Bronchial asthma E. Cserháti 1 st Department of Paediatrics Lecture for english speaking students 5 February 2013
Epidemiology of childhood bronchial asthma Worldwide prevalence of 7-8 and 13-14 years old children with bronchial asthma (ISAAC STUDY) 1,6 36 % (56 countries) Asthma prevalence in Hungarian children 1970-80 0,3-0,8 % 1980-90 about 2 % 2000 4-8 %
Is it Asthma? Presence of any of these signs and symptoms should increase the suspicion of asthma: wheezing-high-pitched whistling sounds when breathing outespecially in children. (A normal chest examination does not exclude asthma). History of any of the following: Cough, worse particularly at night Recurrent wheeze, Recurrent difficult breathing, Recurrent chest tightness Symptoms occur or worsen at night, awakening the patient. Symptoms occur or worsen in a seasonal pattern. The patient also has eczema, hay fever, or a family history of asthma or atopic diseases.
Immediate type skin prick test
Hazel-nut is spreading pollen even at the end of February and beginning March
birch wood birch
Poplar, aspen
Mugwort (Artemisia)
Amrosia elatior, ragweed The most important pollen allergen in Hungary, mostly spreading the pollen in August and September.
Different kindes of moulds
horse
Dog, the hair of the dog often causes allergic diseases
cat The most important animal source of allergy
House dust mites
cockroach One of the most important allergens in the poor districts of big USA cities. In Hungary at that moment not too important.
Measurements of lung function provide an assessment of the severity, reversibility, and variability of airflow limitation, and help confirm the diagnosis of asthma. Spirometry is the preferred method of measuring airflow limitation and its reversibility to establish a diagnosis of asthma. An increase in FEV1 of 12% (or 200 ml) after administration of a bronchodilator indicates reversible airflow limitation consistent with asthma. (However, most asthma patients will not exhibit reversibility at each assessment, and repeated testing is advised.)
The role of viruses in important airways diseases Type of virus common cold Asthma exacerbation Bronchiolitis Rhinovírus +++ +++ ++ Corona vírus +++ ++? Influenza vírus ++ ++ + Adenovirus ++ ++ + Parainfluenza vírus ++ ++ + RS vírus ++ ++ +++
Peak expiratory flow (PEF) measurements can be an important aid in both diagnosis and monitoring of asthma. PEF measurements are ideally compared to the patient s own previous best measurements using his/her own peak flow meter. An improvement of 60 L/min (or 20% of the pre-bronchodilator PEF) after inhalation of a bronchodilator, or diurnal variation in PEF of more than 20% (with twice-dailiy readings, more than 10%), suggests a diagnosis of asthma. Additional diagnostic tests: For patients with symptoms consistent with asthma, but normal lung function, measurements of airway responsiveness to methacholine, histamine, mannitol, or exercise challenge may help establish a diagnosis of asthma. Skin tests with allergens or measurement of specific in individual patients.
Lung function test in a child
Peak expiratory flow test
Bronchial asthma in an infant
The differential diagnosis of bronchial asthma in children Late consequenties of newborn respiratory problems Cystic fibrosis Acute viral bronchiolitis Aspiration Congenital malformations of the lungs Cardiac and vascular diseases Extrabronchial obstruction Endobronchial obstruction Foreign body aspiration Hysteric symptoms
To make sports and being on fresh air is important for bronchial asthma and for wellbeing of children and teenagers. Of course the pollen season means an additional burden for the patients. To seat whole day before the internet means during the whole day indoor allergens challenge.
The fate of the inhaled corticosteroid lung Mouth and throat swallowed part liver absorbtion From the lung (A) absorbtion from the gut Active drug from the gut (B) Systemic circulation Gastro-intestinal tract inactivation In the liver first pass systemic concentration = A+B Barnes and Pedersen, ARRD 1993
The inhalative drugs can reach the lungs with the help of metered dose inhalers, dry powder inhalers or nebulizers
Devices for better inhalation technics
Levels of Asthma Control Characteristic Controlled (All of the following) Partly controlled (Any measure present in any week) Uncontrolled Daytime symptoms Limitations of activities None (twice or less/week) None More than twice/week Any Three or more features of partly controlled asthma present in any week Nocturnal symptoms/awakening None Any Need for reliever/rescue treatment None (twice or less/week More than twice/week Lung function (PEF or FEV1) Normal <80% predicted or personal best (if known) Exacerbations Normal One or more/year* One in any week
Step 1 Step 2 Step 3 Step 4 Step 5 Asthma education Enviromental control As needed rapid actingβ2-agonist As needed rapid actingβ2-agonist Controller options Select one Select one Select one Select one Low-doses inhaled ICS* Low-dose ICS plus long-actingβ2- agonist Medium-or high-dose ICS plus long-acting β2-agonist Oral glucocorticosteroid (lowest dose) Leukotriene Modifier** Medium-or highdose ICS Leukotriene Modifier Anti-IgE Treatment Low-dose ICS plus Leukotriene Modifier Low-dose ICS plus Sustained release theophylline *ICS=inhaled glucocorticosterioids **=Receptor antagonist or synthesis inhibitors
Management Approach Based on Control For Children Older Than 5 Years, Adolescents and Adults Level of Control Treatment Action Controlled Maintain and find lowest controlling step Partly controlled Consider stepping up to gain control Uncontrolled Exacerbation Step up until controlled Treat as exacerbation The available literature on treatment of asthma in children 5 years and younger precludes detailed treatment recommendations. The best documented treatment to control asthma in these age groups in inhaled glucocorticosteroids and at Step 2, a low-dose inhaled glucocorticosteroid is recommended as the initial controller treatment. Equivalent doses of inhaled glucocorticosteroids, some of which may be given as a single daily dose, are provided in Figure 6.