ASTHMA IN CHILDHOOD dr. Ery Olivianto, SpA Dr. dr. Wisnu Barlianto, SpA(K) Prof. Dr. dr. HMS....
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ASTHMA IN CHILDHOOD dr. Ery Olivianto, SpA Dr. dr. Wisnu Barlianto, SpA(K) Prof. Dr. dr. HMS. Chandra Kusuma, SpA(K) Child Health Department Faculty of
ASTHMA IN CHILDHOOD dr. Ery Olivianto, SpA Dr. dr. Wisnu
Barlianto, SpA(K) Prof. Dr. dr. HMS. Chandra Kusuma, SpA(K) Child
Health Department Faculty of Medicine Brawijaya University Saiful
Anwar General Hospital
Slide 2
Old paradigma (1860) Paroxysmal dyspnoea Contraction of smooth
muscle bronchodilator New paradigma (1950) Inflammatory disorder
Corticosteroids Holgate ST. J Allergy Clin Immunol
2011;128:495-505
Slide 3
Definitions Asthma is a chronic inflammatory disorder of the
airways associated with airway hyperresponsiveness and airflow
obstruction that is often reversible either spontaneously or with
treatment WAO. White Book on Allergy, 2011
Slide 4
Epidemiology World Health Organisation estimate 300 million
individuals have asthma worldwide Current rising trends this will
reach 400 million by 2025 Approximately 250,000 people die
prematurely each year from asthma Prevalence in the 13-14 year olds
ranging from 2.1% to 32.2% Prevalence in the 6-7 year olds was
similar to those in the older children with prevalence of wheezing
varying from 4.1%-32.1% Indonesia: 2.6% - 17.4% WAO. White Book on
Allergy, 2011 Pedoman Nasional Asma Anak, 2004
Inflammatory and immune cells involved in asthma Barnes PJ. Nat
Rev Immunol 2010;8:183-192
Slide 7
Asthma inflammatory cascade Bernstein D. Pediatric for Medical
Students 3 rd Ed, 2011
Slide 8
Asthma phenotypes Infant (0-2 years old)Preschool children (3-5
years old)School children (6-12 years old)Adolescents Bacharier LB,
et al,. Allergy 2008: 63: 534
Slide 9
Infantile asthma Asthma affecting infant aged < 2 years 3 or
more episodes of marked expiratory wheezing within the previous 6
months Bacharier LB, et al,. Allergy 2008: 63: 534
Slide 10
Hypothetical yearly prevalence for recurrent wheezing
phenotypes in childhood Leung DM. Pediatric Allergy 2 nd Ed,
2010
Slide 11
Modified Asthma Predictive Index for children (Tucson
Children's Respiratory Study, Tucson, Arizona). Through a
statistically optimized model for 2- to 3-year-old children with
frequent wheezing in the past year, one major criterion or two
minor criteria provided 77% positive predictive value and 97%
specificity for persistent asthma in later childhood Leung DM.
Pediatric Allergy 2 nd Ed, 2010
Slide 12
Asthma phenotypes in children > 2 years Bacharier LB, et
al,. Allergy 2008: 63: 534
Slide 13
Entry point of asthma diagnosis: Recurrent Wheezing and/or
Chronic Recurrent Cough Pedoman Nasional Asma Anak, 2004
Slide 14
Diagnosis Cough and/or Wheeze Clinical history Physical
examination Mantoux test Suggestive of asthma: Episodic Nocturnal
Seasonal Exertional Atopic Indeterminate features or suggestive of
alternative diagnosis Neonatal onset Failure to thrive Chronic
infection Vomiting/choking Focal lung or CVS signs If possible
frequent peak flow measurements : Reversibility (20%) Variability
(20%) Consider Chest and sinus x rays Lung function Bronchial
challenge and/or Bronchodilator response
Slide 15
.. Consider : Sweat test Immune function Ciliary & Reflux
studies Bronchodilator response No response Response WD/ Asthma
Assess severity and etiology Review diagnosis and compliance if
poor response to treatment + ve - ve Alternative diagnosis and
treatment Chest x ray if more than mild episodic disease Trial of
antiasthma treatment Consider asthma as an associated problem Not
asthma Pedoman Nasional Asma Anak, 2004
Slide 16
Differential diagnosis of wheezing in children Nishimuta T.
Allergology International 2011;60:147-169
Slide 17
Bernstein D. Pediatric for Medical Students 3 rd Ed, 2011
Slide 18
Classification of Asthma in Children Chronic Infrequent
episodic asthma Frequent episodic asthma Persistent asthma Acute
Mild attack Moderate attack Severe attack Pedoman Nasional Asma
Anak, 2004
Slide 19
Classification of disease Clinical parameters and lung function
Infrequent episodic asthma Persistent asthma Frequent episodic
asthma Freq of attacks< 1x /monthDaily> 1x /month Duration of
attacks < 1 week Daily >1 week Between episodes No symptoms
Frequent nocturnal symptoms Symptoms (+) Sleep and activity
NormalAffectMay affect Physical examNormalAbnormalMay affect
ControllerNo needSteroid/combination Lung function (No attacks)
PEF/FEV1 >80% PEF/FEV1 15%> 50%> 30% Pedoman Nasional Asma
Anak, 2004
Slide 20
Asthma managements Chronic asthma Long term management Reliever
& Controller Acute asthma Attack management Reliever Pedoman
Nasional Asma Anak, 2004
Slide 21
Asthma managements Chronic asthma Long term management
Algorithm diagnosis & treatment Acute asthma Attack management
Algorithm attack management Pedoman Nasional Asma Anak, 2004
Slide 22
Asthma medication Controller drug to control asthma ie attack
or symptom not easily emerge Inhaled steroid LABA, ALTR Reliever
drug to relieve asthma attack or symptoms -agonist Xanthine
anticholinergic Pedoman Nasional Asma Anak, 2004
> 2 days/week Need for reliever/rescue Nocturnal symptoms or
awakening None (less than twice/week, typically for short periods
of the order of minutes and rapidly relieved by use of a
rapid-acting bronchodilator) Limitations of activities >Twice a
week Daytime symptoms: wheezing, cough, difficult breathing
Uncontrolled (>3 features of partly con- trolled present in any
week) Partly controlled (any measure present in any week)
Controlled Characteristic None (child is fully active, plays and
runs without limitation or symptoms) None (including no nocturnal
coughing during sleep) < 2 days/week (typically for short
periods of the order of minutes and rapidly relieved by use of a
rapid-acting bronchodilator (coughs during sleep or wakes with
cough, wheezing, and/or difficult breathing) Any > 2 days/week
Any (cough, wheeze or difficulty breathing,during exercise, play or
laughing) (typically last minutes or hours or recur, but partially
or fully relieved by a rapid-acting bronchodilator >Twice a week
Any (cough, wheeze or difficulty breathing,during exercise, play or
laughing) (coughs during sleep or wakes with cough, wheezing,
and/or difficult breathing) Any Levels of Asthma Control in
Children 5 years or youngers GINA, 2009
Slide 26
Assessment of severity MildModerateSevere Respiratory arrest
imminent BreathlessWalking Can lie down Talking Infant-softer
Shorter cry Difficult feeding Prefers sitting At rest Infant stops
feeding Hunched forward Talks inSentencesPhrasesWords
AlertnessMaybe agitated Usually agitated Drowsy or confused
Respiratory rate Increased Often >30x/min
Slide 27
Normal rates of breathing in awake children: Age Normal
rates