Long-Term Management of Bronchial Asthma and Wheezy Chest in Children

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1 Long-Term Management of Bronchial Asthma and Wheezy Chest in Children Ali Al-Giurnazi,* Taher Ben-Ahameida**, Elham Al-Karewi,** Awatef Al-Bouacshi*** A. Dau Masaud,**** Abstract: This paper represents a retrospective study of two-hundred patients with bronchial asthma or wheezy chest. The age of the patients ranged between -16 years, who periodically visit the respiratory clinic of Al-jala pediatric Hospital. The study reveals that 67.% of patients suffer from bronchial asthma, whereas 32.% of them suffer from wheezy chest. This diagnosis was based primarily on history and physical examination. According to medical history, we found that 66.% of the patients were atopic, and these manifestations took place mostly from winter to spring 63%. The patients were subjected to treatment with long-term use of Oral Ketotifen 36%, Inhaled Beclomethasone dipropionate 49.%, Inhaled Fluticasone propionate.%, and Inhaled Budesonide 4%. The effect of these drugs was recorded and discussed in relation with recent and relevant publications. Ketotifen was found to be convenient and useful long-term treatment for controlling asthmatic attack in young children aged -4 years. A considerable improvement was observed in patients who received long-term treatment with Beclomethasone and Fluticasone through inhalation. Introduction: Asthma occurs in children and adults. Childhood asthma may continue into adolescence and adulthood, but some adults who develop asthma did not have asthma when they were younger, and vice versa. Millions of people worldwide are affected by asthma, which has become more in recent years. Asthma attacks cause significant disruption to person's life, and severe asthma attacks can be fatal. Asthma is a common disease that involves chronic inflammation of the bronchial tree that causes swelling and narrowing of the airways. The result is difficult breathing. The bronchial narrowing is usually either totally or partially reversible with treatment. 1,2 Bronchial tree that are chronically inflamed may become overly sensitive to allergens (specific triggers) or irritants (non-specific triggers). The airways may become in a state of heightened sensitivity. This is called "bronchial hyperreactivity" (BHR). It is likely that there is a spectrum of bronchial hyperreactivity in all individuals. However, it is clear that asthmatics and allergic individuals (without apparent asthma) have a greater degree of bronchial hyperreactivity than nonasthmatic and non-allergic people. In sensitive individuals, the bronchial tree is more likely to swell and constrict when exposed to triggers such as allergens, tobacco smoke, or exercise. Amongst asthmatics, some may have mild BHR and no symptoms, while others may have severe BHR and chronic symptoms. 2,3 Subjects and methods: The files of two hundred (2) patients (children age -16) with bronchial asthma or wheezy chest were evaluated. The patients periodically visited the respiratory clinic of Al- Jala Children Hospital, and were admitted many times in the same hospital. The evaluation was done according to the following Performa: Patient history, Medical history, Family history, Treatment history, Physical examination, Investigation, Final diagnosis, Drug prescribed, Long-term treatment, side effects of treatment. *) Department of Pharmacology and Clinical Pharmacy, Faculty of Pharmacy, Al-Fateh University of Medical Sciences, Tripoli, Libya. **) Department of Microbiology and Immunology, Faculty of Medicine, Al-Fateh University of Medical sciences, Tripoli, Libya. ***) Department of Pediatric Nephrology, Al-Jala Pediatric Hospital, Tripoli, Libya. ****) Department of Pharmacology Faculty of Medicine, Sebha University Sebha, Libya. 11 Sebha Medical Journal, Vol. 6(2), 27.

2 Results and discussion: Since the 198s there has been a worldwide increase in the prevalence of asthma in both children and adults. This escalating prevalence has led to significant increases in morbidity and mortality due to the disease. In the United States, asthma is the main reason for hospitalization of children and for school absenteeism. The overall death rate from asthma has increased by 4%. Additionally, the annual total cost of treating asthma in the United States is more than $6 billion. 4-6 Asthma is now the most common chronic illness in children, affecting 1 in every. Five percent of adults in North America are also afflicted. In all, there are about 1 million Canadians and million Americans who suffer from this disease. (2) In the present study, 67.% (n=13) of all patients have bronchial asthma, and 32.% (n=6) of all patients have wheezy chest, as illustrated in figure Bronchial asthma Wheezy chest Figure 1: Prevalence of bronchial asthma and wheezy chest. The reason for developing childhood asthma and wheezing is unknown, but there are many risk factors which participate in an attack, such as: low birth weight, family history, gastro esophageal reflux, exposure to allergens, respiratory infections, and smoking. However, children have immature immune system, which is unable to protect the body from environmental factors, and cannot produce sufficient antibodies as a defense against allergens, which cause asthma and wheezing. The results indicate that, the highest incidence is in children under 2 years, by a percentage of 32.% (n=6), which indicates that infancy is the most common age group affected by wheezy chest, and this result is in agreement with other results, which refer to 2%-% of children will have experienced wheezing by the age of 12 months. 7 For the rest of the results, the age group 3-4 years has a percentage of 21.% (n=43), followed by 11.% (n=23) for the age group of -6 years, 14% (n=28) for the age group of 7-8 years, 8.% (n=l 7) for the age group of 9- years, 6% (n=12) for the age group of years, % (n=) for the age group of years, and less common in the age group of -16 years with a percentage of 1% (n=2), as illustrated in figure Sebha Medical Journal, Vol. 6(2), 27.

3 % of patients 3 32.% n= % n=43 11.% n=23 14% n=28 8.% n=17 6% n=12 % n= 1% n= Age (years) Figure 2: Relationship between age and percentage of patients with bronchial asthma or wheezy chest In our study, we observed that incidence of bronchial asthma and wheezy chest is higher in males (6.%, n=l 13) than in females (43.%, n=87), as illustrated in figure 3. This finding is in agreement with others. 8,9 6.% n= % n= Male Femal Sex Figure 3: Relationship between sex and percentage of patients with bronchial asthma or wheezy chest There is little evidence that atopy is a predisposing factor in wheezy infants. Aeroallergen exposure in infancy may be critical in the development of atopic disease and asthma, but atopic asthma is uncommon in the first year of life. (7). However, the results indicate that 66.% (n=133) of all cases have history of atopy, while the rest have no history of atopy by a percentage 33.% (n=67) of all cases, as illustrated in figure Sebha Medical Journal, Vol. 6(2), 27.

4 % of patients 7 66.% n= % n= Atopy No atopy Figure 4: Relationship between history of atopy and percentage of patients with bronchial asthma or wheezy chest It is clear to show, that asthma attacks may be precipitated by different seasonal factors such as pollen grains, cold, and weather changes. Not all patients have the same trigger factor, so asthma attacks occur at any time of the year, and may occur as a result of weather changes, which are related to seasons. In our study, 27% 27% n=4 3% n=6 Winter Spring Summer Winter & Spring Variable (not related to certain season) Figure : Relationship between season of attacks and percentage of patients with bronchial asthma or wheezy chest before commencing long-term treatment An acute, or sudden, asthma attack is usually caused by exposure to allergens or an upper respiratory tract infection. The severity of the attack depends on how well underlying asthma is being controlled. An acute attack is potentially life threatening because it may continue despite the use of usual quick-relief medications (inhaled bronchodilators). People with asthma that is unresponsive to treatment with an inhaler should promptly seek medical 1% n=2 (n=4) of patients had attacks in (winter), 3% (n=6) had attacks in (spring), 1% (n=2) had attacks in (summer) and 33% (n=66) had attacks in (winter & spring). The highest number of patients, 36% (n=72), had attacks at any time of year (variable), as illustrated in figure. 33% n=66 36% n=72 attention at the closest hospital emergency room or asthma specialist office. 2 According to our results, 3% (n=7) of all patients required no emergency treatment, % (n=6) required emergency treatment only once, 22.% (n=4) required emergency treatment twice, and the rest 12.% (n=) required three times emergency treatment, as illustrated in figure Sebha Medical Journal, Vol. 6(2), 27.

5 % of patients 3 3% n=7 % n=6 22.% n= % n= None Figure 6: Number of attacks required emergency treatment and percentage of patients with bronchial asthma or wheezy chest before commencing long-term treatment. With respect to the number of hospitalizations, the results indicate that 43% (n=86) of patients required no hospitalization, 46.% (n=93) of patients required 1-3 hospitalizations, 8% (n=16) of patients required 4-6 hospitalizations, and finally 2.% (n=) of patients required more than six hospitalizations, as illustrated in figure % n=86 46% n=93 8% n=16 None >6 2.% n= Figure 7: Number of hospitalization and percentage of patients with bronchial asthma or wheezy chest before commencing long-term treatment Symptoms may include wheezing, cough, chest tightness, and respiratory distress. Some patients have permanent shortness of breath made worse by various triggers such as infection or an inhaled allergen such as pollen. There may also be a tendency to repeated chest infections, which can cause further symptoms and distress. Sebha Medical Journal, Vol. 6(2), 27.

6 From the medical records of children aged between 1 and years, a total of 68 records, 23.7% of these children had one or more episodes of bronchospasm or wheeze, 23.2% had persistent cough, 2% had been treated with anti-asthma treatment, % had exercise-induced cough or wheeze, and 4.6% had a history of wheezy bronchitis. 11 In contrast, our results show that, 7% (n=) of patients had wheeze, 6% (n=1) had respiratory distress, 64.% (n=129) had cough and finally 3.% (n=71) had crepitation. Patients may have more than one symptom at the same time, as illustrated in figure % n= 6% n=1 64.% n= % n=71 2 Wheeze Respiratory distress Cough Crepitation Figure 8: Percentage of patients with different symptoms and signs of bronchial asthma or wheezy chest The history of medical treatment before admission was important, because asthma is a chronic condition; it usually requires continuous medical care. Patients with moderate to severe asthma have to take longterm medication daily such as antiinflammatory drugs to control the underlying inflammation, and prevent symptoms and attacks. If symptoms occur, short-term medications, such as inhaled short acting B2- agonist, are used. 12 The results indicate that, 34.% (n=69) of our patients had taken oral salbutamol in the past, 17% (n=34) had taken salbutamol by inhalation while 31.% (n=63) had taken oral steroid and 17% (n=34) of all cases had taken inhaled steroid in the past. A few patients had taken more than one medication, as illustrated in figure Sebha Medical Journal, Vol. 6(2), 27.

7 3 34.% n=69 61.% n= % n=34 17% n=34 Oral salbutamol Inhaled salbutamol Oral steriod Inhaled steriod Figure 9: Percentage of patients with bronchial asthma or wheezy chest received different treatment A diagnosis of asthma is usually based on the patient's symptoms, medical history, physical examination, and laboratory tests that measure pulmonary function. Doctors typically look for signs that the patient's airflow is obstructed and that the obstruction is at least partially reversible. Factors that trigger symptoms may be evident, such as exercise, cold air, and exposure to an allergen. However, the precipitating factors may not be clearly identified. Evidence of reversible airway obstruction is often detected in the physical examination or by physiologic testing. Physiologic testing generally is recommended to confirm the diagnosis. During an asthma attack, wheezing can be heard by listening to the chest with a stethoscope. The airway obstruction is considered reversible if the wheezing disappears in response to treatment, or when the suspected triggering factor is removed or resolved. 13 Asthma is an increasingly common chronic disease in both adults and children, which imposes a substantial burden on the patients, on the health-care system and society as a whole in terms of mortality, morbidity, and economic costs. In the absence of a cure for the disease, the goals of asthma care are to avoid mortality, reduce exacerbations, control symptoms, optimize lung function, and allow patients to live as normal as possible, with cost-effective management approaches. 14, National and international guidelines for the management of asthma recommend the use of inhaled corticosteroids as first-line therapy in mild persistent, moderate and severe asthma, and daily symptoms need B-agonist treatment. 13 Viral upper respiratory chest infection is the most frequent precipitating factor associated with acute wheeze. Bronchodilator treatment is often insufficient, and because symptoms are intermittent, continuous prophylactic treatment may seem unjustified. As a result, the use of continuous inhaled steroids is rather disappointing in treating this condition. Alternatively, the aim is to prevent viral induced asthma in pre-school children by starting inhaling corticosteroid at the onset of symptoms. 13 In our study, the patients used more than one medication, but the long-term medications include: inhaled Beclomethasone dipropionate was used by 49.% (n=99), of which 42.% (n=8) showed very promising improvement, but only 7% (n=14) of all cases did not improve after long-term treatment with this medication. Inhaled Fluticasone propionate was used by.% (n=21), of which 7% (n=t4) of all cases improved after long-term treatment with this medication, but only 3.% 17 Sebha Medical Journal, Vol. 6(2), 27.

8 (n=7) of all cases did not improve. However, 4% (n=8) of all cases used inhaled Budesonide, 2% (n=4) of all cases improved after long-term treatment, 2% (n=4) of all cases did not improve, as illustrated in figure, possibly because these patients were not taking their medicine regularly, or their inhalation technique was not appropriate, also the recommended dose might not be enough and need to be increased. On the other hand, Ketotifen was used to treat patients below four years of age with severe and frequent episodes. Ketotifen is an antihistaminic drug, block histamine receptors that cause inflammation of the airways, and may be used as long-term therapy. It reduces severity of symptoms, easy to take, and has no serious side effects. The results show that out of the 36% (n=72) of patients treated with oral ketotifen, 28% (n=6) improved after using this drug for long-term, but only 8% (n=16) did not improve % n=72 28% n=6 Oral Ketotofen 49.% n=99 42.% n=8 8% n=16 7 2% n=4 Inhaled Beclomethsaone dipropionate 2% n=4 iinhaled Budesonide 4% n=8 3.% n=7 7% n=14 سلسلة 1 سلسلة 2 سلسلة 3.% n=21 inhaled Fluticasone propionate Figure : Effect of long-term treatment on relief of symptoms and signs of bronchial asthma or wheezy chest With respect to emergency treatment and hospitalization after commencing therapy, it is clearly shown that emergency treatment and hospitalization were significantly reduced, presumably because of the effect of long-term treatment, which decreased symptoms severity, and duration, through reducing the swelling and inflammation of the airways. The results show that 79.% (n=9) of all patients had no emergency treatment or hospitalization after long-term treatment, 'but the remainder, 2.% (n=41) of all patients required emergency treatment or hospitalization after long-term treatment, perhaps because patients were not taking the inhalers properly, or did not take it regularly, as illustrated in figure Sebha Medical Journal, Vol. 6(2), 27.

9 79.% n= No. emegency tratment nor hospitalization 2.% n=41 No. emegency tratment and hospitalization Figure 11: Percentage of patients required/or did not require emergency treatment or hospitalization after commencing long-term treatment Conclusions and recommendations: Bronchial asthma was found to be more common than wheezy chest in children. The diseases were found to affect mainly the children below 4 years of age. The incidence of the diseases seemed to be more in males than in females. Family history suggesting genetic predisposition was more common in children than those who have no family history. Onset of the diseases were commonly found in children below 4 years of age. Bronchial asthma and wheezy chest presented as frequent attacks. The diseases occured mainly along the year, but it was most common in winter and spring than in other seasons. Most patients required emergency treatment before commencing long-term treatment. The majority of the patients had frequent hospitalization before starting long-term treatment. Wheeze, cough, and respiratory distress were the most common presenting symptoms. In all cases, oral salbutamol and oral steroid were the most commonly used drugs before starting long-term treatment. References: 1. Janet M. Tropy. MD, Cassio Lynm. MA, Richard M. Glass. MD. Patient age (lung diseases). Adult asthma. Jama Middle East, ; Vol. xv, No. 2: Internet explore: com. Ketotifen was a useful drug for long-term treatment in children below 4 years of age, and most patients improved after taking this medication. Beclomethasone dipropionate was another common medication used for long-term treatment, and it had significant therapeutic effect on patients over 4 years of age. Fluticasone propionate was occasionally used for long-term treatment, but this medication resulted in a good improvement of patients. Budesonide was the least commonly used medication for long-term treatment, and had no great significant effect on the disease. The emergency treatment and hospitalization were markedly reduced after commencing long-term treatment. Acknowledgement: Authors are grateful to the General Director of Al-Jala Pediatric Hospital for his cooperation and assistance during the preparation of this study. 3. K. P. Gibbs, J. C. Port Lock. Asthma. Respiratory disorders. Therapeutics, 1993; Global Initiative for Asthma. Pocket Guide for Asthma Management & Prevention. 19 Sebha Medical Journal, Vol. 6(2), 27.

10 Bethesda, Md: NIH Pub. 1998; No B.. Osborne ML, Vollmer WM, Pedula KL, et al. Lack of correlation of symptoms with specialist-assessed long-term asthma severity. Chest. 1999; 1 th Ed: Shim CS, Williams MH Jr. Evaluation of the severity of asthma: patients versus physicians. Am J Med. 68 th Ed, 198; Michael Silverman, Peter D Phelan. The wheezing infant, & Asthma in children. Paediatrics, 199; Fowler MG, Davenport MG, Garg R. School functioning of US children with asthma. Pediatrics. 9 th Ed, 1992; Mannino DM, Homa DM, Pertowski CA, et al. Surveillance for asthma United States, Mor Mortal Wkly Rep CDC Surveill Summ. 1998; 47 th Ed: Internet explore: co.uk.htm. 11. Neville RG, Bryce FP, Robertson FM, Crombie IK, dark RA, Univ Dundee, Dundee. Diagnosis & treatment of asthma in children: usefulness of a review of medical records. UK. BrJ Gen Pract. 42 nd Ed, 1992; Asma Sadek El-Magboub. The prevalence & management of asthma & chronic obstructive pulmonary disease in Libyan patients. A project submitted in partial fulfillment for bachelor degree in pharmaceutical science. Department of pharmacology and clinical pharmacy. August 2; Tripoli. 13. Internet explore: Channel. htm. 2 Sebha Medical Journal, Vol. 6(2), 27.