Dr. W. Wijnant Paediatric Pulmonology Steve Biko Academic Hospital Most common chronic disease in childhood Different phenotypes: Viral wheezer Multiple trigger wheezer Transient wheezer Persistent early onset wheezer Late onset wheezer Atopic asthma 1
Genetic / hereditory predisposition towards T helper 2 immunologic reaction = allergic hypersensitivity reaction Against common environmental antigens Affecting also parts of the body not directly in contact with allergen 2
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ASTHMA RHINITIS ECZEMA FOOD 1. FOOD ALLERGY: (age according to exposure) Milk (cow milk protein) Egg Peanuts, fish Fruits, vegetables Pollen related cross reaction (<1y) (<1y) (1-2y) (>2y) (>3y) 4
1. FOOD ALLERGY: symptoms acute or delayed GIT, skin, resp Colics, reflux, FTT (, refusal, spitting) Confirmed allergy: 6-8% infants, 3.5% older child Perceived allergy 25%? Milk & egg outgrown Peanut, tree nut, fish more freq persisting 2. ATOPIC DERMATITIS, eczema: Dry, scaly skin Pruritus Facial (except mask area), extensor in infants Flexural in older and adults Family, allergy Surinfection 5
3. ALLERGIC RHINITIS / CONJUNCTIVITIS sinuses Itchy, blocked nose Mouth breather Itchy, red eyes. Chronic: brown eyes Seasonal / perennial according to allergy (grass in highveld is almost perennial) 1. LONG FACIES & MOUTH BREATHING 6
2. ALLERGIC SALUTE 3. ALLERGIC SHINERS & DENNE S LINES 7
Intermittent <4 days per week Or <4 weeks Persistent 4 days per week And >4 weeks Mild Normal sleep and No impairment of daily activities, sport, leisure Normal work and school No troublesome symptoms Moderate-Severe 1 or more items Abnormal sleep Impairment of daily activities, sport, leisure Abnormal work and school Troublesome symptoms ARIA = Allergic Rhinitis and its Impact on Asthma. Bousquet et al. J Allergy Clin Immunol. 2001;108 (5 suppl):s147. Bousquet et al. Allergy. 2002;57:841. % 1-5% Green RJ, et al. Prim Care Respir J 2007;16:299-303 8
Airway Signs Inflammation Mucus Hyperresponsiveness bronchoconstriction 1. Swelling 2. Secretions 3. Spasm 9
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COUGH WHEEZE 12
BLOCKED Based on history. Supported by examination & investigations. 13
Complaints: Recurrent cough Nocturnal, early morning Age of onset? Frequency? Atopic march: Food allergy Eczema Rhinitis Conjunctivitis 14
Exacerbations: wheeze, tight chest, SOB Induced: exercise viral infections (common colds) allergen smoke, dust emotion cold air (& ice cream, cold drinks, ) weather changes Improving with bronchodilaters Environment: Carpets (cigarette) Smoke Housing: quality, leaks, mould, cockroaches Pets Bed and bedding (feather duvet / pillow) 15
Family: siblings, parents (RSV) Bronchiolitis early life Exclude other conditions: CLD / bronchiectasis: HIV, clubbing, halitosis TB: chronic (rather than recurrent) cough, TB exposure, loss of weight / appetite, sweating, LN BPD: ex-prem, previous ventilation, O 2 therapy GORD: hoarseness, stridor, regurgitation, pain (peri/post prandial, nocturnal), anorexia, FTT Aspiration: acute, asymmetric chest History! Skin Prick Tests RAST (specific IgE) Infants: food: egg, milk, soya, peanut School age: aeroallergens: house dust mite, moulds, trees, grasses, cockroaches, cat & dog Test both middle group 16
Skin Test Less expensive Greater sensitivity Wide allergen selection Results available immediately FIRST CHOICE TESTING RAST No patient risk Patient-doctor convenience Not suppressed by antihistamines Results are quantitative Preferable to skin testing in: Dermatographism Widespread dermatitis Uncooperative children 17
But not validated in developing countries 18
Infant, young children Acute wheeze and cough During (viral) RTInfections Sometimes with real bronchospasm = bronchiolitis like LRTI 19
Diagnosis: HISTORY Episodic wheeze multiple trigger wheeze Acute vs recurrent RTI Isolated nocturnal exercise atopic parents/ sibling 20
Consider as multiple trigger wheezer if Atopy (API): Eczema, allergic rhinitis Skin Prick Test Eosinophilia Chronic inflammation: responds to trial and relapses when stopped: oral prednisone (1mg/kg/day 10-14/7) or ICS (Budeflam 100 2p bd 6-10/52) ICS for 6-10/52 or OCS for 10-14/7 NO improvement Improvement STOP ICS / OCS low risk for PW/asthma No relapse of symptoms Symptoms relapse high risk for PW/asthma 21
1. Avoid Inflammatory triggers: Dust: avoid carpet, cement. Clean. Housing Smoke: avoid cigarette, mbawola, paraffin Bugs: mites (mattress & pillow cover, wash bedding weekly, avoid carpets) cockroaches (no exposed food, garbage; fix leaks, traps) Mold: Fix leaks, reduce humidity Pets Pollen 22
2. Control Inflammation = Preventer Inhalation corticosteroids (ICS) Twice DAILY maintenance treatment Long Term (optimal effect > 3/12) Adjust dosage: step up/ step down Cromolyn Anti Leukotrienes 23
3. (short acting) Bronchodilation Reliever Salbutamol (Asthavent / Ventolin / Berotec) PRN: only when necessary (cough, wheeze, blocked) Inhalation!! Risk for tolerance when used frequent without ICS 4. Long Acting Bronchodilation: Preventer - Reliever Salmeterol (Serevent) When uncontrolled (step 4 onwards) Preferably combined with ICS (Seretide) 24
NEVER COUGH MIXTURES Step up / Step down: flexible Rx Personal management plan or Frequent follow up: Asthma s: exercise, weather, smoke, Nocturnal cough, disturbing sleep Use of relievers Time off from school / work 25
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Lung function tests Peak expiratory flow COUNSELLING / EDUCATION: Goals: minimum symptoms, exacerbation no emergency visit PEF > 80% Daily ICS necessary Life long, but controllable. 29
ACTION PLAN ACTION PLAN 30
ACTION PLAN!!SPACER!! (all ages) 31
1. Assemble spacer 2. Shake puff well 32
3. Insert puff in spacer 4. Seal mask around face and check breathing 33
5. Spray once and check breathing 5-10x Repeat from beginning for 2 nd puff Atopic Rhinitis (conjunctivitis): Blocked nose leads to mouth breathing: More irritating for lungs (dry, cold air) More exacerbations Rx Nasal steroids (Beclate Aquanase nocte or bd) Anti histamines (Zyrtec, Texa, ) 34
BRONCHODILATION Home: B2 agonist (Asthavent puff + spacer) REPEAT PRN every minute for 10 min 2. Clinic/Casualty: ASTHAVENT PUFF & SPACER Berotec nebs (1 neb = 10-20 puffs!) Systemic CS po Step up maintenance? AB rarely necessary NO COUGH MIXTURES Assessment: Oxygenation: Sats (ABG not necessary) Compliance, education Trigger? (mostly viral RTI) 35
References: NAEP SA Asthma guidelines 2007 ERS guidelines 2008 GINA guidelines 2009 Pediatric Allergy 2nd ed 2010 36