-327

IAP GUIDELINES

3 Or More Episodes Of Airflow Obstruction With Several Of The Following:

• Afebrile Episodes

• Personal Atopy Or Family H/O Atopy / Asthma

• Nocturnal Exacerbations

• Exercise/Activity Induced Symptoms

• Trigger Induced Symptoms

• Seasonal Exacerbations

• Relief With Bronchodilators ± Oral Steroid

Asthma by Consensus, The Indian Academy of Pediatrics 2003

GINA• The following symptoms are highly suggestive of a diagnosis of

asthma: – frequent episodes of wheeze (more than once a month)– activity-induced cough or wheeze – nocturnal cough in periods without viral infections – absence of seasonal variation in wheeze – symptoms that persist after age 3

• A simple clinical index based on:– presence of a wheeze before the age of 3– presence of one major risk factor (parental history of asthma

or eczema) or two of three minor risk factors (eosinophilia, wheezing without colds, and allergic rhinitis) has been shown to predict the presence of asthma in later childhood

Global Initiative for Asthma 2008

GINA• A useful method for confirming the diagnosis of asthma in

children 5 years and younger is a trial of treatment with short-acting bronchodilators and inhaled glucocorticosteroids

• Children 4 to 5 years old can be taught to use a PEF meter, but to ensure reliability parental supervision is required

• Use of spirometry and other measures recommended for older children such as airway responsiveness and markers of airway inflammation is difficult and several require complex equipment making them unsuitable for routine use

GINA 2008

BTS

• Initial assessment of children suspected of having asthma should be based on:– presence of key features in the history and clinical examination– careful consideration of alternative diagnoses

• Using a structured questionnaire may produce a more standardised approach to the recording of presenting clinical features and the basis for a diagnosis of asthma

British Thoracic Society 2008

Clinical features that increase the probability of asthma• More than one of the following symptoms: wheeze, cough, difficulty

breathing, chest tightness, particularly if these symptoms:◊ are frequent and recurrent◊ are worse at night and in the early morning◊ occur in response to, or are worse after, exercise or other triggers, such as exposure to pets, cold or damp air, or with emotions or laughter◊ occur apart from colds

• Personal history of atopic disorder

• Family history of atopic disorder and/or asthma

• Widespread wheeze heard on auscultation

• History of improvement in symptoms or lung function in response to adequate therapy

BTS 2008

Clinical features that lower the probability of asthma

• Symptoms with colds only, with no interval symptoms

• Isolated cough in the absence of wheeze or difficulty breathing

• History of moist cough

• Prominent dizziness, light-headedness, peripheral tingling

• Repeatedly normal physical examination of chest when symptomatic

• Normal peak expiratory flow (PEF) or spirometry when symptomatic

• No response to a trial of asthma therapy

• Clinical features pointing to alternative diagnosis

BTS 2008

Asthma Phenotypes

What do you understand by phenotypes?

• Phenotypes“the visible properties of an organism that are produced by the interaction of genotype and the environment”

-Webster’s New Collegiate Dictionary

Pre

vale

nce

of

wh

eeze

Age YearsMartinez Pediatrics 2002;109:362

Transient wheeze

Non-atopic viralinduced wheeze

Atopic asthma

0 3 6 11

Pre-school “Asthma phenotypes”Wheezing is common in young children but is it asthma?

Asthma phenotypes in childhood

Transient• linked with smoking during pregnancy • viral RTIs • not associated with atopy• remits by school age• Impaired lung function at birth

Asthma phenotypes in childhood

Persistent• not associated with atopy:

- associated with viral RTIs (RSV), - may remit during school age- LTRAs have been found to be beneficial

• associated with atopy: - bronchial responsiveness, impaired lung function - parental history of asthma - most ongoing during school age

Classification of Asthma

• The goal of the treatment is to achieve and maintain control for

prolonged periods with due regard to the safety of treatment, potential for

adverse effects, and the cost of treatment required to achieve this goal.

• Assessment of asthma control should include control of the clinical

manifestations, control of the expected future risk to the patient such as

exacerbations, accelerated decline in the lung function, and side-effects

of the treatment.

• The achievement of good clinical control of asthma leads to reduced risk

of exacerbations.

CharacteristicControlled

(All of the following)

Partly controlled(Any present in any week)

Uncontrolled

Daytime symptoms None (2 or less / week)More than

twice / week

3 or more features of

partly controlled

asthma present in any

week*

Limitations of activities None Any

Nocturnal symptoms /

awakeningNone Any

Need for rescue /

“reliever” treatmentNone (2 or less / week)

More than

twice / week

Lung function#

(PEF or FEV1)Normal

< 80% predicted or

personal best (if known)

on any day

Exacerbation None One or more / year 1 in any week*Any exacerbation should be prompt review of maintenance treatment to ensure that it is adequate.

#Lung function is not a reliable test for children 5 years and younger. GINA 2009

Levels of Asthma Control in Children 5 years and younger

Characteristic Controlled (All of the following) Partly Controlled (Any measure present in any

week)

Uncontrolled (Three or more of features of

partly controlled asthma in any week)

Daytime symptoms – wheezing, cough, difficult breathing

None (less than twice/week, typically

for short periods of on the order minutes and rapidly relieved by

use of a rapid-acting bronchodilator)

More than twice/week(typically for short periods on the order minutes and

rapidly relieved by use of a rapid-acting bronchodilator)

More than twice/week(typically last minutes of hour or

recur, but partially or fully relieved with rapid-acting

bronchodilators)

Limitation of activities

None (child is fully active, plays and

runs without limitation or 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/wakes with cough, wheezing and/or difficult breathing)

Any (typically coughs during sleep/wakes with cough, wheezing and/or difficult breathing)

Need for reliever/rescue treatment

Less than/equal to 2 days/week > 2 days/week > 2 days/week

• Examples of validated measures for assessing clinical control of asthma

include –

• Asthma Control Test (ACT) – www.asthmacontrol.com

• Childhood Asthma Control test (C - Act)

• Asthma Control Questionnaire (ACQ) – www.qoltech.co.uk/asthma1.htm

• Asthma Therapy Assessment Questionnaire (ATAQ) –

www.ataqinstrument.com

• Asthma Control Scoring System

Asthma Treatments

• Classified into Controllers and Relievers

• Controllers – medications to be taken on daily long term basis.

• Relievers – medications to be used on as-needed basis to

relieve symptoms quickly.

• Asthma treatment can be administered in different ways – inhaled,

oral, or by injection.

• Advantage of inhaled therapy - drugs are delivered directly into the

airways, producing higher local concentrations with significantly less

risk of systemic side effects.

• Inhaled medications for asthma are available as pressurized MDIs,

DPIs, soft mist inhalers and nebulized or ‘wet’ aerosols.

• CFC inhaler devices are being phased out due to the impact of CFCs

upon the atmospheric ozone layer, and are being replaced by HFA

devices.

• Choosing an inhaler device for children with asthma *-

Age group Preferred device Alternative device

Younger than 4 years

Pressurized metered-dose inhaler

plus dedicated spacer with face

mask

Nebulizer with face mask

4-5 years

Pressurized metered-dose inhaler

plus dedicated spacer with

mouthpiece

Nebulizer with mouthpiece

Older than 6 years

Dry powder inhaler or breath

actuated pressurized metered-

dose inhaler or pressurized

metered-dose inhaler with spacer

with mouthpiece

Nebulizer with mouthpiece

*Based on efficacy of drug delivery, cost effectiveness, safety, ease of use, and convenience. GINA 2009

Asthma management and prevention

• The goals for successful management of asthma are

1. Achieve and maintain control of symptoms

2. Maintain normal activity levels, including exercise

3. Maintain pulmonary function as close to normal as possible

4. Prevent asthma exacerbations

5. Avoid adverse effects from asthma medications

6. Prevent asthma mortality

Five interrelated components of therapy are required to achieve

and maintain control of asthma-

1. Develop Patient/Doctor partnership

2. Identify and reduce exposure to risk factors

3. Assess, treat, and monitor asthma

4. Manage asthma exacerbations

5. Special considerations

Develop Patient/Doctor partnership -

• Effective management of asthma requires the development of a

partnership between the person with asthma and the health care

team.

• Patients can learn to –

1. Avoid risk factors

2. Take medications correctly

3. Understand the difference between controller and reliever

medications

4. Monitor their status using symptoms and, if relevant, PEF

5. Recognize signs that asthma is worsening and take action

6. Seek medical help as appropriate

• Education should be integral part of all interactions between health care

professional and patients.

• Using variety of methods such as discussions, demonstrations, written

materials, group classes, video/audio tapes, dramas and patient support

groups helps reinforce educational messages.

• Health care professional and patients should prepare a written personal

asthma action plan that is medically appropriate and practical.

• Additional self-management plans can be found on –

1. www.asthma.org.uk

2. www.nhlbisupport.com/asthma/index.html

3. www.asthmaz.co.nz

Identify and reduce exposure to risk factors -

• Measures to prevent the development of asthma and asthma

exacerbations by avoiding or reducing exposure to risk factors

should be implemented wherever possible.

• Reducing patients exposure to some categories of risk factors

improves the control of asthma and reduces medication needs.

Assess, Treat and Monitor Asthma –

• The goal of asthma treatment can be reached in most patients through a continuous cycle that involves – assessing, treating and monitoring asthma.

• Each patient should be assessed to establish his/her current treatment regimen, adherence to the current regimen, and level of asthma control.

• Each patient is assigned to one of five treatment steps.

• At each treatment step, reliever medication should be provided for quick relief of symptoms as needed.

• Inhaled medications are preferred because they deliver drugs directly to the airways where they are needed, resulting in potent therapeutic effects with fewer systemic side effects.

• Inhaled medications for asthma are available as pressurized MDIs, breath actuated MDIs, DPIs and nebulizers.

• Spacer devices make inhalers easier to use and reduce systemic absorption and side effects of ICS.

• Patients should be demonstrated about the use of devices.

• Monitoring is essential to maintain control and establish the lowest step and

dose of treatment to minimize cost and maximize safety.

• If asthma is not controlled, step up the treatment. Improvement is generally

seen within 1 month.

• If asthma is partly controlled, consider stepping up treatment, depending

more effective options available, safety and cost of possible treatment and

patient’s satisfaction with the level of control achieved.

• If controlled asthma is maintained for at least 3 months, step down with a

gradual, stepwise reduction in treatment. The goal is to decrease treatment

to the least medication necessary to maintain control.

Asthma management approach based on control

for children 5 years and younger

Asthma education, Environmental approach, and as needed rapid acting beta -agonists

Controlled on as needed rapid

acting beta2-agonists

Partly controlled on as needed

rapid acting beta2-agonists

Uncontrolled or only partly

controlled on low - dose inhaled

glucocorticosteroid

Controller options

Continue as needed rapid acting

beta2-agonists

Low – dose inhaled

glucocorticosteroid

Double Low – dose inhaled

glucocorticosteroid

Leukotriene modifier

Low – dose inhaled

glucocorticosteroid plus Leukotriene

modifier

To summarize…

• Asthma is an inflammatory illness

• Diagnosis of asthma is clinical, and relies on history

• All asthma does not wheeze

• In children < 3 yrs, WALRI is an important differential diagnosis

• 2 out of 3 children outgrow their asthma

• A family history of asthma / atopy increases risk of asthma

Diagnosis

To summarize…

• Patient education is a very important part of asthma management

• Drugs control, but do not cure asthma

• Clinical grading over time, decides long term management plan

• Mild intermittent asthma does not merit controllers

• Inhaled steroids are mainstay of long term asthma management

• Treatment should be stepped up or stepped down depending upon patient

response

Long term management

Thank You