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Asthma in children
Dr Gulamabbas KhakooBMBCh, FRCPCH
Consultant Paediatrician, Hillingdon Hospital
Consultant in Department of Paediatric Asthma, Allergy and Immunology,
St Mary’s Hospital, W2
Talk outline
• BTS / SIGN 2008 guidelines
• Diagnosing asthma
• Inhaled steroids
• Allergy and asthma
• Allergic rhinitis
2008 BTS / SIGN guideline on the management of
asthma in children
BTS=British Thoracic Society; SIGN=Scottish Intercollegiate Guidelines Network.
Pharmacological management. Thorax 2008;63(Suppl IV):iv1-iv121
2008 Guidelines2.1 DIAGNOSIS IN CHILDREN (1) Clinical features that increase the probability of asthma
• More than one of the following symptoms: wheeze, cough, difficulty breathing, chest tightness, particularly if these symptoms:– are frequent and recurrent– are worse at night and in the early morning– occur in response to, or are worse after, exercise or other
triggers, such as exposure to pets, cold or damp air, or with emotions or laughter
– occur apart from colds• Personal history of atopic disorder• Family history of atopic disorder and/or asthma• Widespread wheeze heard on auscultation• History of improvement in symptoms or lung function in response to
adequate therapy
2008 Guidelines2.4 DIAGNOSIS IN CHILDREN (2)Clinical features that lower the probability of asthma• Isolated cough in the absence of wheeze or difficulty breathing• History of moist cough• Prominent dizziness, light-headedness, peripheral tingling• Repeatedly normal physical examination of chest when
symptomatic • Normal PEF or spirometry when symptomatic• No response to a trial of asthma therapy• Clinical features pointing to alternative diagnosis
2008 Guidelines
• Clinical features pointing to another diagnosis:
Failure to gain weight
Clubbing
Fatty stools
Productive sputum
Other chest findings eg crackles, unequal BS
Inspiratory noises
Barking cough
Early onset rhinorhoea
GOR symptoms
Absence of nocturnal symptoms
CHILD with symptoms that may be due to asthma
Clinical assessment
High Probability Low ProbabilityIntermediate Probability
Yes No
Continue Rx
Response?
Consider referral
Yes
Trial of Treatment
Response?
Asthma diagnosis confirmedContinue Rx and find minimum effective dose
No
Assess compliance and inhaler technique.
Consider further investigation and/or
referral
Consider tests of lung function and atopy
Investigate/treat other condition
Further investigation
Consider referral
Inhaled steroids
Inhaled steroids should be considered for patients
with any of the following asthma-related features:• exacerbations of asthma in the last two years• using inhaled β2 agonists three times a week
or more• symptomatic three times a week or more• waking one night a week.
General advice
• Follow SIGN / BTS guidelines 2008
• Correct inhaler device and technique
• Compliance issues
• Written asthma plans
Children age 5-12 yrs
Children age 5-12 yrs
Children age 5-12 yrs
Children age 5-12 yrs
Children age 5-12 yrs
Children age 5-12 yrs
Children Less than 5 yrs
Children Less than 5 yrs
Children Less than 5 yrs
Children Less than 5 yrs
Children Less than 5 yrs
Using the guidelines
• Non-compliance with inhaled steroids up to 70% or more in very young and teenagers
• Inhaler technique needs checking regularly• Large volume spacer is gold standard • Dry powder inhalers only in >6-8yo• Inhaled steroids and LTRAs more likely to
improve symptoms in atopic children• In asthma + rhinitis, LTRAs may be more
beneficial
Allergies and asthma
• Look for other co-morbid conditions, especially allergic rhinitis (and food allergies)
• Consider skin prick testing (for aeroallergens) if:– Seasonal symptoms (pollens, molds)– Household pets (animal dander)– Perennial symptoms (house dust mite, molds)– Change in environment changes symptoms
Steroids in viral induced asthma
• Oral prednisolone in pre-school viral-induced asthma– No evidence of efficacy in hospitalised children
(except ? multi-factor asthma or atopic children)
• High-dose fluticasone in pre-school viral-induced asthma– Modest reduction in duration of symptoms and less
use of relief beta agonists, but a small reduction in linear growth
• NEJM 2009;360:329-53 (plus editorial)
0.9
2.3
p<0.01
Treating allergic rhinitis cuts asthma costs
• 61% fewer hospitalisations in treated patients
Patientshospitalised over 1-year period (%)
Patients untreatedfor AR
(n=1357)
Patients treated for AR
(n=3587)
2.5
2.0
1.5
1.0
0.5
0.0
Summary• Importance of clinical history especially in the
very young• Look for other markers of allergy• 2008 BTS / SIGN guidelines as a framework• Refer to secondary care if inadequate response
to treatment or possible alternative diagnosis• Asthma management plans, compliance, age-
appropriate delivery device• Allergic rhinitis
The end, any questions