Asthma (1 of 26)
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Asthma (1 of 26) 1 Patient presents w/ signs & symptoms suggestive of asthma 2 3 DIAGNOSIS No ALTERNATIVE Is asthma DIAGNOSIS confi rmed? Yes ASSESS THE LEVEL OF CONTROL OF ASTHMA FOR THE PAST 4 WEEKS Controlled Partly Controlled Uncontrolled (All of the (Presence of 1-2 of these) (Presence of 3-4 of these) following) Children Adolescents Children Adolescents & ≤5 years old & Children ≤5 years old Children 6-11 years old 6-11 years old Frequency of daytime None >Few >2x/week >Few >2x/week symptoms minutes, minutes, >once a week >once a week Limitation of activities None Any Any Any Any Nocturnal waking up or None Any Any Any Any coughing due to asthma Need for reliever None >once/week >2x/week >once/week >2x/week medication* *Reliever medications taken prior to exercise excluded. Modified from: Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention: Updated 2020. TREATMENT A Patient/guardian/caregiver education B Initial treatment of asthma C Management plans for long-term asthma control D Primary prevention E © Periodic assessmentMIMS & monitoring Not all products are available or approved for above use in all countries. Specifi c prescribing information may be found in the latest MIMS. B13 © MIMS Pediatrics 2020 Asthma (2 of 26) 1 ASTHMA • A heterogeneous disease w/ chronic infl ammatory disorder of the airways • e most common chronic disease in pediatric age groups that causes signifi cant morbidity • Characterized by history of respiratory symptoms eg wheeze, shortness of breath, chest tightness & cough ASTHMA that vary over time & in intensity, together w/ variable expiratory airfl ow limitation • Symptoms occur w/ exercise, laughing or crying in the absence of an apparent respiratory infection Symptoms (Recurrent Episodes) • Wheezing • Breathlessness • Heavy breathing • Chest tightness • Reduced activity • Cough that is recurrent or persistent non-productive that may be worse at night 2 DIAGNOSIS History • Identify the symptoms likely to be due to asthma • Determine symptom pattern for the past 3-4 months - Focus on symptoms that occurred in the past 2 weeks • History of variability is essential in the diagnosis of asthma - Variability refers to improvement or worsening of symptoms & lung function occurring over a period of time (eg day to day, month to month or seasonally) Key Indicators for Considering a Diagnosis of Asthma • Episodes of wheezing occurring more than once a month or symptoms occur >3 episodes/year - Wheezing occurring during sleep, activity, laughing, or crying, & with increasing recurrence is likely due to asthma • Activity-induced cough, usually accompanied by wheeze or heavy breathing - Cough should be non-productive, & recurrent or persistent • Nighttime cough or wheeze in the absence of viral infection • Heavy breathing, shortness of breath, or diffi cult breathing during exercise or activity, that is noticeably recurrent increases the likelihood of asthma • Persistence of asthma symptoms beyond age 3 years • Symptoms triggered or exacerbated by animal fur, aerosol, temperature changes, dust mites, drugs, etc • Symptoms (eg cough, wheeze, heavy breathing) lasting longer than 10 days in the presence of an upper respi- ratory tract infection (URTI) • Symptoms improve w/ asthma medication • Presence of patient history or family history of allergic disease (eg atopic dermatitis, allergic rhinitis) Physical Exam • Perform a thorough exam w/ focus on observation of forced expiration & nasal inspection • Hyperexpansion of the thorax • Wheezing during normal breathing or prolonged forced exhalation • Increased nasal secretion, mucosal swelling or nasal polyps • Signs of allergic skin condition • Occasionally, wheezing may not be seen in severe asthma attacks due to markedly reduced airfl ow & ventilation - Other signs may be present (eg cyanosis, drowsiness, tachycardia, diffi culty speaking) Pulmonary Function Testing Spirometry • Preferred diagnostic method - Measures airfl ow limitation & determines reversibility - All measurements should be done before & after administration of inhaled short-acting bronchodilator • Generally valuable in children ≥5 years of age - Some children cannot correctly execute the required maneuvers until age 7 years • Forced vital capacity (FVC) is a measure of the maximal volume of air exhaled from the point of maximal inhalation • © MIMS Volume of air exhaled during the 1st second of this maneuver is called forced expiratory volume in 1 second (FEV1) - FEV1 indicates risk for exacerbations • FEV1/FVC appears to be a more sensitive measure of severity of impairment • Increase in FEV1 ≥12% after administration of a bronchodilator indicates reversible airfl ow limitation B14 © MIMS Pediatrics 2020 Asthma (3 of 26) 2 DIAGNOSIS (CONT’D) Pulmonary Function Testing (Cont'd) Peak Expiratory Flow (PEF) Measurements • Important in diagnosis & monitoring of asthma ASTHMA Bronchodilator Response • Determines reversibility of airfl ow limitation in response to treatment Fractional Concentration of Exhaled Nitric Oxide (FENO) Measurement • Associated w/ increases in eosinophilic levels • An increase in FENO >4 weeks after an URTI in preschool children w/ recurrent symptoms may help in the diagnosis & in predicting intranasal corticosteroid use by school-age • Further studies are needed to prove the use of FENO measurement as a guide for adjusting asthma treatment Other Tests • ere are several lung function tests that do not rely on patient’s cooperation or the ability to perform the required maneuvers - May be valuable in children 2-5 years of age - ese are not evaluated as diagnostic tests for asthma - Commonly used in research studies & specialist centers - Eg impulse oscillometry, specifi c airway resistance, measurements of residual volume • Chest radiography may be used to rule out other pathologies & structural abnormalities Allergy Tests • Presence of food-specifi c IgE &/or atopic dermatitis increases the risk of sensitization to inhaled allergens & may be predictive of developing asthma In vivo Test • Skin prick test In vitro Test • IgE panel test/radioallergosorbent test (RAST) - May be done if in vivo test cannot be performed (eg cases of severe dermatitis) - May be performed if current antihistamine therapy cannot be discontinued, or if there is a known possibility of a life-threatening reaction to food or inhalant Asthma Diagnosis in Children ≤5 Years • Objective measurements of lung function may be diffi cult in this age group • Atopy is a major risk factor for subsequent development of asthma in this age group & it also predicts severity once asthma develops • To help establish a diagnosis of asthma, a diagnostic trial of asthma medications, in addition to a thorough medical history & physical exam, may be useful • Consider asthma if >3 episodes of reversible bronchial obstruction have been noted within the last 6 months - Patients may have virus-induced asthma which is common in this age group 3 ALTERNATIVE DIAGNOSIS Upper Airway Diseases • Allergic rhinitis & chronic rhinosinusitis Large-airway Obstruction • Foreign body obstruction of trachea or bronchus • Vocal cord dysfunction • Vascular rings or laryngeal webs • Enlarged lymph nodes or tumor • Laryngotracheomalacia, tracheal stenosis or bronchostenosis Small-airway Obstruction • Bronchiolitis (viral or obliterative) • Cystic fi brosis • Bronchopulmonary dysplasia • Congenital© heart disease MIMS Other Causes • Recurrent viral lower respiratory tract infection • Tuberculosis • Immune defi ciency • Aspiration due to dysfunction in swallowing mechanism or gastroesophageal refl ux B15 © MIMS Pediatrics 2020 Asthma (4 of 26) A PATIENT/GUARDIAN/CAREGIVER EDUCATION • Includes skills training, symptom monitoring, & a written personal asthma action plan • Aims to actively involve the children, their families & caregivers in managing asthma • Education should be provided over several visits ASTHMA - Studies have shown that asthma control is improved w/ the use of written asthma management plan together w/ careful verbal explanation of the treatment regimen • Develop patient/doctor partnership - Objective is to give patients the ability to control their asthma w/ guidance from health care professionals • e patient, parents & caregivers should be able to apply the following objectives - Avoid triggers & aggravating factors - Take medications accurately & appropriately - Understand the diff erence between “controller” & “reliever” medications - Train about correct inhalation technique - Monitor asthma control status - Recognize signs of worsening asthma & take appropriate action - Seek medical help when necessary Written Asthma Action Plan • May help patients & patient's parents/guardian/caregiver recognize & respond appropriately to an asthma attack • Should include specifi c, individualized instructions about medications & medical care access • Changes to medications may include the following: - Increasing as-needed inhaled low-dose corticosteroid-Formoterol doses - e use of an inhaler containing rapid-onset long-acting beta2-agonist w/ low-dose corticosteroid - Other inhaled corticosteroids & inhaled corticosteroid-long-acting beta2-agonist maintenance controlled regimens - A short-course oral corticosteroids for patients unresponsive to increased doses of reliever & controller medications, rapid deterioration, PEF or FEV1 <60% of personal best, or a history of sudden severe exacerbations B INITIAL TREATMENT OF ASTHMA • After diagnosis of asthma is made, it is recommended to start corticosteroid (inhaled,